Every finding on record at Windsor Nursing and Rehabilitation Center of Corpu

Based on observations, interviews and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents.The facility failed to ensure Resident #1 was secured in bed during a linen change and fell out of bed onto the floor on 05/29/26.This failure could place residents at risk for injury from falling and decreased quality of life.Findings Included:Record review of Resident #1's face sheet indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with an original admission date of 02/25/26. Diagnoses included terminal cirrhosis of the liver (a chronic liver disease characterized by formation of permanent scar tissue (fibrosis) that damages the liver and interferes with its functioning; it can lead to liver failure), A-fib ( an irregular, often rapid heartbeat caused by a glitch in the heart's electrical system that can cause a fluttering feeling in the chest and increase the risk of blood clots and stroke) with a pacemaker, Diabetes, high cholesterol, low potassium, depression, thyroid disease, heart failure, and muscle wasting.Record review of Resident #1's quarterly MDS assessment, dated 05/09/26, revealed Resident # 1 had a BIMS score of 10, indicating she had moderate cognitive impairment. The MDS indicated Resident #1 required supervision with eating, oral, and personal hygiene, and upper body dressing. She required substantial assistance with toileting, bathing, and lower body dressing. She was dependent for footwear, transfers, rolling side to side, sitting to lying, and sit-to-stand. She was always incontinent of bladder and bowel. Her active diagnoses were medically complex conditions. She was on hospice. She was discharged to a local hospital on [DATE], did not return, and was unavailable for an interview.Record review of Resident #1's care plan dated 05/07/26, Goal: The resident has an ADL self-care performance deficit r/t disease process Date Initiated: 05/07/2026. Intervention: May utilize halo grab bars x2 to aid in repositioning and mobility. Date Initiated: 05/06/2026. Bed mobility: The resident is totally dependent on (2) staff for repositioning and turning in bed as necessary. Date Initiated: 05/29/2026. Goal: at risk for falls r/t impaired mobility. Date Initiated: 05/27/2026. Intervention: Concave/scoop mattress in place Date Initiated: 05/30/2026. Goal: Resident #1 has had an actual fall Date Initiated: 05/29/2026. Intervention: 5/29/2026- Resident had a witnessed fall from bed during care. Resident appears to have turned too far during care and fell from the bed. Neuro checks initiated and VS (vital signs) WNL (within normal limits) for baseline. Unable to assess ROM (range of motion) due to resident position, ROM not checked due to risk for further injury. 911 called and she was sent out to ED (emergency department) for further evaluation. Concave/scoop mattress placed for fall prevention. RP (patient representative) /MD (medical director) aware. Date Initiated: 05/29/2026. Record review of physician progress notes dated 05/07/26 revealed .Resident #1 admitted for skilled nursing care, rehabilitation, medication management, monitoring of cirrhosis/hepatic encephalopathy, weakness, fall risk, and chronic medical conditions. Plan: Fall with generalized weakness and debility: continue PT/OT evaluation and treatment; continue fall precautions.Record review of the facility's provider investigation report dated 06/05/26 revealed an incident date of 05/26/26 at 11:45 am. During perineal care and a bed change, the resident fell out of bed and landed on her right shoulder. Originally, it was thought the resident sustained rib fractures. Head-to-toe revealed a skin tear on her right elbow that was treated. The facility notified the RP and physician, initiated abuse & neglect training, fall prevention training, and safe surveys via the social worker. While receiving peri care and getting her bed changed due to diarrhea, the resident was asked to get on her left side. During this process, the resident rolled too far over and fell off the left side of the bed, landing on her right arm/side. She was sent to the ER and returned. Over the next 2 days, she complained of soreness to her right upper chest area. X-rays obtained and results disclosed 3 fractured non-displaced ribs. Hospital records showed old bilateral rib fractures. Comparison x-rays ordered and resulted in no definite radiographic evidence of the acute fracture or dislocation of ribs, stable, and chronic fracture of the right 7th, 8th, and 9th ribs healed with mild deformity unchanged. Hospital x-rays determined no acute injury. The investigation findings were unfounded. Record review of LVN B progress notes dated 05/26/26 at 4:34 pm revealed called by CNA B that resident was on floor. When entering room resident was on right side between bed and wall. Right side of face on floor, right arm behind resident with body on top of it. Left arm bent hold onto the floor. Resident #1 with no brief on. Bed at mid position. Resident alert and oriented x3. Resident #1 said she fell from the bed. 911 called immediately due to resident complaining of pain to head, right shoulder, and hip. Vitals taken WNL (within normal limits). Ambulance arrived. EMTs (emergency medical technician) moved resident to sitting position and cleansed right elbow due to open area. Resident alert and oriented x3. 2 EMTs lifted the resident to stretcher with one EMT grabbing legs and the other hugging from behind . In an interview with the ADM on 06/09/26 at 10:00 am, he said Resident #1's fall was tragic and unfortunate in that no one could have determined that would happen. He said she was not cognitively impaired and was in the facility for a short term stay and then transition to hospice. He said Resident #1 had loose stools frequently resulting in getting complete bed changes. He said he spoke with Resident #1 after the incident and she told him how it happened, how she turned herself. He said she told him she was a little sore on her right arm. He said she only had one halo (circular bed rail), but it was on the opposite of the bed from where she was turning. He said the fall may have been prevented with another halo on the bed. He said at one point her bed was against the wall on the side without a halo and did not know when or who moved the bed away from the wall.In an interview with LVN A on 06/09/2026 at 12:06 pm, she said she was not working the day Resident #1 fell out of bed on 05/26/26. She said she heard the resident rolled out of bed when the CNA B was changing her and got sent to the hospital per protocol. She said x-rays were done that night and she got the report around 10 pm. She said the report said there were fractures on her right-side ribs. She said she called the DON, the doctor, and Resident #1's family member. She said she checked on Resident #1 before she made the calls, and the resident was ok. She said Resident #1 continued to complain of generalized pain over the next few days. Normally, she complained of pain to the left shoulder and Resident #1's family told her she always had that pain. She said Resident #1 was weak in general and confused, depending on her ammonia level. LVN A said Resident #1 could not get out of bed or dress herself. She said Resident #1 could feed herself and brush her teeth. She said Resident #1 had 1 halo on the right side. She said the family, physician, resident or team member could request them. She said no one requested a second rail until after the fall. LVN A said a physician order, updated care plan, and a consent was required for a halo. She said she never looked at Resident #1's care plan. She said she only looked at the Kardex the CNAs used (there was only 1 Kardex) to know which resident had or needed what. In an interview with CNA B on 06/09/2026 at 12:30 pm, she said she worked at the facility for about 6 months. She said she went to change Resident #1 by herself. She said she had worked with the resident several times before. She said the resident had diarrhea often, so the bed had to be changed completely. She said she always turned Resident #1 to her same side (left side). She said she asked the resident to turn to her left side on 05/29/26 and she did. She said Resident #1 kept rolling and ended up on the floor. She said there was no halo on that side of the bed. She said there was no fall mat either. She said normally, Resident #1 would turn on her own. She said she did not have to help her turn, that she did it on her own. She said she immediately got the nurse when she realized Resident #1 fell and the nurse called 911 right away. She said when she was putting the new sheets on the bed, she looked up to see her fall. She said Resident #1 did not make any sounds when she fell but she heard a loud thud. CNA B said, It happened so fast, there was no time to try to stop her fall. She said if there was a halo on that side of the bed, it (the fall) probably would not have happened. She said she and the ADM spoke with the resident after she returned from the hospital [maybe a few days later] she said she had to show the ADM how it happened. She said the ADM asked Resident #1 if she had a weak arm and she said 'no'. In an interview with CNA C on 06/10/2026 at 10:10 am, she said she worked at the facility for about 2 years. She said she worked with Resident #1 frequently. She said she provided peri care & linen changes. She said when Resident #1 first got to the facility, she was able to help turn. She said by the time Resident #1 was discharged , she had been declining and was much weaker and had to have help to turn. She said, Occasionally she would go over too far, and I would have to guide her back toward me. She said Resident #1 never fell. She said Resident #1's bed had one halo on the right side. She said she was not sure if she was supposed to have two of them (halos). She said Resident #1 never asked her but asked other (unknown) CNAs for another one. She said Resident #1 would hold onto the side of the bed and the headboard when she was turned to her left. She said the resident had a weaker right side. She said she could not say for sure, but the second halo might have prevented her from falling off the bed. She said there were no fall mats on either side of Resident #1's bed.In an interview with CNA D on 06/10/2026 at 11:10 am, he said he worked at the facility for about 2 1/2 years. He said he worked with Resident #1 frequently. He said Resident #1 was able to turn on her own. He said he had to keep his hand on her hip to keep her from going too far over. He said he was concerned about that because there was no rail on that side of the bed. He said, Before, the left side of the bed was against the wall and there was a halo on the right side. He said he did not know why or who moved the bed. He said he went in to help CNA B move Resident #1 up in bed before the incident occurred. He said CNA B told him what happened- that she just rolled over too much, and she did not know that was going to happen. He said he told her she should keep a hand on their hip and he was not sure why there was not a second rail. He said he had not asked anyone why there was not a second rail or a matt in there. He said the second rail probably would have kept Resident #1 from falling out of the bed. He said there were no fall mats on either side of Resident #1's bed.In an interview with the DON on 06/10/2026 at 12:02 pm, she said having a second halo could have prevented Resident #1's fall. She said they had some residents with no halos at all. She said the way they (the facility) determined who needed halos and who did not was dependent upon mentation, preference, needs and their ability to use it. She said Resident #1 had the ability and her mentation was good. She said, to her knowledge Resident #1 did not ask for a second halo. She said there should be an order, in the care plan, and a consent for the halos because they could be considered a type of restraint or danger of entrapment. She said Resident #1 had orders for halos dated 05/29/26. She said care plan initiation dated 05/06/26 read, utilize halos x2 for pt mobility, but the 'date created' was 06/01/26. She said Resident #1 had a consent for the halos. She said Resident #1 had a fall on 05/30/26 but did not have an injury. She said Resident #1 was not a fall risk and that was her only fall. She said she was sure if there were fall mats on either side of Resident #1's bed.In an interview with the ADON on 06/10/2026 at 12:40 pm, she said she recalled hearing about Resident #1's fall. She said CNA B was changing her and while she was changing the sheet, Resident #1 overturned and fell off the bed. She said there was no injury except a skin tear on her elbow. She said the halos were not designed to prevent a fall, and she could not speak to that because she did not know what her position Resident #1 was in bed when she fell. She said she did some of the in-house training for the nurse aide training program and said CNA B had repositioning, mechanical lift, and transfers training. The ADON said fall risk assessments were done on every resident upon admission. She said she could not remember if Resident #1 was a fall risk, but she probably was. She said Resident #1 was really with it meaning she had sense and her cognition was good. She said she was not sure if there were fall mats on either side of Resident #1's bed. Record review of CNA B's employee file revealed a one-on-one in-service for proper procedure to provide resident care dated 05/26/26 at 1:00 pm: Reeducated employee on proper procedure for providing care for residents. Always be mindful of resident safety while providing care. When care is completed place bed in lowest position and call light within reach. When a fall occurs report to nurse immediately for further evaluation. Record review of in-services:05/29/26-Abuse/Neglect and fall prevention, teamwork, safe handling of residents. 06/02/26-Abuse/neglect related to falls 06/03/26- medications administration. 06/04/26-Proper transfer techniques (safety, gait belt use, environmental factors), special needs, giving instruction, bed locks, wheelchair locks, mechanical lift is always a 2-person job.Record review of facility discharges revealed Resident #1 was discharged to an acute care hospital on [DATE] for respiratory distress and did not return.Record review of the facility fall risk evaluations for Resident #1 revealed on 05/26/26 High Risk 11.0. On 05/06/2026 admission Low Risk 0.0 Original admission on [DATE] admission Low Risk 5.0.Record review of the facility pre-restraint assessment/screening dated 05/29/26 revealed under Type of restraint currently used (including side rails, Wanderguard, Dutch door), 'Halo x2' was handwritten in the blank. Under Reason for restraint use, the boxes checked were 'recent fall (within 90 days), 'postural/positioning', 'balance problem', and 'weakness'.Record review of the facility physical restraint consent dated 05/29/26 had Resident #1's family member's signature via phone consent. Record review of the facility policy dated 08/15/22 titled, Fall Prevention Program revealed under policy; Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Under definitions, a fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force .Record review of the facility policy dated 07/11/25 titled, Abuse, Neglect, and Exploitation under neglect, means failure of the facility, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of eight residents (Resident #3) reviewed for medication errors. The facility failed to hold Resident #3's midodrine (blood pressure medication) when Resident #3's blood pressure was outside of physician's parameters on April 3rd, 9th, 10th, 15th, and 21st of 2026. This failure could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.The findings include:Record review of Resident #3's face sheet dated 05/04/26 revealed a [AGE] year-old male with an original admission date of 12/15/21 and a current admission date of 07/12/24. Resident #3's pertinent diagnosis included heart failure, unspecified (a clinical condition where the heart cannot pump blood efficiently, but the medical documentation lacks sufficient detail to specify if it is systolic, diastolic, acute, or chronic). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating his cognition was intact. Record review of Resident #3's order summary on 05/04/26 revealed an active order for midodrine oral tablet 10 MG, give 1 tablet by mouth four times a day for BP, hold if BP is greater than 110/60, initiated on 12/26/25. Record review of Resident #3's MAR for April 2026 revealed midodrine was administered at nighttime on the following dates with associated blood pressures:April 3rd, 2026 - 127/76 by LVN EApril 9th, 2026 - 125/67 by LVN EApril 10th, 2026 - 115/73 by LVN BApril 15th, 2026 - 144/61 by LVN CApril 21st, 2026 - 124/87 by LVN E In an interview with the DON at 10:30 AM on 05/05/26, the DON stated the April 2026 MAR for Resident #3 indicated he was administered midodrine 10 MG outside of physician parameters on April 3rd, 9th, 10th, 15, and the 21st. The DON stated the medication should not have been administered on those nights with the blood pressures that were recorded. The DON stated it was important not to administer midodrine outside of parameters because it may lead to hypertension causing heart palpitations or excessive sweating in the resident. A phone interview was attempted with LVN E at 10:39 AM on 05/05/26, but she could not be reached and was left a message to call back. A phone interview was attempted with LVN B at 10:41 AM on 05/05/26, but she could not be reached and was left a message to call back. A phone interview was attempted with LVN C at 11:55 AM on 05/05/26, but she could not be reached and was left a message to call back. Record review of the facility's policy Medication Administration dated 10/24/22 revealed the following policy: .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #64) of 5 residents reviewed for infection control practices. The facility failed to ensure RN A washed her hands prior to beginning wound care, performed hand hygiene and changed gloves between removing soiled dressings and placing clean dressings, and washed her hands after performing wound care for Resident #64. The facility failed to ensure RN A did not place clean wound care supplies on a surface that had not been disinfected. The facility failed to ensure RN A placed a barrier between Resident #64's buttocks and brief during wound care. These failures could place residents at risk of cross-contamination and development or spread of infection. The findings included: Record review of Resident #64's admission record reflected a [AGE] year-old male resident admitted to the facility on [DATE]. His pertinent diagnoses included pressure ulcer of the right buttock- unstageable (localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body with full thickness tissue loss where the wound base is covered by thick, leathery, or sloughy (dead) tissue, making it impossible to see the wound bed), pressure ulcer of the sacrum (the triangular bone at the base of the spine)- unstageable, sepsis- unspecified organism (damage to vital organs caused by an infection), and lymphedema wounds of the right and left arms (fluid buildup and swelling that occurs when your lymphatic system is blocked somewhere in your body, preventing lymph fluid from draining properly). Record review of Resident #64's admission MDS dated [DATE] reflected a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #64's order summary report on 05/04/26 reflected the following orders: Lymphedema wounds to Ieft arm: Clean with NS and dry. Apply [name of a sterile, non-adherent, petrolatum-based wound dressing impregnated with 3% Bismuth Tribromophenate (an antimicrobial), designed for treating light- draining wounds, burns, and surgical sites by providing a moist healing environment, preventing stickiness to the wound, and acting as an antiseptic agent to prevent infection] and wrap with [name of a sterile roll of bulky gauze] daily, one time a day. Lymphedema wounds to right arm: Clean with NS and dry. Apply [name of a sterile, non-adherent, petrolatum-based wound dressing impregnated with 3% Bismuth Tribromophenate (an antimicrobial), designed for treating light- draining wounds, burns, and surgical sites by providing a moist healing environment, preventing stickiness to the wound, and acting as an antiseptic agent to prevent infection] and wrap with [name of a sterile roll of bulky gauze] daily, one time a day. Unstageable pressure injury to right gluteus (cheek of buttocks): clean with NS and dry. Apply [name of water-soluble gel used for wound care], calcium alginate and cover with bordered foam dressing daily, one time a day. Unstageable pressure injury to sacrum: clean with NS and dry. Apply [name of water-soluble gel used for wound care], calcium alginate and cover with bordered foam dressing daily, one time a day. All ordered on 04/15/26. During an observation of Resident #64's wound care on 05/04/2026 beginning at 8:39 am, RN A picked up the wound care supplies (several 4 inch by 4 inch gauze pads, 2 packages of petrolatum gauze, 2 packages of rolled bulky dressing, and a 15ml vial of 0.9% saline), walked into Resident #64's room and set the supplies down on his rolling overbed table which had numerous other personal items on it. RN A did not wash or sanitize her hands prior to putting on gloves and beginning wound care on Resident #64. RN A took her bandage scissors out of her scrub shirt pocket and cut Resident #64's soiled dressings off of his right forearm, then laid the scissors on top of his blanket on his lap. RN A threw away the soiled dressings then picked up the vial of saline, squirted some on Resident #64's wounds on his right arm, put the vial back on the table, picked up a piece of gauze, wiped off one of the wounds, threw the gauze away, and repeated this for the rest of the wounds on his right arm. RN A picked up one of the unopened packages of petrolatum gauze, opened it, removed the dressing from the package, threw the package in the trash, and applied the dressing to Resident #64's right forearm. RN A then picked up one of the unopened packages of rolled gauze, opened it, removed the roll, threw away the package, then applied the rolled gauze to Resident #64's right forearm over the petrolatum gauze. RN A removed her gloves, did not perform hand hygiene, put on a clean pair of gloves, and repeated the same steps for Resident #64's left forearm. After RN A finished Resident #64's wound care on his arms, she removed her gloves, picked up her bandage scissors, and walked out of the room. RN A did not wash her hands after she finished with Resident #64's wound care on his arms. RN A stepped out of the room to get assistance for the rest of Resident #64's wound care to his buttocks and sacral areas. RN A gathered her supplies for Resident #64's wound care with the assistance of the ADON and the DON. RN A washed her hands but put her hands under the water several times while scrubbing. After she washed her hands, RN A touched the doorknob in bathroom, the rolling table, and the bed controls. RN A did not perform hand hygiene, put on gloves, then took off Resident #64's blankets, pillow under his side/bottom, and unfastened the right side of his brief. The ADON and the DON helped and turned Resident #64 on his left side then RN A moved the unsecured side of Resident #64's brief part way down, did not place a barrier between his brief and his buttocks, took off the bordered gauze on his sacrum and right gluteus, threw them in the trash, then touched clean gauze pads with dirty gloves. RN A took off her gloves and washed her hands with soap and water, put on clean gloves and finished with Resident #64's wound care. In an interview on 05/04/26 at 9:21 am, RN A stated she should have gotten a table and wiped it with disinfectant wipes before getting supplies for Resident #64's wound care. She stated she washed her hands before she got to her cart, but she should have washed them again before she started wound care. RN A stated she scrubbed her hands for one minute and got a little more water when she scrubbed because she felt she did not have enough lather. She stated she normally put her supplies on top of the inside of the dressing package but forgot to this time. RN A stated it was important to wash hands before and after wound care to prevent the spread of infection. She stated it was important not to put clean or sterile supplies or dressings on a dirty surface to prevent contamination of the wounds. RN A stated she did not normally do wound care but was filling in for the treatment nurse who was on vacation. RN A stated she had only been at the facility for a couple of months and only worked weekends as needed. In an interview on 05/05/26 at 10:56 am, the WCN stated it was important to wash hands to keep infection down, reduce bacteria, and ensure bacteria were not transferred to residents. She stated it was important to have a clean surface for supplies, so infection or organisms were not transferred from the surface to the resident. The WCN stated it was important to change gloves and clean hands between dirty and clean procedures to ensure bacteria were not transferred back to the resident after the wounds were cleaned. She stated she had competency check offs done once a year which was done about 4 months ago, and she just completed her wound care certification within the last 3 months. The WCN stated RN A had been at the facility for a couple of months, and she had not taught RN A to do wound care. She stated she thought wound care was part of the onboarding paperwork, but she did not know. The WCN stated when she was not at the facility, the floor nurses did wound care and on weekends the usual RN supervisor did it. She stated she thought all the nurses had wound care in their annual skills check offs. The WCN stated in-services on handwashing was part of their online training, and they demonstrated it about every quarter. In an interview on 05/05/26 at 1:51 pm, the DON stated staff did competency checkoffs when hired and annually. She stated she thought at least the basics of wound care were on the check-off. The DON stated she did not know if RN A had a check-off done. The DON stated RN A was hired not that long ago, maybe a month ago, and she only worked weekends. The DON stated staff was in-serviced on infection prevention and hand washing when hired and at least annually. She stated staff also had online education that included hand washing and infection prevention. The DON stated it was very important for hand hygiene to be done properly because it was the first line of defense against spreading germs or bacteria to residents. She stated supplies needed to be put on a clean surface to prevent contamination. The DON stated hand washing was done when the nurse walked into the room, then hand hygiene was done and gloves changed after the soiled dressing was removed and after the wound was cleaned before putting on clean the clean dressing. She stated when wound care was completed for all wounds, the nurse washed her hands before exiting the room. The DON stated it was important to place a barrier under the resident's wound to protect the wound area from the brief or other surface and to prevent potential bacteria from entering the wound. The facility did not provide a completed Wound Treatment Competency Assessment for RN A. Record review of the facility's Hand Hygiene Policy dated 10/24/22 reflected in part: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform band hygiene when indicated, using proper technique consistent with accepted standards of practice. 4. Hand hygiene technique when using soap and water: a. Wet hands with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount of soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. 5. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility's undated Wound Treatment Competency Assessment reflected in part: 4. Performs hand hygiene and puts on gloves/ appropriate PPE as indicated. 5. Places supplies on barrier and clean surface. Open supplies without contaminating. 6. Position the area to be treated. Place a clean barrier next to the resident to protect the bed linen. 7. Remove soiled dressings and discards into appropriate receptacle. 8. Removes gloves, performs hand hygiene, and dons clean gloves. 9. Cleanse the wound as ordered, using gauze once and discard in the appropriate receptacle. 10. Removes gloves, performs hand hygiene, and dons clean gloves. 12. Applies and secures dressing as ordered. 13. Discard all disposable items to the designated receptacle and remove gloves. Take receptacle to cart for disposal. 14. Wash hands.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences, for 2 of 6 residents (Resident #35 and Resident #79) reviewed for call light placement. The facility failed to ensure Resident #35 and Resident #79's call lights were within reach.This failure could place residents at risk of needs and accommodations being unmet.Findings included: 1. Record review of Resident #35's face sheet, dated 05/03/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), ), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), and cerebral infarction (stroke). Record review of Resident #35's MDS, dated [DATE], reflected a BIMS was not conducted as Resident #35 was rarely/never understood. The MDS reflected Resident #35 was dependent for all activities of daily living. Resident #35 was dependent for roll left/right. Record review of Resident #35's care plan, dated 05/03/26, reflected [Resident #35] had an ADL self-care performance deficit related to cerebral infarction. Date initiated: 03/20/25. Interventions: [Resident #35] was dependent on staff for all ADLs. [Resident #35] was at high risk for falls. Date initiated: 03/20/25. Interventions: Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. 2. Record review of Resident #79's face sheet, dated 05/03/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: nontraumatic intracerebral hemorrhage (bleeding within the brain tissue, resulting from underlying health issues rather than external trauma), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), and encephalopathy (disorder that affects brain function). Record review of Resident #79's MDS, dated [DATE], reflected a BIMS score of 7, indicating severe cognitive impairment. The MDS reflected Resident #79 was dependent for toileting hygiene, shower/bathe self, and lower body dressing. Resident #79 required substantial/maximal assistance for personal hygiene and roll left/right. Record review of Resident #79's care plan, dated 05/03/26, reflected [Resident #79] had an ADL self-care performance deficit related to brain injury. Date initiated: 12/13/24. Interventions: [Resident #79] was dependent on staff or required assistance for all ADLs. [Resident #79] was at high risk for falls. Date initiated: 12/13/24. Interventions: Be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. During an interview and observation, on 05/03/26 at 2:20 PM, Resident #35 was asked basic questions and she did not respond. Resident #35 was not interviewable. Resident #35 was lying in bed and not injured or in distress. The call light was hanging on the bed frame behind Resident #35's head and was not within reach. During an interview and observation, on 05/03/26 at 2:25 PM, CNA G stated Resident #35 was not able to reach the call light where it was hanging on the bed frame. CNA G moved the call light and placed it within reach of Resident #35. CNA G stated she was not sure who changed or repositioned Resident #35 last but perhaps they forgot to leave the call light within reach. CNA G stated Resident #35 was not able to use the call light so the staff rounded on her more frequently, but it was still the staff's responsibility to ensure Resident #35's call light was within reach at all times. During an interview and observation, on 05/03/26 at 2:45 PM, Resident #79 was asked basic questions, and she did not respond with coherent answers. Resident #79 was not interviewable. Resident #79 was lying in bed and not injured or in distress. The call light was hanging off the bed with the button hanging towards the floor and was not within reach of Resident #79. During an interview, on 05/03/26 at 2:55 PM, CNA G stated Resident #79 cannot move much but was able to use the call light. CNA G stated Resident #79 was dependent for most needs. CNA G stated Resident #79 liked to be in bed but she did not know who checked on Resident #79 last. CNA G stated it was the staff's responsibility to ensure Resident #79's call light was within reach at all times. During an interview and observation, on 05/03/26 at 3:00 PM, LVN K stated Resident #79's knees were contracted so she does not get up from bed, but was able to move her arms, reposition herself in bed, and press the call light. LVN K stated Resident #79 was not able to reach the call light where it was hanging off the bed. LVN K moved the call light and placed it within reach of Resident #79. LVN K stated the CNAs and the nurses ensured the residents' call lights were left within reach as it was a team effort. LVN K stated Resident #35 was not able to use the call light as Resident #35 was very confused. LVN K stated regardless, staff had to ensure to leave the call light within reach no matter if the resident was able to use it or not, it had to be available and within reach at all times. During an interview, on 05/05/26 at 10:40 AM, the ADON stated staff were instructed to place the call lights within reach for residents at all times, even if the resident was unable to use the call light. The ADON stated Resident #35 had a soft touch pad call light but did not comprehend how to use it. During an interview, on 05/05/26 at 1:45 PM, the DON stated it was the staff's responsibility to ensure the call lights were within reach of the residents. The DON stated regardless of if the resident had the capability to use or press the call light, the call light should have been within reach and not hanging on the bed frame or hanging towards the floor. Record review of the facility's Call Lights: Accessibility and Timely Response policy, dated 10/13/22, reflected - Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 5. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview and record review, the facility failed to have physician orders for the resident's immediate care at time of admission, for 2 of 12 residents (Resident #48 and Resident #124) reviewed for physician admission orders. -The facility failed to ensure Resident #48's Morphine order had specific pain level parameters for administration. -The facility failed to have physician orders in place for Resident #124's indwelling catheter. These failures could place residents at risk of not receiving appropriate care.Findings included: 1. Record review of Resident #48's admission record reflected an [AGE] year-old male originally admitted to the facility on [DATE] and most recently admitted on [DATE]. His relevant diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), alcoholic polyneuropathy (nerve damage caused by years of heavy drinking and poor nutrition that can cause pain, numbness, weakness, balance issues and more), heart failure (when the heart does not pump blood as well as it should causing fluid to build up in the lungs), and chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing). Record review of Resident #48's quarterly MDS dated [DATE] reflected a BIMS score of 1 which indicated he had severe cognitive impairment. Record review of Resident #48's care plan dated 07/12/25 reflected a focus of a terminal diagnosis related to Alzheimer's disease initiated 04/29/26. The focus was the resident's comfort would be maintained through the review date. Interventions included admit patient to routine hospice care with terminal diagnosis of Alzheimer's Disease by [Hospice RN] under the care of medical director [Hospice medical director's name], observe resident closely for signs of pain, administer pain medication as ordered, and notify physician immediately if there is breakthrough pain, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met, work with nursing staff to provide maximum comfort for the resident. Initiated on 04/29/26. Record review of Resident #48's order summary on 05/05/26 reflected the following orders: Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.25 ml by mouth every 2 hours as needed for Pain. Order date 04/16/26. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.5 ml by mouth every 2 hours as needed for Pain. Order date 04/16/26. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 0.75 ml by mouth every 2 hours as needed for Pain. Order date 04/16/26. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML. Give 1 ml by mouth every 2 hours as needed for Pain. Order date 04/16/26. Record review of Resident #48's Morphine order details reflected: Order Summary: Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) *Controlled Drug* Give 0.25 ml by mouth every 2 hours as needed for Pain AND Give 0.50 ml by mouth every 2 hours as needed for Pain AND Give 0.75 ml by mouth every 2 hours as needed for Pain AND Give 1 ml by mouth every 2 hours as needed for Pain. Created by LVN J on 04/16/26. 2. Record review of Resident #124's face sheet, dated 05/04/26, reflected an [AGE] year-old male, admitted on [DATE], diagnoses included: non-ST-segment elevation myocardial infarction (heart attack when a part of the heart is not getting enough oxygen), sepsis (condition caused by the body's extreme response to an infection), chronic kidney disease (kidneys gradually lose function), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and pneumonia (infection that inflames the lungs). Record review of Resident #124's MDS, dated [DATE], reflected MDS was in progress. Resident #124 had a BIMS score of 15, indicating intact cognition. Record review of Resident #124's baseline care plan, dated 04/27/26, reflected [Resident #124] used a catheter. Interventions: check tubing for kinks, monitor and document intake/output as ordered, monitor for signs/symptoms of discomfort, and monitor for signs/symptoms and report to MD for: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. The baseline care plan was completed by LVN K and reviewed/signed off by the DON. Record review of Resident #124's order summary report, dated 05/04/26, reflected there were no orders for Resident #124's indwelling catheter. Record review of Resident #124's order summary report, dated 05/05/26, reflected orders: indwelling urinary catheter care every shift and PRN, clean with soap and water/cleansing wipes every shift and as needed, indwelling urinary catheter: irrigate catheter with 30 MLS of NS as needed, indwelling urinary catheter: change 16 F with 30 ml bulb as needed for PRN plugged or out, check indwelling urinary catheter use securement device every shift use leg strap to secure foley in place, monitor for catheter privacy bag placement every shift, and monitor that collection bag is off the floor and hung below bladder level every shift with start date of: 05/05/26. During an observation and interview, on 05/04/26 at 10:00 AM, Resident #124 stated he was doing well as the staff took care of him. Resident #124 stated he had been at different hospitals and had the catheter placed during one of those visits. Resident #124 stated the facility staff emptied out the bag, checked the tubing, and cleaned it. Resident #124 stated there were no issues with the catheter. Resident #124's urinary bag was observed hanging below the bladder, off the floor with a privacy bag. During an interview, on 05/05/26 at 10:20 AM, LVN F stated Resident #124 had an indwelling catheter and she knew how to care for the catheter with training and following his orders. LVN F was asked what were Resident #124's catheter orders. LVN F reviewed Resident #124 physician's orders and verified there were no orders for the catheter. LVN F stated the admitting nurse was responsible for inputting the orders and the team reviewed/verified the orders. LVN F stated she inputted the orders for the catheter at this time. During an interview, on 05/05/26 at 10:40 AM, the ADON stated for new admissions, the admitting nurse input orders, and called the doctor for clarifications. The ADON stated it was a team effort to review and ensure all orders were in place appropriately. The ADON stated residents with a foley catheter had to have orders in place. The ADON stated Resident #124 had an indwelling foley catheter, but she was unsure if Resident #124 had orders for the catheter. The ADON stated she and LVN F provided catheter care today without issue and Resident #124 had not been injured or harmed. In an interview on 05/05/26 at 11:57 am, LVN J stated for the Morphine orders for Resident #48, the and was automatically put into the order due to the way it was entered into the computer. She stated if the orders were put in separately for each of the Morphine doses, each dose was on the MAR individually and a nurse could mistakenly give a resident too much Morphine. She stated she was not sure how to change the order so it did not put the AND in it. She stated the Morphine order for Resident #48 was a written hospice order that she put into the computer. LVN J stated the hospice orders went into the computer under the facility doctor's name because the hospice doctors could not get into the computerized medical record to electronically sign the order. She stated there was a progress note that said which doctor wrote the orders and the reason there were no pain level parameters was because it was not written that way by the hospice provider. LVN J stated it was important to have pain level parameters, so the nurses knew what amount of Morphine to give the resident based on his pain level. In an attempted interview, on 05/05/26 at 12:15 PM, LVN K was not working. A phone call was attempted and a voicemail was left requesting a callback. During an interview, on 05/05/26 at 1:35 PM, the ADM stated there was no policy for admission orders. During an interview, on 05/05/26 at 1:45 PM, the DON stated Resident #124 was admitted on [DATE] and had the indwelling catheter present on admission. The DON stated Resident #124 should have had orders for the catheter since his admission. The DON stated the admitting nurse inputted the orders and the team verified to ensure all orders were in place and appropriate. The DON stated she reviewed Resident #124's orders and verified he did not have catheter orders until today. The DON stated there was no negative outcome or risk of harm for Resident #124 as staff knew how to care for him and the catheter. The DON stated the CNAs knew to call the nurse for any changes related to the catheter and the nurses knew how to care for the catheter as that was part of their competency checks. The DON stated it was important for orders to be accurate to ensure all staff were aware of how to care for the resident and to provide appropriate care. In an interview on 05/05/26 at 2:26 pm, the DON stated it was important to have parameters for Morphine orders, so the resident was medicated appropriately. She stated it was important to not have the and in the order so that residents were not overmedicated. The DON stated if a resident was overmedicated with Morphine, it could cause decreased respirations and death.

