Every finding on record at Willow Rehab & Nursing

Based on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 4 of 21 residents reviewed. (Resident #24, Resident #27, Resident #33, and Resident #91)1. The facility failed to securely store over the counter medications (hemorrhoid cream) for Resident #24.2.The facility failed to securely store over the counter medication, ear relief ear drops for Resident #27.3.The facility failed to securely store prescribed medication, (Nystatin Topical Cream) for Resident #33.4.The facility failed to securely store prescribed medication, Breyna (budesonide and formoterol fumarate dihydrate) inhalation aerosol for Resident #91.This failure could place residents at risk for adverse reactions.Findings included: Record review of the face sheet dated 04/02/23 indicated Resident #24 was [AGE] years old and was admitted on [DATE] with diagnoses including Cerebellar Ataxia (a neurological condition caused by damage to the cerebellum, resulting in a sudden or progressive loss of voluntary muscle coordination, balance, and gait), Peripheral Vascular Disease (a slow, progressive circulation disorder caused by narrowed, blocked, or spasmodic blood vessels outside the heart and brain, often leading to reduced blood flow to the limbs), Muscle Weakness (a reduced ability to exert force with muscles, often caused by nerve damage, muscular disorders, metabolic imbalances, or inactivity). Record review of the MDS dated [DATE] indicated Resident #24 understands and was understood by others. The MDS indicated a BIMS score of 15 indicating Resident #24 was cognitively intact. Record review of a care plan revised on 06/11/25 indicated Resident #24 had an activities of daily living Self Care Performance Deficit and was at risk for not having their needs met in a timely manner. During an observation on 3/31/26 at 2:50 p.m. it was observed that Resident #24 had a tube of hemorrhoid cream on his bedside dresser. The medication was in plain view and accessible to anyone in the facility. Resident #24 was not available for interview. During an interview on 4/1/26 at 1:10 p.m. ADON F said that all over the counter medications should be stored inside the medication cart or secured somewhere in the facility. She said that there was a potential for residents who did not need the over the counter medication to misuse the medications. She said that all staff are responsible to ensure that medications were not accessible to residents. During an interview on 4/1/26 at 1:49 p.m. the Director of Nurses stated that all nurses are responsible to ensure that medications were stored properly. She said there was a potential that residents could misuse medications that were not theirs. During an interview on 4/1/26 at 2:05 p.m. the Administrator stated that over the counter medications should be stored in the medication cart or medication room. He said that everyone was responsible to have those medications out of resident's rooms. He said that residents could potentially misuse the medications. 2.Record review of the face sheet dated 3/31/26 indicated Resident #27 was [AGE] years old female who was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including mild cognitive impairment of uncertain or unknown etiology, insomnia (difficulty sleeping and cognitive impairment). Record review of the MDS dated [DATE] indicated Resident #27 understands and was understood by others. The MDS indicated a BIMS score of 8 indicating Resident #27 was moderately cognitively impaired. Resident #27 had highly impaired hearing. Record review of a care plan revised on 2/16/26 indicated Resident #27 had impaired cognition and was at risk of further decline in cognitive and functional abilities related to: mild cognitive impairment. Record review of order summary report dated 3/31/26 indicated Resident #27 had no order for Rexall ear relief ear drops. During observation on 3/30/26 at 9:42 AM, Resident #27 was lying in bed asleep. Resident #27 had ear drops on her bedside table. During observation and interview on 3/31/26 at 9:15 AM, Resident #27 was lying in bed. Resident had ear drops at bedside. Resident #27 said she used ear drops at times. During observation on 3/31/26 at 11:56 AM, Resident #27 was lying in bed asleep with ear drops at bedside. 3.Record review of the face sheet dated 3/31/26 indicated Resident #33 was [AGE] years old female who was admitted on [DATE] with diagnoses including unspecified dementia (memory loss and confusion), unspecified dementia, mild, with generalized anxiety disorder and muscle weakness (generalized). Record review of the MDS dated [DATE] indicated Resident #33 understands and was understood by others. The MDS indicated a BIMS score of 14 indicating Resident #33 was cognitively intact. Record review of a care plan revised on 1/13/26 indicated Resident #33 had impaired cognition and was at risk of further decline in cognitive and functional abilities related to: dementia. Interventions included administering medications per physician's orders and monitoring for unusual adverse reactions and effectiveness. Record review of order summary report dated 3/31/26 indicated Resident #33 had no order for Nystatin Cream 100,000 unit/gm. During observation on 3/30/26 at 9:34 AM, Resident #33 was lying in bed watching television. Resident #33 had nystatin cream in a bucket on her nightstand. During observation and interview on 3/31/26 at 9:13 AM, Resident #33 had nystatin cream in a bucket on her nightstand. Resident # 33 said staff used the cream on her buttocks. During observation on 3/31/26 at 11:57 AM, Resident #33 was lying in bed watching television with nystatin cream in a bucket on her nightstand. 4.Record review of the face sheet dated 3/31/26 indicated Resident #91 was [AGE] years old male who was initially admitted on [DATE] and readmitted [DATE] with diagnoses including cerebral infarction (ischemic stroke caused by a blockage in an artery supplying the brain, leading to oxygen deprivation and tissue death), muscle weakness (generalized). Record review of the MDS dated [DATE] indicated Resident #91 understands and was understood by others. The MDS indicated a BIMS score of 15, indicating Resident #91was cognitively intact. Record review of a care plan revised on 10/06/25 indicated Resident #91 had impaired cognition and was at risk of further decline in cognitive and functional abilities related to: mild cognitive impairment. Record review of order summary report dated 3/31/26 indicated Resident #91 had no order for Breyna (budesonide and formoterol fumarate dihydrate) inhalation aerosol 160 mcg/ 4.5 mcg. During observation and interview on 3/30/26 at 10:28 AM, Resident #91 was lying in bed resting. Resident #91 said the staff treated him okay in the facility. Resident #91 had an inhaler on the nightstand. During observation on 3/31/26 at 9:22 AM, Resident #91was lying in bed resting. Resident #91 had an inhaler on his nightstand. During observation on 3/31/26 at 11:50 AM, Resident #91 was lying in bed resting with oxygen in place. Resident #91 had an inhaler on his nightstand. During an interview on 4/1/26 at 10:39 AM, LVN G stated residents should not have medications in their rooms. She stated nursing staff were responsible for ensuring that medications were not in residents' rooms. She stated nurses had informed housekeeping and they had been trained to let nursing staff know if they see medications in resident's rooms while cleaning. She stated the risk was confused residents getting the medications and the residents not taking the medications correctly. During an interview on 4/1/26 at 12:57 PM, ADON F stated she expected a resident to have an order and be able to administer the medication if in their room. She stated if a resident has not had education and been checked off on administering the medication themselves, they should not have the medication in their room. She stated all staff were responsible for prohibiting medications in residents' rooms. She stated the risk was a resident could misuse prescribed over the counter medication. During an interview on 4/1/26 at 1:39 PM, the Director of Nursing stated she does not expect residents to have medications in their rooms. She stated the families bring medications for the residents. She stated all staff were responsible for ensuring the medications were not in the residents' rooms. She stated the risk was that the residents could take the medications inappropriately. The Director of Nursing stated the facility did not have a policy on Medication Storage. During an interview on 4/1/26 at 1:51 PM, the Administrator stated he expected no one in the nursing home was able to self-medicate. He stated if family brought medications from home, it needed to be checked in with the nurse and there needed to be an order for it. He stated the facility does its best by using rounds for medications throughout the facility. He stated the risk was a resident taking a medication that was discontinued and having an interaction with current medication.

Based on observation, interviews, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 (Resident #73) residents reviewed for call lights. The facility failed to ensure Resident #73 had a call light with reach. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.Findings included: Record review of Resident #73's face sheet dated 3/31/26 indicated the resident was [AGE] years old male and originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #73 had diagnoses which included type II diabetes mellitus, lack of coordination, unsteadiness on feet, muscle weakness, epilepsy (unprovoked seizures), other fatigue, age related physical debility (a state of general physical weakness), legal blindness, angina pectoris (chest pain), unspecified convulsions, dysphagia (difficulty swallowing), muscle wasting and atrophy, other abnormalities of gait and mobility and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #73's quarterly MDS assessment dated [DATE] indicated the resident understands and understood by others. Resident #73 had a BIMS score of 9, which indicated moderate impairment in cognition. The MDS indicated Resident #73 required maximal assistance with ADLs. Record review of Resident #73's care plan last revised 10/6/23 indicated Resident #73 had impaired visual function and was at risk for falls, injury and a decline in function debility (legally blind). Intervention included anticipate needs and meet them as able and keep call light in reach when in room or bathroom. During observation on 3/30/26 at 10:21 AM, Resident #73 was lying in bed resting. Resident call light was on the floor under the bed and not within reach. During observation on 3/30/26 at 12:05 PM, Resident #73 continued to lay in bed with the call light under the bed and out of reach. During observation on 3/30/26 at 2:14 PM, Resident #73 continued to lay in bed with the call light under the bed and out of reach. During an interview on 3/31/26 at 3:04 PM, CNA J stated he did not witness Resident #73's call light under his bed. The call light might have fallen under the bed. The aides are responsible for ensuring the residents' call lights are within reach. The risk was the resident could fall and not be able to call for help. During an interview on 3/31/26 at 3:17 PM, CNA H stated that she did not witness Resident #73's call light on the floor, but it probably fell and they did not see it. The aides were mostly responsible for ensuring the residents' call lights were within reach. She stated the risk was anything could happen. During an interview on 4/01/26 at 10:39 AM, LVN G stated she expected for the Residents #73s call lights to be within reach. She stated all the staff were responsible for ensuring the residents' call lights were within reach. She stated the risk was if there was an emergency the resident could not reach staff and the resident could get injured trying to get the call light from the floor. During an interview on 4/1/26 at 12:57 PM, ADON F stated she expects the Resident #73's call light to be within reach. She stated everyone was responsible for ensuring the residents' call lights were within reach. She said the call light is for safety and for residents' needs. During an interview on 4/1/26 at 1:35 PM, the Director of Nursing stated she expects the residents' call lights to be within reach. She stated all staff were responsible for ensuring the call lights were within reach. She stated the risk was the resident not being able to get the help he needed. She stated staff rounded every two hours and as needed, so the staff would be able to address the residents' needs. During an interview on 4/1/26 at 1:51 PM, the Administrator stated he expects residents' call lights to be within reach. He stated the aides do rounds and maintenance were responsible for ensuring the call lights were working. He stated the risk was the resident's inability to be able to call for assistance or help. Record review of the facility Call Light Response policy dated 2/10/21 indicated, .5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 19 residents (Resident #31) reviewed for accidents and supervision. The facility failed to ensure an oxygen cylinder found in Resident #31's room was properly stored. This deficient practice could place residents at risk of injury. Findings included:Record review of Resident #31's face sheet, dated 04/01/26, reflected that Resident #31 was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included paraplegia (impairment of motor or sensory function in the lower extremities) and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Record review of Resident #31's quarterly MDS assessment, dated 03/06/26, reflected that he had a BIMS score of 15, which indicated intact cognition. During an observation on 03/30/2026 at 10:59 AM, Resident #31 was sitting in his motorized wheelchair. There was a freestanding oxygen tank in his room that was not in a caddy. During an observation on 03/30/2026 at 11:57 AM, the freestanding oxygen container was still in Resident #31's room, without a caddy. During an interview on 04/01/2026 at 1:21 PM, ADON F said the oxygen container should have been in a caddy. She said it could cause a hazard and potentially hurt a resident. She said all staff were responsible for ensuring that the oxygen containers were in a caddy. During an interview on 04/01/2026 at 1:55 PM, the DON said the oxygen tank should have been in a caddy. She said it could have fallen over and caused a hazard to the residents. She said the nursing staff was responsible for ensuring that the oxygen container was in a caddy. She said the housekeeping staff were also responsible. During an interview on 04/01/2026 at 2:16 PM, the Administrator said the expectation was that there should not have been any unsecured tanks in the resident's room. He said it could have fallen over and caused a hazard. Record review of the facility's policy, Oxygen Safety, dated 02/11/22, reflected: .It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment.1. Safety is the responsibility of all staff, residents, visitors, and the general public.4. Oxygen Storage -- .c. Cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 20 residents reviewed for respiratory care. (Resident #37) The facility failed to ensure Resident #37's oxygen concentrator had a clean filter. This failure could place residents at risk of respiratory complications or respiratory infection. Findings included:1. Record review of a face sheet dated 3/31/26 indicated Resident #37 was [AGE] years old female and initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (chronic lung disease), chronic respiratory failure and morbid (severe) obesity. Record review of a physician's Order Summary Report dated 3/31/26 for Resident #37 indicated an order to change 02 tubing every Sunday night with a start date of 2/23/26. Record review of a physician's Order Summary Report dated 3/31/26 for Resident #37 indicated an order 02 at 2 liters via nasal cannula continuously every shift with a start date of 2/23/26.Record review of a quarterly MDS dated [DATE] indicated Resident #37 understands and was understood by others. The MDS indicated a BIMS of 15 indicating she was cognitively intact. Resident #37 was dependent on ADLs. The MDS indicated Resident #37 received oxygen therapy while she was a resident in the facility. Record review of a care plan last revised on 3/4/26 indicated Resident #37 uses oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. During an interview and observation on 3/30/26 at 10:49 AM, Resident #37 sat up in a chair resting. Resident said they treated her fine. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator. During an observation on 3/31/26 at 9:23 AM, Resident #37 was in room sitting up in a wheelchair. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator. During an observation on 3/31/26 at 11:52 AM, Resident #37 sat up in a wheelchair in her room watching television. She had on a nasal cannula that was connected to a running oxygen concentrator. There was a gray fuzzy substance on the filter on the concentrator. During an interview on 4/01/26 at 10:39 AM, LVN G stated she expected the resident concentrator air filters to be cleaned. She stated the nursing staff were responsible every Sunday night for checking and cleaning the air filters on the concentrators. She stated the risk was infection and allergens getting into the filtration system of the concentrator. During an interview on 4/01/26 at 12:57 PM, ADON F stated she expected for the resident air filters on concentrators to be cleaned. She stated the nursing staff were responsible for cleaning and replacing the air filters. She stated the risk was a potential for respiratory infection. During an interview on 4/1/26 at 1:39 PM, the Director of Nursing stated that she expected the air filters on the concentrators to be clean. She stated all staff were responsible for ensuring the filters were clean. She stated the risk was infection. The surveyor requested an Oxygen Administration policy. The DON stated the facility did not have a policy on Oxygen Administration. During an interview on 4/1/26 at 1:51 PM, the Administrator stated that he expected the air filters to be cleaned on the concentrators. He stated he was not sure who cleaned the filters. He stated he thought restorative and maintenance were responsible for the air filters. He stated the risk was respiratory issues.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 20 residents reviewed for infection control practices (Resident #9). The facility failed to ensure CNA A changed her gloves and performed hand hygiene appropriately after taking Resident #9's pants off and before performing indwelling catheter care. CNA A also failed to change her gloves and perform hand hygiene prior to touching disposable bags, some containing clean wipes. CNA A placed the dirty and clean disposable bags on Resident #9's bed side table beside his water cup while providing catheter care to Resident #9. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of the undated face sheet indicated Resident #9 was a [AGE] year-old male that admitted [DATE] with a readmission date of 3/27/26. Record review of the physician's orders dated 4/1/26 indicated Resident #9 had diagnoses that included: Multiple Sclerosis (a chronic autoimmune disease of the central nervous system where the immune system attacks the protective myelin sheath covering nerves, causing communication issues between the brain and body), and Diabetes type 2 (the body resists insulin or fails to produce enough, causing high blood sugar), and muscle weakness. The physician's orders indicated he had a Suprapubic catheter (a hollow tube inserted into the bladder through a small abdominal incision, usually just above the pubic bone, to drain urine.) Record review of the undated care plan indicated Resident #9 had Multiple Sclerosis, was dependent with personal hygiene, and had a Suprapubic catheter related to obstructive uropathy (blockage in the urinary tract that prevented urine from flowing) with urine retention (inability to fully empty the bladder.) Record review of the quarterly MDS dated [DATE] indicated Resident #9 had clear speech, understood others , and was understood by others. He had a BIMS score of 14, indicating he was cognitively intact. The MDS indicated he had an indwelling catheter. During an observation on 4/01/2026 at 9:55 AM, CNA A performed catheter care and CNA B assisted. Both washed their hands and donned PPE for EBP precautions. Clear disposable bags were on Resident #9's bedside table with his water cup. CNA A pulled Resident #9's pants down. She then began SP catheter care without changing her gloves or sanitizing her hands. She cleaned the part of the catheter closest to the resident, using both hands, then with the same gloves touched all the disposable bags looking for the dirty bag to discard her used wipe. She took off her gloves and sanitized her hands, donning clean gloves and continued with catheter care. During an interview on 4/1/26 at 10:10 AM CNA A said she should have changed her gloves and sanitized her hands after pulling down Resident #9's pants and before touching the catheter. She said she should have changed gloves before going from dirty to clean. She said these mistakes were a cross contamination and infection control issue. She said she should not have touched all of the bags with her dirty gloves because that was also a cross contamination and infection control issue. CNA A said she should have put the bags on the foot of Resident #9's bed and not on his bed side table especially by his drinking cup. She said doing that was also an infection control problem which could spread infection to staff and residents. She said she was very nervous. During an interview on 4/1/26 at 10:04 AM, CNA B said she realized CNA A had not changed her gloves or sanitized her hands after touching Resident #9's pants and before touching his catheter and she should not have because her gloves were considered dirty. She said CNA A should not have put the dirty bag on the bed side table or touched the bags with her dirty gloves. The dirty bag should not have been on Resident #9's bed side table, or by his water cup. She said these things were an infection control problem and cross contamination. She said she did not know why she did not say anything to CNA A or remind her to change her gloves or wash her hands. During an interview on 4/1/26 at 12:19 PM, LVN E said staff should sanitize their hands and change gloves after touching a resident's clothes and before touching a resident's catheter to prevent infection. She said a dirty bag should not be placed on a resident's bed side table and especially by a resident's water cup. She said touching bags with dirty gloves would contaminate all the bags. LVN E said all these things were infection control and cross contamination issues that could cause illness for staff and residents. During an interview on 4/1/26 at 12:23 PM, CNA C said after touching a resident's clothing, gloves were considered dirty. A staff would have to wash their hands and don clean gloves before touching a resident's catheter, otherwise it would be an infection control problem. She said staff should never put a bag for dirty items on a resident's bed side table. She said cross contamination could cause illness to residents and staff. During an interview on 4/1/26 at 12:30 PM, ADON D said staff should not put a bag for dirty items on a bed side table. She said that was a risk of infection to residents and staff. She said after touching a residents' clothing staff should wash their hands and don clean gloves before touching a resident's catheter. ADON D said if a staff touched disposable bags with gloves that were considered dirty they would all be contaminated. She said all these things were infection control problems that could transmit illness. During an interview on 4/1/26 at 1:20 PM, the DON said after a staff had touched a resident's clothing, they would need to wash their hands and change their gloves before beginning catheter care, because the gloves would be contaminated from the resident's clothing. She said a disposable bag that was for dirty items should never be put on a resident's bed side table. She said if a staff touched disposable bags with gloves they had been using for catheter care and had not changed them, the bags would be considered contaminated. She said that was an infection control and cross contamination issue that could cause illness to staff and residents. The DON said she thought the CNAs were nervous. During an interview on 4/1/26 at 1:37 PM, the ADM said if staff had washed their hands and donned clean gloves it was okay to touch a resident's clothing (remove their pants) then proceed with catheter care. He said if staff were performing catheter care and had not changed their gloves or washed their hands and touched disposable bags with the gloves, the bags would be considered contaminated. The ADM said it was not okay to put disposal bags for dirty items on a resident's bed side table, especially by the resident's drinking cup. He said it was an infection control/cross contamination issue which could cause illness to residents and staff. Record review of a Nursing Peri-Care competency dated 1/16/26 indicated CNA A was proficient in perineal care and catheter care. Record review of a Nursing Peri-Care competency dated 11/19/25 indicated CNA B was proficient in perineal care and catheter care. Record review of an Indwelling Foley Catheter Guidelines Policy dated 5/23/14 with a review date of 2/10/2020 indicated: Anticipated outcome The facility should identify and assess patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections. Record review of an Infection Prevention and Control Program Policy dated 10/24/22 with a reviewed date of 11/6/24 indicated: Policy: The facility has established and maintains 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 as per accepted national standards and guidelines. 4. Standard Precautionsa.All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted while providing resident care services. 16. Staff Educationa.All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. b.All staff are expected to provide care consistent with infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility. d.The Infection control Preventionist implements/monitors/validate that staff are trained in infection control practices.

Based on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, is provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure that CNA B effectively communicated to RN A that Resident #1 requested a nurse. The facility failed to ensure that CNA B recognized a change of condition in Resident #1 that needed to be emergently communicated to RN A. The facility failed to ensure CNA C reported Resident #1's change of condition to RN A. These failures resulted in Resident #1 presenting with signs and symptoms of acute respiratory distress, a medical emergency and delayed her transfer of care to the acute care facility on 5/18/25 where she was diagnosed with acute hypercapnic respiratory failure ( a serious medical condition where the lungs cannot adequately remove carbon dioxide (CO2) from the blood, leading to a buildup of CO2 and a dangerously low blood pH) An Immediate Jeopardy (IJ) was identified on 6/5/25. The IJ template was provided to the facility on 6/5/25 at 5:30 pm. While the IJ was removed on 6/6/25 at 2:37 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor and evaluate the effectiveness of their corrective systems. This failure could place residents requiring respiratory care at risk for exacerbation of condition, as well as placing any residents needing emergency attention at risk for deterioration, irreversible health complications and death. The findings included: Record review of the face sheet dated 6/5/25 for Resident #1 indicated she was re-admitted to the facility on [DATE] with diagnoses including, acute on chronic respiratory failure with hypoxia (occurs when a person with a pre-existing chronic lung condition experiences a sudden worsening of their respiratory status, leading to dangerously low oxygen levels in the blood [hypoxia]), acute on chronic respiratory failure with hypercapnia (sudden worsening of a patient's breathing, where their lungs can't adequately remove carbon dioxide [hypercapnia] and this occurs on top of an existing, long-term respiratory condition), pneumonia, atrial fibrillation (an irregular heart beat that causes the heat to beat rapidly and irregularly, causing the heart to not pump blood efficiently, symptoms can include palpitations, shortness of breath, dizziness if left untreated this heart rhythm can lead to blood clots, stroke and heart failure), acute pulmonary edema (sudden and severe condition where fluid accumulates in the lungs, making it difficult to breathe. It's a medical emergency requiring immediate treatment). Record review of the MDS dated [DATE] indicated Resident #1 made herself understood and understood others. The MDS indicated Resident #1 was unable to complete the interview for BIMS. The sections of the MDS inquiring of short-term memory; Long-term memory; memory /recall ability; and cognitive skills for decision making were not answered. The MDS indicated there was no evidence of acute change in metal status from the resident's baseline. The MDS indicated Resident #1 no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated Resident #1 was dependent on staff for toileting, showers/baths, lower body dressing, putting on/taking off of footwear. The MDS indicated Resident #1 required substantial/ maximal assistance with upper body dressing and personal hygiene. The MDS indicated Resident #1 required supervision, or touching assistance with oral hygiene and required only setup or clean -up assistance with eating. The MDS indicated Resident #1 required substantial maximal assistance with the following position changes; sit to lying (The ability to move from sitting on side of bed to lying flat on bed); lying to sitting on the side of bed (the ability to move from lying on back to sitting on the side of the bed with no back support); sit to stand (the ability to come to a standing position from sitting in a chair , wheelchair or on the side of the bed). The MDS indicated Resident #1 required partial/moderate assistance with roll left to right (the ability to roll from lying on back to the left and right side and return to lying on back on the bed). The MDS indicated toilet transfers, tub/shower transfers, car transfers and walking 10 feet were not attempted due to medical condition or safety concerns. The MDS indicated Resident #1 was frequently incontinent of bowel and bladder. The MDS indicated Resident #1's primary medical condition was debility, cardiorespiratory conditions. The MDS indicated active diagnoses included Atrial Fibrillation or other dysrhythmias, heart failure, pneumonia, seizure disorder, and respiratory failure. Record review of the discharge MDS dated [DATE] indicated Resident #1 had no cognitive impairment (BIMS of 15). Record review of the care plan revised on 3/24/25 indicated Resident #1 had a diagnosis of altered cardiovascular status due to arrythmia, CHF (congestive heart failure). The care plan interventions included, monitor resident for shortness of breath and cyanosis ( a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The care plan indicated Resident #1 had impaired respiratory status and was at risk for shortness of breath, respiratory distress, increased anxiety and hypoxia. The care plan interventions included monitor for shortness of breath, respiratory distress and provide oxygen as ordered. Record review of Resident #1's order summary report as of 5/18/2025, detailed and active order to change o2 tubing and humidifier bottle every night shift every Sunday. As well as an active order to administer oxygen via nasal cannula to maintain SP02 >92 %every shift related to acute and chronic respiratory failure. Record review of the nursing note for Resident #1 dated 5/18/25 at 10 40 p.m., stated RN to room to change o2 (oxygen) tubing and humidifier bottle as order(ed). Roommate states she had been trying to get the nurse for a while and reports she hit the call light and told the CNA that came into the room that (Resident #1) needed the nurse. The nurse was not informed of the resident's request for a nurse. Visual assessment showed the resident to be lying on her left side and she had inadvertently disconnected herself from the oxygen concentrator. The resident was noted to have dusky color, blue fingertips, and shallow respiration. The resident (Resident #1) was immediately placed back on the oxygen concentrator and pulse oximeter reading of 50% oxygen increased to 5 LPM with continuous SP02 monitoring. SpO2 only rose to 70%. 911 was called for emergent transport and immediately placed on non-rebreather at 15 LPM bringing Sp02 up to 94%. This note was written by RN A. Record review of the hospital Discharge summary dated [DATE] indicated Resident #1 was admitted to the hospital on [DATE] with diagnosis of acute hypercapnic respiratory failure. The discharge summary detailed Resident #1 developed severe hypoxia ( critical state where the body's tissues and organs are deprived of adequate oxygen) and hypercapnia ( condition where there is an excessive buildup of carbon dioxide (CO2) in the bloodstream) with lab work and chest x-ray indicating concurrent heart failure exacerbation (sudden worsening of heart failure symptoms, where the heart can no longer effectively pump enough blood to meet the body's needs) and was in chronic atrial fibrillation (also known as long-standing persistent atrial fibrillation, is a heart condition where the upper chambers of the heart [atria] beat irregularly and rapidly for extended periods) on admission . She was treated and discharged back to the nursing facility on 5/20/25. During an interview on 6/4/25 at 12:00 p.m., RN A said CNA B never told her that Resident #1 needed a nurse. RN A said she just happened to go into Resident #1's room when she did because she was changing the oxygen tubing and humidifier as it was ordered to be done on her shift. RN A said when she went into the room it was obvious Resident #1 was respiratory distress. RN A said Resident #1 fingers were blue she was breathing rapid shallow breaths. RN A said her oxygen tubing was disconnected from concentrator, although the nasal cannula remained in her nose. RN A said she put a pulse on oximeter on Resident #1 and Sp02 reading was in the 50's. RN A said she retrieved a mask and turned Resident #1's oxygen up to 5 liters per minute and Sp02 reading came up to the 70's. RN A said she called 911. RN A said when EMS arrived , they had gotten her Spo2 up to 94% on 15 liters per minute before she was transferred to the hospital. RN A said she was very upset that CNA B had not notified her that Resident #1 had requested a nurse. RN A said she would have went to the room right away had she known Resident #1 needed the nurse. RN A said she notified the DON that night of the situation and that CNA B had not notified her (RN A) Resident #1 needed her. During an interview and observation on 6/5/25 at 12:20 p.m., Resident #1 sat in her wheelchair in her room. Resident #1 said she had been to the hospital recently. Resident #1 said she could not recall the exact date and stated she thought it had been a few weeks ago. Resident #1 said the day she went to the hospital she was very light headed and felt the room was spinning. Resident #1 said she had COPD (chronic obstructive pulmonary disease is a progressive lung disease that causes airflow obstruction and breathing difficulties), Afib (atrial fibrillation) and seizure disorder. Resident #1 said she felt like something was wrong and could not catch her breath. Resident #1 said her memory of the event was a little fuzzy and stated her roommate (Resident #2) was in the room with her. Resident #1 said she called for help and CNA B came to the room and helped her set the bed up. Resident #1 said she was feeling really dizzy and short of breath when her roommate had called to get her a nurse. Resident #1 said it seemed like maybe 30 minutes before the nurse came but she really was not sure exactly how long it was before the nurse came in the room. Record review of the face sheet for Resident #2, dated 6/5/25 indicated she was readmitted to the facility on [DATE] with diagnoses including, spinal stenosis, PVD (peripheral vascular disease), morbid obesity and muscle weakness. Record review of the MDS dated [DATE] for Resident #2 indicated she understood others and made herself understood. The MDS indicated Resident #2 had no cognitive impairment (BIMS of 15). The MDS indicated Resident #2 had limited range of motion to both lower extremities and to one upper extremity. The MDS indicated Resident #2 used a wheelchair for mobility. The MDS indicated Resident #2 required substantial/ maximal assistance with sit to lying position changes (the ability to move from sitting on side of bed to lying flat on bed) and required partial/moderate assistance with lying to sitting on the side of the bed (the ability to move from lying on back to sitting on the side of the bed with no back support). The MDS indicated Resident #2 was always incontinent of bladder and frequently incontinent of bowel. During an interview on 6/5/25 at 12:28 p.m., Resident #2 said she couldn't recall the exact date of the event but stated it was approximately a few weeks ago. Resident #2 said she noticed her roommate (Resident #1) struggling with her bed remote. Resident #2 said Resident #1 was trying to raise her bed up. Resident #2 said Resident #1 had pushed her call light for help but said she went ahead and put her call light on also to try and get help for roommate. Resident #2 said she couldn't say exactly how long it was before CNA B came to the room but guessed it was about 15 minutes. Resident #2 said CNA B came into the room and she (Resident #2) told her (CNA B) that Resident #1 needed help with her bed remote. Resident #2 said CNA B helped Resident #1 to raise up the head of the bed and left the room. Resident #2 said a few minutes later her roommate (Resident #1) was having trouble talking to her and she (Resident #2) asked her if she needed the nurse. Resident #2 said she could not remember if she said yes or nodded yes but again put on her call light to get her roommate help. Resident #2 said she just knew Resident #1 needed the nurse. Resident #2 said CNA B answered the call light and came to the door. Resident #2 said she told CNA B Resident #1 needed the nurse. Resident #2 said CNA B said she would let the nurse now and left the room. Resident #2 said it was a really long time, she guessed approximately 45 minutes before the nurse came into the room. Record review of the associate disciplinary memorandum for CNA B i ndicated she was suspended on 5/19/25 pending investigation. The description of violation was Employee failed to notify charge nurse on resident change of condition. Employee failed to follow the company's code of conduct, policies and procedures. The memorandum detailed CNA B's comments were taken via phone and stated .She (CNA B) answered resident (Resident #1's) call light and she (Resident #1) needed help with her bed remote. She (CNA B) assisted her, resident (Resident #1) was not in distress. She (CNA B) stated she answered it the second time and the resident (Resident #1) stated she wanted the nurse. (Resident #1) did not appear to be in any distress. She (CNA B) stated the nurse was at the end of another hall. She (CNA B) told her (RN A) down the hall that (room number) wished to speak with her. She (CNA B) said she assumed the nurse went down there. The memorandum detailed Employee has been educated on notifying charge nurse on change of condition. Continued behavior will result in further disciplinary action up to and including termination .(and) Employee should report changes of condition promptly to charge nurse. The disciplinary memorandum was signed by the DON, ADON D, and human resources personnel E. During an interview on 6/5/25 at 2:00 p.m., the DON said RN A had notified her of the incident. The DON said RN A insisted she had not been notified of Resident #1's request for a nurse and CNA B insisted she had notified RN A. The DON said she herself did not take CNA B's statement because she was out of the facility the following day (5/19/25) but stated ADON B and human resources personnel E took her (CNA B's) statement over the phone. The DON said CNA B was in-serviced over notification of change of condition. The DON said that in-service (notification of change of condition) was started on 5/19/25 for all clinical staff and was ongoing. During an interview on 6/5/25 at 2:20 p.m., ADON B said she called CNA B to ask her about RN A's allegation of not being notified. ADON B said the statement was as documented on the associate disciplinary memorandum dated 5/19/25 for CNA B. During an interview on 6/5/25 at 2:22 p.m., human resources personnel E said she was also on the call made to CNA B to record her statement. Human resources personnel E said the statement was as documented on the associate disciplinary memorandum dated 5/19/25 for CNA B. During an interview on 6/5/25 at 2:37 p.m., CNA B said, on 5/18/25 she responded to Resident #1's call light. CNA B said when she went into the room she asked Resident #1 what she needed and she indicated she needed help with her bed. CNA B said she assisted Resident #1 with raising the head of her bed up and left the room. CNA B said Resident #1 did not appear to be in any distress and made no further requests at that time. CNA B then said later (she could not quantify time between the first and second call light response) she saw the call light was on again for Resident #1 and responded. CNA B said Resident #2 said Resident #1 needed the nurse. CNA B said do you need the nurse and Resident #1 replied that she did need the nurse. CNA B said Resident #1 was fine and did not appear to be in any distress. CNA B said she left the room and RN A was at the end of another hall and yelled to her that Resident #1 needed her. CNA B said the call light for Resident #1 was on again and at this time she retrieved CNA C to assist her as she anticipated she may need assistance as Resident #1 was a large lady. CNA B said CNA C went into the room with her and they provided peri care for Resident #1. CNA B said Resident #1 was fine and was in no distress when herself and CNA C were in the room. CNA B then said she had told RN A multiple times Resident #1 needed her. CNA B said Resident #1's call light came on again. CNA B said from the time herself and CNA C provided peri-care to the call light coming on again was approximately 30 minutes. CNA B said herself and CNA C walked down to the room and saw RN A squatting down at the bedside. CNA B said every time she was in the room Resident #1 was not in distress and her oxygen was on and connected to the concentrator. During an interview on 6/5/25 at 3:00 p.m., CNA C said when she went to help CNA B with Resident #1 on 5/18/25 she (Resident #1) looked like she was going through something. CNA C said Resident #1 wouldn't open her eyes was breathing hard and kinda shallow. CNA C said they provided peri-care and they continued to ask her (Resident #1) questions but she (Resident #1)would not alk to them. CNA C said Resident #1 did have her oxygen tubing in her nose. CNA C said Resident #2 said Resident #1 needed the nurse. CNA C said she looked at CNA B as they were leaving the room and CNA B said to her, she had already notified the nurse. CNA C said she did not go to RN A herself because CNA B told her (CNA C) she had already notified the nurse. CNA C said the call light came on again and she walked with CNA B down to the room. CNA C said RN A was at the bedside and asked the them (CNA B and CNA C) why the oxygen tubing was disconnected from the concentrator and how long had Resident #1 had trouble breathing. Record review of the facility policy and procedure titled Notification of Changes, dated 7/13/25 stated Policy: To provide guidance on when to communicate acute changes in status to MD, MP and/responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known notify the resident's legal representative or appropriate family member of the following: .(2) An emergency response situation that require EMS involvement. (3) A significant change in the physical, mental or psychosocial status of the resident . The Administrator was notified on 6/5/25 at 5:25 p.m. at that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template via email on 6/5/25 at 5:30 p.m. The Plan of Removal was accepted on 6/6/25 at 12:40 p.m.,05/15/25 and detailed the following: .Resident #1 was sent to the ER for evaluation and treatment on 05/18/2025. Resident #1 returned to the facility on 5/20/25; head to toe physical assessment was completed by floor nurse upon return to the facility and documented. The resident was assessed by the Director of Nursing, and she was not in distress and at normal baseline. No adverse effects were noted. (Completion Date: 06/05/2025) The Administrator/Director of Nursing reported this allegation of respiratory care failure to the facility Medical Director. (Completion Date: 06/05/2025) Identification of Residents Affected or Likely to be Affected: Director of Nursing/ or Designee conducted assessments for the 13 residents currently on oxygen therapy or with PRN orders, with no negative findings or changes noted. (Completion Date: 06/05/2025) Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 06/06/2025) On 6/5/25 @ 6:30pm the Director of Nursing, Assistant Director of Nursing, Designee in-serviced direct care staff to include CNAs on recognizing notification of change, effective communication and stop and watch. If a resident presents with a change in condition, the nurse will be notified immediately by each CNA verbally and will describe what change they see with the resident. The CNAs will document on the stop and watch tool simultaneously to communicate the change with the nurse and both CNA and nurse will sign the form. This will be completed by 6/6/25 @ 12pm. Any new staff or staff not present will be in-serviced prior to their next shift. On 6/5/25 @ 6:30pm the Director of Nursing, Assistant Director of Nursing, Designee in-serviced direct care staff to include CNAs on job duties and effective communication which includes updating charge nurses throughout shift of patient status or change of condition immediately by using the stop and watch tool. This will be completed by 6/6/25 @ 12pm. Any new staff or staff not present will be in-serviced prior to their shift. On 6/5/25 @ 6:30pm the Director of Nursing, Assistant Director of Nursing, Designee in-serviced floor nurses on the immediate need of nursing assessment when a change of condition is indicated or notified by CNA. This will be completed by 6/6/25 @ 12pm. Any new staff or staff not present will be in-serviced prior to their shift. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator, Director of Nursing, Assistant Director of Nursing or designee, will review 24-hour report during clinical meeting during morning stand-up daily for any respiratory changes of condition to verify understanding of current policy for recognizing changes of condition, notification, and assessment of residents. Re-education will be provided at the time, if needed. Summary of investigations and incidence of re-education, if required, will be discussed with the facility QAPI committee, and plan may be revised as needed. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. An off-cycle Ad Hoc QAPI meeting was held by the Administrator/ or designee on 06/05/2025 at approximately 6:30 pm via phone conversation with Medical Director to discuss the IJ on respiratory services. We discussed the facility's follow-up plan to sustain compliance. On 6/6/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an interview on 6/6/25 at 12:50 p.m., the DON said the facility had 13 residents who had orders for Oxygen, (either continuous or as needed). The DON said all these Residents were assessed on 06/05/25 and there were no concerns with their Oxygen level. The DON said nursing staff including CNAs, Med Aides and Nurses were in-serviced on recognizing change In condition of a resident. The DON said CNAs cannot assess a resident but can report if they see a resident not being normal. The DON said they (CNAs) were to report the change in condition immediately to the charge nurse. The DON said when a change in condition is identified the staff (CNA) and the nurse will document the reported Change on the Stop and Watch paper form. The DON said and both the staff (CNA) and the nurse must sign. The DON said there had not been a change in condition reported since the training. The DON said staff work 12 hours shift from 6AM to 6PM and 6PM to 6AM. The DON said all nursing staff have received the training and any nursing staff not on the schedule, will be trained by the DON, ADON, or designee prior to starting their shift. The DON said most likely the training of new staff or staff who had not yet been on the schedule will be conducted by the DON or ADON B, but it could be another nurse who had already been trained. The DON said the 24-hour Report will be reviewed during morning meeting and any respiratory changes in condition will be reviewed to verify that new procedure was followed and Stop and Watch form was completed and signed as required. The DON said any new concerns with training or the Stop and watch procedure will be reviewed by the QAPI committee any concerns with re-education will be addressed immediately. The DON said an AD Hoc QAPI meeting was conducted with the Medical Director on 06/05/25 to address any issues that were mentioned in the IJ template. The DON provided copies of current employees and completion of training. No issues were identified. The DON provided a list of the 13 residents with oxygen orders. The surveyor reviewed and no concerns were identified. Of these 13 residents the surveyor interviewed Resident #3, #4, #5, #6, and #7 and found no concerns. During interviews on 6/6/25 from 1:00 p.m., to 2:30 p.m., Nurses and Nurse Aides that represent the 6:00 a.m.- 6:00 p.m. and 6:00 p.m. to 6:00 a.m. shifts (LVN F, LVN G, LVN H, LVN I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O and MA P) as well as confirmed they had received training on reporting change in Condition and documenting on the Stop and Watch form. They said any time there was a change in Condition, the nurse was to respond immediately to assess the resident. CNAs will document the date and time when the change was reported to the nurse, and which nurse the change was reported. All staff were able to describe the procedure on reporting change in condition and Stop and Watch form. On 6/6/25 at 2:37 p.m., the Administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident # 85) CNA T used Resident #85's debit/credit card for her personal use on various dates. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings included: Record review of Resident #85's face sheet, dated 01/29/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Dystonia (a neurological movement disorder characterized by involuntary, sustained, or repetitive muscle contractions that cause abnormal postures or movements), anxiety disorder (feelings of nervousness, panic, or fear), diabetes and high blood pressure. Record review of Resident #85's admission MDS assessment, dated 12/09/24, indicated Resident #85 understood and was understood by others. Her BIMs score was 12, which indicated she was moderately cognitively impaired. Record review of the care plan dated 12/26/24 indicated Resident #85 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to the diagnosis of mild cognitive impairment. The intervention was for staff to engage in simple, structured activities that avoid overly demanding tasks and provide instructions to the resident using clear voice and simple sentences. Repeat as needed and allow resident time to respond. Record review of the Provider Investigation Report dated 01/08/25 indicated Resident #85 was asked on 01/08/25 if she knew why money was being transferred to CNA T's Cash App (a digital wallet application that allows users to send, receive, and save money) account. Resident #85 said she was not aware of any money being transferred to CNA T or ever using Cash App for any activity in the past or currently. Resident #85 showed the previous Administrator, and the Business Office Manager her phone and permitted them to review her phone for a Cash App. Neither the previous interim Administrator nor the Business Office Manager could find any evidence of the Cash App being on Resident #85's phone. Bank statements were received from Resident #85's account. The bank statements indicated money was being transferred via Cash App from the account of Resident #85 to CNA T on multiple dates and times. Resident #85 denied having authorized any ATM withdrawals or Cash App money transfers for CNA T. Record review of the Provider Investigation Report dated 01/08/25 further indicated CNA T said Resident #85 had asked her a couple of times around Christmas 2024 to go shopping at Walmart and the dollar store. CNA T said she bought Resident #85 some outfits, snacks, a refrigerator, and some cash back. CNA T said Resident #85 gave her the PIN to her card so that she could bring some cash back; around $300 to 400 dollars. CNA T said she asked Resident #85 if she was supposed to have that much money and Resident #85 said they could not tell her how to spend her money. CNA T said she gave the cash and the items to Resident #85 but did not keep any receipts. She said that occurred around Christmas time and then again, a couple of weeks ago when she used the ATM at Walmart. CNA T said Resident #85 kept telling her she had to pay a $100 copay at the doctor's office and other stuff. CNA T said no other resident had asked her to go shopping for them. CNA T said Resident #85 gave her the PIN to her card and permission to use her card. She said she would not have had her card or PIN without her consent. Record review of the Provider Investigation Report further indicated on the bank statements, dated 01/09/25, the following transactions were: 12/24/24? ?$2.00-----fee for checking the account 12/24/24? ?$3.00----fee for withdrawal 12/24/24? ?$3.00----fee for withdrawal 12/24/24? ?$30.00--- NSF (non-sufficient funds (NSF) fee is a charge a bank imposes when a transaction is declined due to insufficient funds in an account) 12/24/24? ?$30.00---NSF 12/24/24? ?$400.00----withdrawal 12/24/24? ?$100.00----withdrawal 12/30/24? ?$10.00----Cash App 12/30/24? ?$10.00-----Cash App 12/30/24? ?$25.00---withdrawal in [city name] 12/30/24? ?$30.00---NSF 12/30/24? ?$30.00----NSF 12/30/24? ?$30.00----NSF 12/30/24? ?$30.00----NSF 12/30/24? ?$200.00----Cash App 01/06/25? ?$10.00----Cash App 01/06/25? ?$10.00----Cash App 01/06/25? ?$3.00---service card 01/06/25? ?$10.00----Cash App 01/06/25? ?$10.00----Cash App 01/06/25? ?$10.00----Cash App 01/06/25? ?$200.00----Cash App Total amount withdrawn was: $1,186.00 During an interview on 01/27/25 at 3:14 p.m., the Business Officer Manager said she, the interim Administrator, the DON, the Social Worker, and the Ombudsman met with Resident #85 on 01/08/25 to discuss applied income and payment due to the facility. She said during the conversation Resident #85 said she did not have any money because she had given a staff member her credit card to go shopping for herself and her family member, who was also a resident in the facility, and all their money was gone. The Business Officer Manager asked Resident #85 if she could have permission to call the bank and receive her statements. Resident #85 gave her permission and was also present when she called the bank. After receiving the bank statements, the facility saw the transactions where CNA T was sending money via Cash App to herself from Resident #85's account. The Administrator then did a self-report to the state agency. She said she recalled the bank and set up a trust fund for Resident #85 to prevent further exploitation. She said Resident #85 admitted to giving CNA T her PIN and credit card. She said she totaled the amount stolen from resident #85's account to be $455.00. The Business Officer Manager said as of today (01/27/25) she had not been told to replace Resident #85's money. During a phone interview on 01/27/25 at 3:52 p.m., the assigned Detective said he went to the facility and spoke with the staff and Resident #85. He said they had to get a subpoena for the Cash App record, and it would take a few weeks. He said once they received the records and could prove CNA T had sent the money to her personal account she would be charged with financial abuse of an elderly. He said he had tried to contact CNA T but she did not answer. During an interview on 01/28/25 at 3:01 p.m., Resident #85 said when she and her family member (who was also a resident) arrived at the facility they were homeless because they were kicked out of their house by the landlord. She said CNA T was a staff member who was helping them go get some things they needed but it turned out she took from Resident #85 and she was unsure of how much the aide took. Resident #85 said the Business Officer Manager knew how much money was stolen from her. She said CNA T stole her information and put it on her cash app. Resident #85 said the police were also aware of what CNA T had done and the amount of money she had stolen from her. She said she was upset about the whole situation. Resident #85 admitted she gave CNA T her PIN and credit card to buy things for her such as Dr Pepper, clothes, and a refrigerator and she said CNA T did buy what she had asked for. She said that unknown to her CNA T took out some more money without her consent and sent it to her own Cash App. She said she was going to file charges against CNA T because what she did was wrong. She said she was not sure if the facility was going to return her money but knew they were working on getting everything straight. During an attempted phone interview on 01/28/25 at 3:51 p.m., CNA T did not answer, and a message was left. During an interview on 01/29/25 at 3:20 p.m., ADON F said she expected staff to notify the activity director if any resident wanted something. She said she was aware that Resident #85's credit card had been used by CNA T but was unaware of the whole process because the Administrator and the DON handled it. She said she knew they did an in-service on exploitation with the staff. During an interview on 01/29/25 at 3:50 p.m., the DON said they were having a meeting with Resident #85 and her family member who was also a resident, along with the Business Office Manager, the Ombudsman, the interim Administrator, and herself. She said during the meeting Resident #85 said she did not have any money, and when questioned further she said she had given her credit card to CNA T. Resident #85 did admit she gave CNA T her credit card and PIN. She said the Business Office manager got the bank statements, reviewed them, and saw some cash app activity in CNA T's name. They then called the police and reported this incident to the state agency. She said she did go to Resident #85's room and saw they had some new clothes and bedding. She said they called CNA T who admitted she had gone shopping for Resident #85. She said they immediately suspended CNA T pending investigation. She said after reviewing the bank statements and CNA T admitted she had used the credit card the investigation was completed and Resident #85's misappropriation allegation was substantiated because it did happen. She said they terminated CNA T. She said CNA T should not have taken any resident's credit card. She said the staff were not allowed to take money, credit cards, or anything else from the resident. She said they did an in-service on abuse, neglect, and exploitation. During an interview on 01/29/25 at 421 p.m., the Administrator said she was not employed at the facility when Resident #85's credit card was used. She said they should have been educated on exploitation. She said she did not expect staff to take money or credit cards from any residents. She said they had a process in place for the activity director to shop for all residents. During a phone interview on 01/30/25 at 02:30 p.m., the previous Administrator said they went to have a meeting with Resident #85 and her family member who was a resident about paying their bill to the facility. He said the Ombudsman, the Business Office Manager, and the DON were present during the meeting. He said while talking to Resident #85 she said the CNA kept taking her money, so he started asking when that happened. Resident #85 said it occurred around Christmas 2024. Resident #85 said they needed a few things, so she gave CNA T her credit card and PIN. Resident #85 said CNA T did get the things they needed and returned her credit card. Resident #85 said she noticed money was missing from her bank account but did not tell anyone. Resident #85 said she was paid last week (unknown date) but yet she had no money. The Administrator said he and the Business Office Manager asked if they could get her bank statements and she agreed. We reviewed the bank statements and saw where CNA T was receiving money on her cash app from Resident #85's account. He said he asked Resident #85 again if she approved the transactions done by CNA T and she said, No. He said they asked if they could look at Resident #85's phone and she agreed, and they did not see an application for Cash App on her phone. He said he then collected all the information and sent it to his cooperate office to report it to the Health and Human Services and called the police. The previous Administrator said they did an off-cycle Quality Assurance (QA) and Performance Improvement (PI) meeting where they discussed the credit card issues and came up with a plan for the activity director to only get money for the resident. He said that the resident must be present, tell both the Business Office Manager and the Activity Director what they need, and sign out for the money. He said an in-service was done on abuse, neglect, and exploitation. He said no staff should take money or credit cards from a resident. Record review of the in-service done on 01/08/25 about abuse, exploitation, misappropriation, and taking money and/or credit cards from residents. Record review of the Abuse Neglect and Exploitation, dated 10/24/22, indicated, Policy statement: it is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definition of exploitation means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Misappropriation of Resident Property: means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, threats, or coercion. III. Prevention of Abuse, Neglect, and Exploitation: The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of residents' property, and exploitation that achieves: B. Identifying, correcting, and intervention is in situations in which abuse, neglect, exploitation, and/or misappropriation of residents property is suspected or identified by: taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to residents or other residents'. A. The facility assists staff in understanding the different types of abuse: mental, verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff-to-resident abuse and certain residents-to-resident altercations. VI. Protection of Resident: the facility makes efforts to ensure all residents are protected from psychosocial harm as well as additional abuse during and after the investigation. A. Respond immediately to protect the alleged victim and the integrity of the investigation.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 3 of 5 residents (Resident #20, Resident #76, Resident #5) reviewed for quality of care. The facility failed to prevent Resident #20 from having rubbing alcohol in his room. The facility failed to ensure Resident #76 did not have 5 razors in his room. The facility failed to ensure Resident #5's fall mat was beside his bed on 01/28/25 and 01/29/25. This failure could place residents at risk for injury, harm, and impairment. Findings included: 1. Record review of Resident #20's Admission Record indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone), Insomnia (a sleep disorder that makes it difficult to fall asleep, stay asleep, or get quality sleep), and Mild Cognitive Impairment (a condition where a person has more memory or thinking difficulties than others their age). Record review of Resident #20's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 07 which indicated severe cognitive impairment. The MDS also revealed Resident #20 was understood and understood others. The MDS reflected Resident #20 required assistance with activities of daily living. Record review of Resident #20's Care Plan , revealed a problem initiation on 9/18/2021 reflected Resident #20 had impaired cognition and was at risk for a further decline in cognitive and functional abilities related to age process. During an interview and observation on 1/27/25 at 10:55 a.m. revealed Resident #20 had a bottle of 91% Isopropyl Alcohol on his bedside dresser. He said he used it to clean between his toes. He said he had it for months. During an interview and observation on 1/27/25 at 3:30 p.m., LVN C said that residents were not allowed to have rubbing alcohol on their room. She said that there was a risk that a resident could get ahold of the alcohol and drink it. She said that residents could be placed at risk of poisoning if they drank rubbing alcohol. LVN C was observed removing the rubbing alcohol from the Resident #20's room. During an interview on 1/29/25 at 1:29 p.m., CNA A said that if she found a bottle of rubbing alcohol in a resident's room it should go to the nurse's station as those types of items were not allowed in a resident's room unsupervised. She said there was a risk of poisoning if a resident drank rubbing alcohol. During an interview on 1/29/25 at 2:09 p.m., the Director of Nurses said residents were not allowed to keep rubbing alcohol in their rooms. She said that all staff were responsible to ensure that those types of items were not in the resident's rooms. She said residents could be placed at risk of ingesting the alcohol and subsequent poisoning could occur. During an interview on 1/29/25 at 2:12 p.m., the Administrator said residents were not allowed to keep rubbing alcohol in their rooms. She said that all staff that entered a resident's room and saw an item they were not allowed to have should confiscate that item. She said that residents could be placed at risk of swallowing the alcohol. 45810 2. Record review of Resident #76's face sheet dated 01/29/25 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of mild cognitive impairment, high blood pressure, heart disease, and generalized muscle weakness. Record review of Resident #76's quarterly MDS dated [DATE] indicated he was understood and could understand others. The MDS also indicated he had a BIMS score of 14 which meant he was cognitively intact. The MDS also indicated Resident #76 required supervision assistance with personal hygiene. Record review of Resident #76's care plan dated 06/27/24 indicated he had impaired visual function with interventions for staff to anticipate his needs and keep the call light in reach when in room or in the bathroom. The care plan dated revised on 06/27/24 indicated he had ADL self-care deficit and required limited assistance with personal hygiene. During an observation and interview on 01/27/25 at 09:36 AM revealed Resident #76 was in his room sitting in his wheelchair looking at his phone. He had 5 blue razors on the back of his bathroom sink. Resident #76 said he completed his shaving when he needed to, and the staff would normally give him the razors and he kept them in his bathroom. During an observation on 01/28/25 at 09:07 AM revealed Resident #76 continued to have 5 blue razors on the back of his bathroom sink. During an interview on 01/29/25 at 3:24 PM CNA H said she was unsure why Resident #76 had the 5 blue razors in his bathroom. She said she had just returned to work on 01/29/25 from her off days. CNA H said that if she had given Resident #76 the razors to shave, she would have removed the razors when he was finished with the shave. CNA H said the failure placed a risk for other residents that wander to get the razors and possibly cut themselves. During an interview on 01/29/25 at 03:44 PM ADON F said her expectation was for the razors to be given to the resident when they were needed and when Resident #76 completed the shave the CNAs should have gotten them back from him and placed the razors in the sharp's container. ADON F said all staff were responsible for ensuring no residents had razors or hazardous items a left in the rooms or bathrooms. ADON F said the failure placed all residents at risk for cuts or injury. During an interview on 01/29/25 at 04:23 PM the DON said her expectation was for the CNAs to follow the care plan and tasks needed for Resident #76 and for the CNA to follow up with independent residents and discard the razors in the sharps container as they were supposed to be discarded. The DON said every staff was responsible for ensuring things like razors were not left out in the resident's room. The DON said the failure placed risk for injury for Resident #76 and other residents who wander may get the razors. During an interview on 01/29/25 at 04:47 PM The Administrator said her expectation was for the staff to monitor the razors when the residents had them and when the residents were finished using the razors they should have been removed and placed them the sharps container. The Administrator said the failure of leaving the razors out in Resident #76's bathroom placed a risk is for resident cuts or injuries. She said the facility had residents who may have wandered in #76's room and may not have known how to use the razors that were left out. She said she expected the staff who gave residents the showers and shaves were responsible for ensuring the razors were not left in the residents' rooms. 45879 3. Record review of Resident #5's face sheet, dated 01/29/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (loss of memory), stroke, anxiety (feelings of worry, fear, unease, and apprehension), and diabetes (when your blood sugar is too high). Record review of Resident 5's annual MDS assessment, dated 11/04/24, indicated Resident #5 sometimes understood and was sometimes understood by others. Resident #5's BIMS score was 00 indicating her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with her ADL's including transfers and bed mobility. The MDS indicated she had a fall in the prior assessment. Record review of Resident #5's comprehensive care plan dated 11/17/23 indicated, Resident #5 had the potential for falls related to Hemiplegia/Hemiparesis (a medical condition characterized by paralysis or weakness on one side of the body) affecting the left non-dominant side. The intervention was for staff to apply a fall mat at the bedside. Record review of Resident 5's incident report revealed she had a fall from her bed on 09/11/24 and 09/21/24. During an observation and interview on 01/28/25 at 9:11 a.m., revealed Resident #5 was in her bed with the fall mat beside the wall. No fall mat was noted beside her bed. CNA Q verified the fall mat was not beside Resident #5's bed and said the fall mat should be down because she was at risk of falling. She said she was her aide for the day but did not realize the fall mat was not down. During an observation and interview on 01/29/25 at 10:14 a.m., revealed Resident #5 was in her bed with the fall mat beside the wall. No fall mat was noted beside her bed. CNA R verified the fall mat was beside the wall and not her bed. She said she was her aide but did not realize the mat was beside the wall and not beside her bed. She said she was aware Resident #5 was at risk of falling because her family had informed her. During an interview on 01/29/25 at 3:20 p.m., ADON F said Resident #5 was supposed to have a fall mat beside her bed. She said the staff was responsible for ensuring the fall mat was beside her bed. She said the fall mat was supposed to be beside Resident #5's bed for safety. During an interview on 01/29/25 at 3:50 p.m., the DON said Resident #5 was supposed to have a fall mat beside his bed because she had a fall and was at risk for further falls. She said the nursing staff was responsible for ensuring the fall mat was beside her bed. She said the fall mat was for fall prevention and to prevent an injury. During an interview on 01/29/25 at 4:21 p.m., the Administrator said if Resident #5 had a care plan for a fall mat to be at her bedside, then nursing staff was responsible for ensuring it was beside her bed. She said this resident might have had a fall prior and this was put in place to reduce any injury from further falls. Record review of the facility policy titled, Fall Management System, dated 02/19/21 indicated, It is the policy of this facility that each resident will be assessed to determine his or her risk for falls, and a plan of care implemented based on the resident's assessed needs. A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level. A fall without injury is still a fall. Procedure: A, Identifying: #3. A care plan is implemented for residents at risk profile B., Analysis: #5 Preventative interventions are reviewed, evaluated, and implemented to reduce the reoccurrence of falls. E, Investigation: #2 Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable such as chair alarm, low bed, etc

