Every finding on record at Windemere at Westover Hills

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 3 of 5 medication carts (the 100/300 hall medication aide cart, the 100/300/400 hall nurse cart, and the 700 hall nurse cart) assessed for medication storage and labeling. The facility failed to ensure medications located inside the 100/300 hall medication aide cart, the 100/300/400 hall nurse cart, and the 700 hall nurse cart were stored in properly labeled containers. This failure could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed. The findings included: During an observation of the 700 hall nurse cart on 12/17/2025 at 9:30 AM, an accessed insulin vial was discovered in the cart with no date of removal from refrigeration. During an interview with LVN A on 12/17/2025 at 9:30 AM, LVN A stated if an insulin vial did not have an opened date, the vial could be past the 28 days at room temperature period and be expired. LVN A further stated an undated vial should not be used because it would be unknown if the medication was still effective and would have the desired outcome for the resident. LVN A went on to state the pharmacy would be contacted to determine the fill date of the insulin and if the fill date was beyond 28 days, the vial would be discarded. During an observation of the 100/300 hall medication aide cart on 12/17/2025 at 9:47 AM, two pills were discovered unlabeled, lying in the bottom of the drawer. During an interview with Medication Aide B on 12/17/2025 at 9:47 AM, Medication Aide B stated loose pills should not be in the medication carts, because if a pill was laying in the drawer unlabeled, it would not be known what the pill was. Medication Aide B went on to state that even if a loose pill could be identified, it could not be administered to a resident because it would be unknown for whom it was prescribed. During an observation of the 100/300/400 nurse cart on 12/17/2025 at 11:55 AM, an accessed insulin vial was discovered in the cart with no date of removal from refrigeration, and four pills were found unlabeled, lying in the bottom of the drawer. During an interview with LVN C on 12/17/2025 at 11:55 AM, LVN C stated it was important for the opened date to be documented on the insulin vial, because it was only good for 28 days. LVN C went on to state that if the insulin was expired, it did not work the same. Regarding the loose pills discovered in the cart drawer, LVN C stated if loose pill were left in the medication cart, someone could accidentally take them. LVN C further stated the unlabeled pills could not be administered to any resident, because they would not know what the pill was or to whom it belonged. During an interview with the acting DON on 12/18/25 at 1:10 PM, the acting DON stated her expectation for medication carts was that they were clean and divided properly, that medications were dated, and that there were no expired medications. The acting DON further stated it was important for insulins to be dated, because they did not want expired medications to prevent any errors. The acting DON stated they did not want to give residents expired medications, because there could be an adverse effect, the medication might not be effective, nor treat the condition for which they were ordered. The acting DON stated insulins should be dated any time they were in the cart and as soon as they were taken out of the refrigerator. The acting DON stated if insulins were undated, they did not know how long they had been out of the refrigerator, and they could lose their efficacy. Regarding loose pills in the medication carts, the acting DON stated her expectation was for staff to make sure all pills were properly labeled. The acting DON further stated the importance of properly labeled medications was so they could ensure the correct medication was given to the right resident. The acting DON stated there should never be a pill in the cart not labeled, because they would not know to whom the pill belonged. The acting DON went on to state loose pills should be disposed of, and every cart should have a drug buster for disposal. Record review of the facility's policy titled Labeling of Medications and Biologicals dated 11/1/2025 noted All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications, .All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices, .Labels for individual drug containers must include: h. The expiration date when applicable, .Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. c. Unopened or unaccessed (needle-punctured) vials should be discarded according to the manufacturer's expiration date.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 8 residents (Resident #113, and Resident #16) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #113 did not have a can of disinfectant spray and a plastic pump spray bottle of air freshener in her room. 2. The facility failed to ensure Resident #16 did not have two pairs of scissors in her room.These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.The findings included:1. Record review of Resident #113's face sheet dated 12/18/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included history of falling, symptoms and signs involving cognitive function and awareness, repeated falls, need for assistance with personal care, lack of coordination, and dementia. Record review of Resident #113's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills.Record review of Resident #113's comprehensive care plan with revision date 9/29/25 revealed the resident was non-compliant with safety precautions and at risk for complications with interventions that included providing the resident with opportunities for choice during care provision.During an observation on 12/16/25 at 10:08 a.m. Resident #113 was observed with a can of disinfectant spray and a plastic pump spray bottle of air freshener next to the sink in the resident's room. During an observation on 12/18/25 at 11:37 a.m. Resident #113 was observed with a plastic pump spray bottle of air freshener next to the sink in the resident's room.2. Record review of Resident #16's face sheet dated 12/18/25 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included dry eyes, history of falling, difficulty in walking, lack of coordination, and syncope (fainting) and collapse (refers to a sudden, temporary loss of consciousness caused by a brief reduction in blood flow to the brain followed by a fall or collapse).Record review of Resident #16's most recent quarterly MDS assessment dated [DATE] revealed the resident was cognitively intact for daily decision-making skills.Record review of Resident #16's comprehensive care plan with revision date 6/22/25 revealed the resident was non-compliant with safety precautions and interventions included to encourage as much participation/interaction by the resident as possible during care activities. Resident #16's comprehensive care plan revealed the resident was at risk for impaired visual function related to dry eyes and wore glasses, with interventions that included to monitor/document/report signs and symptoms of acute eye problems.During an observation and interview on 12/16/25 at 10:26 a.m., Resident #16 was observed with a pair of pink handle scissors on a small table next to where the resident was seated in a chair and a pair of black handle scissors on a small desk at the foot of the bed. Resident #16 stated the pink handle scissors were used to open her condiments and the black handle scissors were used to open boxes and packages. During an observation on 12/18/25 at 11:32 a.m., Resident #16 was observed with a pair of pink handle scissors on a small table next to the resident's bed and a pair of black handle scissors on a small desk at the foot of the bed. During an observation and interview on 12/18/25 at 11:46 a.m., CNA E stated, Resident #16 was not supposed to have scissors in the room and there were items residents in the facility were not allowed to have. CNA E stated items such as scissors, nail clippers, and aerosol sprays weren't supposed to be in resident rooms due to safety concerns. CNA E stated there were residents in the facility who wandered and could gain access to those items and hurt themselves. CNA E stated the CNA staff were responsible for making rounds of resident rooms and if items such as scissors were found they were supposed to report it to the nurse.During an observation and interview on 12/18/25 at 11:53 a.m., LVN F observed Resident #16 with a pair of pink handle scissors and a pair of black handle scissors in the resident's room. LVN F stated Resident #16 was not supposed to have scissors in her room because the resident could drop them, have a fall, and cut herself, or somebody else could grab them. LVN F stated she usually went into the resident's room to provide care or obtain vital signs and if she had seen the scissors she would have had to confiscate them for safety reasons. During an observation and interview on 12/18/25 at 11:57 a.m., Resident #113 stated she used the plastic pump spray bottle of air freshener to make her room smell good, and she had thrown out the can of disinfectant spray because she used it up. Observation with CNA E revealed the plastic pump spray bottle in Resident #113's room was not supposed to be in there because it could be used improperly and LVN E stated chemicals, and sharp objects were prohibited from being in a resident's room due to safety concerns. During an interview on 12/18/25 at 1:20 p.m., the Acting DON stated items such as scissors, aerosol cans, and pump sprays which had a label that indicated keeping away from children were prohibited in the resident rooms. The Acting DON stated it was her understanding that residents who were alert and oriented were allowed to keep items such as scissors, but required it be care planned. The Acting DON stated the items discussed could be a potential for an injury or somebody could walk into the room and pick them up which could also lead to potential injury. The Acting DON stated it was a facility wide thing and all staff should be aware of and the expectation of what we could and could not allow in the rooms. The Acting DON stated it was the responsibility of all departments to report and communicate to the nursing staff and supervisors items not allowed in the residents' rooms. During an interview on 12/18/25 at 2:44 p.m., the Administrator stated residents were not allowed to have scissors, aerosol cans or pump sprays in their rooms because it was best practice. The Administrator stated the facility provided a list of prohibited items to the residents or family upon admission.The facility did not provide a policy regarding prohibited items at the time of the exit on 12/19/25.