Based on observation, interviews, and record review, the facility failed to ensure the assessment accurately reflected the resident's status, for 1 of 6 (Resident #124) residents reviewed for accuracy of assessments. The facility failed to ensure Resident #124's baseline care plan was accurate. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Record review of Resident #124's face sheet, dated 05/04/26, reflected an [AGE] year-old male, admitted on [DATE], diagnoses included: non-ST-segment elevation myocardial infarction (heart attack when a part of the heart is not getting enough oxygen), sepsis (condition caused by the body's extreme response to an infection), chronic kidney disease (kidneys gradually lose function), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), and pneumonia (infection that inflames the lungs). Record review of Resident #124's MDS, dated [DATE], reflected the MDS was in progress. Resident #124 had a BIMS score of 15, indicating intact cognition. Record review of Resident #124's baseline care plan, dated 04/27/26, reflected [Resident #124] used an external catheter. There was an option to check off indwelling catheter which was not selected. The baseline care plan was completed by LVN K and reviewed/signed off by the DON. During an observation and interview, on 05/04/26 at 10:00 AM, Resident #124 stated he was doing well as the staff took care of him. Resident #124 stated he had been at different hospitals and had the catheter placed during one of those visits. Resident #124 stated the facility staff emptied out the bag, checked the tubing, and cleaned it. Resident #124 stated there were no issues with the catheter. Resident #124's urinary bag was observed hanging below the bladder, off the floor with a privacy bag. During an interview, on 05/05/26 at 10:40 AM, the ADON stated the initial baseline care plan was completed by the admitting nurse and reviewed/signed off by an RN. During an interview, on 05/05/26 at 11:55 AM, the DON stated there was no policy for resident assessments. In an attempted interview, on 05/05/26 at 12:15 PM, LVN K was not working. A phone call was attempted and a voicemail was left requesting a callback. During an interview, on 05/05/26 at 1:45 PM, the DON stated Resident #124 was admitted on [DATE] and had the indwelling catheter present on admission. The DON stated Resident #124's baseline care plan reflected the use of a catheter, however, it was marked as an external catheter instead of an indwelling catheter. The DON stated the admitting nurse, LVN K, completed the baseline care plan, and the DON was the RN that signed off on the assessment. The DON stated she was supposed to review the information and ensure it was accurate, however, she had been very busy so she only signed off. The DON stated there was no negative outcome or risk of harm for Resident #124 as staff knew how to care for him and the indwelling catheter. The DON stated it was important for the assessments, including the baseline care plan, to be accurate to provide appropriate care for the resident. Record review of the facility's Baseline Care Plan policy, dated 06/06/25, reflected - Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1. The baseline care plan will: b. include the minimum healthcare information necessary to properly are for a resident. 2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident or resident representative, as applicable. b. interventions shall be initiated that address the resident's current needs.

Based on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, for 2 (Resident #106 and Resident #68) of 16 residents reviewed for care plans. - The facility failed to develop Resident #106's care plan in that his oxygen use was not identified and planned for. - The facility failed to ensure Resident #68's care plan reflected the need for enhanced barrier precautions. These failures could place residents at an increased risk of needs going unmet or harm. Findings included: 1. Record review of Resident #106's face sheet dated 05/04/26 revealed a [AGE] year-old male with an admission date of 04/02/26. Resident #106's pertinent diagnosis included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients). Record review of Resident #106's Comprehensive MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident is rarely understood. Further review revealed Resident #106 had not received oxygen within 14 days of the MDS Assessment. Record review of Resident #106's Comprehensive Care Plan dated 05/04/26 revealed oxygen use had not been care planned. 2. Record review of Resident #68's face sheet, dated 05/03/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: acute embolism and thrombosis of deep veins (formation of a blood clot in blood vessels) of left upper extremity, lymphedema (swelling caused by an accumulation of protein-rich fluid in the body's tissues), heart failure (heart muscle unable to pump enough blood), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), muscle wasting and atrophy (reduction in muscle mass and strength), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities). Record review of Resident #68's MDS, dated [DATE], reflected a BIMS score of 13, indicating intact cognition. Record review of Resident #68's care plan, dated 05/03/26, reflected [Resident #68] had potential/actual impairment to skin integrity. [Resident #68] had an alteration in skin integrity related the presence of pressure ulcer/injury. The care plan did not reflect enhanced barrier precautions. During an interview and observation, on 05/03/26 at 3:45 PM, Resident #68 stated she was doing well. Resident #68 stated she had wounds on her legs and feet. Resident #68 stated the staff wore yellow gowns and gloves to provide her care. Resident #68 stated the nurses cleaned the areas and changed the bandages every day. Resident #68 stated she did not remember how long she had the wounds but it has been months. Resident #68 was covered with a blanket, her legs/feet were not visible, and she did not allow to move the blanket. During an interview and observation, on 05/03/26 at 4:27 PM, LVN H was observed donning gown and gloves to enter Resident #68's room. LVN H exited the room at 4:30 PM. LVN H stated Resident #6 was on EBP for wounds that she had since admission. LVN H stated staff knew to wear appropriate PPE by following the signs, having the supplies at the door, and getting updates on residents during shift change. During an observation of Resident #106 in his room at 9:38 AM on 05/04/26, Resident #106 was laying in bed with nasal canula flowing 2 L/M of oxygen. An interview was attempted at this time but Resident #106 was not interviewable. During an interview, on 05/05/26 at 10:40 AM, the ADON stated Resident #68 had wounds and required EBP. The ADON stated Resident #68's need for EBP should have been care planned. During an interview, on 05/05/26 at 1:45 PM, the DON stated Resident #68 had wounds on her feet, toes, knee, and shin which were present since admission on [DATE]. The DON stated Resident #68 required EBP since admission and the EBP should have been care planned. The DON stated she reviewed Resident #68's care plan and verified EBP was not in her care plan. The DON stated there was no negative outcome for Resident #68 and no risk of harm or injury because staff had the supplies and were aware to don PPE for those residents with wounds. The DON stated it was important to develop care plans accurately so everyone knew how to care for the resident. In an interview on 05/05/26 at 1:48 PM, the MDS Nurse stated she was the care management specialist at the facility. The MDS Nurse stated she completed the MDS assessments and completed comprehensive care plans. The MDS Nurse stated it was her fault that oxygen had not been care planned in Resident #106's comprehensive care plan. The MDS Nurse stated she did not have a good reason for why it was not done in a timely manner. The MDS Nurse stated it was important for the care plan to be completed on time so everyone could refer back to it for the resident's care. In an interview with the DON at 2:05 PM on 05/05/26, the DON stated the MDS Nurse was responsible for updating the residents comprehensive care plans. The DON stated Resident #106's oxygen use should have been care planned. The DON stated any time there was a change of condition she expected the comprehensive care plan to be updated no later than 2 business days. The DON stated it was important to update the care plans in a timely manner, so all nurses knew how to properly care for the residents. Record review of the facility policy Comprehensive Care Plans dated 10/24/22 revealed the following policy: .3. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #106) reviewed for respiratory care. The facility failed to ensure LVN C transcribed a physician's order during her shift for oxygen at 2 Lpm as needed into PCC for Resident #9. This deficient practice could place residents at-risk for insufficient or inappropriate care due to other staff not being aware the physician's order existed.The findings include:Record review of Resident #106's face sheet dated 05/04/26 revealed a [AGE] year-old male with an admission date of 04/02/26. Resident #106's pertinent diagnosis included vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients). Record review of Resident #106's Comprehensive MDS assessment dated [DATE] revealed a BIMS score could not be obtained because the resident is rarely understood. Further review revealed Resident #106 had not received oxygen within 14 days of the MDS Assessment. Record review of Resident #106's Comprehensive Care Plan dated 05/04/26 revealed oxygen use had not been care planned. Record review of Resident #106's order summary dated 05/04/26 revealed no orders for oxygen use. Record review of nurse progress notes on 05/04/26 revealed a progress note with an effective date of 04/20/26 at 10:28 PM written by LVN C stated Resident noted to be coughing up think white to clear Phlegm. Pale in color. O2 sating at 84%, resident was afebrile (no fever). Called [Nurse Practitioner] at this time. Order for [Chest X-Ray] STAT given and resident to be placed on oxygen at 3L/M per nasal canula. O2 was given as ordered at this time and resident O2 level at 92%. Resident has PRN order for Duoneb (medication to increase oxygen intake) to be given Q 6 hours PRN. Which was given at this time, Resident noted to relax, breathing normal after neb[ulizer] [treatment] given. During an observation of Resident #106 in his room at 9:38 AM on 05/04/26, Resident #106 was laying in bed with nasal canula flowing 2 L/M of oxygen. An interview was attempted at this time but Resident #106 was not interviewable. In an interview with LVN D at 3:07 PM on 05/04/26, LVN D stated she was the floor nurse for Resident #106 for her shift. LVN D stated she was not sure what the correct L/M of oxygen flow for Resident #106 was. LVN D stated if she needed to look up the correct oxygen flow she would check the orders for Resident #106. LVN D stated she could not find any orders for oxygen use in Resident #106's EHR. LVN D stated it was important to put orders into the EHR for residents so everyone knew how to properly care for them. In an interview with the DON at 2:05 PM on 05/05/26, the DON stated there should have been an order for oxygen for Resident #106 in his EHR. The DON stated the resident went to the hospital about 2 weeks ago, and when he came back he was on oxygen. The DON stated the admitting nurse should have put the new order for oxygen into his EHR. The DON stated the admitting nurse in this case was LVN C. The DON stated it was important to have accurate orders so every nurse could properly care for the residents. A phone interview was attempted with LVN C at 11:55 AM on 05/05/26, but she could not be reached and was left a message to call back. Record review of the undated facility guidelines titled When you are writing/ obtaining orders for one of the following please use the following suggestions for writing orders to have complete and accurate orders revealed the following: .Write prn orders for oxygen if resident uses oxygen.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, for 1 of 6 (Resident #76) residents reviewed for unnecessary medications. The facility failed to ensure Resident #76's Xanax (psychotropic medication for anxiety) medication was not used for an excessive duration. This failure could put residents at risk of harm from adverse reactions or harmful side effects. Findings included: Record review of Resident #76's face sheet, dated 05/04/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: syncope and collapse (temporary loss of consciousness due to reduced blood flow to the brain), malignant neoplasm of the temporal lobe (cancerous tumor in the brain's temporal lobe), sepsis (condition caused by the body's extreme response to an infection), chronic obstructive pulmonary disease (progressive lung disease), muscle wasting and atrophy (reduction in muscle mass and strength), and pneumonia (infection that inflames the lungs). Record review of Resident #76's MDS, dated [DATE], reflected Resident #76 had a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #76's care plan, dated 05/04/26, reflected [Resident #76] used anti-anxiety medications (Xanax) related to anxiety disorder. Date initiated: 04/15/26. Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness. Record review of Resident #76's order summary report, dated 05/04/26, reflected an active order: Xanax oral tablet 0.25 MG (Alprazolam), give 1 tablet by mouth every 24 hours as needed for anxiety with start date of: 04/04/26 and no stop date. Recor review of Resident #76's MAR, dated April-May 2026, reflected Resident #76 was administered Xanax oral tablet 0.25 MG on 04/04/26 at 11:57 AM and 04/07/26 at 6:31 AM.During an interview and observation, on 05/04/26 at 8:05 AM, Resident #76 was asked basic questions and he did not respond. Resident #76 was not interviewable. Resident #76 was lying in bed and not injured or in distress. During an interview, on 05/05/26 at 10:40 AM, the ADON stated PRN psychotropic medications were ordered for 14 days. The ADON stated a new order was obtained to continue to use the medication. The ADON stated Resident #76 had been admitted under hospice services recently as he had declined, and that was the family's decision. The ADON stated there were days when Resident #76 did not respond or interact. During an interview, on 05/05/26 at 1:45 PM, the DON stated Resident #76 had an order for Xanax to be used as needed for anxiety with start date of 04/04/26. The DON stated the order had no stop date. The DON stated Resident #76's order should have had a stop date of 14 days. The DON stated when the order was inputted, the nurse should have ensured the order had a stop date. The DON stated she was not sure who input the order. The DON stated the medication was not being used to sedate Resident #76 or for the staff's convenience. The DON stated there was no negative outcome for Resident #76 and no risk of injury or harm because the medication was only administered as needed. Record review of the facility's Medication Management policy, dated 10/01/19, reflected - Policy: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. F. As needed (PRN) orders include an indication for use. a. If the PRN medication is used to modify behavior, the indication for use is clearly defined in objective terms (what specific symptom is being addressed). c. PRN orders for psychotropic drugs are limited to 14 days.

Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 8 medication carts observed for compliance. The facility failed to ensure the 400-hall medication cart was not left unlocked and unattended by LVN I.This failure could place residents at risk of access and ingestion of medications and risk of drug diversion.Observation on 5/3/26, at 10:30 a.m., the 400-hall medication cart was unlocked and no staff member within view of the cart. During an interview on 5/3/2026 at 10:35 a.m., LVN I verbalized the cart was hers and she had stepped into a room to assist a resident. LVN I verbalized she thought she locked the cart before walking away. LVN I stated it is her responsibility and expected of her to lock the cart. LVN I also stated a resident could have accessed the medications in the drawers that were accessible (all non-narcotics).During an interview on 5/5/2026 at 1:30 p.m., the DON stated it is her expectation for all medication carts to be locked when staff are not in sight of the cart. The DON stated residents on the 400 hall could have accessed the medication in the cart. The DON stated, LVN I has been re-educated regarding leaving the medication cart unlocked. Record review of a facility policy titled, Medication Carts and Supplies for Administering Meds reviewed 10/01/2019, reflected, 2. The medication cart is locked at all times when not in use. and 4. Wheel the medication cart to the resident's room when passing medications or park the medication cart in the doorway of the room with drawers facing the Nurse as she/he stands in the room. The cart must remain in your line of sight when it is not locked. The medication cart is not to be wheeled into a resident group setting.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of 5 residents reviewed for abuse. The facility failed to protect Resident #1 from Resident #2's sexual abuse on 11/21/25 in the dining room during dinner service at around 4:45 PM. This failure could lead to residents developing or exacerbating anxiety, depression, and feelings of embarrassment.The findings included:Record review of Resident #1's face sheet, dated 11/26/25, reflected a [AGE] year-old male with an original admission date of 01/11/22 and a current admission date of 05/03/25. Resident #1's pertinent diagnosis included Cerebral Infarction (a type of ischemic stroke where a blood clot blocks an artery in the brain, leading to the death of brain tissue). Record review of Resident #1's Quarterly MDS assessment, dated 10/17/25, reflected a BIMS score of 1 which indicated severe impairment. Record review of Resident #1's comprehensive care plan, dated 11/26/25, reflected the focus [Resident #1] is at risk for emotional distress r/t sexual incident involving another resident initiated on 11/21/25 and revised on 11/25/25. Interventions listed for this focus included Monitor [Resident #1] for any distress for 3 days initiated on 11/21/25, Psych services to follow up and Staff to ensure [Resident #1] and other resident maintain their distance both initiated on 11/25/25. Record review of Resident #2's face sheet, dated 11/26/25, reflected a [AGE] year-old female with an original admission date of 08/24/24 and a current admission date of 11/15/25. Resident #2's pertinent diagnosis included Alzheimer's Disease (progressive neurological disorder that is the most common cause of dementia, slowly destroying the ability to remember, think, and carry out daily tasks). Record review of Resident #2's Quarterly MDS assessment, dated 08/29/25, reflected a BIMS score of 6 which indicated severe impairment. Record review of Resident #2's comprehensive care plan, dated 11/26/25, reflected the focus [Resident #2] had an incident of inappropriate behavior involving another resident and sexual touching initiated on 11/21/25 and revised on 11/25/25. Interventions listed for the focus included closely monitor resident and ensure she is not sitting next to [Resident #1], Monitor for inappropriate behaviors q shift indefinitely, Monitor for triggers such as overstimulation, confusion, or loneliness and Place [Resident #2] on a 1:1 until 11/24/2025. In an interview with the SSD on 11/25/25 at 2:19 PM, the SSD stated at around 4:45 PM on 11/21/25 she was in the dining room speaking with residents. The SSD stated she made eye contact with Resident #1 from across the room and he gave her a strange look, like he was surprised. The SSD stated she saw Resident #2 sitting next to Resident #1. The SSD stated she bent down to see under the table and saw Resident #2's hand moving around on top of Resident #1's genital area over his pants. The SSD stated Resident #2 did not appear to be grabbing or rubbing with her hand motion. The SSD stated it did not look like Resident #2 was trying to give any sexual gratification to Resident #1. The SSD stated she immediately went over and moved Resident #2 to a different table in the dining room. The SSD stated it took about 10-15 seconds from when she first looked under the table to when she had reached Resident #2 and moved her away from Resident #1. The SSD stated she told Resident #2 that what she was doing was inappropriate, but Resident #2 appeared confused and did not understand what she was doing. The SSD stated she informed the ADM about the incident once the two residents were separated. The SSD stated she had followed up with both residents since the incident and neither had any sign or symptoms of distress related to the incident. The SSD stated she was not aware of any past allegations of sexual abuse for either resident. The SSD stated it was important to protect residents from any type of abuse to ensure that they were not harmed. The SSD stated she was not sure if the physical contact was consensual. The SSD stated after reviewing everything she did not think this incident was sexual abuse. An interview was attempted with Resident #1 on 11/25/25 at 3:51 PM but he was not interviewable. In an interview with Resident #2 on 11/25/25 at 4:09 PM, Resident #2 stated she did not have any problems with any residents at the facility. Resident #2 stated she had never touched another resident inappropriately. Resident #2 stated she would never hurt another person at the facility. Resident #2 stated she mostly kept to herself. In an interview with SW on 11/26/25 at 9:06 AM, SW stated she worked for a local psychiatric services company contracted with the facility. SW stated she started working with Resident #1 and Resident #2 on 10/15/25. SW stated when she first met with Resident #1 he was reserved. Resident #1 stated he has opened up more to her over the past month. SW stated Resident #1 got defensive when she asked him about the sexual abuse incident. SW stated his demeanor changed when she asked him about the incident, indicating he might have remembered the incident. SW stated she asked Resident #1 if he wanted to talk about the incident but he told her no. SW stated Resident #1 told her he felt safe at the facility. SW stated, in her opinion, Resident #1 would be able to consent to sexual activity. SW stated she believed Resident #1 understood more than he communicated. SW stated when she spoke to Resident #2 she did not remember anything about the sexual abuse incident. In an interview with the DON on 11/26/25 at 9:21 AM, the DON stated she first found out about the incident when she received a call from the ADM at around 5:15 PM on 10/21/25. The DON stated she did not believe the contact between Resident #1 and Resident #2 was sexual. The DON stated she did not think Resident #2 intentionally touched Resident #1's groin area. The DON stated she thought if Resident #1 did not want Resident #2 to touch him he would have said something or left the table. The DON stated even though Resident #1 had a low BIMS score, he was still able to communicate when he was angry, sad, or happy. The DON stated she thought both residents were able to consent because they were both able to express their needs. The DON stated she did not think this incident was sexual abuse. The DON stated all residents had the right to be free from abuse at the facility. In an interview with the ADM on 11/26/25 at 10:00 AM, the ADM stated he first learned at the incident at around 5:00 PM on 11/26/25 when he received a call from the SSD. The ADM stated he was the abuse prevention coordinator at the facility. The ADM stated it was his responsibility to [NAME] the investigation, of abuse incidents, report them to the HHS, and keep residents safe. The ADM stated he felt that Resident #1 was able to consent to sexual contact. The ADM stated he did not think it was sexual contact between the two residents because there was no evidence Resident #2 was touching Resident #1 for the sexual gratification of anybody. The ADM stated he did not think this incident was sexual abuse. The ADM stated every resident had the right to be free from abuse at the facility. The ADM stated it was important to protect residents from abuse of any kind to keep them from harm. Record review of the facility's policy Abuse, Neglect and Exploitation, dated 07/11/25, reflected the following policies: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident.

50969 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 5 of 25 residents observed for infection control practices, in that: 1. The facility failed to ensure LVN H and the RA appropriately followed infection control practices when the RA grabbed the top of resident cups by top rims with bare hands, and LVN H grabbed sliced bread, while passing out meal trays to 5 of 25 residents in the dining room during lunch on 03/11/25. 2. The facility failed to post Enhanced Barrier Precaution signs outside the rooms of Resident #88 and #105, so staff and visitors were unaware of what if any precautions were need prior to entering the room. These failures could place residents at risk for cross contamination and infection. Findings include: 1.) During an observation of lunch on 03/11/25 at 12:46 PM LVN H was observed using bare hands to grab the bread slices out of the plastic wrap and placed it on resident trays. An RA was seen grabbing resident cups by the top rim with bare hands and placing it on resident trays. In an interview on 03/11/25 at 12:50 PM LVN H stated she had training once on passing out meal trays since she's been working at facility. LVN H stated staff are not allowed to grab the resident ' s bread or any food with bare hands and did not realize she was doing so. LVN H stated by grabbing resident ' s bread with bare hands, it could spread infections to residents. LVN H stated the last infection control in-service was about a month ago. In an interview on 03/11/25 at 12:59 PM the RA stated he was trained about a few months ago on food handling and passing out meal trays. The RA stated he thought he was grabbing the cups on the sides. The RA stated, well did you see my sanitize my hands? The RA stated the top rim of the cups should not be touched with bare hands as it could spread infection to the residents. The RA sated the last infection control service was about a month and a half ago. In an interview on 03/13/25 at 09:14 AM the DON stated staff should not be grabbing the resident cups by the top rim or grabbing food items such as bread with their bare hands due to infection control. The DON stated by grabbing food items and touching the top rims of resident cups could spread germs to residents. The DON stated an In-service for all staff on food handling and tray set up was conducted on 3/11/25 (observed through record review). In an interview on 03/13/25 at 09:31 AM ADON A stated staff should not be touching the top rims of the resident cups and food items with bare hands because it could contaminate the residents food with bacteria that could potentially be on their hands and spread those germs to the residents who will be putting the items in their mouths. ADON A stated an in-service with all staff was conducted on food handling and tray set up beginning on 3/11/25. Record review of the facility's Infection Prevention and Control Program dated 05/13/23 reflected: Policy This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2.) Record review of Resident #88's face sheet dated 03/13/25 revealed a [AGE] year-old-female with an original admitted [DATE] and a current admitted [DATE]. Record review of Resident #88 ' s admission MDS dated [DATE] revealed a BIMS of 15, intact cognition. The MDS also revealed urinary continence not rated as resident had a catheter. Record review of Resident #88 ' s care plan initiated 03/11/25 revealed a care plan for EBP due to foley catheter. Record review of Resident #88 ' s physician orders with a start date of 03/11/25 revealed an order for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices). The physician ' s orders also revealed an order with a start date 01/28/25 Foley catheter change 16 French (size of the barrel of the catheter) with 30 milliliter bulb as needed. During an observation on 03/11/25 at 10:14 AM of Resident #88 ' s door and room, there were no EBP signs posted, and there was not EBP - PPE cart posted. Resident #88 was also observed at this time to be wheeling out of her room with her Foley bag connected under her wheelchair in a privacy bag. Record review of Resident #105 ' s face sheet dated 03/13/25 revealed an [AGE] year-old-female with an original admitted [DATE]. Record review of Resident #105 ' s admission MDS dated [DATE] revealed a BIMS of 14, intact cognition. The MDS also revealed cardiopulmonary surgery involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords, as well as tracheostomy care. Record review of Resident #105 ' s care plan initiated 02/26/25 revealed a care plan for EPB due to trach. Record review of Resident #105 ' s physician orders with a start date of 03/02/25 revealed an order to change trach collar and tubing with oxygen condensation trap. It also revealed an order with a start date of 02/26/25 for EBP: use gown and gloves for high contact resident care activities for those with known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk for MDR (residents with wounds or indwelling medical devices). During an observation on 03/11/25 at 9:37 AM revealed no EBP sign or EBP - PPE cart on Resident #105 ' s door or wall. In an interview with the wound care nurse on 03/12/25 at 9:25 AM, she stated precaution signs were there to keep the residents and staff safe, and if they were missing it puts all the residents at risk for cross-contamination and infection. She stated that typically the infection control nurse, one of the ADONs, or the DON put up the EBP signs and PPE carts. In an interview with CNA-F on 03/12/25 at 9:54 AM, he stated the ADONs typically put up the signs for EBP. CNA-F stated EBP included the use of gown and gloves with high contact due to them having a possible infection. He stated the precautions were there to keep from spreading infections, and if they did not have the proper signs, infections could spread. He stated that gloves and gowns were typically kept inside the room, but no carts outside that he has seen on the EBP rooms. CNA-F also stated it would be easier if the signs and PPE were outside the room so he would have known what precaution to take and what PPE to put on before entering the room. In an interview with the ICP / ADON-A on 03/13/25 09:20 AM, she stated the DON, ADONs and staff nurses were responsible for putting up EBP signage and carts. She stated that one of the rooms signs must have fallen, and the other room just got missed. If the proper signage and carts were not there, cross contamination could occur, and infections could spread. She also stated that there were no EBP - PPE carts on the doors our outside the rooms because corporate wanted supplies kept in the supply closets, so they kept EBP supplies in the closets, and staff get them from there prior to going into the room and delivering care. In an interview with the DON on 03/13/25 at 9:20 AM, she stated the DON or ADON was responsible for putting up EBP signage, and there was no reason that they were not put up, and they should have been there. The DON also stated the residents would not be protected if staff were not using the proper PPE, especially if they had not known the residents were on EBP. She stated a corporate decision was made to leave the PPE in the supply closets, but CDC recommendation and best practice was to have it available near the room with EBP. Record review of CDC: Long-Term Care Facilities: Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms, dated 04/02/24, revealed the use of gown and gloves for high-contact resident care activities was indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves); For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that required the use of gown and gloves; Make PPE, including gowns and gloves, available immediately outside of the resident room. Website reviewed on 03/13/25 at 10:00 AM: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html Record review of Enhanced Barrier Precautions policy dated 04/05/24 revealed 2) Initiation of Enhanced Barrier Precautions: b. an order for enhanced barrier precautions would be obtained for residents with any of the following: wounds, indwelling medical devices, infection, and/or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. 3) Implementation of Enhanced Barrier Precautions: a. make gowns and gloves available immediately near or outside of the resident ' s room.

Based on observation, interview, and record review, the facility failed to dispose of expired medications for 1 of 4 medication carts (Hall #3 med-cart, a mobile cart used to pass medication) reviewed for storage and 1 of 1 medication room (med-room [ROOM NUMBER]) reviewed for storage, as well as the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 4 med-carts (Hall #3 med-cart) reviewed for storage. 1). The facility failed to dispose from hall #3 med-cart a bottle of antacids that had expired in March of 2022 and a saline enema that had expired in January of 2025. 2.) The facility failed to dispose from med-room [ROOM NUMBER] a box of single dose, prefilled Pneumonia vaccine syringes. 3.) The facility failed to keep Hall #3 med-cart free from employee personal items on 03/12/25 as there was a personal cell phone and a personal aluminum water bottle in bottom drawer of Hall #3 med-cart. 4.) This deficient practice could place residents at risk of receiving medications that were both expired and possibly cross-contaminated by personal items. The findings included: During an observation on 03/12/25 at 12:50 PM of med-pass from Hall #3 med-cart revealed Hall #3 med-cart had an open generic bottle of antacids, approximately 75% full, that had expired in March of 2022, as well as an unopened saline enema that had expired January of 2025, and a personal cell phone and personal aluminum water bottle in the bottom drawer with the blood pressure cuff, plastic cups and disinfecting wipes. During an observation on 03/12/24 at 1:15 PM of the medication refrigerator in med-room [ROOM NUMBER] revealed an open box of 5 single dose, prefilled, Pneumonia vaccine syringes that had expired on 02/05/25. In an interview with MA-D on 03/12/25 01:18 PM, she stated that personal items were not supposed to be in a med-cart because it can cause cross contamination with the medication, but that the items in the cart were not hers, and she did not know who they belonged to. She also stated that she usually checked her med-cart for expired medications, and she had not realized that there were expired medications in the cart. She stated that if expired medications were administered to the residents, they might be ineffective or could possibly make them sick. In an interview with the DON on 03/12/25 01:10 PM, she stated that the nurses knew they were not supposed to have personal items in the med-cart, and that water bottle did belong to MA-D because she had overheard her earlier in the day saying that she used it to give residents tap water. She stated she was not sure about the phone, but assumed it was MA-D ' s since it was with her water bottle, and she did not understand why she lied about it when she should have just told the truth. The DON also stated it was everyone's responsibility to check for expired meds, and ADONs checked carts weekly, and if an expired medication was left on the cart or the in the med-room nurses could possibly give a medication that was less effective or not effective at all. In an interview with ADON-A on 03/12/25 at 5:21 PM, she stated that it was all the nurses and medication aides ' responsibilities to check their med-carts for expired meds, as well as the ADONs checked them weekly, so she was unsure of how the expired medications got missed on Hall #3 ' s med-cart, and giving expired medications to residents could make them sick. She also stated that the nurses were not supposed to keep personal belongings in the med-carts due to possible cross-contamination with the medications. In an interview with DON 03/13/25 12:25 PM, she stated that she looked for a policy on med storage, personal items in the med cart and expired meds, but she could not find any policies specific to these things. Record review of Medication Policies revised 10/01/19 revealed drugs, which have been dispensed for individual residents, were not to be used beyond the expiration date indicated by the manufacturer, by the pharmacy. It was the responsibility of all nurses who administer medications to monitor the expiration dates of the medication. Expired medications would not be administered in the facility. All expired medications would be disposed of per facility policy. Record review of Medication Administration: Medication Carts and Supplies for Administering Meds policy revised 10/01/19 revealed the facility maintains equipment and supplies necessary for the preparation and administration of medication to residents. The purpose of the mobile medication system was to ensure appropriate control and surveillance of resident assigned medications.