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for food safety requirements. The facility failed to prepare fried eggs with pasteurized eggs. The facility failed to ensure the kitchen staff had an operable paper towel dispenser to wash their hands instead of placing the paper towel roll on the clean dish rack. The facility failed to ensure the Dietary Manager in training and the [NAME] Helper properly performed hand hygiene while assisting with preparing resident meals in the kitchen. These failures could place residents at risk for foodborne illness. Findings included: 1.During an observation on 01/27/24 at 8:45 AM, the refrigerator had 2 (30 count) flats and 1/3 of a (30 count) flat of large white eggs. The white eggs did not have the P stamped on the eggs indicating pasteurized eggs. During an interview on 01/27/25 at 8:50 AM, the Dietary Manager said she prepared the orders in the kitchen and had the pasteurized eggs on a do not substitute list and she did not realize they received the unpasteurized eggs. During a record review and interview on 01/28/25 at 9:35 AM, the Dietary Manager provided the dietary cards for the residents who ate fried eggs. The listing indicated there were 8 residents who received fried eggs. The Dietary Manager said the unpasteurized eggs should not be used in the kitchen. The Dietary Manager said using the unpasteurized eggs could make the residents sick. Record review of a grocery delivery listing dated 01/21/25 provided by the DM on 01/29/25 indicated the facility received one box with 15 dozen eggs (large grade AA white) that were substituted because the vendor was out of the pasteurized eggs. During an interview on 01/29/25 at 3:53 PM, ADON E said her expectation was for the kitchen to only serve pasteurized eggs. She said the kitchen was responsible for ensuring they only had pasteurized eggs and it placed the residents at risk for infection. During an interview on 01/29/25 at 4:33 PM, the DON said her expectation was for the kitchen to not use any unpasteurized eggs and the failure placed the residents at a risk for infection. The DON said the Dietary Manager was responsible for ensuring the eggs were correctly ordered as unpasteurized. During an interview on 01/29/25 at 4:51 PM, the Administrator said the Dietary Manager was responsible for ensuring the residents received unpasteurized eggs. She said the Dietary Manager should have ensured the correct unpasteurized eggs were received. The Administrator said she would be checking for the correctly ordered eggs. The Administrator said the failure placed the residents at risk for infection from the bacteria in eggs or allergies. 2. During an observation on 01/27/25 at 11:43 AM, the Dietary Manager in training washed her hands and turned the faucet off prior to grabbing her paper towels that were hanging on top of a clean dish rack to dry her hands. When she grabbed the paper towels water splashed on the clean dishes. During an observation on 01/27/25 at 11:58 AM, [NAME] Helper L washed his hands for less than 20 seconds and turned the faucet off prior to grabbing paper towels that were hanging on top of a clean dish rack to dry his hands prior to preparing resident trays for lunch. When he grabbed the paper towels water splashed on the clean dishes. During an observation on 01/28/25 at 9:35 AM, the Dietary Manager said she had asked the previous administrator, but the paper towel holder was never replaced. She said she understood the paper towel being placed on the clean rack was a risk for infection for the residents. During an interview on 01/28/25 at 9:44 AM, [NAME] L said the paper towel holder had been broken for months. She said the Dietary Manager had always enforced proper handwashing but the previous Administrator told her the broken paper towel holder was not in their budget. During an interview on 01/29/25 at 3:58 PM, ADON E said the paper towel holder being broken was unacceptable and should have been in working order and used correctly. She said that places a risk for infection control. ADON E said the dietary staff were responsible and should have notified the need for correct paper towel or purchase a new paper towel dispenser. During an interview on 01/29/25 at 4:30 PM, the DON said her expectation was for the kitchen to have a properly working paper towel holder to use for hand washing and to perform handwashing properly. The DON said she was not aware that the paper towel holder was broken but the staff and nursing administration were responsible for ensuring the staff were washing hands correctly. The DON said the failure placed a risk for infection for all residents. During an interview on 01/29/25 at 4:54 PM, the Administrator said she expected the equipment to be working properly. She said the Maintenance Director and the Dietary Manager were responsible for ensuring the paper towel holder were operable. The Administrator said the failure placed a risk for infection control. 3. During an observation on 01/27/25 at 11:43 AM, the Dietary Manager in training washed her hands and turned the faucet off prior to grabbing her paper towel to dry her hands. During an observation on 01/27/25 at 11:58 AM, [NAME] Helper L washed his hands for less than 20 seconds and turned the faucet off prior to grabbing paper towel to dry his hands prior to preparing resident trays for lunch. During an observation and interview on 01/28/25 at 9:42 AM, [NAME] Helper L washed his hands for less than 20 seconds and turned the faucet off prior to grabbing paper towel to dry his hands. [NAME] Helper L said he realized he washed his hands improperly and he thought he was supposed to wash his hands for 2 minutes. He then began to wash his hands again and turned the faucet off prior to grabbing his paper towel to dry his hands. He said the last time he had handwashing proficiency was during a COVID outbreak, but he guessed he was washing his hands correctly. He said the failure could place resident at risk for germs being passed and infections. During an observation and interview 01/28/25 at 9:50 AM, the Dietary Manager in training washed her hands and turned the faucet off prior to grabbing paper towels to dry her hands. She said she had just realized what she was doing and just got in a hurry and forgot. She said she did recall improperly washing her hands on 01/27/25. The Dietary Manager in training said the failure could cause infections to residents. During an interview on 01/29/25 at 3:55 PM, ADON F said she expected proper handwashing to be performed in the kitchen by all staff. She said the Dietary Manager and Nursing Management were responsible for ensuring staff wash their hands properly. The ADON F said the failure placed a risk is for infection and germs to be shared to all residents. During an interview on 01/29/25 at 4:30 PM, the DON said her expectation was for the kitchen to perform handwashing properly. She said the kitchen staff and nursing staff were responsible for ensuring they were washing hands correctly. The DON said the failure placed a risk is for infection for all residents. During an interview on 01/29/25 at 4:55 PM, the Administrator said handwashing performed properly was expected by all staff. She said the Nursing management (DON and ADONs) were responsible for ensuring all staff performed proper handwashing. The Administrator said the failure placed a risk for all resident to get infections and germs. Record review of the facility policy Food Safety and Sanitation Plan revised on 11/2017 indicated: Policy: It is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur .Basis of Control .2. Receiving-When food, food products or beverages are delivered to the facility, the staff will inspect items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. Delivery will be checked against the purchase order .Eggs may be received at 45 degrees or below and shall be pasteurized .13. Personal Hygiene Practices-through hand washing is required . Record review of FDA Food Code 2022 Chapter 2. Accessed on 02/11/2025 at 11:20 AM indicated: Management and Personnel 2-103.11 Person in Charge. The PERSON IN CHARGE shall ensure that: (D) EMPLOYEES are effectively cleaning their hands, by routinely monitoring the EMPLOYEES' handwashing . Hands and Arms 2-301.12 Cleaning Procedure .food emloyees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or amrs for at least 20 seconds .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 3 of 8 resident personal refrigerators reviewed for food safety (Resident #62, Resident #61, and Resident #56). 1. The facility failed to ensure the refrigerator for Resident #62 did not contain expired milk. 2. The facility failed to ensure the refrigerator in Resident #61's room did not contain expired strawberry yogurt. 3. The facility failed to ensure the refrigerator for Resident #56 did not contain expired baked beans and expired macaroni and cheese. This failure could place resident at risk for food borne illnesses. Findings included: 1. Record review of Resident #62's face sheet, dated [DATE], indicated she was an [AGE] year-old female, admitted to the facility originally on [DATE], and readmitted on [DATE]. Her diagnoses included dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life and activities), and biliary acute pancreatitis (a condition where the pancreas becomes inflamed due to gallstones). Record review of Resident #62's significant change MDS assessment, dated [DATE], indicated she had a BIMS score of 0, which indicated severe cognitive impairment. She did not exhibit behaviors of rejection of care or wandering. She required moderate assistance with some activities of daily living. During an observation on [DATE] at 09:11 AM, Resident #62 was in her room lying in bed resting. There was 1 container of expired whole milk (dated [DATE]) in her refrigerator. During an observation on [DATE] at 02:18 PM, the container of expired whole milk was still in Resident #62's refrigerator. 2. Record review of Resident #61's face sheet, dated [DATE], indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life and activities), major depressive disorder (common mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior). Record review of Resident #61's quarterly MDS assessment, dated [DATE], indicated his BIMS score was 13, which indicated intact cognition. He did not exhibit behaviors of rejection of care or wandering. He was independent with all of his activities of daily living, except for bathing, which he required set-up assistance. During an observation and interview on [DATE] at 09:21 AM, Resident #61 was lying in bed in his room watching TV. He said the refrigerator in the room is his roommate's, who was out of the facility in the hospital. He said no one has looked at the refrigerator in a while. There was 1 expired strawberry yogurt (dated [DATE]) in the refrigerator. During an observation on [DATE] at 02:15 PM, the refrigerator in Resident #61's room still had the expired strawberry yogurt in the refrigerator. During an observation on [DATE] at 09:00 AM, the refrigerator in Resident #61's room still had the expired strawberry yogurt in the refrigerator. 3. Record review of Resident #56's face sheet, dated [DATE], indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic diastolic heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), osteoarthritis (common type of joint disease that causes pain, stiffness, and swelling in the joints), and dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life and activities). Record review of Resident #56's quarterly MDS assessment, dated [DATE], indicated she had a BIMS score of 15 which indicated intact cognition. Resident #56 did not exhibit behaviors of rejection of care or wandering. During an observation on [DATE] at 09:31 AM, Resident #56 was lying in bed in her room watching TV. Inside the refrigerator next to her bed there was 2 containers of expired baked beans (1 dated [DATE] and 1 dated [DATE]), and 1 container of expired macaroni and cheese (dated [DATE]). During an observation on [DATE] at 11:35 AM, all three expired containers of food were inside Resident #56's refrigerator. During an observation on [DATE] at 02:16 PM, all three expired containers of food were inside Resident #56's refrigerator. During an observation on [DATE] at 09:02 AM, all three expired containers of food were inside Resident #56's refrigerator. During a group interview with both ADONs on [DATE] at 01:27 PM, ADON F said she expected the staff to go through the resident fridges and throw away the expired food. ADON E said the risk was that the residents could potentially get sick from the expired food. ADON E said the receptionist was responsible for throwing away the expired foods. ADON E said she expected the CNAs to also check the refrigerators. ADON F the usual receptionist was not working this day. During an interview on [DATE] at 01:40 PM, the DON said she expected the staff to check the fridges for expired food. She said the risk was that ingestion of expired food could cause sickness. During an interview on [DATE] at 01:48 PM, the Administrator said she expected the staff to clean the fridges and throwaway the expired food. She said the risk to the residents was that they may get sick if the expired foods were consumed. Record review of the facility's policy, Resident Refrigerators, last revised [DATE], stated: .Dormitory-sized refrigerators are allowed in a resident's room under the following conditions: a. The refrigerator is inspected by maintenance personnel and deemed safe prior to use b. The refrigerator maintains proper temperatures. c. Sufficient space exists in the resident's room to accommodate the refrigerator without requiring the use of extension cord or multi-plug adapter. d. The resident complies with the facility's policy for use of the refrigerator . .Staff shall inspect the refrigerator weekly, clean as needed, and discard any foods that are out of compliance . .Foods with use-by dates shall be discarded accordingly . .Noncompliance with safety and sanitation requirements of this policy will result in the removal of the refrigerator from the resident's room .

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 3 of 20 residents (Resident #47, Resident #5, and Resident #54) reviewed for infection control practices. The facility failed to ensure latex gloves, resident's clothes, briefs, and wet clothes were not left on the floor of the resident #47's room . The facility failed to ensure Resident #54's gastrostomy tube piston syringe was properly changed out and covered in the provided plastic bag on 01/27/25 and 01/28/25. The facility failed to ensure RN S wore a gown when she flushed and disconnected Resident #5 gastrostomy tube (also known as a G-tube, is a thin, flexible tube inserted through the abdominal wall directly into the stomach used to provide nutrition and medications directly to the stomach when a person is unable to eat or drink adequately by mouth). These failures placed residents at risk for cross contamination and infection. Findings include: 1. Record review of a face sheet dated 07/24/24 revealed Resident #47 was an [AGE] year-old female admitted on [DATE] with diagnoses including Dementia (a general term for a group of brain conditions that cause a decline in mental abilities), Muscle Weakness (a loss of muscle strength that makes it difficult to move or contract muscles), Hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone). Record review of an admission MDS dated [DATE] revealed Resident #47 was understood and understood others. The MDS revealed Resident #47 had a BIMS (cognitive/mental status) of 02 which indicated severe cognitive impact. The MDS indicated Resident #47 needed assistance with most activities of daily living. Record review of a care plan initiated on 10/26/2023 and revised on 11/17/2023 revealed Resident #47 had an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. During an observation on 1/27/25 at 10:28 a.m., Resident #47's room had latex gloves that had been doffed appropriately, as if they had been used in a procedure, laying on the floor, folded clothes stacked on top of each other laying on the floor with a clean disposable adult brief laying open next to them, and a pile of wet clothes in the bathroom floor. Resident #47 was unable to be interviewed by surveyor. During an interview on 1/29/25 at 1:29 p.m., CNA A said that used personal protective equipment, including gloves, should not be left on the floor of a resident's room. She said there were trashcans and biohazard trashcans to throw away used personal protective equipment depending on how it was used. She said clothes and adult briefs are not to be left on the floor they should be stored in cabinets or dressers. She said that clothes should not be left on the floor of the resident's restroom as they too have an appropriate place to store them before they are sent to laundry. She said the clothes would be bagged and stored in a plastic bin. She said residents could be placed at risk for infection if they came into contact with soiled personal protective equipment, briefs, or clothes. During an interview on 1/29/25 at 1:37 p.m., LVN B said that all personal protective equipment should go into a trashcan once it has been used. She said clean clothes should be stored in cabinets or drawers. She said that clean briefs should not be stored on the floor. She said that there is a risk for infection when used personal protective equipment, clothes, and briefs were left on the floor. During an interview on 1/29/25 at 2:04 p.m., the Director of Nursing said used personal protective equipment goes into a biohazard bag or a trashcan. She said facility policy says to keep trash picked up including personal protective equipment. She said clean clothes and briefs goes into the resident's cabinets. She said dirty clothes are to be bagged by CNAs and sent to laundry. She said residents could be placed at risk of infection if they come into contact with used personal protective equipment or dirty clothes. She said there is a risk of contaminating clothes and clean briefs if they are just left on the floor. She said it was all staff's responsibility to ensure that resident's rooms were clean, and they were not exposed to infection risks. During an interview on 1/29/25 at 2:12 p.m., the Administrator said based on her experience personal protective equipment that had been used in a procedure goes into a biohazard bag or trashcan depending on how it was used. She said that personal protective equipment is not disposed of by staff on the floor. She said clean clothes are stored in the dresser drawer as well as the briefs. She said residents could be placed at risk for infection if they came into contact with used personal protective equipment. 45810 2. Record review of Resident #54's face sheet dated 01/29/25 indicated he was an [AGE] year-old male who originally admitted to the facility on [DATE] with the diagnoses dementia (a general decline in cognitive abilities that affect's a person ability to perform ADLs), cerebral infarction ( disrupted blood flow to the brain), high blood pressure, attention to gastrostomy tube, and malnutrition (lack of nutrients in the body). Record review of Resident #54's annual MDS dated [DATE] indicated resident was rarely understood and rarely could understand others. The MDS also indicated he had a BIMS score of 0 and had short-term and long-term memory problems. The MDS indicated he required total assistance from staff for all ADLs and required 51% or more of his calories through a feeding tube. Record review of Resident #54's care plan revised on 10/06/23 indicated he required the use of a feeding tube with interventions to administer tube feeding and water flushes as ordered. Record review of Resident #54's order summary report as of 01/29/25 indicated he had an order for: Change and date piston syringe every night shift for feeding tube with a start date of 11/28/2023 and no end date. Record review of Resident #54's administration record dated January 2025 indicated LVN U signed the record for changing and dating the gastrostomy syringe on 01/26/25. During an observation on 01/27/25 at 09:29 AM, Resident #54 was lying in bed and had his gastrostomy tube piston syringe lying on his bedside table unbagged and dated 1/26/25 at 0600 with white sediment in the tip. During an observation on 01/27/25 at 02:39 PM, Resident #54's gastrostomy tube piston syringe was lying on the bedside table uncovered and no bag in site and continued to have white sediment in the tip. During an observation on 01/28/25 at 09:06 AM, Resident #54's gastrostomy tube syringe was lying on bed side table dated 1/28/25 but laying outside the plastic bag. During an interview on 01/29/25 at 03:50 PM, ADON F said her expectation was for the night nurse to have changed and dated the piston syringe and all nurses should have rinsed the gastrostomy piston syringe after use, placed in the plastic bag and hang it properly. ADON F said the failure placed Resident #54 at risk for infection. During an interview on 01/29/25 at 04:28 PM, the DON said her expectation were for the gastrostomy piston syringes to be changed out every night by the night nurses and bagged and dated. The charge nurse should always keep the syringes in the plastic bag and the charge nurses were responsible for ensuring the gastrostomy piston syringe was kept in the bag. The DON said the failure placed a risk for Resident #54 to get an infection because the gastrostomy piston syringe was not rinsed or properly contained. During an interview on 01/29/25 at 04:49 PM, the Administrator said the night nurses should have been following doctor's orders and the gastrostomy piston syringe should have been changed out, dated, and bagged daily. She said the failure placed the risk for infection. During a telephone interview on 01/29/25 at 05:23 PM, LVN U said she thought she changed out the piston syringe for Resident #54. She said it must have been misplaced. She said the failure placed a risk for Resident #54 to have bacterial build up in the syringe and cause infections. 45879 3.Record review of Resident #5's face sheet, dated 01/29/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dysphagia (swallowing difficulties), dementia (loss of memory), stroke, anxiety (feelings of worry, fear, unease, and apprehension), and diabetes (when your blood sugar is too high). Record review of Resident #5's annual MDS assessment, dated 11/04/24, indicated Resident #5 sometimes understood and was sometimes understood by others. Resident #5's BIMS score was 00 indicating her cognition was severely impaired. The MDS indicated Resident #5 required extensive assistance with her ADLs. The MDS indicated she had a feeding tube. Record review of Resident #5's Physician order dated 04/09/24 indicated: Enhanced barrier precautions in place every shift. Record review of Resident #5's Physician order dated 05/25/24 indicated: Glucerna 1.2 via tube feeding (gastrostomy tube) at 60 milliliters per hour x 22 hours. Record review of Resident #5's comprehensive care plan dated 04/02/24 indicated, Resident #5 required Enhanced Barrier Precautions related to her feeding tube. The intervention was for staff to wear gowns and gloves during high-contact resident care activities. During an observation on 01/28/25 at 9:37 a.m., Resident #5 had a sign for Enhanced Barrier Precautions also known as EBP which indicated they recommended staff to wear gowns and gloves while providing care for any resident who had any of the following: 1) infection or 2) a wound or indwelling medical device, even if the resident was not known to be infected, above her bed. During an observation on 01/28/25 at 9:46 a.m., RN S came into Resident #5's room flushed and disconnected her gastrostomy tube without wearing a gown. During an interview on 01/28/25 at 4:06 p.m., RN S said she flushed and disconnected Resident #5's gastrostomy tube but did not put on the proper PPE. She said she was supposed to wear a gown and gloves, but she only wore gloves. She said Resident #5 was on EBP because of the risk of getting infected. During an interview on 1/29/25 at 3:50 p.m., the DON said she expected staff to follow the precautions for EBP. She said she had given several in-services on infection control. She said staff should wear gloves and gowns when giving meds or flushing a gastrostomy tube. She said she expected RN S to wear her gown and gloves when flushing Resident #5's gastrostomy tube. She said she was responsible for ensuring all staff wore the required PPE. She said Resident #5 was at risk of infection because she had an opening to her skin (gastrostomy). During an interview on 01/29/25 at 4:21 p.m., the Administrator said all staff were responsible for following the infection control practices. She said she expected the nurse to wear the proper PPE such as a gown and glove when in a resident's room who required EBP. She said they would have to do another in-service and monitor for proper PPE usage. The administrator said if they were not wearing the appropriate PPE then they could spread germs or infection to someone else. Record review of the facility policy titled, Infection Control Plan: Overview, from the Infection Prevention and Control Program revised 11/6/24, indicated, This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted while providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. 6.Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expands the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. During high-contact resident care activities: 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. b. Clean linen shall be always separated from soiled linen. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the linen shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom.

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 6 (Resident #72) residents reviewed for call lights. The facility failed to ensure Resident #72's call button was within reach while Resident #72 was in her bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: Record review of Resident #72's face sheet, dated 01/25/24 indicated Resident #72 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Dementia (memory loss), high blood pressure, and Gastroesophageal Reflux Disease also known as GERD (is a chronic digestive condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms). Record review of Resident #72's annual MDS assessment, dated 01/10/25, indicated that she understood and was understood by others. Resident #72 had a BIMs score of 03 which indicated she was cognitively impaired. Resident #72 required assistance with bathing. The MDS indicated she was occasionally incontinent of bowel and bladder. Record review of Resident #72's Comprehensive Care Plan dated 02/20/24 reflected Resident #72 had the potential for falls related to unsteady gait at times. The intervention was for staff to place the resident's call light within reach and encourage the resident to use it for assistance as needed. During an observation and interview on 01/27/25 at 9:09 a.m., revealed Resident #72 was sitting on the side of her bed. No call light was noted within reach. A call light was hanging on the wall behind the room divider curtain. Resident #72 said she did not know where her call light was. SHe, she said if she needed anything she would walk to the door to alert staff. During an observation on 01/27/25 at 2:38 p.m., revealed Resident #72 was walking back from the bathroom with her walker and sat on the side of her bed. The call light was hanging on the wall behind the room divider curtain. During an observation and interview on 01/27/25 at 2:44 p.m., revealed the Treatment Nurse entered Resident #72's room and said she did not see her call light. She then looked behind the curtain and saw the call light hanging against the wall. She said the call light should be within Resident #72's reach in case she needed it. She said all staff was responsible for ensuring the call light was within reach. She said the risk could be the resident would not get help if needed. During an interview on 01/29/25 at 03:50 p.m., ADON #2 said all residents should have a call light and should always be within reach. She said if a resident did not have their call light it could lead to falls or the resident not getting the help they need. During an interview on 01/29/25 at 03:50 p.m., the DON said she expected call lights to be accessible to the residents. She said all staff should check on the residents and ensure they have a call light and that the call light was within reach. The DON said failure to have or keep the call lights within reach could cause a resident to fall. During an interview on 01/29/25 at 04:21 p.m., the Administrator said she expected all call lights to be working and within reach of each resident. She said all staff should ensure the call lights were within reach. She said call lights were a way for the residents to communicate if they needed anything. Record review of the facility policy title, Call Light Response, dated 02/10/21 indicated, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or a centralized location to ensure appropriate response. #5 With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of the resident and secure as needed.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #32) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #32. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (major depressive disorder and post-traumatic stress disorder) were present upon Resident #32's admitted on 04/21/22. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #32's face sheet, dated 01/27/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a mental illness that causes a persistent low mood and loss of interest in activities) with an onset date of 04/25/19, and post-traumatic stress disorder (a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances) with an onset date of 02/23/21. Record review of Resident #32's annual MDS assessment, dated 12/27/24, indicated she had a BIMS score of 15, which indicated intact cognition. The assessment further indicated she received an antianxiety and an antidepressant medication during the assessment window. Record review of Resident #32's PASRR Level 1 Screening, dated 12/18/24, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #32 did not have a mental illness. During an interview on 01/29/25 at 09:40 AM, MDS coordinator D said she did not think Resident #32 would be PASRR positive if a PL1 was submitted with mental illness marked yes. She said Resident #32 did not have a recent hospitalization related to her mental illness so she would likely not qualify for PASRR services. During an interview on 01/29/25 at 10:09 AM, MDS coordinator D said she did not think the PL1 form dated 12/18/24 should have been marked yes for mental illness because the form was completed due to a change of ownership. She said since she thought that Resident #32 was unlikely to become PASRR positive she did not think the form needed to be fixed and resubmitted. She said if the local authority had come out to the facility, she did not think Resident #32 would have been deemed PASRR positive for mental illness. During an interview on 01/29/25 at 01:48 PM, the Administrator said she had worked at the facility for 3 days. She said she was not clinical and was not sure how to answer this surveyor's questions related to PASRR. Record review of the facility's policy, Preadmission and Screening Resident Review (PASRR) Rules, last revised July 2023, stated: .It is the intent of [corporate name] to meet and abide by all state and federal regulations that pertain to resident preadmission and screening resident review (PASRR) rules . .Referring Entity completes a PL1 . .if negative: .If the resident has a qualifying MI (mental illness) diagnosis and the NF feels the resident should be positive they should talk to the referring entity and ask them to correct the PL1 .

Based on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 6 residents (Residents #74) reviewed for ADL care. The facility failed to ensure Resident #74 was showered on 01/01/25, 01/06/25, 01/13/25, 01/15/25 and 01/20/25. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Findings included: Record review of Resident #74's face sheet, dated 01/29/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included stroke, depression (sadness), diabetes, and high blood pressure. Record review of Resident #74's quarterly MDS assessment, dated 11/06/24, indicated Resident #74 understood and was understood by others. His BIMs score was a 14, which indicated he was cognitively intact. The MDS indicated he required touch assistance for showering, limited assistance for dressing, and maximum assistance for transferring. Record review of the care plan dated 08/12/24 indicated Resident #74 had an ADL self-care performance deficit and was at risk for not having his needs met in a timely manner related to Hemiplegia (a medical condition characterized by paralysis or weakness on one side of the body) affecting the right dominant side and weakness. The interventions were for staff to assist with bathing. During an interview on 01/28/25 at 12:17 p.m., Resident #74 said he was not getting his showers 3 times a week. He said he was lucky to get a shower 1 time a week. He said he had told the Administrator about missing his showers. He said staff would start giving him showers 3 times a week for a while and then would slack off again. He said he would like to get his showers 3 times a week. Record review of Resident #74's point of care history dated 01/01/25-01/31/25, did not indicate Resident #74 was bathed on the following dates: 01/01/25, 01/06/25, 01/13/25, 01/15/25 and 01/20/25. During an interview on 01/29/25 at 11:08 a.m., CNA O said she had given Resident #74 a shower on her day shifts several times. She said he was a Monday, Wednesday, and Friday night shift shower. She said he would ask her to shower him because he had not received his shower on the night shift. During an interview and record review on 01/29/25 at 10:36 a.m., LVN P said showers should be given according to the shower schedule. LVN P said A beds (beds closer to the door) were day shift showers and B beds (closest to the window) were night shift showers. He said periodically they would have residents who would say they did not receive their baths, but staff would make sure they got them. LVN P said the nurses were responsible for ensuring the baths were provided. He said when the aides gave a shower, they would bring the shower sheets so that the nurses could sign the shower sheets indicating the shower had been given and place the signed sheet in the shower book. LVN P and the state surveyor looked through the shower book and could not locate any shower sheets for Resident #74 for January 2025. He said he was not aware Resident #74 was not receiving his showers. During an interview on 01/29/25 at 3:20 p.m., ADON F said Resident #74 should be getting his showers 3 times a week. She said she was not aware of Resident #74 refusing his showers. She said if he did refuse his showers then the charge nurse should document the refusal in his chart. She said failure to receive a shower, or a missed shower could lead to skin issues. During an interview on 01/29/25 at 3:50 p.m., the DON said she expected showers to be given according to the shower schedule. She said the staff was aware of the shower days because it was on point of care and the task assignment. She said she was unaware of Resident #74 missed showers. She said if a resident refused his/her shower(s) then the charge nurse was supposed to document it in his/her chart and depending on how many refusals notify the responsible party. She said showers should be given for cleanliness and prevention of skin breakdown. During an interview on .01/29/25 at 4:21 p.m., the Administrator said she started at the facility 01/27/25. She said she expected the residents to receive their baths and expected the staff to document if they did not receive them. The Administrator said the charge nurse was responsible for ensuring the showers were completed. She said showers were given for sanitary and infection reasons. Record review of the facility policy titled, Resident Showers, dated 02/11/22 indicated, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 residents (Resident's #27 and Resident #290) reviewed for respiratory care. 1. The facility failed to ensure staff followed the policy for dating the oxygen tubing and bagging the CPAP (a machine that uses mild air pressure to keep breathing airways open while you sleep) on 01/27/25 and 01/28/25 for Resident #27. 2. The facility failed to ensure staff followed the policy for bagging and dating Resident #290's Handheld nebulizer on 01/27/25 and 01/29/25. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Finding included: 1.Record review of Resident #27's face sheet, dated 01/29/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), Dementia (memory loss), and diabetes. Record review of Resident #27's significant change in condition MDS assessment, dated 12/12/24, indicated Resident #27 was understood and usually understood by others. The MDS assessment indicated she had a BIMS score of 07 indicating she was severely cognitively impaired. Resident #27 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS indicated she required oxygen. Record review of Resident #27's physician's order dated 09/09/24 indicated Change oxygen tubing and humidifier bottle every Sunday night and ensuring the tubing was dated when changed. Record review of Resident #27's physician's order dated 10/08/24 indicated Apply oxygen at 2-3 Liter per minute via nasal cannula. Record review of Resident #27's physician's order dated 10/08/24 indicated CPAP at night with settings 5 expiratory pressure, and 15 inspiratory pressures at bedtime for sleep apnea (cessation of breathing) related to acute respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues). Record review of Resident #27's comprehensive care plan, dated 08/08/24, indicated Resident #27 required oxygen therapy routinely or as needed related to ineffective gas exchange secondary to respiratory illness. The intervention of the care plan was for staff to administer oxygen as ordered. Record review of Resident #27's comprehensive care plan, dated 11/20/24, indicated Resident #27 Refuses CPAP at night at times and takes off the mask at night. The intervention was for staff to continue to encourage the resident to wear her CPAP mask. During an observation on 01/27/25 at 10:01 a.m., revealed Resident #27 was in her bed with her eyes closed. Resident #27 had oxygen tubing on the back of her wheelchair bagged but not dated and her CPAP mask sitting on the bedside table not bagged. During an observation on 01/28/25 at 9:05 a.m., revealed Resident #27 was in her bed with her eyes closed. Resident #27's CPAP mask was sitting on the bedside table not bagged. 2. Record review of Resident #290's face sheet, dated 01/29/25 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Dementia (loss of memory), anxiety (a persistent worry, fear, and nervousness that can interfere with daily life), and sleep disorder (a medical condition that affects how well a person sleeps). Record review of Resident #290's admission MDS assessment, dated 01/26/25, indicated Resident #290 understood others and was understood by others. Resident #290's BIMS score was 09, which indicated she was moderately cognitively impaired. The MDS indicated Resident #290 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up for eating. The MDS during the 7-day look-back period did not indicate Resident #290 was receiving handheld nebulizers. Record review of Resident #290 physician's orders dated 01/27/25 indicated, Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML) 0.083% (Albuterol Sulfate) 1 dose via mask every 6 hours as needed for shortness of breath. Record review of Resident #290 physician's orders dated 01/28/25 indicated, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally three times a day for cough/shortness of breath for 3 Days. Record review of Resident#290's care plan dated 01/20/24 did not indicate any plan of care for handheld nebulizers. During an observation on 01/27/25 at 10:18 a.m., revealed Resident #290 had her handheld nebulizer sitting on the nightstand not bagged or dated. During an observation and interview on 01/29/25 at 2:38 p.m., LVN P verified Resident #290's HHN was sitting on the bedside table undated or bagged. He said he had given Resident #290 a breathing treatment earlier but did not ensure the HHN was placed back in a bag. He said the HHN should be dated and bagged when not in use. During an interview on 1/29/25 at 3:50 p.m., the DON said she expected oxygen and HHN tubing to be dated and bagged when not in use. She said the CPAP mask should be bagged when not in use. She said the nursing staff should ensure the items were dated and the tubing bagged, and the administrative nurses should make rounds to ensure the items were dated and bagged. She said they should be bagged to prevent infection control issues. During an interview on 01/29/25 at 4:21 p.m., the Administrator said oxygen and HHN tubing should be bagged and dated. She said the nurses needed to ensure they were changed, dated, and bagged when not in use. She said those things were done to prevent infection. Record review of the facility policy titled, Oxygen Administration dated 09/12/14 indicated, Policy: to describe methods for delivering oxygen to improve tissue oxygenation. Completion of procedure: #2 When oxygen is not in use, store oxygen tubing and nasal cannula or mask in a small plastic bag. #3 Change disposable parts once a week and label with a date (tubing plastic bag mask or Cannula).

Based on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 5.56%, based on 2 errors out of 36 opportunities, which involved 2 of 6 residents (Resident #37 and Resident #80) reviewed for medication administration. 1. The facility failed to administer Resident #37's eye drops ophthalmic solution 0.05% Tetrahydrozoline HCL medication (used for temporary treatment of eye redness and irritation.) as ordered. 2. The facility failed to administer Resident #80's Aspirin chewable 81mg medication (used to help prevent a heart attack or clot-related stroke) as ordered. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #37's face sheet, dated 01/28/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included intracranial injury (damage to the brain caused by an external force), and hemiplegia (a medical condition characterized by paralysis or weakness on one side of the body). Record review of Resident #37's quarterly MDS assessment, dated 01/15/25, indicated he had a BIMS score of 03, which indicated severe cognitive impairment. He did not exhibit behaviors of rejection of care or wandering. Record review of Resident #37's physician's orders, dated 01/28/25 indicated this order: *Eye Drops Ophthalmic Solution 0.05% Tetrahydrozoline HCL. Instill 1 drop in both eyes in the morning for dry eyes. The start date was 10/23/24. Record review of Resident #37's MAR for January 2024, dated 01/28/25, indicated the eye drops tetrahydrozoline HCL were not administered on 01/28/25. The MAR gave a reason code of 9 which indicated other / see nurse notes. Record review of Resident #37's progress notes, dated 01/28/25, indicated a note written by Medication Aide G that stated: Eye Drops Ophthalmic Solution 0.05% Instill 1 drop in both eyes in the morning for dry eyes[.] Med is not in the [building] but has been ordered During an observation and interview on 01/28/25 at 7:33 AM, Medication Aide G did not administer Resident #37's eye drops medication. Medication Aide G said she did not have the eye drops on her cart. She said the drops have been ordered from the pharmacy, but they have not yet been delivered to the facility. She said she notified the nurse that she was unable to give the eye drops. She said the medication would likely be delivered that evening. 2. Record review of Resident #80's face sheet, dated 01/28/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die) and intracardiac thrombosis (a condition where a blood clot forms within the heart chambers). Record review of Resident #80's quarterly MDS assessment, dated 11/27/24, indicated he had a BIMS score of 15, which indicated intact cognition. He did not exhibit behaviors of rejection of care or wandering. Record review of Resident #80's physician's orders, dated 01/28/25, indicated this order: *Aspirin low dose oral tablet chewable 81mg. Give 1 tablet by mouth in the morning for heart health. The start date was 08/22/24. Record review of Resident #80's MAR for the month of January 2025, dated 01/28/25, indicated he was administered the Aspirin 81mg medication on 01/28/25. During an observation on 01/28/25 at 7:45 AM, Medication Aide G administered aspirin 81mg Enteric Coated 1 tablet to Resident #80. During an interview on 01/28/25 at 3:41 PM, Medication Aide G said she did not realize she had given the enteric coated form instead of the chewable form of the aspirin. She said she did not think there was a risk to the resident because of him receiving the wrong form. She said she should have given the chewable tablet that was ordered. During a group interview with both ADONS on 01/29/25 at 1:27 PM, ADON E said she expected the eye drops medication to have been ordered and available for the resident to have. ADON E said she expected the medication aides to administer the correct form of the aspirin medication. ADON F said the risk to the resident was that the resident was not receiving the benefit of the medication if they are not administered it. During an interview on 01/29/25 at 1:40 PM, the DON said she expected the staff to have the medication needed on the cart and to let someone know so they can get it in the building if they do not have stock of the medication. she said she expected the med aide to give the proper form of the medications. During an interview on 01/29/25 at 1:48 PM, the Administrator said her expectation was that the residents get their medications as ordered and in the form they were ordered. She said the risk would be that the resident did not get the intended benefit of the eye drops when it was not administered. During an interview on 01/29/25 at 3:43 PM, the DON said they do not have a policy for ordering medications. Record review of the facility's policy, Medication - Treatment Administration and Documentation, last revised on 02/02/14, stated: .Medication are administered according to manufacturers guidelines unless otherwise indicated by physician order . .Process 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments 2. Verify administration accuracy by checking the medication with the MAR three (3) times 3. Verify and provide medication or treatment focused assessment .as indicated by manufacturers guidelines or physician orders 4. Administer the medication according to the physician order .

Based on observations, interviews, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 21 residents (Resident #56) reviewed for storage of medication. The facility failed to securely store medications, Resident #56 had a white cream and green powder substances found at her bedside inside medicine cups. These failures could place residents at risk for adverse reactions to medications or overdose. Findings included: Record review of Resident #56's face sheet, dated 01/29/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic diastolic heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), osteoarthritis (common type of joint disease that causes pain, stiffness, and swelling in the joints), and dementia (a syndrome characterized by a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life and activities). Record review of Resident #56's quarterly MDS assessment, dated 12/19/24, indicated she had a BIMS score of 15 which indicated intact cognition. Resident #56 did not exhibit behaviors of rejection of care or wandering. Record review of Resident #56's physician's orders, dated 01/29/25, indicated an order for apple zinc oxide barrier cream under breast and abdominal folds for yeast prevention every 12 hours as needed. The start date was 02/28/24. The orders also indicated an order for nystatin external cream, apply to affected areas topically every 12 hours as needed for yeast. The orders did not contain a medication that matched the green powder. There were no wound care orders in the physician's orders. During an observation and interview on 01/27/25 at 9:31 AM, Resident #56 was lying in bed in her room. There was 1 medicine cup that had a white cream substance and 1 medicine cup that had a green powder substance at the bedside. Resident #56 said the cream and green powder were for a wound on her bottom. She said the staff sometimes leave it on her bedside or in the bathroom so she can use it. During an observation on 01/27/25 at 11:35 AM, the medicine cup of a white cream substance and the medicine cup of a green powder substance were still at Resident #56's bedside. During an observation on 01/27/25 at 2:16 PM, the medicine cup of a white cream substance and the medicine cup of a green powder substance were still at Resident #56's bedside. During an interview on 01/29/25 at 1:27 PM, ADON E said she did not expect the staff to leave the medication at her bedside. ADON E said the risk was that someone could ingest the medication or have a potential adverse reaction to the medication. ADON E said she was not sure what the medications were. During an interview on 01/29/25 at 1:40 PM, the DON said she never expects medications to be left at the bedside. She said the risk was that another resident could ingest the medication. She said the medications also should have been labelled. During an interview on 01/29/25 at 1:48 PM, the Administrator said she expected the medications to not be left at the bedside. She said she did not feel there was a risk to the residents because of the medication at the bedside. Record review of the facility's policy, Medication Storage, dated 01/20/21, stated: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . .1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 5 residents (Resident #54) reviewed for hospice services. The facility failed to obtain Resident #54's most recent updated hospice medication profile to indicate Resident #54 was taking Lorazepam (an antianxiety medication) 1mg tab scheduled every 12 hours scheduled instead of every 4 hours as needed. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of Resident #54's face sheet dated 01/29/25 indicated he was an [AGE] year-old male who originally admitted to the facility on [DATE] with the diagnoses dementia (a general decline in cognitive abilities that affect's a person ability to perform ADLs), cerebral infarction (disrupted blood flow to the brain), high blood pressure, attention to gastrostomy tube, and malnutrition (lack of nutrients in the body). Record review of Resident #54's annual MDS dated [DATE] indicated resident was rarely understood and rarely could understand others. The MDS also indicated he had a BIMS score of 0 and had short-term and long-term memory problems. The MDS indicated he required total assistance from staff for all ADLs and required 51% or more of his calories through a feeding tube. Record review of Resident #54's care plan revised on 10/16/24 indicated he had a terminal illness and was receiving hospice services with interventions to coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #54's hospice binder on 01/29/25 at 09:37 AM indicated the last medication profile was printed on 08/05/24. Record review of Resident #54's EMR on 01/29/25 at 11:04 AM, indicated the hospice medication record and the facility's physician order did not match. The following order was noted on the facility's order summary report and not in Resident #54's hospice medication record: 1.Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1mg via G-Tube every 12 hours for Anxiety / Yelling Out related to ANXIETY DISORDER, UNSPECIFIED Record review of Resident #54's hospice medication record dated 08/05/24 indicated he had an order for: 1. Lorazepam (ATIVAN) 1MG tab; Give 1 tablet by gastrostomy tube every 4 hours as needed for anxiety for 367 days dated 12/19/23-12/19/24. During an interview on 01/29/25 at 03:47 PM, ADON F said the hospice nurse should bring the paperwork when they visit and keep the paperwork updated for the facility staff. ADON F said the failure placed a risk for the lack of communication and changes in care. During an interview on 01/29/25 at 04:25 PM, the DON said her expectation was for the most updated information to be kept in Resident #54's hospice binder. She said the hospice staff were responsible and the charge nurses and nursing administration (DON and 2 ADONs) should be looking at the binders to ensure they are being updated. The DON said the failure placed a risk for medications given that were not ordered or the hospice chart having incorrect information. During an interview on 01/29/25 at 04:44 PM, the Administrator said her expectation was for the hospice nurse to come in and ensure they bring the updated paperwork and the nursing staff at the facility were responsible for ensuring the paperwork is updated as well. She said the failure placed a risk to the resident was a potential for harm due to the medications not matching. Record review of the facility Coordination of Hospice Services Policy revised 03/12/2022 indicated: Policy: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines: 1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible.