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 5 carts (500 hall nurse cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life. The findings included: During an observation of the 500 hall nurse cart on 12/18/2025 at 8:40 AM, a sample of controlled medications was inventoried for accuracy with LVN D. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs. However, record review of the comprehensive controlled medication reconciliation log used for the cart audit during shift change revealed the log was missing a signature. During an interview with LVN D on 12/18/2025 at 8:40 AM, LVN D stated it was important for the controlled medication reconciliation log to be signed at each shift change with the oncoming or off going staff member to document that the count of the controlled medications was accurate. LVN D further stated it was necessary to sign the reconciliation log, so she did not get blamed for something another staff member did. During an interview with the acting DON on 12/18/25 at 1:10 PM, the acting DON stated her expectation for the controlled medication reconciliation logs was that the logs should be signed off every time staff members counted controlled medications between shift changes. The acting DON further stated it was important for the logs to be signed each shift to ensure the counts of controlled medications were correct and there were no diversions. The DON went on to state if the log is missing signatures, it made it hard because they only have the last signature to go off, and a medication could have been given to the wrong resident or be lost. Record review of the facility's policy titled Controlled Substance Administration & Accountability dated 11/1/25, noted It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure, .Inventory Verification: b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided with such care, consistent with professional standards of practice for 2 of 4 residents (Resident #7, and #29) reviewed for respiratory care.1. The facility failed to ensure Resident #7's oxygen concentrator filter was cleaned and free of debris.2. The facility failed to ensure Resident #29's oxygen concentrator filter was cleaned and free of debris, the oxygen tubing was touching the floor, and the oxygen flow rate was set according to the physician's ordersThese deficient practices could place residents at risk for an increase in respiratory complications. The findings included:1. Record review of Resident #7's face sheet dated 12/17/25 reflected an [AGE] year-old female admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that included aftercare following joint replacement surgery, chronic obstructive pulmonary disease (a long-term, progressive lung disease that makes it difficult to breathe due to airflow obstruction that is not fully reversible), need for assistance with personal care, cough, shortness of breath, lack of coordination, and heart failure. Record review of Resident #7's most recent comprehensive MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills, was dependent on staff for mobility and transfers, and required oxygen therapy. Record review of Resident #7's comprehensive care plan with revision date 12/8/25 reflected the resident used supplemental oxygen and was at risk for complications with interventions that included to give medications as ordered by the physician, and provide oxygen as ordered. Record review of Resident #7's Order Summary Report dated 12/17/25 reflected the following:- Oxygen at 2-4 L per minute via nasal cannula as needed with order date 12/15/25 and no end date.- Oxygen tubing and humidifier change every night shift every Sunday with order date 3/30/25 and no end date. During an interview and observation on 12/17/25 at 7:57 a.m. Resident #7 was observed with the oxygen concentrator operating via a nasal cannula at 2 LPM. Resident #7's oxygen concentrator had a filter in the back that appeared to have a layer of built-up lint/dust. Resident #7 stated nursing staff handled the oxygen concentrator because she was unable to get out of bed. During an observation on 12/18/25 at 8:02 a.m. revealed Resident #7 was in bed with the oxygen concentrator operating via the nasal cannula. Resident #7's oxygen concentrator had a filter in the back that appeared to have a layer of built-up lint/dust. During an observation and interview on 12/18/25 at 8:07 a.m. LVN F revealed nursing staff were responsible for setting up and changing the tubing and humidifier bottle on the oxygen concentrators. LVN F stated, while she was scheduled to be on duty, she would change out the tubing with the nasal cannula at least every two days because the cannula could get dirty and was responsible to ensure the liters of oxygen was set according to physician's orders. LVN F stated she did not know the oxygen concentrator had a filter and did not know where it was located. LVN F removed the oxygen filter from behind Resident 7's concentrator and stated, it's dirty. LVN F stated, the oxygen filter appeared to be covered in dust and stated, Resident #7 was breathing that (the dust). LVN F stated Resident #7 had breathing issues and the dirty filter could cause the resident to develop an infection. LVN F stated Resident #7 used the oxygen concentrator continuously. 2. Record review of Resident #29's face sheet dated 12/18/25 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a long-term, progressive lung disease that makes it difficult to breathe due to airflow obstruction that is not fully reversible), need for assistance with personal care, allergic rhinitis (an inflammation of the lining of the nose caused by an allergic reaction to airborne substances such as pollen, dust mites, mold, or pet dander), wheezing (a high-pitched, whistling sound heard during breathing, usually when air flow through narrowed or partially blocked airways), difficulty in walking, and shortness of breath. Record review of Resident #29's most recent quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills, was dependent on staff for mobility and transfers, and required oxygen therapy. Record review of Resident #29's comprehensive care plan with revision date 12/12/25 reflected the resident was treated with oxygen related to chronic obstructive pulmonary disease and was at risk for complications with interventions that included to give medications ordered by the physician, and provide oxygen as ordered. Record review of Resident #29's Order Summary Report dated 12/18/25 reflected the following:- Oxygen at 2-4 L per minute via nasal cannula to keep oxygen saturation above 90% as needed related to chronic obstructive pulmonary disease with order date 12/15/25 and no end date.- Oxygen tubing and humidifier change every night shift every Sunday with order date 8/18/25 and no end date. During an observation and interview on 12/18/25 at 7:43 a.m., Resident #29 stated the oxygen concentrator tubing was changed by nursing every Sunday night. Resident #29 was observed with the oxygen concentrator operating via the nasal cannula at 0.5 LPM. Resident #29's oxygen tubing connected to the concentrator was observed touching the floor, and the filter on the back of the concentrator appeared to have a layer of built-up lint/dust. Resident #29 stated she did not touch the oxygen concentrator because she was unable to reach the unit. Resident #29 stated she was treated with oxygen consistently since she was re-admitted from the hospital (8/11/25). During an observation and interview on 12/18/25 at 7:50 a.m., LVN G stated Resident #29 was treated with oxygen as needed. LVN G stated the nursing staff were responsible for setting up and changing the tubing and humidifier bottle on the oxygen concentrators. LVN G stated she changed out the tubing and humidifier bottle on Sunday (12/14/25) but had not changed Resident #29's oxygen filter as it was done once a month. LVN G observed Resident #29's oxygen tubing touching the floor but was not sure if that was a problem and would not know how to keep it off the floor. LVN G stated Resident #29's oxygen filter looked like it had dust on it and should not be that way. LVN G observed Resident #29's oxygen level setting and stated it was not supposed to be set at 0.5 LPM but should be set from 2 LPM to 5 LPM and did not know why it was set that way. LVN G stated the setting could not have been changed by Resident #29 because the resident was not able to get to it. LVN G stated the dust on the oxygen filter was getting into the resident's lungs and the oxygen setting below orders meant the resident could develop a respiratory infection and the resident already had compromised lungs.During an interview on 12/18/25 at 1:20 p.m., the Acting DON stated it was her expectation for the nursing staff to ensure they checked the oxygen concentrator settings, filters and tubing. The Acting DON stated the oxygen settings should be checked every shift to reflect they were set by the physician's orders. The Acting DON stated the end of the oxygen tubing such as the cannula and the opposite end of the tubing connected to the concentrator were not supposed to be touching the floor but was not sure about the excess tubing touching the floor and would have to check the facility policy. The Acting DON stated nursing was responsible for checking the filters on the oxygen concentrators to ensure they were clean and if not, they were supposed to be changed out. The Acting DON stated dirty oxygen filters could cause respiratory issues and since dust had particles they could be inhaled by the resident and could cause a respiratory infection. Record review of the facility's policy titled Oxygen Concentrator dated 11/1/25 reflected in part, .The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators.An 'oxygen concentrator' is a medical device that extracts oxygen from room air.Oxygen is administered under orders of the attending physician.The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen.Follow manufacturer recommendations for the frequency of cleaning filters.Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on interview and record review, the facility failed to ensure the residents' clinical record was complete and accurate for 1 (Resident #130) of 25 residents reviewed, in that: Resident #130's diagnoses of Insomnia and Dementia were not present on the resident's diagnoses list. This deficient practice could result in delayed or improper care due to inaccurate clinical records. The findings were:Record review of Resident #130's face sheet, dated 12/18/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including Acute respiratory failure with hypoxia, Acute kidney failure, and Muscle weakness. Record review of Resident #130's admission MDS, dated [DATE], revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #130's care plan, revised 07/25/2025, revealed [Resident #130] is resistive to care and medications. Record review of Resident #130's clinical record revealed a psychiatric provider note, date 09/22/2025, Tertiary Treating Dx: F51.02 - Adjustment insomnia. Dx Treating 4: F02.B3 - Dementia in other diseases classified elsewhere, moderate, with mood disturbance. Record review of Resident #130's clinical record revealed an order, dated 09/01/2025, Order Summary: Melatonin Oral Tablet 3 MG Give 3 tablet by mouth at bedtime for insomnia. Further review revealed an order, dated 09/22/2025, Order Summary: Aricept Oral Tablet 5 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for dementia. Further review of Resident #130's clinical record revealed the diagnoses of Insomnia and Dementia were not among the listed diagnoses and therefore did not populate on the resident's face sheet. During an interview with RN/MDS H on 12/18/2025 at 3:35 p.m., RN/MDS H confirmed Resident #130's diagnoses of Insomnia and Dementia were not included in the diagnosis list and therefore did not populate on the resident's face sheet. RN/MDS H confirmed the resident's diagnoses list, care plan, and physician orders should be uniform, and stated it was important for providers and clinicians to have an accurate understanding of the residents' health status. RN/MDS H confirmed that hospitals and other providers outside of the facility relied upon the resident face sheet for information about the residents' health status. During an interview with the Administrator on 12/19/2025 at 8:30 a.m., the Administrator confirmed the resident's diagnoses list, care plan, and physician orders should be uniform, and stated it was important for providers and clinicians to have an accurate understanding of the residents' health status. Record review of the facility policy, Documentation in Medical Record, dated 11/01/2025, revealed, Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on and interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 4 residents (Resident #1) reviewed for physician notification of changes. The facility failed to inform Resident #1's physician on 3/11/25 when a BP of 80/42 was obtained by LVN A before Resident #1 was transported to dialysis. Resident #1 was treated for hypotension at the hospital after being sent there from dialysis. An Immediate Jeopardy (IJ) was identified on 4/11/25. The IJ template was presented to the facility ED and DON on 4/11/25 at 6:30 pm. While the IJ was removed on 4/16/25 at 11:16 am, 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 due to the facility's need to evaluate the effectiveness of the corrective measures. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of the Face Sheet, dated 4/10/25, reflected Resident #1 was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease (kidneys can longer function due to permanent damage). Record review of Resident #1's comprehensive MDS assessment, dated 3/14/25, reflected Resident #1 had a BIMS score of 12, suggesting moderately impaired cognition. Further review reflected Resident #1 had an ostomy (a surgical procedure to create an opening on the abdominal wall); renal insufficiency, renal failure, or end stage renal disease; received dialysis; received PT and OT. Record review of Resident #1's Care Plan, dated 4/16/25, reflected: . [Resident #1] is at risk for .abnormal BP related to renal failure .Notify MD of .BP concerns . Record review of Resident #1's dialysis Treatment Details Report, dated 3/11/25 10:31 am - 1:31 pm, reflected Resident #1 had a pre-treatment BP of 88/43. Further review revealed the Treatment Nurse Assessment section reflected: .Comment PRE Patient is hypotensive; MD was notified of low BP, verbal order given to .bolus 500 mLs of NS at start of treatment and see if BP stabilizes .O2 administered at 2 LMP [sic] for BP support; CN called nursing facility and they stated his BP was 80/42 and had requested to go to the [Hospital] prior to arrival here at the dialysis facility; Patient agreed to dialyze first then go to the [Hospital] post treatment, if still needed. POST patient is requesting to be taken to the [Hospital] for generalized weakness and hypotension .CLOSE TREATMENT REASON Patient Choice (AMA, feels unwell .) Record review of Resident #1's Progress Note, effective date 3/11/25 at 11:14 am and written by LVN A, reflected, .Resident complains of generalized pain and requesting to be sent out to [Hospital] to see Nephrologist. Resident VS 80/42 [BP], 70 [HR], 18 [RR], 92% [SpO2], 97.9 [T]. notified ADON [RN OO] and made resident aware that if he was [sic] to be sent out, he would more than likely be taken to an ER nearby and if he went to dialysis, he could follow up with his nephrologist there. Resident voiced understanding .Resident transferred to dialysis via [Ambulance company] at 0940 [9:40 am]. Received call from [Dialysis RN] who stated that resident BP remains low, [Dialysis RN] obtained orders from Nephrologist to administer IV fluids to stabilize BP, if unable to do so resident will be sent out to [Hospital] for further eval and treatment. [NP J] and [Facility] ADON made aware . Record review of Resident #1's Occupational Therapy Treatment Encounter Note, dated 3/11/25, reflected: . he was c/o max pain to posterior neck. he reported he did not want any therapy today .He reported after dialysis he was planning to go to [Hospital] (by [rideshare] if he had to) to get a full assessment to out why he has been feeling sick, having increased neck pain and having issues with low BP. Notified Nurse who reported she was aware of this .Electronically signed by [OT] 3/11/25 01:45:47 PM . Record review of Resident #1's Progress Note, effective date 3/12/25 at 3:32 am and written by LVN B, reflected, .this nurse received call from [Hospital A], and received report that pt was on transport back to [Facility]. as per report .pt was taken to hospital from dialysis for low BP. Pt was administered a total of 1500 cc of fluids and BP did increase with last set of vs before dc of 110/55 [BP], 60 [HR], 18 [RR], 97% [SpO2] Ra, and 98.4 [T] .vs obtained 105/45 [BP], 94 [HR], 92% [SpO2], 98.8 [T], and 16 [RR] . During a telephone interview on 4/11/25 at 12:36 pm, LVN A said she reported Resident #1's BP of 80/42 on 3/11/25 to RN OO (Former ADON), the Dialysis nurse, and believed she also spoke to the NP. LVN A said she called the DC on 3/11/25 to report Resident #1's BP of 80/42 and was told that Resident #1 had received fluids but was still requesting to go to the hospital, so the DC sent him to the hospital. LVN A then stated she did not initiate the call to the DC to notify them of Resident #1's BP of 80/42 but sent the dialysis communication form with the resident. LVN A further stated the dialysis called her to inform her of Resident #1's low BP. LVN A said the facility policy was to follow-up with the ADON and NP regarding changes in resident condition and swore she had documented her contact with the NP regarding Resident #1's BP of 80/42 on 3/11/25. LVN A said she was unable to find the text she sent NP J regarding Resident #1's BP on 3/11/25 but knew that NP J was notified and LVN A did not receive any new orders from NP J on 3/11/15 to treat Resident #1's BP but was told to send the resident to dialysis. A phone interview was attempted on 4/11/25 at 2:06 pm with LVN A that was unsuccessful, no call back received. A phone interview was attempted on 4/11/25 at 2:20 pm with LVN A that was unsuccessful, no call back received. During a telephone interview on 4/11/25 at 1:22 pm, NP H said she did not have any text messages from the facility on 3/11/25. NP H further stated that the facility was responsible for notifying her of any abnormal findings. NP H said she should have been notified of Resident #1's BP of 80/42 on 3/11/25. NP H said had she been notified of Resident #1's condition on 3/11/25, Resident #1 would have been sent to the hospital via EMS. NP H further stated she would not have told the facility staff to send Resident #1 to dialysis because he was hypotensive, and his BP was not sustainable for dialysis or everyday life. During a telephone interview on 4/11/25 at 2:25 pm, RN OO (Former ADON), who was no longer employed at the facility, said he did not remember what happened with Resident #1 on 3/11/25, he said he should have been notified of Resident #1's BP but did not remember if he was. RN OO said the facility had a protocol that stated the physician/NP was to be notified if a resident had a low BP. RN OO said the charge nurse, he believed was LVN A, was responsible for notifying the physician/NP regarding Resident #1's BP of 80/42 for recommendations. During an interview on 4/11/25 at 2:56 pm, the DON said Resident #1 was sent to the hospital from the DC, where he received fluids on 3/11/25. The DON said she was not notified of Resident #1's BP of 80/42 on 3/11/25. The DON further stated that Resident #1's documentation reflected that RN OO (Former ADON) was notified and that RN OO would have recommended that the NP be called. The DON said that according to Resident #1's documentation, it seemed the NP was notified of Resident #1's BP of 80/42 on 3/11/25 before he went to dialysis. During an interview on 4/11/25 at 4:12 pm, the DON said that Resident #1's fluctuation in BP was due to dialysis, he was new to dialysis, and this was common with dialysis residents. During an interview on 4/14/25 at 1:16 pm, the OT said she saw Resident #1 before dialysis. The OT said that Resident #1 complained of pain to his neck. The OT said that she was told by Resident #1 that he had told the nurse he wanted to go to the hospital and wanted a full assessment because his BP had been low. The OT further stated she did let the nurse know that Resident #1 was not feeling well and wanted to go to the hospital and would go however he could. The OT said she believed the nurse she reported this to was LVN A and LVN A said she was aware of Resident #1's concerns. During an interview on 4/16/25 at 2:28 pm, the DON said nurses were responsible for communicating any changes in resident condition and the ADON was responsible for monitoring to ensure nurses were notifying the physician/NP about changes in resident condition through communication with the nurses. The DON said that LVN A said she contacted NP J regarding Resident #1's BP and thought that Resident #1 would have been able to see the nephrologist quicker if he went to dialysis. The DON said it was important to communicate with the DC and the physician/NP about changes in resident condition prior to dialysis because it might be determined that the resident should not go to dialysis or intervention may be ordered for the resident. The DON further stated that LVN A documented she contacted NP J, and it was determined Resident #1 should go to dialysis. The DON said dialysis residents' BP fluctuated and it was the responsibility of the DC to decide whether they will treat the resident or not. A phone interview was attempted on 4/16/25 at 3:01 pm with the ADON that was unsuccessful, no call back received. During a telephone interview on 4/16/25 at 12:36 pm, NP J said she was not familiar with Resident #1. NP J further stated she did not have recollection of a notification regarding a BP of 80/42 or request to go to the hospital on 3/11/25. NP J said if she had been notified, she would have addressed the BP by asking questions and assessing the situation further to see what interventions to put in place. During a telephone interview on 4/16/25 at 3:06 pm, the DCS said the DC was not called prior to Resident #1 arriving to the center on 3/11/25. The DCS further stated the DC did not have a physician on-site. The DCS said the physician was notified by the DC on 3/11/25 that Resident #1 had low BP and an order was received to administer fluids to rule out dehydration. The DCS said IV fluids were administered to Resident #1, but the low BP did not resolve so the resident had to be sent to the hospital. During an interview on 4/16/25 at 3:04 pm, the ED said the nurse manager, or the DON were responsible for ensuring the physician/NP was contacted when there was a change in resident condition by reviewing the 24-hour report. The ED further stated the facility policy stated the physician/NP should be notified regarding changes in resident condition. Record review of facility policy Resident Rights, revised December 2016, reflected: .1. Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to .f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility . Record review of facility policy Change in a Resident's Condition or Status, revised February 2021, reflected: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) .d. significant change in resident' physical/emotional/mental condition. This was determined to be an Immediate Jeopardy (IJ) on 4/11/25. The IJ template was presented to the facility ED and DON on 4/11/25 at 6:30 pm. The following Plan of Removal (POR) was accepted on 4/12/25 at 3:12 pm: [Facility] Plan of Removal for Immediate Jeopardy F580 IJ- Notification of Change Date/Time of Notification to the Facility: 04/11/2025 at 6:30pm This is to confirm the submission of our Plan of Removal (POR) provided by this facility. For F580 IJ. The submission of this POR does not constitute an admission on the part of the facility as to accuracy of the surveyor's findings, the conclusion drawn from there, nor is the scope and or severity regarding any deficiency cited applied correctly. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 is no longer in the facility. On 4/11/2025 at 7:32 PM the facility Executive Director and Director of Nursing notified the Medical Director of receiving the Immediate Jeopardy. The Executive Director and DON notified the Medical Director and the Attending Physician of the resident who had an adverse reaction. All notifications were completed by 4/11/2025. On 04/11/25 at 7:30pm An Emergency QAPI meeting, via TEAMS was held with the Medical Director, LNHA, DON, ADON's, the Regional Director of Clinical Services, the Director of Regulatory Compliance, The CNO and the Regional [NAME] President to review present policies and protocols on Notification of Change and Abuse, Neglect and Misappropriation Prevention. The policies and protocols were deemed sufficient. The QAPI team also formulated the interventions to be presented for the Plan of Removal. On 04/11/2025 The Administrator, DON and ADON's were re in serviced by the RDCS (Regional Director of Clinical Services) on Policies and Protocol concerning Physician Notification, Change in Condition, Abuse Prevention, and Hydration Dashboard review. On 4/11/2025 an in-service was initiated by DON/Designee on the Change of Condition/Interact policy to include a pre and post test, Physician notification, and the abuse policy to include what to do in the event the patient request to go to the hospital. On 4/11/2025, the facility initiated education to CNA/CMA, and Therapists will be in-serviced on notification of condition changes and utilization of our stop and watch tool to report changes in patient condition to the licensed staff, to include if a patient requests to go to the hospital. The facility will complete education with licensed nursing staff by 4/12/2025. Any staff who are not present to complete the in-servicing by 4/12/2025 will be required to complete the in-servicing at the start of their next shift before beginning work. The facility will complete in-service with CNA/CMA and Therapist by 4/12/2025. Any staff who are not present to complete in-service by 4/12/2025 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. Abuse, neglect, and exploitation education with licensed and non-licensed staff will be completed by 4/13/2025. Any staff who are not present to complete the training by 4/13/2025 will be required to complete the in-service at the start of their next shift before beginning work. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 4/11/25-The Director of Nursing and nurse leadership completed 100% checks of resident vital signs, identifying any vitals that are not within normal limits and will ensure the providers were notified. This was completed on 4/11/2025, all residents were at their baseline and stable. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur: On 4/11/2025-The facility initiated, at a minimum, daily vital signs for all patients to assist in identifying changes in resident conditions. On 4/11/2025-The physician notification policy was updated to include if a resident requests to go to the hospital. On 4/11/2025- The DON/designee initiated in-servicing with the licensed nurses to review vital signs every shift by running the patient vital sign report in the EHR for abnormal results and initiating the change of condition process, if indicated. Any staff who are not present to complete the training by 4/11/2025 will be required to complete the in-service at the start of their next shift before beginning work. New hires will also be in-serviced prior to the start of their shift. On 4/11/2025- the Director of Nursing and Administrator were in-serviced by the Sr. Regional Director of Clinical Services on the following policies: reporting change in condition, the Interact process, change of condition, abuse and neglect, and the hydration dashboard review. The was completed on 4/11/2025. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will review the hydration dashboard daily for patient changes of condition such as abnormal vital signs, poor meal intake and dehydration symptoms, and will follow up with the charge nurses to ensure the change of condition process was followed. On the weekend, the supervisor/designee will review the hydration dashboard daily for patient changes of condition and will follow up with the charge nurses to ensure the change of condition process was followed. The hydration dashboard will be printed and filed in a binder daily for 1 week then weekly for 3 weeks beginning 4/11/25. The Director of Nursing/or designee will review resident 24-hour report and dashboard (nursing documentation) daily for 1 week, then weekly for 3 weeks beginning 4/11/2025 to monitor for patient change of conditions and ensure notification to providers was done utilizing a check off tool. The Director of Nursing/or designee will monitor to ensure the nurses are running the patient vital sign report every shift daily for 1 week, then weekly for 3 weeks beginning 4/11/2025 utilizing a check off tool. This process will be validated and checked off, by the Administrator/and or designee to ensure compliance of notification change utilizing a check off tool daily used for compliance. Results of audits and reviews will be reported to and reviewed by QAPI committee monthly for three months. POR verification: During a telephone interview on 4/14/25 at 4:11 pm, the MD said he was informed of the IJ. Record review of QAPI meeting minutes, dated 4/11/25, reflected the facility immediately contacted the executive team and MD of the IJ. Further review revealed 100% of residents VS were reviewed, education regarding changes in condition, notifying the physician of clinical changes, and abuse/neglect/exploitation will be completed, and the DON will review the Hydration Dashboard (report used to review residents' VS, meal intake, etc. to monitor residents for dehydration) and results of audits reported to the QAPI committee. Record review of staff training reflected 30 of 30 full time licensed nursing staff across all shifts had been in-serviced. In-services included: Change in Condition (including when a resident requested to go to the hospital), reviewing the VS reports every shift, Physician Notification (including notifying the physician/NP of changes in resident condition). Record review of staff training reflected 40 of 40 unlicensed staff/Therapists across all shifts had been in-serviced. In-service included Stop and Watch, an early warning tool used to identify changes in resident condition. Record review of staff training reflected 88 of 88 full time staff had been in-serviced regarding abuse and neglect, including when to report and to whom to report. Interviews between 4/13/25 at 11:51 am and 4/14/25 at 2:24 pm with 37% of staff employed at the facility (LVN B, RN F, LVN I, CNA K, CNA L, CMA M, CMA N, LVN O, RN P, HSKPR Q, REC R, HSKPR S, CNA T, CNA U, CNA V, CNA W, CMA X, LVN Y, LVN AA, LVN BB, CNA DD, CNA EE, CNA FF, CNA GG, CNA JJ, REC LL, REC MM, LVN NN, OT, PT, and DOR) revealed in-services were conducted. Interviewed staff said ins-services included: abuse/neglect and who to report it to, Stop and Watch (a tool used to document/report changes in resident condition), notifying the Physician/NP of changes in resident condition, documentation of changes in condition using SBAR, and review/documentation of VS every shift, and what to do if a resident requests to go to the hospital. Staff interviewed included: 7 staff worked 6:00 am - 2:00 pm, 7 staff worked 2:00 pm - 10:00 pm, 5 staff who worked 10:00 pm - 6:00 am, 3 staff who worked 8:00 AM - 5:00 PM, 5 staff worked 6:00 AM - 10:00 PM, and 4 staff who worked PRN. Record review of VS logs reflected 100% of residents' VS were reviewed by the DON and abnormal values were noted and the physician/NP notified as needed for resident with abnormal VS values. During an interview on 4/13/25 at 12:32 pm, the DON said nurses were expected to obtain and document VS every shift and she or the weekend supervisor would review the report daily for abnormal values. Record review of staff training reflected the ED and DON were in-serviced on 4/11/25 by RDCS regarding physician notification, change in condition, abuse/neglect, SBAR, and Hydration Dashboard review. Record review of staff training reflected 8 of 8 nurse supervisors were in-serviced on 4/13/25 by the DON regarding the Vital Sign Monitor Tracking Tool. Interviews between 4/13/25 at 1:47 pm - 2:00 pm with 3 nurse supervisors (RN F, LVN I, and LVN LL) revealed an in-service was conducted regarding the Vital Sign Monitor Tracking Tool. The nurse supervisors said they were expected to review their assigned residents' VS every shift for trends, sign the form to document completion, and give it to the ADON/DON. The nurse supervisors further stated they were expected to complete a CIC form and notify the physician/NP for any abnormal values noted. During an interview on 4/14/25 at 3:38 pm, the DON said she reviewed VS for 100% of residents residing at the facility. The DON further stated all abnormal VS were reported to the physician/NP and SBARs completed for all residents identified. the DON said she/designee/staffing coordinator were responsible for ensuring all new hires, PRN and agency staff were in-serviced related to abuse/neglect, Stop and Watch Early Warning Tool, change in condition, and SBAR, prior to the start of their next shift. During an interview on 4/14/25 at 3:40 pm, the DON said she was responsible for ensuring nurses reviewed resident VS every shift. The DON further stated a log was implemented and nurses were expected to review VS for their assigned resident, document on the log whether any trends/patterns were identified, sign the log, contact the physician/MD if needed, and complete a progress note or SBAR if needed. During an interview on 4/14/25 at 3:43 pm, the DON said she was in-serviced on 4/11/25 by the RDCS regarding her responsibility related to VS, the Hydration Monitoring Tool, physician notifications, CIC, SBAR, and abuse/neglect. During an interview on 4/14/25 at 3:46 pm, the ED said she was in-serviced on 4/11/25 by the RDCS regarding CIC, abuse/neglect, notifying the physicians regarding any changes in resident condition, SBAR, Hydration Dashboard, VS, and weight summaries. Record review of the facility policy Physician Notification, revised April 2025, reflected it was updated to include resident requests to go to the hospital. The ED, DON, and RDCN were informed the Immediate Jeopardy was removed on 4/16/25 at 11:16 am. While the IJ was removed, 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, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to immediately intervene when Resident #1 was found to have a BP of 80/42, complained of generalized pain, and requested to go to the hospital on 3/11/25. An Immediate Jeopardy (IJ) was identified on 4/14/25. The IJ template was presented to the facility ED, DON, RDCS, and VPO (via telephone) on 4/14/25 at 1:58 pm. While the IJ was removed on 4/16/25 at 11:16 am, 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, due to the facility's need to evaluate the effectiveness of the corrective measures. This failure could affect residents who experience a change in condition by placing them at risk for a delay in medical treatment, decline in health, and death. Findings included: Record review of the Face Sheet, dated 4/10/25, reflected Resident #1 was admitted to the facility on [DATE] with diagnoses that included: End Stage Renal Disease (kidneys can longer function due to permanent damage). Record review of Resident #1's comprehensive MDS assessment, dated 3/14/25, reflected Resident #1 had a BIMS score of 12, suggesting moderately impaired cognition. Further review reflected Resident #1 had an ostomy (a surgical procedure to create an opening on the abdominal wall); renal insufficiency, renal failure, or end stage renal disease; received dialysis; received PT and OT. Record review of Resident #1's Care Plan, dated 4/16/25, reflected: . [Resident #1] is at risk for .abnormal BP related to renal failure .Notify MD of .BP concerns . Record review of Resident #1's dialysis Treatment Details Report, dated 3/11/25 10:31 am - 1:31 pm, reflected Resident #1 had a pre-treatment BP of 88/43. Further review revealed the Treatment Nurse Assessment section reflected: .Comment PRE Patient is hypotensive; MD was notified of low BP, verbal order given to .bolus 500 mLs of NS at start of treatment and see if BP stabilizes .O2 administered at 2 LMP [sic] for BP support; CN called nursing facility and they stated his BP was 80/42 and had requested to go to the [Hospital] prior to arrival here at the dialysis facility; Patient agreed to dialyze first then go to the [Hospital] post treatment, if still needed. POST patient is requesting to be taken to the [Hospital] for generalized weakness and hypotension .CLOSE TREATMENT REASON Patient Choice (AMA, feels unwell .) Record review of Resident #1's Progress Note, effective date 3/11/25 at 11:14 am and written by LVN A reflected, .Resident complains of generalized pain and requesting to be sent out to [Hospital] to see Nephrologist. Resident VS 80/42 [BP], 70 [HR], 18 [RR], 92% [SpO2], 97.9 [T] .made resident aware that if he was to be sent out, he would more than likely be taken to an ER nearby and if he went to dialysis, he could follow up with his nephrologist there. Resident voiced understanding .Resident transferred to dialysis via [Ambulance company] at 0940 [9:40 am]. Received call from [Dialysis RN] who stated that resident BP remains low, [Dialysis RN] obtained orders from Nephrologist to administer IV fluids to stabilize BP, if unable to do so resident will be sent out to [Hospital] for further eval and treatment . Record review of Resident #1's Occupational Therapy Treatment Encounter Note, dated 3/11/25, reflected: .he was c/o max pain to posterior neck. he reported he did not want any therapy today .He reported after dialysis he was planning to go to [Hospital] (by [Rideshare] if he had to) to get a full assessment to find out why he has been feeling sick, having increased neck pain and having issues with low bp. Notified Nurse who reported she was aware of this .Electronically signed by [OT] 3/11/25 01:45:47 PM . Record review of Resident #1's Progress Note, effective date 3/12/25 at 3:32 am and written by LVN B reflected, .pt was taken to hospital from dialysis for low BP. Pt was administered a total of 1500 cc of fluids and BP did increase with last set of vs before dc of 110/55 [BP], 60 [HR], 18 [RR], 97% [SpO2] Ra, and 98.4 [T] .vs obtained 105/45 [BP], 94 [HR], 92% [SpO2], 98.8 [T], and 16 [RR] . During a telephone interview on 4/11/25 at 12:36 pm, LVN A said she reported Resident #1's BP of 80/42 and request to go to Hospital A on 3/11/25 to RN OO (Former ADON), the dialysis nurse, and believed she also spoke to the NP. LVN A further stated she was told by RN OO not to send Resident #1 to the hospital but to inform the NP and send Resident #1 to dialysis as scheduled. LVN A said she was told by RN OO that Resident #1 usually had low BPs and it would be best for him to go to dialysis. LVN A said Resident #1 requested to go to the ER and wanted to be seen by his nephrologist and was told by RN OO that Resident #1 would be seen by the nephrologist at the dialysis center. LVN A said she did not know if there was a nephrologist at the dialysis center. LVN A said she was told by the dialysis center that they reached out to the nephrologist and was told to administer fluids to Resident #1. LVN A further stated she was told by the dialysis center that Resident #1 requested to the hospital and Resident #1 was sent to the hospital by the dialysis center. LVN A said she was asked by the dialysis center why Resident #1 was not sent to the hospital when he requested to go. LVN A said if a resident requested to go the hospital, she was expected to assess the resident and notify the ADON. A request for Resident #1's medical records was submitted to Hospital A on 4/16/25, records are pending. During a telephone interview on 4/11/25 at 1:22 pm, NP H said had she been notified of Resident #1's condition on 3/11/25, Resident #1 would have been sent to the hospital via EMS. NP H further stated she would not have told the facility staff to send Resident #1 to dialysis because he was hypotensive, and his BP was not sustainable for dialysis or everyday life. During a telephone interview on 4/11/25 at 2:25 pm, RN OO (Former ADON), who was no longer employed at the facility, said he did not remember what happened with Resident #1 on 3/11/25. RN OO said if a resident requested to go the hospital, the physician would be called for orders and the resident was usually transported to the hospital per resident request. RN OO said the charge nurse, he believed was LVN A, was responsible for notifying the physician/NP regarding Resident #1's BP of 80/42 for recommendations. RN OO said he would not have sent Resident #1 to dialysis; the physician would have been contacted for orders. RN OO further stated it was his understanding there was a nephrologist at the dialysis center, but he was not sure. During an interview on 4/11/25 at 2:56 pm, the DON said Resident #1 was sent to the hospital from the DC, where he received fluids on 3/11/25. The DON further stated LVN A should have sent Resident #1 to the hospital on 3/11/25, adding this was the resident's right. The DON said the nephrologist managed the DC but did not think he was always at the DC. During an interview on 4/11/25 at 4:12 pm, the DON said that Resident #1's fluctuation in BP was due to dialysis, he was new to dialysis, and BP fluctuations were common with dialysis residents. During an interview on 4/1/425 at 1:16 pm, the OT said she saw Resident #1 before dialysis. The OT said that Resident #1 complained of pain to his neck. The OT said that she was told by Resident #1 that he had told the nurse he wanted to go to the hospital and wanted a full assessment because his BP had been low. The OT further stated she did let the nurse know that Resident #1 was not feeling well and wanted to go to the hospital and would go however he could. The OT said she believed the nurse she reported this to was LVN A and LVN A said she was aware of Resident #1's concerns. During an interview on 4/16/25 at 2:28 pm, the DON said LVN A thought that Resident #1 would have been able to see the nephrologist quicker if he went to dialysis. The DON said it was important to communicate with the DC and the physician/NP about changes in resident condition prior to dialysis because it might be determined that the resident should not go to dialysis or intervention may be ordered for the resident. The DON further stated that LVN A documented she contacted NP J, and it was determined Resident #1 should go to dialysis. The DON said dialysis residents' BP fluctuated and it was the responsibility of the DC to decide whether they will treat the resident or not. During a telephone interview on 4/16/25 at 3:06 pm, the DCS said the DC did not have a physician on-site. The DCS said the physician was notified by the DC on 3/11/25 that Resident #1 had low BP and an order was received to administer fluids to rule out dehydration. The DCS said IV fluids were administered to Resident #1, but the low BP did not resolve so the resident had to be sent to the hospital. Record review of facility policy Change in a Resident's Condition or Status, revised February 2021, reflected: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an) .d. significant change in resident' physical/emotional/mental condition. Record review of facility policy Physician Notification, revised April 2025, reflected: The types of conditions which arise frequently are listed. This list is not inclusive .Vital signs .Patient requests to go to the hospital. It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment .The nurse will: - Recognize the condition change .- Notify the physician, patient and patient representative of any change in condition . This was determined to be an Immediate Jeopardy (IJ) on 4/14/25. The IJ template was presented to the facility ED, DON, RDCS, and VPO (via telephone) on 4/14/25 at 1:58 pm. The following Plan of Removal (POR) was accepted on 4/15/25 at 11:19 am: [Facility] Plan of Removal for Immediate Jeopardy F684 IJ- Quality of Care Date/Time of Notification to the Facility: 04/14/2025 at 1:58 pm This is to confirm the submission of our Plan of Removal (POR) provided by this facility. For F684 IJ. The submission of this POR does not constitute an admission on the part of the facility as to accuracy of the surveyor's findings, the conclusion drawn from there, nor is the scope and or severity regarding any deficiency cited applied correctly. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 is no longer in the facility. On 4/11/2025 at 7:32 PM the facility Executive Director and Director of Nursing notified the Medical Director of receiving the Immediate Jeopardy. The Executive Director and DON notified the Medical Director and the Attending Physician of the resident who had an adverse reaction. All notifications were completed by 4/11/2025. On 4/14/2025- The facility Executive Director and Director of Nursing notified the facility Medical Director of the F684 Quality of Care Immediate Jeopardy tag. On 04/11/25 at 7:30pm An Emergency QAPI meeting, via TEAMS was held with the Medical Director, LNHA, DON, ADON's, the Regional Director of Clinical Services, the Director of Regulatory Compliance, The CNO and the Regional [NAME] President to review present policies and protocols on Notification of Change and Abuse, Neglect and Misappropriation Prevention. The policies and protocols were deemed sufficient. The QAPI team also formulated the interventions to be presented for the Plan of Removal. On 04/11/2025 The Administrator, DON and ADON's were re in-serviced by the RDCS (Regional Director of Clinical Services) on Policies and Protocol concerning Physician Notification, Change in Condition, Abuse Prevention, and Hydration Dashboard review. On 4/11/2025 an in-service was initiated by DON/Designee on the Change of Condition/Interact policy to include a pre and post test, Physician notification, and the abuse policy to include what to do in the event the patient request to go to the hospital. The Interact process incorporates the resident's request to go to the hospital. On 4/11/2025, the facility initiated education to CNA/CMA, and Therapists will be in-serviced on notification of condition changes and utilization of our stop and watch tool to report changes in patient condition to the licensed staff, to include if a patient requests to go to the hospital. The facility completed education with licensed nursing staff on 4/12/2025. Any staff who were not present to complete the in-servicing by 4/12/2025 are required to complete the in-servicing at the start of their next shift before beginning work. The facility completed in-service with CNA/CMA and Therapist on 4/12/2025. Any staff who are were not present to complete in-service by 4/12/2025 are required to complete the in-service at the start of their next shift before beginning work. New hires or PRN staff will also be in-serviced prior to the start of their shift. Abuse, neglect, and exploitation education with licensed and non-licensed staff was completed on 4/13/2025. Any staff who were not present to complete the training on 4/13/2025 are required to complete the in-service at the start of their next shift before beginning work. On 4/12/2025- The facility completed in-service with licensed nursing staff on recognizing abnormal versus normal vital signs. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 4/11/25-The Director of Nursing and nurse leadership completed 100% checks of resident vital signs, identifying any vitals that are not within normal limits and will ensure the providers were notified. This was completed on 4/11/2025, all residents were at their baseline and stable. Measures to be put into place or systemic changes made to ensure that the deficient practice will not recur: On 4/11/2025-The facility initiated, at a minimum, daily vital signs for all patients to assist in identifying changes in resident conditions. On 4/11/2025-The physician notification policy was updated to include if a resident requests to go to the hospital. This policy incorporates the resident requesting to go to the hospital. On 4/11/2025- The DON/designee initiated in-servicing with the licensed nurses to review vital signs every shift by running the patient vital sign report in the EHR for abnormal results and initiating the change of condition process, if indicated. The nurses will document on a vital sign tracking log to validate this process was done daily for 1 week then weekly for 3 weeks thereafter. Any staff who were not present to complete the training on 4/11/2025 are required to complete the in-service at the start of their next shift before beginning work. New hires will also be in-serviced prior to the start of their shift. On 4/11/2025- the Director of Nursing and Administrator were in-serviced by the Sr. Regional Director of Clinical Services on the following policies: reporting change in condition, the Interact process, change of condition, abuse and neglect, and the hydration dashboard review. This was completed on 4/11/2025. How the facility plans to monitor its performance to make sure that solutions are sustained: The DON/designee will review the hydration dashboard daily for patient changes of condition such as abnormal vital signs, poor meal intake and dehydration symptoms, and will follow up with the charge nurses to ensure the change of condition process was followed. On the weekend, the supervisor/designee will review the hydration dashboard daily for patient changes of condition and will follow up with the charge nurses to ensure the change of condition process was followed. The hydration dashboard will be printed and filed in a binder daily for 1 week then weekly for 3 weeks beginning 4/11/25. The Director of Nursing/or designee will review resident 24-hour report and dashboard (nursing documentation) daily for 1 week, then weekly for 3 weeks beginning 4/11/2025 to monitor for patient change of conditions and ensure notification to providers was done utilizing a check off tool. The Director of Nursing/or designee is monitoring to ensure the nurses are running the patient vital sign report every shift daily for 1 week, then weekly for 3 weeks beginning 4/11/2025 utilizing a check off tool to validate the v/s report she completed by the nurses were done. Results of audits and reviews will be reported to and reviewed by QAPI committee monthly for three months. POR verification: During a telephone interview on 4/14/25 at 4:11 pm, the MD said he was informed of the IJ. Record review of QAPI meeting minutes, dated 4/11/25, reflected the facility immediately contacted the executive team and MD of the IJ. Further review revealed 100% of residents VS were reviewed, education regarding changes in condition, notifying the physician of clinical changes, and abuse/neglect/exploitation will be completed, and the DON will review the Hydration Dashboard (report used to review residents' VS, meal intake, etc. to monitor residents for dehydration) and results of audits reported to the QAPI committee. Record review of staff training reflected 30 of 30 fulltime licensed nursing staff across all shifts had been in-serviced. in-services included: Change in Condition (including when a resident requested to go to the hospital), reviewing the VS reports every shift, Physician Notification (including notifying the physician/NP of changes in resident condition). Record review of staff training reflected 40 of 40 unlicensed staff/Therapists across all shifts had been in-serviced. in-service included Stop and Watch, an early warning tool used to identify changes in resident condition. Record review of staff training reflected 88 of 88 fulltime staff had been in-serviced regarding abuse and neglect, including when to report and to whom to report. Interviews between 4/13/25 at 11:51 am and 4/14/25 at 2:24 pm with 37% of staff employed at the facility (LVN B, RN F, LVN I, CNA K, CNA L, CMA M, CMA N, LVN O, RN P, HSKPR Q, REC R, HSKPR S, CNA T, CNA U, CNA V, CNA W, CMA X, LVN Y, LVN AA, LVN BB, CNA DD, CNA EE, CNA FF, CNA GG, CNA JJ, REC LL, REC MM, LVN NN, OT, PT, and DOR) revealed in-services were conducted. Interviewed staff said ins-services included: abuse/neglect and who to report it to, Stop and Watch (a tool used to document/report changes in resident condition), notifying the Physician/NP of changes in resident condition, documentation of changes in condition using SBAR, and review/documentation of VS every shift, and what to do if a resident requests to go to the hospital. Of staff interviewed, 7 staff worked 6:00 am - 2:00 pm, 7 staff worked 2:00 pm - 10:00 pm, 5 staff who worked 10:00 pm - 6:00 am, 3 staff who worked 8:00 AM - 5:00 PM, 5 staff worked 6:00 AM - 10:00 PM, and 4 staff who worked PRN. Record review of 100% of residents' VS was conducted by the DON and abnormal values were noted and the physician/NP notified. During an interview on 4/13/25 at 12:32 pm, the DON said nurses were expected to obtain and document VS every shift and she or the weekend supervisor would review the report daily for abnormal values. Record review of staff training reflected the ED and DON were in-serviced on 4/11/25 by RDCS regarding physician notification, change in condition, abuse/neglect, SBAR, and Hydration Dashboard review. Record review of staff training reflected 8 of 8 nurse supervisors were in-serviced on 4/13/25 by the DON regarding the Vital Sign Monitor Tracking Tool. Interviews between 4/13/25 at 1:47 pm - 2:00 pm with 3 nurse supervisors (RN F, LVN I, and LVN LL) revealed an in-service was conducted regarding the Vital Sign Monitor Tracking Tool. The nurse supervisors said they were expected to review their assigned residents' VS every shift for trends, sign the form to document completion, and give it to the ADON/DON. The nurse supervisors further stated they were expected to complete a CIC form and notify the physician/NP for any abnormal values noted. During an interview on 4/14/25 at 3:38 pm, the DON said she reviewed VS for 100% of residents residing at the facility. The DON further stated all abnormal VS were reported to the physician/NP and SBARs completed for all residents identified. the DON said she/designee/staffing coordinator were responsible for ensuring all new hires, PRN and agency staff were in-serviced related to abuse/neglect, Stop and Watch Early Warning Tool, change in condition, and SBAR, prior to the start of their next shift. During an interview on 4/14/25 at 3:40 pm, the DON said she was responsible for ensuring nurses reviewed resident VS every shift. The DON further stated a log was implemented and nurses were expected to review VS for their assigned resident, document on the log whether any trends/patterns were identified, sign the log, contact the physician/MD if needed, and complete a progress note or SBAR if needed. During an interview on 4/14/25 at 3:43 pm, the DON said she was in-serviced on 4/11/25 by the RDCS regarding her responsibility related to VS, the Hydration Monitoring Tool, physician notifications, CIC, SBAR, and abuse/neglect. During an interview on 4/14/25 at 3:46 pm, the ED said she was in-serviced on 4/11/25 by the RDCS regarding CIC, abuse/neglect, notifying the physicians regarding any changes in resident condition, SBAR, Hydration Dashboard, VS, and weight summaries. Record review of the facility policy Physician Notification, revised April 2025, reflected it was updated to include resident requests to go to the hospital. The ED, DON, and RDCN were informed the Immediate Jeopardy was removed on 4/16/25 at 11:16 am. While the IJ was removed, 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, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interviews and record reviews, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASARR) Level 1 residents with mental illness were provided with a PASARR Level II Evaluation and Assessment for 3 of 3 residents (#9, #27 and #38) reviewed for PASARR services. 1. The facility failed to identify Resident #9 as having several diagnoses related to Mental Illness including paranoid schizophrenia, manor depressive disorder, panic disorder, unspecified mood [affective] disorder and anxiety disorder, on the PASARR screening which would require a PASARR Level II assessment. 2. The facility failed to identify Resident #27 as having a diagnosis of unspecified Psychosis, a mental illness, which would require a PASARR Level II assessment. 3. The facility failed to identify Resident #38 as having a diagnosis of Bipolar Disorder, a mental illness which would require a PASARR Level II assessment. These deficient practices could place residents at risk to a diminished quality of life by not receiving or benefiting from specialized services. 1. Record review of Resident #9's Face Sheet reflected an [AGE] year-old male last admitted to facility 06/12/23. The Face Sheet indicated Resident #9 had a Prior Community Stay from 03/31/23 - 05/17/23. His diagnoses included the following: * paranoid schizophrenia (a chronic condition that can cause paranoia making it hard to tell what is real and what is not), *major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest), *panic disorder (mental and behavioral disorder characterized by reoccurring unexpected panic attacks), *unspecified mood [affective] disorder (a disturbance in mood which is abnormally depressed or elated) and *anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident #9's PASARR Level 1 Screening dated 08/16/23 indicated No for C0090 Primary Diagnosis of Dementia and No for C0100 Is there evidence or an indicator this is an individual that has a Mental Illness. Record Review of psychiatric assessment by contracted psychological services indicated a service date on 04/10/23. The assessment noted an admitted [DATE]. That assessment indicated a Primary Treatment Diagnosis of Paranoid Schizophrenia with a Secondary Treating Diagnoses of Panic disorder (episodic paroxysmal anxiety) without agoraphobia. The mental health assessor documented that Resident #9 told the assessor that he had dealt with mental illness issues since he was in his 20's. Resident #9 was unavailable for interviews throughout this survey since he was found asleep in his room with the door closed and lights off. During an interview, an unidentified C.N.A. indicated that Resident #9 slept all day and was awake at night. He did usually wake up for meals and then would go back to sleep. Record review of the most recent MDS dated [DATE] revealed a BIMS score of 11, indicating resident had moderate cognitive impairment. The MDS did not indicate whether or not a PASARR II assessment had been completed. During an interview on 09/13/24 at 08:30 AM, the Senior DON revealed she stated the schizophrenia diagnosis was made by [mental health assessor] after admission. The Senior DON said a Form 1012 [Mental Illness/Dementia Resident Review] should have been done to [determine whether a resident with a Negative PASARR Level needs further evaluation] and was not completed. The Senior DON stated the MDS Nurse who normally reviewed PASARR's was out on medical leave. 2. Review of Resident #27's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of unspecified Psychosis. Review of Resident #27's quarterly MDS assessment, dated 6/10/24, revealed her BIMS was 0 meaning she was not able to complete the Brief Interview for Mental Status. Further review revealed she had a diagnosis of Depression. Review of Resident #27's Care Plan, effective 2/26/23, revealed she had a diagnosis of Depression w/psychotic symptoms. Review of Resident #27's PASARR Level 1 Screening, dated 8/14/23, revealed she did not have a mental illness. 3. Review of Resident #38's face sheet, undated, revealed she was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder. Review of Resident #38's quarterly MDS, dated [DATE], revealed a diagnosis of Bipolar Disorder. Review of Resident #38's Care Plan, effective 2/26/23, revealed has diagnosis of Manic Depression (Bi Polar) and can have mood swings from euphoria to depression. Review of Resident #38's PASARR Level 1 Screening, dated 8/16/23, revealed she did not have a mental illness. Interview on 09/13/24 at 4:11 PM with LVN A revealed the Senior DON explained a resident with a diagnosis of mental illness would require them to complete another PASARR and submit it to the local authorities. They would decide if the resident met the criteria for specialized services. LVN A stated upon reviewing Resident #38's face sheet, it reflected a diagnosis of Bipolar Disorder and Resident #27's face sheet reflected a diagnosis of unspecified Psychosis. Record review of the facility's Assessments policy dated November 2017 addressed PASARR as follows: 8. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the Patient's/Resident's medical record. In addition, the facility must provide or obtain the required services from an outside resource from a Medicare and/or Medicaid provider to provide any rehabilitative services such as physical therapy, speech-language pathology, occupational therapy, and rehabilitative services for mental disorders and intellectual disability, required in the Patient's comprehensive plan of care. 41095