Based on observation, interview, and record review, the facility failed to review and revise the care plans for 1 of 5 residents (Resident #1) whose care plans were reviewed, in that: The facility failed to ensure Resident #1's care plans accurately reflected current mobility and activity level and status. These failures could place residents at risk of receiving inadequate individualized care and services. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old female with an original admitted [DATE] and current admitted [DATE]. Record review of quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of 08, which suggests moderate cognitive impairment. The MDS also revealed that resident had functional impairment on one side of lower extremity, utilized a wheelchair for mobility, and was dependent with dressing, hygiene, and toileting. Record review of Resident #1's Care Plan revealed resident enjoyed attending group activities, and she ambulated independently via wheelchair, but may needed assistance at times, initiated 7/17/23 and no revision. It also revealed Resident #1 had an activities of daily living self-care performance deficit related to impaired mobility and Dementia; limited physical mobility related to weakness and disease processes; high risk for fall related to impaired mobility and Dementia. In an observation on 1/27/25 at 1:10 PM, 2:00 PM, and 3:00 PM, Resident #1 was not in her bed because she was at dialysis. In an observation on 1/28/25 at 8:40 AM and 10:15 AM, Resident #1 was observed to be lying in her bed. She raised her head to acknowledge surveyor but did not turn or rotate her body. In an interview with CNA-A on 1/27/25 at 1:20 PM, she stated Resident #1 did not fall frequently that she knew of because she was bed bound. CNA-A stated the resident was trying to get up by herself, and she was not supposed to, and that was how she fell previously in July 2024, and since that fall the resident had declined physically and mentally, and she stays in bed all the time, except when she had to go to dialysis. CNA-A stated that when she went to change the resident, she found her on the floor on her side by the bed. She stated Resident #1 was cognitive enough to push the light when she needed something prior to the fall, but she had declined a lot, and she was more confused since that fall. CNA-A stated she immediately called the nurse to check Resident #1 when she found her on the floor. She stated staff were in-serviced over falls at monthly meetings and every time there was an incident, as well as their annual in-services. She also stated abuse and neglect was in-services monthly and in between as needed. CNA-A stated Resident #1 never complained about abuse or neglect to her, but if she had seen or heard about it, she would have reported it to her charge nurse and the Administrator, who was the abuse and neglect coordinator. In an interview with CNA-B on 1/27/25 at 1:30 PM, he stated he had worked on Hall 4 for a while and knew Resident #1 fairly well but did not work with her often because she preferred to have female staff to take care of her. He stated Resident #1 did not ambulate, nor did she use her wheelchair for mobility since declining after the fall in July 2024. He also stated that Resident #1 was no longer able to roll or turn herself in bed to assist with any of her care. CNA-B stated Resident #1 had not been able to move much or reposition herself in bed for many months now. In an interview with LVN-C on 1/27/25 at 2:10 PM, she stated that Resident #1 did not fall a lot. Resident #1 used to get in her chair and go to the bathroom before she started to decline quite a bit. The decline seemed to happen after the big fall with hip fracture in July 2024 from her trying to transfer herself to get ready for dialysis. She stated that Resident #1 no longer got herself up, transferred herself, or assisted with rolling or repositioning in bed. Resident #1 had gotten a lot weaker, and she only gets up for dialysis, and at times therapy, if it was ordered, but she mostly did not get up anymore. She stated that Resident #1 can tell you if she wanted to get out of bed or if she was in pain. She knows how to use her call light. LVN-C stated that care plans were updated by the MDS nurse and the social worker typically. She stated that Resident #1 had not had any further falls since the major fall that caused the hip fracture in July 2024. In an interview with the ADON on 1/27/25 at 2:30 PM, she stated that Resident did not fall a lot. She had declined so much that she only gets out of bed to go to dialysis. The fall occurred when resident was trying to get or transfer out of bed to get ready for dialysis, but she was confused because she did not have dialysis that day. She no longer tries to transfer self or get out of bed except dialysis days, and she was typically transferred by staff to wheelchair or stretcher. She stated the MDS nurse was the one who updated the care plan, but she can see that the care plan needs to be updated and personalized as it still says Resident #1 was ambulatory with her wheelchair. In an interview with the MDS Nurse on 1/27/25 at 2:55 PM, she stated she realized Resident #1's care plan still showed ambulatory with wheelchair and limited mobility, but she was changing it to impaired mobility, as well as removing the activities care plan stating that Resident #1 attends group activities and ambulates independently via wheelchair. She stated the Activities Director updated the activities care plans, and the care plans were done at minimum with the MDS assessment and with acute changes. She stated that Resident #1 had declined so much that her dialysis sessions were decreased to twice a week and less time. She stated Resident #1 no longer likes to get out of bed other than having go to dialysis. She was still able to verbalize wants and needs and could answer questions depending on the complexity of questions. She stated Resident #1 had been refusing dialysis recently, and she was more tired and wanted to be left alone. MDS Nurse did not remember the exact situation but remembered Resident #1's fall in July 2024. She stated she did not fall frequently and had not fallen since then. The MDS Nurse stated she will get with the Activities Director right now to have her update and change the care plan, so it did not reflect that Resident #1 was still mobile with wheelchair as she was only transferred from bed to stretcher/chair for dialysis now. In an interview with the Activities Director on 1/27/25 at 3:12 PM, she stated she reviewed and updated the activity care plans quarterly and with any changes. She stated Resident #1 had a fall a while back and a recent hospital stay, and her care plan needed to be updated to accurately reflect these things. She also stated that the care plan should have been updated in November, but the activities portion had not been revised since July 2024 due to Resident #1 being in and out of the hospital. The Activities Director stated that there was a corporate person who used to look over the care plans to check that they were complete and accurate, and to see if anything was missed, but right now there was no system in place to show the care plans were being checked or updated as needed. She stated Resident #1 no longer gets up to activities, and she was going to update this in the care plan, even though it was already updated in her assessment. In an interview with the Administrator on 1/27/25 at 3:19 PM, he stated vaguely remembered Resident #1's fall from July 2024, and typically with a fall, the CNA will alert the nurse to assess resident for pain and the physical condition. They were in-serviced on falls at least monthly as well, and if there was an incident. Administrator stated the care plans were covered in QAPI meetings, and he had noticed there was a deficit with them. The MDS nurse and Interdisciplinary team updated the care plans driven by the care management nurse. As a plan of correction, the Administrator stated they were care planning individuals who were triggering more on metrics, such as the residents who had the most needs. The Interdisciplinary Team reports whether or not the care plans were updated, including the activities portion, and we have recognized that care planning needs to be brought up to speed, and more person centered. The Administrator stated that the Director of Nursing was much more versed in this process as a former MDS coordinator with experience looking at the quality of the care plan and given the fact that Resident #1 had a fall recently, as well as a hospital stay, her care plan should have been reviewed more thoroughly and updated.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling and serving food. These failures placed residents who received food from the kitchen at risk for food borne illness. Findings include: During an observation on 12/12/2023 beginning at 11:31 a.m., observed the Morning Cook as she picked up a piece of round, raw frozen sausage out of a small box with no gloves on, only using her bare hand. Observed the Morning Cook as she took the raw, round, frozen sausage and wrapped a napkin around the patty and placed the sausage in the microwave. Observed the Morning Cook as she immediately poured flat noodles out of plastic bag into a pan of water on the stove and then poured the extra, uncooked noodles into a zip lock bag and closed the seal on the bag. Observed the Morning Cook as she removed a plate from the plate warmer and placed the plate on the counter, then she removed two slices of bread from a bag and placed both in the toaster with no gloves on, only using her bare hand. Observed the Morning Cook as she went to the stove and removed a small frying pan and sprayed cooking spray on the inside of the pan without washing her hands. Observed the Morning Cook as she cracked an egg into the pan not using gloves. Observed the Morning Cook as she walked across the kitchen to the 33-gallon rubber trash can and lifted the lid with her bare hand and discarded the eggs shells. Observed the Kitchen Cook as she walked back to the stove and picked up a spoon and stirred the noodles, then picked up a spatula to stir the egg. Observed the Morning Cook as she removed the sausage patty from the microwave by holding the item with her bare hand and the napkin and placed the sausage on the plate. Observed during the time frame that the Morning Cook did not wear gloves or wash her hands. During an observation on 12/12/2023 at 11:40 a.m., observed a dark gray 33-gallon plastic trash can that was placed next to the wall approximately eight (8) feet from the stove. Observed the trashcan was over-filled with trash items with the lid sitting above the rim of trashcan. Observed the lid of the trashcan was stained with yellow and orange substances and had black marks and smudges on the top and rim of the lid. During an observation on 12/12/2023 at 11:42 a.m., observed the Morning Cook as she picked up a plate and spooned beef tips onto the plate and then sat the plate down on the counter and walked over to the 33-gallon rubber trash can and lifted the lid and placed a piece of paper into the rubber trash can. Observed the Morning Cook as she walked back to the stove and resumed spooning beef tips onto a plate. The Morning Cook did not wash her hands after touching the rubber trash can. During an interview on 12/12/23 at 11:45 a.m., the Dietary Manager said the kitchen staff were required to wear gloves when touching food. During an observation on 12/12/2023 at 11:49 a.m., observed the Morning Cook as she picked up multiple slices of bread and tore the bread into pieces with her bare hands and placed the bread into the puree machine. The Morning Cook had not washed her hands. Observed the Morning Cook as she walked over to the 33-gallon rubber trashcan and lifted the lid and threw away the plastic bag and walked back to the counter and pureed the bread by placing the lid the on machine and turning the machine on. At no time was the Morning Cook observed wearing gloves or washing her hands. During an observation on 12/12/2023 at 12:04 p.m., observed the Morning Cook as she put food on a plate and handed plate to the Dietary Aide, with her thumb on the inside of the plate touching the butter noodles. Observed the Morning Cook as she took her hand and wiped the food off her thumb onto her pants. Observed the Morning Cook was not wearing gloves. During an interview on 12/12/23 at 1:35 p.m., the Dietary Aide said she had been at the facility for [AGE] years. The Dietary Aide said when she touched raw or cooked food with her hands, she was required to wear gloves and had been in-serviced on the requirement. The Dietary Aide said the trash can with the lid that had to be lifted with her hand to place trash in was unacceptable and a source of cross-contamination. The Dietary Aide said she had been trained on employee sanitation and food storage. During an interview on 12/12/2023 at 1:48 p.m., the Morning Cook said she had been at the facility for nine (9) years. The Morning Cook said she knew that she was not supposed to touch food items with her bare hands, and she was required to wear gloves when she handled food. The Morning Cook said she aware that during lunch preparation on that day, she touched a frozen sausage patty, the bread she had put in the toaster, and bread she had crumbled to puree without wearing gloves and without washing her hands. The Morning Cook said she was in a hurry and forgot to put gloves on. The Morning Cook said she was aware that she needed to wash her hands after she changed her gloves, when she touched the trash can including the lid, or touch her face or hair. The Morning Cook said that when she touched the trash can lid with her bare hand and then touched food without washing her hands or wearing gloves was cross contamination. The Morning Cook said cross contamination could make the residents who were served out of the kitchen sick. The Morning Cook said she was trained on employee sanitation, food storage, and food preparation and handling. During an interview on 12/14/2023 at 1:51 p.m., the Dietary Manager said she had been at the facility for [AGE] years. The Dietary Manager said the Morning Cook touching food with her bare hands instead of wearing gloves was unacceptable and she said the Morning Cook knew better. The Dietary Manager said what had occurred during observations on 12/12/2023 did not meet her expectations. The Dietary Manager said the Morning Cook touching the trash can lid and not washing her hands was unacceptable. The Dietary Manager said the action would cause cross contamination and could contaminate the food and make the residents sick. The Dietary Manager said kitchen staff were required to wear gloves when they touched food. The Dietary Manager said kitchen staff were required to wash their hands when they touched the trash cans, touched their face, went to the bathroom, or changed gloves. The Dietary Manager said the Morning Cook putting her thumb in the noodles when she served the plate and then handing the plate to the Dietary Aide did not meet her expectations. Record review of the facility's policy, Food Preparation and Handling, dated 06/01/2019, revealed to ensure that all food served by the facility was of good quality and safe for consumption, all food would be prepared and handled according to the state and US Food Codes and HACCP guidelines. Procedure included preparing food with the least manual contact possible. Do not allow bare hands to touch raw food directly. Record review of the facility's policy, Employee Sanitation, dated 10/01/2018, revealed employees must wash their hands and exposed portions of their arms at designated hand washing facilities immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles; during food preparation, as often as necessary to remove soi and contamination and prevent cross contamination when changing tasks.

Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 49 days out of 438 days reviewed. The facility failed to have an RN for 8 consecutive hours 7 days a week for 49 days out of 438 days reviewed from September 30, 2022, through December 11, 2023. These failures could place all residents at risk for their clinical needs not being met. Findings included: Review of daily staffing data revealed the facility did not provide the services of an RN on the following dates: October 16, 2022, October 29, 2022 October 30, 2022, December 25, 2022, December 31, 2022, January 28, 2023, March 05, 2023, March 15, 2023, April 08, 2023, April 15, 2023, May 01, 2023, May 28, 2023, June 04, 2023, June 17, 2023, June 25, 2023, July 01, 2023, July 02, 2023, July 16, 2023, July 19, 2023, July 30, 2023, August 01, 2023, August 14, 2023, August 16, 2023, August 17, 2023, August 18, 2023, and October 01, 2023. Review of daily staffing data revealed the facility did not provide the services of an RN for 8 consecutive hours on the following dates: October 10, 2022 an RN was onsite for 7.94 hours, November 09, 2022 an RN was onsite for 7.12 hours, November 12, 2022 an RN was onsite for 1.02 hours, November 13, 2022 an RN was onsite for 7.52 hours, December 24, 2022 an RN was onsite for 7.82 hours, January 01, 2023 an RN was onsite for 3 hours, January 10, 2023 an RN was onsite for 5.6 hours, January 15, 2023 an RN was onsite for 7.59 hours, January 21, 2023 an RN was onsite for 7.43 hours, January 22, 2023 an RN was onsite for 4.03 hours, February 20, 2023 an RN was onsite for 7.43 hours, February 26, 2023 an RN was onsite for 2.88 hours, March 12, 2023 an RN was onsite for 7.83 hours, March 18, 2023 an RN was onsite for 2.04 hours, April 11, 2023 an RN was onsite for 7.95 hours, April 28, 2023 an RN was onsite for 7.85 hours, May 07, 2023 an RN was onsite for 6.82 hours, May 23, 2023 an RN was onsite for 5.57 hours, June 24, 2023 an RN was onsite for 2.08 hours, July 15, 2023 an RN was onsite for 2.40 hours, July 17, 2023 an RN was onsite for 5.10 hours, August 15, 2023 an RN was onsite for 5.80 hours, October 21, 2023 an RN was onsite for 1.90 hours. Review of the Payroll Based Journal report dated 12/06/2023 revealed No RN hours triggered as an area of concern. The following dates were identified: May 20, 2023, June 03, 2023, June 7, 2023, June 16, 2023, June 18, 2023, and June 19, 2023. The facility provided records indicating RN hours as follows: May 20, 2023, 8.17 hours, June 03, 2023, 11.29 hours, June 7, 2023, 20.32 hours, June 16, 2023, 11.15 hours, June 18, 2023, 11.25 hours, and June 19, 2023, 11.48 hours. During an interview on 12/14/23 at 1:30 PM, the administrator stated his expectation of Registered Nurse coverage was at least 8 hours a day, 7 days a week. He stated staying in compliance with regulations was important for the facility and the residents. He stated the importance was because of the expertise an RN had to handle critical issues that may occur. The administrator explained the discrepancy on the payroll-based journal report was due to agency nurse coverage that was not captured in the system for the report. During an interview on 12/14/23 at 1:45 PM, the DON stated her expectation of Registered Nurse coverage was for an RN to be on-site the required number of hours. She stated she was a [NAME] for making sure to meet the requirement. The DON explained the purpose of complying with the requirement was due to the advanced training and knowledge an RN had to deal with complex issues such as in an emergency. The DON stated the quality of care was improved when an RN was onsite for at least 8 hours every day of the week. During an interview on 12/14/23 at 2:06 PM, the ADON stated having an RN onsite everyday was necessary due to an RN's increased scope of practice. She stated RNs were equipped to perform more advanced tasks in resident care. During an interview on 12/14/23 at 2:13 PM, RN A stated an RN was trained to perform an in-depth assessment. She stated an RN's advanced skills could make a difference in being able to care for a resident's needs in the facility versus transferring a resident to an acute care facility. RN A explained the facility protocol if an RN did not show up for a shift, staff had been instructed to call the DON. She stated all nursing staff aware an RN must be in the building for 8 hours every day. Review of the facility policy titled Nursing Services - Registered Nurse (RN) dated October 2022 revealed under the Policy Explanation and Compliance Guidelines section, item 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #1) reviewed for infection control. 1. CNA A did not perform hand hygiene or glove changes after touching Resident #1's purple foot pad/foam on Resident #1's foot, nor did she perform hand hygiene during perineal care . This failure could place residents at risk for infection. The findings include: Record review of Resident #1's face sheet, dated 12/01/2023, reflected the resident was initially admitted to the facility on [DATE], and readmitted [DATE]. Resident #1 was an [AGE] year-old female with diagnoses which included: Acute Kidney Failure (kidney failure), Type 2 Diabetes mellitus (A chronic condition that affects the way the body processes blood sugar ) , Cerebral Infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), and malignant neoplasm of left kidney (cancer left kidney). Record review of Resident #1's Admission MDS, dated [DATE], documented a 14/15 BIMS score, which indicated the resident was cognitively intact. Resident #1 was coded to have an indwelling catheter. Resident #1 also required extensive assistance of staff to assist in activities of daily living. Record review of Resident #1's Comprehensive Care Plan, date initiated 12/13/2022, reflected Focus: Resident #1 has bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through review date. Interventions: brief use: The resident uses disposable briefs. Change (Q 2 hrs.) and PRN. Clean peri -area with each incontinence . During an observation on 12/01/2023 at 3:16 PM, revealed CNA A applied two sets of clean gloves, followed by removal and adjustment of Resident #1's purple foot pad/foam, and continued by retrieving cleaning wipes, and began cleaning Resident #1's perineal area. CNA A did not perform hand hygiene nor glove changing after touching Resident #1's foot and prior to beginning perineal care. While CNA A performed perineal care, CNA A removed the first set of contaminated gloves, but did not perform hand hygiene when she completed cleaning Resident #1's perineal area and began cleaning Resident #1's gluteal fold area. During an interview on 12/01/2023 at 3:32 PM, CNA A stated by her changing her gloves throughout the perineal care would be an adequate form of hand hygiene. CNA A stated she was nervous, and usually just changed gloves when cleaning front (perineum) to back (gluteal folds). CNA A did not give a definitive answer when asked what could happened if hand hygiene was not performed. CNA A stated washing her hands was a way to keep infection from being passed on to the resident or staff. CNA A stated infection could affect the well-being of a resident. CNA A stated she performed hand hygiene before perineal care and after perineal care, and continued by stating she was not aware to perform hand hygiene during perineal care. CNA A did not give a definitive answer as to why she did not change her second pair of gloves. CNA A stated she was last in-serviced about hand hygiene about three weeks ago, CNA A stated she was given a competency check off yearly on perineal care . During an interview on 12/01/2023 at 3:59 PM, the DON stated the facility followed CDC guidelines regarding hand hygiene infection control. The DON stated CNA A after touching Resident #1's foot pad/foam, CNA A should have removed her contaminated gloves and performed hand hygiene prior to commencement of perineal care. The DON stated by not performing hand hygiene and changing gloves, CNA A potentially introduced infection by cross-contamination from Resident #1's foot to perineal area. The DON stated cross contamination of the microorganism that lived on the surface of Resident #1's skin into Resident #1's vaginal area could cause infection. The DON stated infection could potentially lead to urinary tract infections, or sepsis which could jeopardize the well-being of Resident #1's health. The DON stated once CNA A completed Resident #1's perineal care, CNA A should have removed her gloves, performed hand hygiene, applied new clean gloves, and continued with cleaning Resident #1's gluteal area. The DON reiterated the potential adverse reaction of cross-contamination and infection severity. The DON stated the ADON administers competency checkoffs upon hire, annually, and as needed. The DON stated the ADON in serviced the clinical staff on perineal care. Record review of the facility's Infection Control (Handwashing/PPE) in-service, dated 11/09/2023, reflected CNA A was in attendance. Record review of the facility's CNA Orientation Skills Checklist competency checkoff, dated 02/15/2023, reflected CNA A completed Infection Control: Handwashing/gloves and Personal care: peri-care/female. Record review of the facility's Perineal Care Policy, dated 10/24/2022, reflected: .6. Perform hand hygiene and put on gloves 9. If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. 10. Change gloves if soiled and continue with perineal care Record review of the Hand Hygiene Policy, dated 10/24/22, reflected, .2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. (no table attached) . 6. The use of gloves does not replace hand hygiene. Record review of the facility's Peri-Care: Female procedure, undated, policy reflected, .2. Wash hands thoroughly; . 9. With non-dominant hand separate and hold labia 10. Remove gloves, perform hand hygiene. DON (put on) new gloves. Record review of the CDC Guidelines online at https://www.cdc.gov/handhygiene/providers/index.html, regarding Hand Hygiene in Healthcare Settings, dated January 8, 2021, reflected Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal.