Based on record review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 2 of 5 residents (Resident #1 and Resident #2) reviewed for discharge rights, in that: The facility failed to ensure Resident #1 had a safe and orderly discharge to a home environment on 9/12/2024. Resident #1 was discharged from the facility with no place to go and made to sit outside and found approximately 7 hours later on the ground behind the facility and transported to the hospital with A-fib and high blood pressure. The facility failed to ensure Resident #2 had a safe and orderly discharge to a home environment on 11/14/2024. Resident #2 who needed supervision and assistance with some ADL's and was a moderate fall risk was discharged to a motel and had multiple falls. The failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/10/2024 at 4:28 p.m . The IJ template was provided to the facility on [DATE] at 4:28 p.m. While the IJ was removed on 12/12/2024 at 4:15 p.m., the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern until interventions were put in place to ensure residents were discharged safely. The failures could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan. The findings were : 1.Record review of Resident #1's face sheet, dated 12/9/2024, indicated Resident #1 was a [AGE] year old male that admitted to the facility on [DATE] with his most recent admission on 8/8/2024 with diagnoses of hemiplegia and hemiparesis following cerebrovascular (blood flow to the brain) disease affecting left non-dominant side (weakness on the left side of the body), type 2 diabetes mellitus with diabetic neuropathy (high blood sugar with nerve damage), and unspecified symptoms and signs involving the nervous system. Record review of Resident #1's quarterly MDS, dated [DATE], revealed the following: -C0500. BIMS Summary Score= 14 signifying no cognitive impairment. - G0170. A. Roll left and right - The ability to roll from lying on back to left and right side and return to lying on back on the bed. The answer was, Independent. - G0170. B. Sit to lying - The ability to move from sitting on side of bed to lying flat on the bed. The answer was, Supervision or touching assistance. - G0170. C. Lying to sitting on side of bed - The ability to move from lying on the back to sitting on the side of the bed and with no back support. The answer was, Supervision or touching assistance. - G0170. D. Sit to Stand - The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The was Independent. - G0170. E. Chair/bed-to-to-chair transfer - The ability to transfer to and from a bed to chair (or wheelchair). The answer was, Supervision or touching assistance. - G0170. F. Toilet transfer - The ability to get on and off a toilet or commode. The answer was, Supervision or touching assistance. - G0170. FF. Tub/shower transfer - The ability to get in and out of a tub/shower. The answer was, Supervision or touching assistance. - Q0400: Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? The answer for this item was No. Record review of Resident #1's care plan dated 10/26/2022 and revised on 9/17/2024 indicated: Resident had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner with interventions that included: Bed Mobility: Limited assistance., Transfers: Usually independent but may need limited assistance at times., Toileting: Limited assistance, Ambulation: Ambulates only with therapy and needs extensive assistance, Wheelchair: Independent with an electric scooter, Dressing: Extensive assistance, Bathing: Extensive assistance. Record review of Resident #1's psychological services note dated 8/20/2024 indicated Resident #1 was seen by psychiatric services due to displayed symptoms such as adjustment difficulty, agitation, aggressive behaviors, anger and depression. Patient risk of aggression is at risk for verbal aggression Pt has a history of verbal aggression but none was noted in this session. Record review of Resident #1's psychological services note dated 9/4/2024 indicated Resident #1 was seen by psychiatric services due to displayed symptoms such as adjustment difficulty, agitation, aggressive behaviors, anger and depression. Patient risk of aggression is at risk for verbal aggression Pt has a history of verbal aggression but none was noted in this session. Record review of Physician/NP/PA Progress Note-V3 dated 9/11/2024 indicated: 8. Musculoskeletal: c. Unstable gait. 3. Concern for a condition or chronic disease that may result in a life expectancy less than 6 months a. Yes. Record review of progress notes for Resident #1 dated 9/12/2024 at 4:26 PM written by ADON B indicated: Resident in the front lobby screaming and cursing at staff. Attempted to calm resident but he continued to curse at staff and was speeding around the nurse's station in his motorized wheelchair. She asked the resident to slow down, and he stated he wanted to get out of the facility. She attempted to get the resident to move to a manual chair due to safety concerns for himself and other residents. She said he became even more irate and was cursing out the staff. The resident stated he was leaving, and to let him out of the door. She informed him that if he left it would be against medical advice, and the resident stated that he didn't care he was not staying at the facility any longer. She said she spoke with the Ombudsman and informed her of the situation and let her know that he was demanding to leave and refused to sign any paperwork. She said the Ombudsman said the resident was allowed to go if that is what he wanted. She said she went back and spoke with the resident again and he was sitting at the front screaming for someone to open the door and let him out. She offered the resident his belongings, he screamed where do you want me to put it and said let him out of the door. She said she asked the resident one more time to sign paperwork and stated he was not signing. She said she informed him that if he left the building he would no longer be a resident at the facility. Resident #1 said he was leaving. Resident #1 was then allowed to leave the building. She said she called his hospice provider and spoke with Hospice RN C to inform her of the situation. The physician was notified. She said she attempted to notify Resident #1's family member but her contact information had been removed from the chart. Record review of progress note for Resident #1 dated 9/12/2024 at 5:19 PM written by ADON B indicated: Hospice RN C arrived at the facility. She said Hospice RN C was there to speak with the Administrator and nursing staff about the resident choosing to leave. She said Hospice RN C was informed of Resident #1's behavior and that the facility could not hold Resident #1 against his will. She said Hospice RN C said she would attempt to find placement for Resident #1 that night. She said while Hospice RN C was at the facility Resident #1 was given all of his personal belongings. She said Hospice RN C was able to contact Resident #1's other family member. Record review of Against Medical Advice (AMA Form) dated 9/12/2024 indicated Resident #1 was not educated on the risks of leaving the facility against medical advice. ADON A and ADON B both signed and dated the form 9/12/2024. Resident #1 did not sign the form. Record review of progress note dated 9/12/2024 at 5:25 PM written by ADON A indicated: ADON A spoke with Hospice RN C outside the front door of the facility with Resident #1. She stated she asked Hospice RN C if she had a working phone number for Resident #1's family member and she stated she did not have a working phone number. She stated Hospice RN C stated Resident #1's other family member did not want him in her home. She stated Hospice RN C stated she was working on emergency respite or placement as he was still in hospice care and she was awaiting return phone calls. Record review of progress note dated 9/12/2024 at 7:54 PM written by the Administrator indicated: The Administrator stated he had spoken with the Hospice CEO and notified him of the situation which Resident #1 insisted on leaving against medical advice. He stated the Hospice CEO stated he understood and would find emergency respite for Resident #1 that night. Record review of progress note dated 9/13/2024 at 11:12 AM written by the DON indicated: Resident #1 was being discharged to another type of facility on 9/12/2024. A referral had been made to a hospice provider. Record review of Resident #1's hospital records dated 9/13/2024 at 12:30 AM indicated Resident #1 [AGE] year old male resident of the nursing home for over a year patient said that he is here because the nurse said that he had atrial (two upper chambers of the heart) for he has known atrial Fib (irregular beating of the heart in the two upper chambers) he is a cardiac defibrillator apparently the patient got into some type of conflict with people at the nursing home over some pain medication he somehow used a scooter when outside and then was told he was not allowed to return inside so he laid down outside rest or sleep and then was unable to get up because of chronic left-sided paralysis from a stroke and generalized weakness nurse came out and examined him and said he had A-fib and called EMS and he was transported patient reported that he has been nauseated with vomiting yesterday had some diarrhea yesterday not having any specific pain especially not chest pain and vomited today patient reports that he is into hospice care past history includes COPD stroke diabetes CHF CABG hypertension MI peripheral vascular disease . Pt arrived via EMS with c/o fatigue, headache, and nausea. Pt reported that he was kicked out of the nursing home today after a verbal altercation with staff. Pt reported that he was laying on a bench outside when he began feeling weak. Pt reported hx of stroke and now has left sided arm and leg weakness for that.]sic] Resident #1 had lab work performed at the hospital which indicated Resident #1's glucose was high at 154 (normal 74-118), his BUN (blood urea nitrogen) level was high at 22 (normal 6-20), his potassium level was low at 2.8 (normal 3.6-5.1), his chloride level was low at 99 (normal 101-111). Resident #1's chest x-ray indicated Mild pulmonary edema (swelling) and small left pleural effusion (accumulation of fluid between the lungs and chest wall). During an interview on 12/10/2024 at 9:59 AM Hospice RN C said she had seen Resident #1 the day before he was discharged and the facility wanted a recommendation to go to a behavioral hospital. She said she did not agree with a behavioral hospital, and they would make medication changes. She said on 9/12/2024 she received a call from ADON B that they were kicking Resident #1 out and she went to the facility and the resident was sitting outside and the facility would not let him back in. She said she went into the facility and talked to the Administrator, ADON A, and ADON B and they said he had threatened to run over a nurse. She said they told her they had asked for a behavioral hospital referral, and they would not agree. She said Resident #1 had gotten out of bed and asked for pain medication and the nurse was arguing with Resident #1 about his pain medication. She said she spoke with Resident #1, and he told her yes, he had threatened to run over the nurse, but it was out of anger, and he didn't mean it. She said Resident #1 had some vulgar language but felt like the staff was provoking him. She said Resident #1 told her he just wanted to smoke, and the facility told him if he went out the door, they would not let him back in. She said the facility Administrator said they had called the Ombudsman and she said yes kick him out. She said the facility put all his belongings in 3 trash bags and put them outside with him. She said the facility told her Resident #1 was not allowed to go back in the facility. She said she sat outside with Resident #1 and tried calling to find Resident #1 emergency placement. She said she then talked to the Administrator again to ask for Resident #1 to stay at the facility for that night until she could find placement for him the next day and said the Administrator told her no Resident #1 was not going back in the facility. She said she told the Administrator she was trying but did not think she would be able to find placement for Resident #1 that day because it was after 5:00 PM and the Administrator told her it was not his problem. She said she was not able to find respite care for the resident at that time. She said she was not comfortable leaving Resident #1 at the facility because he was in his scooter and his battery was going to die but she had been outside the facility with Resident #1 for 2-3 hours and she had to leave. She said she notified the facility that she had to leave, and they told her that it was not their problem he could not stay and by that time night shift was there. She said she left Resident #1 sitting outside under the front cover of the patio with his belongings on the ground at about 7:30pm. She said after she left, she did not get contacted by the facility. She said she found out the next morning that Resident #1 had went to the hospital. She said she was able to find placement the next morning at another facility. During a phone interview on 12/10/2024 at 7:53 PM, LVN F said when she got to the facility at 6:00 pm on 9/12/2024 and she saw Resident #1 in the front of the building calling his family member. She said there were several people with him, but she didn't know who they were. She said she did not see him anymore after that. LVN F said on 9/12/2024 at around 11:00 PM the CNAs took the barrels out to the trash and saw Resident #1 lying on the ground outside at the back of the facility. She said she didn't know if he fell or if he got down on the ground himself. She said Resident #1 was not coherent and was not himself and could not carry on a conversation. She said she did not know if he had taken any medications. She said she did not see any visible injuries, but she could not see in the dark. She said they called 911 for him to be transported to the hospital to be evaluated. During a phone interview on 12/10/2024 at 8:24 PM LVN G said she gets to work at 6pm. She said she saw Resident #1 outside when she got to work on 9/12/2024. She said Resident #1 was outside with a lady but didn't know who she was. She said when she got report and was told Resident #1 had left the building against medical advice and being erratic. She said no one told her he was not allowed to come back in the building. She said she did try to look for Resident #1 by driving around the front and the back of building to see if she could see him. She said she never saw him again that night. She said she didn't know the CNAs had found Resident #1 outside in the back. Said she didn't find that out until days later. She said she had no knowledge of LVN F calling 911 that night. 2. Record review of Resident #2's face sheet, dated 12/9/2024, indicated Resident #2 was a [AGE] year old male that admitted to the facility on [DATE] with his most recent admission on 10/01/2024 with diagnoses of fracture of neck, type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar with nerve damage), and central cord syndrome at unspecified level of cervical spinal cord. Record review of Resident #2's quarterly MDS, dated [DATE], revealed the following: -C0500. BIMS Summary Score= 15 signifying no cognitive impairment. - G0170. A. Roll left and right - The ability to roll from lying on back to left and right side and return to lying on back on the bed. The answer was, Independent. - G0170. B. Sit to lying - The ability to move from sitting on side of bed to lying flat on the bed. The answer was, Independent. - G0170. C. Lying to sitting on side of bed - The ability to move from lying on the back to sitting on the side of the bed and with no back support. The answer was, Independent. - G0170. D. Sit to Stand - The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. The was Independent. - G0170. E. Chair/bed-to-to-chair transfer - The ability to transfer to and from a bed to chair (or wheelchair). The answer was, Independent. - G0170. F. Toilet transfer - The ability to get on and off a toilet or commode. The answer was, Independent. - G0170. FF. Tub/shower transfer - The ability to get in and out of a tub/shower. The answer was, Independent. - Q0400: Discharge Plan A. Is active discharge planning already occurring for the resident to return to the community? The answer for this item was Yes. Record review of Resident #2's care plan dated 11/14/2023 and revised on 11/20/2024 indicated: Resident had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner with interventions that included: Bed Mobility: independent., Transfers: uses sliding board supervision., Toileting: independent may need assist at times., Ambulation: supervision, Wheelchair: Independent, Dressing: independent, Bathing: independent. Record review of a document titled, Notice of Discharge of Non-Payment, dated 10/15/2024, revealed Resident #2 was given a 30-day discharge notice on 10/15/2024 with a discharge date of [DATE]. The reasons for discharge were list as: discharge of non-payment . Resident #2 had the right to appeal this action as outlined in DHS' Fair Hearings, Fraud and Civil Rights Handbook by requesting a hearing through the Medicaid eligibility worker at the local DADS office within ten (10) days. The notice was signed by Resident #2 on 10/15/2024. Record review of progress note for Resident #2 dated 11/5/2024 at 11:54 AM written by the Social Worker indicated: the Social Worker met with Resident #2 to discuss discharge plans. The Social Worker discussed the barriers of finding shelter without an income and encouraged Resident #2 to reach out to family and friends for assistance until an income was established. The Social Worker discussed the option of a shelter for discharge. Resident #2 discussed needing a wheelchair prior to discharge. The Social Worker would continue to monitor changes in discharge plans. Record review of progress note for Resident #2 dated 11/14/2024 at 11:50 AM written by LVN D indicated: Resident #2 discharged from the facility on 11/14/2024 at 11:50 AM. A friend assisted in loading Resident #2's belongings and helped with transportation from the facility. Resident #2 was discharged with all medications and instructions. Record review of progress note for Resident #2 dated 11/14/2024 at 12:00 PM written by ADON B indicated: Resident #2 had been discharged home on 11/14/2024. A referral had been made to a durable medical equipment supplier. During an interview on 12/09/2024 at 1:01 PM, ADON A said Resident #2 did not want to discharge from the facility. She said she was not sure where Resident #2 had discharged to, but she thought maybe a homeless shelter. She said the Social Worker had handled Resident #2's discharge. During an interview on 12/092024 at 1:15 PM the Social Worker said Resident #2 lost his medical necessity for Medicaid to continue to pay for the resident to be at the facility. She said Resident #2 did not have any income therefore he did not have a way to pay to continue to stay at the facility or to discharge to an assisted living facility. She said she did not know Resident #2 was discharging to a motel until the day Resident #2 discharged . She said discharging to a motel was never a safe discharge. She said the facility was notified from his insurance the day after Resident #2 discharged that Resident #2 met medical necessity for a program called money follows the person. She said to her knowledge Resident #2 did not have an income that he needed to be admitted to an assisted living facility. She said she thought a friend of Resident #2 had picked him up from the facility and drove him to the motel. She said she was not at the facility when Resident #1 had discharged against medical advice from the facility. During an interview on 12/09/2024 at 1:30 PM, MDS E said Resident #2 was denied for medical necessity for Medicaid since August 12, 2024 because he had improved physically. She said Resident #2 was unable to pay or meet medical necessity for Medicaid and needed to discharge from the facility. She said upon discharge she thought he was supposed to be going to stay with his friend. She said the resident was physically able to care for himself and felt like discharging to a motel was a safe discharge. During an interview on 12/09/2024 at 1:40 PM, the BOM said Resident #2 lost his medical necessity back in August of 2024. She said since Resident #2 did not have a payor source they issued a 30-day discharge notice. She said she was not aware Resident #2 did not have a place to discharge to and said Resident #2 told her he had a cousin he could live with. Said she did not know who picked him up the day Resident #2 discharged and said Resident #2 never told her that he didn't have a place to go. She said she never told Resident #2 that he had to be out the next day of corporate would come and put him out of the facility. During an interview on 12/09/2024 at 1:49 PM, Resident #2 said the BOM told him at 3:00 pm on Wednesday 11/13/24 that he had to be out of the facility the next day. He said the BOM told him he had to be out of the facility or corporate would come and physically put him out. He said he believed her because he had just seen the facility put out his friend Resident #1. He said the facility gave him a 30-day discharge letter, but he was told by the Social Worker not to worry about it and that she didn't think the facility would actually discharge him. He said the Social Worker did not do anything to help him with discharge planning. He said the Ombudsman had asked to have a discharge care plan meeting, but it was never scheduled. He said the Social Worker did not file the paperwork to help get assistance to be discharged to an assisted living facility. He said he spoke with the social security office, and they told him the facility had not submitted any forms for him. He said he was discharged to the motel with his medications, but he could not take care of himself. He said he had become friends with a husband of a nurse that worked at the facility and that was who transported him to the motel. He said since the facility had discharged him to the motel, he had fallen 5 times and had to be taken to the hospital. He said he could not pop the pills out of the blister packs because of the weakness due to being paralyzed on his left side so his cousin came to the motel and put his medication in cups for him to take . During an interview on 12/10/2024 at 10:14 AM, ADON B said Resident #1 was asked to slow down in his motorized wheelchair on 9/12/2024. She said Resident #1 got irate and started cussing and flying around in his motorized wheelchair at the nurse's station. She said when they told Resident #1 he needed to get in a manual wheelchair he got mad and said he didn't want to be there anymore. She said she told Resident #1 if he was going to leave, she needed him to sign against medical advice paperwork. She said he told her he wasn't signing anything. She said she called the Ombudsman, and the Ombudsman told her that Resident #1 had the right to leave if that was what he wanted. She said she asked Resident #1 to sign the against medical advice paperwork and he still refused to sign the paperwork and was still cussing. She said she let him out the front door and they contacted Hospice RN C at around 4:00 PM. She said Hospice RN C was going to try to find Resident #1 emergency placement. She said when she left a couple hours later Resident #1, and Hospice RN C were outside in front of the facility. She said the Administrator also called hospice and they said Resident #1 was in their care and they were trying to find emergency placement. She said about 11:00pm the nurse at the facility called and told her Resident #1 was sitting outside in his chair. She said the facility nurse called 911 to have him checked out at the hospital. She said Resident #1 was fine, and he was discharged from the hospital . She said while Resident #1 was sitting in front of the hospital in a wheelchair he rolled down the hill and fell out of the chair in the parking lot. She said Resident #1 was then admitted to the hospital after that fall. She said they were never contacted by Hospice RN C for Resident #1 to stay at the facility until placement could be found. She said they did not discharge him onto the street, he was in hospice care outside of the facility. She said at 7:30pm she asked the on-duty nurses to look and see if Resident #1 was still on the property and Resident #1 was not on the property. She Said Resident #2 was supposed to be discharged to assisted living, but he was denied due to not having a payor source. She said Resident #2 had a home to go back to which was living with his cousin, but he didn't want to go back there. She said Resident #2 agreed to go to a motel and Resident #2 and his cousin would figure out living arrangements. She said Resident #2 did not qualify for the money follows the person. She said the day Resident #2 was discharged the cousin picked him up. She said she felt like Resident #2's discharge to a motel was a safe discharge . During an interview on 12/10/2024 at 10:14 AM, the Administrator said Hospice RN C never asked him if Resident #1 could stay at the facility until she could find placement for him. He said when he left the faciity on [DATE] Resident #1 and Hospice RN C were in front of the facility and Hospice RN C was on the phone, and he did not speak to her at that time. He said he felt like by Resident #2 discharging to a motel that it was a safe discharge for Resident #2. During an interview on 12/10/2024 at 11:17 AM, the Ombudsman said that she had some concerns with the way the facility had discharged some of the residents. She said she felt like the staff should have tried to reason with Resident #1 after his outburst and allowed him to stay until the Hospice RN C could have found him safe placement. She said she had spoken with the facility Social Worker multiple times regarding Resident #2's discharge. She said Resident #2 had begged the Social Worker and the Administrator to stay at the facility because he had nowhere to go. She said the Social Worker had told her multiple times that Resident #2 could discharge to a homeless shelter and that she had told the Social Worker multiple times that was not a safe discharge. She said she had tried multiple times with the Social Worker to schedule a discharge care plan meeting and it never got scheduled. She said she spoke with the Administrator to try to get a discharge care plan meeting scheduled and then found out that Resident #2 had been discharged . During an interview on 12/10/2024 at 10:28 AM, the Social Worker said she had been in constant contact with the Ombudsman. She said Resident #1 had been issued a 30-day discharge notice several times because he had been verbally aggressive in the facility and also had not been paying for his stay. She said he then started paying so the 30-day discharge had been rescinded. She said she contacted hospice for a behavioral hospital referral the day before he discharged , and hospice said no please wait they would do medication changes and they would send out a nurse. She said Resident #1 was known to have behavioral outbursts and was in agreeance to go to the behavioral hospital. She said the next thing she knew he was gone. She said all she could remember was Resident #1 tried to run someone over with his scooter but could not remember anything else specific. She said she was in constant conversation with the Ombudsman about Resident #2's discharge planning. She said without income it was hard to come up with a safe discharge plan. She said she pushed for Resident #2's friends to take him in until he had an income. She said she couldn't send him to the shelter because he would not agree to go. She said the Ombudsman told her it was not a safe discharge for Resident #2 to go to a shelter. She said the Ombudsman did request a discharge care plan meeting, but it never happened. She said she had discussed with Resident #2 what his discharge plans were several times and did think it was necessary to have a discharge care plan meeting. An IJ was identified on 12/10/2024. The IJ template was provided to the facility on [DATE] at 4:28 PM . The facility Administrator, and ADON A, ADON B, RDO, and Regional Nurse Consultant were notified, and a plan of removal was requested. During a phone interview on 12/11/2024 at 2:52 PM LVN H said when she got to work the night of 9/12/2024 Resident #1 was outside with a lady that was on the phone. She said Resident #1 told her that he had been kicked out of the facility. She said at 11:00 pm that night Resident #1 was outside on the ground; there was a wooden ramp and Resident #1 was lying on the ground adjacent to the ramp. She said Resident #1 told her that he was going to lay down on the ramp to sleep. She said the CNAs and LVN F were out there with her. She said the resident was oriented. Said she did not see any injuries, but the resident was diaphoretic (excessive sweating due to an underlying health condition or a medication) and had urinated on himself. She said LVN F took his blood pressure, and it was 240/130 (normal 120/80) which was what prompted the 911 call. She said she was told Resident #1 had left the facility against medical advice and was not allowed back in the facility. She said it was typical behavior for Resident #1 to become verbally aggressive. She said the night before there was an issue about a pain pill, she said he was on scheduled pain medications then medication as needed for breakthrough pain. She said she was told Resident #1 and LVN G began arguing and he threatened to run over the nurse with the scooter. During an interview on 12/11/2024 at 3:25 PM Receptionist J said she worked the evening that Resident #1 discharged from the facility. She said Resident #1 was out back of the facility talking to adult protective services. She said she didn't see Resident #1 when she got back from break about 8:45 PM. She said that Resident #1's behavior in general was aggressive and she witnessed the incident. She said Resident #1 and LVN G were arguing. She said the resident was being discharged due to non-payment, vapes, cigarettes, and wasn't following the rules and telling people that he was going to run them over. She said Resident #1 asked her to let him out the door. She said Resident #1 was going to call someone to pick him up. She said Resident #1 called her back outside for her to get him his phone and chair chargers. She said she stood outside and talked to Resident #1 until hospice got to the facility. She said when she was out back, Resident #1 was out back of the facility, and she gave him a cigarette and lighter about 6:25pm. Attempted interview on 12/12/2024 at 2:00 PM with the DON. The DON was no available for interview. Attempted interview on 12/12/2024 at 2:05 PM with the Administrator. The Administrator was not available for interview. Record review of facility policy titled Transfer and Discharge (including AMA) dated 10/10/2017 and last reviewed on 9/1/2023 indicated: This facility complies with federal regulations to permit each resident to remain in the facility, and not transfer or dischar [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #3) residents reviewed for supervision. The facility failed to respond to door alarm that resulted in Resident #3 elopement on 9/20/2024. Resident #3, who had dementia, left the facility through an alarmed door on 9/20/2024 at 5:05 PM. The resident wandered approximately 200 yards down the road from the facility driveway and was intercepted by Medical Records and returned to the facility. An IJ was identified on 12/11/2024. The IJ template was provided to the facility on [DATE] at 1:55 PM. While the IJ was removed on 12/12/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because (e.g.) all staff had not been trained on the facilities missing residents' policy and elopement assessments. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included : Record review of Resident #3's facility's electronic face sheet dated 12/11/2024 revealed an [AGE] year-old female admitted to the facility on [DATE] for 3 days respite care with diagnosis of dementia with other behavioral disturbance (problem with thinking and behaviors), senile degeneration of brain (decline in mental abilities), and temporal sclerosis (scarring in the brain). Record review of Resident #3's discharge MDS assessment dated [DATE] revealed a BIMS (brief interview for mental status) score was not obtained. She required supervision or touching assistance with dressing, toilet use and personal hygiene, and required supervision or touching assistance with walking more than 150 feet. Record review of Resident #3's care plan dated 09/20/2024 revealed Resident #3 wandered related to cognitive impairment and was at risk for injury with interventions that included: 1. Attempt to determine any pattern or cause of wandering. 2. Reassure resident when distressed over placement. 3. Redirect is resident enters a restricted area. 4. Notify the immediate supervisor if unable to locate the resident. 5. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . Record review of Resident #3's admission elopement risk assessment dated [DATE] at 7:08 PM revealed she was at risk for elopement or unsafe wandering. Record review of hospice admission orders for Resident #3 dated 9/20/2024 indicated: Pt does wander at times. Record review of nursing progress note for Resident #3 dated 9/20/2024 at 5:46 PM written by LVN O revealed the nurse on 300 hall stated she heard her door alarm go off but saw no one. Room and patient check was done and could not locate Resident #3. A person that worked at the facility called and said on her way home she saw Resident #3 walking toward the school. She called and said she picked the resident up and was bringing her back. Resident #3 was taken to her room and a full body assessment was done with no injuries were noted. The Administrator, ADON B, and DON were notified. Hospice and family were notified. A [NAME] guard was applied to Resident #3. Record review of nursing progress note for Resident #3 dated 9/20/2024 at 8:30 PM written by RN Q indicated a CNA arrived at the facility to sit with Resident #3 to deter wandering behaviors. Resident #3 was in bed sleeping at that time. Record review of nursing progress note for Resident #3 dated 9/20/2024 at 9:00 PM written by LVN Q indicated Resident #3 had 1 to 1 sitter in her room at that time. Record review of nursing progress note Resident #3 dated 9/21/2024 at 2:08 PM written by LVN O indicated Resident #3 attempted to get out of door at the end of the 200 hall and had removed her wander guard. The wander guard was replaced on Resident #3 and LVN O was stationed in the hall to monitor the hall while CNAs could continue to have lunch, make rounds and answer call lights. Record review of nursing progress note for Resident #3 dated 9/21/2024 at 6:19 PM written by LVN O indicated Resident #3 walked up and down the halls several times and was re-directed back to her room. Resident #3 was given a magazine and snacks. Resident #3 walked with her shoes in her hands. She was re-directed for short periods of time. Record review of nursing progress note for Resident #3 dated 9/21/2024 at 7:57 PM written by RN Q indicated the CNA was sitting with Resident #3 in her room while RN Q passed medications. The wander guard was in place. Record review of nursing progress note for Resident #3 dated 9/22/2024 at 1:15 PM written by ADON B indicated Resident #3's family member was at the facility to take her home. Resident #3 was discharged home at that time. During an interview on 12/11/2024 at 10:21 AM Medical Records said she left work about 5:05pm on 9/20/2024. She said she left from the back of the building because her car was parked in the back and there was a driveway behind the facility. She said Resident #3 had just crossed the road behind the facility and was walking towards the school up the road. She said she wasn't for sure if the lady she saw was a resident, so she called another employee at the facility to confirm she was a resident. She said she kept an eye on the lady until she found out if she was a resident at the facility. She said once she confirmed the lady was a resident, she got Resident #3 in her car, and she willingly went back to the facility with her. During an observation and interviews on 12/11/2024 at 10:45 AM, of the 300-hall door with Medical Records revealed the 300-hall door when pushed opened and alarmed. The exterior gate was unlocked and open. Medical Records and the surveyor walked the path the resident took during elopement. Upon walking around the exterior of the building the exterior gate on both sides of the dining room were unlocked and open. The 500-hall exterior gate was unlocked and open. The 600-hall exterior gate was unlocked and open. The wander guard did not set off the alarm on the 200, 500, 600 halls and did alarm in the dining room after a delay. The alarm on the 300-hall door did alarm with the wander guard (the only hall) but the alarm on the door had a small magnet that slid down the door frame and did not alarm when opened the second time. The Maintenance Director said there was a signal problem with the wander guard as to why the wander guards were not working on all the doors except the 300-hall door. During an interview on 12/11/2024 at 11:00 AM the Maintenance Director said the 300-hall door had a magnet that was attached with double sided tape to the door frame and had slipped down and had to be pushed back up into place for the door alarm to sound when the door opened. He said he would put some new tape on the magnet to hold it in place. He said the magnet would have to be pushed back into place each time the door was opened for the alarm to sound. He said if the magnet was not pushed back into place each time, the door alarm would not sound if the door was opened. He said a resident could get out of the door without the alarm sounding and no one would know. He said there must be a problem with the signal from the wander guards at the doors as to why some of the doors did not alarm when the wander guard was close to the doors. He said after the elopement he checked all doors, and all doors were functioning properly. During an interview on 12/11/2024 at 11:32 AM LVN O said she was not notified that she would be getting an admission on 9/20/2024. She said Resident #3 admitted at a little after 8:00 am on 9/20/2024. She said the Administrator brought Resident #3 and showed her the room and then left and did not give her any paperwork or admission orders for Resident #3. She said she called the DON and asked for admission orders and paperwork. She said the DON told her the Administrator had the orders and must have locked them up in his office, so she had to wait till hospice came about 3:00 pm before receiving admission orders and paperwork. LVN O said she was at the end of the 200 hall doing blood sugar checks and could not hear the alarm going off. She said LVN P asked her if she was missing a resident around 5:00 PM. She said she never heard an alarm going off. She said once she got back to the nurse's station, she heard the alarm going off on the 300 hall. She said they started doing a head count. LVN O said she drove around the building and then went down the main road. She said she made it back to the facility and by that time Medical Records had picked Resident #3 up by the school and brought her back to the facility. She said she notified the Administrator and the DON of the elopement. She said once Resident #3 was back at the facility she did an assessment and then Resident #3 ate dinner and went to bed. She said the next day Resident #3 took the wander guard off and was walking down the hallway. LVN O said she got a table and chair and sat in the hall by her room for the rest of the day and did not have any further incidents. LVN O said she got a call from the DON and told her not to come in the next day on Sunday 9/22/2024 that she was suspended pending investigation of the elopement. She said ADON B then called and told her all was clear and go ahead and come back to work on Wednesday 9/25/2024. LVN O said then she received another call from the DON and told her to go the Administrator's office and don't clock in on Wednesday. She said on Wednesday the Administrator and DON told her the CEO told them to terminate her due to the elopement. LVN O said prior to the elopement she had no paperwork that said Resident #3 was an elopement risk. LVN O said after she received the hospice orders on the back sheet of the hospice paperwork it said Resident #3 wandered. She said hospice told her Resident #3 wandered around the house but never made an attempt to get out of the house. LVN O said Resident #3 was outside of the facility for maybe 10-15 minutes. She said typically when a resident admitted the nurse did an elopement assessment upon admission. An IJ was identified on 12/11/2024. The facility Administrator, and ADON A, ADON B, RDO, and Regional Nurse Consultant were notified, and a plan of removal was requested. Attempted interview on 12/12/2024 at 2:00 PM with the DON. The DON was no available for interview. Attempted interview on 12/12/2024 at 2:05 PM with the Administrator. The Administrator was not available for interview. Record review of the facility's Missing Residents policy dated 10/24/2022 revealed This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 4: monitoring and managing residents at risk for elopement or unsafe wandering: A- residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The facility's plan of removal was accepted on 12/12/2024 at 1:37 p.m. and included: 4. Immediate Action Taken G. Resident #3 is no longer in the facility as of September 23, 2024. H. On 12/11/2024 The Maintenance Director/Designee completed environmental assessments to include checks on all doors. I. On 12/11/2024 The ADON and/or designee completed elopement assessments on all facility residents with no changes noted. J. On 12/11/2024 The ADON and/or designee completed in-service education with facility direct care nursing staff on the missing resident policy which ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. The facility RNC completed in-service education with the facility Admin and ADONs. Facility direct care nursing staff were trained prior to their next shift. The Missing Resident Policy Inservice Education included Residents will be assessed within 4 hours for risk of elopement and unsafe wandering upon admission, quarterly, and as needed throughout their stay at the facility. K. On 12/11/2024 The ADON and/or designee completed a Missing Resident Drill with facility direct care staff to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident. Facility direct care staff completed a missing resident drill prior to their next shift. This was completed on 12/11/2024 by 10:00 pm. L. On 12/12/24 The facility RNC completed in-service education with the facility Administrator regarding do not take a resident to their room without notifying the admitting nurse and providing the admission paperwork to them. 5. Identification of Residents Affected or Likely to be Affected: C. No other residents identified , on 12/11/24 the facility ADON and/or Designee completed elopement assessments on all facility residents with no new changes noted. This will be completed on 12/11/24 by 10:00 pm. 3.Actions to Prevent Occurrence/Recurrence: D. As of 12/11/2024, any staff member hired for direct nursing staff the following will be completed during orientation by the facility DON and/or designee: In-service education with facility direct care nursing staff on the missing resident policy which ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. The DON and/or designee will complete a Missing Resident Drill with facility direct care staff during orientation to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident. E. The ADON/Designee will conduct weekly random missing resident drills two (2) times a week for six (6) weeks to ensure facility staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert to notify all other staff members of the missing resident. F. Results of weekly observations will be reviewed in the morning meeting by the Administrator or designee. On 12/11/2024 the facility's Administrator notified the Medical Director to conduct an AdHOC QAPI meeting regarding the Immediate Jeopardy the facility received related to Free of Accidents/ Hazards/ Supervision and reviewed plan to sustain compliance On 12/12/2024 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the electronic medical record indicated Resident #3 discharged from the facility on 9/22/2024. Record review of completed environmental assessments dated 12/11/2024 to include checks on all doors. Observation on 12/12/2024 at 3:00 PM of all facility doors will all door alarms currently working. Record review of elopement assessments dated 12/12/2024 on all 9 residents identified as elopement risks. Record review of an in-service dated 12/11/24 at 2:30pm titled Missing Person Policy revealed it was signed by the Administrator, ADON A, and ADON B. Record review of an in-service titled Elopement/Missing Person Drill dated 12/11/24 revealed it was signed by 52 employees of various disciplines and shifts. Record review of an in-service titled Do not take a resident to their room without notifying the admitting nurse . dated 12/12/24 revealed it was signed by the Administrator. Record review of an off cycle AdHoc QAPI meeting held on 12/11/24 at 3:35pm to discuss accidents, Hazards and Supervision. The following interviews were conducted to ensure staff understood education received: During an interview on 12/12/2024 at 3:40 PM ADON A said the following were steps in searching for a missing resident: page a silver alert, print the census and check for missing residents, perform a head count. She said she would start searching the facility grounds for the missing resident. She said she would notify the physician, family, DON, Administrator, and police. Once the resident was found a complete head to toe assessment should be done. She said the elopement assessment should be completed within four hours of admission. During an interview on 12/12/2024 at 3:44 PM LVN K said the following were steps in searching for a missing resident: Page code silver, head count, search, notify the MD, family and police. She said the elopement assessment was to be completed within 4 hours of admission. During an interview on 12/12/2024 at 3:48 PM LVN L said the following were steps in searching for a missing resident: Call silver alert, start a head count, search, notify the Administrator, DON, family and police. She said the elopement assessment was to be completed within 4 hours of admission. During an interview on 12/12/2024 at 3:50 PM LVN D said the following were steps in searching for a missing resident: Call silver alert, start head count, searching, notify physician, family and Police. He said the elopement assessment is to be completed within 4 hours of admission. During an interview on 12/12/2024 at 3:52 PM RN M said the following were steps in searching for a missing resident: Call silver alert, start head count, identification, search, notify the physician, family, and police. He said the elopement assessment was to be completed within 4 hours of admission. During an interview on 12/12/2024 at 3:54 PM ADON B said the following were steps in searching for a missing resident: Call code silver, start a head count, identification, search, notify the physician, Administrator, police, and family. She said the elopement assessment was to be completed within 4 hours of admission. During an interview on 12/12/2024 at 3:59 PM MDS N said the following were steps in searching for a missing resident: Call silver alert, start a head count, search, notify the Administrator, DON, family and police. She said the elopement assessment was to be completed within 4 hours of admission. During an interview on 12/12/2024 at 4:01 PM MDS E said the following were steps in searching for a missing resident: Call code silver, start a head count, identification, search, notify the physician, Administrator, police, and family. She said the elopement assessment was to be completed within 4 hours of admission. During an interview on 12/12/2024 at 4:03 PM CNA R said the following were steps in searching for a missing resident: Call code silver, search, head count, call 911. During an interview on 12/12/2024 at 4:04 PM CNA S said the following were steps in searching for a missing resident: Call silver alert, head count, search, and call 911. During an interview on 12/12/2024 at 4:06 PM MA U said the following were steps in searching for a missing resident: Call code silver, search, head count, and call 911. During an interview on 12/12/2024 at 4:08 PM CNA T said the following were steps in searching for a missing resident: Call code silver, head count, search, and call 911. On 12/12/2024 at 4:15 p.m., ADON A, ADON B, and Regional Nurse Consultant were notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 21 residents reviewed for pain management. (Resident #24) The facility failed to reorder Resident #24's [MEDICATION(S)] timely therefore leaving her without the pain medication for 7 days. The facility failed to adequately assess Resident #24's pain. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Record review of a face sheet dated 10/20/22 indicated Resident #24 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24 had an order dated 6/17/22 to refer to physical therapy for neck pain. Resident #24 had an order dated 09/20/21 for [MEDICATION(S)] tablet 10/325 mg twice daily for pain. Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #24 was understood and understands. Resident #24's BIMs score was 13 indicating cognitively intact. The MDS indicated Resident #24 required extensive assistance with bed mobility, transfers, dressing, eating, and toilet use. She required total assistance with bathing. The MDS section I8000 indicated dorsalgia and an active diagnosis. The section J0100 of the MDS indicated Resident #24 had scheduled pain mediation regimen and received non-medication interventions for pain. J0200 indicated a pain assessment was completed. The Section J0300 of the MDS indicated she had pain in the last 5 days of the assessment period. J0400 indicated she had pain frequently and J0600 indicated her pain level was an 8 out of 10 during the last 5 days (describing the worst pain over the 5-day period). Record review of the comprehensive care plan dated 09/28/21 and revised on 10/28/21 indicated Resident #24 was at risk for pain related to immobility, arthritis, and wound. The goal of the care plan was Resident #24 would not have moderate to severe pain, her pain would be below her pain level, pain or discomfort relieved in a timely manner, and maintain highest level of practical ADL function and not experience a decline. The interventions included using a numerical or verbal pain scale to rate her pain, administer pain medications and treatments per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/18/22 at 9:05 a.m., Resident #24 indicated the first week of October she had no pain medication available . Resident #24 indicated she could not remember her pain scale during the time period, but she indicated she was never completely without pain in her back. Resident #24 indicated very seldom do the nurse's assess for pain. Record review of a Narcotic Administration Record dated 08/31/22 indicated the pharmacy filled 55 [MEDICATION(S)] ([MEDICATION(S)]) 10/325 mg for Resident #24. The first dose of medication was administered on 09/01/22 at 8:00 a.m., and the last dose was given on 09/28/22. The total of the 55 [MEDICATION(S)] was administered to Resident #24 over the days of 09/01/22 through 09/28/22 at 8:00 a.m. There were no doses for the evening of 09/28/22. Resident #24 had no routine twice daily doses of the [MEDICATION(S)] on 9/29/22 and 9/30/22. Record review of the pharmacy delivery manifest ID PAK 2213 indicated on 10/05/22 at 9:50 p.m., Resident #24's [MEDICATION(S)] was delivered on 2 cards with a total of 55 tablets. Record review of a Narcotic Administration Record dated 10/05/22 indicated the pharmacy filled 55 [MEDICATION(S)] 10/325 mg ([MEDICATION(S)]). The facility staff administered the first dose on 10/06/22 at 8:30 a.m. Resident #24 had no routine twice daily doses of the [MEDICATION(S)] for pain provided on 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/05/22. Record review of Resident #24's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an EMR (electronic medical record) dated October 2022 indicated [MEDICATION(S)] 10/325 mg give one tablet two times a day for pain denoted not administered on the dates of 10/01/22 -10/05/22. The EMR failed to indicate why Resident #24's pain medication was administered. During an interview on 10/20/22 at 10:05 a.m., the responsible party of Resident #24 indicated recently Resident #24 had ran out of her pain medications at the first of October. The responsible party indicated Resident #24 had made her aware of not having her pain medication available. The responsible party said Resident #24 has severe back pain and called her because during this time she was hurting. During an observation and interview on 10/20/22 at 3:44 p.m., LVN E indicated Resident #24 had received her last dose of [MEDICATION(S)] on her shift at the end of September. LVN E indicated she had sent over a request to Resident #24's physician indicating a triplicate was needed . LVN E indicated she was off and when she returned the medication was available. The narcotic lock box in the medication room indicated the box contained [MEDICATION(S)]/[MEDICATION(S)] and Tylenol with [MEDICATION(S)] available for use. LVN E indicated the nurses were responsible for ensuring Resident #24's pain medication was reordered timely. During an interview on 10/20/22 at 3:55 p.m., RN W indicated she was not aware Resident #24's [MEDICATION(S)] was not available for use during 9/28/22 -10/05/22 . RN W indicated a special prescription was required for this medication and the nurses must notify the physician. RN W indicated the prescription should be obtained at least a week before the last dose. During an interview on 10/20/22 at 3:58 p.m., the pharmacist indicated the triplicate prescription for the [MEDICATION(S)] was received on 10/05/22 and the medication was delivered on 10/05/22. The pharmacist indicated no phone calls were received to access any of the [MEDICATION(S)] from the locked safe in the facility. The pharmacist also indicated the physician would have had to release a triplicate prescription to access the [MEDICATION(S)]/[MEDICATION(S)] from the safe before an access code would be provided to the nurse. During an interview on 10/21/22 at 12:43 p.m., the Administrator indicated he expected all medications to be available.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 21 residents reviewed for pharmacy services. (Resident # 24) The facility failed to reorder Resident #24's [MEDICATION(S)] timely therefore leaving her without the pain medication for 7 days. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. Findings included: Record review of a face sheet dated 10/20/22 indicated Resident #24 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dorsalgia (severe back pain), pain in left shoulder, [CONDITION(S)], and anxiety. Record review of the consolidated physician's orders dated 10/20/22 indicated Resident #24 had an order to assess for pain and rate level of pain using a numeric scale every shift dated 04/29/22. Resident #24 had an order dated 6/17/22 to refer to physical therapy for neck pain. Resident #24 had an order dated 09/20/21 for [MEDICATION(S)] tablet 10/325 mg twice daily for pain. Record review of the most recent Quarterly MDS dated [DATE] indicated Resident #24 was understood and understands. Resident #24's BIMs score was 13 indicating cognitively intact. The MDS indicated Resident #24 required extensive assistance with bed mobility, transfers, dressing, eating, and toilet use. She required total assistance with bathing. The MDS section I8000 indicated dorsalgia and an active diagnosis. The section J0100 of the MDS indicated Resident #24 had scheduled pain mediation regimen and received non-medication interventions for pain. J0200 indicated a pain assessment was completed. The Section J0300 of the MDS indicated she had pain in the last 5 days of the assessment period. J0400 indicated she had pain frequently and J0600 indicated her pain level was an 8 out of 10 during the last 5 days (describing the worst pain over the 5-day period). Record review of the comprehensive care plan dated 09/28/21 and revised on 10/28/21 indicated Resident #24 was at risk for pain related to immobility, arthritis, and wound. The goal of the care plan was Resident #24 would not have moderate to severe pain, her pain would be below her pain level, pain or discomfort relieved in a timely manner, and maintain highest level of practical ADL function and not experience a decline. The interventions included using a numerical or verbal pain scale to rate her pain, administer pain medications and treatments per physician's orders and when requested, attempt non-pharmacological pain interventions, and evaluate the effectiveness of the pain medications. During an interview on 10/18/22 at 9:05 a.m., Resident #24 indicated the first week of October she had no pain medication available . Resident #24 indicated she could not remember her pain scale during the time period, but she indicated she was never completely without pain in her back. Resident #24 indicated very seldom do the nurse's assess for pain. Record review of a Narcotic Administration Record dated 08/31/22 indicated the pharmacy filled 55 [MEDICATION(S)] ([MEDICATION(S)]) 10/325 mg for Resident #24. The first dose of medication was administered on 09/01/22 at 8:00 a.m., and the last dose was given on 09/28/22. The total of the 55 [MEDICATION(S)] was administered to Resident #24 over the days of 09/01/22 through 09/28/22 at 8:00 a.m. There were no doses for the evening of 09/28/22. Resident #24 had no routine twice daily doses of the [MEDICATION(S)] on 9/29/22 and 9/30/22. Record review of the pharmacy delivery manifest ID PAK 2213 indicated on 10/05/22 at 9:50 p.m., Resident #24's [MEDICATION(S)] was delivered on 2 cards with a total of 55 tablets. Record review of a Narcotic Administration Record dated 10/05/22 indicated the pharmacy filled 55 [MEDICATION(S)] 10/325 mg ([MEDICATION(S)]). The facility staff administered the first dose on 10/06/22 at 8:30 a.m. Resident #24 had no routine twice daily doses of the [MEDICATION(S)] for pain provided on 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/05/22. Record review of Resident #24's medication administration record dated September 2022 indicated [MEDICATION(S)] 10/325mg one tablet twice daily for pain denoted not administered on the dates of 09/28/22 evening dose, and twice daily doses on 09/29/22 and 09/30/22 . The medication administration record did not indicate why Resident #24 did not receive her pain medication. Record review of an EMR (electronic medical record) dated October 2022 indicated [MEDICATION(S)] 10/325 mg give one tablet two times a day for pain denoted not administered on the dates of 10/01/22 -10/05/22. The EMR failed to indicate why Resident #24's pain medication was administered. During an interview on 10/20/22 at 10:05 a.m., the responsible party of Resident #24 indicated recently Resident #24 had ran out of her pain medications at the first of October. The responsible party indicated Resident #24 had made her aware of not having her pain medication available. The responsible party said Resident #24 has severe back pain and called her because during this time she was hurting. During an observation and interview on 10/20/22 at 3:44 p.m., LVN E indicated Resident #24 had received her last dose of [MEDICATION(S)] on her shift at the end of September. LVN E indicated she had sent over a request to Resident #24's physician indicating a triplicate was needed . LVN E indicated she was off and when she returned the medication was available. The narcotic lock box in the medication room indicated the box contained [MEDICATION(S)]/[MEDICATION(S)] and Tylenol with [MEDICATION(S)] available for use. LVN E indicated the nurses were responsible for ensuring Resident #24's pain medication was reordered timely. During an interview on 10/20/22 at 3:55 p.m., RN W indicated she was not aware Resident #24's [MEDICATION(S)] was not available for use during 9/28/22 -10/05/22 . RN W indicated a special prescription was required for this medication and the nurses must notify the physician. RN W indicated the prescription should be obtained at least a week before the last dose. During an interview on 10/20/22 at 3:58 p.m., the pharmacist indicated the triplicate prescription for the [MEDICATION(S)] was received on 10/05/22 and the medication was delivered on 10/05/22. The pharmacist indicated no phone calls were received to access any of the [MEDICATION(S)] from the locked safe in the facility. The pharmacist also indicated the physician would have had to release a triplicate prescription to access the [MEDICATION(S)]/[MEDICATION(S)] from the safe before an access code would be provided to the nurse. During an interview on 10/21/22 at 12:43 p.m., the Administrator indicated he expected all medications to be available.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents reviewed (Resident #1) for neglect. 1. The facility failed to follow their Fall Management System policy. 2. The facility failed to ensure interventions were in place for Resident #1 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. The facility failed to ensure neurological checks were completed when Resident #1 had an unwitnessed fall. The LVN documented neurological checks were completed; however, video reviewed by the police indicated the LVN did not enter the resident's room for 3 hours and 50 minutes after the fall when the resident had another fall. 4. The facility failed to notify the physician and the family when the resident had a fall. 5. The facility CNA C failed to ensure Resident #1 was assessed for injuries prior to moving her off the floor. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:30 p.m. While the IJ was removed on [DATE] at 5:30 p.m., the facility remained out of compliance at a scope of a isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for falls, injuries, and death. Findings included: Record review of Resident #1's Medical Diagnose sheet indicated a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #1's Quarterly MDS, dated [DATE], indicated a BIMS score of 5, which indicated severely impaired cognition. Her functional status indicated supervision and one-person physical assist for bed mobility, transfer, walking in the room, dressing and toilet use. The MDS Fall History on Admission/Entry or Reentry indicated the resident was not assessed for falls prior to admission. She had one fall since admission with no major injury. Record Review of Resident #1's Care Plan, with an initial date of [DATE] and last revised on [DATE], listed a focus area of ADL self-care performance deficit and risk for not having needs met in a timely manner. Interventions were bed mobility with supervision, transfers with supervision, toileting with supervision, ambulation walks independently in her room, wheelchair with supervision, dressing limited, personal hygiene with supervision, bathing supervision of one person. Encourage the resident to use [NAME] light for assistance before attempting any activities of daily living that resident cannot do independently. Resident #1 had a Focus area of incontinence. The resident was incontinent of bowel/bladder related to impaired mobility and the age process. Revised on [DATE]. Interventions were check frequently for wetness and soiling, change as needed. Assist to the toilet as needed. A Care Plan Focus area indicated hospice terminal prognosis. The resident had a terminal illness and was receiving hospice or palliative care. During the end-of-life process weight loss, skin breakdown, dehydration, fecal impaction and gradual or rapid loss of the ability to move may be unavoidable. The initial date was [DATE] with no revision date. A Focus area of Falls. The resident had the potential for falls related to dementia and disease process. Initiated on [DATE] with no revisions. Interventions were to anticipate and meet the resident's needs. Review information on past falls and attempt to determine the cause of falls. Record possible root causes. After or removal any potential causes if possible and educate the resident, family, and caregivers, IDT as to causes. Record review of a fall assessment, dated [DATE], indicated Resident # 1 had a score of 9 (moderate risk for falls.) Her gait analysis indicated she required hands on assistance to move from place to place. Record review of Resident #1 's incident report, dated [DATE] at 5:35 p.m., indicated the resident had a fall. She said she had been in the bathroom. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident report indicated the resident had predisposing situation factors such as ambulating without assist signed by LVN K. No fall assessment and no care plan update was noted. Record review of an incident report, dated [DATE] at 4:00 p.m., indicated Resident #1 had a fall in the bathroom. The predisposing psychological factors indicated she was confused, she had weakness or [CONDITION(S)], gait balance, impaired memory, and recent illness. Predisposing situation factors included ambulating without assistance. The incident report indicated the resident was noted on the floor in the bathroom with her pull up on top of her pants. Resident #1 said stated I have been here since night before last. The action taken was the resident was assessed, assisted to the commode, redressed, and assisted to bed. No skin tear or bruises noted neurological checks begun. The resident was oriented to person only notes. The incident report was signed by LVN K. A note at the bottom of the report said provide no slip socks for the resident. The note was signed by the DON. There was no fall assessment and no care plan update documented. Record review of Resident #1's incident report, dated [DATE] at 11:10 p.m., indicated a CNA (B) noted the resident sitting on the floor at the bedside and alerted the nurse. The resident was sitting on the floor with her right side against the bed and head facing towards the head of the bed. There were no injuries noted at this time. The resident did not comment as to why she was sitting on the floor. The report indicated predisposing environmental factors were poor lighting and furniture. Previous predisposing psychological factors confused, drowsy, weakness, [CONDITION(S)], gait impaired, and impaired mobility. The predisposing situational factors ambulating without assistance and improper footwear. The incident report was signed by LVN A. Record review of a nursing note, dated [DATE] at 11:10 a.m., indicated a CNA (B) noted Resident #1 sitting on the floor at bedside and alerted nurse. The resident was found sitting on the floor with her right side against the bed and her head facing toward the head of the bed. There were no injuries noted at this time. The resident was assessed from head to toe, no injuries noted. The DON, family, and doctor were notified. Neuro checks were started and within normal limits. All the resident's needs were met by staff, and call light in reach. The nursing note was signed by LVN A. Record review of Resident #1's incident report, dated [DATE] at 3:00 a.m., indicated the resident was found by CNA (C)and helped to bedside. When the nurse entered the room, resident was sitting on the bedside. The nurse noted large hematoma to the forehead with slight abrasion on hematoma. The resident was unable to give a description. Her mental status oriented to person only. The predisposing environmental factors were clutter and crowding. The predisposing environmental factors were poor lighting and furniture. The predisposing psychological factors confused, drowsy, weakness, fainted, gait imbalance, and impaired memory. Predisposing situational factors included ambulating without assist and improper footwear. The resident was sent to the hospital for evaluation. The report was signed by LVN A. Record review of a handwritten statement written by CNA C, dated [DATE], indicated at 3:00 a.m. on [DATE] Resident #1 was noted to be in the middle of the floor in a fetal position. She was wearing socks. I assisted her back to bed per her request. I saw a knot on her head, and I stayed with her until the nurse came in the room. Record review of Resident #1's Hospital Encounter Summary dated [DATE]- [DATE], indicated the reason for the visit was a fall. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge Condition was stable. The hospital course stated this [AGE] year-old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Electrocardiogram showed [CONDITION(S)] with rapid ventricular response. A magnetic resonance imaging of the brain was negative for [CONDITION(S)]. The patient had C2 (second vertebra of the neck) fracture secondary to ground level fall. Neurosurgery and trauma surgery evaluated the patient and recommended cervical collar with no surgical interventions for 6 weeks. The patient discharged in hemodynamically (stable pumping heart and good circulation of blood) stable condition. Record review of Resident #1's fall assessment, dated [DATE], indicated a score of 11 (moderate risk for falls.) She had 1 to 2 falls over the last 6 months, occasional incontinence of bladder, and used an assistive device such as a walker. Record review of Resident #1's Neurological Assessment Flow Sheet with instructions to document the date and time of each assessment then proceeded as follows, check the level of consciousness, pupil response for each eye, motor functions, hand grasps, extremities, pain response, and vitals. The form indicated the following: -On [DATE] at 11:10 p.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 11:25 p.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 11:40 p.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 11:55 p.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 12:25 a.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 12:55 a.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 1:25 a.m. the level of consciousness, pupil response, for each eye, motor functions, hand grapes, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. -On [DATE] at 1:55 a.m. the level of consciousness, pupil response, for each eye, motor functions, hand grasps, extremities, pain response vitals were documented. The signature was initialed by LVN A as completed. Each time the form listed the level of consciousness as alert, pupil response as brisk, hand grasps were equal, moved all extremities, and appropriate pain response. Vital signs were documented within normal limits. The observations of seizures, headaches, vomiting, and paralysis was none. On [DATE] at 3:55 a.m. the next scheduled time for a check was documented as hospital. The times on the form were filled out until [DATE] at 9:55 a.m. Record review of a fax to hospice from the facility indicated an occurrence on [DATE] at 12:00 a.m. in patient room. It indicated LVN A reported Resident #1 experienced two falls, the first on [DATE] and the second on [DATE] at 3:30 a.m. stating the patient hit her head and was transported to the hospital for evaluation and treatment. Record review of an in-service, dated [DATE] and signed by the former DON, indicated fall management. Attached to the in-service was a Patient Evaluation Post Fall Guideline form. The form indicated upon the occurrence of an incident and may have caused injury to a patient, the patient was evaluated to determine the presence or absence of injury prior to being moved. Remain with the patient. The evaluation included at a minimum. The location of the patient, vital signs and level of consciousness, skin condition, range of motion, presence or absence of pain, and neuro checks. (CNA C's signature was not on the in-service sign in sheet.) Record review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan with an initial date of [DATE] and last revised on [DATE], revealed Resident #1 had a Focused area of falls. The resident had the potential for falls related to dementia and disease process. The resident had an actual fall on [DATE] without injury. She had an actual fall with injury and hospital admission on [DATE]. On [DATE] the family declined therapy after she had a ground level fall and was admitted to hospice services. Interventions were a fall mat, keep the bed in lowest position when not providing care, low bed, and placed the call light within reach. Record review of Resident #1's nursing notes, dated [DATE] at 8:57 a.m., indicated the resident admitted with heart failure. There was an abrasion noted to the middle front of the scalp 4 cm by 2.5 cm with hematoma noted to the middle front of the forehead. Under the abrasion 3.5 cm x 3 cm black discoloration to the right eye. Above the right eyebrow and below was 8 cm x 6 cm, black discoloration. Under left eye was a 3 cm x 2 cm. with black discoloration to the right side of face from the top of the head to the middle of the cheek that measured 12 cm x 10.5 cm. The resident did not complain of pain and there were no signs of acute distress, respirations were even and unlabored. No open wounds or other areas noted, will continue to monitor. The call light and fluids were within reach and family at bedside. Record review of a nutritional risk assessment, dated [DATE], indicated Resident #1 weighed 77.3 pounds was 62 inches tall. Record review of a Hospice narrative note, dated [DATE], indicated Resident #1 was readmitted to hospice with a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was previously on servers and had several falls on [DATE], in which she hit her head and sustained a severe bump on her forehead, which swelled. She was transported to the hospital where she stayed until [DATE] and was discharged back to the nursing home. She had declined since her fall. She is now bedbound and minimally responsive to tactile stimuli. She attempted to open her eyes but was unsuccessful. She refused to wear the oxygen and removed it often. She also refused to wear the C collar (neck brace) and removed it as well. She received [MEDICATION(S)] as needed every six hours scheduled to control discomfort. After today, dietary attempted to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The family refused and diet was ordered as pureed as tolerated per the family request. The family elected palliative care with hospice services and declined aggressive treatments. Written by Hospice RN. Record Review of nursing notes, dated [DATE] at 12:55 a.m., indicated Resident #1 was deceased . Record review of a police report with a completion dated [DATE] and completed by Police Detective M indicated footage was downloaded from the camera overlooking the hallway where Resident #1 resided. The report indicated the footage was from [DATE] from 7:00 p.m. to 4:00 a.m. on [DATE]. The video indicated LVN A entered Resident #1's room on [DATE] at 11:04 p.m. and the next entrance was on [DATE] at 2:55 a.m. The police report indicated during the interview with LVN A he said he was in Resident #1's room on [DATE] around 11:00 p.m. when an aide alerted him, she had fallen. LVN A told the Deceive he was in Resident #1's room again on [DATE] around 3:00 a.m. when she had her second fall. During an interview on [DATE] at 4:45 a.m., LVN A said Resident #1 had a fall at about 11:00 p.m. on [DATE]. He said when he went into the room, Resident #1 was sitting on the floor beside the bed. He said he assessed her, and she did not have any injuries. LVN A said Resident #1 was independent since her admission to the facility and she went to the bathroom by herself. He said Resident #1 had a second fall on the same night around 3:00 a.m. on [DATE]. An aide told him Resident #1 had fallen. When he went in the room CNA C had already assisted Resident #1 to the bed. Resident #1 was sitting on the side of the bed when he first observed her. Resident #1 had a big knot on the side of her head. He said the knot was about the size of the palm of his hand and he had never seen anything like it. There was a small abrasion at the top of her forehead. LVN A said at that time he did not assess her he just called 911. He said Resident #1 was on Hospice prior to the fall and she was a small lady. LVN A said he observed the room and he had not seen anything the resident could have hit her head on during the fall. He said initially when he had gone in the room Resident #1 was sitting on the side of the bed talking but the more, she talked the more confused she became. During an interview on ,d+[DATE] 22 at 5:00 a.m., CNA B said she worked at the facility about a year. CNA B said she did not work with Resident #1 on a regular basis. She said she discovered her on the floor on [DATE] about 11:00 p.m. and informed LVN A. She said on the morning of [DATE] about 3:00 a.m. she and CNA C were walking down the hall. They noticed Resident #1 in her room, in the in the middle of the floor in front of the bed. The aide said she did not see anything on the floor Resident #1 could have hit her head on. She left to notify LVN A of the fall. CNA B said she did not see the knot on Resident #1's head until she was sitting on the side of the bed. During an interview and observation on [DATE] at 5:04 a.m., CNA C said she worked at the facility about six months. She and CNA B were doing rounds on [DATE] at about 3:00 a.m. when they saw Resident #1 on the floor face down. CNA C she said she helped Resident #1 up to the side of her bed. Resident #1 was very fragile and she was hollering in pain. CNA C said she knew she was not supposed to assist the resident in getting up. However, it was an emotional reaction to seeing the resident in distress. CNA C said Resident #1 had a very large knot on her forehead. The aide said she used to work the hall and Resident #1 took care of herself. During an observation CNA C showed the room and the area where Resident #1 was found on the floor. She said it was the same as the night Resident #1 had fallen except the bed was made. She said there was no blood on the floor or on any of the furniture. Observation on the room showed a nightstand beside Resident #1's bed and an empty bed closer to the door. The aide indicated the resident was not close to either object when she was found. The aide said it may have been possible Resident #1 hit the corner of the empty bed while falling. However, when they found her, she was not close to the bed. The aide said it was a Styrofoam boot noted to be close to the Resident #1's head. During an interview and observation on [DATE] at 5:21 a.m. with Resident #1's family member in Resident #1's room, she said she was not notified about the first fall, LVN A called her after the second fall and told her about both falls at that time. The family said Resident #1 had a broken nose, a fractured neck, and two cracked bones in her spine. The family member said prior to the fall Resident #1 was walking and talking. The hospital did an MRI of her head and said she had no fractures in her head and no stroke. Observation of Resident #1 showed a large dark, raised area on the right side of her forehead. The area was about the size of the palm of a hand, the area covered most of the right side of the forehead and cheek. The area had a nickel sized abrasion on the center of her forehead. The right side of her forehead and face were swollen and her cheek was swollen and bruised. Resident #1 had two black eyes, the right side being larger than the left. Resident #1 was noted to have a bruise on her right hand and on her right arm. Resident #1 did not speak, she appeared to be restless trying to take her clothes off, she never opened her eyes, but did not appear to be asleep. The family member said Resident #1 no longer spoke. Interview during the entrance conference on [DATE] at 10:00 a.m. with the Administrator, DON, LVN/ADON D and LVN/ADON E, they said Resident #1 was noted on the floor face down on [DATE] at 3:00 a.m. She had a large knot on her forehead and sent to the emergency room immediately after. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 5:11 p.m., the DON said she worked at the facility for about 6 weeks as the DON. She said she thought they put a fall mat in place after Resident #1's [DATE] fall. The DON said she did not know of any previous fall. During an interview on [DATE] at 9:30 a.m., LVN/ADON D and ADON/LVN E said they did not have anyone on a toileting program they did not have that intervention in place for residents. During an interview on [DATE] at 10:53 a.m., LVN F said she worked at the facility about four months. She said Resident #1 needed assistance to the bathroom. The resident had a walker to use in the room, and staff would tell her to use her call light. However, Resident #1 never used the light. She said Resident #1 wore pull ups and did have incontinent episodes. The LVN said they would take her food tray in a sit it up for her. The resident usually stayed in her room, she sat on the side of the bed or was in bed asleep. During an interview on [DATE] at 11:00 a.m., CNA G said she worked at the facility for a few months. She said Resident #1 would go to the bathroom, however, she saw her multiple times squatting against the wall urinating in her pull up. Resident #1 would stand with her back on the wall and squat like she was on the toilet. The aide said Resident #1 knew when she needed to go to the bathroom. She said Resident #1 was unsteady unless she had the walker. CNA G said Resident #1 would never pull the call light for assistance. She said they did not keep her bed in a low position because it had to be comfortable for Resident #1 to get up because she was tall. The aide said when Resident #1 had incontinent episodes, she would allow the staff to clean up. CNA G said Resident #1 was not fully cognitive but could make her needs known. She said sometimes Resident #1 would say she did not need help but would allow them to help her. The aide said sometimes Resident #1 would not have on pants or pull ups and the staff would have to help her get dressed. During an interview on [DATE] at 11:12 a.m., CNA H said Resident #1 could walk to the bathroom. CNA H said she saw Resident #1with nothing on but a shirt and she wore pull ups. She said Resident #1 had to be reminded to use her walker. During an interview on [DATE] at 1:40 p.m., LVN I said Resident #1's MDS for [DATE] was still in progress. She said the CNA work sheets indicated the resident was supervision of one person for most ADLs. She said the look back over the last 10 days of CNA ADL sheets to make the MDS determination about Resident #1's functional status which was she required supervision and one person assist with ADLs. She said she did not make acute changes to the care plan for falls or medical issues. Those were completed by the nurses. During an interview on [DATE] at 10:25 a.m., the DON, ADON D and ADON E said they were not aware Resident #1 squatted on the wall to use the bathroom. They never considered a bedside commode for her. They said the resident's cognitive status varied from day to day, that was likely the reason some staff said she needed assistance and other staff said she did not. They did not know if the bedside commode would have made a difference and they did not have a toileting program. During an interview on [DATE] at 11:02 a.m., LVN K said Resident #1 required assistance with going to the bathroom. LVN L said she completed the incident reports for [DATE] and [DATE]. LVN K said during both falls Resident #1 had on regular socks. She said Resident # 1 often got up on her own and would not let them assist. Resident #1had a walker and a cane but would not use either. LVN K said she was not aware Resident #1 was squatting on the wall but she did need assistance to the bathroom. During a telephone interview on [DATE] at 3:25 p.m., LVN A said he completed incident reports for [DATE] and [DATE] on Resident #1. He said the resident had nothing on her feet for either fall. The clutter he mentioned in the report was clutter on the table. There was nothing to trip over, she did have an Oxygen concentrator, but it was on the other side of the bed. LVN A said the lighting in the room was not good. He said Resident #1 was basically independent, and he did not see anything she could have tripped over. During a telephone interview on [DATE] at 8:18 a.m., Police Detective M said he completed the investigation regarding Resident #1 and the facility. He said he downloaded a copy of the video footage from the camera for the hall Resident #1 resided. He looked at the footage from [DATE] from 7:00 p.m. to [DATE] at 4:00 a.m. He said he did not think they had a copy because the video was due to rerecord the next day. He said the video appeared to be motion activated. It was not a continuous tape. He said LVNA may have walked down the hall more than two times. However, he did not go into the resident's room except on [DATE] at 11:04 p.m. and [DATE] at 2:55 a.m. Police Detective M said at no time did he see him go in the room in-between. He said he went in a few times after 2:55 a.m. He only documented when someone went into the room. The Police Detective also stated one of the aides was very vocal about LVN A not doing his job and neglecting Resident #1. Resident #1 had falls at 11:04 p.m. and 2:55 a.m. During a telephone interview on [DATE] at 12:00 p.m., CNA C said she had concerns about LVN A neglecting Resident #1 on the second fall, that was the only time CNA A was in the room with Resident #1 was on [DATE] about 3:00 a.m. She said LVN A never took her blood pressure or assessed the resident at all. He waited on emergency services to do the assessment. She said she did not receive an in-service about picking up Resident #1 prior to her being assessed. She said they talked to her and told her she could have injured the resident more by moving her. CNA C said she no longer worked at the facility because the whole incident upset her, and she wanted nothing to do with it and hung up the phone. During an interview on [DATE] at 12:20 p.m., LVN E/ADON said they did an in- service on falls related to Resident #1. The staff were told not to move the resident prior to an assessment by the nurse, movement of the resident could cause additional injury. She said the former DON did the in services as well. She said the family member told her LVN A had not contacted her about the first fall. During a telephone interview on [DATE] at 12:35 p.m., the NP said Resident #1 was not her patient. She was on hospice. If someone did call her on the night of her fall she did not remember. If someone did call her, they should not have, Resident #1 was on hospice and that doctor should have been notified. The NP said she had heard about the second fall. During a telephone interview on [DATE] at 1:34 p.m., LVN A said he sometimes, if there was no injury, notified the physician the next day. He said if he put he notified the physician in his notes, he must have but could not remember which physician he notified. He could not say if he notified the hospice physician, the NP, or the medical director. LVN A said he called the family and told them the resident was being taken to the hospital. He could not explain how he had gone into the residents room [ROOM NUMBER] times and the video camera did not note his entering the room once between 11:00 p.m. and 3:00 a.m. He could not say if he did the neuro checks, he kept saying Resident #1 was fine and had no injury. After he hung up at 1:45 p.m. the Administrator and two ADONs said LVN A did not give a definite answer if he did the neuro checks or not. The Administrator said the cameras were motion activated and he did not watch the video. During a telephone interview on [DATE] at 1:56 p.m., LVNA called back to say he did see Resident #1 between 11:00 p.m. and 3:00 p.m. but could not say for sure how many times he went in her room. He said his paperwork said he did the neuro checks. During a telephone interview on [DATE] at 2:00 p.m., Hospice RN said LVN A had let them know Resident #1 had fallen after the second fall, she sent a fax verification form. Record review of the facilities fall management system policy, dated [DATE], indicated it is the policy of the facilities that each resident will be assessed to determine his or her risk for fall and a plan of care implemented based on the residents' assessed needs. The purpose of addressing these factors is to better understand the resident's activities as they are related to falls. The procedure is on admission and quarterly and was significant change in status and licensed nurse will complete a fall assessment for each resident the risk areas are to be assessed mental status ambulatory elimination status gait balance perpetual deficits fall histories and predisposing disease and conditions. A care plan is implemented for residents at risk for falls. A resident that scores 10 or above per the following assessment may represent high risk for falls. Preventive interventions are reviewed evaluated and implemented to reduce the reoccurrence of falls. Nursing administration or designee will be responsible for validation and reevaluation of residents at risk for falls as effectiveness of interventions a file management program. Documentation requirements for residents sustaining a fall. The licensed nurse will document the fall on the nurses notes of the medical record. The documentation will reflect notifications to legal representatives and attending physician or agent of the fall. The licensed nurse will assess and document the condition of the resident at least once per shift for at least 72 hours post fall. Unwitnessed falls are co [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and interventions to prevent accidents/falls for 1 of 6 residents reviewed (Resident #1) for accidents. The facility failed to ensure Resident #1 received supervision with toileting as required by her MDS and Care Plan. The facility failed to reevaluate Resident #1 after two falls. The facility failed to update her care plan and put additional measures in place to prevent falls. The facility failed to have interventions in place to prevent the risks of falls. The resident had two falls in one night. The last fall resulted in a large hematoma to the head, and broken bones in her neck and back. These failures resulted in the Resident #1 sustaining harm and could cause other residents harm due o falls. Findings included: Record review Resident #1's Medical Diagnose sheet indicated was a [AGE] year-old female admitted to the facility on [DATE] with [CONDITION(S)] ([CONDITION(S)] lung disease that causes obstructed air flow from the lungs), high blood pressure, [CONDITION(S)] (an irregular and often very rapid heart rhythm), and dementia without behavioral disturbance. Record Review of Resident #1's MDS dated [DATE] indicated a BIMS score of 5 (severely impaired cognition). Her functional status indicated supervision and one-person physical assist for bed mobility, transfer, walking in the room, dressing and toilet use. Review of her MDS Fall History on Admission/Entry or Reentry indicated the resident was not assessed for falls prior to admission. She had one fall since admission with no major injury. Record Review of Resident #1's Care Plan with an initial date of [DATE] and last revised on [DATE] listed a Focus area of ADL self-care performance deficit and risk for not having needs met in a timely manner. Interventions were bed mobility with supervision, transfers with supervision, toileting with supervision, ambulation walks independently in her room, wheelchair with supervision, dressing limited, personal hygiene with supervision, bathing supervision of one person. Encourage the resident to use [NAME] light for assistance before attempting any activities of daily living that resident cannot do independently. Resident #1 had a Focus area of incontinence. The resident was incontinent of bowel/bladder related to impaired mobility and the age process. Revised on [DATE]. Interventions were check frequently for wetness and soiling, change as need. Assist to the toilet as needed. A Care Plan Focus area indicated hospice terminal prognosis. The resident had a terminal illness and was receiving hospice or palliative care. During the end-of-life process weight loss, skin breakdown, dehydration, fecal impaction and gradual or rapid loss of the ability to move may be unavoidable. The initial dated was [DATE] with no revision date. A Focus area of Falls. The resident had the potential for falls related to dementia and disease process. Initiated on [DATE] with no revisions. Interventions were to anticipate and meet the resident's needs. Review information on past falls and attempt to determine the cause of falls. Record possible root causes. After or removal any potential causes if possible and educate the resident, family, and caregivers, IDT as to causes. Record review of a fall assessment dated [DATE] indicated Resident # 1 had a score of 9 (moderate risk for falls.) Her gait analysis indicated she required hands on assistance to move from place to place. Record review of Resident #1 's incident report dated [DATE] at 5:35 p.m. indicated the resident had a fall. She said she had been in the bathroom. The resident was assessed with no injury and no complaints of pain. The incident report indicated the resident had predisposing situation factors such as ambulating without assist signed by LVN K. (no fall assessment and no care plan update noted) Record review of an incident report dated [DATE] at 4:00 p.m. indicated Resident #1 had a fall in the bathroom. The predisposing psychological factors indicated she was confused, she had weakness or [CONDITION(S)], gait balance, impaired memory, and recent illness. Predisposing situation factors included ambulating without assistance. The incident report indicated the resident was noted on the floor in the bathroom with her pull up on top of her pants. Resident #1 said stated I have been here since night before last. The action taken was the resident was assessed, assisted to the commode, redressed, and assisted to bed. No skin tear bruises noted neurological checks begun. The resident was oriented to person only notes. The Incident report was signed by LVN K. A note at the bottom of the report said provide no slip socks for the resident. The note was signed by the DON. (no fall assessment and no care plan update.) Record review of Resident #1's incident report dated [DATE] at 11:10 p.m. indicated a CNA noted resident sitting on the floor at the bedside and alerted nurse. The resident was sitting in the floor with her right side against the bed and head facing towards the head of the bed. There were no injuries noted at this time. The resident did not comment as to why she was sitting on the floor. The report indicated predisposing environmental factors were poor lighting and furniture. Previous predisposing psychological factors confused, drowsy, weakness, [CONDITION(S)], gait impaired, and impaired mobility. The predisposing situational factors ambulating without assistance and improper footwear. The incident report was signed by LVN A. Record review of Resident #1's incident report dated [DATE] at 3:00 a.m. indicated the resident was found by CNA and helped to bedside. When the nurse entered the room, resident was sitting on the bedside. The nurse noted large hematoma to the forehead with slight abrasion on hematoma. The resident was unable to give a description. Her mental status oriented to person only. The predisposing environmental factors were clutter and crowding. The predisposing environmental factors poor lighting and furniture. The predisposing psychological factors confused, drowsy, weakness, fainted, gait imbalance, and impaired memory. Predisposing situational factors included ambulating without assist and improper footwear. Resident sent to the hospital for evaluation. The report was signed by LVN A. Record review Resident #1's Hospital Encounter Summary dated [DATE]- [DATE] indicated the reason for the visit was a fall. Resident #1's diagnoses were [CONDITION(S)] (primary diagnosis), closed non displaced fracture of third cervical vertebra (neck), unspecified fracture morphology, initial encounter, compression fracture of thoracic vertebra (bone in the spine), unspecified thoracic vertebral level, initial encounter, contusion (bruise) of scalp, initial encounter, [MEDICATION(S)] (inflammation of the bladder), [CONDITION(S)] acute(damage or disease that affects the brain), and fall from ground level. Discharge Condition was stable. The hospital course stated this [AGE] year-old female with a past medical history of essential hypertension, diabetes presented to the hospital with [CONDITION(S)] with rapid ventricular rate. Electrocardiogram showed [CONDITION(S)] with rapid ventricular response. A magnetic resonance imaging of the brain was negative for [CONDITION(S)]. The patient had C2 (second vertebra of the neck) fracture secondary to ground level fall. Neurosurgery and trauma surgery evaluated the patient and recommended cervical collar with no surgical interventions for 6 weeks. The patient discharged in hemodynamically (stable pumping heart and good circulation of blood.) stable condition. Record review of Resident #1's fall assessment dated [DATE] indicated a score of 11 (moderate risk for falls.) She had 1 to 2 falls over the last 6 months, occasional incontinence of bladder, and used an assistive device such as a walker. Record review of Diagnoses Sheet dated [DATE] indicated Resident #1 had additional diagnoses of contusion of the scalp, [MEDICATION(S)] unspecified without hematuria, metabolic [CONDITION(S)], nondisplaced fracture of third cervical vertebra subsequent encounter for fracture with routine healing, wedge compression fracture of unspecified thoracic vertebra subsequent encounter for fracture with routine healing, and unspecified severe protein malnutrition, and unspecified fall. Record Review of Resident #1's Care Plan with an initial date of [DATE] and last revised on [DATE]. Resident #1 had a Focused area of falls. The resident had the potential for falls related to dementia, and disease process. The resident had an actual fall on [DATE] without injury. She had an actual fall with injury and hospital admission [DATE]. On [DATE] the family declined therapy after she had a ground level fall and was admitted to hospice services. Interventions were a fall mat, keep the bed in lowest position when not providing care, low bed, and placed the call light within reach. Review of Resident #1's nursing notes dated [DATE] at 8:57 a.m. indicated the resident admitted with heart failure. There is an abrasion noted to the middle front of scalp 4cm by 2.5 cm with hematoma noted to the middle front of forehead. Under the abrasion 3.5 cm x 3 cm black discoloration to the right eye. Above the right eyebrow and below was 8 cm x 6 cm, black discoloration. Under left eye was a 3 cm x 2 cm. with black discoloration to the right side of face from the top of the head to the middle of the cheek that measured 12 cm x 10.5 cm. The resident did not complain of pain and there were no signs of acute distress, respirations were even, and unlabored. No open wounds or other areas noted will continue to monitor. The call light and fluids were within reach, and family at bedside. Review of a nutritional risk assessment dated [DATE] indicated Resident #1 weighed 77.3 pounds was 62 inches tall. Record Review of nursing notes dated [DATE] at 12:55 a.m. indicated Resident #1 was deceased . During an interview on [DATE] at 4:45 a.m. LVN A said Resident #1 had a fall at about 11:00 on [DATE]. He said when he went into the room Resident #1, was sitting on the floor beside the bed. LVN A said Resident #1 was independent since her admission to the facility, and she went to the bathroom by herself. He said Resident #1 had a second fall on the same night around 3:00 a.m. on [DATE]. An aide told him Resident #1 had fallen. When he observed her, she had a big knot on the side of her head. He said the knot was about the size of the palm of his hand and he had never seen anything like it. There was a small abrasion at the top of her forehead. LVN A said at that time he did not assess her he just called 911. He said Resident #1 was on Hospice prior to the fall, and she was a small lady. LVN A said he observed the room and he had not seen anything that the resident could have hit her head on during the fall. He said initially when he had gone in the room Resident #1 was sitting on the side of the bed talking but the more she talked the more confused she became. During an interview on ,d+[DATE] 22 at 5:00 a.m. CNA B said she worked at the facility about a year. CNA B said she did not work with Resident #1 on a regular basis. She said she discovered her on the floor on [DATE] about 11:00 p.m. and let LVN A know. She said on the morning of [DATE] she and CNA C were walking down the hall. They noticed Resident #1 in her room, in the in the middle of the floor in front of the bed. The aide said she did not see anything on the floor that Resident #1 could have hit her head on. She left to notify the LVN A of the fall. CNA B said she did not see the knot on Resident #1's head until she was sitting on the side of the bed. During an interview and observation on ,d+[DATE] 22 at 5:04 a.m. CNA C said she worked at the facility about six months. She and CNA B were doing rounds on [DATE] at about 3:00 a.m. when they saw Resident #1 on the floor face down. CNA C she said she helped Resident #1 up to the side of her bed. Resident #1 was very fragile, and she was hollering in pain. CNA C said she knew she was not supposed to assist the resident in getting up. However, it was an emotional reaction to seeing the resident in distress. CNA C said Resident #1 had a very large knot on her forehead. The aide said she used to work the hall and Resident #1 took care of herself. During an observation CNA C showed the room and the area where Resident #1 was found on the floor. She said it was the same as the night Resident #1 had fallen except the bed was made. She said there was no blood on the floor or on any of the furniture. Observation on the room showed a nightstand beside Resident #1's bed and an empty bed closer to the door. The aide indicated the resident was not close to either object when she was found. The aide said it may have been possible Resident #1 hit the corner of the empty bed while falling. However, when they found her, she was not close to the bed. The aide said it was a Styrofoam boot noted to be close to the Resident #1's head. During an interview and observation on [DATE] at 5:21 a.m. with Resident #1's family member in Resident #1's room. The family said Resident #1 had a broken nose, a fractured neck, and two cracked bones in her spine. The family member said prior to the fall Resident #1 was walking and talking. The hospital did an MRI of her head and said that she had no fractures in her head and no stroke. Observation of Resident #1 showed a large dark, raised area on the right side of her forehead. The area was about the size of the palm of a hand, the area coved most of the right side of the forehead and cheek. That area had a nickel sized abrasion on the center of her forehead. The right side of her forehead and face was swollen and cheek was swollen and bruised. Resident #1 had two black eyes, the right side being larger than the left. Resident #1 was noted to have a bruise on her right hand and on her right arm. Resident #1 did not speak, she appeared to be restless trying to take her clothes off, she never opened her eyes, but did not appear to be asleep. The family member said Resident #1 no longer spoke. During the entrance conference on [DATE] at 10:00 a.m. with the Administrator, DON, LVN/ADON D and LVN/ADON E they said Resident #1 was noted on the floor face down. She had a large knot on her forehead and sent to the emergency room immediately after. Resident #1 had a history of falls but went to the bathroom independently. During an interview on [DATE] at 5:11 p.m. the DON said she worked at the facility for about 6 weeks as DON. She said she thought they put a fall mat in place after Resident #1's [DATE] fall. The DON said she did not know of any previous fall. During an interview on [DATE] at 9:30 a.m. LVN/ADON D and ADON/LVN E said they did not have anyone on a toileting program they do not have that intervention in place for residents. During an interview on [DATE] at 10:53 a.m. LVN F said she had worked at the facility about four months. She said Resident #1 needed assistance to the bathroom. The resident had a walker to use in the room, and staff would tell her use your call light. However, Resident #1 never used the light. She said Resident #1 wore pull ups and did have incontinent episodes. The LVN said they would take her tray in a sit it up for her. The resident usually stayed in her room, she sat on side of bed, or was in bed asleep. During an interview on [DATE] at 11:00 a.m. CNA G said she worked at the facility for a few months. She said Resident #1 would go to the bathroom. However, she had seen her multiple times squatting against the wall urinating in her pull up. Resident #1 would stand with her back on the wall and squat like she was on the toilet. The aide said Resident #1 knew when she needed to go to the bathroom. She said Resident #1 was unsteady unless she had the walker. CNA G said Resident #1 would never pull the call light for assistance. She said they did not keep her bed in a low position because it had to be comfortable for Resident #1 to get up because she was tall. The aide said when Resident #1 had incontinent episodes, she would allow the staff to clean up. CNA G said Resident #1 was basically the same since she worked at the facility, she was not fully cognitive but could make her needs known. She said sometimes Resident #1 would say she did not need help but would allow them to help her. The aide said sometimes Resident #1 would not have on pants or pull ups and the staff would have to help her get dressed. During an interview on [DATE] at 11:12 a.m. CNA H said Resident #1 could walk to the bathroom. CNA H said she had seen Resident #1with noting on but a shirt and she wore pull ups. She said Resident #1 had to be reminded to use her walker. During an interview on [DATE] at 1:40 p.m. LVN I said Resident #1's MDS for [DATE] was still in progress. She said the CNA work sheets indicated the resident was supervision of one person for most ADLs. She said the look back over the last 10 days of CNA ADL sheets to make the MDS determination about Resident #1's functional status. She said she did not make acute changes to the care plan for falls or medical issues. Those were completed by the nurses. During an interview on [DATE] at 10:25 a.m. DON and ADON D and ADON E said they were not aware Resident #1 squatted on the wall to use the bathroom. They never considered a bedside commode for her. They said the resident's cognitive status varied from day to day, that was likely the reason some staff said she needed assistance and other staff said she did not. They did not know if the bedside commode would have made a difference and they do not have a toileting program. During an interview on [DATE] at 11:02 a.m. LVN K said Resident #1 required assistance with going to the bathroom. LVN L said she completed the incident reports for [DATE] and [DATE]. LVN K said during both fall Resident #1 had on regular socks. She said Resident # 1 often got up on her own and would not let them assist. Resident #1 1 had a walker and a cane but would not use either. LVN K said she was not aware Resident #1 was squatting on the wall but did need assistance to the bathroom. During a telephone interview on [DATE] at 3:25 p.m. LVN A said he completed incident reports for [DATE] and [DATE] on Resident #1. He said the resident had nothing on her feet for either fall. The clutter he mentioned in the report was clutter on the table. There was nothing to trip over, she did have an Oxygen concentrator, but it was on the other side of the bed. LVN A said the lighting in the room was not good. He said Resident #1 was basically independent, and he did not see anything she could have tripped over. Record review of the facilities fall management system policy dated [DATE] indicated it is the policy of the facilities that each resident will be assessed to determine his or her risk for fall and a plan of care implemented based on the residents' assessed needs. The purpose of addressing these factors is to better understand the resident's activities as they are related to falls. The procedure is on admission and quarterly and was significant change in status and licensed nurse with complete a fall assessment for each resident the risk areas are to be assessed mental status ambulatory elimination status gait balance perpetual deficits fall histories and predisposing disease and conditions. A care plan is implemented for residents at risk for falls. A resident that scores 10 or above per the following assessment may represent high risk for falls. Preventive interventions are reviewed evaluated and implemented to reduce the reoccurrence of falls. Nursing administration or designee will be responsible for validation and reevaluation of residents at risk for falls as effectiveness of interventions a file management program. An administrative nurse will ensure that the president's plan of care is revised to reflect each fall and interventions that were implemented. Interventions will be implemented to prevent the resident from sustaining further falls based on the investigation results the licensed nurse will initiate intervention measures as soon as practicable.

Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 1 of 5 residents reviewed for neglect. (Resident #1) The facility neglected to assess Resident #1's level of pain prior, during, or after wound care treatment and did not administer pain medication to prevent/alleviate the resident's pain. She experienced pain daily due [MEDICAL CONDITION], ant bites, and [DIAGNOSES REDACTED]. (a rare skin disorder that causes painful blisters) Resident #1 could not be touched or moved without experiencing excruciating pain. An Immediate Jeopardy situation was identified on 07/31/18. The Immediate Jeopardy was removed on 08/01/18. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents who received pain management at risk for not having their pain addressed. Findings included: A face sheet dated 08/01/18 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. During an interview on 08/01/18 at 3:06 p.m., the DON said she had no knowledge of any ant bites on 06/03/18. She said today (8/1/18) was her first time seeing the nursing note indicating ants where biting Resident #1 on 06/03/18. The DON said the nurse who found the ants on Resident #1 on 6/3/18 should have completed an incident report. She said Resident #1's physician should have been notified. A physician order [REDACTED].#1 indicated the staff was to assess the resident's level of pain prior, during, and after wound care treatment each shift and the acceptable level of pain was 0 out of 10. The pain administration records dated 6/27-30/18 indicated Resident # 1 had no pain and received no pain medication. The MDS dated [DATE] indicated Resident # 1 was moderately impaired cognitively. The resident required extensive assistance of two persons with physical assistance with bed mobility, transfer, and dressing. The assessment indicated Resident #1 received a scheduled pain medication regimen and pain medication as ordered. The pain assessment interview indicated Resident #1 did not have pain present. The resident had moisture associated skin damage. A care plan updated 7/17/18 indicated Resident #1 was at risk for pain related [MEDICAL CONDITION]. Interventions included .administer pain medications and treatments per the physician's orders [REDACTED]. The plan indicated Resident #1 was at risk for pressure ulcers. Interventions included .reposition at least every 2 hours, more often as needed or requested and weekly skin checks to monitor for redness, circulatory problems, open areas, and other changes . Resident #1's care plan did not address the pain associated with the open wounds to her body or diaper [MEDICAL CONDITION]. A Non-Pressure Skin Condition Report dated 6/11/18 indicated Resident #1 had a [DIAGNOSES REDACTED] area to the right second toe with the condition of. The area was 2 centimeters by 2.5 cm with no depth, a scant amount of fluid drainage, and no odor. The note indicated the plan of care was updated. The report indicated Resident #1 had no pain. A Non-Pressure Skin Condition Report dated 7/17/18 indicated Resident #1 had the following areas: *right upper extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The report indicated the plan of care was updated and the resident did not experience pain. *left upper extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The report indicated the plan of care was updated and the resident did not experience pain. *right lower extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The areas were not measured. The report indicated the plan of care was updated. Resident #1 did not experience pain. *Area to lower back extending to lower buttocks Resident #1 had diaper [MEDICAL CONDITION]. The area was described as having clear, yellow, blood-tinged fluid draining. The areas were described as scattered all over the backside. There were no measurements. The report indicated Resident #1 may be allergic to the brief. The report indicated the plan of care was updated. Resident #1 was not experiencing pain related to the wound. The wound edges were macerated (soft tissue due to excessive moisture). A Wound Evaluation & Management Summary dated 7/19/18 indicated Resident #1 had diaper [MEDICAL CONDITION] of unknown duration. The exam indicated the resident was calm and co-operative. Resident #1 was noted to have [MEDICAL CONDITION] to the back and irritated [MEDICAL CONDITION] to the groin/buttock. The report indicated the resident had chronic [MEDICAL CONDITION] on the buttocks and back. The report indicated to leave brief off as much as possible and continue barrier cream. The treatment was listed as house barrier daily to affected areas. A physician order [REDACTED].>*[MEDICATION NAME] sulfate solution 20 milligram (mg)/ milliliter(ml) to be given 0.5 to 1 ml sublingually every hour as needed for pain/dyspnea (difficult or labored breathing); *clean diaper [MEDICAL CONDITION] to the lower back extending to both buttocks with normal saline, pat dry, and apply barrier cream to area every day and as needed and encourage to leave open to air as much as possible; *clean [DIAGNOSES REDACTED] wound to the right second toe with normal saline, pat dry, and apply skin prep to area and cover with a dry dressing every day and as needed; *assess the resident's level of pain prior during and after wound care; and acceptable level of pain was 0 on a pain scale of 0 to 10; *monitor [DIAGNOSES REDACTED] bump/blisters to the left /right upper extremity every day for signs and symptoms of infection on every shift. A physician order [REDACTED]. The TAR dated 6/27-30/18 indicated Resident #1 had no pain and received no pain medication during wound care treatment. A TAR dated 7/1-31/18 indicated Resident #1 had pain on 7/22/18 during wound care treatment. The record did not document any other pain. A MAR indicated [REDACTED]. A physician telephone order dated 7/23/18 indicated Resident #1 was admitted to hospice care. A Non-Pressure Skin Condition Report dated 7/23/18 indicated Resident #1 was admitted to hospice and there were no changes to the following areas: right second toe; left upper extremity; right lower extremity; and area to lower back extending to lower buttocks. A hospice note completed by the nurse practitioner dated 7/24/18 indicated Resident #1 did not have logical communication and would cry out in pain with movement. The note indicated Resident #1 had a diffused pattern of [DIAGNOSES REDACTED]tous papules ranging from 1-3 millimeters located on the head/face, interdigit on both upper extremities, arms, stomach, torso and back. The note indicated .These [MEDICAL CONDITION] have central hemorrhagic punctums . The note indicated the resident's linens had gross amount of blood speckling. The note indicated the [MEDICAL CONDITION] were suspicious for bed bugs or scabies and was suggested to be a form of [MEDICAL CONDITION] herpetiform. (chronic blistering skin condition, characterized by blisters filled with a watery fluid) The note indicated Resident #1 yelled in pain during the exam. There was no indication Resident #1 received pain medication. The 24 -hour nursing report dated 7/26/18 (no time) indicated ants were found in Resident #1's room. The note indicated the room was deep cleaned, no bites noted, and Resident #1 denied discomfort/pain. The nursing notes dated 7/26/18 -8/1/18 for Resident #1 did not indicate any documentation that Resident #1 was assessed regarding the ants found in her room on 7/26/18. There was no incident report found. During an interview on 07/31/18 at 6:22 a.m., CNA C said she provided care for Resident #1. She said Resident #1 always cried out in pain during care. CNA C said she did not have to report Resident #1's pain because all the staff knew. She said on 7/26/18 Resident #1 was discovered with ants all over her body. She said a rat's nest was found under Resident #1's dresser on 7/26/18. CNA C said she reported the ants to the maintenance supervisor on 7/26/18. During an interview on 07/31/18 at 7:59 a.m., the maintenance supervisor said he was aware of the ants in Resident #1's room on 7/26/18. He said he sprayed for ants, used bait stations for rats and called the exterminator. The maintenance director said the exterminators had not been out yet. During an interview on 07/31/18 at 7:07 a.m., CNA A said on 7/26/18 she found ants all over the body of Resident #1. CNA A said ants were in Resident #1's hair. She said there was a rat nest under Resident #1's dresser and when CNA G moved the dresser, about 3 rats ran out of the nest. CNA A said she reported the incident to LVN E, but she never came to the room to assess Resident #1. CNA A said she and CNA G took Resident #1 to the shower and put her in another bed until the administrator arrived. CNA A said the administrator had them move Resident #1 back into her bed. CNA A said Resident #1 had some areas on her arm prior to this incident, but they were not as bad as they were now. CNA A said on 7/26/18 when she went into Resident #1's room to reposition her, she was hollering and trying to scratch her arms. During an interview on 07/31/18 at 6:33 a.m., LVN E said Resident #1 had a lot of open areas due to immune disease. LVN E said on 7/26/18 ants where found all over Resident #1. She said after assessing Resident #1 the areas they looked like the same thing as her [DIAGNOSES REDACTED]. LVN E said Resident #1 was not in pain on 7/26/18. During an interview on 07/31/18 at 9:07 a.m., LVN H said Resident #1 had [DIAGNOSES REDACTED] to her upper extremities and the current treatment was monitoring. LVN H said Resident #1 has diaper [MEDICAL CONDITION] to her backside and the treatment was barrier cream. LVN H said she heard about the ants and she looked at Resident #1's skin. LVN H said if she would have known the ants were all over Resident #1, she would have called hospice. During an interview on 07/31/18 at 11:20 a.m., CNA G said Resident #1 first had a blister on her foot, then her hands, then it progressed to her bottom. CNA G said Resident #1 had been screaming out for approximately 2 months during care because she was in pain. CNA G said Resident #1 used to be able to get into her recliner and did not have pain like now. CNA G said on 07/26/18 around 6:10 a.m. she found a trail of ants on Resident #1 approximately 20 to 30, mostly on her right side. CNA G said Resident #1's interaction was not good because of her pain. CNA G said Resident #1 associated the pain with the staff and does not want to be moved. She said Resident #1 would say, Not Again, Not Again. During an interview on 07/31/18 at 8:10 a.m., the DON said she was aware there were ants found in Resident #1's room on 7/26/18, but did not know, the ants were on her body. The DON said the nurse who found the ants on Resident #1 on 7/26/18 should have completed an assessment, notified the physician, and completed an incident report. A Wound Evaluation & Management Summary dated 7/26/18 indicated Resident #1 had normal skin except for the groin/buttocks area. The exam indicated the resident had wound to the groin/buttock. The resident had diaper [MEDICAL CONDITION] and no change was noted. A Non-Pressure Skin Condition Report for Resident #1 dated 7/30/18 indicated the areas on her right second toe; left upper extremity; right lower extremity had improved and drying out. There was no change to the area on her lower back extending to lower buttocks. A progress note from the wound care physician dated 7/31/18 indicated on 7/26/18 Resident #1 had wounds in addition to the wounds on her back and buttocks. The resident had dry scabs noted on the feet and hands. The note indicated Resident #1 had a history of [REDACTED]. The note indicated these wounds started as blisters and then dried out to scabs. During an observation on 07/31/18 at 6:20 a.m., Resident #1 was heard yelling from the hallway and behind her the closed door. CNAs A and B were changing Resident #1's gown and she yelled Owww! and grimaced. Resident #1 had multiple open wounds to her back, buttocks, upper body, arms, and on her right second toe. During an interview on 07/31/18 at 6:25 a.m., CNA D said she provided care for Resident #1 last week. CNA D said Resident #1 was in pain and moaning and grunting during care. CNA D said she reported Resident #1's complaints of pain it to LVN E. During an interview on 07/31/18 at 6:59 a.m., CNA B said this was his first time providing care to Resident #1. CNA B said Resident #1 shouted every time he moved her even a little. CNA B said he notified LVN F that Resident #1 was in pain and LVN F said there was not much they could do because Resident #1 was on hospice. CNA B said he changed out Resident #1's gown because it had several spots of blood on it. CNA B said he changed out the sheets and pad on Resident #1's bed, but did not apply anything to her spots because CNA A told him that they were not supposed to because Resident #1 was on hospice. During an interview on 07/31/18 at 11:45 a.m., LVN F said she was not aware Resident #1 had pain during care until 7/31/18. LVN F said she had not provided Resident #1 any additional medication except for her routine Tylenol 4 (1 tablet 2 times a day) which started 7/25/18. During an observation on 07/31/18 at 8:45 a.m., Resident #1 was lying in bed. Resident #1 was screaming when CNA B touched her to turn her. Resident #1 had multiple open areas to her back and spots of blood over the entire pad under her. Resident #1 yelled out I cannot stand this I cannot do this, and Oh! It hurts. During an observation on 07/31/18 at 11:28 a.m., Resident #1 yelled out when CNA B turned her to observe the wounds to her back and buttocks area. The wounds on Resident #1's back, buttocks, and groin area were open, red sore-like draining areas. Resident #1 yelled out owwww! with facial grimacing, furrowing her brow, and sucking in her mouth while grabbing at CNA B's arm. Resident #1 had an incontinent pad stuck to her back and the CNA B pulled the pad off Resident #1's back to observe the areas. As CNA B peeled the stuck pad off Resident #1's back, Resident #1 yelled out owww! again. The pad was covered in light brown, light pinkish red drainage. Resident #1 continued to groan and yell out in pain as CNA B turned her onto her other side to reposition. A narcotic administration record dated 07/25/18 for Resident #1 indicated a supply of [MEDICATION NAME] was received. On 07/30/18, LVN E administered Resident #1 0.5 mg at 3:00 a.m. for pain. No other prn (as needed) [MEDICATION NAME] was documented as being administered. During an interview on 07/31/18 at 12:06 p.m., LVN H said she completed treatments for Resident #1, daily. She said Resident #1 yelled out in pain during the treatment. LVN H said she notified the charge nurse assigned to Resident #1 that shift and expected her to address the pain for Resident #1. LVN H said Resident #1 had declined in the last 2 weeks to the point of not getting out of bed. The Resident Abuse policy dated 12/05/16 revised 09/13/17 indicated .the resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment . The nursing policy and procedure manual 02/2005 revised 09/13/2017 indicated .all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administration or the DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse or supervisor in charge. The charge nurse or supervisor must immediately contact the Administrator or the DON of the incident. The nurse must document all incidents of alleged abuse/neglect on grievance form which may include the 24-hour report. All incident reports go directly to the Administrator, or in their absence the DON. The administrator or designated representative will immediately begin an investigation and follow the State guidelines for reporting incidents and accidents . The administrator was informed on 07/31/18 at 4:00 p.m., that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on 08/01/18 at 4:00 p.m., and included: .(Resident #1) is being reviewed and evaluated for pain during care using the PAINAD scale by (LVN J) on (MONTH) 31, (YEAR). Appropriate interventions will be implemented including being medicated for pain if indicated. (Resident #1) pain care plan is being reviewed, evaluated and updated by (RN DON) (MONTH) 31, (YEAR). Resident's pain regimen is being reviewed, evaluated and updated by (ADON J) LVN and attending physician (MONTH) 31, (YEAR). (Hospice nurse) RN from Texas Hospice came to center to coordinated care; with (DON) RN, they reviewed and evaluated resident's care plan, and pain regimen (MONTH) 31. (YEAR). Care Plan revision Intervention; 1) Ask resident prior to care if in pain and report to nurse; 2) If resident complains of pain during care or treatments stop and notify the nurse 3) Reposition from left side to right side with positioning devices unless she is eating her meal or Staff is providing care; 4) Staff to observe for signs or symptoms of pain; and report to nurse 5) Administer pain medications per physician's orders [REDACTED].> 6) Notify physician if pain unrelieved by ordered medication, or new 7) 1:1 music therapy 3 x week PRN Treatment 1) Treatment per physician orders 2) Easy Air Mattress for comfort 3) Therapy to evaluate for pain and bed mobility, provide staff training; Pain Regimen o Tylenol #4, tab po TID o Tylenol #4, tab po q 8 hours PRN Break through pain for facial grimacing/frowning, breathing heavy/ moderate pain o [MEDICATION NAME] 20 mg/ml 0.5ml-1ml SL q 1hour PRN with verbal expression of pain crying, moaning, crying out, yelling etc/severe pain Other Residents that could be affected Non-interviewable residents are being reviewed and evaluated using the PAINAD scale by the license nurse on (MONTH) 31, (YEAR). Using a QAPI tool, the DON/designee is identifying the pain of interviewable residents using a numeric pain evaluation (MONTH) 31. (YEAR) Appropriate interventions will be implemented including being medicated for pain. Residents with pain identified will have their care plan reviewed, evaluated and updated by (DON) RN by (MONTH) 1, (YEAR). Any resident identified with pain will have their pain regimen reviewed and evaluated and updated by LVN and attending Physician (MONTH) 31. (YEAR). Education Licensed Nurses and Certified Nurse Assistants will receive in service by DON/RN designee on o Pain Management Policy o Is it Pain (sign/symptoms of pain), starting (MONTH) 31, (YEAR) and will be completed by (MONTH) 1, (YEAR). No license nurse Or Certified Nurse Assistant will be allowed to return to work after August,2018 until they have completed this in service. Education will include posttest. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services (DON), RN designee, will complete random pain assessment audits during activity and care to monitor process for six (6) consecutive weeks. Audits will be reviewed by the Quality Assurance Performance Improvement Committee which evaluates audits and makes recommendations to sustain compliance two times a month. Quality Assessment and Performance Improvement A QA&A meeting will be conducted by Administrator on (MONTH) 31, (YEAR) to validate that the facility's Pain Management System is in place. The Center's medical directors were notified at 5:00 pm on (MONTH) 31, (YEAR) of the Immediate Jeopardy and plan to sustain compliance. (sic) On 08/01/18 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: The clinical record indicated Resident #1 was evaluated for pain during care using the PAINAD scale by the DON, and appropriate interventions were implemented including being medicated for pain if indicated. Resident #1's pain care plan was reviewed, evaluated and updated by the DON. Resident #1's pain regimen was reviewed, evaluated and updated by the DON and attending physician and the hospice agency came to coordinate care with the DON. 10 nursing staff (7 LVNs, and 3 CNAs) members from all shifts, were interviewed and said they received training regarding pain management, how to assess pain, and who to report to if symptoms of pain are not being resolved. On 08/01/18 at 5:15 p.m. the facility director was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/31/18 indicated 44 residents received pain management.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 5 residents reviewed for neglect. (Resident #1) The facility neglected to assess Resident #1's level of pain prior, during, or after wound care treatment and did not administer pain medication to prevent/alleviate the resident's pain. She experienced daily pain due [MEDICAL CONDITION], ant bites, and [DIAGNOSES REDACTED]. (a rare skin disorder that causes painful blisters) Resident #1 could not be touched or moved without experiencing excruciating pain. An Immediate Jeopardy situation was identified on 07/31/18. The Immediate Jeopardy was removed on 08/01/18. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents who received pain management at risk for not having their pain addressed. Findings included: The Resident Abuse policy dated 12/05/16 revised 09/13/17 indicated .the resident has the right to e free from abuse, neglect, misappropriation of resident's property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment . The nursing policy and procedure manual 02/2005 revised 09/13/2017 indicated .all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administration or the DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse or supervisor in charge. The charge nurse or supervisor must immediately contact the Administrator or the DON of the incident. The nurse must document all incidents of alleged abuse/neglect on grievance form which may include the 24-hour report. All incident reports go directly to the Administrator, or in their absence the DON. The administrator or designated representative will immediately begin an investigation and follow the State guidelines for reporting incidents and accidents . A face sheet dated 08/01/18 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. During an interview on 08/01/18 at 3:06 p.m., the DON said she had no knowledge of any ant bites on 06/03/18. She said today (8/1/18) was her first time seeing the nursing note indicating ants where biting Resident #1 on 06/03/18. The DON said the nurse who found the ants on Resident #1 on 6/3/18 should have completed an incident report. She said Resident #1's physician should have been notified. A physician order [REDACTED].#1 indicated the staff was to assess the resident's level of pain prior, during, and after wound care treatment each shift and the acceptable level of pain was 0 out of 10. The pain administration records dated 6/27-30/18 indicated Resident # 1 had no pain and received no pain medication. The MDS dated [DATE] indicated Resident # 1 was moderately impaired cognitively. The resident required extensive assistance of two persons with physical assistance with bed mobility, transfer, and dressing. The assessment indicated Resident #1 received a scheduled pain medication regimen and pain medication as ordered. The pain assessment interview indicated Resident #1 did not have pain present. The resident had moisture associated skin damage. A care plan updated 7/17/18 indicated Resident #1 was at risk for pain related [MEDICAL CONDITION]. Interventions included .administer pain medications and treatments per the physician's orders [REDACTED]. The plan indicated Resident #1 was at risk for pressure ulcers. Interventions included .reposition at least every 2 hours, more often as needed or requested and weekly skin checks to monitor for redness, circulatory problems, open areas, and other changes . Resident #1's care plan did not address the pain associated with the open wounds to her body or diaper [MEDICAL CONDITION]. A Non-Pressure Skin Condition Report dated 6/11/18 indicated Resident #1 had a [DIAGNOSES REDACTED] area to the right second toe with the condition of. The area was 2 centimeters by 2.5 cm with no depth, a scant amount of fluid drainage, and no odor. The note indicated the plan of care was updated. The report indicated Resident #1 had no pain. A Non-Pressure Skin Condition Report dated 7/17/18 indicated Resident #1 had the following areas: *right upper extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The report indicated the plan of care was updated and the resident did not experience pain. *left upper extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The report indicated the plan of care was updated and the resident did not experience pain. *right lower extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The areas were not measured. The report indicated the plan of care was updated. Resident #1 did not experience pain. *Area to lower back extending to lower buttocks Resident #1 had diaper [MEDICAL CONDITION]. The area was described as having clear, yellow, blood-tinged fluid draining. The areas were described as scattered all over the backside. There were no measurements. The report indicated Resident #1 may be allergic to the brief. The report indicated the plan of care was updated. Resident #1 was not experiencing pain related to the wound. The wound edges were macerated (soft tissue due to excessive moisture). A Wound Evaluation & Management Summary dated 7/19/18 indicated Resident #1 had diaper [MEDICAL CONDITION] of unknown duration. The exam indicated the resident was calm and co-operative. Resident #1 was noted to have [MEDICAL CONDITION] to the back and irritated [MEDICAL CONDITION] to the groin/buttock. The report indicated the resident had chronic [MEDICAL CONDITION] on the buttocks and back. The report indicated to leave brief off as much as possible and continue barrier cream. The treatment was listed as house barrier daily to affected areas. A physician order [REDACTED].>*[MEDICATION NAME] sulfate solution 20 milligram (mg)/ milliliter(ml) to be given 0.5 to 1 ml sublingually every hour as needed for pain/dyspnea (difficult or labored breathing); *clean diaper [MEDICAL CONDITION] to the lower back extending to both buttocks with normal saline, pat dry, and apply barrier cream to area every day and as needed and encourage to leave open to air as much as possible; *clean [DIAGNOSES REDACTED] wound to the right second toe with normal saline, pat dry, and apply skin prep to area and cover with a dry dressing every day and as needed; *assess the resident's level of pain prior during and after wound care; and acceptable level of pain was 0 on a pain scale of 0 to 10; *monitor [DIAGNOSES REDACTED] bump/blisters to the left /right upper extremity every day for signs and symptoms of infection on every shift. A physician order [REDACTED]. The TAR dated 6/27-30/18 indicated Resident #1 had no pain and received no pain medication during wound care treatment. A TAR dated 7/1-31/18 indicated Resident #1 had pain on 7/22/18 during wound care treatment. The record did not document any other pain. A MAR indicated [REDACTED]. A physician telephone order dated 7/23/18 indicated Resident #1 was admitted to hospice care. A Non-Pressure Skin Condition Report dated 7/23/18 indicated Resident #1 was admitted to hospice and there were no changes to the following areas: right second toe; left upper extremity; right lower extremity; and area to lower back extending to lower buttocks. A hospice note completed by the nurse practitioner dated 7/24/18 indicated Resident #1 did not have logical communication and would cry out in pain with movement. The note indicated Resident #1 had a diffused pattern of [DIAGNOSES REDACTED]tous papules ranging from 1-3 millimeters located on the head/face, interdigit on both upper extremities, arms, stomach, torso and back. The note indicated .These [MEDICAL CONDITION] have central hemorrhagic punctums . The note indicated the resident's linens had gross amount of blood speckling. The note indicated the [MEDICAL CONDITION] were suspicious for bed bugs or scabies and was suggested to be a form of [MEDICAL CONDITION] herpetiform. (chronic blistering skin condition, characterized by blisters filled with a watery fluid) The note indicated Resident #1 yelled in pain during the exam. There was no indication Resident #1 received pain medication. The 24 -hour nursing report dated 7/26/18 (no time) indicated ants were found in Resident #1's room. The note indicated the room was deep cleaned, no bites noted, and Resident #1 denied discomfort/pain. The nursing notes dated 7/26/18 -8/1/18 for Resident #1 did not indicate any documentation that Resident #1 was assessed regarding the ants found in her room on 7/26/18. There was no incident report found. During an interview on 07/31/18 at 6:22 a.m., CNA C said she provided care for Resident #1. She said Resident #1 always cried out in pain during care. CNA C said she did not have to report Resident #1's pain because all the staff knew. She said on 7/26/18 Resident #1 was discovered with ants all over her body. She said a rat's nest was found under Resident #1's dresser on 7/26/18. CNA C said she reported the ants to the maintenance supervisor on 7/26/18. During an interview on 07/31/18 at 7:59 a.m., the maintenance supervisor said he was aware of the ants in Resident #1's room on 7/26/18. He said he sprayed for ants, used bait stations for rats and called the exterminator. The maintenance director said the exterminators had not been out yet. During an interview on 07/31/18 at 7:07 a.m., CNA A said on 7/26/18 she found ants all over the body of Resident #1. CNA A said ants were in Resident #1's hair. She said there was a rat nest under Resident #1's dresser and when CNA G moved the dresser, about 3 rats ran out of the nest. CNA A said she reported the incident to LVN E, but she never came to the room to assess Resident #1. CNA A said she and CNA G took Resident #1 to the shower and put her in another bed until the administrator arrived. CNA A said the administrator had them move Resident #1 back into her bed. CNA A said Resident #1 had some areas on her arm prior to this incident, but they were not as bad as they were now. CNA A said on 7/26/18 when she went into Resident #1's room to reposition her, she was hollering and trying to scratch her arms. During an interview on 07/31/18 at 6:33 a.m., LVN E said Resident #1 had a lot of open areas due to immune disease. LVN E said on 7/26/18 ants where found all over Resident #1. She said after assessing Resident #1 the areas they looked like the same thing as her [DIAGNOSES REDACTED]. LVN E said Resident #1 was not in pain on 7/26/18. During an interview on 07/31/18 at 9:07 a.m., LVN H said Resident #1 had [DIAGNOSES REDACTED] to her upper extremities and the current treatment was monitoring. LVN H said Resident #1 has diaper [MEDICAL CONDITION] to her backside and the treatment was barrier cream. LVN H said she heard about the ants and she looked at Resident #1's skin. LVN H said if she would have known the ants were all over Resident #1, she would have called hospice. During an interview on 07/31/18 at 11:20 a.m., CNA G said Resident #1 first had a blister on her foot, then her hands, then it progressed to her bottom. CNA G said Resident #1 had been screaming out for approximately 2 months during care because she was in pain. CNA G said Resident #1 used to be able to get into her recliner and did not have pain like now. CNA G said on 07/26/18 around 6:10 a.m. she found a trail of ants on Resident #1 approximately 20 to 30, mostly on her right side. CNA G said Resident #1's interaction was not good because of her pain. CNA G said Resident #1 associated the pain with the staff and does not want to be moved. She said Resident #1 would say, Not Again, Not Again. During an interview on 07/31/18 at 8:10 a.m., the DON said she was aware there were ants found in Resident #1's room on 7/26/18, but did not know, the ants were on her body. The DON said the nurse who found the ants on Resident #1 on 7/26/18 should have completed an assessment, notified the physician, and completed an incident report. A Wound Evaluation & Management Summary dated 7/26/18 indicated Resident #1 had normal skin except for the groin/buttocks area. The exam indicated the resident had wound to the groin/buttock. The resident had diaper [MEDICAL CONDITION] and no change was noted. A Non-Pressure Skin Condition Report for Resident #1 dated 7/30/18 indicated the areas on her right second toe; left upper extremity; right lower extremity had improved and drying out. There was no change to the area on her lower back extending to lower buttocks. A progress note from the wound care physician dated 7/31/18 indicated on 7/26/18 Resident #1 had wounds in addition to the wounds on her back and buttocks. The resident had dry scabs noted on the feet and hands. The note indicated Resident #1 had a history of [REDACTED]. The note indicated these wounds started as blisters and then dried out to scabs. During an observation on 07/31/18 at 6:20 a.m., Resident #1 was heard yelling from the hallway and behind her the closed door. CNAs A and B were changing Resident #1's gown and she yelled Owww! and grimaced. Resident #1 had multiple open wounds to her back, buttocks, upper body, arms, and on her right second toe. During an interview on 07/31/18 at 6:25 a.m., CNA D said she provided care for Resident #1 last week. CNA D said Resident #1 was in pain and moaning and grunting during care. CNA D said she reported Resident #1's complaints of pain it to LVN E. During an interview on 07/31/18 at 6:59 a.m., CNA B said this was his first time providing care to Resident #1. CNA B said Resident #1 shouted every time he moved her even a little. CNA B said he notified LVN F that Resident #1 was in pain and LVN F said there was not much they could do because Resident #1 was on hospice. CNA B said he changed out Resident #1's gown because it had several spots of blood on it. CNA B said he changed out the sheets and pad on Resident #1's bed, but did not apply anything to her spots because CNA A told him that they were not supposed to because Resident #1 was on hospice. During an interview on 07/31/18 at 11:45 a.m., LVN F said she was not aware Resident #1 had pain during care until 7/31/18. LVN F said she had not provided Resident #1 any additional medication except for her routine Tylenol 4 (1 tablet 2 times a day) which started 7/25/18. During an observation on 07/31/18 at 8:45 a.m., Resident #1 was lying in bed. Resident #1 was screaming when CNA B touched her to turn her. Resident #1 had multiple open areas to her back and spots of blood over the entire pad under her. Resident #1 yelled out I cannot stand this I cannot do this, and Oh! It hurts. During an observation on 07/31/18 at 11:28 a.m., Resident #1 yelled out when CNA B turned her to observe the wounds to her back and buttocks area. The wounds on Resident #1's back, buttocks, and groin area were open, red sore-like draining areas. Resident #1 yelled out owwww! with facial grimacing, furrowing her brow, and sucking in her mouth while grabbing at CNA B's arm. Resident #1 had an incontinent pad stuck to her back and the CNA B pulled the pad off Resident #1's back to observe the areas. As CNA B peeled the stuck pad off Resident #1's back, Resident #1 yelled out owww! again. The pad was covered in light brown, light pinkish red drainage. Resident #1 continued to groan and yell out in pain as CNA B turned her onto her other side to reposition. A narcotic administration record dated 07/25/18 for Resident #1 indicated a supply of [MEDICATION NAME] was received. On 07/30/18, LVN E administered Resident #1 0.5 mg at 3:00 a.m. for pain. No other prn (as needed) [MEDICATION NAME] was documented as being administered. During an interview on 07/31/18 at 12:06 p.m., LVN H said she completed treatments for Resident #1, daily. She said Resident #1 yelled out in pain during the treatment. LVN H said she notified the charge nurse assigned to Resident #1 that shift and expected her to address the pain for Resident #1. LVN H said Resident #1 had declined in the last 2 weeks to the point of not getting out of bed. The Resident Abuse policy dated 12/05/16 revised 09/13/17 indicated .the resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment . The nursing policy and procedure manual 02/2005 revised 09/13/2017 indicated .all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administration or the DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse or supervisor in charge. The charge nurse or supervisor must immediately contact the Administrator or the DON of the incident. The nurse must document all incidents of alleged abuse/neglect on grievance form which may include the 24-hour report. All incident reports go directly to the Administrator, or in their absence the DON. The administrator or designated representative will immediately begin an investigation and follow the State guidelines for reporting incidents and accidents . The administrator was informed on 07/31/18 at 4:00 p.m., that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on 08/01/18 at 4:00 p.m., and included: .(Resident #1) is being reviewed and evaluated for pain during care using the PAINAD scale by (LVN J) on (MONTH) 31, (YEAR). Appropriate interventions will be implemented including being medicated for pain if indicated. (Resident #1) pain care plan is being reviewed, evaluated and updated by (RN DON) (MONTH) 31, (YEAR). Resident's pain regimen is being reviewed, evaluated and updated by (ADON J) LVN and attending physician (MONTH) 31, (YEAR). (Hospice nurse) RN from Texas Hospice came to center to coordinated care; with (DON) RN, they reviewed and evaluated resident's care plan, and pain regimen (MONTH) 31. (YEAR). Care Plan revision Intervention; 1) Ask resident prior to care if in pain and report to nurse; 2) If resident complains of pain during care or treatments stop and notify the nurse 3) Reposition from left side to right side with positioning devices unless she is eating her meal or Staff is providing care; 4) Staff to observe for signs or symptoms of pain; and report to nurse 5) Administer pain medications per physician's orders [REDACTED].> 6) Notify physician if pain unrelieved by ordered medication, or new 7) 1:1 music therapy 3 x week PRN Treatment 1) Treatment per physician orders 2) Easy Air Mattress for comfort 3) Therapy to evaluate for pain and bed mobility, provide staff training; Pain Regimen o Tylenol #4, tab po TID o Tylenol #4, tab po q 8 hours PRN Break through pain for facial grimacing/frowning, breathing heavy/ moderate pain o [MEDICATION NAME] 20 mg/ml 0.5ml-1ml SL q 1hour PRN with verbal expression of pain crying, moaning, crying out, yelling etc/severe pain Other Residents that could be affected Non-interviewable residents are being reviewed and evaluated using the PAINAD scale by the license nurse on (MONTH) 31, (YEAR). Using a QAPI tool, the DON/designee is identifying the pain of interviewable residents using a numeric pain evaluation (MONTH) 31. (YEAR) Appropriate interventions will be implemented including being medicated for pain. Residents with pain identified will have their care plan reviewed, evaluated and updated by (DON) RN by (MONTH) 1, (YEAR). Any resident identified with pain will have their pain regimen reviewed and evaluated and updated by LVN and attending Physician (MONTH) 31. (YEAR). Education Licensed Nurses and Certified Nurse Assistants will receive in service by DON/RN designee on o Pain Management Policy o Is it Pain (sign/symptoms of pain), starting (MONTH) 31, (YEAR) and will be completed by (MONTH) 1, (YEAR). No license nurse Or Certified Nurse Assistant will be allowed to return to work after August,2018 until they have completed this in service. Education will include posttest. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services (DON), RN designee, will complete random pain assessment audits during activity and care to monitor process for six (6) consecutive weeks. Audits will be reviewed by the Quality Assurance Performance Improvement Committee which evaluates audits and makes recommendations to sustain compliance two times a month. Quality Assessment and Performance Improvement A QA&A meeting will be conducted by Administrator on (MONTH) 31, (YEAR) to validate that the facility's Pain Management System is in place. The Center's medical directors were notified at 5:00 pm on (MONTH) 31, (YEAR) of the Immediate Jeopardy and plan to sustain compliance. (sic) On 08/01/18 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: The clinical record indicated Resident #1 was evaluated for pain during care using the PAINAD scale by the DON, and appropriate interventions were implemented including being medicated for pain if indicated. Resident #1's pain care plan was reviewed, evaluated and updated by the DON. Resident #1's pain regimen was reviewed, evaluated and updated by the DON and attending physician and the hospice agency came to coordinate care with the DON. 10 nursing staff (7 LVNs, and 3 CNAs) members from all shifts, were interviewed and said they received training regarding pain management, how to assess pain, and who to report to if symptoms of pain are not being resolved. On 08/01/18 at 5:15 p.m. the facility director was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/31/18 indicated 44 residents received pain management.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care based on their comprehensive assessment and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents reviewed for pain management. (Resident #1) The facility did not assess Resident #1's level of pain prior, during, or after wound care treatment and did not administer pain medication to prevent/alleviate the resident's pain. She experienced daily pain due [MEDICAL CONDITION], ant bites, and [DIAGNOSES REDACTED]. (a rare skin disorder that causes painful blisters) Resident #1 could not be touched or moved without experiencing excruciating pain. An Immediate Jeopardy situation was identified on 07/31/18. The Immediate Jeopardy was removed on 08/01/18. The facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 44 residents who received pain management at risk for not having their pain addressed. Findings included: A face sheet dated 08/01/18 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. During an interview on 08/01/18 at 3:06 p.m., the DON said she had no knowledge of any ant bites on 06/03/18. She said today (8/1/18) was her first time seeing the nursing note indicating ants where biting Resident #1 on 06/03/18. The DON said the nurse who found the ants on Resident #1 on 6/3/18 should have completed an incident report. She said Resident #1's physician should have been notified. A physician order [REDACTED].#1 indicated the staff was to assess the resident's level of pain prior, during, and after wound care treatment each shift and the acceptable level of pain was 0 out of 10. The pain administration records dated 6/27-30/18 indicated Resident # 1 had no pain and received no pain medication. The MDS dated [DATE] indicated Resident # 1 was moderately impaired cognitively. The resident required extensive assistance of two persons with physical assistance with bed mobility, transfer, and dressing. The assessment indicated Resident #1 received a scheduled pain medication regimen and pain medication as ordered. The pain assessment interview indicated Resident #1 did not have pain present. The resident had moisture associated skin damage. A care plan updated 7/17/18 indicated Resident #1 was at risk for pain related [MEDICAL CONDITION]. Interventions included .administer pain medications and treatments per the physician's orders [REDACTED]. The plan indicated Resident #1 was at risk for pressure ulcers. Interventions included .reposition at least every 2 hours, more often as needed or requested and weekly skin checks to monitor for redness, circulatory problems, open areas, and other changes . Resident #1's care plan did not address the pain associated with the open wounds to her body or diaper [MEDICAL CONDITION]. A Non-Pressure Skin Condition Report dated 6/11/18 indicated Resident #1 had a [DIAGNOSES REDACTED] area to the right second toe with the condition of. The area was 2 centimeters by 2.5 cm with no depth, a scant amount of fluid drainage, and no odor. The note indicated the plan of care was updated. The report indicated Resident #1 had no pain. A Non-Pressure Skin Condition Report dated 7/17/18 indicated Resident #1 had the following areas: *right upper extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The report indicated the plan of care was updated and the resident did not experience pain. *left upper extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The report indicated the plan of care was updated and the resident did not experience pain. *right lower extremity Resident #1 had [DIAGNOSES REDACTED]/blisters with black/brown scabs. The areas were not measured. The report indicated the plan of care was updated. Resident #1 did not experience pain. *Area to lower back extending to lower buttocks Resident #1 had diaper [MEDICAL CONDITION]. The area was described as having clear, yellow, blood-tinged fluid draining. The areas were described as scattered all over the backside. There were no measurements. The report indicated Resident #1 may be allergic to the brief. The report indicated the plan of care was updated. Resident #1 was not experiencing pain related to the wound. The wound edges were macerated (soft tissue due to excessive moisture). A Wound Evaluation & Management Summary dated 7/19/18 indicated Resident #1 had diaper [MEDICAL CONDITION] of unknown duration. The exam indicated the resident was calm and co-operative. Resident #1 was noted to have [MEDICAL CONDITION] to the back and irritated [MEDICAL CONDITION] to the groin/buttock. The report indicated the resident had chronic [MEDICAL CONDITION] on the buttocks and back. The report indicated to leave brief off as much as possible and continue barrier cream. The treatment was listed as house barrier daily to affected areas. A physician order [REDACTED].>*[MEDICATION NAME] sulfate solution 20 milligram (mg)/ milliliter(ml) to be given 0.5 to 1 ml sublingually every hour as needed for pain/dyspnea (difficult or labored breathing); *clean diaper [MEDICAL CONDITION] to the lower back extending to both buttocks with normal saline, pat dry, and apply barrier cream to area every day and as needed and encourage to leave open to air as much as possible; *clean [DIAGNOSES REDACTED] wound to the right second toe with normal saline, pat dry, and apply skin prep to area and cover with a dry dressing every day and as needed; *assess the resident's level of pain prior during and after wound care; and acceptable level of pain was 0 on a pain scale of 0 to 10; *monitor [DIAGNOSES REDACTED] bump/blisters to the left /right upper extremity every day for signs and symptoms of infection on every shift. A physician order [REDACTED]. The TAR dated 6/27-30/18 indicated Resident #1 had no pain and received no pain medication during wound care treatment. A TAR dated 7/1-31/18 indicated Resident #1 had pain on 7/22/18 during wound care treatment. The record did not document any other pain. A MAR indicated [REDACTED]. A physician telephone order dated 7/23/18 indicated Resident #1 was admitted to hospice care. A Non-Pressure Skin Condition Report dated 7/23/18 indicated Resident #1 was admitted to hospice and there were no changes to the following areas: right second toe; left upper extremity; right lower extremity; and area to lower back extending to lower buttocks. A hospice note completed by the nurse practitioner dated 7/24/18 indicated Resident #1 did not have logical communication and would cry out in pain with movement. The note indicated Resident #1 had a diffused pattern of [DIAGNOSES REDACTED]tous papules ranging from 1-3 millimeters located on the head/face, interdigit on both upper extremities, arms, stomach, torso and back. The note indicated .These [MEDICAL CONDITION] have central hemorrhagic punctums . The note indicated the resident's linens had gross amount of blood speckling. The note indicated the [MEDICAL CONDITION] were suspicious for bed bugs or scabies and was suggested to be a form of [MEDICAL CONDITION] herpetiform. (chronic blistering skin condition, characterized by blisters filled with a watery fluid) The note indicated Resident #1 yelled in pain during the exam. There was no indication Resident #1 received pain medication. The 24 -hour nursing report dated 7/26/18 (no time) indicated ants were found in Resident #1's room. The note indicated the room was deep cleaned, no bites noted, and Resident #1 denied discomfort/pain. The nursing notes dated 7/26/18 -8/1/18 for Resident #1 did not indicate any documentation that Resident #1 was assessed regarding the ants found in her room on 7/26/18. There was no incident report found. During an interview on 07/31/18 at 6:22 a.m., CNA C said she provided care for Resident #1. She said Resident #1 always cried out in pain during care. CNA C said she did not have to report Resident #1's pain because all the staff knew. She said on 7/26/18 Resident #1 was discovered with ants all over her body. She said a rat's nest was found under Resident #1's dresser on 7/26/18. CNA C said she reported the ants to the maintenance supervisor on 7/26/18. During an interview on 07/31/18 at 7:59 a.m., the maintenance supervisor said he was aware of the ants in Resident #1's room on 7/26/18. He said he sprayed for ants, used bait stations for rats and called the exterminator. The maintenance director said the exterminators had not been out yet. During an interview on 07/31/18 at 7:07 a.m., CNA A said on 7/26/18 she found ants all over the body of Resident #1. CNA A said ants were in Resident #1's hair. She said there was a rat nest under Resident #1's dresser and when CNA G moved the dresser, about 3 rats ran out of the nest. CNA A said she reported the incident to LVN E, but she never came to the room to assess Resident #1. CNA A said she and CNA G took Resident #1 to the shower and put her in another bed until the administrator arrived. CNA A said the administrator had them move Resident #1 back into her bed. CNA A said Resident #1 had some areas on her arm prior to this incident, but they were not as bad as they were now. CNA A said on 7/26/18 when she went into Resident #1's room to reposition her, she was hollering and trying to scratch her arms. During an interview on 07/31/18 at 6:33 a.m., LVN E said Resident #1 had a lot of open areas due to immune disease. LVN E said on 7/26/18 ants where found all over Resident #1. She said after assessing Resident #1 the areas they looked like the same thing as her [DIAGNOSES REDACTED]. LVN E said Resident #1 was not in pain on 7/26/18. During an interview on 07/31/18 at 9:07 a.m., LVN H said Resident #1 had [DIAGNOSES REDACTED] to her upper extremities and the current treatment was monitoring. LVN H said Resident #1 has diaper [MEDICAL CONDITION] to her backside and the treatment was barrier cream. LVN H said she heard about the ants and she looked at Resident #1's skin. LVN H said if she would have known the ants were all over Resident #1, she would have called hospice. During an interview on 07/31/18 at 11:20 a.m., CNA G said Resident #1 first had a blister on her foot, then her hands, then it progressed to her bottom. CNA G said Resident #1 had been screaming out for approximately 2 months during care because she was in pain. CNA G said Resident #1 used to be able to get into her recliner and did not have pain like now. CNA G said on 07/26/18 around 6:10 a.m. she found a trail of ants on Resident #1 approximately 20 to 30, mostly on her right side. CNA G said Resident #1's interaction was not good because of her pain. CNA G said Resident #1 associated the pain with the staff and does not want to be moved. She said Resident #1 would say, Not Again, Not Again. During an interview on 07/31/18 at 8:10 a.m., the DON said she was aware there were ants found in Resident #1's room on 7/26/18, but did not know, the ants were on her body. The DON said the nurse who found the ants on Resident #1 on 7/26/18 should have completed an assessment, notified the physician, and completed an incident report. A Wound Evaluation & Management Summary dated 7/26/18 indicated Resident #1 had normal skin except for the groin/buttocks area. The exam indicated the resident had wound to the groin/buttock. The resident had diaper [MEDICAL CONDITION] and no change was noted. A Non-Pressure Skin Condition Report for Resident #1 dated 7/30/18 indicated the areas on her right second toe; left upper extremity; right lower extremity had improved and drying out. There was no change to the area on her lower back extending to lower buttocks. A progress note from the wound care physician dated 7/31/18 indicated on 7/26/18 Resident #1 had wounds in addition to the wounds on her back and buttocks. The resident had dry scabs noted on the feet and hands. The note indicated Resident #1 had a history of [REDACTED]. The note indicated these wounds started as blisters and then dried out to scabs. During an observation on 07/31/18 at 6:20 a.m., Resident #1 was heard yelling from the hallway and behind her the closed door. CNAs A and B were changing Resident #1's gown and she yelled Owww! and grimaced. Resident #1 had multiple open wounds to her back, buttocks, upper body, arms, and on her right second toe. During an interview on 07/31/18 at 6:25 a.m., CNA D said she provided care for Resident #1 last week. CNA D said Resident #1 was in pain and moaning and grunting during care. CNA D said she reported Resident #1's complaints of pain it to LVN E. During an interview on 07/31/18 at 6:59 a.m., CNA B said this was his first time providing care to Resident #1. CNA B said Resident #1 shouted every time he moved her even a little. CNA B said he notified LVN F that Resident #1 was in pain and LVN F said there was not much they could do because Resident #1 was on hospice. CNA B said he changed out Resident #1's gown because it had several spots of blood on it. CNA B said he changed out the sheets and pad on Resident #1's bed, but did not apply anything to her spots because CNA A told him that they were not supposed to because Resident #1 was on hospice. During an interview on 07/31/18 at 11:45 a.m., LVN F said she was not aware Resident #1 had pain during care until 7/31/18. LVN F said she had not provided Resident #1 any additional medication except for her routine Tylenol 4 (1 tablet 2 times a day) which started 7/25/18. During an observation on 07/31/18 at 8:45 a.m., Resident #1 was lying in bed. Resident #1 was screaming when CNA B touched her to turn her. Resident #1 had multiple open areas to her back and spots of blood over the entire pad under her. Resident #1 yelled out I cannot stand this I cannot do this, and Oh! It hurts. During an observation on 07/31/18 at 11:28 a.m., Resident #1 yelled out when CNA B turned her to observe the wounds to her back and buttocks area. The wounds on Resident #1's back, buttocks, and groin area were open, red sore-like draining areas. Resident #1 yelled out owwww! with facial grimacing, furrowing her brow, and sucking in her mouth while grabbing at CNA B's arm. Resident #1 had an incontinent pad stuck to her back and the CNA B pulled the pad off Resident #1's back to observe the areas. As CNA B peeled the stuck pad off Resident #1's back, Resident #1 yelled out owww! again. The pad was covered in light brown, light pinkish red drainage. Resident #1 continued to groan and yell out in pain as CNA B turned her onto her other side to reposition. A narcotic administration record dated 07/25/18 for Resident #1 indicated a supply of [MEDICATION NAME] was received. On 07/30/18, LVN E administered Resident #1 0.5 mg at 3:00 a.m. for pain. No other prn (as needed) [MEDICATION NAME] was documented as being administered. During an interview on 07/31/18 at 12:06 p.m., LVN H said she completed treatments for Resident #1, daily. She said Resident #1 yelled out in pain during the treatment. LVN H said she notified the charge nurse assigned to Resident #1 that shift and expected her to address the pain for Resident #1. LVN H said Resident #1 had declined in the last 2 weeks to the point of not getting out of bed. The Resident Abuse policy dated 12/05/16 revised 09/13/17 indicated .the resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment . The nursing policy and procedure manual 02/2005 revised 09/13/2017 indicated .all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administration or the DON. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the charge nurse or supervisor in charge. The charge nurse or supervisor must immediately contact the Administrator or the DON of the incident. The nurse must document all incidents of alleged abuse/neglect on grievance form which may include the 24-hour report. All incident reports go directly to the Administrator, or in their absence the DON. The administrator or designated representative will immediately begin an investigation and follow the State guidelines for reporting incidents and accidents . The administrator was informed on 07/31/18 at 4:00 p.m., that an Immediate Jeopardy was identified due to the above failures. The facility's plan of removal was accepted on 08/01/18 at 4:00 p.m., and included: .(Resident #1) is being reviewed and evaluated for pain during care using the PAINAD scale by (LVN J) on (MONTH) 31, (YEAR). Appropriate interventions will be implemented including being medicated for pain if indicated. (Resident #1) pain care plan is being reviewed, evaluated and updated by (RN DON) (MONTH) 31, (YEAR). Resident's pain regimen is being reviewed, evaluated and updated by (ADON J) LVN and attending physician (MONTH) 31, (YEAR). (Hospice nurse) RN from Texas Hospice came to center to coordinated care; with (DON) RN, they reviewed and evaluated resident's care plan, and pain regimen (MONTH) 31. (YEAR). Care Plan revision Intervention; 1) Ask resident prior to care if in pain and report to nurse; 2) If resident complains of pain during care or treatments stop and notify the nurse 3) Reposition from left side to right side with positioning devices unless she is eating her meal or Staff is providing care; 4) Staff to observe for signs or symptoms of pain; and report to nurse 5) Administer pain medications per physician's orders [REDACTED].> 6) Notify physician if pain unrelieved by ordered medication, or new 7) 1:1 music therapy 3 x week PRN Treatment 1) Treatment per physician orders 2) Easy Air Mattress for comfort 3) Therapy to evaluate for pain and bed mobility, provide staff training; Pain Regimen o Tylenol #4, tab po TID o Tylenol #4, tab po q 8 hours PRN Break through pain for facial grimacing/frowning, breathing heavy/ moderate pain o [MEDICATION NAME] 20 mg/ml 0.5ml-1ml SL q 1hour PRN with verbal expression of pain crying, moaning, crying out, yelling etc/severe pain Other Residents that could be affected Non-interviewable residents are being reviewed and evaluated using the PAINAD scale by the license nurse on (MONTH) 31, (YEAR). Using a QAPI tool, the DON/designee is identifying the pain of interviewable residents using a numeric pain evaluation (MONTH) 31. (YEAR) Appropriate interventions will be implemented including being medicated for pain. Residents with pain identified will have their care plan reviewed, evaluated and updated by (DON) RN by (MONTH) 1, (YEAR). Any resident identified with pain will have their pain regimen reviewed and evaluated and updated by LVN and attending Physician (MONTH) 31. (YEAR). Education Licensed Nurses and Certified Nurse Assistants will receive in service by DON/RN designee on o Pain Management Policy o Is it Pain (sign/symptoms of pain), starting (MONTH) 31, (YEAR) and will be completed by (MONTH) 1, (YEAR). No license nurse Or Certified Nurse Assistant will be allowed to return to work after August,2018 until they have completed this in service. Education will include posttest. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services (DON), RN designee, will complete random pain assessment audits during activity and care to monitor process for six (6) consecutive weeks. Audits will be reviewed by the Quality Assurance Performance Improvement Committee which evaluates audits and makes recommendations to sustain compliance two times a month. Quality Assessment and Performance Improvement A QA&A meeting will be conducted by Administrator on (MONTH) 31, (YEAR) to validate that the facility's Pain Management System is in place. The Center's medical directors were notified at 5:00 pm on (MONTH) 31, (YEAR) of the Immediate Jeopardy and plan to sustain compliance. (sic) On 08/01/18 the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: The clinical record indicated Resident #1 was evaluated for pain during care using the PAINAD scale by the DON, and appropriate interventions were implemented including being medicated for pain if indicated. Resident #1's pain care plan was reviewed, evaluated and updated by the DON. Resident #1's pain regimen was reviewed, evaluated and updated by the DON and attending physician and the hospice agency came to coordinate care with the DON. 10 nursing staff (7 LVNs, and 3 CNAs) members from all shifts, were interviewed and said they received training regarding pain management, how to assess pain, and who to report to if symptoms of pain are not being resolved. On 08/01/18 at 5:15 p.m. the facility director was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 7/31/18 indicated 44 residents received pain management.