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Clean utensils and dishware had food particles from previous meals. This deficient practice could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness. The findings were: During a confidential group meeting on 09/12/2024 at11:00 a.m., members of the resident group stated utensils and dishware regularly have food particles from previous meals on them. Observation of clean utensils in the kitchen on 09/13/2024 at 11:42 a.m. revealed food particles on the utensils. During an interview with Dietary Aide H, at the same time as the observation, Dietary Aide H confirmed the utensils had been cleaned and food particles remained on them. Observation of clean dishware in the kitchen on 09/13/2024 at 11:46 a.m. revealed food particles on the dishware. During an interview with Dietary Aide H, at the same time as the observation, Dietary Aide H confirmed the dishware had been cleaned and food particles remained on them. During an interview with the Dietary Manager on 09/13/2024 at 1:05 p.m., the Dietary Manager stated utensils and dishware should not have food particles remaining from previous meals and stated he would ensure that utensils and dishware were washed more thoroughly. During an interview with the Administrator on 09/13/2024 at 1:12 p.m., the Administrator stated that her expectation was that utensils and dishware should be cleaned thoroughly and not have food particles from previous meals remaining. Record review of the facility policy, Sanitization, revised November 2022, revealed, The food service area is maintained in a clean and sanitary manner.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 11 resident rooms (Resident #206) reviewed for storage of drugs. The facility failed to ensure medications were not left at the bedside for Resident #206. This deficient practice could place residents at risk of medication misuse or drug diversion. The findings included: Record review of Resident #206's face sheet, dated 9/11/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), acquired absence of lung, myasthenia gravis (a chronic autoimmune disorder that causes muscle weakness), hypotension (low blood pressure), fluid overload, gout (a type of arthritis characterized by sudden severe attacks of pain, redness, and swelling in the joints), hypokalemia (abnormally low levels of potassium in the blood), anorexia (an eating disorder characterized by an intense fear of gaining weight), and pain. Record review of Resident #206's baseline care plan, dated 9/5/24 revealed the resident was alert and cognitively intact, had disorders of the cardiac/circulatory system, and diseases and disorders of the nervous system. Record review of Resident #206's Physician Order Sheet for September 2024 revealed the following: - acetazolamide 250 mg tablet one time daily for fluid overload with order date 9/5/24 and no stop date - bumetanide 1 mg tablet two times daily for fluid overload with order date 9/5/24 and no stop date - colchicine 0.6 mg tablet one time daily for gout with order date 9/5/24 and no stop date - omeprazole 40 mg capsule, two tablets daily for gastro-esophageal reflux with order date 9/5/24 and no stop date - prednisone 20 mg tablet, (2 tablets to equal 40 mg) one time daily for myasthenia gravis with order date 9/5/24 and no stop date - spironolactone 25 mg tablet one time daily for fluid overload with order date 9/5/24 and no stop date - nystatin 100,000 unit/ml oral suspension four times daily for candida stomatitis with order date 9/6/24 and no stop date - midodrine 10 mg tablet three times daily for hypotension with order date 9/6/24 and no stop date - Effer-K 20 mEq effervescent tablet one time daily for hypokalemia with order date 9/7/24 and no stop date -review of the Physician Order Sheet did not have an order for the resident to self-administer medications Record review of Resident #206's MAR for September 10, 2024, revealed the following medications scheduled at 7:00 a.m., were signed out by LVN B: - acetazolamide 250 mg tablet one time daily for fluid overload - bumetanide 1 mg tablet two times daily for fluid overload - colchicine 0.6 mg tablet one time daily for gout - omeprazole 40 mg capsule, two tablets daily for gastro-esophageal reflux - prednisone 20 mg tablet, (2 tablets to equal 40 mg) one time daily for myasthenia gravis - spironolactone 25 mg tablet one time daily for fluid overload - nystatin 100,000 unit/ml oral suspension four times daily for candida stomatitis - midodrine 10 mg tablet three times daily for hypotension - Effer-K 20 mEq effervescent tablet one time daily for hypokalemia Observation on 9/10/24 at 9:45 a.m. revealed Resident #206 walking out of her room holding a medication cup with several pills in the cup. Resident #206 was intercepted by the ADON who then re-directed Resident #206, still holding the medication cup with the pills back into the resident's room. Observation on 9/10/24 at 9:47 a.m. revealed the ADON walked out of Resident #206's room. During an observation and interview on 9/10/24 at 9:47 a.m., Resident #206 was sitting up in a chair with the bedside table in front of her, and the medication cup with the pills were not seen. Resident #206 was observed with a medication cup half filled with a milky solution. Resident #206 stated she was in her room participating in a televisit appointment (a remote appointment with a doctor or other medical professional over the internet) at 8:00 a.m. with her doctor when the female CNA came into the room with the cup of pills. Resident #206 stated the doctor told her to wait and not take the pills because the doctor was going to go over the medications with her. Resident #206 stated she told the female CNA she was discussing medications with the doctor and the female CNA gave them (the cup of pills) to me and left. Resident #206 stated, the RN (ADON who was observed re-directing the resident back into her room) who came in the room took my pills and told me I was not supposed to have the pills with me. Observation on 9/10/24 at 9:52 a.m. revealed the ADON returned to Resident #206's bedside with a medication cup of pills. The ADON asked Resident #206 to provide her with the name of the doctor the resident had the televisit with, wrote down the information and then placed the medication cup with the pills in front of the resident and told her to take them. Resident #206 asked the ADON to identify one of the pills she was given and the ADON stated she did not know and would have to go check, maybe vitamin C? Resident #206 retrieved the medication cup with the milky solution in it and stated she was supposed to swish and spit it out into the sink. During an interview on 9/10/24 at 9:56 a.m., the ADON stated medications were not supposed to be left at the bedside and the nursing staff were supposed to observe the resident taking the medication because if not observed the resident could throw the medications away, hoard the medications or save them for the next medication pass. The ADON stated the resident could have a negative side effect if the medications were not taken correctly. The ADON revealed she did not pull the medications she gave to Resident #206. The ADON stated, I should not be giving Resident #206 pills that I did not pull myself because I don't know what they are, but I did go verify with the nurse, LVN B. During an interview on 9/10/24 at 10:01 a.m., LVN B revealed Resident #206 was on the phone and asked the resident if she wanted to take her medications or hold the medications. LVN B stated, Resident #206 said she would take the medications. LVN B stated, I don't leave them (medications) at the bedside, but I made that exception because she (Resident #206) is alert and oriented. LVN B stated she left the medications because I just wanted to finish the med pass and help on the floor. LVN B revealed she should not have left the medications at the bedside because the resident may not take them, pocket them, or could hurt herself or have side effects from not taking her medications. During an interview on 9/12/24 at 6:46 p.m., the Senior DON stated, the nurse should not leave medications with the resident. The Senior DON stated, the nurse should not give a medication it the nurse did not pull it, draw it, or pop it because it is not best practice. The Senior DON stated the resident could have a potential negative outcome. Record review of the facility policy and procedure titled, Administering Medications, Version 2.1 revealed in part, .Medications are administered in a safe and timely manner, and as prescribed .1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so .