Based on Observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment for 1 of 1 hall reviewed for the environment in that: The facility failed to prohibit a gas-powered [NAME] from being driven inside the building. This failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment Findings were: Observation on 10/19/23 at 3:15 p.m. revealed the MS unlocked, disarmed, and opened two doors at the end of hall 400 that led to the outside of the front of the facility, the other door was directly across the hallway leading outside to the courtyard. A person on a stand-up type lawn [NAME] drove the running [NAME] inside the building, through the doors, mowed the courtyard, and drove the running [NAME] back through the doors, into the building, across the hallway, and out of the facility. The MS closed, locked, and re-armed the doors after the [NAME] was outside the facility. An interview with the MS on 10/20/23 at 10:50 a.m. stated the maintenance department had been allowing the gas-powered [NAME] to come through the doorways forever. The MS stated, Yesterday, they came through the doors with the gas-powered lawn [NAME], across the hall, and into the courtyard to [NAME], then back through the doors, across the hallway. The MS stated the facility had a new lawn service, and they did not have access to open the doors. When asked who opened the locked doors for the [NAME] driver, the MS stated, That's a good question. The MS stated the maintenance department opened the doors. This surveyor stated, That would be you? The MS nodded his head up and down and stated, Yes, the maintenance department. The MS stated the lawn service used to weed-eat the courtyard and when asked what had changed, stated, That's a really good question, and could not say. The MS stated the maintenance department let them (the lawn service) in and opened the doors and it should not be allowed. The MS stated the maintenance department stood between the doors while the [NAME] crossed the hall to ensure no one got run over by the stand-up gas-powered [NAME]. When asked why gas-powered machinery should not be inside the facility, the MS stated, That's a really good question, then stated it was not good to allow a gas-powered [NAME] to go through the building because the combustion and exhaust could cause respiratory issues with the residents and staff, especially since the physical therapy department was only about 10 feet from the doors that were used to allow the gas-powered [NAME] to go through the building. The MS stated there was another way to get to the courtyard without driving a [NAME] through the building, but it was a long way around (on the sidewalk). An interview with the ADM on 10/20/23 at 4:33 p.m. stated since he had been at the facility, that was the first time he had heard of it (allowing a gas-powered [NAME] to go through the doors, cross the hallway, and return the same way). The ADM stated he spoke with the MS who told him it was a rare occurrence, and they usually only used a weed eater to [NAME] the courtyard. The ADM stated the MS told him the reason they did it (drive the [NAME] through the building) was because the grass was higher than usual. He told the MS to contact the lawn [NAME] company to tell them not to do that again, and the MS told the ADM he would call them ASAP. The ADM stated the MS had made that call and the lawn [NAME] company would speak with their staff. The ADM stated it could pose a situation where people (residents, staff, surveyors, visitors) could get hurt. The ADM stated, It was stupid for them to do that. It was lazy. The Adm stated that would never be okay (to drive a gas-powered [NAME] through the building). References: NFPA 99 Health Care Facilities Code (2012) 15.3 Special Hazard Protection for Flammable Liquids and Gases. 15.3.1 The storage and handling of flammable liquids or gases shall be in accordance with the following applicable standards: (1) NFPA 30, Flammable and Combustible Liquids Code NFPA 30 Flammable and Combustible Liquids Code (2012) 6.5 Control of Ignition Sources 6.5.1 General. Precautions shall be taken to prevent the ignition of flammable vapors by sources such as the following: (1) Open flames (2) Lightning (3) Hot surfaces (4) Radiant heat (5) Smoking (6) Cutting and [NAME] (7) Spontaneous ignition (8) *Frictional heat or sparks (9) Static electricity (10) Electrical sparks (11) Stray currents (12) Ovens, furnaces and heating equipment

Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials including adult protective services and law enforcement, for 3 of 5 residents reviewed for abuse (Residents #1, #2, and #4) The facility failed to report: -Resident #1's breast was grabbed on 01/23/23 occasion and slapped on the buttocks on 02/09/23 by (Resident #3) -Resident #2's breast was grabbed on 02/20/23 by Resident #3 -Resident #4 was slapped on the head on 01/29/23 by Resident #5 - The facility failed to implement the facility's policies and procedures for reporting to the proper authorities for Residents #1, #2, and #4 This failure could place residents at risk for unreported allegations of abuse without proper investigation and reporting Findings were: A record review of Resident #1's face sheet with an initial admitted [DATE], and most recent admission of 06/21/21 documented an independent and self-representative [AGE] year-old female with relevant diagnoses of vascular dementia, without behavioral disturbance, chronic obstructive pulmonary disease, insomnia, heart disease, high blood pressure, anxiety disorder, major depressive disorder, muscle wasting and atrophy. A record review of Resident #1's MDS dated [DATE] documented she was a smoker had a BIMS score of 14, indicating intact cognition, was cognitively and functionally independent with a walker, was frequently incontinent of bowel and occasionally incontinent of the bladder and was receiving Psyche services. A record review of Resident #3's face sheet dated 07/31/21 and discharged [DATE] documented a [AGE] year-old male with diagnoses of vascular dementia, without behavioral disturbance, insomnia, heart disease, heart failure, chest pain, high blood pressure, reflux, muscle wasting and atrophy. Resident #3. Was his own representative. A record review of Resident #3's MDS dated [DATE] documented he was a smoker and had a BIMS score of 12, indicating moderately impaired cognition, and a cognitive and functional ability to transfer himself with 1 staff to assist and was continent. MDS dated [DATE] documented a BIMS score of 12 and Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) for 1-3 days, and remained continent. A record review of Resident #3's Change in Condition Report dated 02/09/23 documented: the resident stated he hit Resident #1 on her bottom to tell her to keep moving in the hallway, whereas he was separated from the other resident and placed on q15-minute monitoring. There were no other changes documented. A record review of Resident #3's Discharge Plan and Summary dated 02/22/23 documented the Reason for Discharge was inappropriate behaviors and discharge to a sister facility all-male unit. A record review of Resident #3's Care Plan dated 01/30/23 documented Resident #3 had the potential for inappropriate touching behavior. Date Initiated: 01/30/2023. Resident #3 will have no evidence of behavior problems by the review date. Date Initiated: 01/30/202. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed. Date Initiated: 01/30/2023.: Resident #3 was to be monitored by staff when interacting with Resident #1, whom he had previously touched. Date Initiated: 01/30/2023. Resident #3 was receiving Psychiatric services and was taking sedatives/hypnotics, and antidepressants. He was also being treated for his heart condition, high cholesterol, and high blood pressure. A record review of Resident #1's progress notes dated 01/23/23 at 3:50 pm documented Resident #1 was returning to the facility from a scheduled smoke break with Resident #3. When entering the building Resident #3 grabbed Resident #1's breast from behind. Resident #1 then came to the nurse's station and stated, I don't want him to be grabbing my breast. and pointed toward Resident #3. The nurse followed Resident #1 into her room to verify what had happened. Resident #1 stated, I don't want to get him in trouble I just want him to stop doing that. When Resident #1 was asked if it had happened before, Resident #1 stated, No he usually asks me to grab my breast, but I tell him no, but today he did it when I wasn't looking. A record review of the facility investigation report, completed by the ADM, dated 01/23/23 documented a resident-to-resident incident involving Resident #1 and Resident #3 upon returning from a smoke break wherein Resident #1 reported to a charge nurse that Resident #3 had grabbed her breast. She stated that she did not want to get him into trouble, she just wanted him to stop doing that. When asked if she would rather Resident #3 not attend smoking with her, she said, Oh, no, he is fine to continue to smoke with me as long as he doesn't do that again. She stated that they don't really talk much, and he doesn't bother her. She is not afraid of him. The SW and nurse visited Resident #3 and asked the resident if he had touched the other resident inappropriately. He stated yes, I don't know why, it just felt good to do. When told Resident #3 did not want him to do that again, he said okay, fine, I won't do it again. He said he was sorry and understood he was not to touch any resident in an inappropriate manner. Conclusion: Substantiated. This was a resident-to-resident incident. No further incidents between residents. Staff notified to monitor residents during smoke breaks and activities. An interview with the ADM on 05/09/23 at 2:15 PM stated he was surprised to find out that Resident #3 had been asking Resident #1 if he could touch her breasts, and after all the plans the facility put into place because of it, Resident #3 spanked Resident #1 on her butt. The ADM stated Resident #3 was discharged to another facility after moving to another hall, away from the female resident, which did not work out. An interview with the ADM on 05/09/23 at 3:50 PM stated he had not notified the local authorities about this sexual abuse. A record review of the facility investigation report, completed by the ADM, dated 02/09/23 documented a resident-to-resident incident involving Resident #1 and Resident #3; While returning from smoking, Residents #1 and #3 turned onto the hallway where they both resided. Resident #1 suddenly stopped with her walker due to obstacles and other residents in wheelchairs blocking her way. Resident #3 was directly behind her when she stopped. Resident #3 reportedly slapped Resident#1 on her bottom and told her to keep moving. Resident #1 cried out Stop that, which alerted staff to the incident. Conclusion: Substantiated. This was a resident-to-resident incident. No further incidents between residents. Staff notified to monitor residents during smoke breaks and activities. Residents now reside in different units so that they no longer walk together in the hallway to and from smoking. They no longer sit at the same table for activities and meals. We do not believe Resident #3 meant anything sexual with his slap on Resident #1's bottom. An interview with Resident #1 on 05/09/23 at 2:45 PM stated Resident #3 asked her if he could kiss her and she did a couple of times in the beginning, but that one time, he grabbed my breast from behind and she didn't like it. Another time he swatted her on her butt, and she was not expecting that, either. Resident #1 stated the facility got rid of him for it, and she was sad about that because he was a good guy and they all miss him. Resident #1 stated, he was just a dirty old man-it was no big deal, he just got a little too comfortable. Resident #1 stated they could have worked something out (she and Resident #3). Resident #1 stated she did not appreciate it when Resident #3 smacked her on the rear. Resident #1 stated, No one had the right to do that except her husband, and he was dead. Resident #1 stated she didn't want Resident #3 to get moved-he was a good friend, and his getting moved was worse than him smacking her. A record review of Resident #2's face sheet dated 07/08/21 documented a [AGE] year-old female with relevant diagnoses of Alzheimer's, major depressive disorder, recurrent, high blood pressure, diabetes, abnormalities of gait and mobility, muscle wasting and atrophy, dysphasia, and had total blindness in both eyes. A record review of Resident #2's MDS dated [DATE] documented a BIMS score of zero, indicating severely impaired cognition, as it was upon admission on 07/08/21. A record review of the facility investigation report, completed by the ADM, dated 02/20/23 documented Resident #6 reported he had witnessed Resident #3 grab Resident #2's breasts. The report documented Resident #6 stated that Resident #3 had gone up to Resident #2 in the hallway and grabbed her breasts and she elbowed him, and he went back to his room. A full body assessment of Resident #2 showed no bruising. Residents #2 and #3 denied the incident but Resident #6 that reported the incident was alert and oriented and had a BIMS of 11, indicating moderate cognitive impairment. Resident #6 was unavailable for an interview during this investigation. An interview with the ADM on 05/09/23 at 3:50 PM stated he had not notified the local authorities about this sexual abuse. Observation and attempted Interview with Resident #2 on 05/10/23 at 10:37 AM revealed she was seated at a table in activities with 2 other female residents, observing per AA. Resident #2 was awake and sitting upright with her eyes closed in a wheelchair (she is totally blind). Resident #2 swung her feet with her ankles crossed. Resident #2 did not speak and would occasionally utter a low-pitched sound. The AA stated the resident could answer some questions. When asked by this surveyor if she enjoyed her lunch, she slurred, Yes. When asked what she had to eat, she slurred, Yes. A record review of Resident #5's face sheet documented an initial admission of 01/11/22 and re-admission on 01/27/22 and documented a [AGE] year-old male with relevant diagnoses of stroke, chronic viral hepatitis, seizures, alcoholic cirrhosis of the liver, traumatic subarachnoid hemorrhage (bleeding in the brain from trauma) without loss of consciousness, dysphagia, reflux, wasting and atrophy, and high blood pressure. A record review of Resident #5's MDS dated [DATE] documented he was a smoker, at risk for wandering, and had a BIMS score of 6, indicating severe cognitive impairment. A record review of Resident #4's face sheet dated 03/04/13 documented a [AGE] year-old male with relevant diagnoses of obstructive hydrocephalus, (too much fluid on the brain), heart disease, high blood pressure, stroke- affecting the left side, cataracts, epilepsy, osteoarthritis, kidney cancer, and abnormalities of gait and mobility. A record review of Resident #4's MDS dated [DATE] documented a BIMS score of 11, indicating moderately impaired cognition. A record review of the facility investigation report, completed by the ADM, dated 01/29/23 documented a resident-to-resident incident involving Resident #4 and Resident #5 wherein Resident #4 reported that Resident #5 came up to him in the dining room and slapped him on the head. Observation of Resident #5 in activities on 05/10/23 at 10:33 AM revealed he was seated at a table by himself. An interview with Resident #4 on 05/10/23 at 10:14 AM recalled the incident on 01/29/23-Resident #5 stated he was in the dining room waiting for breakfast and talking to his friend at the table and Resident #5 came up to him and hit him on the head for no reason. Resident #4 stated he asked Resident #5, How come you hit me? I didn't do nothing to you. Resident #4 stated he did not know Resident #5 was behind him. Resident #4 stated Resident #5 told him he needed to hush. Resident #4 stated he was singing, and he sang every morning about Jesus and thanked him for a beautiful morning. Resident #4 stated after Resident #5 hit him, LVN A took him away somewhere (he did not know where), and he ate his breakfast. Resident #4 stated he could not go into the dining room anymore until Resident #5 leaves (the dining room). Resident #4 stated he did not have any pain or anything (after he was slapped). Resident #4 stated the staff tells Resident #5 to leave him alone because he sang well. Resident #4 stated Resident #5 had not hit him again since. A record review of the facility investigation report witness statement written by LVN A stated Resident #4 reported to her after Resident #5 slapped him on the head. LVN A interviewed Resident #5 as to why he struck Resident #4. Resident #5 stated, Because he's mean, and I don't like him and the noise he makes. LVN A described Resident #5's behavior when he left the dining room as, Resident #5 got upset, threw his chair, and told her to go to hell as he left the dining room. LVN A was not available for an interview during this survey. An interview with Resident #5 on 05/10/23 at 1:20 PM stated he did not recall the incident but stated he gets mad sometimes for no reason and that he had hit people before. Resident #5 stated his head was messed up. Resident #5 then stated he hit someone a long time ago but no one since then. When asked why he hit the other resident, he stated, I forgot. Resident #5 stated he gets upset easily sometimes but did not know why. Resident #5 had nothing else to say. An interview with the ADM on 05/10/23 at 1:45 PM stated there had been any other incidents with Resident #5. An interview with CNA A on 05/10/23 at 2:25 PM stated if she saw something, she would tell the ADM and put that person in safety or use the chain of command-tell the nurse. CNA A stated she had never had to report abuse in her [AGE] years of experience. An interview with CNA B on 05/10/23 at 2:28 PM stated she had never had to report abuse. CNA B stated abuse was any molestation or anything the residents might do, like hitting or biting-things like that. CNA B stated she would report any kind of abuse to the ADON or the charge nurse or the DON, and especially the ADM. CNA B stated she gets training on abuse & reporting-last time was last month. An interview with the ENV on 05/10/23 at 2:28 PM stated she had never had to report abuse for anybody like a resident or staff. The ENV stated she would tell the ADM because he was the Abuse coordinator. The ENV stated she gets training on abuse at least monthly or if something happened-last training was last month. An interview with the RCS on 05/10/23 at 2:40 PM stated the ADM was the Abuse Coordinator. The RCS stated the ADM had not called the local authorities and he should have. The RCS stated the ADM had not called the local authorities because it was not in the latest guideline he referred to. The RCS stated the ADM was advised to go by the facility policy. The RCS stated her director of clinical operations said the same thing. The RCS stated multiple in-services on abuse and reporting abuse have been done. The RCS stated she did not know if the ADM had attended one. An interview with the DON on 05/10/23 at 2:44 PM stated abuse should be reported immediately to the abuse coordinator (ADM) first, then her, whom she would report to the ADM. The DON stated reporting to the local authorities should be part of the reporting requirements. The DON stated she placed the plan (care plans) that staff had to be with the smokers, and a staff member was always with the smokers and individually if only one of the residents wanted to go to smoke. The DON stated she was responsible for care planning and in-services to the nursing staff. The DON stated the ADM did not ask her advice on whether he should or should not call the local authorities. An interview with the ADM on 05/10/23 at 3:00 PM stated he did not call the local authorities because he had not associated the sexual abuse and abuse with a crime. The ADM stated that had the sexual abuse and the abuse had been from an outside person, it would have triggered to call the local authorities. The ADM stated he was not advised by anyone to not call the authorities when he consulted with corporate. The ADM stated it was important to tell local authorities if there were a crime. The ADM stated he didn't think the sexual abuse and abuse was a crime. The ADM stated he called HHSC, had a group meeting with corporate and it did not come up and he could not say why he did not report the sexual abuse and abuse to the local authorities. The ADM stated he could understand if the sexual abuse was an aggressive kind of situation, but it was not, and it just did not click. The ADM provided police reports for intakes 407620, 402567, and 405763. The reports were dated 05/09/23 at 4:29 PM. The ADM stated he had not read the facility policy on abuse. A record review of the facility policy, Abuse, Neglect, and Exploitation dated 08/15/22 documented that abuse means the willful infliction of injury . willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Law enforcement is the full range of potential responders to elder abuse, neglect, and exploitation including police, sheriffs, detectives, public safety officers . Under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse . 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse . to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Under II. Employee Training, C. Topics will include 1. Prohibiting and preventing all forms of abuse .2. Identifying what constitutes abuse .3. Recognizing signs of abuse .4. Reporting process for abuse . Under VII. Reporting/Response, A. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .

Based on observation, interview and record review, the facility failed to store all drugs and biological's in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys for one nurse medication cart (200 Hall) out of three medication carts reviewed for labeling and storage of biologicals, in that: 1a. LVN E left the 200 Hall medication cart unlocked and unattended. b. LVN E left Resident #85's insulin vial on top of the medication cart unlocked and unattended. 2. The facility failed to store controlled medications awaiting to be destroyed in a permanently affixed compartment for storage. These deficient practices could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel. The findings included: 1a &b. Observation of 09/28/22 at 7:45 AM of the 200 Hall medication nurse cart revealed the cart was unlocked and not attended to by any staff. At 7:47 AM, LVN E opened the door, walked out of Resident #85's room, which was located across from the medication cart, and immediately said I left it unlocked, I walked in the room and forgot to lock it. LVN E said the medication cart should be locked when not in use. LVN E said leaving the medication cart unlocked could lead to a resident or anyone else getting in the cart and taking medications that were not prescribed to them. Observation of medication pass on 08/28/22 at 07:47 AM revealed LVN E administered Resident #85 her medications. LVN E walked out of Resident #85's room holding Resident #85's [MEDICATION(S)] (A drug used to control the amount of sugar in the blood of patients with diabetes) vial then set the vial on top of the medication cart. Approximately 30 seconds later, LVN E walked back into Resident #85's room and bathroom to wash her hands leaving the [MEDICATION(S)] insulin vial on top of the medication cart, unsecured and out of her line of sight. Interview with LVN E on 09/28/22 at 7:58 AM revealed she said she forgot she left Resident #85's [MEDICATION(S)] vial on top of the medication cart unsupervised. LVN E said she should have put the vial back in her medication cart and lock it. LVN E said she knew she should not leave medication unlocked and unsupervised but I wasn't thinking. LVN E said she did not recall when she last received any training on proper medication storage but had been a nurse working in a hospital and knew about keeping medications locked. LVN E said leaving the medication out unlocked and unsupervised could allow easy access to the medication by anyone and possibly cause an adverse reaction. Interview with the Director of Nurses (DON) and the Administrator on 09/30/22 at 8:53 AM revealed the DON said medication carts should be locked at all times, when not in use. The DON said medications should not be left on top of the medication cart unsupervised. The DON said medications should not be left unsupervised because anyone could get the medication and take it and possibly ingest it and have a reaction. The DON and Administrator said they both conducted rounds throughout the facility multiple times a day checking medication carts. Record review of LVN E's Orientation Skills Checklist dated 07/21/22 revealed she demonstrated competency in the areas of pharmacy services and medication administration. 2. Inspection of the facility's designated controlled medication storage located in the Director of Nurses (DON) office locked closet revealed 17 controlled medications were stored in the two drawer file cabinet. The file cabinet was not permanently affixed to the wall or floor. The DON demonstrated repositioning of the cabinet when removing the medications from the top drawer. The following medication blister packs and/or liquids were located in the top drawer: [MEDICATION(S)] (pain medication used to treat mild to moderate pain) 50 milligrams (mg) blister pack - 88 tablets [MEDICATION(S)] (narcotic analgesic agent for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] (used to prevent and control seizures) 0.25 mg blister pack - 45 tablets Acetaminophen with [MEDICATION(S)] (used to relieve mild to moderate pain) 100 mg/ 5 ml solution - 300 ml solution [MEDICATION(S)] 5 mg-325 mg blister pack - 34 tablets [MEDICATION(S)] (opioid drug used to treat moderate to severe pain) 100 mg/5 ml solution - 29.25 ml solution [MEDICATION(S)] [MEDICATION(S)] (used to treat anxiety) 2 mg/ml solution - 20.75 ml solution [MEDICATION(S)] (used to treat anxiety and panic disorders) 0.5 mg tablets - 91 tablets Interview with the DON on 09/30/22 at 10:53 AM revealed she said she did not know the cabinet should be permanently affixed. The DON said she had not have a permanently affixed storage area for the controlled medications. The DON said the controlled medications should be in a permanently affixed area to prevent from someone taking the entire cabinet with the medications in it. Interview with the DON on 09/30/22 at 2:01 PM revealed she said she searched the facility's policy and procedures and did not have a policy regarding storage of controlled medications needing to be stored in a permanently affixed compartment storage. Record review of the facility's Controlled Substance Destruction policy and procedure dated 10/01/19 documented Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Record review of the facility's Medication Carts and Supplies for Administering Meds policy and procedure dated 10/01/19 documented .The mobile medication cart will be used to facilitate administration of medications to residents. The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. Med Carts: .2. The medication cart is locked at all times when not in use. 3. Do not leave the medication cart unlocked or unattended in the resident care areas. 4. Wheel the medication cart to the resident's room when passing medications or park the medication cart in the doorway of the room with drawers facing the nurse as she/he stands in the room. The cart must maintain in your line of sight when it is not locked. Medication Administration Guidelines: .f. Don't leave bottles or cards. etc. out on top of the med cart or counter. Keep wandering or mentally impaired patients in mind. g. Wash you hands with soap and water or sanitize your hands before giving someone medication. h. Wash your hands after you give someone medication. P. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by .