Based on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure ulcers from developing for 5 of 5 residents reviewed for pressure ulcers. (Residents #s 1, 2, 6, 8, and 11) The facility did not consistently provide pressure relieving interventions for Resident #2's feet to prevent the resident from developing pressure ulcers. Resident #2 developed a facility acquired stage 3 pressure ulcer on his right heel. The right heel pressure ulcer healed; however, the wound reopened, worsening to an unstageable pressure ulcer. The facility did not provide interventions for Resident #1's feet to prevent the resident from developing a pressure ulcer. Resident #1 was not repositioned or provided incontinent care for over 4 hours. She developed facility acquired stage 1 pressure ulcers of the left and right heels. The facility did not provide turning and repositioning in a manner that prevented friction and shearing for Resident #s 6, 8, and 11 who were at risk for the development of pressure ulcers. The wound care nurse (LVN) positioned Resident #'s 2, 6, 8, and 11 on their sides while abruptly jerking the draw sheet underneath the residents; she did not obtain the necessary assistance in accordance with the comprehensive assessment and care plan. This failure could place 29 residents who received preventive skin care at risk for the development of new pressures ulcers and the worsening of existing pressure ulcers. Findings included: 1. Admission record dated 05/24/17 indicated Resident #2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 understood others and was able to make his needs known. He was dependent on staff with transfers, bed mobility, dressing, and toilet use. He required extensive assistance with transfers and personal hygiene. He had a [MEDICAL CONDITION] bag and an indwelling urinary catheter. The resident was at risk for pressure ulcers and was admitted with a Stage 4 pressure ulcer. An MDS dated [DATE] indicated Resident #2 understood others and was able to make his needs known. The resident was cognitively intact. He was dependent on staff with transfers, bed mobility, dressing, and toilet use. He required extensive assistance with transfers and personal hygiene. He had a [MEDICAL CONDITION] bag and an indwelling urinary catheter. The resident was at risk for pressure ulcers and was admitted with a Stage 4 pressure ulcer and currently had a facility acquired Stage 3. A care plan initiated 12/28/16 and last updated 08/08/17 indicated Resident #2 was at risk for developing pressure ulcers. Interventions included weekly skin checks to monitor for redness or open areas, and other changes in skin integrity and to elevate (float) the resident's heels. A wound assessment from the Wound Healing Clinic dated 08/04/17 indicated Resident #2 had a stage 3 pressure ulcer on his right heel that was acquired on 03/14/17. The wound was measured at 1.1 cm x 0.8 cm x 0.1 cm. The assessment indicated Resident #2 was to wear soft boot to his feet with socks on and a heel lift boots to be used in physical therapy and while in wheelchair. A wound assessment dated [DATE] from the Wound Healing Clinic indicated Resident #2 had a healed stage 3 pressure ulcer on his right heel. Resident #2 was discharged from the wound care center with orders to: continue to protect new skin with gauze or opti-foam for 2-3 weeks, to continue to change the resident's position every 2 hours, and to utilize offloading boots long term. Nursing note dated 08/24/17 indicated Resident #2's healed stage 3 pressure ulcer on his right heel reopened today. The notes indicated the facility acquired area continued to be a stage 3 pressure ulcer on his right heel. The wound measured 1.5 cm x 1.5 cm x 0.1 cm and described with no undermining or tunneling and 100% granulation (healthy, red in color) tissue in the wound bed. There was light serosanguineous drainage noted and the wound edges were with in normal limits. Resident #2 was to have heel offloading boots on while he was in bed. The resident was non-compliant with following the wound care specialist orders and his pressure ulcer re-opened. Interventions included a low air loss (LAL) mattress and wheelchair cushion. These interventions were already in place when the wound reopened. Educated resident on importance caring for his wound. Followed by Wound Care clinic. Skin assessed daily. Resident has medical [DIAGNOSES REDACTED]. The wound care clinic physician order [REDACTED].#2's reopened stage 3 pressure ulcer on his right heel with normal saline, pat dry, apply zinc oxide to the peri-wound, apply collagen to wound bed. calcium alginate apply foam dressing daily and as needed. The wound physician's wound assessment dated [DATE] indicated this was Resident #2's initial evaluation. Recommendations included: to reposition Resident #2 per facility protocol and to off-load (float) the resident's heels while he was in bed. The wound assessment indicated the right heel pressure ulcer measured 1 cm x 0.5 cm x 0.1, with a surface area measuring 0.50 cm. The wound was described to have light serous drainage and 100% granulation tissue. The wound physician wound assessment dated [DATE] indicated Resident #2's right heel pressure ulcer had deteriorated. The wound size was measured at 0.9 cm x 2.4 cm x 0.1 cm with a surface area measuring 2.16 cm. The wound was described to have light serous drainage with 5% of the wound bed covered with thick adherent devitalized (dead tissue ranging in colors of tan, brown, yellow, and black and can be wet or dry tissue) necrotic (dead tissue black in color). The other 95% of the wound bed had granulation tissue. The assessment indicated the resident required a surgical excisional debridement on 09/07/17. The physician recommended to continue treating the pressure ulcer with a collagen dressing daily, a dry protective dressing, to continue repositioning the resident per facility protocol, and to off-load (float) the resident's heels while he was in bed. The wound physician wound assessment dated [DATE] indicated Resident #2's right heel pressure ulcer's progress showed no change. The wound was measured at 0.9 cm x 2.4 cm x 0.1 cm with a surface area measuring 2.16 cm. The pressure ulcer was described to have light serous drainage with 5% of the wound bed covered with thick adherent devitalized necrotic tissue and granulation tissue 95%. A surgical excisional debridement was performed on 09/14/17. The physician recommended to continue treating the pressure ulcer daily with a collagen dressing, a dry protective dressing, to continue repositioning per facility protocol, and to off-load (float) the resident's heels in while he was in bed. During an observation and interview on 09/18/17 at 11:59 a.m., the treatment nurse provided wound care for Resident #2's right heel pressure ulcer. Upon entrance into Resident #2's room he was found lying in bed with his floating heels on. The treatment nurse removed the contaminated dressing from the resident's right heel and there was an ample amount of brownish-red drainage on the dressing. The wound bed was not visible and was 95% covered with moist yellow and dark brown slough. The wound edges were macerated and had a dark purplish gray hue around the proximal edges of the wound. The treatment nurse measured the right heel pressure ulcer to be 2.5 cm x 2.7 cm x 0.1 cm. The treatment nurse said Resident #2's pressure ulcer looked worse than it did the week before. She said the pressure ulcer fluctuated in size. During an interview on 09/19/17 at 3:26 p.m., Resident #2 said he felt his right heel pressure ulcer was not healing properly because the staff did not know how to put his floating boots on properly, so over the past two weeks he made sure to tell them if they were not on correct. He said the staff did not put them on today when they placed him back in bed. During an observation on 9/19/17 at 3:00 p.m., Resident #2 was lying on his back while in bed sleeping. His heels were not offloaded, he did not have anything but socks on and he was lying with his heels on the mattress. During an observation and interview on 09/19/17 at 3:19 p.m., Resident #2 was lying in bed asleep on his back without the heel offloading boots on. LVN L said Resident #2 did not have the heel offloading boots on because he would not allow the CNAs to put them on him. Resident #2 said the CNAs who placed him in bed did not put the boots on him. During an interview on 09/19/17 at 3:26 p.m., Resident #2 said he had never refused allowing the staff to place the heel boots on him while he was in bed. .Consolidated physician orders [REDACTED].#1 was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment and clear speech. She was understood by others and was able to understand others. She required extensive assistance of 2 staff for bed mobility, transfers, and toileting. She was at risk for the development of pressure ulcers and had no identified pressure ulcers at the time of this assessment. The Patient Risk Profile dated 6/29/17 at 9:51 a.m., indicated the following: On 1/4/17, 3/3/17, and 6/29/17 Resident #1 was identified to be at risk for developing pressure ulcers. A radiology report dated 8/30/17 indicated Resident #1 had avascular necrosis of the left femoral head and failure of hardware. A care plan initiated 4/18/16 and reviewed 9/15/17 indicated Resident #1 was at risk for the development of pressure ulcers related to incontinence and impaired mobility. Interventions included .reposition at least every 2 hours ., check frequently for wetness and soiling, every two hours and provide incontinence care as needed .monitor and report to MD (medical director) as needed changes in skin status: appearance, color, impaired skin .pressure relieving/reducing devices on bed/chair . During an observation on 9/17/17 at 2:35 p.m., Resident #1 was lying in bed on her back with the head of bed elevated 45 degrees, and her heels were not floating off the surface of the mattress. A strong odor of urine and feces permeated the air. During an interview on 9/17/17 at 2:42 p.m., RN R said Resident #1 was incontinent of bowel and bladder and she had a recent fall with a fracture to her left hip. RN R said the resident recently had weight loss. He said he did not know if Resident #1 had skin breakdown. During an interview and observation on 9/17/17 at 2:48 p.m., Resident #1 said she was dirty and needed to be changed. She said both of her heels burned and she had not been changed or repositioned since breakfast. Her left leg was flexed at the hip and both heels were on the mattress. During an observation and interview on 9/17/17 at 3 p.m., CNA P and CNA Q provided Resident #1 incontinence care. Resident #1 had a large bowel movement that was adhered to the inner aspect of her right thigh, perineum, and buttocks. The top sheet had a large yellow stain and the bottom sheet was saturated with urine from her waist to her knees. Both buttocks were red and blanchable. Her heels each had silver-dollar sized reddened area. CNA Q pressed on the area on resident's left and right heel and the redness on each heel was non-blanchable. Resident #1 indicated her heels were painful to touch. Resident #1 repeated she had not been provided repositioning or incontinent care today since breakfast. CNA P and CNA Q said Resident #1 required 2 staff to turn and provide incontinent care. CNA P AND CNA Q said this was their first round since shift change at 2:00 p.m. During an observation on 9/17/17 at 5:40 p.m., Resident #1 was lying on her back in bed with the head of the bed elevated 30 degrees, both heels were on the bed. During an interview on 9/18/17 at 11:25 a.m., CNA S said she worked on 9/17/17 from 6:00 a.m. until 2:00 p.m. and did not provide incontinent care or repositioning assistance for Resident #1. She said she thought CNA T had provided the care. During an interview on 9/18/17 at 1:50 p.m., CNA T said she was assigned Resident #1 on 9/17/17. She said Resident #1 was provided incontinent care around 10 a.m. on 9/17/17, although the ADL Detailed Entry Report indicated she provided incontinent care before 7:22a.m. She said she did not provide turning/repositioning or incontinent care any other time during her shift. She said she should have provided positioning and incontinent care prior to end of shift. During an interview on 9/17/17 at 5:45 p.m., the DON she expected staff to provide incontinent care and positioning as needed. During an observation on 9/17/17 at 5:50 p.m., after surveyor intervention the DON told RN R to check Resident #1's heels and off load them. During an observation and interview on 9/17/17 at 6:30 p.m. Resident #1's heels were off loaded on pillows. Both heels remained reddened the size of silver dollars. Resident #1 said her right heel was not burning anymore, but she could still feel some discomfort in the left heel but it was much better. During an interview on 9/17/17 at 6:31 p.m. RN R said he was waiting on orders for Resident #1's reddened heels. He said he had staff to off load her heels and they remained red. He said a stage 1 pressure ulcer would be accompanied by blisters and Resident #1 did not have blisters only redness of both heels. A nursing note dated 9/17/17 (no time) (after surveyor intervention) RN R indicated Resident #1's heels had been off loaded and orders for skin treatment would be clarified the following day. The note did not offer any further description of the heels, whether blanchable or non-blanchable; and did not indicate the areas of the right and left heels were measured. During an interview on 9/18/17 at 2:50 p.m. RN R said he was told by the DON to apply skin prep to both heels and he said he wrote orders to off load the heels on 9/17/17. He could not identify the stage of the reddened heels but said they remained red today. A nursing note dated 9/18/17 (no time), RN R indicated Resident #1 had new orders for the redness on her heels to apply skin prep to both of her heels every shift as a prevention for pressure ulcers. The notes indicated to elevate the resident's heels and provide a cushion to offset heel boots. During an interview on 9/19/17 at 8:59 a.m., the wound care nurse said she assessed Resident #1's heels this am and did not initiate a skin assessment sheet for because they had blanchable redness. She said they called the physician and received orders to apply skin prep to both heels every shift and applied pressure relieving boots. A nursing note dated 9/18/17 at 3:00 p.m., indicated Resident #1's heels were assessed as follows: the treatment nurse assessed bilateral heels. Red blanchable 2 cm x 2 cm right heel, 2.5 cm x 2.0 cm lt. heel. No complaint of pain noted. Notified MD: NON: skin prep every shift for prevention. Notified nurse. Heel off loading boots put in place . During an interview on 9/19/17 at 8:45 a.m. the DON said Resident #1's heels were red, but blanchable when she evaluated them on 9/18/17. She said she did not stage them, but interventions were put in place to offload Resident #1's heels to prevent further injury. 3. Physician order [REDACTED].#6 readmitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. Orders with a start date of 6/29/17 included to clean shear to the left buttocks with normal saline, pat dry, apply collagen to area, and cover with dry dressing every 2 days and as needed and clean deep tissue injury to the right heel with normal saline and pat dry. Apply [MEDICATION NAME] to wound bed, cover with dry dressing every 2 days and as needed. A MDS dated [DATE] indicated Resident #6 had moderately impaired cognition, unclear speech, was rarely understood, and rarely understood others. Resident #6 required extensive assistance of 2 staff for bed mobility and transfers, was incontinent of bowel and bladder, and had an unhealed unstageable pressure ulcer measuring 3.0 cm x 3.0 cm with eschar. The MDS did not identify the pressure ulcer of the left inner buttock and coccyx. A care plan dated 5/13/17 indicated Resident #6 had an excoriation to his left inner buttock with skin erosion caused by prolonged exposure to a source of moisture caused by incontinence. Approaches included encourage resident to turn and reposition at least every 2 hours and offload wound, LAL(low air loss mattress), educate staff to prevent shearing forces and friction during transfers and care. A review on 5/13/17 indicated clean with normal saline. Pat dry. Apply skin prep peri-wound. Cover with [MEDICATION NAME] Q (every) 3 days. A review on 6/5/17 indicated he was readmitted with orders to clean with normal saline. Pat dry. Apply Venelex cream (a topical cream used to promote debridement of eschar), cover with ABD pad Q day and PRN (as needed). On 6/29/17 a review of the care plan progress note indicated the wound care physician assessed and treated the wound and new orders to clean with normal saline. Apply collagen to wound bed. Cover with dry dressing every 2 days and prn. A Braden Scale dated 4/25/17 indicated Resident #6 was at risk for developing pressure ulcers. The Wound Assessment Details Report sheet indicated Resident #6 had the following: *6/5/17-Left buttock, excoriation, partial thickness, measuring 6.0 cm x 0.9cm x 0.0 cm. *9/5/17-Left buttock, excoriation, partial thickness, measuring 1.2cm x 2.0 cm x 0.10 cm An MDS dated [DATE] indicated Resident #5 had moderately impaired cognition, unclear speech, was rarely understood, and rarely understood others. Resident #6 required extensive assistance of 2 staff for bed mobility and transfers and was incontinent of bowel and bladder. The resident had one unhealed unstageable pressure ulcer measuring 3.0 cm x 3.0 cm with eschar at the time of this assessment. A MDS note dated 8/17/17 at 5:26 p.m. said Resident #6 has potential for pressure ulcer development related to incontinence, impaired mobility and unplanned weight loss. On admission 6/5/17 he had an unstageable wound to his right heel which continue to be unstageable but on assessment done 8/13/17 was now covered with Eschar. Note Text: On record review and discussion with facility treatment nurse Resident has 2 active wounds. He has a pressure wound to his Rt. Heel that after today's discussion was determined to be unstageable due to eschar. On admission this wound presented as a deep tissue injury described as purple ecchymosis: 100%. The most recent description in wound rounds dated 8/8/17 describes tissue type as necrotic hard, firm, adherent 100 %. Measurement of 3.0 cm x 3.0 cm x 0.01 cm but on MDS depth was not recorded due to depth cannot be measured with 100% Eschar present. He also has a partial thickness trauma wound to his left buttock that on 8/8/17 had slough over 10% of the wound bed. A care plan dated 5/13/17 indicated Resident #6 had an excoriation on his left inner buttock with skin erosion caused by prolonged exposure to a source of moisture caused by incontinence. Approaches included: encourage resident to turn and reposition at least every 2 hours and offload wound, provide a LAL(low air loss mattress), and to educate staff to prevent shearing forces and friction during transfers and care of the resident. A treatment sheet dated September, 2017 indicated Resident #6 was receiving wound care to a shear on the left buttocks every 2 days and as needed. A nurse's note date 5/7/17 at 0500 a.m. indicated Resident #6 had an open reddened area on the left buttock. A nurse's note dated 5/7/17 indicated Resident #6 had a 6cm x 1cm horizontal open area on the left buttocks, the area around the wound was macerated and moist. The area is described as being 3 cm from the anal sphincter. A Wound Care Specialist Evaluation dated 9/14/17 indicated Resident #6's wound on his buttock measured 1.8 cm x 0.7 cm x 0.1 cm, with light serous drainage, and 100% granulation tissue. Wound Progress: No change. Recommendations included: off-load wound, reposition per facility protocol. During an observation on 9/17/17 at 4:40 p.m. Resident #6 was lying in bed on his back with the head of bed elevated 45 degrees. He was receiving an enteral feeding through a gastrostomy tube. He was positioned on a low air loss mattress and both feet were off loaded in pressure relieving boots. During an interview on 9/17/17 at 4:40 p.m. R said Resident #6 was dependent on 2 staff for turning and repositioning. He said Resident #6 had a pressure ulcer on his right heel but did not know the stage of the ulcer, and he also had a shear on his buttocks. During an observation on 9/18/17 08:45 a.m. Resident #6 was lying in his bed on his back. The head of bed was elevated 45 degrees and he was receiving enteral nutrition by pump. The feeding was infused over 14 hours. During an interview on 9/18/17 at 8:47 a.m. the wound care nurse said Resident #6 had an area on his tailbone and left buttock that began breaking down due to moisture associated [MEDICAL CONDITION] because of fecal incontinence. He was sent to the hospital and came back with worsening of the same wound. She said the same area is being treated as an excoriation caused by trauma and he is being followed by the wound care physician. She said the wound was never identified as a pressure ulcer. She said Resident #6 also has an unstageable pressure ulcer to his right heel. During an observation of wound care on 9/18/17 at 8:50 a.m. the wound care nurse informed Resident #6 she would perform wound care to his buttock and ask him to begin turning to his left side. She grasped the draw sheet with both hands and in an upward jerking motion pulled the draw sheet. The sheet slid against Resident #6's skin as the wound care nurse pulled rolling him onto his left side. A stage 2 pressure ulcer was observed over the coccyx and upper left buttock crease. After cleansing the wound over the coccyx and inner left upper buttock, measurements were taken as follows: 0.7cm x 0.7 cm x 0.1 cm. The wound edges were well defined, the wound bed appeared red with 100 % granulation tissue. The surrounding skin was intact and pale due to depigmentation. Collagen and a dry dressing was applied. During an interview on 9/18/17 at 3:38 p.m. the DON said she expected 2 staff assist Resident #6 for turning and repositioning using a draw sheet. She said residents who are at risk for skin breakdown and are unable to turn themselves are at greater risk for friction and shear which could cause worsening of current pressure ulcers and the development of new ones. 4. Physician orders [REDACTED].#8 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #8 was severely impaired cognitively and usually understood others and usually made herself understood. Resident #8 required extensive 2 person assistance with bed mobility. The MDS indicated Resident #8 was at risk of developing pressure ulcers, but no pressure ulcers were identified. A care plan dated 09/17/17 indicated Resident #8 required extensive to total weight bearing assistance for bed mobility. The care plan indicated Resident #8 was at risk for pressure ulcer development and had a shear to her inner buttock. Interventions included to prevent shearing forces and friction during transfers. A skin condition report dated 09/17/17 indicated Resident #8 had a new 0.5 cm x0.5 cm x 0.1 cm open area on her coccyx that was identified as a shear. Treatment included cleanse area with normal saline, collagen to wound bed, and cover with duoderm every 3 days or as needed. During an observation on 09/18/17 at 10:54 a.m., the treatment nurse attempted to roll Resident #8 from her back to her right side to perform wound care. The treatment nurse grabbed the draw sheet with both hands and abruptly pulled the draw sheet up until Resident #8 rolled to her right side. The treatment nurse rolled Resident #8 from her back to her right side without assistance. 5. A consolidated physician orders [REDACTED].#11 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A Patient Risk Profile with an assessment date of 1/4/17 indicated Resident #11 was at moderate risk for the development of pressure ulcers. A Wound Assessment Details Report dated 9/11/17 identified the following Right lower buttock-Skin Stripping-facility -acquired. Denuded, measured 5.20 cm x 2.0 cm x 0.10 cm. The wound bed was pale pink or red. Comments: Resident has shearing to area. Treatment in place. An Interdisciplinary Care Plan dated 9/11/17 indicated Resident #11 had a shear on his right lower buttocks. Approaches included turn every 2 hours and educate staff to prevent shearing forces and friction during transfers. A MDS dated [DATE] indicated Resident #11 had severe cognitive impairment, unclear speech, and was rarely understood. He required extensive assist of two staff for bed mobility, transfers, and toileting and was incontinent of bowel and bladder. He was determined to be at risk for pressure ulcer by clinical assessment and had a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device checked. There was no current pressure ulcers assessed or identified. A care plan dated 6/14/17 indicated Resident #11 was at risk for pressure ulcer development due to immobility. Resident #11 had self-care performance deficits. He required extensive to total weight bearing assistance for bed mobility. A Treatment Sheet indicated Resident #11 was receiving treatments to his right lower buttock every days as follows: Cleanse shear to right lower buttock with normal saline, pat dry, apply skin prep around the shear and cover with [MEDICATION NAME] dressing. During and observation on 9/17/17 at 9:05 a.m., Resident #11 was lying on his back on a scoop mattress. He had limited range of motion in his upper extremities. During an interview on 9/17/17 at 3:55 p.m., CNA P said Resident #11 required a Hoyer (mechanical lift) for transfers and 2 staff to turn and reposition him. CNA P said 2 weeks ago he reported an open area on Residents #11's right lower buttock to the nurse. During an interview on 9/18/17 at 9:12 a.m., the wound care nurse said Resident #11 had a shear on his right lower buttocks, but it was not related to pressure. She said the open area was identified 7 days ago. She said Resident #11 was not on a turning a repositioning program, he could turn himself, and he scooted on the mattress and while up in the wheelchair. During an observation on 9/18/17 at 9:20 a.m., the wound care nurse asked Resident #11 to turn to his left side, she grasped the draw sheet and jerked in an upward motion sliding over 3 quarters of the sheet out from under Resident #5's buttocks. The wound care nurse said I need you to help me. Resident #5 attempted to assist, but was unable to lift his buttocks off the bed. The wound care nurse pushed Resident #11 over onto his left side and pulled his hips over using her hands under his legs and buttocks. She removed a [MEDICATION NAME] dressing from the right lower buttock, cleansed the wound with normal saline, patted dry. The wound measured 0.6 cm x 0.7 cm x less than 0.1 cm. The wound care nurse applied skin prep around the open area and then applied a [MEDICATION NAME] dressing. During an interview on 9/18/17 at 3:38 p.m., the DON said she expected 2 staff would assist residents for turning and repositioning with a draw sheet because dragging by one staff could cause skin breakdown due to friction and sheering. The NPUAP (National Pressure Ulcer Advisory Panel) website, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages, accessed 9/25/17 indicated the following on Pressure ulcers (Injuries): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. .Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). .Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. A Skin Management Policy and Procedure with a revision date of 2/1/14 indicated .A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or in combination with shear . Plan of Care 7. The initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not to be limited to: promoting the prevention of pressure ulcer development, promoting the healing of pressure ulcers that are present, prevention of infection of the wound to the extent possible The CMS 672 dated 9/17/17 indicated 29 residents received preventive skin care.