39075 Based on observation, interview and record review the facility failed to maintain medical records on each resident that were accurately documented in accordance with accepted professional standards and practices for 3 of 10 Residents (Resident #41, Resident #32 and Resident #45) whose records were reviewed. 1. LVN C failed to document an assessment after Resident #41 had a fall. 2. Nursing staff failed to sign and date the assist rail/enabler evaluation for Resident #32 which made the evaluation invalid. 3. Nursing staff failed to obtain a consent from Resident 45's family representative for the use of an assist rail/enabler. These deficient practices could affect any residents who have medical records and could result in misinformation about professional care provided. The findings were: 1. Record review of Resident #41's face sheet, dated 9/12/24, revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), abnormalities of gait and mobility, muscle weakness, lack of coordination and history of falling. Record review of Resident #41's most recent quarterly MDS assessment, dated 8/25/24 revealed the resident was cognitively intact for daily decision-making skills, was always incontinent of bowel and bladder, and required partial/moderate assistance with chair/bed-to-chair transfer. Record review of Resident #41's comprehensive care plan, with effective date 5/29/24, revealed the resident had a potential for falls related to unsteady gait and generalized weakness and had a fall on 8/22/24 and 9/5/24. Interventions for falls included keeping areas free of obstructions, reminding the resident to request assistance with transfers and remind the resident not to take a shower without assistance. Record review of the comprehensive care plan further revealed the resident had a fall from the bed on 8/22/24 and had a rug burn to the forehead with no other injuries noted. Record review of Resident #41's Clinical Note Entry dated 8/20/24 and time stamped 10:32 p.m. by LVN C revealed the resident was moved from the 300 hall to the 700 hall due to air conditioning issues in the resident's room. Record review of Resident #41's Clinical Note Entry dated 8/28/24 and time stamped 10:30 a.m., by LVN D revealed the resident's family member voiced concerns about the resident's mental status after a recent fall and requested a CT scan of the head. Record review of Resident #41's Patient Visit Information from the hospital, dated 8/28/24 revealed a head CT was performed with negative results for acute intracranial abnormality and an ultrasound of the left lower extremity was negative for acute DVT. During an interview on 9/12/24 at 11:36 a.m., LVN E revealed Resident #41 was transferred from the 300 hall to the 700 hall, where the LVN was the charge nurse, on 8/21/24 because of air conditioning issues. LVN E revealed he was given report and told by the overnight charge nurse that although the resident was now on his hall, the 300 hall charge nurse who was LVN D would continue to work with the resident. LVN E stated he was notified by CNA F on 8/22/24 that Resident #41 had an unwitnessed fall and needed to be checked. LVN E stated he went to Resident #41's room and observed her already on the bed with what appeared to be a rug burn on the forehead, and since I didn't know this patient for anything, or had seen her from the day before, I didn't know if it was something new or existing. LVN E stated the resident was alert and oriented and told him she had fallen and hit her head. LVN E stated he then went to LVN D to report about the fall and stated LVN D told him the resident was not his patient. LVN E stated he then made contact with the ADON who informed him that Resident #41 was now his patient because she was moved to his hall. LVN E stated he then called the doctor and the resident's RP to report the fall. LVN E stated the NP was in the building at the time, the NP assessed the resident and did not give any new orders. LVN E stated he continued with neurological checks and assumed responsibility for the resident. During an interview on 9/12/24 at 12:58 p.m., LVN D revealed Resident #41 had been moved from the 300 hall to the 700 hall due to air conditioning issues on 8/20/24 during the overnight shift. LVN D stated he received report from the overnight nurse about the move and the resident's medications were moved to the 700 hall medication cart. LVN D stated, since the resident was moved from the 300 hall to the 700 hall, LVN E should have assumed responsibility for Resident #41. LVN D stated, LVN E brought back Resident #41's medications to him and LVN D stated, no, the patient is over there. LVN D stated he did not want to confront LVN E and informed the ADON about the matter. LVN D stated, when Resident #41 fell , it was LVN E's patient. LVN D stated, CNA F came and told me Resident #41 fell (8/22/24). Me and CNA F helped her up, I did an assessment, checked for injuries and I saw the injury to the forehead and then told CNA F to go tell LVN E that the resident had fallen. I never talked to LVN E. LVN D further stated he felt he had done his part by checking the resident and getting her up off the floor. LVN D revealed, I did not document any of that. Now I feel like I should have documented that, because after talking with you (the State Surveyor) I should have documented what I did and what I saw. During an interview on 9/12/24 at 1:15 p.m., CNA F stated he was told by LVN E that Resident #41 was moved to their hall but was not their patient. CNA F stated he continued to make his usual rounds and included Resident #41. CNA F revealed he discovered Resident #41 on the floor and reported it to LVN D but was told by LVN D that the resident belonged to LVN E. CNA F stated, my thought was, we just need to get her up. CNA F stated LVN D went to the resident's room to investigate and LVN D helped him get the resident off the floor. CNA F stated LVN D asked Resident #41 what had happened, took her vital signs, and left. During an interview on 9/12/24 at 1:46 p.m., the ADON stated, Resident #41 had an unwitnessed fall on 8/22/24, LVN D made an initial assessment but did not document it. The ADON stated, everything is wrong with that. If LVN D was saying Resident #41 was not his patient, LVN D should have notified LVN E, and they should have assessed the resident together. Here nor there, if it's not documented, it didn't happen. 2. Review of Resident #32's quarterly MDS, dated [DATE] revealed she was admitted to the facility on [DATE] with diagnosis of Heart Failure. Review of Resident #32's assist rail/enabler evaluation, dated with admitted [DATE] was not signed or dated by the nurse who conducted the evaluation. Observation on 09/10/24 at 10:24 AM revealed Resident #32 was lying in bed with two side rails up. Interview on 9/13/24 at 4:11 PM with LVN A revealed the admitting nurse typically assessed residents for the use of side rails. Interview on 9/13/24 at 5:30 PM with the RN Consultant revealed the admitting nurse did not sign or date the side rail evaluation for Resident #32 making the evaluation invalid. She stated staff was to make sure all resident documents were completely filled out. 3. Review of Resident #45's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of Vascular Dementia unspecified. Further review revealed she had family members who were designated as emergency contacts. Review of Resident #45's consent for the use of side rails, dated 5/30/23, was not signed by a family member. Observation on 09/10/24 at 1:30 PM revealed Resident #45 was lying in bed with two side rails up. Interview on 9/13/24 at 4:11 PM with LVN A revealed the admitting nurse typically had the Resident's family member sign the consent for the use of side rails. Interview on 9/13/24 at 5:30 PM with the RN Consultant revealed the admitting nurse was responsible for ensuring the family member signed the consent for Resident's use of side rails otherwise the Resident could not use the side rails. The RN Consultant stated staff was to make sure all resident documents were accuarate and all areas were completed as required.