Based on observation, interview and record review. The facility failed to implement its policies and procedures that prohibit neglect of residents for three Residents (R#1, R #20 and R #9) of 23 Residents reviewed for neglect. R #1's Oxygen was set at 2 LPM on portable Oxygen tank and the physician's orders [REDACTED].#1 to receive 3 LPM PRN. R #1 exhibited signs and symptoms of [MEDICAL CONDITION] during a shower and was not assessed for [MEDICAL CONDITION] until SaO2 Saturation levels were requested by State Surveyor. R #1 had Physician order [REDACTED]. R #9 did not receive oxygen (O2) as ordered by the physician. R #20 did not receive oxygen (O2) as ordered by the physician. This deficient practice placed 23 residents at risk for [MEDICAL CONDITION] and 74 residents receiving preventable skin care due to not receiving assessments, care and services needed to prevent delay in treatment, further skin breakdown, complications and possible death. The Findings were: R #1 R #1's Face Sheet (no date) revealed R #1 was an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] Fibrillation (abnormal electrical conduction in the heart), [MEDICAL CONDITION], Heart Failure, Malnourished, [MEDICAL CONDITION] (lung disease causing impaired gas exchange in the lungs) and Liver Aneurysm. R #1's significant change Minimum (MDS) data set [DATE] revealed R #1 was able to make himself understood and was understood by others. R #1 had clear speech. R #1's Brief Interview for Mental Status (BIMS) was scored 10 (cognition was moderately impaired). R #1 required extensive assistance by two people for bed mobility, transfers, dressing, and personal hygiene. R #1 had a Stage III pressure ulcer. R #1 was assessed as having occasional pain, and had received oxygen therapy. R #1's Care Plan revealed Problem Onset: [DATE] (R #1) requires Oxygen Therapy R/T [MEDICAL CONDITION], He is at risk for ineffective breathing, decreased activity tolerance and anxiety Goal and Target Date *Will Maintain Therapeutic O2 Saturation levels Over the Next 90 days *Will not have any complications related to [MEDICAL CONDITION] over the next 90 days Approaches *Observe for C/O SOB, Dyspnea (and) difficulty breathing *Oxygen: O2 @ 3 Liters Per Nasal Cannula PRN to relieve S/S of [MEDICAL CONDITION] related to respiratory distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other *Report any abnormal O2 SAT level or increased SOB to MD (and) RP ASAP . R #1's consolidated Physician order [REDACTED]. Oxygen: O2 (at) 2 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other R #1's Skilled Nursing MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen: O2 (at) 2 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other On [DATE] and [DATE] MAR was initialed as given and coded 3 6:00 a.m.-2:00 p.m. shift On [DATE] and [DATE] MAR was initialed as given and coded 2 2:00 p.m.-10:00 p.m., and 10:00 p.m.-6:00 a.m. shifts. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. shift and initialed and coded 2 as given on the 2:00 p.m.-10:00 p.m. shift On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts and initialed as given and coded 2 on the 10:00 p.m.-6:00 a.m. shift. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 10:00 p.m.-6:00 a.m. shift., then on the 2:00 p.m.-10:00 p.m. shift was initialed as given but there was no code documented. On [DATE] MAR was initialed as given and coded 3 on the 6:00 a.m.-2:00 p.m. shift and initialed as given and coded 0 on the 2:00 p.m.-10:00 p.m. shift. On [DATE] MAR was initialed as given and coded 3 on the 6:00 a.m.-2:00 p.m. shift. On [DATE], [DATE] and [DATE], MAR was initialed as given and coded (blank) on the 6:00 a.m.-2:00 p.m. shift, and initialed as given and coded 0 on the 2:00 p.m.-10:00 p.m. shifts. There was no further documentation on this MAR that O2 PRN was given and there was a notation indicating there was an order change. There was a second MAR with documentation starting on [DATE]. R #1's Blank MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sats Record Results 8. Other On [DATE] through [DATE] MAR was initialed as given and there was no coding documented on the 6:00 a.m.-2:00 p.m. shift. On [DATE] through [DATE] MAR was initialed as given and there was no coding documented on the 6:00 a.m.-2:00 p.m. shift. On [DATE] through [DATE], [DATE], [DATE], [DATE] and [DATE] MAR was initialed as given and there was no coding documented on the 10:00 p.m.-6:00 a.m. shift. R #1's consolidated Physician order [REDACTED]. (start date [DATE]) R #1's consolidated Physician order [REDACTED]. Oxygen: O2 (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other R #1's Skilled Nursing MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen: O2 (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other There was no documentation [DATE] and [DATE] that R #1 received Oxygen. On [DATE] MAR was initialed as given coded 2 on the 6:00 a.m.-2:00 p.m. shift. On [DATE] at 10:12 a.m., observation accompanied by LVN X revealed R #1's was lying in bed awake with oxygen concentrator set at 3 LPM. There was a round sticker on the oxygen concentrator with the number 3 written on it. R #1 had scratch marks to his bilateral upper extremities. R #1 said his arms itched and started scratching at his arms. Interview with R #1 said he was a retired firefighter in the city for [AGE] years. R #1 said his wife was deceased , and that he did not have any children. R #1 was orientated to person and place. LVN X said R #1 was always scratching himself because of his liver problems. ( R#1 was not wearing any Geri Sleeves) On [DATE] at 5:38 p.m., R #1 was lying in bed with no Geri Sleeves on his bilateral upper extremities. On [DATE] at 8:40 a.m., observation revealed R #1 was in the shower room fully clothed with his coat on. CNAs L and M were in the shower room with R #1. CNA L said R #1 was usually bathed by Hospice but on the days Hospice aides do not come that they get him out of bed for a shower because the Hospice aides only give R #1 a bed bath and R #1 prefers a shower. Surveyor observation revealed R #1's portable O2 tank was set at 2 LPM, R #1 had a Nasal cannula in place. CNAs L and M removed R #1's coat and asked him if he was ready for his shower. R #1 said yes and said he was cold. As CNAs L and M were removing R #1's clothing R #1 began to have muscle twitching and said Ouch, what was that? CNA L said, Are you OK (R#1) are you ready for your shower? R #1 said go ahead you are going to do what you want to do anyway. CNA M said, do you want to take a shower (R #1)? R #1 said, I don't know I need some air, my nose is stopped up, I feel nauseous, I feel like I could throw up. CNA L said she was going to go get the nurse because R #1's oxygen tubing needed to be disconnected because it was wrapped around the wheel chair. (R #1 did not have Geri Sleeves on when CNAs removed his coat) At 8:48 a.m., RN P entered the shower room with CNA L. RN P disconnected the O2 tubing, untangled it from the wheel chair and reconnected the tube to the O2 tank. R #1 said, I feel dizzy then yelled out help, help, someone call the paramedic RN P asked R #1 if he was in pain. R #1 started to have muscle twitching again and said Ouch, what was that? Surveyor asked RN P to please take a pulse oximeter reading on R #1. RN P reached into her pocket and pulled out a pulse oximeter and attached it to R #1's right first digit. The reading was 85%-86% and the pulse was 98. Surveyor asked RN P what the O2 setting was set at on R #1's O2 tank. RN P said 2 LPM per the physician's orders [REDACTED].>-RN P left the shower room and returned at 8:57 a.m. with a white pill in a cup. RN P said R #1's O2 was supposed to be set at 3 LPM,and she changed the O2 setting to 3 LPM. -At 9:00 a.m., RN P checked R #1's O2 Sats and obtained a reading of 83% and the pulse rate was 97. RN P asked R #1 if he wanted to take a pain pill. R #1 said no. RN P said she would have to waste the pain medication and left the room. -RN P returned to the shower room at 9:10 a.m., and after several failed attempts of not being able to obtain a reading for R #1's O2 Sats the oximeter reading was 79%. RN P said she was not sure if her pulse oximeter was functioning properly and said she was going to get another meter. -At 9:13 a.m., CNAs L and M transferred R #1 from the wheel chair to the shower chair. -At 9:16 a.m., RN P returned to the shower room with another O2 tank and said the tank he was currently using was showing that 1000 psi of air was used already and that was not possible because she just put a brand new full tank on R #1 this a.m. a couple of hours ago. -At 9:18 a.m. RN P attempted several times to obtain R #1's O2 Sats without success (the pulse oximeter was not registering % of Oxygen). Surveyor asked if she was using the same meter and RN P said, yes. RN P turned R #1's oxygen up to 4 LPM and said she would return after R #1's shower to recheck R #1's O2 Sats. (RN P left R #1 for 47 minutes before re-assessing R #1's respiratory status) -At 10:05 a.m., RN P returned to the shower room and obtained R #1's O2 Sats; R #1's right first digit reading was 74%, at 10:07 a.m., R #1's left fifth digit reading was 82%. -At 10:15 a.m. RN P said she was told by the Director of Nurses (DON) that R #1's O2 was ordered for 2 LPM and that she did not change the O2 rate. RN P said the DON set R #1's O2 at 2 LPM. RN P said if O2 was not administered per Physician order [REDACTED]. RN P said, I feel so stupid, I should have checked the order myself. I was just doing what I was told. -At 10:19 a.m. (R #1 had returned to his room and was lying in bed) RN P changed R #1's O2 portable oxygen to R #1's oxygen concentrator and set the O2 at 4 LPM. RN P said she had called Hospice earlier and obtained orders for O2 ,[DATE] Liters PRN. -At 10:25 a.m. RN P checked R #1's O2 Sats and the Oximeter reading was 92%. RN P said R #1's O2 Sats were much better since increasing the Oxygen rate. On [DATE] at 4:15 p.m., interview with LVN X said she was the ADON for the 200 hall where R #1 resided. LVN X said the documentation for O2 Sats should have been documented on the MAR. LVN X said if the O2 Sats was not documented on R #1's MARs then his Sats were not taken. LVN X said it was important for the nurses to obtain O2 Sats when a resident was on oxygen to ensure the resident was receiving the adequate oxygenation. LVN X said she had heard about R #1 received wrong rate for his oxygen but was not aware R #1's Sats dropped as low as 74%. On [DATE] at 4:46 p.m. R #1 was lying in bed and did not have his Geri Sleeves on. On [DATE] at 1:25 p.m., interview with CNA L said R #1 should have Geri Sleeves on all the time because R #1 was always scratching himself and had fragile skin. CNA L said the CNA that was assigned to R #1 could look up in the Kiosk and they would know that he had Geri Sleeves. On [DATE] at 1:35 p.m., interview with CNA W said she was just helping out on the 200 hall on [DATE]. CNA W said R #1 always had Geri Sleeves on when he first was admitted to another floor and did not know if R #1 still was suppose to wear the Geri Sleeves. CNA W said who ever bathed R #1 would know if R #1 was supposed to wear Geri Sleeves. On [DATE] at 9:00 a.m., interview with CNA M said she was just helping out with R #1's bath [DATE] and did not know if R #1 was to have Geri Sleeves on. CNA M said any aide assigned to R #1 could have looked up his care plan in the Kiosk or asked the Charge Nurse. On [DATE] at 1:45 p.m., DON said that she was told yesterday morning by LVN K that R #1's Oxygen order was for 2 LPM and she instructed LVN K to set R #1's Oxygen rate to 2 LPM. On [DATE] at 5:50 p.m., Surveyor notified the DON R #1 did not have Geri Sleeves on [DATE] or [DATE]. DON said, (R #1) had his sleeves on yesterday. Review of LVN K's written Witness Statement dated [DATE] at 2:00 p.m. revealed on [DATE] at around 8:30 a.m. the DON asked LVN K to check R #1's oxygen orders for rate. LVN K checked R #1's consolidated orders which were for oxygen 2 LPM so LVN K notified the DON. The DON directed LVN K to change the oxygen flow rate on R #1's tank to 2 LPM and LVN K changed the rate to 2 LPM. LVN K wrote she had recently returned to work on [DATE] and was unaware the facility had changed systems and was unaware R #1 was admitted back to Hospice. LVN K's written statement revealed after R #1 was taken down the hall she checked R #1's orders and saw that behind the consolidated orders there was an order for [REDACTED]. R #9 Record review of R #9's Face Sheet dated [DATE] revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. R #9's [DIAGNOSES REDACTED]. Record review of R #9's admission MDS dated [DATE] revealed she was cognitively intact and she was able to make herself understood and she understood others. The MDS indicated she had a Foley catheter and was occasionally incontinent of bowel. Other health conditions such as shortness of breath was not checked. Respiratory treatments were not checked. Record review of R #9's Physician orders [REDACTED]. O2 at 2 liters per nasal cannula (tubing) continuously to relieve [MEDICAL CONDITION] related to shortness of breath (SOB), [DIAGNOSES REDACTED]. During an observation and interview on [DATE] at 9:30 a.m., accompanied by LVN A, R #9 was resting in her bed. A O2 concentrator with a nasal cannula was next to the bed. R #9 was not wearing the O2. The canister was turned off. R #9 stated she did not wear the O2 any longer and did not need it. LVN A stated R #9 did not want to wear the O2 any longer and R #9 would not keep the nasal cannula in her nose. During an observation and interview, accompanied by LVN A, on [DATE] at 5:00 p.m. revealed R #9 sitting up in bed. R #9 did not have O2 on, the canister and cannula was next to the bed. LVN A took R #9 O2 saturation and it was between 94% and 96%. LVN A stated an O2 saturation over 92% was good and she would call R #9's Physician and have the O2 order changed to as needed for SOB. R #9 had regular respirations and no SOB. R #9 stated she did not need the O2 any longer. R #20 Record review of R #20's face Sheet dated [DATE] revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of R #20's admission MDS dated [DATE] revealed she was cognitively intact and she was able to make herself understood and she understood others. [MEDICAL CONDITION] was checked as a diagnosis, Shortness of Breath was not checked and Respiratory treatments were checked. Record review of R #20's Physician orders [REDACTED]. O2 at 3 liters per minute per nasal cannula continuously to relieve [MEDICAL CONDITION] related to SOB. Diagnoses: [REDACTED]. In an observation on [DATE] at 2:00 p.m. revealed R #20 resting in bed. R #20 was awake with O2 nasal cannula on the concentrator was set at 5 liters per minute. During an observation and interview on [DATE] at 3:15 p.m. LVN D confirmed R #20's O2 was set at 5 liters. LVN D set the O2 at 2 liters. LVN D stated R #20 used 2 liters of O2. LVN D pointed out the sticker on R #20's concentrator that was labeled 2L, LVN D stated that sticker indicated how many liters the resident was to receive. During an observation and interview on [DATE] at 3:40 p.m. LVN A confirmed R #20's O2 was set at 2 liters. LVN A reviewed R #20's Physician orders [REDACTED]. LVN A changed R #20's O2 to 3 liters. LVN A removed the sticker that had 2L from the concentrator. LVN A stated the sticker was incorrect and she would replace it. Observation on [DATE] at 11:55 a.m. revealed R #20 up in a chair at bedside. Surveyor observed the O2 concentrator was off. R #20 had the nasal cannula on. During an observation and interview on [DATE] at 12:00 p.m. LVN F confirmed R #20's concentrator was off. LVN F stated R #20 had came back from a shower about 45 minutes ago and she reconnected R #20 to the O2. LVN F stated the concentrator may have accidentally been turned off when R #20 was moved and getting R #20 positioned in the chair at the bedside. LVN F turned the concentrator on and it was set at 3 liters. Review of Facility Policy and Procedure Revised date ,[DATE] titled Facility Abuse Prohibition Policy and Procedure .Policy Use Statement: This policy is intended to set out all practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and comply with applicable nursing home regulations as required by law . On [DATE] at 2:55 p.m., interview with the Administrator revealed she refers to the Provider Letter ,[DATE] as part of the Abuse/Neglect protocol. According to Provider Letter ,[DATE] [DATE] Neglect .'The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness .The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident .' On [DATE] at 1:45 p.m., DON gave surveyor a copy from Lippincott's Nursing Procedures and said the facility did not have a policy and procedure for oxygen use because they used Lippincott. Review of Lippincott's Page 573 titled Oxygen Administration revealed A patient will need oxygen therapy when hypoxemia results from respiratory or cardiac emergency or an increase in metabolic function .The adequacy of oxygen therapy is determined by arterial blood gas analysis, oximetry monitoring, and clinical examinations .Implementation *Verify the practitioner's order for the oxygen therapy because oxygen is considered a medication or therapy and should be prescribed .*Obtain a baseline physical assessment, including vital signs, breath sounds, oxygen saturation, and physical assessment . According to Physician order [REDACTED]. According to Centers of Medicare and Medicaid Services 672 dated [DATE] revealed there was 73 residents in the facility receiving preventative skin care.