Based on observation, interview, and record review the facility failed to ensure the physician was consulted regarding a significant change in condition for 1 of 2 residents reviewed for wound care treatment. (Resident #4) The facility did not immediately consult with Resident #4's physician when he developed a blister to his toe and the arterial wounds to his lower legs and feet deteriorated. Resident #4 developed gangrene of his toes on both lower legs which resulted in endovascular (surgical procedure in which a catheter containing medications or miniature instruments is inserted through the skin into a blood vessel for the treatment of [REDACTED]. An Immediate Jeopardy situation was identified on 8/31/16. The Immediate Jeopardy was removed on 09/01/16. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed 11 residents with pressure injuries and 32 residents receiving preventative skin care at risk of receiving inadequate care and services and for worsening or developing skin integrity issues. The findings included: An admission record dated 8/31/16 indicated Resident #4 had an initial admission date of [DATE]. The Order Summary Report dated August 2016 indicated Resident #4 was [AGE] years, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. There were no orders for wound care treatments in the August 2016 consolidated physician orders. A Braden Scale-For Predicting Pressure Sore Risk dated 2/2/16 indicated Resident #4 had a mild risk for pressure injury development. An accident and incident report dated 7/12/16 indicated Resident #4's left foot was run over by another resident with an electric wheelchair. No injuries were noted. A care plan dated 7/15/16 indicated Resident #4 had a blister to his second left toe. Interventions included provide treatment as . ordered, assess skin weekly, monitor for signs and symptoms of infection, notify physician of any change, and apply skin protection as ordered . The most recent MDS dated [DATE] indicated Resident #4 had clear speech and was usually able to understand others. The resident's cognition was severely impaired. Resident #4 was totally dependent with bathing and required extensive assistance with transfers, dressing, personal hygiene, and toileting. The resident was incontinent with bowel and bladder. The MDS indicated Resident #4 was at risk for developing pressure injuries. The MDS indicated Resident #4 did not have any venous or arterial ulcers present, no foot infections, and no skin and ulcer treatments were being provided. Left second toe The Non-Pressure Skin Condition Reports dated 7/15/16 for Resident #4's left second toe indicated a new area measuring 1.5 centimeter (cm) X 1.5 cm. The area was described as a fluid filled blister. There were no (weekly) non-pressure skin condition reports for Resident #4's left second toe from 7/15/16 until 8/17/16. The Non-Pressure Skin Condition Reports dated 8/17/16 for Resident #4's left second toe indicated 1.1 cm X 1.2 cm area. The wound bed was black/brown and the surrounding skin was pink and bright red. The progress was not changed. During an interview on 8/31/16 at 12:30 p.m., the treatment nurse said she was unaware a skin assessment sheet dated 7/15/16 indicated the resident had a blister on his 2nd great toe of the left foot. She said the physician was not notified on 7/15/16 of the blister on the 2nd great toe. The treatment nurse said she did not know why the physician was not notified. The treatment nurse indicated the nurse who discovered a new skin issue was to notifiy the physician.The treatment nurse said there was no treatment being done to Resident #4's feet or toes. The treatment nurse said she did not assess Resident #4's feet. Right foot The Non-Pressure Skin Condition Reports dated 8/17/16 for Resident #4's right foot second toe indicated a new area measuring 1.6 cm X 1.8 cm. The wound bed was black/brown and the surrounding tissue was pink and bright red. Right calf The Non-Pressure Skin Condition Reports dated 8/17/16 for Resident #4's right calf indicated a new area measuring 1.0 cm by 1.5 cm. The wound bed was black/brown and the surrounding tissue was pink and bright red. Left calf The Non-Pressure Skin Condition Reports for Resident #4's left calf indicated the following: *7/31/16 - a new area of extreme dry skin to the left calf measuring 3 cm X 3 cm area. The area was described as no exudate and no odor. The report indicated the physician was notified and new treatment was received. There were no (weekly) non-pressure skin condition reports for Resident #4's left calf from 7/31/16 until 8/15/16. *8/15/16 - 3 cm X 3 cm area to the left calf. The area was described as no exudate and no odor. The area was not changed and continue treatment. *8/17/16 - 1.2 X 1.1 area to the left calf. The wound bed was black/brown and the surrounding tissue was pink and bright red. The progress was not changed and treatment was changed. Right shin The Non-Pressure Skin Condition Reports for Resident #4's right shin indicated the following: *7/31/16 - a new area of extreme dry skin to the right shin measuring 3 cm X 3cm. The area was described as no exudate and no odor. The report indicated the condition was extremely dry skin. There were no (weekly) non-pressure skin condition reports for Resident #4's Right shin from 7/31/16 until 8/15/16. *8/15/16 - 3 cm X 3 cm area on right shin. The area was described as no exudate and no odor. The area was not changed and continue treatment. *8/17/16 - 7.5 cm X 4.0 cm area on right shin. The wound bed was black/brown and the surrounding tissue was pink and bright red. The area was not changed and treatment was changed. A nursing note dated 7/31/16 indicated Resident #4 had callous places on both lower legs and feet. Both legs and feet were noted to be extremely dry with a 3 cm X 3 cm hard area to the back of the calf and a 3 cm X 3 cm hard area to front of the left shin. A telephone physician order [REDACTED].#4 had an order for [REDACTED]. A treatment administration record dated August 2016 indicated Resident #4 did not receive aqua phor/ derma phor to both lower legs daily and as needed for dry skin for 7 days (8/2/16; 8/3/16; 8/4/16; 8/6/16; 8/7/16; 8/8/16; and 8/9/16.) A care plan dated 7/31/16 indicated Resident #4 had extremely dry skin to both lower legs. Interventions included .perform daily treatments as ordered, complete weekly skin assessments, monitor for any breakdown and signs and symptoms of infection, and apply medications as ordered . During an interview on 8/31/16 at 12:30 p.m., the treatment nurse said on 8/12/16 she noticed Resident #4's legs were getting bad. She said the resident had a black patch of dry skin on his shins and had hard dry skin on his calves, but knew the wound care physician was coming on 8/17/16 so she made a reminder for herself to have the wound care physician look at the resident's legs. The treatment nurse said she classified the areas on Resident #4's legs as [MEDICAL CONDITION]. The treatment nurse said on 8/17/16 the wound physician said Resident #4 had arterial ulcers to both of his legs and 2 toes were gangrene (one toe on each foot). A telephone order dated 8/17/16 indicated Resident #4 had an order for [REDACTED]. A Wound Care Specialist Initial Evaluation dated 8/17/16 indicated Resident #4's lower left and right leg were warm and had mild swelling. The left and right foot pulses could not be detected. The left and right lower legs had a wound. The evaluation recommended a Doppler study (ultrasound to measure blood flow) skin prep to the right and left second toe daily, skin prep to the right shin, and left and right calf once daily. The evaluation indicated the following: *Arterial wound of the left second toe that was greater than 1 day old. The wound size was 1.1 cm x 1.2 cm. *Arterial wound of the right second toe that was greater than 1 day old. The wound size was 1.6 cm x 1.8 cm. *Arterial wound of the right anterior shin that was greater than 1 day old. The wound size was 7.5 cm x 4.0 cm. *Arterial wound of the right calf that was greater than 1 day old. The wound size was 1.0 cm x 1.5 cm. *Arterial wound of the left calf that was greater than 1 day old. The wound size was 1.2 cm x 1.1 cm. A telephone order dated 8/17/16 indicated Resident #4 was to receive a skin prep to the right and left second toe daily. The current orders for both legs were discontined and changed to apply skin prep to the right shin, and left and right calf daily until healed. A telephone order dated 8/17/16 indicated Resident #4 had and order for a Doppler study to both lower legs due to [DIAGNOSES REDACTED]. A care plan dated 8/17/16 indicated Resident #4 had a problem of alteration in skin integrity; arterial ulcer to the right calf and right second toe. Interventions included .provide treatment as ordered, monitor for signs and symptoms of infection, notify the physician of any change, assess skin weekly and record findings, monitor for skin break down and report to physician and nurse practitioner . A daily skilled nursing note dated 8/17/16 indicated the nurse practitioner was notified Resident #4 had darkened tender areas to both lower legs. A new order was received to send the resident to the emergency room for an evaluation. The emergency room physician documentation dated 8/17/16 indicated Resident #4 was seen in the emergency room for complaints of wounds. The documentation indicated the resident was diagnosed with [REDACTED]. The resident was diagnosed with [REDACTED]. A daily skilled nursing note dated 8/17/16 at 4:15 p.m., indicated Resident #4 returned from the hospital. A new order was noted for Keflex 500 mg four times a day for 10 days. An x-ray of Resident #4's right foot dated 8/17/16 indicated vascular calcifications consistent with diabetes, [MEDICAL CONDITION], and soft tissue swelling of the right foot. An x-ray of Resident #4's knee dated 8/17/16 indicated Resident #4 decreased bone mineralization of his right lower leg. The resident had extensive [MEDICAL CONDITION] (plaque buildup) calcification to the level of the ankle and moderate tibialfemoral (knee joints) compartment [MEDICAL CONDITION] ([MEDICAL CONDITION] joint disease.) An physician order [REDACTED].#4 had an order for [REDACTED]. A Doppler study dated 8/18/16 indicated Resident #4 had marked generalized material [MEDICAL CONDITION] of the entire left lower leg, and the right leg was marked with arterial [MEDICAL CONDITION]. A physician's telephone order dated 8/19/16 indicated Resident #4 was to receive a surgical consult. A physician's telephone order dated 8/21/16 indicated Resident #4 was to be sent to the local hospital due to being unresponsive, eyes fixed. The hospital History and Physical indicated Resident #4 was admitted [DATE] at 4:07 p.m. with [DIAGNOSES REDACTED]. A medical imaging report dated 8/21/16 indicated Resident #4 had dry gangrene of the toes of both lower extremities. The report indicated severe stenosis of a single remaining vessel in the right calf and occlusion of all 3 left calf vessels. A medical imaging report dated 8/26/16 indicated Resident #4 had to have a atherectomy (a minimally invasive endovascular surgery technique for removing [MEDICAL CONDITION] from blood vessels within the body) performed with a follow-up angioplasty (an endovascular procedure to widen narrowed or obstructed arteries or veins, An empty, collapsed balloon, known as a balloon catheter, was passed over a wire into the narrowed locations and then inflated to a fixed size) in his right leg accessed through his right femoral artery. The resident also had an atherectomy with angioplasty in his left leg accessed through his left femoral artery. During an interview on 8/31/16 at 1:33 p.m., the DON said something should have been done on 7/15/16 when the blister was found on Resident #4's toe. The DON said the physician should have been notified. During an interview on 8/31/16 at 2:27 p.m., the treatment nurse said on 8/12/16 Resident #4's legs looked like they were deteriorating, like something was eating into his skin. The treatment nurse said she did not notify Resident #4's physician because she did not think the resident needed immediate attention. The treatment nurse said from 8/12/16-8/17/16 his legs did get worse and she never changed the treatment or called the treatment physician or the primary care physician. The treatment nurse said she did not realize Resident #4 had arterial/vascular ulcers. She said something should have been done sooner. During an interview on 8/31/16 at 3:54 p.m. and 4:07 p.m., Resident #4's physician said on 7/31/16 he was notified Resident #4 had dry skin and a hard area to the back of calf and front of leg on the shin. He said on 8/19/16 he was notified of the Doppler results, and the wound physician assessment completed on 8/17/16. Resident #4 ' s physician said he was not notified on 7/15/16 of the blister on Resident #4's toe. The physician said he was not notified on 8/12/16 that resident's wounds were deteriorating. During an interview on 8/31/16 at 2:18 p.m., LVN E said she was unaware Resident #4 had sores on his foot until she was told about the gangrene on 8/17/16. LVN E said she completed a full body skin assessment on 8/17/16 and the resident had no skin integrity issues on his feet or toes. LVN E said she completed weekly skin assessments on Resident #4 and initialed it as complete on his MAR. LVN E said she only completed a skin sheet if an issue was found and then followed it up with documentation. LVN E said the only issue she was aware of was the [MEDICAL CONDITION] to the Resident #4's right and left leg, which was handled on 7/31/16. LVN E said treatments were the responsibility of the weekend nurse. The MAR indicated [REDACTED]. During an interview on 9/1/16 at 12:56 p.m., LVN D said Resident #4 had been complaining of hurting and burning to his feet and legs for a while. LVN D said Resident #4 had an order to apply cream to his legs for dryness and blistering. She said the beginning of August 2016 Resident #4's legs were dry and blistering. LVN D said she got an order on 7/29/16 for [MEDICATION NAME] for pain, but did not assess the resident's feet. She said she was told by the treatment nurse on 8/17/16 the resident had gangrene to his feet and she notified the physician. During a telephone interview on 8/31/16 at 3:04 p.m., CNA B said she gave Resident #4 a bath in July 2016 and he complained his feet were real tender and sore. CNA B said the 3rd toe on the left foot and the shin had an odd discoloration, and the right shin looked like it had an abrasion. CNA B said she filled out a stop watch sheet (new area to skin) and documented and circled the areas that were painful to the resident on back of a shower sheet in July 2016, and turned it into her charge nurse. During an intrview on 8/31/16 at 3:15 p.m., the ADON said if CNAs found skin issues on any resident they were to complete a stop watch sheet and give it to their charge nurse. She said the stop watch sheets for July 2016 had been shredded. During a telephone interview on 8/31/16 at 3:11p.m., CNA C said Resident #4 complained of foot pain during care in July and August 2016. She said she verbally reported the complaint of pain to her charge nurse. During an observation and interview with the hospital nurse on 9/1/16 at 9:17 a.m., Resident #4 was at the hospital. He had a large area to the right shin was covered by hard dark eschar, with reddish pinkish areas around the wound area. Resident #4's left shin had a large area covered in hard dark eschar, with reddish, pinkish areas around the wound. Both feet and toes were darkened and the second toe on each foot was extremely hard and black, all toes were dark. Resident #4's left heel was very mushy to touch. The hospital nurse said Resident #4 developed a pressure injury to the bottom of the left heel, due to the eschar on both legs. The hospital nurse said she was unable to stage the wounds. She said the wounds to Resident # legs were not [MEDICAL CONDITION]. The hospital nurse said Resident #4's toes were gangrene. Resident #4 said he told the staff at the nursing home his feet and legs were causing him pain. He said he felt as if they were burning. Resident #4 said no one looked at his feet after he made several complaints, and only started paying more attention to his legs when the physician came. The resident said this all started about a month or two ago when another resident ran over his left foot with her wheelchair and even then the staff did not look at his foot. The resident said he was not being provided proper care at the nursing home. The Skin Management Policy revised 2/1/14 indicated .Implement/Ongoing Strategy 6. The wound nurse or licensed nurse completes a weekly evaluation on patients with other skin conditions or skin alterations (e.g., skin tears, surgical incisions, rashes, ect.). Documentation is entered on the Non Pressure Ulcer Form 7. Nursing assistants perform skin observations with routine care. The Skin Worksheet Tool is completed by the nursing assistant at least two times per week. Results are submitted to the licensed nurse for review and follow-up as needed . Evaluate .6. If change in patient condition occurs, such as deterioration in or development of new risk factors or skin alterations, the license nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record . The administrator and DON were notified on 8/31/16 at 4:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Plan of Removal was accepted on 8/31/16 at 8:17 p.m. and included: Resident #4 was currently in the hospital. All resident's residing in the center will be assessed for any alterations in their skin. This will be completed today August 31, 2016 by DON, ADONs, Charge Nurses and Regional Nurse consultant. Any resident found to have any alteration in their skin will have notification made to their physician regarding appropriate treatment orders. Any resident found to have any alteration in their skin will be referred to Wound Physician and will have weekly skin assessment completed and documented by the center. Any resident with current alteration in their skin were reviewed and evaluated to ensure that notification to physician was made regarding any changes in any residents skin if applicable. This was completed today August 31, 2016 by (DON). On 8/31/16 at 8:17 p.m, the surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Three LVNs were interviewed and said they were in-serviced to conduct weekly skin assessments, and notify the physician of all skin changes. They said if any resident was found to have alteration in their skin a referral would be made to the wound physician and skin assessments would be completed and documented weekly. Four CNAs were interviewed and said they would notify the nurse of any skin conditions. The administrator, DON and ADON indicated they were in-serviced on the information and were knowledgeable about changes in procedures. On 9/1/16 at 3:30 p.m., the administrator and DON were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 8/31/16 indicated 11 residents with pressure injuries and 32 residents receiving preventative skin care.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 2 residents reviewed for assessment. (Resident #4) The facility did not assess Resident #4's toes, provide treatment as ordered to the resident's lower legs, identify arterial wounds to the lower legs, and immediately notify the physician of the blister to his toe and the deterioration of arterial wounds to his lower legs and feet. Resident #4 developed gangrene of his toes on both lower legs which resulted in endovascular (surgical procedure in which a catheter containing medications or miniature instruments is inserted through the skin into a blood vessel for the treatment of [REDACTED]. An Immediate Jeopardy situation was identified on 8/31/16. The Immediate Jeopardy was removed on 09/01/16. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed 11 residents with pressure injuries and 32 residents receiving preventative skin care at risk of receiving inadequate care and services and for worsening or developing skin integrity issues. The findings included: An admission record dated 8/31/16 indicated Resident #4 had an initial admission date of [DATE]. The Order Summary Report dated August 2016 indicated Resident #4 was [AGE] years, admitted [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. There were no orders for wound care treatments in the August 2016 consolidated physician orders. A Braden Scale-For Predicting Pressure Sore Risk dated 2/2/16 indicated Resident #4 had a mild risk for pressure injury development. An accident and incident report dated 7/12/16 indicated Resident #4's left foot was run over by another resident with an electric wheelchair. No injuries were noted. A care plan dated 7/15/16 indicated Resident #4 had a blister to his second left toe. Interventions included provide treatment as . ordered, assess skin weekly, monitor for signs and symptoms of infection, notify physician of any change, and apply skin protection as ordered . The most recent MDS dated [DATE] indicated Resident #4 had clear speech and was usually able to understand others. The resident's cognition was severely impaired. Resident #4 was totally dependent with bathing and required extensive assistance with transfers, dressing, personal hygiene, and toileting. The resident was incontinent with bowel and bladder. The MDS indicated Resident #4 was at risk for developing pressure injuries. The MDS indicated Resident #4 did not have any venous or arterial ulcers present, no foot infections, and no skin and ulcer treatments were being provided. Left second toe The Non-Pressure Skin Condition Reports dated 7/15/16 for Resident #4's left second toe indicated a new area measuring 1.5 centimeter (cm) X 1.5 cm. The area was described as a fluid filled blister. There were no (weekly) non-pressure skin condition reports for Resident #4's left second toe from 7/15/16 until 8/17/16. The Non-Pressure Skin Condition Reports dated 8/17/16 for Resident #4's left second toe indicated 1.1 cm X 1.2 cm area. The wound bed was black/brown and the surrounding skin was pink and bright red. The progress was not changed. During an interview on 8/31/16 at 12:30 p.m., the treatment nurse said she was unaware a skin assessment sheet dated 7/15/16 indicated the resident had a blister on his 2nd great toe of the left foot. She said the physician was not notified on 7/15/16 of the blister on the 2nd great toe. The treatment nurse said she did not know why the physician was not notified. The treatment nurse indicated the nurse who discovered a new skin issue was to notifiy the physician.The treatment nurse said there was no treatment being done to Resident #4's feet or toes. The treatment nurse said she did not assess Resident #4's feet. Right foot The Non-Pressure Skin Condition Reports dated 8/17/16 for Resident #4's right foot second toe indicated a new area measuring 1.6 cm X 1.8 cm. The wound bed was black/brown and the surrounding tissue was pink and bright red. Right calf The Non-Pressure Skin Condition Reports dated 8/17/16 for Resident #4's right calf indicated a new area measuring 1.0 cm by 1.5 cm. The wound bed was black/brown and the surrounding tissue was pink and bright red. Left calf The Non-Pressure Skin Condition Reports for Resident #4's left calf indicated the following: *7/31/16 - a new area of extreme dry skin to the left calf measuring 3 cm X 3 cm area. The area was described as no exudate and no odor. The report indicated the physician was notified and new treatment was received. There were no (weekly) non-pressure skin condition reports for Resident #4's left calf from 7/31/16 until 8/15/16. *8/15/16 - 3 cm X 3 cm area to the left calf. The area was described as no exudate and no odor. The area was not changed and continue treatment. *8/17/16 - 1.2 X 1.1 area to the left calf. The wound bed was black/brown and the surrounding tissue was pink and bright red. The progress was not changed and treatment was changed. Right shin The Non-Pressure Skin Condition Reports for Resident #4's right shin indicated the following: *7/31/16 - a new area of extreme dry skin to the right shin measuring 3 cm X 3cm. The area was described as no exudate and no odor. The report indicated the condition was extremely dry skin. There were no (weekly) non-pressure skin condition reports for Resident #4's Right shin from 7/31/16 until 8/15/16. *8/15/16 - 3 cm X 3 cm area on right shin. The area was described as no exudate and no odor. The area was not changed and continue treatment. *8/17/16 - 7.5 cm X 4.0 cm area on right shin. The wound bed was black/brown and the surrounding tissue was pink and bright red. The area was not changed and treatment was changed. A nursing note dated 7/31/16 indicated Resident #4 had callous places on both lower legs and feet. Both legs and feet were noted to be extremely dry with a 3 cm X 3 cm hard area to the back of the calf and a 3 cm X 3 cm hard area to front of the left shin. A telephone physician order [REDACTED].#4 had an order for [REDACTED]. A treatment administration record dated August 2016 indicated Resident #4 did not receive aqua phor/ derma phor to both lower legs daily and as needed for dry skin for 7 days (8/2/16; 8/3/16; 8/4/16; 8/6/16; 8/7/16; 8/8/16; and 8/9/16.) A care plan dated 7/31/16 indicated Resident #4 had extremely dry skin to both lower legs. Interventions included .perform daily treatments as ordered, complete weekly skin assessments, monitor for any breakdown and signs and symptoms of infection, and apply medications as ordered . During an interview on 8/31/16 at 12:30 p.m., the treatment nurse said on 8/12/16 she noticed Resident #4's legs were getting bad. She said the resident had a black patch of dry skin on his shins and had hard dry skin on his calves, but knew the wound care physician was coming on 8/17/16 so she made a reminder for herself to have the wound care physician look at the resident's legs. The treatment nurse said she classified the areas on Resident #4's legs as [MEDICAL CONDITION]. The treatment nurse said on 8/17/16 the wound physician said Resident #4 had arterial ulcers to both of his legs and 2 toes were gangrene (one toe on each foot). A telephone order dated 8/17/16 indicated Resident #4 had an order for [REDACTED]. A Wound Care Specialist Initial Evaluation dated 8/17/16 indicated Resident #4's lower left and right leg were warm and had mild swelling. The left and right foot pulses could not be detected. The left and right lower legs had a wound. The evaluation recommended a Doppler study (ultrasound to measure blood flow) skin prep to the right and left second toe daily, skin prep to the right shin, and left and right calf once daily. The evaluation indicated the following: *Arterial wound of the left second toe that was greater than 1 day old. The wound size was 1.1 cm x 1.2 cm. *Arterial wound of the right second toe that was greater than 1 day old. The wound size was 1.6 cm x 1.8 cm. *Arterial wound of the right anterior shin that was greater than 1 day old. The wound size was 7.5 cm x 4.0 cm. *Arterial wound of the right calf that was greater than 1 day old. The wound size was 1.0 cm x 1.5 cm. *Arterial wound of the left calf that was greater than 1 day old. The wound size was 1.2 cm x 1.1 cm. A telephone order dated 8/17/16 indicated Resident #4 was to receive a skin prep to the right and left second toe daily. The current orders for both legs were discontined and changed to apply skin prep to the right shin, and left and right calf daily until healed. A telephone order dated 8/17/16 indicated Resident #4 had and order for a Doppler study to both lower legs due to [DIAGNOSES REDACTED]. A care plan dated 8/17/16 indicated Resident #4 had a problem of alteration in skin integrity; arterial ulcer to the right calf and right second toe. Interventions included .provide treatment as ordered, monitor for signs and symptoms of infection, notify the physician of any change, assess skin weekly and record findings, monitor for skin break down and report to physician and nurse practitioner . A daily skilled nursing note dated 8/17/16 indicated the nurse practitioner was notified Resident #4 had darkened tender areas to both lower legs. A new order was received to send the resident to the emergency room for an evaluation. The emergency room physician documentation dated 8/17/16 indicated Resident #4 was seen in the emergency room for complaints of wounds. The documentation indicated the resident was diagnosed with [REDACTED]. The resident was diagnosed with [REDACTED]. A daily skilled nursing note dated 8/17/16 at 4:15 p.m., indicated Resident #4 returned from the hospital. A new order was noted for Keflex 500 mg four times a day for 10 days. An x-ray of Resident #4's right foot dated 8/17/16 indicated vascular calcifications consistent with diabetes, [MEDICAL CONDITION], and soft tissue swelling of the right foot. An x-ray of Resident #4's knee dated 8/17/16 indicated Resident #4 decreased bone mineralization of his right lower leg. The resident had extensive [MEDICAL CONDITION] (plaque buildup) calcification to the level of the ankle and moderate tibialfemoral (knee joints) compartment [MEDICAL CONDITION] ([MEDICAL CONDITION] joint disease.) An physician order [REDACTED].#4 had an order for [REDACTED]. A Doppler study dated 8/18/16 indicated Resident #4 had marked generalized material [MEDICAL CONDITION] of the entire left lower leg, and the right leg was marked with arterial [MEDICAL CONDITION]. A physician's telephone order dated 8/19/16 indicated Resident #4 was to receive a surgical consult. A physician's telephone order dated 8/21/16 indicated Resident #4 was to be sent to the local hospital due to being unresponsive, eyes fixed. The hospital History and Physical indicated Resident #4 was admitted [DATE] at 4:07 p.m. with [DIAGNOSES REDACTED]. A medical imaging report dated 8/21/16 indicated Resident #4 had dry gangrene of the toes of both lower extremities. The report indicated severe stenosis of a single remaining vessel in the right calf and occlusion of all 3 left calf vessels. A medical imaging report dated 8/26/16 indicated Resident #4 had to have a atherectomy (a minimally invasive endovascular surgery technique for removing [MEDICAL CONDITION] from blood vessels within the body) performed with a follow-up angioplasty (an endovascular procedure to widen narrowed or obstructed arteries or veins, An empty, collapsed balloon, known as a balloon catheter, was passed over a wire into the narrowed locations and then inflated to a fixed size) in his right leg accessed through his right femoral artery. The resident also had an atherectomy with angioplasty in his left leg accessed through his left femoral artery. During an interview on 8/31/16 at 1:33 p.m., the DON said something should have been done on 7/15/16 when the blister was found on Resident #4's toe. The DON said the physician should have been notified. During an interview on 8/31/16 at 2:27 p.m., the treatment nurse said on 8/12/16 Resident #4's legs looked like they were deteriorating, like something was eating into his skin. The treatment nurse said she did not notify Resident #4's physician because she did not think the resident needed immediate attention. The treatment nurse said from 8/12/16-8/17/16 his legs did get worse and she never changed the treatment or called the treatment physician or the primary care physician. The treatment nurse said she did not realize Resident #4 had arterial/vascular ulcers. She said something should have been done sooner. During an interview on 8/31/16 at 3:54 p.m. and 4:07 p.m., Resident #4's physician said on 7/31/16 he was notified Resident #4 had dry skin and a hard area to the back of calf and front of leg on the shin. He said on 8/19/16 he was notified of the Doppler results, and the wound physician assessment completed on 8/17/16. Resident #4 ' s physician said he was not notified on 7/15/16 of the blister on Resident #4's toe. The physician said he was not notified on 8/12/16 that resident's wounds were deteriorating. During an interview on 8/31/16 at 2:18 p.m., LVN E said she was unaware Resident #4 had sores on his foot until she was told about the gangrene on 8/17/16. LVN E said she completed a full body skin assessment on 8/17/16 and the resident had no skin integrity issues on his feet or toes. LVN E said she completed weekly skin assessments on Resident #4 and initialed it as complete on his MAR. LVN E said she only completed a skin sheet if an issue was found and then followed it up with documentation. LVN E said the only issue she was aware of was the [MEDICAL CONDITION] to the Resident #4's right and left leg, which was handled on 7/31/16. LVN E said treatments were the responsibility of the weekend nurse. The MAR indicated [REDACTED]. During an interview on 9/1/16 at 12:56 p.m., LVN D said Resident #4 had been complaining of hurting and burning to his feet and legs for a while. LVN D said Resident #4 had an order to apply cream to his legs for dryness and blistering. She said the beginning of August 2016 Resident #4's legs were dry and blistering. LVN D said she got an order on 7/29/16 for [MEDICATION NAME] for pain, but did not assess the resident's feet. She said she was told by the treatment nurse on 8/17/16 the resident had gangrene to his feet and she notified the physician. During a telephone interview on 8/31/16 at 3:04 p.m., CNA B said she gave Resident #4 a bath in July 2016 and he complained his feet were real tender and sore. CNA B said the 3rd toe on the left foot and the shin had an odd discoloration, and the right shin looked like it had an abrasion. CNA B said she filled out a stop watch sheet (new area to skin) and documented and circled the areas that were painful to the resident on back of a shower sheet in July 2016, and turned it into her charge nurse. During an intrview on 8/31/16 at 3:15 p.m., the ADON said if CNAs found skin issues on any resident they were to complete a stop watch sheet and give it to their charge nurse. She said the stop watch sheets for July 2016 had been shredded. During a telephone interview on 8/31/16 at 3:11p.m., CNA C said Resident #4 complained of foot pain during care in July and August 2016. She said she verbally reported the complaint of pain to her charge nurse. During an observation and interview with the hospital nurse on 9/1/16 at 9:17 a.m., Resident #4 was at the hospital. He had a large area to the right shin was covered by hard dark eschar, with reddish pinkish areas around the wound area. Resident #4's left shin had a large area covered in hard dark eschar, with reddish, pinkish areas around the wound. Both feet and toes were darkened and the second toe on each foot was extremely hard and black, all toes were dark. Resident #4's left heel was very mushy to touch. The hospital nurse said Resident #4 developed a pressure injury to the bottom of the left heel, due to the eschar on both legs. The hospital nurse said she was unable to stage the wounds. She said the wounds to Resident # legs were not [MEDICAL CONDITION]. The hospital nurse said Resident #4's toes were gangrene. Resident #4 said he told the staff at the nursing home his feet and legs were causing him pain. He said he felt as if they were burning. Resident #4 said no one looked at his feet after he made several complaints, and only started paying more attention to his legs when the physician came. The resident said this all started about a month or two ago when another resident ran over his left foot with her wheelchair and even then the staff did not look at his foot. The resident said he was not being provided proper care at the nursing home. The Skin Management Policy revised 2/1/14 indicated .Implement/Ongoing Strategy 6. The wound nurse or licensed nurse completes a weekly evaluation on patients with other skin conditions or skin alterations (e.g., skin tears, surgical incisions, rashes, ect.). Documentation is entered on the Non Pressure Ulcer Form 7. Nursing assistants perform skin observations with routine care. The Skin Worksheet Tool is completed by the nursing assistant at least two times per week. Results are submitted to the licensed nurse for review and follow-up as needed . Evaluate .6. If change in patient condition occurs, such as deterioration in or development of new risk factors or skin alterations, the license nurse notifies the physician, wound team, family or responsible party and documents follow up in the clinical record. The patient's plan of care is then updated to reflect the patient's current status and care needs. Communications with the physician, patient and family are documented in the clinical record . The administrator and DON were notified on 8/31/16 at 4:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Plan of Removal was accepted on 8/31/16 at 8:17 p.m. and included: Resident #4 was currently in the hospital. All resident's residing in the center will be assessed for any alterations in their skin. This will be completed today August 31, 2016 by DON, ADONs, Charge Nurses and Regional Nurse consultant. Any resident found to have any alteration in their skin will have notification made to their physician regarding appropriate treatment orders. Any resident found to have any alteration in their skin will be referred to Wound Physician and will have weekly skin assessment completed and documented by the center. Any resident with current alteration in their skin were reviewed and evaluated to ensure that notification to physician was made regarding any changes in any residents skin if applicable. This was completed today August 31, 2016 by (DON). On 8/31/16 at 8:17 p.m, the surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Three LVNs were interviewed and said they were in-serviced to conduct weekly skin assessments, and notify the physician of all skin changes. They said if any resident was found to have alteration in their skin a referral would be made to the wound physician and skin assessments would be completed and documented weekly. Four CNAs were interviewed and said they would notify the nurse of any skin conditions. The administrator, DON and ADON indicated they were in-serviced on the information and were knowledgeable about changes in procedures. On 9/1/16 at 3:30 p.m., the administrator and DON were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 8/31/16 indicated 11 residents with pressure injuries and 32 residents receiving preventative skin care.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision with assistive devices and environment free of accidents/hazards for 2 of 2 residents reviewed for accident/hazards. (Resident #s 1 and 3) CNA A did not transfer Resident #1 properly. Resident #1 sustained a fractured wrist during the transfer. CNA A did not transfer Resident #3 properly. This failure placed 81 residents who required assistance with transfers at risk for discomfort and injuries. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS 07/21/16 indicated Resident #1 required extensive assistance of two persons with transfers. The ADL care plan dated 9/15/15 indicated Resident #1 required extensive to total weight bearing assistance of staff with transfers. An incident report dated 8/18/16 indicated Resident #1 reported to a CNA that the CNA taking care of her got frustrated with her and caused a bruise and raised area to the top of her right forearm. A nursing note dated late entry on 8/18/16 at 7:15 a.m., indicated CNA reported Resident #1 had large bruises to her right forearm . The note indicated the bruise on Resident #1's right forearm measured 8 centimeter (cm) X 8.5 cm with a raised are in the center that measured 5 cm X4.5 cm. There was a bruise measuring 4 cm X 3 cm also noted to upper forearm near elbow. During an interview and observation on 8/31/16 at 5:56 p.m., Resident #1 said her injury was caused by CNA A. Resident #1 said CNA A got frustrated because she could not get her up and grabbed her by the wrist as she was falling down. The resident said she had three hill like bumps on her arm and one was big. Resident #1 said she never would have thought she would have sustained a broken bone in a facility. Resident #1 was sitting in wheelchair with right arm resting on top of chest wrapped in Ace bandage from fingers to elbow. During a telephone interview on 9/1/16 at 12:56 p.m., LVN D said on 8/18/16 during breakfast time an aide came to her and informed her Resident #1 had discoloration to her arm and it was swollen. LVN D said the resident said the CNA A got frustrated with her. The nurse said all the CNAs who worked on the hall where called into the DON's office and the resident was able to identify the employee. During an interview on 8/31/16 at 11:10 a.m., the DON said Resident #1 told her a CNA was trying to get her up and got frustrated and grabbed her by the arm on 8/18/16. The DON said she pulled up the residents ' sleeve and there was discoloration with a small raised area. The DON said she interviewed CNA A and she said she tried to transfer the resident by herself and did not want to seek help to transfer the resident. An x-ray dated 8/18/15 indicated .There is a questionable fracture of the distal radius as well as the ulnar styloid . The transfer policy dated 2/5/15 indicated to .apply gait belt to resident if necessary . 2. Physician orders [REDACTED].# 3 was [AGE] years old readmitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 required extensive two person assistance with transfers. The ADL care plan indicated Resident #3 required supervision to extensive assist for transfers. During an interview on 9/1/16 at 12:40 p.m., CNA A said she did not know to use a gait belt when transferring Resident #1. CNA A said resident had been declining, was not able to assist with the transfer, and she had spent 30 minutes trying to transfer the resident. CNA A said she used to be able to grab the resident under the arms and the resident would help a little with standing, but she was unable to assist on that day. CNA A said she did not intentionally break Resident #1's wrist. CNA A said she was unaware Resident #3 required a Hoyer to lift transfer. CNA A transfered Resident #3 with a gait belt by herself. During an interview on 09/01/16 at 1:08 p.m., the DON said the CNAs should have the knowledge that gait belts were used when transferring residents; it comes with orientation of being a CNA. The DON said CNA A should have used a gait belt when transferring Resident # 1. The DON said she was unaware CNA A transferred Resident #3 without using the Hoyer lift; she said the resident was changed to a Hoyer lift this month and the CNA should have been aware. An in-service dated July/August 2016 indicated .Resident #3 is now on Hoyer lift transfers . The inservice was signed by CNA A indicating she was aware of the change. A transfer roster dated 08/31/16 indicated 81 residents required assistance with transfers.