Based on interview and record review the facility failed to ensure each assessment must accurately reflect the resident's status for 2 of 13 Residents (Resident #27 and Resident #45) reviewed for accuracy of assessments. 1. MDS staff failed to ensure Resident #27's quarterly MDS, 6/10/24, reflected she had a range of motion impairment on her upper extremity. 2. MDS staff coded Resident #45's quarterly MDS assessment, dated 9/13/24, having a significant weight loss. Resident #45 did not experience a significant weight loss during the look back period. These deficient practicers could affect residents by inaccurately reflecting their status which could contribute to residents not receiving necessary care and services. The findings were: 1. Review of MDS history dating back to 2021 revealed Resident #27 had a history of ROM impairment on upper and lower extremity. Review of Resident #27's quarterly MDS, dated [DATE], revealed Resident #27 had ROM impairment to lower extremity and she received Occupational services. Review of Occupational Therapy note, dated 6/10/24, revealed Resident #27 had left-sided hemiplegia. Review of Resident #27's Care Plan, dated 2/26/23, revealed Resident #27 had left-sided hemiparesis related to CVA (Stroke). 2. Review of Resident #45's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of vascular Dementia unspecified. Review of Resident #45's quarterly MDS assessment, dated 9/13/24, revealed Resident #45 experienced a significant weight loss. Review of Resident #45's weights revealed on 6/14/24 she weighed 150 pounds and on 9/10/24 she weighed 157.80. Review of Resident #45's Care Plan, dated, 5/31/23, revealed K/0300.1 Weight loss; 5% or more in last 30 days (7/6/2023 -18.40 LBS); 9/12/23 Wt loss: Triggered for -28.5lbs/-14.59lbs x 90 days; 1/5/24- 153.20 continues with weight loss - 7.93 in 90 days; 3/8/24: (Resident #45) triggered for unintended weight loss of 7.60lbs/10.58% in 180 days. STATUS: Active (Current). Interview on 09/13/24 at 3:53 PM with LVN A revealed Resident #45's quarterly MDS assessment, dated 9/13/24, was coded for weight loss. LVN A stated in reviewing Resident #45's weights she gained weight from June 2024 to September 2024. She stated Resident 45's MDS assessment was inaccurate. She stated it was important to ensure it was accurate because it drove the Care Plan. The Care Plan was a tool nursing staff used to review the Resident's status. It guided them to provide the care and services Resident #45 needed. Interview on 09/13/24 at 4:00 PM with the ADON revealed Resident #45's MDS assessment was inaccurate. She stated assessments should be accurate as well as Care Plans because they provided nursing staff with a picture of Resident #45's status; needs. Inteview on 9/13/24 at 6:00 PM with the ADM revealed the facility did not have a policy which defined an inaccurate MDS. She stated MDS staff used the RAI as a guide for completing MDS assessments. 41651

Based on interview and record review the facility failed to ensure a registered nurse signed and certified the assessment was completed for 1 of 5 Residents (Resident #45) reviewed for assessment certification. An RN did not sign Resident #45's quarterly assessment when it was completed on 9/13/24. This deficient practice could affect any resident and result in the residents' assessment not being valid. The findings were: Review of Resident #45's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of vascular Dementia unspecified. Review of Resident #45's quarterly MDS assessment completed on 9/13/24 revealed the only staff who signed it was an LVN. An RN did not sign. Interview on 09/13/24 at 3:53 PM with LVN A revealed the most recent quarterly MDS assessment, dated 9/13/24, revealed an LVN signed it but according to RAI criteria an RN had to sign off on it because an LVN could not technically conduct a resident assessment. Interview on 9/13/24 at 4:00 PM with the ADON revealed she stated an RN had to sign off because an LVN could not technically conduct a resident assessment. Review of a facility policy, Comprehensive Assessments revised March 2020 read, Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals.

Based on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. The findings were: During a confidential group meeting on 09/12/2024 at11:00 a.m., members of the resident group stated that they do not receive mail on Saturdays and stated they feel this practice is disrespectful. During an interview with Receptionist G on 09/12/2024 at 4:24 p.m., Receptionist G stated she had been directed by person who hired her (no longer with facility) to place all mail received on Saturdays, including resident mail, in the Business Office Manager's (BOM) mailbox, and confirmed the BOM does not work on weekends. During an interview with the BOM on 09/12/2024 at 4:32 p.m., the BOM confirmed she does not work on weekends, stated all mail received on Saturday is left in her box by receptionist, she distributes to intended recipients, and gives resident mail to the Activity Director (AD) to distribute to residents on Mondays. During an interview with the AD on 09/13/2024 at 11:02 a.m., the AD confirmed that resident mail received on Saturdays is not given to residents until Monday because mail is received in the late afternoon after the weekend Manager on Duty has left for the day, and confirmed resident mail is left for her to distribute to residents on Mondays. During an interview with the Administrator on 09/13/2024 at 1:12 p.m., the Administrator confirmed that residents should receive their mail on Saturdays and stated that the facility practice would change to ensure resident mail is disbursed on the day it is received. Record review of the facility policy, Resident Rights, revised February 2021, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .cc. access to a telephone, mail, and email .

Based on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 1 of 5 Residents (Resident #45) whose records were reviewed. MDS Staff failed to ensure Resident #45's quarterly MDS assessment, dated 9/13/24m was completed within 120 days of the annual MDS assessment, dated 5/6/24 This deficient practice could affect any resident and result in resident's not receiving the needed services. The findings were: Review of Resident #45's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of vascular Dementia unspecified. Review of Resident #45's MDS history revealed she had an annual MDS assessment completed on 5/6/24 and then the following quarterly MDS assessment was not completed until 9/13/24; 130 days later. Interview on 09/13/24 at 03:53 PM with LVN A revealed the most recent quarterly MDS assessment was completed on 9/13/24. She stated the previous annual MDS assessment was completed on 5/19/24. LVN A stated they had 3 months to complete an assessment according to the MDS RAI. She further stated it was important to complete the assessments timely because they drove the resident Care Plan which identified the care and services each resident would receive based on their needs. Interview on 9/13/24 at 4 PM with the ADON revealed she stated each resident's assessment was due every 3 months; 120 days. The ADON also stated it was important for staff to assess the resident's functional capabilities timely because it drove the Care Plan and it identified the care and services the resident would receive. Review of a facility policy, Comprehensive Assessments revised March 2020 read, Comprehensive assessments are conducted to assist in developing person-centered care plans. 1. Comprehensive assessments are conducted in accordance with criteria and timeframe's established in the Resident Assessment Instrument (RAI) User Manual.