Based on observation, interview and record review. The facility failed to implement its written policies and procedures that prohibit neglect of residents for three Residents (R#1, and R #20) of 23 Residents reviewed for abuse and neglect. The facility failed to screen employees prior to employment. -R #1's Oxygen was set at 2 LPM on portable Oxygen tank and the physician's orders [REDACTED].#1 to receive 3 LPM PRN. R #1 exhibited signs and symptoms of [MEDICAL CONDITION] during a shower and was not assessed for [MEDICAL CONDITION] until SaO2 Saturation levels were requested by State Surveyor. R #1 had Physician order [REDACTED]. -R #20's wheelchair was not strapped down properly which resulted in pain to her back and left elbow. The facility did not immediately report the incident to the Texas Department of Aging and Disability services (DADS). -The facility did not complete reference checks on two employees, Med Aide H and CNA V, of two employees reviewed for compliance with facility hiring practices for new employees. These deficient practices placed 23 residents at risk for [MEDICAL CONDITION] and 74 residents receiving preventable skin care due to not receiving assessments, care and services needed to prevent delay in treatment, further skin breakdown, complications and possible death. In addition it placed 112 Residents at risk of being abused, neglected or mistreated by employees who had a history of [REDACTED]. The Findings were: Review of Facility Policy and Procedure Revised date ,[DATE] titled Facility Abuse Prohibition Policy and Procedure .Policy Use Statement: This policy is intended to set out all practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and comply with applicable nursing home regulations as required by law . Procedure: The facility abuse prohibition policy includes but is not limited to the following components: screening of potential employees; . Component I: Screening The facility administrative staff will use reasonable efforts not to knowingly hire any individual who has a history of abusing other persons. The facility will generally conduct employment background screenings, reference checks and criminal conviction investigation checks on all individuals making application for employment with the facility. On [DATE] at 2:55 p.m., interview with the Administrator revealed she refers to the Provider Letter ,[DATE] as part of the Abuse/Neglect protocol. According to Texas Department of Aging and Disability Services Provider Letter ,[DATE] [DATE] Neglect .'The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness .The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident .Facility staff must report abuse, neglect, exploitation and other incidents to: DADS Consumer Rights and Services Section (800) [PHONE NUMBER] immediately (within 24 hours) upon learning of the incident and send a written investigation report to the Consumer Rights and Services Section within 5 working days after the telephone report. On [DATE] at 1:45 p.m., DON gave surveyor a copy from Lippincott's Nursing Procedures and said the facility did not have a policy and procedure for oxygen use because they used Lippincott. Review of Lippincott's Page 573 titled Oxygen Administration revealed A patient will need oxygen therapy when hypoxemia results from respiratory or cardiac emergency or an increase in metabolic function .The adequacy of oxygen therapy is determined by arterial blood gas analysis, oximetry monitoring, and clinical examinations .Implementation *Verify the practitioner's order for the oxygen therapy because oxygen is considered a medication or therapy and should be prescribed .*Obtain a baseline physical assessment, including vital signs, breath sounds, oxygen saturation, and physical assessment . R #1 R #1's Face Sheet (no date) revealed R #1 was an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] Fibrillation (abnormal electrical conduction in the heart), [MEDICAL CONDITION], Heart Failure, Malnourished, [MEDICAL CONDITION] (lung disease causing impaired gas exchange in the lungs) and Liver Aneurysm. R #1's significant change Minimum (MDS) data set [DATE] revealed R #1 was able to make himself understood and was understood by others. R #1 had clear speech. R #1's Brief Interview for Mental Status (BIMS) was scored 10 (cognition was moderately impaired). R #1 required extensive assistance by two people for bed mobility, transfers, dressing, and personal hygiene. R #1 had a Stage III pressure ulcer. R #1 was assessed as having occasional pain, and had received oxygen therapy. R #1's Care Plan revealed Problem Onset: [DATE] (R #1) requires Oxygen Therapy R/T [MEDICAL CONDITION], He is at risk for ineffective breathing, decreased activity tolerance and anxiety Goal and Target Date *Will Maintain Therapeutic O2 Saturation levels Over the Next 90 days *Will not have any complications related to [MEDICAL CONDITION] over the next 90 days Approaches *Observe for C/O SOB, Dyspnea (and) difficulty breathing *Oxygen: O2 @ 3 Liters Per Nasal Cannula PRN to relieve S/S of [MEDICAL CONDITION] related to respiratory distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other *Report any abnormal O2 SAT level or increased SOB to MD (and) RP ASAP . R #1's consolidated Physician order [REDACTED]. Oxygen: O2 (at) 2 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other R #1's Skilled Nursing MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen: O2 (at) 2 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other On [DATE] and [DATE] MAR was initialed as given and coded 3 6:00 a.m.-2:00 p.m. shift On [DATE] and [DATE] MAR was initialed as given and coded 2 2:00 p.m.-10:00 p.m., and 10:00 p.m.-6:00 a.m. shifts. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. shift and initialed and coded 2 as given on the 2:00 p.m.-10:00 p.m. shift On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts and initialed as given and coded 2 on the 10:00 p.m.-6:00 a.m. shift. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 10:00 p.m.-6:00 a.m. shift., then on the 2:00 p.m.-10:00 p.m. shift was initialed as given but there was no code documented. On [DATE] MAR was initialed as given and coded 3 on the 6:00 a.m.-2:00 p.m. shift and initialed as given and coded 0 on the 2:00 p.m.-10:00 p.m. shift. On [DATE] MAR was initialed as given and coded 3 on the 6:00 a.m.-2:00 p.m. shift. On [DATE], [DATE] and [DATE], MAR was initialed as given and coded (blank) on the 6:00 a.m.-2:00 p.m. shift, and initialed as given and coded 0 on the 2:00 p.m.-10:00 p.m. shifts. There was no further documentation on this MAR that O2 PRN was given and there was a notation indicating there was an order change. There was a second MAR with documentation starting on [DATE]. R #1's Blank MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sats Record Results 8. Other On [DATE] through [DATE] MAR was initialed as given and there was no coding documented on the 6:00 a.m.-2:00 p.m. shift. On [DATE] through [DATE] MAR was initialed as given and there was no coding documented on the 6:00 a.m.-2:00 p.m. shift. On [DATE] through [DATE], [DATE], [DATE], [DATE] and [DATE] MAR was initialed as given and there was no coding documented on the 10:00 p.m.-6:00 a.m. shift. R #1's consolidated Physician order [REDACTED]. (start date [DATE]) R #1's consolidated Physician order [REDACTED]. Oxygen: O2 (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other R #1's Skilled Nursing MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen: O2 (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other There was no documentation [DATE] and [DATE] that R #1 received Oxygen. On [DATE] MAR was initialed as given coded 2 on the 6:00 a.m.-2:00 p.m. shift. On [DATE] at 10:12 a.m., observation accompanied by LVN X revealed R #1's was lying in bed awake with oxygen concentrator set at 3 LPM. There was a round sticker on the oxygen concentrator with the number 3 written on it. R #1 had scratch marks to his bilateral upper extremities. R #1 said his arms itched and started scratching at his arms. Interview with R #1 said he was a retired firefighter in the city for [AGE] years. R #1 said his wife was deceased , and that he did not have any children. R #1 was orientated to person and place. LVN X said R #1 was always scratching himself because of his liver problems. ( R#1 was not wearing any Geri Sleeves) On [DATE] at 5:38 p.m., R #1 was lying in bed with no Geri Sleeves on his bilateral upper extremities. On [DATE] at 8:40 a.m., observation revealed R #1 was in the shower room fully clothed with his coat on. CNAs L and M were in the shower room with R #1. CNA L said R #1 was usually bathed by Hospice but on the days Hospice aides do not come that they get him out of bed for a shower because the Hospice aides only give R #1 a bed bath and R #1 prefers a shower. Surveyor observation revealed R #1's portable O2 tank was set at 2 LPM, R #1 had a Nasal cannula in place. CNAs L and M removed R #1's coat and asked him if he was ready for his shower. R #1 said yes and said he was cold. As CNAs L and M were removing R #1's clothing R #1 began to have muscle twitching and said Ouch, what was that? CNA L said, Are you OK (R#1) are you ready for your shower? R #1 said go ahead you are going to do what you want to do anyway. CNA M said, do you want to take a shower (R #1)? R #1 said, I don't know I need some air, my nose is stopped up, I feel nauseous, I feel like I could throw up. CNA L said she was going to go get the nurse because R #1's oxygen tubing needed to be disconnected because it was wrapped around the wheel chair. (R #1 did not have Geri Sleeves on when CNAs removed his coat) At 8:48 a.m., RN P entered the shower room with CNA L. RN P disconnected the O2 tubing, untangled it from the wheel chair and reconnected the tube to the O2 tank. R #1 said, I feel dizzy then yelled out help, help, someone call the paramedic RN P asked R #1 if he was in pain. R #1 started to have muscle twitching again and said Ouch, what was that? Surveyor asked RN P to please take a pulse oximetry reading on R #1. RN P reached into her pocket and pulled out a pulse oximetry and attached it to R #1's right first digit. The reading was 85%-86% and the pulse was 98. Surveyor asked RN P what the O2 setting was set at on R #1's O2 tank. RN P said 2 LPM per the physician's orders [REDACTED].>RN P left the shower room and returned at 8:57 a.m. with a white pill in a cup. RN P said R #1's O2 was supposed to be set at 3 LPM,and she changed the O2 setting to 3 LPM. At 9:00 a.m., RN P checked R #1's O2 Sats and obtained a reading of 83% and the pulse rate was 97. RN P asked R #1 if he wanted to take a pain pill. R #1 said no. RN P said she would have to waste the pain medication and left the room. RN returned to the shower room at 9:10 a.m., and after several failed attempts of not being able to obtain a reading for R #1's O2 Sats the oximeter reading was 79%. RN P said she was not sure if her pulse oximeter was functioning properly and said she was going to get another meter. At 9:13 a.m., CNAs L and M transferred R #1 from the wheel chair to the shower chair. At 9:16 a.m., RN P returned to the shower room with another O2 tank and said the tank he was currently using was showing that 1000 psi of air was used already and that was not possible because she just put a brand new full tank on R #1 this a.m. a couple of hours ago. At 9:18 a.m. RN P attempted several times to obtain R #1's O2 Sats without success (the pulse oximetry was not registering % of Oxygen). Surveyor asked if she was using the same meter and RN P said, yes. RN P turned R #1's oxygen up top 4 LPM and said she would return after R #1's shower to recheck R #1's O2 Sats. (RN P left R #1 for 47 minutes before re-assessing R #1's respiratory status) At 10:05 a.m., RN P returned to the shower room and obtained R #1's O2 Sats; R #1's right first digit reading was 74%, at 10:07 a.m., R #1's left fifth digit reading was 82%. At 10:15 a.m. RN P said she was told by the Director of Nurses (DON) that R #1's O2 was ordered for 2 LPM and that she did not change the O2 rate. RN P said the DON set R #1's O2 at 2 LPM. RN P said if O2 was not administered per Physician order [REDACTED]. RN P said, I feel so stupid, I should have checked the order myself. I was just doing what I was told. At 10:19 a.m. (R #1 had returned to his room and was lying in bed) RN P changed R #1's O2 portable oxygen to R #1's oxygen concentrator and set the O2 at 4 LPM. RN P said she had called Hospice earlier and obtained orders for O2 ,[DATE] Liters PRN. At 10:25 a.m. RN P checked R #1's O2 Sats and the Oximetry reading was 92%. RN P said R #1's O2 Sats were much better since increasing the Oxygen rate. On [DATE] at 4:15 p.m., interview with LVN X said she was the ADON for the 200 hall where R #1 resided. LVN X said the documentation for O2 Sats should have been documented on the MAR. LVN X said if the O2 Sats was not documented on R #1's MARs then his Sats were not taken. LVN X said it was important for the nurses to obtain O2 Sats when a resident was on oxygen to ensure the resident was receiving the adequate oxygenation. LVN X said she had heard about R #1 received wrong rate for his oxygen but was not aware R #1's Sats dropped as low as 74%. On [DATE] at 4:46 p.m. R #1 was lying in bed and did not have his Geri Sleeves on. On [DATE] at 1:25 p.m., interview with CNA L said R #1 should have Geri Sleeves on all the time because R #1 was always scratching himself and had fragile skin. CNA L said the CNA that was assigned to R #1 could look up in the Kiosk and they would know that he had Geri Sleeves. On [DATE] at 1:35 p.m., interview with CNA W said she was just helping out on the 200 hall on [DATE]. CNA W said R #1 always had Geri Sleeves on when he first was admitted to another floor and did not know if R #1 still was suppose to wear the Geri Sleeves. CNA W said who ever bathed R #1 would know if R #1 was supposed to wear Geri Sleeves. On [DATE] at 9:00 a.m., interview with CNA M said she was just helping out with R #1's bath [DATE] and did not know if R #1 was to have Geri Sleeves on. CNA M said any aide assigned to R #1 could have looked up his care plan in the Kiosk or asked the Charge Nurse. On [DATE] at 1:45 p.m., DON said that she was told yesterday morning by LVN K that R #1's Oxygen order was for 2 LPM and she instructed LVN K to set R #1's Oxygen rate to 2 LPM. On [DATE] at 5:50 p.m., Surveyor notified the DON R #1 did not have Geri Sleeves on [DATE] or [DATE]. DON said, (R #1) had his sleeves on yesterday. Review of LVN K's written Witness Statement dated [DATE] at 2:00 p.m. revealed on [DATE] at around 8:30 a.m. the DON asked LVN K to check R #1's oxygen orders for rate. LVN K checked R #1's consolidated orders which were for oxygen 2 LPM so LVN K notified the DON. The DON directed LVN K to change the oxygen flow rate on R #1's tank to 2 LPM and LVN K changed the rate to 2 LPM. LVN K wrote she had recently returned to work on [DATE] and was unaware the facility had changed systems and was unaware R #1 was admitted back to Hospice. LVN K's written statement revealed after R #1 was taken down the hall she checked R #1's orders and saw that behind the consolidated orders there was an order for [REDACTED]. R #20 Record review of the facility's policy Reporting/Response dated ,[DATE] revealed .The facility Administrator/Designee will report all allegations of abuse, neglect and exploitation to the Texas Department of Human Services . . Record review of R #20's face Sheet dated [DATE] revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of R #20's admission MDS dated [DATE] revealed she was cognitively intact and she was able to make herself understood and she understood others. [MEDICAL CONDITION] was checked as a diagnosis, Shortness of Breath was not checked and Respiratory treatments were checked. Review of the facility Resident Incident Report revealed the following description of the incident: On [DATE] at approximately 3:30 p.m. R #20 was on the facility van and the front wheels of her wheelchair were not strapped down. When the van came to a stop her wheelchair tilted backwards. The front wheels came off the floor when the wheelchair tilted backwards. The back of the wheelchair had a oxygen tank and the wheelchair did not tilt any farther, it was resting on the seat frame behind it. The van driver pulled into the appointment office parking lot. R #20 stated her back hurt from the oxygen tank pushing against her back when she was tilted. When R #20 returned to the facility she complained of pain to her back and left elbow. Tylenol #3 was given and a x-ray to the spine/[MEDICATION NAME] area was ordered and a CT SCAN of the elbow was ordered. The x-ray and CT SCAN were negative for fractures. In an interview on [DATE] at 300 p.m. the Administrator stated the incident involving R #20 did not fall into the category to be reported. The Administrator stated examples of incidents to report were unwitnessed injuries, and injuries of unknown origin. The Administrator stated there was no injury to R #20. The Administrator stated the x-ray and CT SCAN showed no fracture. The Administrator stated the van driver was not willingly neglectful but had omitted strapping the front wheelchair wheels. Record review of Texas Department of Aging and Disability Services Provider Letter #,[DATE] dated [DATE] indicated the following; Facility staff must report abuse, neglect, exploitation and other incidents to: DADS Consumer Rights and Services Section (800) [PHONE NUMBER] immediately (within 24 hours) upon learning of the incident and send a written investigation report to the Consumer Rights and Services Section within 5 working days after the telephone report. Reference Checks: Review of Med Aide H's Personnel Record revealed he was hired on [DATE]. Review of Employee Reference Check found in Med Aide H's Personnel record revealed no reference checks had been completed prior to Med Aide H's hire date. Review of CNA V's Personnel Record revealed he was hired on [DATE]. Review of Employee Reference Check found in CNA V's Personnel record revealed no reference checks had been completed prior to CNA V's hire date. In an interview on [DATE] at 4:00 p.m., Human Resources Coordinator (HR) J said the facility had a policy that all new applicants were required to have reference checks completed prior to their hire date. HR J said she did not know why reference checks were incomplete with Med Aide H and CNA V. According to Physician order [REDACTED]. According to Centers of Medicare and Medicaid Services 672 dated [DATE] revealed there was 73 residents in the facility receiving preventative skin care and a census of 112 Residents.

Based on observation, interview and record review the facility failed to ensure proper treatment and care for three Residents (R #1, R #9 and R #20) of five Residents reviewed for oxygen services. R #1's Oxygen was set at 2 LPM on portable Oxygen tank and the physician's orders [REDACTED].#1 to receive 3 LPM PRN. R #1 exhibited signs and symptoms of [MEDICAL CONDITION] during a shower and was not assessed for [MEDICAL CONDITION] until SaO2 Saturation levels were requested by State Surveyor. R #9 did not receive oxygen (O2) as ordered by the physician. R #20 did not receive oxygen (O2) as ordered by the physician. These deficient practices placed 23 residents at risk for [MEDICAL CONDITION] due to not receiving assessments, care and services needed to prevent delay in treatment, complications and possible death. The findings were: R #1 R #1's Face Sheet (no date) revealed R #1 was an [AGE] year old male admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] Fibrillation (abnormal electrical conduction in the heart), [MEDICAL CONDITION], Heart Failure, Malnourished, [MEDICAL CONDITION] (lung disease causing impaired gas exchange in the lungs) and Liver Aneurysm. R #1's significant change Minimum (MDS) data set [DATE] revealed R #1 was able to make himself understood and was understood by others. R #1 had clear speech. R #1's Brief Interview for Mental Status (BIMS) was scored 10 (cognition was moderately impaired). R #1 required extensive assistance by two people for bed mobility, transfers, dressing, and personal hygiene. R #1 had a Stage III pressure ulcer. R #1 was assessed as having occasional pain, and had received oxygen therapy. R #1's Care Plan revealed Problem Onset: [DATE] (R #1) requires Oxygen Therapy R/T [MEDICAL CONDITION], He is at risk for ineffective breathing, decreased activity tolerance and anxiety Goal and Target Date *Will Maintain Therapeutic O2 Saturation levels Over the Next 90 days *Will not have any complications related to [MEDICAL CONDITION] over the next 90 days Approaches *Observe for C/O SOB, Dyspnea (and) difficulty breathing *Oxygen: O2 @ 3 Liters Per Nasal Cannula PRN to relieve S/S of [MEDICAL CONDITION] related to respiratory distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other *Report any abnormal O2 SAT level or increased SOB to MD (and) RP ASAP . R #1's consolidated Physician order [REDACTED]. Oxygen: O2 (at) 2 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other R #1's Skilled Nursing MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen: O2 (at) 2 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other On [DATE] and [DATE] MAR was initialed as given and coded 3 6:00 a.m.-2:00 p.m. shift On [DATE] and [DATE] MAR was initialed as given and coded 2 2:00 p.m.-10:00 p.m., and 10:00 p.m.-6:00 a.m. shifts. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. shift and initialed and coded 2 as given on the 2:00 p.m.-10:00 p.m. shift On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 2:00 p.m.-10:00 p.m. shifts and initialed as given and coded 2 on the 10:00 p.m.-6:00 a.m. shift. On [DATE] MAR was initialed as given and coded 0 on the 6:00 a.m.-2:00 p.m. and 10:00 p.m.-6:00 a.m. shift., then on the 2:00 p.m.-10:00 p.m. shift was initialed as given but there was no code documented. On [DATE] MAR was initialed as given and coded 3 on the 6:00 a.m.-2:00 p.m. shift and initialed as given and coded 0 on the 2:00 p.m.-10:00 p.m. shift. On [DATE] MAR was initialed as given and coded 3 on the 6:00 a.m.-2:00 p.m. shift. On [DATE], [DATE] and [DATE], MAR was initialed as given and coded (blank) on the 6:00 a.m.-2:00 p.m. shift, and initialed as given and coded 0 on the 2:00 p.m.-10:00 p.m. shifts. There was no further documentation on this MAR that O2 PRN was given and there was a notation indicating there was an order change. There was a second MAR with documentation starting on [DATE]. R #1's Blank MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sats Record Results 8. Other On [DATE] through [DATE] MAR was initialed as given and there was no coding documented on the 6:00 a.m.-2:00 p.m. shift. On [DATE] through [DATE] MAR was initialed as given and there was no coding documented on the 6:00 a.m.-2:00 p.m. shift. On [DATE] through [DATE], [DATE], [DATE], [DATE] and [DATE] MAR was initialed as given and there was no coding documented on the 10:00 p.m.-6:00 a.m. shift. R #1's consolidated Physician order [REDACTED]. Oxygen: O2 (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other R #1's Skilled Nursing MAR dated ,[DATE] revealed; (start date [DATE]) Oxygen: O2 (at) 3 Liters Per Min Per Nasal Cannula PRN To Relieve S/S Of [MEDICAL CONDITION] Related To Resp Distress. Code S/S: 1. Headache 2. Fatigue 3. SOB 4. Nausea 5. Change In Level Of Consciousness 6. Cyanosis 7. Low O2 Sat Document Results 8. Other There was no documentation [DATE] and [DATE] that R #1 received Oxygen. On [DATE] MAR was initialed as given coded 2 on the 6:00 a.m.-2:00 p.m. shift. On [DATE] at 10:12 a.m., observation revealed R #1's was lying in bed awake with oxygen concentrator set at 3 LPM. There was a round sticker on the oxygen concentrator with the number 3 written on it. Interview with R #1 said he was a retired firefighter in the city for [AGE] years. R #1 said his wife was deceased , and that he did not have any children. R #1 was orientated to person and place. On [DATE] at 8:40 a.m., observation revealed R #1 was in the shower room fully clothed with his coat on. CNAs L and M were in the shower room with R #1. CNA L said R #1 was usually bathed by Hospice but on the days Hospice aides do not come that they get him out of bed for a shower because the Hospice aides only give R #1 a bed bath and R #1 prefers a shower. Surveyor observation revealed R #1's portable O2 tank was set at 2 LPM, R #1 had a Nasal cannula in place. CNAs L and M removed R #1's coat and asked him if he was ready for his shower. R #1 said yes and said he was cold. As CNAs L and M were removing R #1's clothing R #1 began to have muscle twitching and said Ouch, what was that? CNA L said, Are you OK (R#1) are you ready for your shower? R #1 said go ahead you are going to do what you want to do anyway. CNA M said, do you want to take a shower (R #1)? R #1 said, I don't know I need some air, my nose is stopped up, I feel nauseous, I feel like I could throw up. CNA L said she was going to go get the nurse because R #1's oxygen tubing needed to be disconnected because it was wrapped around the wheel chair. At 8:48 a.m., RN P entered the shower room with CNA L. RN P disconnected the O2 tubing, untangled it from the wheel chair and reconnected the tube to the O2 tank. R #1 said, I feel dizzy then yelled out help, help, someone call the paramedic RN P asked R #1 if he was in pain. R #1 started to have muscle twitching again and said Ouch, what was that? Surveyor asked RN P to please take a pulse oximeter reading on R #1. RN P reached into her pocket and pulled out a pulse oximeter and attached it to R #1's right first digit. The reading was 85%-86% and the pulse was 98. Surveyor asked RN P what the O2 setting was set at on R #1's O2 tank. RN P said 2 LPM per the physician's orders [REDACTED].>-RN P left the shower room and returned at 8:57 a.m. with a white pill in a cup. RN P said R #1's O2 was supposed to be set at 3 LPM,and she changed the O2 setting to 3 LPM. -At 9:00 a.m., RN P checked R #1's O2 Sats and obtained a reading of 83% and the pulse rate was 97. RN P asked R #1 if he wanted to take a pain pill. R #1 said no. RN P said she would have to waste the pain medication and left the room. -RN P returned to the shower room at 9:10 a.m., and after several failed attempts of not being able to obtain a reading for R #1's O2 Sats the oximeter reading was 79%. RN P said she was not sure if her pulse oximeter was functioning properly and said she was going to get another meter. -At 9:13 a.m., CNAs L and M transferred R #1 from the wheel chair to the shower chair. -At 9:16 a.m., RN P returned to the shower room with another O2 tank and said the tank he was currently using was showing that 1000 psi of air was used already and that was not possible because she just put a brand new full tank on R #1 this a.m. a couple of hours ago. -At 9:18 a.m. RN P attempted several times to obtain R #1's O2 Sats without success (the pulse oximetry was not registering % of Oxygen). Surveyor asked if she was using the same meter and RN P said, yes. RN P turned R #1's oxygen up to 4 LPM and said she would return after R #1's shower to recheck R #1's O2 Sats. (RN P left R #1 for 47 minutes before re-assessing R #1's respiratory status) -At 10:05 a.m., RN P returned to the shower room and obtained R #1's O2 Sats; R #1's right first digit reading was 74%, at 10:07 a.m., R #1's left fifth digit reading was 82%. -At 10:15 a.m. RN P said she was told by the Director of Nurses (DON) that R #1's O2 was ordered for 2 LPM and that she did not change the O2 rate. RN P said the DON set R #1's O2 at 2 LPM. RN P said if O2 was not administered per Physician order [REDACTED]. RN P said, I feel so stupid, I should have checked the order myself. I was just doing what I was told. -At 10:19 a.m. (R #1 had returned to his room and was lying in bed) RN P changed R #1's O2 portable oxygen to R #1's oxygen concentrator and set the O2 at 4 LPM. RN P said she had called Hospice earlier and obtained orders for O2 ,[DATE] Liters PRN. -At 10:25 a.m. RN P checked R #1's O2 Sats and the Oximeter reading was 92%. RN P said R #1's O2 Sats were much better since increasing the Oxygen rate. On [DATE] at 4:15 p.m., interview with LVN X said she was the ADON for the 200 hall where R #1 resided. LVN X said the documentation for O2 Sats should have been documented on the MAR. LVN X said if the O2 Sats was not documented on R #1's MARs then his Sats were not taken. LVN X said it was important for the nurses to obtain O2 Sats when a resident was on oxygen to ensure the resident was receiving the adequate oxygenation. LVN X said she had heard about R #1 received wrong rate for his oxygen but was not aware R #1's Sats dropped as low as 74%. On [DATE] at 1:45 p.m., DON said that she was told yesterday morning by LVN K that R #1's Oxygen order was for 2 LPM and she instructed LVN K to set R #1's Oxygen rate to 2 LPM. Review of LVN K's written Witness Statement dated [DATE] at 2:00 p.m. revealed on [DATE] at around 8:30 a.m. the DON asked LVN K to check R #1's oxygen orders for rate. LVN K checked R #1's consolidated orders which were for oxygen 2 LPM so LVN K notified the DON. The DON directed LVN K to change the oxygen flow rate on R #1's tank to 2 LPM and LVN K changed the rate to 2 LPM. LVN K wrote she had recently returned to work on [DATE] and was unaware the facility had changed systems and was unaware R #1 was admitted back to Hospice. LVN K's written statement revealed after R #1 was taken down the hall she checked R #1's orders and saw that behind the consolidated orders there was an order for [REDACTED]. R #9 Record review of R #9's Face Sheet dated [DATE] revealed a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. R #9's [DIAGNOSES REDACTED]. Record review of R #9's admission MDS dated [DATE] revealed she was cognitively intact and she was able to make herself understood and she understood others. The MDS indicated she had a Foley catheter and was occasionally incontinent of bowel. Other health conditions such as shortness of breath was not checked. Respiratory treatments were not checked. Record review of R #9's Physician orders [REDACTED]. O2 at 2 liters per nasal cannula (tubing) continuously to relieve [MEDICAL CONDITION] related to shortness of breath (SOB), [DIAGNOSES REDACTED]. During an observation and interview on [DATE] at 9:30 a.m., accompanied by LVN A, R #9 was resting in her bed. A O2 concentrator with a nasal cannula was next to the bed. R #9 was not wearing the O2. The canister was turned off. R #9 stated she did not wear the O2 any longer and did not need it. LVN A stated R #9 did not want to wear the O2 any longer and R #9 would not keep the nasal cannula in her nose. During an observation and interview, accompanied by LVN A, on [DATE] at 5:00 p.m. revealed R #9 sitting up in bed. R #9 did not have O2 on, the canister and cannula was next to the bed. LVN A took R #9 O2 saturation and it was between 94% and 96%. LVN A stated an O2 saturation over 92% was good and she would call R #9's Physician and have the O2 order changed to as needed for SOB. R #9 had regular respirations and no SOB. R #9 stated she did not need the O2 any longer. R #20 Record review of R #20's face Sheet dated [DATE] revealed a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of R #20's admission MDS dated [DATE] revealed she was cognitively intact and she was able to make herself understood and she understood others. [MEDICAL CONDITION] was checked as a diagnosis, Shortness of Breath was not checked and Respiratory treatments were checked. Record review of R #20's Physician orders [REDACTED]. O2 at 3 liters per minute per nasal cannula continuously to relieve [MEDICAL CONDITION] related to SOB. Diagnoses: [REDACTED]. In an observation on [DATE] at 2:00 p.m. revealed R #20 resting in bed. R #20 was awake with O2 nasal cannula on the concentrator was set at 5 liters per minute. During an observation and interview on [DATE] at 3:15 p.m. LVN D confirmed R #20's O2 was set at 5 liters. LVN D set the O2 at 2 liters. LVN D stated R #20 used 2 liters of O2. LVN D pointed out the sticker on R #20's concentrator that was labeled 2L, LVN D stated that sticker indicated how many liters the resident was to receive. During an observation and interview on [DATE] at 3:40 p.m. LVN A confirmed R #20's O2 was set at 2 liters. LVN A reviewed R #20's Physician orders [REDACTED]. LVN A changed R #20's O2 to 3 liters. LVN A removed the sticker that had 2L from the concentrator. LVN A stated the sticker was incorrect and she would replace it. Observation on [DATE] at 11:55 a.m. revealed R #20 up in a chair at bedside. Surveyor observed the O2 concentrator was off. R #20 had the nasal cannula on. During an observation and interview on [DATE] at 12:00 p.m. LVN F confirmed R #20's concentrator was off. LVN F stated R #20 had came back from a shower about 45 minutes ago and she reconnected R #20 to the O2. LVN F stated the concentrator may have accidentally been turned off when R #20 was moved and getting R #20 positioned in the chair at the bedside. LVN F turned the concentrator on and it was set at 3 liters. On [DATE] at 1:45 p.m., DON gave surveyor a copy from Lippincott's Nursing Procedures and said the facility did not have a policy and procedure for oxygen use because they used Lippincott. Review of Lippincott's Page 573 titled Oxygen Administration revealed A patient will need oxygen therapy when hypoxemia results from respiratory or cardiac emergency or an increase in metabolic function .The adequacy of oxygen therapy is determined by arterial blood gas analysis, oximetry monitoring, and clinical examinations .Implementation *Verify the practitioner's order for the oxygen therapy because oxygen is considered a medication or therapy and should be prescribed .*Obtain a baseline physical assessment, including vital signs, breath sounds, oxygen saturation, and physical assessment . According to Physician order [REDACTED].