Based on interview and record review, the facility failed to ensure 1 (CNA A) of 2 CNAs observed demonstrated competency in techniques to care for needs identified through assessments and in the plan of care for 2 of 2 residents reviewed for transfer. (Resident #s 1 and 3) CNA A did not transfer Resident #1 properly. Resident #1 sustained a fractured wrist during the transfer. CNA A did not transfer Resident #3 properly. This failure placed 81 residents who required assistance with transfers at risk for discomfort and injuries. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS 07/21/16 indicated Resident #1 required extensive assistance of two persons with transfers. The ADL care plan dated 9/15/15 indicated Resident #1 required extensive to total weight bearing assistance of staff with transfers. An incident report dated 8/18/16 indicated Resident #1 reported to a CNA that the CNA taking care of her got frustrated with her and caused a bruise and raised area to the top of her right forearm. A nursing note dated late entry on 8/18/16 at 7:15 a.m., indicated CNA reported Resident #1 had large bruises to her right forearm . The note indicated the bruise on Resident #1's right forearm measured 8 centimeter (cm) X 8.5 cm with a raised are in the center that measured 5 cm X4.5 cm. There was a bruise measuring 4 cm X 3 cm also noted to upper forearm near elbow. During an interview and observation on 8/31/16 at 5:56 p.m., Resident #1 said her injury was caused by CNA A. Resident #1 said CNA A got frustrated because she could not get her up and grabbed her by the wrist as she was falling down. The resident said she had three hill like bumps on her arm and one was big. Resident #1 said she never would have thought she would have sustained a broken bone in a facility. Resident #1 was sitting in wheelchair with right arm resting on top of chest wrapped in Ace bandage from fingers to elbow. During a telephone interview on 9/1/16 at 12:56 p.m., LVN D said on 8/18/16 during breakfast time an aide came to her and informed her Resident #1 had discoloration to her arm and it was swollen. LVN D said the resident said the CNA A got frustrated with her. The nurse said all the CNAs who worked on the hall where called into the DON's office and the resident was able to identify the employee. During an interview on 8/31/16 at 11:10 a.m., the DON said Resident #1 told her a CNA was trying to get her up and got frustrated and grabbed her by the arm on 8/18/16. The DON said she pulled up the residents ' sleeve and there was discoloration with a small raised area. The DON said she interviewed CNA A and she said she tried to transfer the resident by herself and did not want to seek help to transfer the resident. An x-ray dated 8/18/15 indicated .There is a questionable [MEDICAL CONDITION] radius as well as the ulnar styloid . The transfer policy dated 2/5/15 indicated to .apply gait belt to resident if necessary . 2. Physician orders [REDACTED].# 3 was [AGE] years old readmitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 required extensive two person assistance with transfers. The ADL care plan indicated Resident #3 required supervision to extensive assist for transfers. During an interview on 9/1/16 at 12:40 p.m., CNA A said she did not know to use a gait belt when transferring Resident #1. CNA A said resident had been declining, was not able to assist with the transfer, and she had spent 30 minutes trying to transfer the resident. CNA A said she used to be able to grab the resident under the arms and the resident would help a little with standing, but she was unable to assist on that day. CNA A said she did not intentionally break Resident #1's wrist. CNA A said she was unaware Resident #3 required a Hoyer to lift transfer. CNA A transfered Resident #3 with a gait belt by herself. During an interview on 09/01/16 at 1:08 p.m., the DON said the CNAs should have the knowledge that gait belts were used when transferring residents; it comes with orientation of being a CNA. The DON said CNA A should have used a gait belt when transferring Resident # 1. The DON said she was unaware CNA A transferred Resident #3 without using the Hoyer lift; she said the resident was changed to a Hoyer lift this month and the CNA should have been aware. An in-service dated July/August 2016 indicated Resident #3 is now on Hoyer lift transfers . The inservice was signed by CNA A indicating she was aware of the change. A transfer roster dated 08/31/16 indicated 81 residents required assistance with transfers.

Based on interview and record review the facility failed to ensure the physician was consulted for 1 of 5 residents reviewed for [MEDICATION NAME] and 1 of 2 residents reviewed for [MEDICATION NAME]. (Resident # 25) Resident #25 received [MEDICATION NAME] (treats heart failure and slows and strengthens the heart beat) and [MEDICATION NAME] (blood thinner). The facility did not notify the physican Resident #25's pulse was less than 60, she did not receive the [MEDICATION NAME] multiple times in September and [DATE], and Resident #25 continued to complain of a headache, nausea, and vomiting for 6 days prior to her death on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 16 residents receiving [MEDICATION NAME] at risk for serious bleeding or death and 7 residents receiving [MEDICATION NAME] at risk for [MEDICATION NAME] toxicity or death. Findings included: Physician orders [REDACTED].#25, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The resident had an order for [REDACTED]. The orders indicated the resident was a do not resuscitate. A hospital history and physical dated [DATE] indicated Resident #25 for [MEDICATION NAME], but had multiple [MEDICAL CONDITION] in the past and her [MEDICATION NAME] level was not at a therapeutic level. The most recent MDS dated [DATE] indicated Resident #25 had severely impaired cognition, clear speech, and usually understood others. Resident #25 was incontinent of bowel and bladder and was at risk for falls. The resident had an additional [DIAGNOSES REDACTED]. A care plan dated [DATE] for Resident #25 did not did not address the use of the [MEDICATION NAME]. The care plan indicated the resident had a focus of anticoagulant (blood thinner) related to [MEDICAL CONDITION]. The plan indicated: laboratory services as ordered, monitor, document and report to the physician signs and symptoms of anticoagulant complications such as sudden severe headaches, nausea, vomiting, joint pain, loss of appetite, and sudden changes in mental status. A laboratory requisition dated [DATE] indicated a request for a [MEDICATION NAME] level to be drawn on Resident #25 on the morning of [DATE]. The requisition indicated the blood was not drawn due to the resident's combative behavior. A nursing note dated [DATE] at 2:30 a.m. indicated Resident # 25 was yelling and tried to hit staff and the laboratory representative. There were no written orders in Resident #25's nursing notes from [DATE] - [DATE] for a [MEDICATION NAME] level or an explanation for the one time request of the [MEDICATION NAME] level. A pharmacy evaluation review for Resident #25 dated [DATE] indicated a request to update the resident's anticoagulant record sheet with [MEDICATION NAME] dose and her latest INR results. The review indicated the resident's [MEDICATION NAME] was frequently held due to a pulse less than 60 and recommended discussion with the physician. The [DATE] MAR indicated [REDACTED] *,[DATE] pulse 59, *,[DATE] pulse 52, *,[DATE] pulse 47, *,[DATE] pulse 53, *,[DATE] pulse 58, *,[DATE] pulse 55. The [DATE] MAR indicated [REDACTED] *,[DATE] pulse 58, *,[DATE] pulse 59, *,[DATE] pulse 56, *,[DATE] pulse 59 *,[DATE] pulse (not legible), *,[DATE] pulse 51, *,[DATE] pulse 51, *,[DATE] pulse 45, *,[DATE] pulse 56. The nursing notes for Resident #25 from [DATE] through [DATE] did not indicate the physician was notified the [MEDICATION NAME] was held due to the resident's pulse being less than 60. During an interview on [DATE] at 9:30 am, Resident #25 said she was nauseated and fearful to eat the food because she continued to be nauseated. Resident #25 said she did not eat her breakfast due to her stomach bothering her. The nursing notes for Resident #25 indicated the following: *[DATE] at 3:00 p.m. Resident #25 complained of a headache The resident received Tylenol, Geri Mox-, and [MEDICATION NAME]. The note indicated at 4:00 p.m. Resident #25 continued to complain of nausea, vomiting, and a headache. The physician was notified and order was received for [MEDICATION NAME] (treats constipation). *[DATE] indicated Resident #25 was nauseated on the day and night shift. The note did not contain further assessment or intervention. During an interview on [DATE] at 11:22 a.m., LVN W said Resident #25 had an unidentified gentlemen visitor on Saturday ([DATE]) or Sunday ([DATE]) and he told her Resident #25 said she had been throwing up all day and no one was paying attention. The nurse said she reviewed the record and found where the resident was sick the day before. She said she did not observe the resident's vomit. She said she did not assess the resident and did not notify the physician. The nursing notes for Resident #25 indicated the following: *[DATE] at 12:47 p.m. Resident #25 experienced nausea and vomiting. New order received for [MEDICATION NAME] (nausea and vomiting). At 1:55 p.m. resident complained of a throbbing headache in the area of her forehead. Nausea and vomiting were checked on the skilled nurse assessment boxes for the day, evening, and night shifts. *[DATE] at 10:27 a.m. Resident #25 complained she had not eaten in two days and complained of no appetite. The skilled nursing note assessment boxes were checked on day and night shifts as positive for nausea and vomiting. The skilled nurse note did not include further assessment or intervention. *[DATE] at 10:27 a.m. Resident #25 complained of a headache at 8:10 a.m., described as throbbing in the front of forehead. Resident also complained of no appetite and had not eaten in two days. At 1:45 p.m. Resident #25 complained of a throbbing headache in the front of forehead. The skilled nursing note indicated nausea and vomiting were present on the day and night shift with no further assessment or intervention documented. During an interview on [DATE] at 4:52 p.m., LVN B said Resident #25 complained of a headache that morning ([DATE]) around breakfast and wanted to get back in bed. She said she was not aware of the nausea and vomiting. The nursing notes for Resident #25 indicated the following: *[DATE] at 11:35 a.m. Resident #25 was found unresponsive with slow labored respirations. At 11:37 a.m., the DON indicated Resident #25 had no heart beat or respirations and was pronounced dead at 11:43 a.m. During an interview on [DATE] at 2:30 p.m., the DON said she was unable to locate orders for monitoring [MEDICATION NAME] levels or [MEDICATION NAME] for Resident #25. The DON said the physician had standing orders for laboratory services to monitor [MEDICATION NAME] and [MEDICATION NAME] levels, but the corporate office asked them not to use the standing orders. The DON said no monitoring laboratory services had been drawn for this resident. The DON indicated there was no care plan for the [MEDICATION NAME]. During an interview on [DATE] at 3:00 p.m., Resident #25's physician said he did not routinely monitor [MEDICATION NAME] levels unless a resident had [DIAGNOSES REDACTED]. He said he could not recall if the facility had informed him that Resident #25 had complained of nausea, vomiting, and headache. The physician indicated he was not notified of the resident ' s heart rates below 60. The physician said he routinely monitored [MEDICATION NAME] therapy a minimum of every two weeks and more often if indicated. The physician said he was unaware Resident #25 had not had blood drawn to monitor the [MEDICATION NAME] or the facility was no longer following his standing orders for blood draws for the [MEDICATION NAME]. The website http://druginserts.com/lib/rx/meds/[MEDICATION NAME]-4/page/2/ accessed [DATE] indicated: Monitor for signs and symptoms of [MEDICATION NAME] toxicity and clinical response. Adjust dose based on toxicity, efficacy, and blood levels. Serum [MEDICATION NAME] levels less than 0.5 ng/mL have been associated with diminished efficacy, while levels above 2 ng/mL have been associated with increased toxicity without increased benefit .Signs and symptoms of [MEDICATION NAME] toxicity include anorexia, nausea, vomiting Low body weight, advanced age or impaired renal function, [DIAGNOSES REDACTED], hypercalcemia, or [DIAGNOSES REDACTED] may predispose to [MEDICATION NAME] toxicity. Obtain serum [MEDICATION NAME] levels in patients with signs or symptoms of [MEDICATION NAME] therapy and interrupt or adjust dose if necessary .Assess serum electrolytes and renal function periodically . the dosage of [MEDICATION NAME] should be carefully selected and monitored in elderly patients . The website [MEDICATION NAME] Prescribing Information-Bristol-Myers Squibb packageinserts.bms.com/pi/[MEDICATION NAME].pdf accessed on [DATE] indicated .The dosage and administration of [MEDICATION NAME] must be individualized for each patient according to the patient ' s INR response to the drug. Adjust the dose based on the patient ' s INR and the condition being treated . The website indicated the target INR for patients with [MEDICAL CONDITION] was 2.5 (range, 2XXX,[DATE].0). Adverse reactions were noted to include gastrointestinal disorders: nausea, vomiting, diarrhea, taste perversion, abdominal pain, flatulence, and bloating. It was noted the physician should be notified immediately if any unusual bleeding or symptoms occur. The signs and symptoms of bleeding included: pain, swelling or discomfort, headache,dizziness, or weakness. The website <http://www.uptodate.com/contents/[MEDICATION NAME]-[MEDICATION NAME]-beyond-the- basiics> accessed [DATE] indicated .If the INR is below the target range (ie, under anticoagulated), there is an increased risk of clotting. On the other hand, if the INR is above the target range (ie, over-anticoagulated), there is an increased risk of bleeding .The [MEDICATION NAME] dose may have to be adjusted if the INR is too high or too low, or if you start a new medicine or become ill . The administrator and DON were notified on [DATE] at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Plan of Removal was accepted on [DATE] at 7:55 p.m. and included: .Resident #25 no longer resided in the facility and no actions could be taken . The center immediately reviewed all residents with [MEDICATION NAME] orders to validate there were lab orders. If lab orders are not ordered the nurse will assess resident for signs and symptoms of bleeding, bruising, and bloody gums and notify the Physician for orders. This will be completed [DATE]. The center immediately reviewed all residents with [MEDICATION NAME] orders to validate there were lab orders. If the lab is not ordered the nurse will assess resident for signs and symptoms of dig toxicity such as Lethargy, drowsiness, fatigue, Neuralgia, [MEDICAL CONDITION], Shortness of breath, slow heart rate, Headache, Visual disturbances, Anorexia, Weight Loss, Dizziness ' -Confusion, N/V, [MEDICAL CONDITION], Diarrhea and notify the physician for orders. The DON/ADON will use the admission check list on new residents to validate resident that have therapeutic lab values are ordered. In-house resident on medication requiring therapeutic lab values the charge nurse will use the lab protocol to obtain lab orders. The facility will contact all attending physicians that we no longer use standing orders but have lab protocol. The charge nurses will review the lab protocol with the physicians to obtain lab orders for medications that require therapeutic lab monitoring. All nurses will be educated on the adverse drug policy and the Therapeutic lab protocol by the DON and designee. This will be completed by [DATE] and any nurse that has not received the education will not be allowed to work until the education is completed. All CNAs will be educated to recognize signs and symptoms of adverse reactions and notify the nurse. Signs and symptoms for [MEDICATION NAME] toxicity are bleeding, bruising, and bloody gums. Signs and symptoms for [MEDICATION NAME] toxicity are Lethargy, drowsiness, fatigue, Neuralgia, [MEDICAL CONDITION], Shortness of breath, slow heart rate, Headache, Visual disturbances, Anorexia, Weight Loss, Dizziness ' -Confusion, N/V, [MEDICAL CONDITION], Diarrhea. This will be completed by [DATE] and any CNA that has not received the education will not be allowed to work until the education is completed. The medical directors were notified of the immediate jeopardy. The DON/ADON will use the admission checklist to ensure therapeutic labs have been ordered for patients requiring therapeutic lab monitoring The surveyors confirmed the facility had implemented sufficiently to remove the Immediate Jeopardy on [DATE] by: *Information was reviewed on chart and lab audits. *Six LVNs and twelve CNAs were interviewed and they demonstrated they were in-serviced on the information regarding [MEDICATION NAME] and [MEDICATION NAME]. They were knowledgeable about changes in procedures. *In-service documentation was reviewed and indicated all staff (except prn and staff on leave) were in-serviced as indicated on correct documentation of monitoring [MEDICATION NAME] and [MEDICATION NAME] therapy, such as labs and signs and symptoms of bleeding or [MEDICATION NAME] toxicity. *The policies for Anticoagulation Drug Therapy and Adverse Medication Event were reviewed and contained the required information for monitoring and staff responsibilities. *Interviews with the administrator, DON and ADON indicated they were in-serviced on the information and were knowledgeable about changes in procedures. On [DATE] at 11:50 a.m., the administrator and DON were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list obtained from the DON dated [DATE] indicated 16 residents received [MEDICATION NAME] and 7 residents received [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed provide care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment for 3 of 32 residents reviewed for assessment. (Resident #s 15, 23 and 25) Resident #25 received [MEDICATION NAME] (blood thinner) and [MEDICATION NAME] (treats heart failure and slows and strengthens the heart beat). The facility did not assess for signs and symptoms of adverse reactions for the use of the [MEDICATION NAME] or [MEDICATION NAME], did not consult with the physician, and did not monitor laboratory levels for the [MEDICATION NAME] and [MEDICATION NAME]. An Immediate Jeopardy situation was identified on 10/29/15. The Immediate Jeopardy was removed on 10/30/15. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 16 residents receiving [MEDICATION NAME] at risk for serious bleeding or death and 7 residents receiving [MEDICATION NAME] at risk for [MEDICATION NAME] toxicity or death. Non-immediate jeopardy: Resident #15's surgical incision was not assessed and treatment was not provided to the incision. This failure could place 1 resident with a surgical incision at risk for developing infections. Findings included: 1. Physician orders [REDACTED].#25, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The resident had an order for [REDACTED]. The orders indicated the resident was a do not resuscitate. A hospital history and physical dated 09/04/15 indicated Resident #25 had multiple [MEDICAL CONDITION] in the past and her [MEDICATION NAME] level was not at a therapeutic level. The most recent MDS dated [DATE] indicated Resident #25 had severely impaired cognition, clear speech, and usually understood others. Resident #25 was incontinent of bowel and bladder and was at risk for falls. The resident had an additional [DIAGNOSES REDACTED]. A care plan dated 09/18/15 for Resident #25 did not did not address the use of the [MEDICATION NAME]. The care plan indicated the resident had a focus of anticoagulant (blood thinner) related to [MEDICAL CONDITION]. The plan indicated: laboratory services as ordered, monitor, document and report to the physician signs and symptoms of anticoagulant complications such as sudden severe headaches, nausea, vomiting, joint pain, loss of appetite, and sudden changes in mental status. A laboratory requisition dated 09/08/15 indicated a request for a [MEDICATION NAME] level to be drawn on Resident #25 on the morning of 09/09/15. The requisition indicated the blood was not drawn due to the resident's combative behavior. A nursing note dated 09/09/15 at 2:30 a.m. indicated Resident # 25 was yelling and tried to hit staff and the laboratory representative. There were no written orders in Resident #25's nursing notes from 9/8/15 - 10/27/15 for a [MEDICATION NAME] level or an explanation for the one time request of the [MEDICATION NAME] level. A pharmacy evaluation review for Resident #25 dated 10/07/15 indicated a request to update the resident's anticoagulant record sheet with [MEDICATION NAME] dose and her latest INR results. The review indicated the resident's [MEDICATION NAME] was frequently held due to a pulse less than 60 and recommended discussion with the physician. The September 2015 MAR indicated [REDACTED] *9/16 pulse 59, *9/18 pulse 52, *9/19 pulse 47, *9/20 pulse 53, *9/22 pulse 58, *9/28 pulse 55. The October 2015 MAR indicated [REDACTED] *10/1 pulse 58, *10/3 pulse 59, *10/5 pulse 56, *10/6 pulse 59 *10/9 pulse (not legible) *10/10 pulse 51, *10/14 pulse 51, *10/15 pulse 45, *10/22 pulse 56. The nursing notes for Resident #25 from 9/8/15 through 10/27/15 did not indicate the physician was notified the [MEDICATION NAME] was held due to the resident's pulse being less than 60. During an interview on 10/27/15 at 9:30 am, Resident #25 said she was nauseated and fearful to eat the food because she continued to be nauseated. Resident #25 said she did not eat her breakfast due to her stomach bothering her. The nursing notes for Resident #25 indicated the following: *10/22/15 at 3:00 p.m. Resident #25 complained of a headache The resident received Tylenol, Geri Mox-, and [MEDICATION NAME]. The note indicated at 4:00 p.m. Resident #25 continued to complain of nausea, vomiting, and a headache. The physician was notified and order was received for [MEDICATION NAME] (treats constipation). *10/23/15 indicated Resident #25 was nauseated on the day and night shift. The note did not contain further assessment or intervention. During an interview on 10/29/15 at 11:22 a.m., LVN W said Resident #25 had an unidentified gentlemen visitor on Saturday (10/24/15) or Sunday (10/25/15) and he told her Resident #25 said she had been throwing up all day and no one was paying attention. The nurse said she reviewed the record and found where the resident was sick the day before. She said she did not observe the resident's vomit. She said she did not assess the resident and did not notify the physician. The nursing notes for Resident #25 indicated the following: *10/24/15 at 12:47 p.m. Resident #25 experienced nausea and vomiting. New order received for [MEDICATION NAME] (nausea and vomiting). At 1:55 p.m. resident complained of a throbbing headache in the area of her forehead. Nausea and vomiting were checked on the skilled nurse assessment boxes for the day, evening, and night shifts. *10/25/15 at 10:27 a.m. Resident #25 complained she had not eaten in two days and complained of no appetite. The skilled nursing note assessment boxes were checked on day and night shifts as positive for nausea and vomiting. The skilled nurse note did not include further assessment or intervention. *10/26/15 at 10:27 a.m. Resident #25 complained of a headache at 8:10 a.m., described as throbbing in the front of forehead. Resident also complained of no appetite and had not eaten in two days. At 1:45 p.m. Resident #25 complained of a throbbing headache in the front of forehead. The skilled nursing note indicated nausea and vomiting were present on the day and night shift with no further assessment or intervention documented. The MAR for October 2015 indicated Resident #25 received medications that included: *[MEDICATION NAME] on 10/22/15 and 10/24/15, *[MEDICATION NAME] on one occasion on 10/24/15. *Tylenol on 10/1, 10/4, 10/7, 10/17, 10/21, 10/22, 10/24, and 10/26. A Pain Management Flowsheet indicated Resident #25 received Tylenol on the following days: *10/17/15 complaint of general pain *10/21/15 complaint of headache *10/22/15 complaint of headache *10/24/15 complaint of headache *10/26/15 at 8:00 a.m. complaint of headache *10/26/15 at 2:00 p.m. complaint of headache During an interview on 10/27/15 at 4:52 p.m., LVN B said Resident #25 complained of a headache that morning (10/27/15) around breakfast and wanted to get back in bed. The LVN said she did not assess the resident and did not notify the physician. She said she was not aware of the nausea and vomiting. The nursing notes for Resident #25 indicated the following: *10/27/15 at 11:35 a.m. Resident #25 was found unresponsive with slow labored respirations. At 11:37 a.m., the DON indicated Resident #25 had no heart beat or respirations and was pronounced dead at 11:43 a.m. During an interview on 10/27/15 at 4:55 p.m., LVN J said Resident #25 never really complained about pain. The LVN said she had not observed the resident's vomit. During an interview on 10/29/15 at 2:30 p.m., the DON said she was unable to locate orders for monitoring [MEDICATION NAME] levels or [MEDICATION NAME] for Resident #25. The DON said the physician had standing orders for laboratory services to monitor [MEDICATION NAME] and [MEDICATION NAME] levels, but the corporate office asked them not to use the standing orders. The DON said no monitoring laboratory services had been drawn for this resident. The DON indicated there was no care plan for the [MEDICATION NAME]. During an interview on 10/29/15 at 3:00 p.m., Resident #25's physician said he did not routinely monitor [MEDICATION NAME] levels unless a resident had [DIAGNOSES REDACTED]. He said he could not recall if the facility had informed him that Resident #25 had complained of nausea, vomiting, and headache. The physician indicated he was not notified of the resident ' s heart rates below 60. The physician said he routinely monitored [MEDICATION NAME] therapy a minimum of every two weeks and more often if indicated. The physician said he was unaware Resident #25 had not had blood drawn to monitor the [MEDICATION NAME] or the facility was no longer following his standing orders for blood draws for the [MEDICATION NAME]. The website http://druginserts.com/lib/rx/meds/[MEDICATION NAME]-4/page/2/ accessed 10/30/15 indicated: Monitor for signs and symptoms of [MEDICATION NAME] toxicity and clinical response. Adjust dose based on toxicity, efficacy, and blood levels. Serum [MEDICATION NAME] levels less than 0.5 ng/mL have been associated with diminished efficacy, while levels above 2 ng/mL have been associated with increased toxicity without increased benefit .Signs and symptoms of [MEDICATION NAME] toxicity include anorexia, nausea, vomiting Low body weight, advanced age or impaired renal function, [DIAGNOSES REDACTED], hypercalcemia, or [DIAGNOSES REDACTED] may predispose to [MEDICATION NAME] toxicity. Obtain serum [MEDICATION NAME] levels in patients with signs or symptoms of [MEDICATION NAME] therapy and interrupt or adjust dose if necessary .Assess serum electrolytes and renal function periodically . the dosage of [MEDICATION NAME] should be carefully selected and monitored in elderly patients . The website [MEDICATION NAME] Prescribing Information-Bristol-Myers Squibb packageinserts.bms.com/pi/[MEDICATION NAME].pdf accessed on 10/30/15 indicated .The dosage and administration of [MEDICATION NAME] must be individualized for each patient according to the patient ' s INR response to the drug. Adjust the dose based on the patient ' s INR and the condition being treated . The website indicated the target INR for patients with [MEDICAL CONDITION] was 2.5 (range, 2.0-3.0). Adverse reactions were noted to include gastrointestinal disorders: nausea, vomiting, diarrhea, taste perversion, abdominal pain, flatulence, and bloating. It was noted the physician should be notified immediately if any unusual bleeding or symptoms occur. The signs and symptoms of bleeding included: pain, swelling or discomfort, headache,dizziness, or weakness. The website <http://www.uptodate.com/contents/[MEDICATION NAME]-[MEDICATION NAME]-beyond-the- basiics> accessed 11/6/15 indicated .If the INR is below the target range (ie, under anticoagulated), there is an increased risk of clotting. On the other hand, if the INR is above the target range (ie, over-anticoagulated), there is an increased risk of bleeding .The [MEDICATION NAME] dose may have to be adjusted if the INR is too high or too low, or if you start a new medicine or become ill . 2. admission orders [REDACTED]. The admission orders [REDACTED]. The admission orders [REDACTED]. There were no telephone orders from 10/05/15 to 10/29/15 that indicated Resident #23 required monitoring labs for [MEDICATION NAME]. The most recent MDS dated [DATE] indicated Resident #23 had severe cognitive impairment, required supervision for all ADLs, and had received anticoagulation therapy for 5 days. A care plan dated 09/29/15 did not indicate Resident #23 was receiving anticoagulation therapy. The MAR indicated [REDACTED]. The Pre-Treatment form from the [MEDICAL TREATMENT] center dated 10/27/15 did not indicate Resident #23 had received PT/INR levels for [MEDICATION NAME] monitoring. The form also did not indicate Resident #23 was receiving [MEDICATION NAME]. During an interview on 10/29/15 at 2:50 p.m., LVN B said the facility originally utilized standing orders for the medical directors. She said the standing orders would have included labs monitoring medications such as [MEDICATION NAME] or [MEDICATION NAME]. LVN B said the corporate office said they could no longer use the standing orders for the physicians a few months ago and she was not sure if the physicians were notified. LVN B said Resident #23 usually had labs drawn while she was at [MEDICAL TREATMENT] and assumed they would monitor the PT/INR levels. LVN B said when she looked at the labs that were drawn during Resident #23 ' s last [MEDICAL TREATMENT] visit; the PT/INR levels were not drawn. A telephone order dated 10/29/15 indicated Resident #23 was to receive a stat PT/INR level, then she would receive a PT/INR level monthly. A laboratory result dated 10/29/15 indicated Resident #23 ' s PT level was high at 45.5 seconds and INR was high at 3.9 . The laboratory results indicated .current recommendations were for an INR of 2.0 - 3.0 for all anticoagulated patients . The expected range listed on the laboratory report for the PT level was 9.6-13.6 seconds. An Anticoagulant Record Sheet dated 10/29/15 indicated a new order was received to hold Resident #23 ' s [MEDICATION NAME] and to recheck the PT/INR in the morning. A telephone order dated 10/30/15 indicated new order was received to hold Resident #23 ' s [MEDICATION NAME] and to recheck the PT/INR in the morning. An Anticoagulant Drug Therapy policy dated 09/01/2015 indicated .Residents receiving anticoagulant therapy have laboratory tests ordered and results are available and used to monitor and adjust therapy. The policy indicated the physician/NP/PA gives the orders for starting or continuing anticoagulation therapy .timing and use of appropriate laboratory measures to monitor response, proper dose adjustment based on lab parameters/clinical response . The pharmacy reviews and verifies the physician's order [REDACTED].reviews lab values and responds to values outside of range in collaboration with the ordering physician .monitors resident for signs/symptoms of side effects/adverse drug event . The Adverse Medication Event Policy dated 09/01/15 indicated .it is the policy of the facility to monitor residents at risk for Adverse Drug Events through systems and processes to minimize risks associated with medications. The policy indicated medications that may be considered with high risk related Adverse Event included [MEDICAL CONDITION] and [MEDICATION NAME]. The policy also indicated .lab tests are used for medications that are monitored and adjusted through therapeutic blood levels. The administrator and DON were notified on 10/29/15 at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Plan of Removal was accepted on 10/29/15 at 7:55 p.m. and included: .Resident #25 no longer resided in the facility and no actions could be taken. Resident #23 was assessed immediately 10/29/15 for signs and symptoms of bleeding by the ADON/RN and notified her attending physician. Resident #23 ' s attending physician ordered a stat PT/INR and to check PT/INR every month. Resident #23 ' s responsible party was notified 10-29-15 of the new lab orders. The center immediately reviewed all residents with [MEDICATION NAME] orders to validate there were lab orders. If lab orders are not ordered the nurse will assess resident for signs and symptoms of bleeding, bruising, and bloody gums and notify the Physician for orders. This will be completed 10-29-15. The center immediately reviewed all residents with [MEDICATION NAME] orders to validate there were lab orders. If the lab is not ordered the nurse will assess resident for signs and symptoms of dig toxicity such as Lethargy, drowsiness, fatigue, Neuralgia, [MEDICAL CONDITION], Shortness of breath, slow heart rate, Headache, Visual disturbances, Anorexia, Weight Loss, Dizziness ' -Confusion, N/V, [MEDICAL CONDITION], Diarrhea and notify the physician for orders. The DON/ADON will use the admission check list on new residents to validate resident that have therapeutic lab values are ordered. In-house resident on medication requiring therapeutic lab values the charge nurse will use the lab protocol to obtain lab orders. The facility will contact all attending physicians that we no longer use standing orders but have lab protocol. The charge nurses will review the lab protocol with the physicians to obtain lab orders for medications that require therapeutic lab monitoring. All nurses will be educated on the adverse drug policy and the Therapeutic lab protocol by the DON and designee. This will be completed by October 30, 2015 and any nurse that has not received the education will not be allowed to work until the education is completed. All CNAs will be educated to recognize signs and symptoms of adverse reactions and notify the nurse. Signs and symptoms for [MEDICATION NAME] toxicity are bleeding, bruising, and bloody gums. Signs and symptoms for [MEDICATION NAME] toxicity are Lethargy, drowsiness, fatigue, Neuralgia, [MEDICAL CONDITION], Shortness of breath, slow heart rate, Headache, Visual disturbances, Anorexia, Weight Loss, Dizziness ' -Confusion, N/V, [MEDICAL CONDITION], Diarrhea. This will be completed by October 30, 2015 and any CNA that has not received the education will not be allowed to work until the education is completed. The medical directors were notified of the immediate jeopardy. The DON/ADON will use the admission checklist to ensure therapeutic labs have been ordered for patients requiring therapeutic lab monitoring The surveyors confirmed the facility had implemented sufficiently to remove the Immediate Jeopardy on 10/30/15 by: *Information was reviewed on chart and lab audits. *Six LVNs and twelve CNAs were interviewed and they demonstrated they were in-serviced on the information regarding [MEDICATION NAME] and [MEDICATION NAME]. They were knowledgeable about changes in procedures. *In-service documentation was reviewed and indicated all staff (except prn and staff on leave) were in-serviced as indicated on correct documentation of monitoring [MEDICATION NAME] and [MEDICATION NAME] therapy, such as labs and signs and symptoms of bleeding or [MEDICATION NAME] toxicity. *The policies for Anticoagulation Drug Therapy and Adverse Medication Event were reviewed and contained the required information for monitoring and staff responsibilities. *Interviews with the administrator, DON and ADON indicated they were in-serviced on the information and were knowledgeable about changes in procedures. On 10/30/2015 at 11:50 a.m., the administrator and DON were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Non Imediate Jeopardy: 3. An Admission Resident Data Collection Tool dated 10/08/2015 at 5:00 p.m., indicated Resident #15 had a surgical incision to the left middle back. Physician orders [REDACTED].# 15 was admitted with an order to change dressing as needed. A history and physical dated 10/12/2015 indicated Resident #15 was [AGE] years with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #15 had no cognitive impairment, required extensive assistance with toileting, and had a surgical wound. An interim plan of care dated 10/08/2015 indicated Resident #15 had wound care to a surgical wound to left middle back. A nursing note dated 10/08/2015 at 5:00 p.m., indicated Resident #15 was admitted to the facility with daily wound care to surgical incision to left middle back. A non-pressure skin condition report dated 10/08/2015, indicated a surgical incision to left mid back measured 5.5 cm X 0.5 cm X 0.5 cm. and to continue treatment. The October 2015 Treatment Administration Record did not document Resident #15 received daily wound care to the surgical wound to the left mid back. Nursing note dated 10/27/15 indicated Resident #15 requested her sheets be changed and her surgical site be assessed. The note indicated the surgical site had yellow tinged drainage from a small opening. Nursing notes from 10/09/2015 to 10/26/2015 did not address the status of the wound or the presence or lack of drainage from wound for Resident #15. Nursing notes for Resident #15 indicated the following: *10/27/15 at 10:35 a.m. Charge nurse reported yellowish drainage coming from surgical site down the back. New order received to send the resident to the emergency room for evaluation. *10/27/15 at 3:30 p.m. Resident back in the facility from emergency room . Report received from emergency room [DIAGNOSES REDACTED]. The resident received a new order for [MEDICATION NAME] (used to treat serious infections caused by bacteria). During an interview on 10/27/2015 at 4:45 p.m. LVN J said Resident #15 did not have any drainage to her lower back and she had orders for medication from the hospital. During an interview on 10/27/2015 at 4:55 p.m. the DON said she was unaware until today (10/27/15) Resident #15 had any drainage from her surgical wound and she was sent to the hospital after contacting the physician. The DON stated she expected the CNAs to communicate with the charge nurses any changes in the resident's condition. During an interview on 10/27/2015 at 4:55 p.m. LVN J said Resident #15 never had a daily dressing change to her surgical incision site. LVN J said the site should have been checked daily and documented in the nursing notes or on the treatment administration record. She said 10/27/2015 was the first time she was aware of any drainage from the surgical site. She said she communicated with the treating physician and was instructed to send the resident to the hospital. During an interview on 10/27/2015 at 5:03 p.m. the ADON said she assessed Resident #15's surgical site on 10/27/15 and found yellowish clear drainage. The ADON said she called the physician and was instructed to send the resident to the hospital for evaluation. The ADON said she saw yellowish drainage on the resident's sheets. She said she was not aware that the resident had drainage since Friday. During an interview on 10/28/2015 at 9:15 a.m. the physician said he expected the staff to either contact him or the surgeon if a resident was admitted and there were no dressing change orders. He said he was not contacted prior to 10/27/2015 to inform him of any drainage from the surgical site to Resident # 15's back. A list obtained from the DON dated 10/29/15 indicated 16 residents received [MEDICATION NAME] and 7 residents received [MEDICATION NAME] at the time of the incident. A list obtained for the DON dated 10/30/15 indicated 1 resident had a surgical incision.

Based on interview and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 2 (Resident #s 23 and 25) of 5 residents reviewed for [MEDICATION NAME] and 1 (Resident # 25) of 2 residents reviewed for [MEDICATION NAME] use. Resident #25 received [MEDICATION NAME] (blood thinner) and [MEDICATION NAME] (treats heart failure and slows and strengthens the heart beat). The facility did not monitor the use of the [MEDICATION NAME] and [MEDICATION NAME]. Resident #25 complained of a throbbing headache, nausea, and vomiting for 6 days prior to her death on [DATE]. Resident #23 received [MEDICATION NAME] daily for 26 days. The facility did not monitor the use of the [MEDICATION NAME]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 16 residents receiving [MEDICATION NAME] at risk for serious bleeding or death and 7 residents receiving [MEDICATION NAME] at risk for [MEDICATION NAME] toxicity or death. Findings included: 1. Physician orders [REDACTED].#25, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The resident had an order for [REDACTED]. The orders indicated the resident was a do not resuscitate. A hospital history and physical dated [DATE] indicated Resident #25had multiple [MEDICAL CONDITION] in the past and her [MEDICATION NAME] level was not at a therapeutic level. The most recent MDS dated [DATE] indicated Resident #25 had severely impaired cognition, clear speech, and usually understood others. Resident #25 was incontinent of bowel and bladder and was at risk for falls. The resident had an additional [DIAGNOSES REDACTED]. A care plan dated [DATE] for Resident #25 did not did not address the use of the [MEDICATION NAME]. The care plan indicated the resident had a focus of anticoagulant (blood thinner) related to [MEDICAL CONDITION]. The plan indicated: laboratory services as ordered, monitor, document and report to the physician signs and symptoms of anticoagulant complications such as sudden severe headaches, nausea, vomiting, joint pain, loss of appetite, and sudden changes in mental status. A laboratory requisition dated [DATE] indicated a request for a [MEDICATION NAME] level to be drawn on Resident #25 on the morning of [DATE]. The requisition indicated the blood was not drawn due to the resident's combative behavior. A nursing note dated [DATE] at 2:30 a.m. indicated Resident # 25 was yelling and tried to hit staff and the laboratory representative. There were no written orders in Resident #25's nursing notes from [DATE] - [DATE] for a [MEDICATION NAME] level or an explanation for the one time request of the [MEDICATION NAME] level. A pharmacy evaluation review for Resident #25 dated [DATE] indicated a request to update the resident's anticoagulant record sheet with [MEDICATION NAME] dose and her latest INR results. The review indicated the resident's [MEDICATION NAME] was frequently held due to a pulse less than 60 and recommended discussion with the physician. The [DATE] MAR indicated [REDACTED] *,[DATE] pulse 59, *,[DATE] pulse 52, *,[DATE] pulse 47, *,[DATE] pulse 53, *,[DATE] pulse 58, *,[DATE] pulse 55. The [DATE] MAR indicated [REDACTED] *,[DATE] pulse 58, *,[DATE] pulse 59, *,[DATE] pulse 56, *,[DATE] pulse 59 *,[DATE] pulse (not legible), *,[DATE] pulse 51, *,[DATE] pulse 51, *,[DATE] pulse 45, *,[DATE] pulse 56. The nursing notes for Resident #25 from [DATE] through [DATE] did not indicate the physician was notified the [MEDICATION NAME] was held due to the resident's pulse being less than 60. During an interview on [DATE] at 9:30 am, Resident #25 said she was nauseated and fearful to eat the food because she continued to be nauseated. Resident #25 said she did not eat her breakfast due to her stomach bothering her. The nursing notes for Resident #25 indicated the following: *[DATE] at 3:00 p.m. Resident #25 complained of a headache The resident received Tylenol, Geri Mox-, and [MEDICATION NAME]. The note indicated at 4:00 p.m. Resident #25 continued to complain of nausea, vomiting, and a headache. The physician was notified and order was received for [MEDICATION NAME] (treats constipation). *[DATE] indicated Resident #25 was nauseated on the day and night shift. The note did not contain further assessment or intervention. During an interview on [DATE] at 11:22 a.m., LVN W said Resident #25 had an unidentified gentlemen visitor on Saturday ([DATE]) or Sunday ([DATE]) and he told her Resident #25 said she had been throwing up all day and no one was paying attention. The nurse said she reviewed the record and found where the resident was sick the day before. She said she did not observe the resident's vomit. She said she did not assess the resident and did not notify the physician. The nursing notes for Resident #25 indicated the following: *[DATE] at 12:47 p.m. Resident #25 experienced nausea and vomiting. New order received for [MEDICATION NAME] (nausea and vomiting). At 1:55 p.m. resident complained of a throbbing headache in the area of her forehead. Nausea and vomiting were checked on the skilled nurse assessment boxes for the day, evening, and night shifts. *[DATE] at 10:27 a.m. Resident #25 complained she had not eaten in two days and complained of no appetite. The skilled nursing note assessment boxes were checked on day and night shifts as positive for nausea and vomiting. The skilled nurse note did not include further assessment or intervention. *[DATE] at 10:27 a.m. Resident #25 complained of a headache at 8:10 a.m., described as throbbing in the front of forehead. Resident also complained of no appetite and had not eaten in two days. At 1:45 p.m. Resident #25 complained of a throbbing headache in the front of forehead. The skilled nursing note indicated nausea and vomiting were present on the day and night shift with no further assessment or intervention documented. During an interview on [DATE] at 4:52 p.m., LVN B said Resident #25 complained of a headache that morning ([DATE]) around breakfast and wanted to get back in bed. She said she was not aware of the nausea and vomiting. The nursing notes for Resident #25 indicated the following: *[DATE] at 11:35 a.m. Resident #25 was found unresponsive with slow labored respirations. At 11:37 a.m., the DON indicated Resident #25 had no heart beat or respirations and was pronounced dead at 11:43 a.m. During an interview on [DATE] at 2:30 p.m., the DON said she was unable to locate orders for monitoring [MEDICATION NAME] levels or [MEDICATION NAME] for Resident #25. The DON said the physician had standing orders for laboratory services to monitor [MEDICATION NAME] and [MEDICATION NAME] levels, but the corporate office asked them not to use the standing orders. The DON said no monitoring laboratory services had been drawn for this resident. The DON indicated there was no care plan for the [MEDICATION NAME]. During an interview on [DATE] at 3:00 p.m., Resident #25's physician said he did not routinely monitor [MEDICATION NAME] levels unless a resident had [DIAGNOSES REDACTED]. He said he could not recall if the facility had informed him that Resident #25 had complained of nausea, vomiting, and headache. The physician indicated he was not notified of the resident ' s heart rates below 60. The physician said he routinely monitored [MEDICATION NAME] therapy a minimum of every two weeks and more often if indicated. The physician said he was unaware Resident #25 had not had blood drawn to monitor the [MEDICATION NAME] or the facility was no longer following his standing orders for blood draws for the [MEDICATION NAME]. The website http://druginserts.com/lib/rx/meds/[MEDICATION NAME]-4/page/2/ accessed [DATE] indicated: Monitor for signs and symptoms of [MEDICATION NAME] toxicity and clinical response. Adjust dose based on toxicity, efficacy, and blood levels. Serum [MEDICATION NAME] levels less than 0.5 ng/mL have been associated with diminished efficacy, while levels above 2 ng/mL have been associated with increased toxicity without increased benefit .Signs and symptoms of [MEDICATION NAME] toxicity include anorexia, nausea, vomiting Low body weight, advanced age or impaired renal function, [DIAGNOSES REDACTED], hypercalcemia, or [DIAGNOSES REDACTED] may predispose to [MEDICATION NAME] toxicity. Obtain serum [MEDICATION NAME] levels in patients with signs or symptoms of [MEDICATION NAME] therapy and interrupt or adjust dose if necessary .Assess serum electrolytes and renal function periodically . the dosage of [MEDICATION NAME] should be carefully selected and monitored in elderly patients . The website [MEDICATION NAME] Prescribing Information-Bristol-Myers Squibb packageinserts.bms.com/pi/[MEDICATION NAME].pdf accessed on [DATE] indicated .The dosage and administration of [MEDICATION NAME] must be individualized for each patient according to the patient ' s INR response to the drug. Adjust the dose based on the patient ' s INR and the condition being treated . The website indicated the target INR for patients with [MEDICAL CONDITION] was 2.5 (range, 2XXX,[DATE].0). Adverse reactions were noted to include gastrointestinal disorders: nausea, vomiting, diarrhea, taste perversion, abdominal pain, flatulence, and bloating. It was noted the physician should be notified immediately if any unusual bleeding or symptoms occur. The signs and symptoms of bleeding included: pain, swelling or discomfort, headache,dizziness, or weakness. The website <http://www.uptodate.com/contents/[MEDICATION NAME]-[MEDICATION NAME]-beyond-the- basiics> accessed [DATE] indicated .If the INR is below the target range (ie, under anticoagulated), there is an increased risk of clotting. On the other hand, if the INR is above the target range (ie, over-anticoagulated), there is an increased risk of bleeding .The [MEDICATION NAME] dose may have to be adjusted if the INR is too high or too low, or if you start a new medicine or become ill . 2. admission orders [REDACTED]. The admission orders [REDACTED]. The admission orders [REDACTED]. There were no telephone orders from [DATE] to [DATE] that indicated Resident #23 required monitoring labs for [MEDICATION NAME]. The most recent MDS dated [DATE] indicated Resident #23 had severe cognitive impairment, required supervision for all ADLs, and had received anticoagulation therapy for 5 days. A care plan dated [DATE] did not indicate Resident #23 was receiving anticoagulation therapy. The MAR indicated [REDACTED]. The Pre-Treatment form from the [MEDICAL TREATMENT] center dated [DATE] did not indicate Resident #23 had received PT/INR levels for [MEDICATION NAME] monitoring. The form also did not indicate Resident #23 was receiving [MEDICATION NAME]. During an interview on [DATE] at 2:50 p.m., LVN B said the facility originally utilized standing orders for the medical directors. She said the standing orders would have included labs monitoring medications such as [MEDICATION NAME] or [MEDICATION NAME]. LVN B said the corporate office said they could no longer use the standing orders for the physicians a few months ago and she was not sure if the physicians were notified. LVN B said Resident #23 usually had labs drawn while she was at [MEDICAL TREATMENT] and assumed they would monitor the PT/INR levels. LVN B said when she looked at the labs that were drawn during Resident #23 ' s last [MEDICAL TREATMENT] visit; the PT/INR levels were not drawn. A telephone order dated [DATE] indicated Resident #23 was to receive a stat PT/INR level, then she would receive a PT/INR level monthly. A laboratory result dated [DATE] indicated Resident #23 ' s PT level was high at 45.5 seconds and INR was high at 3.9 . The laboratory results indicated .current recommendations were for an INR of 2.0 - 3.0 for all anticoagulated patients . The expected range listed on the laboratory report for the PT level was 9XXX,[DATE].6 seconds. An Anticoagulant Record Sheet dated [DATE] indicated a new order was received to hold Resident #23 ' s [MEDICATION NAME] and to recheck the PT/INR in the morning. A telephone order dated [DATE] indicated new order was received to hold Resident #23 ' s [MEDICATION NAME] and to recheck the PT/INR in the morning. An Anticoagulant Drug Therapy policy dated [DATE] indicated .Residents receiving anticoagulant therapy have laboratory tests ordered and results are available and used to monitor and adjust therapy. The policy indicated the physician/NP/PA gives the orders for starting or continuing anticoagulation therapy .timing and use of appropriate laboratory measures to monitor response, proper dose adjustment based on lab parameters/clinical response . The pharmacy reviews and verifies the physician's order [REDACTED].reviews lab values and responds to values outside of range in collaboration with the ordering physician .monitors resident for signs/symptoms of side effects/adverse drug event . The Adverse Medication Event Policy dated [DATE] indicated .it is the policy of the facility to monitor residents at risk for Adverse Drug Events through systems and processes to minimize risks associated with medications. The policy indicated medications that may be considered with high risk related Adverse Event included [MEDICAL CONDITION] and [MEDICATION NAME]. The policy also indicated .lab tests are used for medications that are monitored and adjusted through therapeutic blood levels. The administrator and DON were notified on [DATE] at 3:05 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Plan of Removal was accepted on [DATE] at 7:55 p.m. and included: .Resident #25 no longer resided in the facility and no actions could be taken. Resident #23 was assessed immediately [DATE] for signs and symptoms of bleeding by the ADON/RN and notified her attending physician. Resident #23 ' s attending physician ordered a stat PT/INR and to check PT/INR every month. Resident #23 ' s responsible party was notified [DATE] of the new lab orders. The center immediately reviewed all residents with [MEDICATION NAME] orders to validate there were lab orders. If lab orders are not ordered the nurse will assess resident for signs and symptoms of bleeding, bruising, and bloody gums and notify the Physician for orders. This will be completed [DATE]. The center immediately reviewed all residents with [MEDICATION NAME] orders to validate there were lab orders. If the lab is not ordered the nurse will assess resident for signs and symptoms of dig toxicity such as Lethargy, drowsiness, fatigue, Neuralgia, [MEDICAL CONDITION], Shortness of breath, slow heart rate, Headache, Visual disturbances, Anorexia, Weight Loss, Dizziness ' -Confusion, N/V, [MEDICAL CONDITION], Diarrhea and notify the physician for orders. The DON/ADON will use the admission check list on new residents to validate resident that have therapeutic lab values are ordered. In-house resident on medication requiring therapeutic lab values the charge nurse will use the lab protocol to obtain lab orders. The facility will contact all attending physicians that we no longer use standing orders but have lab protocol. The charge nurses will review the lab protocol with the physicians to obtain lab orders for medications that require therapeutic lab monitoring. All nurses will be educated on the adverse drug policy and the Therapeutic lab protocol by the DON and designee. This will be completed by [DATE] and any nurse that has not received the education will not be allowed to work until the education is completed. All CNAs will be educated to recognize signs and symptoms of adverse reactions and notify the nurse. Signs and symptoms for [MEDICATION NAME] toxicity are bleeding, bruising, and bloody gums. Signs and symptoms for [MEDICATION NAME] toxicity are Lethargy, drowsiness, fatigue, Neuralgia, [MEDICAL CONDITION], Shortness of breath, slow heart rate, Headache, Visual disturbances, Anorexia, Weight Loss, Dizziness ' -Confusion, N/V, [MEDICAL CONDITION], Diarrhea. This will be completed by [DATE] and any CNA that has not received the education will not be allowed to work until the education is completed. The medical directors were notified of the immediate jeopardy. The DON/ADON will use the admission checklist to ensure therapeutic labs have been ordered for patients requiring therapeutic lab monitoring The surveyors confirmed the facility had implemented sufficiently to remove the Immediate Jeopardy on [DATE] by: *Information was reviewed on chart and lab audits. *Six LVNs and twelve CNAs were interviewed and they demonstrated they were in-serviced on the information regarding [MEDICATION NAME] and [MEDICATION NAME]. They were knowledgeable about changes in procedures. *In-service documentation was reviewed and indicated all staff (except prn and staff on leave) were in-serviced as indicated on correct documentation of monitoring [MEDICATION NAME] and [MEDICATION NAME] therapy, such as labs and signs and symptoms of bleeding or [MEDICATION NAME] toxicity. *The policies for Anticoagulation Drug Therapy and Adverse Medication Event were reviewed and contained the required information for monitoring and staff responsibilities. *Interviews with the administrator, DON and ADON indicated they were in-serviced on the information and were knowledgeable about changes in procedures. On [DATE] at 11:50 a.m., the administrator and DON were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A list obtained from the DON dated [DATE] indicated 16 residents received [MEDICATION NAME] and 7 residents received [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 13 residents reviewed for neglect. (Resident # 4) Resident #4 was admitted with a history of suicide attempts. The resident attempted suicide at the facility. The facility did not implement interventions in place to prevent the resident from attempting suicide at the facility. This failure was determined to be past non-compliance immediate jeopardy from 1/24/14 through 6/2/14 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 22 residents identified with signs and symptoms of depression at risk for neglect. Findings included: Physician orders [REDACTED].#4 admitted [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Resident #4 received [MEDICATION NAME] tablet 10/325 milligram (mg) every 4 hours as needed for pain,[MEDICATION NAME] 350 mg at bedtime for muscle spasms. A physician's telephone order dated 8/5/14, for M.S.[MEDICATION NAME] (contains [MEDICATION NAME] sulfate) 15 mg two times a day for pain. The admission MDS assessment dated [DATE] indicated Resident #4 was admitted [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Resident #4 was independent in her thought process and her cognitive status was intact. The resident had thoughts that she would be better off dead, or of hurting herself in some way. The MDS indicated the responsible staff or provider were informed there was a potential for resident self-harm. The most recent MDS assessment dated [DATE] indicated Resident #4 was re-admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. The MDS indicated Resident #4 was independent in her thought process and her cognitive status was intact. The resident had thoughts that she would be better off dead, or of hurting herself in some way. The MDS indicated the responsible staff or provider were informed there was a potential for resident self-harm. The initial care plan dated 1/31/14 did not address suicidal ideation or the history of suicide attempt by Resident #4 prior to her initial admission. The care plan was not updated. An initial social service history dated 1/27/14 indicated Resident #4 attempted to commit suicide by overdosing [MEDICATION NAME](sleep aide). During an interview on 8/04/14 at 3:48 p.m., Resident #4 said she attempted suicide at the facility on 6/2/14. She said staff did not monitor to ensure she took her medicine. Resident #4 said she hoarded M.S.[MEDICATION NAME] and took two hands full of the pain medication. The resident said since her readmission to the facility from the psychiatric hospital, the staff was "a little better at watching." During an interview on 8/05/14 at 10:33 a.m., the DON said Resident #4 was transferred to the emergency roiagnom on [DATE] due to lethargy and elevated blood sugar. She said she was not aware of the resident's suicide attempt on 6/2/14 prior to the resident's transfer to the hospital. The DON said Resident #4 was not on suicide precautions prior to the 6/2/14 suicide attempt and an investigation was not completed regarding the suicide attempt. The DON said the resident required supervision with medications. During an interview on 8/05/14 at 10:58 a.m., the DON said the SW was informed by the hospital that Resident #4 attempted suicide on 6/2/14 at the facility. She said Resident #4 told the emergency room staff she had attempted suicide. The DON said they only had the resident's word that she hoarded pills from the facility. She said prior to Resident #4 being transferred to the emergency room she was seeing the psychologist. The DON said Resident #4 attended a day program 2 times a week at an outside psychiatric facility. She said there were no medications administered at the day program. During an interview on 8/05/14 at 11:39 a.m., LVN C said she administered medications to Resident #4. She said Resident #4 attempted to get the staff administering medications on Hall 300 to leave her medications on her nightstand. She said Resident #4 told staff she would take the medication later. LVN C said she nor did her MAs leave any medications for Resident # 4 to take later. During an interview on 8/06/14 at 11:15 a.m., the Medicare MDS Coordinator and the Medicaid MDS Coordinator said the care plan for Resident #4 had not been updated since the initial care plan was completed 1/31/14 and there was no care plan for suicidal attempts or suicidal ideation. The Medicare MDS Coordinator said, "there was no standardized suicide care plan, I guess I need to make one up." During interviews with the administrator and the DON on 8/06/14 at 11:26 a.m., the DON said Resident #4's care plan should "absolutely" address the potential of a suicide attempt since suicidal ideation was triggered on her MDS. The DON said when Resident #4 returned from the psychiatric hospital on [DATE] to the facility due to a suicide attempt a care plan should have been created to address the potential of a suicide attempt. The administrator and DON indicated prior to the residents readmission on 6/19/14 there were no interventions in place to prevent Resident #4 from attempting suicide. They indicated staff was in-serviced to monitor the resident for the potential of a suicide attempt after the residents re-admission on 6/19/14. During an interview on 8/06/14 at 2:42 p.m., the psychologist said she worked with Resident #4 prior to the suicide attempt on 6/2/14 and currently worked with the resident. She said she had been working with Resident #4 as the resident had initially been admitted to the facility from a psychiatric hospital due to a suicide attempt in the community. Resident #4 had taken an overdose of medications and set her home on fire. The psychologist said every time she met with Resident #4 she would ask her if she was suicidal and the resident would indicate she was not suicidal but would say she could not find a purpose for living. The psychologist said she was worried about Resident #4 because she knew her family was getting ready to move out of state. The psychologist said she met with the resident on, 5/28/14, the Wednesday before she attempted suicide because she was worried about how the resident would react when her family left. The psychologist said the resident needed someone to monitor her to ensure she did not make a suicide attempt. The psychologist said she met with the administrator, DON and the SW and expressed her concerns and discussed having staff watch Resident #4 closely on the scheduled day (6/2/14) of her family's move. She said "they knew all about it" and should have been doing something more. The psychologist said facility staff did not know what was wrong when Resident #4 was sent out to theER on [DATE], but if the resident said she hoarded pills from the facility, they should have taken her word and either changed her medications to liquid, patches or injections. She indicated the staff needed to watch the resident closely to ensure she was taking her pain medications, because she did not think the resident could be trusted with pills. During an interview on 8/06/14 at 3:55 p.m., the AD said prior to Resident #4's suicide attempt at the facility she received no training regarding watching the resident. The Abuse Prohibition Policy and Procedure last revised 07/12 indicated the following: " ...Policy: Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. The following procedures will be operationalized in order that residents will not be subject to abuse by anyone..." "...The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services (if appropriate) will be notified in accordance with federal and state law..." It was determined this failure placed Resident #4 in an Immediate Jeopardy situation from 1/24/14 through 6/2/14. The facility took the following actions to correct the non-compliance on 07/08/14: During an interview on 8/06/14 at 3:55 p.m., the AD said since the resident's re-admission to the facility from the psychiatric hospital the administrator gave an in-service about monitoring Resident #4's behaviors and if she began making comments such as being better off dead or no longer having anything to live for to report this to the administrator. The AD said staff was provided a hand out regarding suicide protocols. During an interview on 8/06/14 at 4:00 p.m., MA X said prior to Resident #4's transfer from the facility to the emergency room , no training had been received regarding monitoring the resident for self-injurious behavior. The MA said she caught Resident #4, about 3 weeks prior to her being transferred to the emergency room , "pocketing medications in her cheeks." She said she saw her doing this only once. MA X said she reported the incident to the charge nurse, but unable to remember who the nurse was. She said the nurse told her to make sure Resident #4 drank a lot of water to wash the pills down. On 8/06/14 at 4:16 p.m., the AD provided a copy of the handout provided when Resident #4 was re-admitted to the facility on [DATE]. The un-dated handout addressed Clinical Practice Guidelines Suicide Protocol and indicated the following: " ...Anticipated Outcome Patients who are potentially dangerous to themselves are rendered as safe as possible to reduce the risk of self-harm ... " " ...Fundamental Information Suicide safeguards are instituted for new or re-admits from an outside agency that treated the patient for suicide attempts ... " " ...Process *Upon admission to the facility the patient is placed on one-to-one staff supervision until consulting practitioner or primary physician completes a psychosocial assessment and deems the patient safe to be independent in the facility..... *All packages, and clothes brought into the facility and for the patient is inspected by the nursing staff in the presence of the patient. *The patient's mouth is inspected after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are preferable. *The care plan identifies the interventions used to render a patient as safe as possible to reduce the risk of self-harm. *Upon hire and as indicated the staff are in-serviced on the signs and symptoms of suicide and reporting responsibility..." An LVN, MA, AD, and CNA were interviewed and said they were in-serviced regarding suicide precautions and monitoring for suicide ideation. The CMS Form 672 dated 08/04/14 indicated 22 residents with documented signs and symptoms of depression.