Based on observation, interview and record review the facility failed to ensure the interdisciplinary team reviewed and revised each resident's Care Plan after each assessment, including both the comprehensive and quarterly review assessments for 2 of 5 Residents (Resident #45 and Resident #70) whose records were reviewed. 1. MDS staff failed to revise Resident #45's Care Plan to reflect she did not experience significant weight loss. 2. MDS staff failed to revise Resident #70's Care Plan to reflect she used side rails for bed mobility. These deficient practices could contribute to residents not receiving the care and services as needed. The findings were: 1. Review of Resident #45's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnosis of vascular Dementia unspecified. Review of Resident #45's quarterly MDS assessment, dated 9/13/24, revealed Resident #45 experienced a significant weight loss. Review of Resident #45's weights revealed on 6/14/24 she weighed 150 pounds and on 9/10/24 she weighed 157.80 pounds. Review of Resident #45's CP revealed K/0300.1 Weight loss; 5% or more in last 30 days (7/6/2023 -18.40 LBS); 9/12/23 Wt loss: Triggered for -28.5 lbs/-14.59 lbs x 90 days; 1/5/24- 153.20 continues with weight loss - 7.93 in 90 days; 3/8/24: (Resident #45) triggered for unintended weight loss of 7.60 lbs/10.58% in 180 days. STATUS: Active (Current). Interview on 09/13/24 at 3:53 PM with LVN A revealed Resident #45's revealed the Care Plan, effective 5/31/24, was inaccurate and was not revised to reflect Resident #45 had not experienced significant weight loss. LVN A stated the Care Plan was a tool nursing staff used to review the Resident's status. It guided them when providing the care and services Resident #45 needed. Interview on 09/13/24 at 4:00 PM with the ADON revealed Resident #45's Care Plan, effective 5/31/24) was inaccurate. She stated Care Plans should be accurate because they provided nursing staff with a picture of Resident #45's status; care needs. 2. Review of Resident #70's face sheet, undated, revealed she was admitted to the facility on [DATE] with a diagnoses of Depression. Review of Resident #70's quarterly MDS, dated [DATE], revealed her BIMS was 15 reflecting she was alert and oriented. Review of Resident #70's physician's orders for September 2024 revealed an order for SR's for mobility and repositioning. Review of Resident #70's, effective 4/3/23, revealed did not include the use of side rails Observation and interview on 09/13/24 at 12:57 PM revealed Resident #70 sitting in bed eating lunch. The bed had two side rails up. Interview on 09/13/24 at 3:48 PM with LVN A revealed a Resident #70's Care Plan was not accurate because it did not reflect Resident #70's overall condition. Interview on 09/13/24 at 5:45 PM with the Corporate RN revealed Resident #70 used side rails while in bed. Review of a facility policy, Patient Care Management System 12, Assessments, read 6. Each Care Plan must be reviewed and updated by the interdisciplinary Care Plan team quarterly, upon each change in condition and upon re-admission.

Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 1 medication aide medication cart, reviewed for security. The nurse medication cart was unattended and unlocked. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: During an observation and interview on 08/21/2024 at 11:55 AM, revealed the facility's nurses' medication cart was unattended, and unlocked. The medication cart was observed to be parked in the middle of the hall away from the nurse's station. Further observation revealed no nursing staff in the immediate area and observed LVN A seated at the nurse's station. The surveyor alerted LVN A to the unlocked nurse medication cart parked in the middle of the hall unsupervised and unattended. LVN A stated the cart was the nurse medication cart, was unlocked, unsupervised and unattended. LVN A stated the cart was assigned to LVN B who was not in the vicinity and LVN A did not know her whereabouts. LVN A stated the cart should be locked when not attended. LVN A stated the cart had residents' medications which included injectable, controlled narcotics, and oral medications. During an interview on 08/21/2024 at 03:02 PM the ADON stated all medications should be stored in locked compartments, narcotic medications should be under a double lock, and the keys should be in the possession of the nurse. The ADON stated an unlocked medication cart could place residents at risk for residents not receiving the therapeutic effects of their medications and or loss of control of their property. A record review of the facility's Medication Labeling and Storage policy dated February 2023 revealed, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation Medication Storage . 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . Controlled substances (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to maintain the cleanliness of the juice dispensers found within the kitchen. 3. The facility failed to remove expired and past dated items from the dry food storage. 4. The facility failed to complete daily temperature logs of reach-in refrigerators and freezers found within the kitchen and nourishment room. 5. The facility failed to ensure the chemical dishwasher operated at or above 120 degrees Fahrenheit. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on [DATE] beginning at 9:02 AM revealed the following: The walk-in refrigerator to have recorded temperatures ranging from 39 degrees to 46 degrees for the month of August. The ice maker within the kitchen was revealed to have a black substance built up inside the unit. The juice dispenser to have encrusted red and orange mass build up on and adjacent to the dispensing spout. The chemical dishwasher to have recorded temperatures ranging from 107 - 122 during the wash cycle and 115 - 123 during the rinse cycle. Interview on [DATE] at 9:34 AM, the DM stated the kitchen staff was responsible for emptying and cleaning out the ice maker every 3 months by draining and emptying the ice maker and cleaning it from the inside. She stated the MS had just cleaned the ice maker within the last few weeks. The DM stated he did not notice the black substance build-up and could not identify what it was. The DM stated the ice maker should be cleaned and would contact his MS to have it partially disassembled to remove the black substance build up as the substance could cause foodborne illness in residents who consume ice from the ice maker. The DM stated the staff who enter the kitchen in the morning are responsible for completing the temperature logs for all fridges and freezers, in addition to reporting to herself and the MS if the fridges or freezers are reaching high temperatures. The DM stated the expected protocol when staff are recording temperatures out of expected scope for any major appliance are to report them to himself and the maintenance supervisor. The DM stated the risks associated with these failures was a potential for foodborne illness in residents. The DM stated the nourishment rooms are not the responsibility of the dietary department. Observation on [DATE] at 11:02 AM revealed the following items within the dry food storage: (1) Unit of crackers best by dated [DATE] (2) Units of key lime flavoring sauce best by dated [DATE] & [DATE] (1) Unit of white chocolate sauce best by dated [DATE] (1) Unit of chocolate sauce best by dated [DATE] (3) Units of thickened cranberry juice use by dated [DATE] Interview on [DATE] at 11:14 AM, the DM stated he was unaware of the past dated items within the dry food storage and expects all of his staff who enter the dry food storage to remove any items past dated. He stated he does not complete a routine audit of the dry food storage. The DM stated his policy for best by dated items is to treat them the same as use by items and to dispose of them upon reaching the listed date. The DM stated the risk associated with failing to remove expired items would be a potential for foodborne illness. Observation on [DATE] at 1:48 PM, Nourishment Room A was revealed to have a temperature log with temperatures ranging from 32 to 46 degrees Fahrenheit. The ice maker within Nourishment Room A was revealed to also contain a black substance build up within the unit. Observation on [DATE] at 4:07 PM, Nourishment Room B was revealed to have a temperature recording of 44 degrees Fahrenheit on [DATE] and [DATE] with a current internal temperature of 50 degrees Fahrenheit. Interview on [DATE] at 4:43 PM, the MS stated he was not aware of the black substance build up of the ice makers within the kitchen or the nourishment rooms and had planned to have a vendor come to service the units as they had never received a service [NAME] to this before. The MS stated the refrigerators and respective logbooks detailing high temperatures have never been reported to him historically. The MS stated the low temperatures of the chemical dishwasher within the kitchen have never been reported to him. Interview on [DATE] at 4:57 PM, the ADM stated she was unaware of the concerns identified within the kitchen and nourishment rooms and stated it is her expectation that the dietary department report concerns and temperatures outside of expected ranges to the MS. The ADM stated the responsibility of the nourishment rooms to be the nursing department however she believes there was a confusion of this distinction to the nursing department as there had been administration changes recently and new staff. Record review of the facility nutritional policy titled Refrigerator/Freezer Temperature log, undated, reflected Person assigned or DSM must record temperature for each refrigerator and freezer and sign in column provided . take temperatures at same time every morning (AM) and evening (PM). The morning reaching should preferably be taken upon opening the department. Record review of the facility nutritional policy titled Cleaning of the Ice Machine, undated, reflected The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Record review of the facility nutritional policy titled Food Storage and Supplies, undated, reflected All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects . Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and ,d+[DATE].11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part ,d+[DATE] of this Code and SANITIZED as specified under Part ,d+[DATE] of this Code; P (B) Single-service and single-use articles.

Based on observation, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 2 of 3 residents (Resident #50 and #62) reviewed for oxygen therapy in that: 1. Resident #50's oxygen concentrator filter was covered in a thick white substance. 2. Resident #62's oxygen was provided oxygen inconsistent with the physician's order. These failures could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery. The findings included: 1. Record review of Resident #50's face sheet, dated 8/16/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cerebral infarct (a stroke, a disrupted blood flow to the brain due to problems with the blood vessels that supply it), acute and chronic respiratory failure with hypoxia (not enough oxygen in your blood, but your levels of carbon dioxide are close to normal, mild intermittent asthma (a respiratory condition marked by spasms in the lungs causing difficulty in breathing), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), wheezing (breathing with a whistling or rattling sound in the chest caused by partially blocked airway), need for assistance with personal care, tracheostomy status (incision in the windpipe made to relieve an obstruction to breathing and may be used to deliver oxygen to the lung) and respiratory disorders. Record review of Resident #50's most recent quarterly MDS assessment, dated 6/13/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and required oxygen therapy. Record review of Resident #50's comprehensive care plan, effective date 2/23/23 revealed the resident had a tracheostomy and was at risk for increased secretions/congestion and infections with interventions that included to provide oxygen per orders. Further review of Resident #50's comprehensive care plan revealed the resident was unable to maintain oxygen saturation and received oxygen at 8 liters per minute via a trach collar. Record review of Resident #50's Physician Order Sheet, dated 8/17/23 revealed the following: -Oxygen at 8 liters per minute, oxygen administered via trach collar by shift, with order date 4/14/23 and no end date. Observation on 8/15/23 at 9:19 a.m. revealed Resident #50 in bed with the oxygen concentrator operating via trach collar at 8 liters per minute. Further observation revealed Resident #50 had two oxygen filters, one on the left of the concentrator and one on the right, both covered in a thick white substance. Observation on 8/16/23 at 10:14 a.m. revealed Resident #50 in bed with the oxygen concentrator operating via trach collar at 8 liters per minute. The filters on the left and right side of the oxygen concentrator were covered in a thick white substance. Observation on 8/17/23 at 10:37 a.m. revealed Resident #50 in bed with the oxygen concentrator operating via trach collar at 8 liters per minute. The filter on the left of the oxygen concentrator was black and no longer covered in a thick white substance. The filter on the right of the concentrator was covered in a thick white substance. During an observation and interview on 8/17/23 at 10:38 a.m., LVN B revealed Resident #50 required continuous oxygen therapy and further revealed the facility nursing staff were responsible for ensuring the filters on the oxygen concentrator were cleaned as needed. LVN B revealed Resident #50's oxygen concentrator had only one filter and had cleaned the oxygen filter on the left of the concentrator. LVN B revealed, after observing the oxygen concentrator filter on the right, he was not aware the oxygen concentrator had two filters. LVN B removed the filter on the right of the oxygen concentrator and stated, it's dirty, it looks like dust. LVN B revealed the oxygen concentrator filters needed to be cleaned by nursing staff because it could cause the resident to have respiratory problems. During an observation and interview on 8/17/23 at 4:18 p.m., the DON stated, when the (oxygen) concentrator has 10 or more liters, it has two filters, but most staff didn't know that, and I learned that through trial and error. The DON stated all facility nurses were responsible for checking the filters, but mostly the nurse managers when doing their daily rounds. The DON, after observing a photo of the oxygen concentrator filter used by Resident #50 stated, it looks like bad, cheap carpet. The DON revealed, a dirty oxygen concentrator filter could impede the resident's breathing or cause a respiratory issue. 2. Record review of Resident #62's face sheet, dated 8/18/23 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included Chronic obstructive pulmonary disease with (acute) lower respiratory infection. Record review of Resident #62's most recent quarterly MDS assessment, dated 8/18/23 reflected the resident was moderately impaired for daily decision-making skills. Record review of Resident #62's physician order referring to oxygen, dated 4/26/23 reflected Oxygen (O2) at 2 L/min per nasal cannula. Record review of Resident #62's comprehensive person-centered care plan, dated 8/16/23, reflected only areas related to: pressure ulcer development, current skin conditions, and advanced directive code status without any indication of oxygen therapy or any other area of care. Interview and observation on 8/16/23 at 4:59 p.m., Resident #62 was revealed to be receiving oxygen via nasal cannula at three liters per minute. Resident #62 stated, I don't change my oxygen, I feel okay but I can't get out of bed or change it even if I wanted to Interview and observation on 8/18/23 at 9:21 AM revealed Resident #62 to be receiving oxygen via three liters per minute via nasal cannula. Resident #62 stated she did not change the oxygen level and the nurses are the only ones who do it. Interview on 8/18/23 at 9:27 AM, RN D stated resident's physician orders are followed exactly however when related to respiratory care, a resident assessment by nursing would trigger for the order to be requested to be updated to change the oxygen volume. RN D stated she observed Resident #62's oxygen to be currently at three liters per minute and stated Resident #62 to be normally needing this amount of oxygen. RN D stated the expected protocol when this occurred was to communicate with the physician to be the correct volume and to have had the physician update the order. Interview on 8/18/23 at 3:52 PM, the DON stated the nursing staff were expected to contact the physician to update the physician order based on the assessment of respiratory needs. Interview on 8/18/23 at 4:49 PM, the ADM stated it is her expectation that nursing staff communicate and inform the physician if respiratory care requirements for residents change and thus submit an order change. Record review of the facility policy and procedure titled, Protocol for Oxygen Administration, updated March 2019 revealed in part, .Oxygen concentrator filters will be assessed for cleanliness . 45307

Based on observation, interview, and record review the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #18) reviewed for feeding tubes. The facility failed to ensure LVN A properly administered crushed medications into Resident #18's feeding tube. This failure could place residents who received medications via a feeding tube at risk for medical complications or a decline in health. The findings included: Record review of Resident #18's face sheet, dated 8/16/23 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, need for assistance with personal care, enterocolitis (inflammation that occurs throughout the intestines) due to clostridium difficile (bacterial infection) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #18's most recent quarterly MDS assessment, dated 5/6/23 revealed the resident was severely cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #18's comprehensive care plan, effective date 2/22/23 revealed the resident received tube feedings with the goal to receive adequate nutrition without side effects associated with tube feedings. Record review of Resident #18's Physician Order Sheet, dated 8/17/23 revealed the following: 1. Crush Medications before administering through G-tube (feeding tube) by shift, with order date 2/24/23 and no end date 2. Flush G-Tube (feeding tube) with 50 cc water before and after medication administration by shift, with order date 4/25/23 and no end date 3. Pramipexole 0.5 mg tablet g-tube one time daily for Parkinson's disease with order date 3/1/23 and no end date 4. Ropinirole 0.25 mg tablet enteral tube three times daily for Parkinson's disease with order date 3/1/23 and no end date 5. Carbidopa 25 mg-levodopa 250 mg tablet g-tube three times daily for Parkinson's disease with order date 3/1/23 and no end date 6. Cranberry extract 425 mg capsule, 2 capsules g-tube one time daily for disorders of urinary system with order date 3/1/23 and no end date 7. Multivitamin with minerals tablet, 1 tablet enteral tube one time daily for nutritional deficiency with order date 3/1/23 and no end date 8. Vitamin C 500 mg tablet enteral tube two times daily for nutritional deficiency with order date 3/1/23 and no end date 9. Levetiracetam 100 mg/ml oral solution for seizures, 10 ml g-tube two times daily with order date 3/1/23 and no end date 10. Lorazepam 0.5 mg tablet (0.25 ml = 0.5 mg) g-tube for seizures every 8 hours with order date 7/30/23 and no end date Observation on 8/16/23 at 7:28 a.m., during the medication pass, LVN A removed 7 pills/capsules from the blister packs and from stock bottles for Resident #18 and placed them into one medication cup. LVN poured a liquid medication into a separate medication cup. LVN A then took the pills/capsules from the cup and crushed each pill individually but poured multiple medications into the same cup. LVN A had 3 medication cups that contained 1 liquid medication and 2 cups with the remainder 7 crushed pills/capsules mixed together. LVN A then administered 30 cc of water to Resident #18's feeding tube before administering the first cup of medication and then flushed each medication with 10 to 15 cc of water between the remaining cups of medication. LVN A then administered approximately 30 cc of water to Resident #18's feeding tube after medication administration. During an interview on 8/16/23 at 1:48 p.m., LVN A revealed she was nervous and stated, I don't know why I mixed the medications together, I don't know why I did that. LVN A revealed the medications administered to Resident #18 had to be administered through the feeding tube one medication at a time but did not know the actual reason why other than it was facility protocol. LVN A then stated, I'm gonna say that mixing the medications while administering during peg (feeding tube) is probably not safe for the resident. During an interview on 8/16/23 at 4:52 p.m., the DON revealed she believed it was ok to cocktail the medications, but best practice was to put each medication in a separate cup. The DON revealed, separating and flushing each medication separately won't plug the feeding tube and maybe because the medications would not dissolve well or medications could interactive with other medications. Record review of LVN A's competency training titled, Medication Administration Through a Feeding Tube, dated 7/27/23 revealed LVN A had satisfied the requirements for administering medications through a feeding tube. Further review of the competency training revealed in part: -3. Dilute liquid medication and crush/dilute tablets .Never mix different liquid medications together -Prepare medications individually for administration -4. Dilute liquid medications with 10-30 cc of water and dissolve or suspend crushed medications in 5-10 cc of water -9. Administer medications, flushing with 5-10 cc (or per physician's orders) of warm water between each medication Record review of the facility policy and procedure, titled Medication Administration Through a Feeding Tube, updated March 2019 revealed in part, .Purpose .To provide a route for accurate and timely medication administration for a Patient who cannot or should not take medications orally .If tablets are crushed, crush to a fine powder and dissolve in water .Prepare medications individually for administration .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents for 1 of 5 residents (#5) whose care was reviewed for accidents and hazards in that: LVN B provided coffee to Resident #5 in a water pitcher while he appeared sedated and Resident #5 sustained second-[MEDICAL CONDITION] the coffee. This deficient practice could place residents at risk for serious injuries and burns. The findings were: Record review of Resident #5's face sheet, dated 12/8/2020, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #5's progress note dated 12/7/2020 revealed Late entry: On 12/6/2020 at 7:00 a.m. resident appeared to be in a sedated state, asked for a cup of coffee in one of his pitchers before closing eyes and snoring again, resident was given coffee and warned that the coffee was hot and to let it cool down before drinking. At 7:30 a.m. Resident #5 called for help and upon entering the room coffee was seen all over resident and resident's bed. Review of Resident #5's progress note dated 12/7/2020 revealed the NP classified [MEDICAL CONDITION] the left top thigh, inner thigh, and right inner thigh as second degree burns. Review of Resident #5's wound assessment dated [DATE] revealed the left inner thigh burn measured 1 cm x 2 cm, the left top thigh burn measured 8 cm x 6 cm, and his right inner thigh burn measured 0.7 cm x 1 cm. Observation of Resident #5'[MEDICAL CONDITION] 12/8/2020 at 1:46 p.m. with the Treatment Nurse revealed redness and blisters corresponding to the wound assessment that was dated 12/07/2020. Interview on 12/8/2020 at 1:46 p.m. Resident #5 stated he was about to eat breakfast and when he reached for his food his pinky got caught on the pitcher with coffee and it spilled on him. Interview on 12/8/2020 at 2:04 p.m. LVN B stated Resident #5 asked for coffee in one of his pitchers and noticed he appeared to be sedated. LVN B left the room and returned with the coffee and told him it was hot and not to drink it yet. LVN B stated she heard a call for help a little later and when she walked into Resident #5's room noticed he had coffee spilt everywhere. LVN B confirmed she did not report the incident to the DON. Interview on 12/8/2020 at 3:07 p.m. the Administrator stated LVN B should not have put hot coffee in the water pitcher for Resident #5. Review of an article in PubMed.gov read as follows: Format: Abstract Burns. 2008 Aug;34(5):648-54. doi: 10.1016/j.burns.2007.09.012. Epub 2008 [DATE]. Calculating the optimum temperature for serving hot beverages. Brown F, Diller KR. Hot beverages such as tea, hot chocolate, and coffee are frequently served at temperatures between 160 degrees F (71.1 degrees C) and 185 degrees F (85 degrees C). Brief exposures to liquids in this temperature range can cause significant scald burns. However, hot beverages must be served at a temperature that is high enough to provide a satisfactory sensation to the consumer. This paper presents an analysis to quantify hot beverage temperatures that balance limiting the potential scald burn hazard and maintaining an acceptable perception of adequate product warmth. Recent data from the literature defines the consumer preferred drinking temperature of coffee. A metric accommodates the thermal effects of both scald hazard and product taste to identify an optimal recommended serving temperature. The preferred drinking temperature of coffee is specified in the literature as 140+/-15 degrees F (60+/-8.3 degrees C) for a population of 300 subjects. A linear (with respect to temperature) figure of merit merged the two effects to identify an optimal drinking temperature of approximately 136 degrees F (57.8 degrees C). The analysis points to a reduction in the presently recommended serving temperature of coffee to achieve the combined result of reducing the scald burn hazard and improving customer satisfaction.

Based on observation, interview and record review, the facility failed to ensure adequate supervision to prevent accidents for 1 of 5 residents (Resident #4) whose care was reviewed for accidents in that: 1. The facility failed to ensure a newly hired CNA was oriented on proper transfer for each resident resulting in resident #4 being transferred without a gait belt and dropped which resulted in two fractured femurs and a fractured right hip. 2. The staff did not know the signs and symptoms of AD or how to properly respond and did not assess Resident #3 for pain and noxious stimuli that could result in AD. An Immediate Jeopardy situation was identified on 5/25/17. The Immediate Jeopardy was removed on 05/30/17. The facility remained out of compliance at a scope of wide spread and severity at actual harm due to the facility's need to monitor and evaluate the effectiveness on the plan of Removal. This deficient practice could affect the 33 residents who required assistance with transfers and 2 residents with the [DIAGNOSES REDACTED]. The findings were: 1. Review of Resident #4's face sheet dated 5/18/17 revealed the resident was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS of 3 which indicated severe cognitive impairment. The MDS further revealed in section G, Functional Status, that the resident required assistance from two+ persons for transfers. Review of the Care Plan updated on 5/11/17 revealed she was at risk for falls related to poor balance and vision. The goal was for the resident to demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 days. The interventions were to keep areas free of obstructions, place call light within easy reach, remind the resident to call for assistance before moving from bed to chair and from chair to bed, respond promptly to calls for assistance to the toilet, footwear will fit properly and have non-skid soles, and provide reminders to use ambulation and transfer assist devices. Review of Resident #4's comprehensive plan of care review date of 10/25/2016, revealed the care plan did not address her need for transfers. Interview on 5/25/17 at 2:00 p.m. with LVN I revealed that Resident #4's care plan did not address her transfer status or assistance with ADL's and she did not know why. She stated that Resident #4's care plan needed to be transfer with 1-2 person and gait belt. Review of Resident #4's CNA assignment sheet provided on 5/18/17 revealed she was assist x1 with gaitbelt. Review of the incident report dated 5/11/17 revealed Resident # 4 stated the CNA was transferring the resident to the wheelchair and the resident started to slide off the front of the wheelchair. Review of the radiology report dated 5/11/17 revealed a fracture of the right femoral neck. Review of medical records from local hospital revealed bilateral distal femur fractures and right proximal hip fracture. Observation on 5/18/17 at 11:25 a.m. at a local hospital with the resident's licensed nurse revealed resident #4 receiving IV Tylenol, a nasal gastric tube in place, 3-4+ edema on her feet and left arm and 3 red, 1 inch scratches on her mid-spinal cord. The licensed nurse confirmed resident #4 had two fractured femurs and had surgery on both. Interview on 5/18/17 at 4:50 p.m. with CNA A revealed she was helping resident #4's roommate up and decided to help resident #4 up for breakfast. She revealed this was her first day on her own and she had never worked with resident #4 before. She further revealed she was unaware if resident #4 required a 1 or 2 person assist for transfer nor did she go find out. CNA A confirmed she did not use a gait belt and bear hugged resident #4. She revealed the resident lost her footing and both she and the resident fell to the floor forward. When resident #4 came down she hit both her knees. CNA A leaned the resident against the wheelchair and straightened out her legs. CNA A got the attention of a MA who had the charge nurse come assess the resident. CNA A stated after LVN B performed his assessment they both transferred resident #4 to the wheelchair without using a gait belt and lifted her under her arms. After breakfast, CNA A took resident to the café across from the nurses' station. Resident #4 complained of pain and CNA A revealed LVN B instructed her to take the resident to her room, put her in bed and to perform an assessment. CNA A further revealed during her assessment of the resident she found resident #4's right leg crooked and notified LVN B. Interview on 5/18/17 at 5:20 p.m. with LVN B revealed he was notified by the MA that there was a fall. He further revealed he went to resident #4's room and found her sitting on the floor leaning against her wheelchair with both legs to her left side. He revealed he performed his assessment and then assisted CNA A with transferring resident #4 back into her wheelchair. He confirmed during the transfer a gait belt was not used and they lifted the resident up under her arms. After breakfast, CNA A notified him that the resident was in bed, in pain and there was swelling to her right knee. Interview on 5/18/17 at 5:40 p.m. with the ADON revealed she fed resident #4 at breakfast and the resident did not eat well. She further revealed resident #4 told her (ADON) that her legs hurt. The ADON instructed CNA A to take the resident to the charge nurse for pain medication. The ADON revealed after breakfast, she went to check on the resident and found her lying in her bed in extreme pain. The ADON further revealed it was then she learned resident #4 had a fall earlier that morning. An x-ray of resident #4's right side was taken which revealed a fractured femur. The ADON revealed the mobile x-ray was unable to do the left side at the time because the resident was in a lot of pain. Interview on 5/18/17 at 6:05 p.m. with the Staffing Coordinator revealed CNA A was a new hire as of 5/2/17. She further revealed CNA A oriented on the floor on 5/3 and 5/4/17 and then was on her own starting 5/4/17. She revealed the facility uses a Partner in Excellence Program and had received feedback that CNA A had done well. On day 5 of an employee's day of work a skills check is done. The Staffing Coordinator revealed that CNA A had not had her skills check done because of the facility's full book survey. Review of staff daily sign in sheets revealed CNA A oriented on 5/3/17 and 5/4/17 and then worked alone on 5/8/17, 5/9/17, 5/10/17, and 5/11/17. 2. Record review of Resident #3's face sheet dated 5/10/17, revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Admission history and physical dated 2/20/17 and signed by the Medical Director included the [DIAGNOSES REDACTED]. Definition of Autonomic Dysreflexia: Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.-The Institute for Spinal Cord Injury. Record review of Resident #3's 5 day MDS dated [DATE] for Resident #3 revealed a BIMS score of 15 which indicated the resident to be cognitively intact. The MDS further revealed Resident #3 to be totally dependent on staff for care. Observation of Resident #3 on 5/9/17 at 9:04 a.m. revealed the resident had his clothing changed because it was saturated in sweat. Observation on 5/9/17 at 2:47 p.m. further revealed the resident with a towel wrapped around his neck because he was sweating profusely. The resident called for staff LVN E, and told her he is very sweaty and asks that his blood pressure be taken. Interview with Resident #3 on 5/10/17 at 9:22 a.m. revealed that resident does not feel good. He stated that the staff did not listen to his needs. He stated that he tried to tell them about his Dysreflexia but the staff didn't listen and it made him anxious. Resident #3 stated he knew his body and when it didn't feel well he will ask them to check his bladder and catheter or give him a suppository in hopes that it would relieve the pain he cannot physically feel. He further revealed that he sometimes got very frustrated and angry that the staff didn't listen. Interview with LVN E on 5/9/17 at 3:10 p.m. revealed that resident #3 was very needy.' She confirmed that staff members sometimes ignore his calls because of his constant anxiety and neediness. LVN E stateed she did not have training in treating residents with AD. Interview on 5/9/17 at 3:21 p.m. with LVN E, ADON G, and DON revealed that they did not know what AD means, they did not know the signs and symptoms of AD or how to properly respond to a resident with a spinal cord injury who was having symptoms of AD. Interview with DON on 5/10/17 at 4:07 p.m. revealed that staff caring for Resident #3 should be aware of his history and physical including Autonomic Dysreflexia, effective assessment and management of pain that could trigger AD, and staff should know how to respond appropriately to the symptoms including sweating, increase in BP, and requests for pain management. Interview on 5/25/17 at 1:00 p.m. with CNA T who was assigned Resident #3 for the day shift revealed that Resident #3 required total care, a two person mechanical transfer, and seemed really anxious, and sweats a lot. She said that she did not know anything about AD. Interview on 5/25/17 at 1:15 p.m. with LVN H who was assigned Resident #3 for the day shift revealed that she had heard about autonomic Dysreflexia and was able to describe some of the triggers, but did not know that Resident #3 had it as a diagnosis, and that his pressure sores which he had could be considered a trigger. She described Resident #3 as very demanding. LVN H was not aware that the Midodrine (used to lower BP) 5mg tab for Resident #3 was ordered for his AD. Review of the facility's Abuse Protocol dated 11/16 revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator, Corporate Nurse and the ADON were notified on 5/25/17 at 3:09 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 05/25/17 at 4:30 pm and included: Proper Transfer of Patients using Gait Belt a. Nursing staff was in-serviced with a return demonstration completed on 05/25/17 on proper transfer of patients using gait belt. Nursing staff unavailable for the in service will not be allowed to work until such in-services have been given. b. The facility conducted an audit on 05/25/17 of all patients that require assistance with transfers. ADL Care Guide and care plan were audited for transfer status accuracy. c. Routine monitoring of nursing staff to ensure gait belts are accessible and utilized properly. d. New staff members will be in-serviced on transfers and use of gait belt by the Rehabilitation Manager and /or designee before the staff is assigned to provide care for patients. On 5/30/17 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 7 CNAs, 5 LVNs, and 2 RNs were interviewed and said they were trained on 1 and 2 person transfers, 17 had returned transfer demonstration. The above staff also indicated they knew to use a gait belt for transfers and knew where to find how many staff a resident needed to transfer with. An In-Service, dated 5/25/17, concerning transfers techniques was reviewed and contained the names of 107 staff who attended. Five transfers with gait belt were observed and staff used appropriate technique and followed resident's plan of care for type of transfer. On 5/30/17 at 4:00 p.m. the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at scope of isolated and severity potential of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Management of Patients with Autonomic Dysreflexia a. Nursing staff were in-serviced and competency exams completed on 05/25/17 on the [DIAGNOSES REDACTED]. Nursing staff unavailable for the in service will not be allowed to work until such in-services and competency exams have been given. b. The patients identified by the survey team as having a [DIAGNOSES REDACTED]. c. The facility conducted an audit on 05/25/17 of patients with a [DIAGNOSES REDACTED]. d. Any signs, symptoms and treatment of [REDACTED]. e. New staff members will be in-serviced on the [DIAGNOSES REDACTED]. An identifier for the [DIAGNOSES REDACTED]. On 5/28/17 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 7 CNAs, 5 LVNs, and 2 RNs were interviewed and said they were trained on AD. Seven CNAs, 5 LVNs, and 2 RNs could identified the symptoms of AD and could identify the appropriate response. An In-Service, dated 5/25/17 concerning AD and how to respond appropriately was reviewed and contained the names of 70 staff who attended. Information provided by the facility on 6/9/17 revealed 33 residents require assistance with transfer at the facility. Information provided by the facility on 5/917 revealed that 2 patients had [DIAGNOSES REDACTED].