Based on interview and record review the facility failed to implement written policies and procedures that prohibit neglect for 1 of 13 residents reviewed for abuse/neglect. (Resident #4) Resident #4 was admitted with a history of a suicide attempts. The resident attempted suicide at the facility. The facility did not investigate or implement interventions in place to prevent the resident from attempting suicide at the facility. The facility did not report the incident to state agency. This failure was determined to be past non-compliance immediate jeopardy from 1/24/14 through 6/2/14 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 22 residents identified with depression at risk for neglect. Findings included: The Abuse Prohibition Policy and Procedure last revised 07/12 indicated the following: " ...Policy: Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. The following procedures will be operationalized in order that residents will not be subject to abuse by anyone..." "...The facility shall ensure that all alleged violations are reported immediately to the administrator or the administrative designee. Local law enforcement, the state survey agency and the Department of Family and Protective Services (if appropriate) will be notified in accordance with federal and state law. Investigation: A. The facility must have evidence that all violations, including allegations are thoroughly investigated. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. B. All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON..." Physician orders [REDACTED].#4 admitted [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Resident #4 received [MEDICATION NAME] tablet 10/325 milligram (mg) every 4 hours as needed for pain,[MEDICATION NAME] 350 mg at bedtime for muscle spasms. A physician's telephone order dated 8/5/14, for M.S.[MEDICATION NAME] (contain [MEDICATION NAME] sulfate)15 mg two times a day for pain. The admission MDS assessment dated [DATE] indicated Resident #4 was admitted [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Resident #4 was independent in her thought process and her cognitive status was intact. The resident had thoughts that she would be better off dead, or of hurting herself in some way. The MDS indicated the responsible staff or provider was informed there was a potential for resident self-harm. The most recent MDS assessment dated [DATE] indicated Resident #4 was re-admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. The MDS indicated Resident #4 was independent in her thought process and her cognitive status was intact. The resident had thoughts that she would be better off dead, or of hurting herself in some way. The MDS indicated the responsible staff or provider were informed there was a potential for resident self-harm. The initial care plan dated 1/31/14 did not address suicidal ideation or the suicide attempt by Resident #4 prior to her initial admission. The care plan was not updated. An initial social service history dated 1/27/14 indicated Resident #4 attempted to commit suicide by overdosing [MEDICATION NAME](sleep aide). During an interview on 8/04/14 at 3:48 p.m., Resident #4 said she attempted suicide at the facility on 6/2/14. She said staff did not monitor to ensure she took her medicine. Resident #4 said she hoarded M.S.[MEDICATION NAME] and took two hands full of the pain medication. The resident said since her readmission to the facility from the psychiatric hospital, the staff was "a little better at watching." During an interview on 8/05/14 at 10:33 a.m., the DON said Resident #4 was transferred to the emergency roiagnom on [DATE] due to lethargy and elevated blood sugar. She said she was not aware of the resident's suicide attempt on 6/2/14 prior to the resident's transfer to the hospital. The DON said Resident #4 was not on suicide precautions prior to the 6/2/14 suicide attempt and an investigation was not completed regarding the suicide attempt. The DON said the resident required supervision with medications. During an interview on 8/05/14 at 10:58 a.m., the DON said they only had Resident #4's word that she hoarded pills from the facility and used them to overdose, so no investigation was completed. She said if the facility had been aware of suicidal attempts an investigation would have been completed. During an interview with on 8/06/14 at 11:26 a.m., the administrator denied knowledge of Resident #4's suicide attempt. During an interview on 8/05/14 at 11:39 a.m., LVN C said she administered medications to Resident #4. She said Resident #4 attempted to get the staff administering medications on Hall 300 to leave her medications on her nightstand. She said Resident #4 told staff she would take the medication later. LVN C said she nor did her MAs leave any medications for Resident # 4 to take later. During an interview on 8/06/14 at 11:15 a.m., the Medicare MDS Coordinator and the Medicaid MDS Coordinator said the care plan for Resident #4 had not been updated since the initial care plan was completed 1/31/14 and there was no care plan for suicidal attempts or suicidal ideation. The Medicare MDS Coordinator said, "there was no standardized suicide care plan, I guess I need to make one up." During an interview on 8/06/14 at 11:26 a.m., the DON said Resident #4's care plan should "absolutely" address the potential of a suicide attempt since suicidal ideation was triggered on her MDS. The DON said when Resident #4 returned from the psychiatric hospital on [DATE] to the facility due to a suicide attempt a care plan should have been created to address the potential of a suicide attempt. The administrator and DON indicated prior to the residents readmission on 6/19/14 there were no interventions in place to prevent Resident #4 from attempting suicide. They indicated staff was in-serviced to monitor the resident for the potential of a suicide attempt after the residents re-admission on 6/19/14. During an interview on 8/06/14 at 2:42 p.m., the psychologist said she worked with Resident #4 prior to the suicide attempt on 6/2/14 and currently worked with the resident. She said she had been working with Resident #4 as the resident had initially been admitted to the facility from a psychiatric hospital due to a suicide attempt in the community. Resident #4 had taken an overdose of medications and set her home on fire. The psychologist said every time she met with Resident #4 she would ask her if she was suicidal and the resident would indicate she was not suicidal but would say she could not find a purpose for living. The psychologist said she was worried about Resident #4 because she knew her family was getting ready to move out of state. The psychologist said she met with the resident on, 5/28/14, the Wednesday before she attempted suicide because she was worried about how the resident would react when her family left. The psychologist said the resident needed someone to monitor her to ensure she did not make a suicide attempt. The psychologist said she met with the administrator, DON and the SW and expressed her concerns and discussed having staff watch Resident #4 closely on the scheduled day (6/2/14) of her family's move. She said "they knew all about it" and should have been doing something more. The psychologist said facility staff did not know what was wrong when Resident #4 was sent out to theER on [DATE], but if the resident said she hoarded pills from the facility, they should have taken her word and either changed her medications to liquid, patches or injections. She indicated the staff needed to watch the resident closely to ensure she was taking her pain medications, because she did not think the resident could be trusted with pills. During an interview on 8/06/14 at 3:55 p.m., the AD said prior to Resident #4's suicide attempt at the facility she received no training regarding watching the resident. It was determined this failure placed Resident #4 in an Immediate Jeopardy situation from 1/24/14 through 6/2/14. The facility took the following actions to correct the non-compliance on 07/08/14: During an interview on 8/06/14 at 3:55 p.m., the AD said since the resident's re-admission to the facility from the psychiatric hospital the administrator gave an in-service about monitoring Resident #4's behaviors and if she began making comments such as being better off dead or no longer having anything to live for to report this to the administrator. The AD said staff was provided a hand out regarding suicide protocols. During an interview on 8/06/14 at 4:00 p.m., MA X said prior to Resident #4's transfer from the facility to the emergency room , no training had been received regarding monitoring the resident for self-injurious behavior. The MA said she caught Resident #4, about 3 weeks prior to her being transferred to the emergency room , "pocketing medications in her cheeks." She said she saw her doing this only once. MA X said she reported the incident to the charge nurse, but unable to remember who the nurse was. She said the nurse told her to make sure Resident #4 drank a lot of water to wash the pills down. On 8/06/14 at 4:16 p.m., the AD provided a copy of the handout provided when Resident #4 was re-admitted to the facility on [DATE]. The un-dated handout addressed Clinical Practice Guidelines Suicide Protocol and indicated the following: " ...Anticipated Outcome Patients who are potentially dangerous to themselves are rendered as safe as possible to reduce the risk of self-harm ... " " ...Fundamental Information Suicide safeguards are instituted for new or re-admits from an outside agency that treated the patient for suicide attempts ... " " ...Process *Upon admission to the facility the patient is placed on one-to-one staff supervision until consulting practitioner or primary physician completes a psychosocial assessment and deems the patient safe to be independent in the facility..... *All packages, and clothes brought into the facility and for the patient is inspected by the nursing staff in the presence of the patient. *The patient's mouth is inspected after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are preferable. *The care plan identifies the interventions used to render a patient as safe as possible to reduce the risk of self-harm. *Upon hire and as indicated the staff are in-serviced on the signs and symptoms of suicide and reporting responsibility..." An LVN, MA, AD, and CNA were interviewed and said they were in-serviced regarding suicide precautions and monitoring for suicide ideation. The CMS Form 672 dated 08/04/14 indicated 22 residents with documented signs and symptoms of depression.

Based on observation, interview, and record review, the facility failed to develop and revise the comprehensive care plan to meet the needs of 2 of 13 residents reviewed for care plans. (Resident #s 7 and 4) Past Immediate Jeopardy Resident #4 was admitted with a history of suicide attempts. The resident attempted suicide at the facility. Resident # 4 did not have a care plan to address suicidal ideation and attempts. This failure was determined to be past non-compliance immediate jeopardy from 1/24/14 through 6/2/14 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Resident # 7 did not have a care plan to address [MEDICAL CONDITION]-resistant staphylococcus aureus, (MRSA) form of bacterial infection that is resistant to numerous antibiotics) of a wound and the need for a thickened liquid. This failure could place 22 residents identified with signs and symptoms of depression, 6 residents with pressure ulcers, and 31 residents with special diets at risk for not getting their needs meet. Findings included: 1. Physician orders [REDACTED].#4 admitted [DATE] was [AGE] years old with [DIAGNOSES REDACTED]. Resident #4 received [MEDICATION NAME] tablet 10/325 milligram (mg) every 4 hours as needed for pain,[MEDICATION NAME] 350 mg at bedtime for muscle spasms. A physician's telephone order dated 8/5/14 indicated Resident #4 had an order for [REDACTED]. The admission MDS assessment dated [DATE] indicated Resident #4 was admitted [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. Resident #4 was independent in her thought process and her cognitive status was intact. The resident had thoughts that she would be better off dead, or of hurting herself in some way. The MDS indicated the responsible staff or provider were informed there was a potential for resident self-harm. The most recent MDS assessment dated [DATE] indicated Resident #4 was re-admitted to the facility on [DATE] from a psychiatric hospital with [DIAGNOSES REDACTED]. The MDS indicated Resident #4 was independent in her thought process and her cognitive status was intact. The resident had thoughts that she would be better off dead, or of hurting herself in some way. The MDS indicated the responsible staff or provider were informed there was a potential for resident self-harm. The initial care plan dated 1/31/14 did not address suicidal ideation or the suicide attempt by Resident #4 prior to her initial admission. The care plan was not updated. An initial social service history dated 1/27/14 indicated Resident #4 attempted to commit suicide by overdosing [MEDICATION NAME](sleep aide). During an interview on 8/04/14 at 3:48 p.m., Resident #4 said she attempted suicide at the facility on 6/2/14. She said staff did not monitor to ensure she took her medicine. Resident #4 said she hoarded M.S.[MEDICATION NAME] and took two hands full of the pain medication. The resident said since her readmission to the facility from the psychiatric hospital, the staff was "a little better at watching." During an interview on 8/05/14 at 10:33 a.m., the DON said Resident #4 was transferred to the emergency roiagnom on [DATE] due to lethargy and elevated blood sugar. She said she was not aware of the resident's suicide attempt on 6/2/14 prior to the resident's transfer to the hospital. The DON said Resident #4 was not on suicide precautions prior to the 6/2/14 suicide attempt. During an interview on 8/05/14 at 10:58 a.m., the DON said the SW was informed by the hospital that Resident #4 attempted suicide on 6/2/14 at the facility. She said Resident #4 told the emergency room staff she had attempted suicide. The DON said they only had the resident's word that she hoarded pills from the facility. She said prior to Resident #4 being transferred to the emergency room she was seeing the psychologist. The DON said Resident #4 attended a day program 2 times a week at an outside psychiatric facility due to her suicide attempt prior to admission. The DON said the resident required supervision with medications. During an interview on 8/06/14 at 11:15 a.m., the Medicare MDS Coordinator and the Medicaid MDS Coordinator said the care plan for Resident #4 had not been updated since the initial care plan was completed 1/31/14. She said there was no care plan for suicidal attempts or suicidal ideation. The Medicare MDS Coordinator said, "there was no standardized suicide care plan, I guess I need to make one up." During an interview on 8/06/14 at 11:26 a.m., the DON said Resident #4's care plan should "absolutely" address the potential of a suicide attempt since suicidal ideation was triggered on her MDS. The DON said when Resident #4 returned from the psychiatric hospital on [DATE] to the facility due to a suicide attempt a care plan should have been created to address the potential of a suicide attempt. The administrator and DON indicated prior to the resident's readmission on 6/19/14 there were no interventions in place to prevent Resident #4 from attempting suicide. They indicated staff was in-serviced to monitor the resident for the potential of a suicide attempt after the resident's re-admission on 6/19/14. This failure placed Resident #4 in an Immediate Jeopardy situation from 1/24/14 through 6/2/14. The psychologist completed an initial Mental Status Examination on 2/5/14 with targeted behaviors of suicidal ideation and negative and angry statements. The facility took the following actions to correct the non-compliance on 07/08/14: During an interview on 8/06/14 at 3:55 p.m., the AD said since the resident's re-admission to the facility from the psychiatric hospital the administrator gave an in-service about monitoring Resident #4's behaviors and if she began making comments such as being better off dead or no longer having anything to live for to report this to the administrator. The AD said staff was provided a hand out regarding suicide protocols. During an interview on 8/06/14 at 4:00 p.m., MA X said prior to Resident #4's transfer from the facility to the emergency room , no training had been received regarding monitoring the resident for self-injurious behavior. The MA said she caught Resident #4, about 3 weeks prior to her being transferred to the emergency room , "pocketing medications in her cheeks." She said she saw her doing this only once. MA X said she reported the incident to the charge nurse, but unable to remember who the nurse was. She said the nurse told her to make sure Resident #4 drank a lot of water to wash the pills down. On 8/06/14 at 4:16 p.m., the AD provided a copy of the handout provided when Resident #4 was re-admitted to the facility on [DATE]. The un-dated handout addressed Clinical Practice Guidelines Suicide Protocol and indicated the following: " ...Anticipated Outcome Patients who are potentially dangerous to themselves are rendered as safe as possible to reduce the risk of self-harm ... " " ...Fundamental Information Suicide safeguards are instituted for new or re-admits from an outside agency that treated the patient for suicide attempts ... " " ...Process *Upon admission to the facility the patient is placed on one-to-one staff supervision until consulting practitioner or primary physician completes a psychosocial assessment and deems the patient safe to be independent in the facility..... *All packages, and clothes brought into the facility and for the patient is inspected by the nursing staff in the presence of the patient. *The patient's mouth is inspected after giving medication in tablet form to make sure it has been swallowed; liquid concentrates are preferable. *The care plan identifies the interventions used to render a patient as safe as possible to reduce the risk of self-harm. *Upon hire and as indicated the staff are in-serviced on the signs and symptoms of suicide and reporting responsibility..." An LVN, MA, AD, and CNA were interviewed and said they were in-serviced regarding suicide precautions and monitoring for suicide ideation. Non immediate Jeopardy 2. Physician orders [REDACTED].#7 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #7 was re-admitted on [DATE] from an acute care facility with active [DIAGNOSES REDACTED]. The MDS indicated Resident #7 had severe cognitive impairment, required extensive assistance with ADLs and required a mechanically altered diet. The MDS did not indicate Resident #7 had an [MEDICAL CONDITION] infection in her wounds. A care plan updated 7/8/14 indicated Resident #7 had a [DIAGNOSES REDACTED]. The goal was for "the resident to remain free of infections and complications from the diagnosis." The care plan did not address the [MEDICAL CONDITION] infection or the requirement of thickened liquids. During observations on 8/5/14 at 7:10 a.m., 9:00 a.m., 9:50 a.m., 10:25 a.m., 12:30 p.m. 1:15 p.m. and 4:15 p.m. Resident #7 had a pitcher of un-thickened ice water with a straw sitting on her bedside table. During an interview on 8/5/14 at 10:25 a.m., LVN B, charge nurse for Hall 300 (Resident #7s hall) said she did not know of anyone on Hall 300 that had an order for [REDACTED]. During an interview on 8/6/14 at 11:00 a.m., the DON said she expected all areas of resident care to be addressed in the care plan. An undated facility policy entitled "Resident care plan" indicated: ..." the purpose of the care plan is to provide a specific plan of care for each resident based upon assessment data from each discipline including the MDS. Review automatic triggers on the MDS....... as well as dietary problems......and all problems identified on all assessments. List all care to be provided for the problem listed.....communicate vital information to all staff providing direct resident care......list infection control measures." The CMS Form 672 dated 08/04/14 indicated 22 residents with documented signs and symptoms of depression, 6 residents with pressure ulcers, and 31 residents with special diets.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure ulcers for 3 of 7 residents reviewed for pressure ulcers. (Resident #s 2, 3, and 5) Resident #2 had a Stage IV pressure ulcer on her sacrum that was infected. The facility did not notify the physician of the final wound culture results and the resident did not receive treatment for [REDACTED]. This failure contributed to the worsening of an existing pressure ulcer for Resident # 2. This failure could place 6 residents with pressure ulcers at risk [MEDICAL CONDITION] (potentially fatal whole-body inflammation) and osteo[DIAGNOSES REDACTED] (infection of the bone caused by bacteria). This failure created an Immediate Jeopardy situation identified on 8/6/14. The Immediate Jeopardy was removed on 8/7/14. The facility remained out of compliance at a pattern of no actual harm with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 2. Resident #5 had deep tissue injuries to both of her heels. The facility did not provide repositioning or pressure relief per the plan of care. 3. Resident #3 had a history of [REDACTED]. The facility did not provide repositioning or pressure relief per the plan of care. This failure could place 48 residents receiving preventive skin care at risk for developing new pressure ulcers and decline in existing pressure ulcers. Findings included: 1. Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #2 required extensive assistance with bed mobility and toilet use, had a catheter and was incontinent of bowel. The resident had severe cognitive impairment and no behavior problems. Resident #2 had one unstageable pressure ulcer at the time of this assessment. A Braden scale assessment dated [DATE] indicated Resident #2 was at high risk for skin breakdown. A pressure ulcer care plan dated 06/04/14 indicated staff were to assist Resident #2 with turning/repositioning every two hours while in bed and every hour when up in her wheelchair. The resident was not to be positioned on her pressure ulcer. Skin assessment sheets for Resident #2, completed by the treatment nurse, indicated the following: *03/11/14 - Resident #2 was admitted with an unstageable pressure ulcer to the coccyx (sacral area) measuring 3.5 cm x 6.5 cm x 0.1 cm with no exudate or odor noted, 75% slough and 25% black eschar was noted to wound bed. The surrounding tissue was pink and normal. *03/18/14 - an unstageable pressure ulcer to the coccyx measuring 2.9 cm x 6 cm x 0 with no exudate or odor noted, 90% slough and 10% brown eschar noted to wound bed. Comments noted the measurements included a new area to the width and a decrease in eschar. Surrounding tissue was pink and normal. *04/15/14 - an unstageable pressure ulcer to the coccyx measuring 4 cm x 3.5 cm x 0.1 cm with no exudate or odor noted, slough and black eschar noted to wound bed. Surrounding tissue was pink and normal. *04/22/14 - an unstageable pressure ulcer to the coccyx measuring 4.2 cm x 5 cm x 0.1 cm with no exudate or odor noted, slough and eschar noted to wound bed. Surrounding tissue was bright red. *04/29/14 - an unstageable pressure ulcer to the coccyx measuring 4 cm x 4.5 cm x 1.7 cm with no exudate or odor noted, slough and eschar noted to wound bed. Surrounding tissue was black/brown. *05/06/14 - an unstageable pressure ulcer to the coccyx measuring 4 cm x 5 cm x 1.7 cm with no exudate or odor noted, slough noted to the wound bed and the surrounding tissue was dark red/purple. *05/26/14 - an unstageable pressure ulcer to the coccyx measuring 5.5 cm x 5 cm x 1.5 cm with no exudate or odor noted, slough noted to the wound bed and the surrounding tissue was dark red/purple. Comments noted the wound was debrided on 05/28/14. *06/02/14 - an unstageable pressure ulcer to the coccyx measuring 4.5 cm x 4.5 cm x 1 cm with small amount of serosanguineous (thin, watery, pale red to pink) drainage and slight odor noted, eschar noted to the wound bed and the surrounding tissue was pink and appeared macerated (soften or become softened by soaking in a liquid). A care plan updated 6/4/14 indicated Resident #2 ' s pressure ulcer on her coccyx was treated with Daiken ' s solution and gauze. The interventions included to inform the physician of adverse changes in status of the ulcer such as increased drainage, redness, warmth, and pain. *06/09/14 - an unstageable pressure ulcer to the coccyx measuring 4 cm x 5 cm x 1.5 cm with moderate amount of serosanguineous drainage and moderate odor noted, eschar noted to the wound bed and the surrounding tissue was pink and appeared macerated. *06/16/14 - an unstageable pressure ulcer to the coccyx measuring 4.5 cm x 4 cm x 1 cm with moderate amount of serosanguineous drainage and moderate odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. *06/23/14 - an unstageable pressure ulcer to the coccyx measuring 4.5 cm x 5.5 cm x 2 cm with moderate amounts of serosanguineous drainage and moderate odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. *07/01/17 - an unstageable pressure ulcer to the coccyx measuring 4.5 cm x 9 cm x 2 cm with moderate amounts of serosanguineous drainage and moderate odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. A telephone order dated 07/01/14 indicated Resident #2 ' s wound care treatment was changed to cleanse with normal saline, pat dry, apply skin prep to peri-wound, apply Santyl to wound bed, pack with gauze and cover with dry dressing daily. Skin assessment sheets for Resident #2, completed by the treatment nurse, indicated the following: *07/08/14 - an unstageable pressure ulcer to the coccyx measuring 4.5 cm x 9 cm x 2 cm with large amounts of sero-sanguineous drainage and foul odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. A wound culture was collected. There was no documentation of change in treatments for Resident #2 ' s pressure sore to her sacrum. According to the website, <http://www.nlm.nih.gov/medlineplus>, accessed 08/18/14, signs of infection included: *A foul odor from the ulcer *Pus coming out of the ulcer *Redness and tenderness around the ulcer *Skin close to the ulcer is warm and swollen " An infection can spread to the rest of the body and cause serious problems. Signs that the infection may have spread to the blood can include fever, weakness, and confusion. " Wound culture final results collected 7/10/14 dated 07/12/14 indicated Resident #2 had an infection. The resident had bacteria that consisted of Proteus Vulgaris, [MEDICATION NAME] Faecalls, and Escherichia Coli in her wound to her coccyx. There were no indications on the final laboratory results that the physician was notified. The resident ' s wound infection was noted to be resistant to [MEDICATION NAME] ([MEDICATION NAME]); however, [MEDICATION NAME] was not a drug tested . The final wound culture results were not available on the chart. On 8/6/14, the DON had to call the lab to have the final results faxed to the facility. A telephone order dated 07/10/14 indicated Resident #2 received [MEDICATION NAME] (antibiotic) 100mg twice daily for a urinary tract infection. The July 2014 MAR for Resident #2 indicated she received [MEDICATION NAME] from 07/10/14 - 07/20/14. Laboratory results collected 7/11/14 dated 07/11/14 indicated Resident #2 had a high white blood count of 15.1 (reference range 4.1-9.3). A telephone order dated 07/11/14 indicated Resident #2 was receiving [MEDICATION NAME] (antibiotic) 500mg twice daily for pneumonia. The July 2014 MAR for Resident #2 indicated she received [MEDICATION NAME] from 07/11/14 - 07/20/14. During an interview on 08/06/14 at 1:04 p.m., the nurse practitioner said he could not remember if he was notified of Resident #2's wound culture results. He said the resident was on antibiotics for a urinary tract infection and pneumonia. The nurse practitioner said he would not initially order antibiotic therapy for Resident #2 since she was already on antibiotics for a urinary tract infection and pneumonia, and they were his main concern. The nurse practitioner also said he would not have changed the antibiotics to cover the bacteria in the wound. He said it would be a good idea to shift the resident's weight while she was up in her wheelchair and would definitely help with healing. The nurse practitioner said if a resident had an infected wound, they would be at risk [MEDICAL CONDITION] and osteo[DIAGNOSES REDACTED], especially if the bone was exposed. The NP said he had not assessed Resident #2 ' s pressure ulcer " in a while. " Skin assessment sheets for Resident #2, completed by the treatment nurse, indicated the following: *07/15/14 - an unstageable pressure ulcer to the coccyx measuring 6 cm x 6 cm x 2 cm with large amounts of serosanguineous drainage and foul odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. *07/22/14 - an unstageable pressure ulcer to the coccyx measuring 6 cm x 7 cm x 2.1 cm with large amounts of serosanguineous drainage and foul odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. *07/29/14 - an unstageable pressure ulcer to the coccyx measuring 7.2 cm x 5.2 cm x 1 cm with large amounts of serosanguineous drainage and foul odor noted, eschar and slough noted to the wound bed and the surrounding tissue was pink and appeared macerated. During an observation with the treatment nurse on 08/05/14 at 2:25 p.m., Resident #2 had a pressure ulcer to her sacral area. The pressure ulcer had a red wound bed with a small amount of slough/eschar at the 12 o'clock position, and the surrounding tissue was dark red with an extending reddened area to the 8 o'clock position. The wound had large amounts of purulent drainage and a foul odor. The bone was visible. The treatment nurse cleansed the wound with normal saline, patted dry with gauze, applied Santyl to the eschar remaining on the wound, placed a dry gauze to the inside of the wound, and covered with an adhering pad. According to the website, <http://www.nlm.nih.gov/medlineplus>, accessed 08/18/14, signs of infection included: *A foul odor from the ulcer *Pus coming out of the ulcer *Redness and tenderness around the ulcer *Skin close to the ulcer is warm and swollen " An infection can spread to the rest of the body and cause serious problems. Signs that the infection may have spread to the blood can include fever, weakness, and confusion. " During an interview on 08/05/14 at 4:00 p.m., the treatment nurse said she measured wounds on Wednesdays. She said she started working at the facility in April 2014 as the wound care nurse. The treatment nurse said she had no formal training, but she did go to a one day lecture provided by the facility. The treatment nurse indicated the wound did not open until 07/15/14 when she first documented measurements of undermining and tunneling. She said Resident #2 was not currently on any antibiotics. During an observation on 08/06/14 at 9:13 a.m., the treatment nurse measured Resident # 2 ' s pressure ulcer on her sacral area. The measurements were 6.5 cm x 7 cm x 2.2 cm. During an interview on 08/06/14 at 12:10 p.m., the DON said the physician should be notified immediately of laboratory results. She said she was not sure if the physician was notified of Resident #2's final wound culture results since there was not documentation. She said the final wound culture results were not on Resident #2 ' s chart and she had to inform the lab to fax them to the facility. The DON said the resident's bone on her coccyx had been exposed for a while. A patient ' s guide to [MEDICATION NAME] SANTYL ointment dated 2013 indicated the ointment was used to debride chronic skin ulcers. The guide indicated when an infection was present in the wound, a topical antibiotic powder should be applied to the wound site before applying SANTYL ointment. If the infection does not respond, discontinue use of SANTYL Ointment until the infection is resolved. The International Guideline Pressure Ulcer Treatment Technical Report dated 2009 indicated "Infected pressure ulcers do not heal. Prevention, early [DIAGNOSES REDACTED]. " The facility pressure ulcer prevention and skin care management protocol dated December 2004 indicated the following: "The facility shall identify residents that are at risk for skin alteration in skin integrity, provide interventions to reduce the risk of pressure ulcer development, prevent infection and further skin breakdown and provide treatment and services that promote healing, prevent infection and skin breakdown. " The National Pressure Ulcer Advisory Panel at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 8/8/14, noted the following: " International NPUAP-EPUAP Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated ... Pressure Ulcer Stages/Categories ...Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. ....Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body ' s natural (biological) cover" and should not be removed ... " The administrator and DON were notified on 08/06/14 at 2:34 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 8/06/14 at 8:31 p.m., and included: *Resident #2 to be repositioned every one hour while in her chair. *The DON conducted a pain assessment on Resident #2 the attending physician was notified and orders were received for [MEDICATION NAME] tablet 1mg (milligram) by mouth every 4 hours routinely, and every 1 hour PRN (as needed) for breakthrough pain. *Stat (immediate) labs were ordered to rule [MEDICAL CONDITION]. *Resident#2 ' s skin was evaluated after she was placed in bed with no new skin alterations identified. The resident ' s treatment was changed to Acquacel AG (silver) daily. *All residents with pressure ulcers and those at risk will have Braden scale used to identify if their positioning needs are met by the DON, ADONs, Wound Nurse and RN C. *All residents with pressure ulcers were reviewed and evaluated to ensure there pain regimen is effective and will be adjusted if needed. This was completed August 6, 2014 by DON, ADONS, Wound Nurse and RN C. The surveyors confirmed on 08/07/14 at 1:55 p.m., the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: *Six CNAs, three nurses and the wound care nurse were interviewed and said they were in-serviced regarding stages of skin breakdown and prevention and treatment of [REDACTED]. *A repositioning validation tool had been developed and implemented to monitor turning and repositioning of residents at risk for skin breakdown. *New care plans were implemented for residents identified at high risk for skin breakdown to reflect turning a repositioning every hour while up in chair. *Pain assessments were completed on all residents identified with current skin breakdown. On 8/07/14 at 1:55 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. 2. Physician orders [REDACTED].#5, re-admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] was incomplete at the time of review, but indicated Resident #5 had severely impaired cognitive skills for decision making. The last completed MDS, dated [DATE], indicated Resident #5 required extensive assistance of 2 or more persons for bed mobility, was cognitively intact, and had one Stage II pressure ulcer, which was not present on admission. A pressure ulcer care plan for Resident #5 ' s left heel wound, dated 07/15/14 indicated staff were to protect the ulcer and surrounding skin from friction, shear, and pressure, trauma. Staff were to turn and reposition resident at least every 2 hours while in bed and every hour when up in wheelchair and avoid positioning the resident on the pressure ulcer. No special equipment was checked on the care plan. A skin assessment sheet dated 07/29/14 for Resident #9, completed by the treatment nurse, indicated a deep tissue injury pressure ulcer on her left heel measured 2.3 cm x 1.6 cm with black/brown eschar. The skin surrounding the ulcer was whitish/gray and intact. A pressure sore care plan for Resident #5 ' s right heel wound, dated 07/25/14 indicated staff were to protect ulcer and surrounding skin from friction, shear, and pressure, trauma. Staff were to turn and reposition resident at least every 2 hours while in bed and every hour when up in wheelchair and avoid positioning the resident on the pressure ulcer. No special equipment was checked on the care plan. A skin assessment sheet dated 08/01/14 for Resident #5 completed by the treatment nurse, indicated an unstageable pressure ulcer on her right heel measured 1.3 cm x 1.5 cm with black/brown eschar. The skin surrounding the ulcer was whitish/gray and intact. The Interim Plan of Care, used as a nurse aide care plan, did not mention Resident #5's existing wounds, or the need to offload the resident's heels. During an observation on 8/4/14 at 3:52 p.m., Resident #5 was lying in bed. Her heels were not offloaded. During an observation on 8/5/14 at 8:40 a.m., Resident #5 was in therapy, sitting in her wheelchair and she had socks on her feet. The resident ' s heels were not offloaded and were against the foot rests of the wheelchair. During an observation on 8/5/14 at 9:10 a.m., Resident #5 was in her wheelchair, parked against the wall facing the nursing station. She was asleep and had a blanket covering her body. The resident ' s heels were not offloaded and were against the foot rests of the wheelchair. During an observation on 8/6/14 at 8:35 a.m., Resident #5 was eating breakfast while sitting in her wheelchair in the dining room. The resident ' s heels were not offloaded and were against the foot rests of the wheelchair. During an observation on 8/6/14 at 9:30 a.m., Resident #5 was sleeping in her wheelchair in her room. The resident ' s heels were not offloaded and were against the foot rests of the wheelchair. She was not repositioned while sitting in her wheelchair. During an observation on 8/6/14 at 10:30 a.m., Resident #5 sat in her wheelchair and had not been repositioned. The resident moaned and said it hurt to be slumped in the chair. She asked for assistance to be repositioned because her "bottom hurts from sitting." During an observation and interview on 8/6/14 at 10:49 a.m., CNA AA and the treatment nurse transferred Resident #5 from her wheelchair to her bed. Resident #5 had a 10 cm x 10 cm blanchable reddened area on her sacrum. Resident #5 ' s left lateral (outer) heel pressure ulcer was unstageable and covered with 1.7 x 2 cm of black eschar. Resident #5 ' s right heel pressure ulcer was unstageable and covered with 1 cm x 0.7 cm black eschar. CNA AA and the treatment nurse did not offload Resident #5 ' s heels. The resident rubbed her heels into the sheets and said her heels were painful. The treatment nurse said she thought there was an order to offload Resident #5 ' s heels. During an interview on 8/6/14 at 11:35 a.m., the treatment nurse said she went to a one day in-service provided by her employer. This in-service was comprised of lecture and included "training for what kinds of treatment to do for different wound types." The treatment nurse said she had never seen any heel offloading devices at the facility. During an observation on 8/6/14 at 6:15 p.m., Resident #5 was in her wheelchair in her room. The resident ' s heels were not offloaded and against the foot rests of the wheelchair. During an observation and interview on 8/7/14 at 8:45 a.m., Resident #5 was up in her wheelchair with her right heel against the foot rest. The left foot was on the floor. Resident #5 said her heels hurt and asked, "I wonder what that is?" I wish it would get better." Resident #5 said her buttocks "hurts I think from sitting up so long." During an interview on 8/6/14 at 2:25 p.m., the director of nursing (DON) said she expected a resident with pressure ulcers on the heels to have the heels offloaded, a nutritional assessment, and turned frequently. 3. Physician orders [REDACTED].#3 was a [AGE] year old male, admitted [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED].#3's pressure ulcer on his coccyx was discontinued. The most recent MDS annual assessment dated [DATE] indicated Resident #3 had a severely impaired cognitive status, was incontinent of bowel and bladder, and required extensive assistance from staff for all ADLs bed mobility. Resident #3 was identified as being at risk of developing a pressure ulcer and had a Stage II pressure ulcer on 05/24/14. The care plan dated 6/17/14 indicated Resident #3 had deficit in ADLs and required incontinent care every two hours and as needed. The care plan indicated Resident #3 had a potential for alteration in skin integrity. The interventions included the resident was to be turned and repositioned every two hours and as needed and staff was to follow the policy on incontinent care. During a continuous observation on 8/5/14 from 8:15 a.m. until 12:30 p.m., Resident #3 sat in his wheelchair against the wall in front of the nursing station. During this time period, Resident #3 was not provided incontinent care or turned or repositioned to prevent pressure ulcers. During an observation on 8/5/14 at 2:15 p.m., CNAs H and J provided incontinent care for Resident #3. As Resident #3 was transferred from his wheelchair to his bed, a strong urine odor was noted in his room. Resident #3's brief was removed during incontinent care and was saturated with urine. Resident #3's pants were changed because they were saturated with urine. The resident ' s skin on his buttocks was moist with grayish macerated areas. During an interview on 8/5/14 at 1:50 p.m., CNA H said he provided incontinent care to Resident #3 before breakfast. During an interview on 8/5/14 at 1:55 p.m., CNA J said she assisted CNA H with incontinent care for Resident #3 prior to breakfast this morning. She said no further incontinent care had been provided to Resident #3. During an interview on 8/6/14 at 8:45 a.m., LVN K said she expected CNAs to provide turning, repositioning, and incontinent care to residents every two hours and as needed. LVN K said she communicated with CNAs to ensure residents were being turned, repositioned, and their needs meet. During an interview on 8/6/14 at 10:45 a.m., the DON indicated her expectation was for residents to be provided incontinent care and turned and repositioned "at least every two hours and as needed for comfort." She said there was not a document for CNAs to indicate if incontinent care or turning and repositioning was provided. The CMS 672 dated 08/06/14 indicated 6 residents had pressure ulcers and 48 residents received preventive skin care.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief interventions to ensure adequate pain relief for 1 of 8 residents reviewed for pain. (Resident #2) The treatment nurse did not loosen the gauze from Resident #2's wound to prevent pain. The treatment nurse removed the gauze which had Resident #2's skin stuck in the gauze. This failure could place 14 residents receiving pain management at risk for unrelieved pain. Findings included: Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The resident had an order for [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #2 required extensive assistance with bed mobility and toilet use, had a catheter and was incontinent of bowel. The resident had severe cognitive impairment and no behavior problems. The MDS indicated the resident received scheduled and as needed pain medications, and during the assessment the resident indicated she had frequent pain. A care plan dated 06/04/14 indicated Resident #2 had complaints of pain and received routine or as needed pain medications. Interventions listed for staff were assessing the resident's pain level, documentation, and assessing the effectiveness of the medications administered. The MAR for August 2014 indicated Resident #2 received her scheduled [MEDICATION NAME] and [MEDICATION NAME] as ordered. The MAR indicated [REDACTED]. During an observation and interview on 08/05/14 at 11:30 a.m., Resident #2 was in her bed lying on her right side. The resident said she did not lie on her back because she had a ulcer on her "bottom" that hurt too bad. During a treatment observation with the treatment nurse on 08/05/14 at 2:25 p.m., Resident #2 had an unstageable pressure ulcer to her right ankle. The pressure ulcer had white slough covering the wound bed; the surrounding edges were open and had slight amount of drainage noted to the dressing that had dried. The treatment nurse attempted to remove the dressing and Resident #2 hollered out and asked the treatment nurse to stop. The treatment nurse stopped momentarily, and then began to remove the remaining part of the dressing that was stuck to the resident's skin. Skin was noted on the dressing removed. The treatment nurse did not apply anything to the wound to loosen the dressing. During an interview on 08/06/14 at 10:15 am, CNA W said Resident #2 would lay on her sides while she was in bed. She said it was not comfortable for Resident #2 to lay on her back due to her pressure sore to her sacrum. A Pain Management policy dated 09/2009 indicated "...Resident who have pain symptoms or who have the potential for pain shall be appropriately monitored, receive treatment for [REDACTED]. During an interview on 08/06/14 at 1:40 p.m., the DON said during the dressing change for Resident #2, the treatment nurse should have loosened the gauze with saline prior to removing. An undated list provided by the DON on 08/11/14 at 3:11 p.m., indicated 14 residents received pain management.