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, for, 1 of 2 residents (#3) with [DIAGNOSES REDACTED]. 1. The facility did not assess Resident #3 for pain and noxious stimuli that could result in AD. 2. The staff did not know the signs and symptoms of AD or how to properly respond. An Immediate Jeopardy situation was identified on 5/25/17. The Immediate Jeopardy was removed on 5/28/17. The facility remained out of compliance at a scope of isolated, and severity at potential for minimal harm because the facility had not had time to monitor and evaluate the effectiveness of the plan of Removal. This deficient practice placed 1 of 2 residents who had [DIAGNOSES REDACTED]. The findings were: Record review of Resident #3's face sheet dated 5/10/17, revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Admission history and physical dated 2/20/17 and signed by the Medical Director included the [DIAGNOSES REDACTED]. Definition of Autonomic Dysreflexia: Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.-The Institute for Spinal Cord Injury. Record review of Resident #3's 5 day MDS dated [DATE] for Resident #3 revealed a BIMS score of 15 which indicated the resident to be cognitively intact. The MDS further revealed Resident #3 to be totally dependent on staff for care. Observation of Resident #3 on 5/9/17 at 9:04 a.m. revealed the resident had his clothing changed because it was saturated in sweat. Observation on 5/9/17 at 2:47 p.m. further revealed the resident with a towel wrapped around his neck because he was sweating profusely. The resident called for staff LVN E, and told her he is very sweaty and asks that his blood pressure be taken. Interview with Resident #3 on 5/10/17 at 9:22 a.m. revealed that resident does not feel good. He stated that the staff did not listen to his needs. He stated that he tried to tell them about his Dysreflexia but the staff didn't listen and it made him anxious. Resident #3 stated he knew his body and when it didn't feel well he will ask them to check his bladder and catheter or give him a suppository in hopes that it would relieve the pain he cannot physically feel. He further revealed that he sometimes got very frustrated and angry that the staff didn't listen. Interview with LVN E on 5/9/17 at 3:10 p.m. revealed that resident #3 was very needy.' She confirmed that staff members sometimes ignore his calls because of his constant anxiety and neediness. LVN E stateed she did not have training in treating residents with AD. Interview on 5/9/17 at 3:21 p.m. with LVN E, ADON G, and DON revealed they did not know what AD means, they did not know the signs and symptoms of AD or how to properly respond to a resident with a spinal cord injury who was having symptoms of AD. Interview with DON on 5/10/17 at 4:07 p.m. revealed that staff caring for Resident #3 should be aware of his history and physical including Autonomic Dysreflexia, effective assessment and management of pain that could trigger AD, and staff should know how to respond appropriately to the symptoms including sweating, increase in BP, and requests for pain management. Interview on 5/25/17 at 1:00 p.m. with CNA T who was assigned Resident #3 for the day shift revealed that Resident #3 required total care, a two person mechanical transfer, and seemed really anxious, and sweats a lot. She said that she did not know anything about AD. Interview on 5/25/17 at 1:15 p.m. with LVN H who was assigned Resident #3 for the day shift revealed that she had heard about autonomic Dysreflexia and was able to describe some of the triggers, but did not know that Resident #3 had it as a diagnosis, and that his pressure sores which he had could be considered a trigger. She described Resident #3 as very demanding. LVN H was not aware that the [MEDICATION NAME] (used to lower BP) 5mg tab for Resident #3 was ordered for his AD. Record review of the staff inservice sheet dated 5/10/17 and 5/11/17 for Nurses and Certified Nursing Assistants for Spinal Cord Injury and AD in Spinal Cord Injury revealed that CNA T signed that she attended the 30 minute training. The Administrator, Corporate Nurse and the ADON were notified on 5/25/17 at 3:09 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 05/25/17 at 4:30 p.m. and included: Management of Patients with Autonomic Dysreflexia a. Nursing staff were in-serviced and competency exams completed on 05/25/17 on the [DIAGNOSES REDACTED]. Nursing staff unavailable for the in service will not be allowed to work until such in-services and competency exams have been given. b. The patients identified by the survey team as having a [DIAGNOSES REDACTED]. c. The facility conducted an audit on 05/25/17 of patients with a [DIAGNOSES REDACTED]. d. Any signs, symptoms and treatment of [REDACTED]. e. New staff members will be in-serviced on the [DIAGNOSES REDACTED]. An identifier for the [DIAGNOSES REDACTED]. On 5/28/17 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 7 CNAs, 5 LVNs, and 2 RNs were interviewed and said they were trained on AD. Seven CNAs, 5 LVNs, and 2 RNs could identified the symptoms of AD and could identify the appropriate response. An In-Service, dated 5/25/17 concerning AD and how to respond appropriately was reviewed and contained the names of 70 staff who attended. On 5/28/17 the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern at actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Information provided by the facility revealed that 2 patients had [DIAGNOSES REDACTED].

Based on interviews, observation and record reviews, the facility failed to implement the facility's written policies and procedures that prohibit neglect of residents for 2 of 5 residents reviewed for neglect (residents # 3 and #4) in that:: 1. The facility failed to ensure a newly hired CNA was oriented on proper transfer for each resident resulting in resident #4 being transferred without a gait belt and dropped which resulted in two fractured femurs and a fractured right hip. 2. The staff did not know the signs and symptoms of AD or how to properly respond and did not assess Resident #3 for pain and noxious stimuli that could result in AD. An Immediate Jeopardy situation was identified on 5/25/17. The Immediate Jeopardy was removed on 05/28/17. The facility remained out of compliance at a scope of wide spread and severity at actual harm due to the facility's need to monitor and evaluate the effectiveness on the plan of Removal. This deficient practice could affect the 33 residents who required assistance with transfers and 2 residents with the [DIAGNOSES REDACTED]. The findings were: 1. Review of the facility's Abuse Protocol dated 11/16 revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident #4's face sheet dated 5/18/17 revealed the resident was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS of 3 which indicated severe cognitive impairment. The MDS further revealed in section G, Functional Status, that the resident required assistance from two+ persons for transfers. Review of the Care Plan updated on 5/11/17 revealed she was at risk for falls related to poor balance and vision. The goal was for the resident to demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 days. The interventions were to keep areas free of obstructions, place call light within easy reach, remind the resident to call for assistance before moving from bed to chair and from chair to bed, respond promptly to calls for assistance to the toilet, footwear will fit properly and have non-skid soles, and provide reminders to use ambulation and transfer assist devices. Review of Resident #4's comprehensive plan of care review date of 10/25/2016, revealed the care plan did not address her need for transfers. Interview on 5/25/17 at 2:00 p.m. with LVN I revealed that Resident #4's care plan did not address her transfer status or assistance with ADL's and she did not know why. She stated that Resident #4's care plan needed to be transfer with 1-2 person and gait belt. Review of Resident #4's CNA assignment sheet provided on 5/18/17 revealed she was assist x1 with gaitbelt. Review of the incident report dated 5/11/17 revealed Resident # 4 stated the CNA was transferring the resident to the wheelchair and the resident started to slide off the front of the wheelchair. Review of the radiology report dated 5/11/17 revealed a [MEDICAL CONDITION] femoral neck. Review of medical records from local hospital revealed bilateral distal femur fractures and right proximal [MEDICAL CONDITION]. Observation on 5/18/17 at 11:25 a.m. at a local hospital with the resident's licensed nurse revealed resident #4 receiving IV Tylenol, a nasal gastric tube in place, 3-4+ [MEDICAL CONDITION] on her feet and left arm and 3 red, 1 inch scratches on her mid-spinal cord. The licensed nurse confirmed resident #4 had two fractured femurs and had surgery on both. Interview on 5/18/17 at 4:50 p.m. with CNA A revealed she was helping resident #4's roommate up and decided to help resident #4 up for breakfast. She revealed this was her first day on her own and she had never worked with resident #4 before. She further revealed she was unaware if resident #4 required a 1 or 2 person assist for transfer nor did she go find out. CNA A confirmed she did not use a gait belt and bear hugged resident #4. She revealed the resident lost her footing and both she and the resident fell to the floor forward. When resident #4 came down she hit both her knees. CNA A leaned the resident against the wheelchair and straightened out her legs. CNA A got the attention of a MA who had the charge nurse come assess the resident. CNA A stated after LVN B performed his assessment they both transferred resident #4 to the wheelchair without using a gait belt and lifted her under her arms. After breakfast, CNA A took resident to the café across from the nurses' station. Resident #4 complained of pain and CNA A revealed LVN B instructed her to take the resident to her room, put her in bed and to perform an assessment. CNA A further revealed during her assessment of the resident she found resident #4's right leg crooked and notified LVN B. Interview on 5/18/17 at 5:20 p.m. with LVN B revealed he was notified by the MA that there was a fall. He further revealed he went to resident #4's room and found her sitting on the floor leaning against her wheelchair with both legs to her left side. He revealed he performed his assessment and then assisted CNA A with transferring resident #4 back into her wheelchair. He confirmed during the transfer a gait belt was not used and they lifted the resident up under her arms. After breakfast, CNA A notified him that the resident was in bed, in pain and there was swelling to her right knee. Interview on 5/18/17 at 5:40 p.m. with the ADON revealed she fed resident #4 at breakfast and the resident did not eat well. She further revealed resident #4 told her (ADON) that her legs hurt. The ADON instructed CNA A to take the resident to the charge nurse for pain medication. The ADON revealed after breakfast, she went to check on the resident and found her lying in her bed in extreme pain. The ADON further revealed it was then she learned resident #4 had a fall earlier that morning. An x-ray of resident #4's right side was taken which revealed a fractured femur. The ADON revealed the mobile x-ray was unable to do the left side at the time because the resident was in a lot of pain. Interview on 5/18/17 at 6:05 p.m. with the Staffing Coordinator revealed CNA A was a new hire as of 5/2/17. She further revealed CNA A oriented on the floor on 5/3 and 5/4/17 and then was on her own starting 5/4/17. She revealed the facility uses a Partner in Excellence Program and had received feedback that CNA A had done well. On day 5 of an employee's day of work a skills check is done. The Staffing Coordinator revealed that CNA A had not had her skills check done because of the facility's full book survey. Review of staff daily sign in sheets revealed CNA A oriented on 5/3/17 and 5/4/17 and then worked alone on 5/8/17, 5/9/17, 5/10/17, and 5/11/17. 2. Record review of Resident #3's face sheet dated 5/10/17, revealed he was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's Admission history and physical dated 2/20/17 and signed by the Medical Director included the [DIAGNOSES REDACTED]. Definition of Autonomic Dysreflexia: Autonomic Dysreflexia (AD), also known as Hyperreflexia, is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and if not treated can lead to stroke and possibly death. Individuals with SCI at the T-6 level or above are at greater risk. AD usually occurs because of a noxious (irritating) stimulus below the level of the injury. Symptoms include headache, facial flush, perspiration, and a stuffy nose.-The Institute for Spinal Cord Injury. Record review of Resident #3's 5 day MDS dated [DATE] for Resident #3 revealed a BIMS score of 15 which indicated the resident to be cognitively intact. The MDS further revealed Resident #3 to be totally dependent on staff for care. Observation of Resident #3 on 5/9/17 at 9:04 a.m. revealed the resident had his clothing changed because it was saturated in sweat. Observation on 5/9/17 at 2:47 p.m. further revealed the resident with a towel wrapped around his neck because he was sweating profusely. The resident called for staff LVN E, and told her he is very sweaty and asks that his blood pressure be taken. Interview with Resident #3 on 5/10/17 at 9:22 a.m. revealed that resident does not feel good. He stated that the staff did not listen to his needs. He stated that he tried to tell them about his Dysreflexia but the staff didn't listen and it made him anxious. Resident #3 stated he knew his body and when it didn't feel well he will ask them to check his bladder and catheter or give him a suppository in hopes that it would relieve the pain he cannot physically feel. He further revealed that he sometimes got very frustrated and angry that the staff didn't listen. Interview with LVN E on 5/9/17 at 3:10 p.m. revealed that resident #3 was very needy.' She confirmed that staff members sometimes ignore his calls because of his constant anxiety and neediness. LVN E stateed she did not have training in treating residents with AD. Interview on 5/9/17 at 3:21 p.m. with LVN E, ADON G, and DON revealed that they did not know what AD means, they did not know the signs and symptoms of AD or how to properly respond to a resident with a spinal cord injury who was having symptoms of AD. Interview with DON on 5/10/17 at 4:07 p.m. revealed that staff caring for Resident #3 should be aware of his history and physical including Autonomic Dysreflexia, effective assessment and management of pain that could trigger AD, and staff should know how to respond appropriately to the symptoms including sweating, increase in BP, and requests for pain management. Interview on 5/25/17 at 1:00 p.m. with CNA T who was assigned Resident #3 for the day shift revealed that Resident #3 required total care, a two person mechanical transfer, and seemed really anxious, and sweats a lot. She said that she did not know anything about AD. Interview on 5/25/17 at 1:15 p.m. with LVN H who was assigned Resident #3 for the day shift revealed that she had heard about autonomic Dysreflexia and was able to describe some of the triggers, but did not know that Resident #3 had it as a diagnosis, and that his pressure sores which he had could be considered a trigger. She described Resident #3 as very demanding. LVN H was not aware that the [MEDICATION NAME] (used to lower BP) 5mg tab for Resident #3 was ordered for his AD. The Administrator, Corporate Nurse and the ADON were notified on 5/25/17 at 3:09 p.m. that an Immediate Jeopardy situation was identified. The facility's Plan of Removal was accepted on 05/25/17 at 4:30 pm and included: Proper Transfer of Patients using Gait Belt a. Nursing staff was in-serviced with a return demonstration completed on 05/25/17 on proper transfer of patients using gait belt. Nursing staff unavailable for the in service will not be allowed to work until such in-services have been given. b. The facility conducted an audit on 05/25/17 of all patients that require assistance with transfers. ADL Care Guide and care plan were audited for transfer status accuracy. c. Routine monitoring of nursing staff to ensure gait belts are accessible and utilized properly. d. New staff members will be in-serviced on transfers and use of gait belt by the Rehabilitation Manager and /or designee before the staff is assigned to provide care for patients. On 5/28/17 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 7 CNAs, 5 LVNs, and 2 RNs were interviewed and said they were trained on 1 and 2 person transfers, 17 had returned transfer demonstration. The above staff also indicated they knew to use a gait belt for transfers and knew where to find how many staff a resident needed to transfer with. An In-Service, dated 5/25/17, concerning transfers techniques was reviewed and contained the names of 107 staff who attended. Five transfers with gait belt were observed and staff used appropriate technique and followed resident's plan of care for type of transfer. On 5/28/17 the Immediate Jeopardy was removed; however, the facility remained out of compliance at scope of isolated and severity potential of actual harm because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. Management of Patients with Autonomic Dysreflexia a. Nursing staff were in-serviced and competency exams completed on 05/25/17 on the [DIAGNOSES REDACTED]. Nursing staff unavailable for the in service will not be allowed to work until such in-services and competency exams have been given. b. The patients identified by the survey team as having a [DIAGNOSES REDACTED]. c. The facility conducted an audit on 05/25/17 of patients with a [DIAGNOSES REDACTED]. d. Any signs, symptoms and treatment of [REDACTED]. e. New staff members will be in-serviced on the [DIAGNOSES REDACTED]. An identifier for the [DIAGNOSES REDACTED]. On 5/28/17 the surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: 7 CNAs, 5 LVNs, and 2 RNs were interviewed and said they were trained on AD. Seven CNAs, 5 LVNs, and 2 RNs could identified the symptoms of AD and could identify the appropriate response. An In-Service, dated 5/25/17 concerning AD and how to respond appropriately was reviewed and contained the names of 70 staff who attended. Information provided by the facility on 6/9/17 revealed 33 residents require assistance with transfer at the facility. Information provided by the facility on 5/917 revealed that 2 patients had [DIAGNOSES REDACTED].