Based on observation, interview and record review the facility failed to ensure sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 Residents (R #1, R #2, R #3, R #4, R #6, R #7, R #14, R #15, R #16, and R #17) of 17 residents reviewed for provision of care. The facility did not provide sufficient staff according to the residents' identified staffing needs by not providing timely assistance to prevent falls, provide incontinent care, repositioning, passing fluids, administering medications or answering call lights timely. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE], while the IJ was removed on [DATE], the facility remained out of compliance at a scope of widespread and severity level of actual harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures placed one resident in the hospital and likely contributed to death for one resident in the facility and could place the 109 residents who resided in the facility higher risk of neglect and delay medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #1's Face Sheet dated [DATE] indicated she was admitted to the facility on [DATE]. R #1 was [AGE] years old. R #1's Physician's Consolidated Orders dated [DATE] indicated R #1's current [DIAGNOSES REDACTED]. R #1 was a Full Code. R #1's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] indicated R #1 was placed on Hospice. R #1 had minimal difficulty hearing (difficulty when setting was noisy or when a person spoke softly), had clear speech, had clear comprehension (was able to make herself understood and understood others). R #1 was cognitively aware and able to make decisions. R #1 required extensive assistance from two staff persons for bed mobility and toileting. R #1 required extensive assistance from one staff person for transferring, dressing, personal hygiene, and physical assistance from one staff for bathing. R #1 was always continent of bladder and bowel. R #1 participated in the MDS Assessment and Goal Setting. R #1's Mortician's Receipt/Death Report dated [DATE] revealed R #1 was pronounced dead by HN PP on [DATE] at 4:45 a.m., after being fully coded by the Emergency Medical Team. The cause of death was not documented on the form. R #1's Discharge Summary dated [DATE] revealed there was not a cause of death documented on the form. On [DATE] at 7:15 a.m. LVN A stated she had worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. LVN A stated CNA U was assigned to work Hall 300 and LVN A was the Charge Nurse for Halls 300 and 400. LVN A stated she was working on Hall 400 and at approximately 2:15 a.m. she walked to the nurse's station located in the middle of the facility. LVN A stated she observed two call lights lit outside the doors on Hall 300. LVN A stated there was not a nurse or a CNA on Hall 300. LVN A stated CNA U had left the facility and did not notify her prior to leaving. LVN A stated at approximately 2:15 a.m. to 2:30 a.m., she told CNA CC and CNA N to go and answer the call lights on Hall 300. LVN A stated CNA N and CNA CC found R #1 unresponsive. CNA N yelled for LVN A to help. LVN A stated she did not feel a pulse on R #1 but initiated Cardio [MEDICAL CONDITION] Resuscitation (CPR) because R #1 was a full code. LVN A stated R #1's call light was turned on in the room and lit up outside of the room. LVN A stated R #1 was supposed to be elevated when in bed, never lying flat. LVN A stated R #1 was lying flat in the bed. LVN A stated R #1 had been coherent, capable of turning the call light on and had used the call light on many occasions in the past to request oxygen. On [DATE] at 9:55 a.m., the DON stated even if she (CNA U) had been on Hall 300 it did not mean she (R #1) would have lived. The DON stated in [DATE] the facility changed the staffing model. The new staffing model only required two nurses on the 10:00 p.m. to 6:00 a.m. shift, and each nurse split two halls. The DON stated there had been several doctors and nurses who were upset over Hall 300 not having nursing coverage. On [DATE] at 11:15 a.m., PA VV stated she was very familiar with R #1. PA VV stated R #1 was very capable of voicing her needs. PA VV stated R #1 did not have a history of [MEDICAL CONDITION] nor any [DIAGNOSES REDACTED]. PA VV stated she last assessed R #1 on [DATE] and R #1 did not have complaints of shortness of breath on [DATE]. PA VV stated R #1 had a chest x-ray [DATE] that indicated consolidations were present (lung tissue that becomes engorged with fluid or tissue). PA VV stated she had ordered R #1 [MEDICATION NAME] treatments every six hours while awake, times one week, then every six hours PRN for Shortness of Breath and cough. PA VV stated she ordered a repeat chest x-ray one week after R #1 received the [MEDICATION NAME] treatments to see if R #1's lungs had cleared up. PA VV reviewed R #1's record with surveyor present and was not able to locate the chest x-ray. PA VV stated she had observed R #1 sitting in the facility the afternoon of [DATE]. PA VV stated R #1 looked great. PA VV stated R #1 had been put on Hospice and was gaining weight. PA VV stated I was very shocked to hear the next day she (R #1) was deceased . PA VV stated she had voiced her concerns to the facility regarding a nurse not being assigned to Hall 300. On [DATE] at 9:35 a.m., FM TT stated on [DATE] she was at the facility with R #1. FM TT stated, I don't know why I left. FM TT stated when she arrived on [DATE] R #1 was wheezing and asking for a breathing treatment. FM TT stated she requested a breathing treatment for [REDACTED]. FM TT stated R #1 had breathing treatments ordered as needed. FM TT stated R #1 had not received the breathing treatment by 6:30 p.m. and FM TT was too afraid to go and ask the nurse again to administer R #1 a breathing treatment. FM TT stated I was afraid to ask for more things for (R #1). I felt threatened. FM TT stated R #1 had been neglected many times since she had been admitted and FM TT had made many complaints to the Director of Nursing and the Administrator. FM TT stated she had previously been told by management she could move her mother (R #1) if she was not happy at the facility. FM TT stated she had been told by the DON that staff were afraid of her and the facility had to have two staff go into the room as witnesses when she was visiting R #1. FM TT stated the DON told her the facility could not be pulling staff. FM TT stated you never knew who the nurse was for the 300 Hall because the hall was split up between so many nurses. FM TT stated the nurses were assigned halls and after they finished rounds on their assigned halls they (nurses) would go to Hall 300. FM TT stated on [DATE] she notified the Hospice Social Worker who told her to call the Hospice Nurse and tell her to come immediately. On [DATE] at 5:38 p.m., the DON stated R #1 was on Hospice and was going down. The DON stated even if R #1 had been found in time R #1 would have still expired because she was a Do Not Resuscitate and not due to not having a nurse on Hall 300. R #2 R #2's Face Sheet dated [DATE] indicated R #2 was admitted to the facility at 2:30 p.m. on [DATE]. R #2 was [AGE] years old. R #2's admission orders [REDACTED] -continuous O2 at 3 liters (L) per nasal canula for signs and symptoms of [MEDICAL CONDITION] due to shortness of breath, -[MEDICAL CONDITION]-(Continuous Positive Airway Pressure, respiratory ventilation primarily used in the treatment of [REDACTED]. -[MEDICATION NAME] 3 milliliters (ml), PRN ever six hours for [DIAGNOSES REDACTED]. R #2's Medicare Nurses Note dated [DATE] revealed R #2's [DIAGNOSES REDACTED]. R #2's O2 SAT level was 96%, Blood Pressure ,[DATE], Respirations 22 and Pulse 81. R #2 had Shortness of Breath/trouble breathing/lying flat. R #2 had [MEDICAL CONDITION] (paralysis). R #2 received O2 Therapy. R #2 was alert and oriented to person, place and time. R #2's respirations were even and unlabored with O2 at 3 liters per nasal canula. [MEDICAL CONDITION] at bs (bedside), head of bed up 45 degrees for comfort. Requires max assistance with care. Call light within reach. Monitor for changes. R #2's Initial Plan of Care dated [DATE] revealed R #2 was alert and his vision, hearing and speech were normal. R #2 required assistance by staff for hair care, mouth care, shower and toileting. R #2 was continent of bowel and bladder and utilized a bedpan for toileting. R #2 was independent with eating. R #2 utilized a wheelchair and required a mechanical lift for transfers. Additional notes on the bottom of the Initial Plan of Care indicated R #2 was a two person for Activities of Daily Living (ADLs, hygiene, bathing, showers, incontinent care and transfers) and peri-care-mechanical lift. R #2 can verbalize his needs. R #2's required continuous O2, [MEDICAL CONDITION] at night or PRN breathing treatments was not included in R #2's Initial Plan of Care. R #2's Fire Department Patient Care Report dated [DATE] and completed by the EMT indicated the EMTs were dispatched to the facility on [DATE] due to R #2 having difficulty breathing. The Report indicated the EMTs arrived in R #2's room at 5:30 p.m. on [DATE]. R #2 was sitting in a bed and oriented to person, place, time and events. Complained of difficulty breathing. Patient stated he had difficulty breathing since this morning at 5:00 a.m. ([DATE]). Patient stated at 6:00 a.m. he received a breathing treatment from the staff. After treatment was finished, patient was placed on [MEDICAL CONDITION] machine. Patient stated that he did not receive any relief from his [MEDICAL CONDITION] machine all day. Patient stated that he was constantly calling for nurses to help him and they never did. His condition gradually worsened. Vital signs were taken and noted. Room Air O2 sat was at 76 percent, lung sounds diminished bilaterally. Patient was still on the [MEDICAL CONDITION] mask at this time. It was noticed that the [MEDICAL CONDITION] machine was not turned on or connected to any oxygen. Patient was placed on NRB (non-rebreather, device used in medical emergencies that requires oxygen therapy) immediately. No cyanosis was noted and patient did not seem to be in any respiratory distress. Nursing staff at facility stated they were not aware of the current situation. Patient was moved to ambulance. IV access was unable to be obtained. Male stated he had immense relief from O2. O2 SATS were noted to go up to 99 percent. En route patient was much improved. EMTs arrived at the local hospital at 5:54 p.m. on [DATE]. Nurse's Notes dated [DATE] at 6:00 p.m.-Noted Emergency Medical Services (EMS) 911 enter facility and ask for room [ROOM NUMBER] A, upon entrance to room noted resident (R #2) with [MEDICAL CONDITION] on. R #2 stated, I called them, I'm short of breath. EMS asked R #2 how long had he been like this, R #2 responded all day. R #2's O2 SATS 93% with 3 liters O2 via nasal canula. R #2 informed EMS he wanted to go to the hospital. Resident transferred on stretcher and out of facility alert and oriented. Archived Time Cards dated [DATE] indicated three LVNS worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and two CNAs. Emergency Physician Record dated [DATE] revealed R #2's chief complaint was shortness of breath with an onset of one day. R #2 was alert and oriented. R #2's Arterial Blood Gas (ABG-measurement of how much oxygen and carbon [MEDICATION NAME] are in the blood) in the emergency room were: -77.3-pCO2 (Partial pressure of carbon [MEDICATION NAME]). The within normal range of pC02 was ,[DATE] mm hg. -PO2- (Partial pressure of oxygen). The normal range of oxygen saturation level is 95% to 99%. According to http://www.webmd.com dated [DATE], -pCO2-measures the pressure of carbon [MEDICATION NAME] dissolved in the blood and how well carbon [MEDICATION NAME] is able to move out of the body. -pO2 measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. On [DATE] at 9:20 a.m., surveyor attempted to call ER Physician OO. Surveyor left a message. During an interview with Hospital Physician ZZ on [DATE] at 10:30 a.m. surveyor requested Physician ZZ to review the emergency room Laboratory Report dated [DATE] at 7:17 p.m. Physician ZZ reviewed the report and stated R #2's, pO2 was ok but not good and the pCO2 77.3% could cause unconsciousness and could cause death. The laboratory Report had a handwritten note that indicated R #2 was at the nursing facility, had difficulty breathing since 6:00 a.m., [MEDICAL CONDITION] was completely off and no O2 was connected. According to http://www.ncbi.nlm.nih.gov/ Carbon [MEDICATION NAME] main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level.At higher concentrations it leads to an increased respiratory rate, [MEDICAL CONDITION] cardic arrhythmia and impaired consciousness. Concentrations greater than 10% may cause convulsions, coma and death. According to http://www.merriam-webster.com Asphyxia is a lack of oxygen or excess of carbon [MEDICATION NAME] in the body that is usually caused by interruption of breathing and that causes unconsciousness. R #2's chest x-ray dated [DATE] indicated R #2 had moderate to large right pleural effusion with right lower lobe consolidation and mild central [MEDICAL CONDITION] vascularity. According to http://www.nlm.nih.gov obtained [DATE] pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an abnormal, excessive collection of this fluid. Symptoms of Pleural effusion include.cough, rapid breathing, shortness of breath. Observation and subsequent interview with R #2 in the Hospital on [DATE] at 9:35 a.m., revealed R #2 lying in a hospital bed. R #2 had O2 nasal canula. R #2 stated, I would say I was neglected by the facility. R #2 stated he was admitted to the facility on [DATE] and his room was on Hall 300. R #2 said he was a little groggy but he was told that evening or night by an unknown lady there is not enough staff, once we leave the hall it will be a while till we get back. R #2 stated on [DATE] he would turn on the call light and it would take an hour or two for anyone to get to his room. R #2 stated at 5:00 a.m. on [DATE] he could not breathe and he was given a nebulizer treatment. R #2 stated he felt better for a while. R #2 stated his wife and son arrived at approximately 9:00 a.m. and R #2 said he could not snap out of it. R #2 stated his wife went and told a nurse he was having trouble breathing. R #2 said a nurse came in and gave him a pain pill ([MEDICATION NAME]) and an anxiety medication ([MEDICATION NAME]). R #2 stated his wife tried to wake him up in the afternoon but he he was out of it. R #2 stated his wife left around 3:00 p.m. and the CNAs told him once we leave the hallway it will be a while before we are back. You can't be yelling. You have to wait. R #2 stated, I did yell for help and someone came in and said you cannot be yelling there is other residents. R #2 stated a nurse came in around 5:00 p.m. on [DATE] and he told her something is not right, I can't breath. R #2 stated the nurse did not say anything, just left him hanging. R #2 stated he called 911. R #2 stated he had turned on his call light many times during the day and it took a long time to be answered. R #2 stated he did not turn on his call light at the time he called 911. R #2 stated I could not handle it. R #2 stated, I may be ignorant to things but I thought they (EMTs) said I was not even hooked up to oxygen. R #2 stated the EMTs got his O2 level back up and asked him if he wanted to stay or go to the emergency room . R #2 stated he could tell by the tone of the EMTs voice it would be better for him to go to the emergency room . R #2 stated when he was in the emergency room his CO2 levels were high and he was told the CO2 levels being high was from him not getting O2. On [DATE] at 12:30 p.m. FM MM stated she and her son visited R #2 on [DATE]. FM MM stated R #2 was very groggy and she could not wake R #2 up. FM MM stated R #2 was swollen and looked like a blow fish. FM MM stated she went to the nurse's station and told someone R #2 was having a hard time breathing. FM MM stated R #2 was given his pain medication by an unknown nurse. FM MM stated R #2 had turned on the call light and it took 1-,[DATE] hours to get answered. FM MM stated when she was in R #2's room visiting she heard a CNA tell R #2 they did not have enough staff to put him on the bedpan. FM MM stated she left the facility to run errands and was called back to the facility by Staff Person Q to sign R #2's admission papers. FM MM stated Staff Person Q told her to tell R #2 tell him (R #2) to bear with us, not to call 911. FM MM stated after she signed the admission papers she went back to R #2's room and still could not wake R #2 up. FM MM stated it was not normal but she thought R #2 was resting. FM MM stated she left the facility at approximately 3:00 p.m. on [DATE]. FM MM stated a little later she received a phone call from R #2 and he told her he could not breathe. FM MM stated R #2 was gasping. FM MM stated R #2 told her he had called 911. FM MM stated she called the nursing facility and they told her the EMTs were in the room with R #2. FM MM stated in the emergency room she heard the doctor say R #2 had Carbon [MEDICATION NAME] poisoning that was dangerously high. On 02/ ,[DATE] at 3:00 p.m., CNA X stated she worked the 2:00 p.m. to 10:00 p.m. shift on Hall 300 on [DATE]. CNA X stated she was not assigned R #2 but had checked R #2 at the beginning of the shift for incontinence. CNA X stated R #2 looked woozie. CNA X stated R #2 had his [MEDICAL CONDITION] mask on. CNA X stated she asked LVN G if R #2 was supposed to have on the [MEDICAL CONDITION] mask and LVN G said R #2 had put the [MEDICAL CONDITION] mask on himself. CNA X stated later R #6 who resided on Hall 300 told her R #2 had been yelling for help on the 10:00 p.m. to 6:00 a.m. shift. R #6 stated R #2 was yelling, does anyone work here? CNA X stated R #2 said I called 911, I could not breathe. On [DATE] at 9:55 a.m. the DON stated R #2 wanted to be in the hospital. The DON stated R #2 had many medical conditions and she did not know why R #2 was placed on Hall 300. The DON stated Hall 300 they (residents) can use their call lights but is not light care. On [DATE] at 2:15 p.m. LVN G stated she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. LVN G stated she was working on Hall 300 and R #2 never told her he was having trouble breathing. LVN G stated when she did her initial rounds after arriving at the facility R #2 had on his O2 nasal canula. LVN G stated R #2's [MEDICAL CONDITION] machine was on the nightstand next to his bed. LVN G stated she left Hall 300 after 5:00 p.m. to work on another hall. LVN G stated there was not a nurse on Hall 300 after she left. R #3 R #3's Face Sheet sheet [DATE] indicated R #3 was admitted to the facility on [DATE]. R #3 was [AGE] years old. R #3's Physician's Consolidated orders dated February 2015 indicated R #3's [DIAGNOSES REDACTED]. R #3 may have bed alarm to alert staff of when Resident (R #3) attempted to get up per self. R #3's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R #3 had no difficulty with hearing normal conversation, had unclear speech (slurred or mumbled words), usually made himself understood (difficulty communicating some words or finishing thoughts but is able if given time) and usually understood others (missed some part/intent but comprehended most conversation). R #3's cognition was impaired and R #3 was not able to make decisions. R #3 required extensive assistance from one staff person for transferring, toileting, dressing and personal hygiene. R # 3 required limited assistance with locomotion out of his room. R #3 utilized a wheelchair. R #3's Fall Care Plan dated [DATE] revealed R #3 was at risk for falls and injury due to [DIAGNOSES REDACTED]. The goal of the plan was for R #3 to not have any falls and not experience any injuries from falls. The approaches to be utilized were: -assist R #3 with stand-by assistance for all ambulation, -assist R #3 with one staff member for all ambulation, -keep walker within R #3's reach, -remind R #3 to ask for assistance., -staff will continue to redirect R #3 due to his continuation of self transferring without assistance, -self-release belt in wheelchair and bed alarm in place to help alert staff when R #3 may be attempting to self transfer. R #3's Resident Incident Report dated [DATE] at 2:00 a.m. indicated CNA N found R #3 on the floor sitting at the end of his bed, bleeding from a laceration to his head. R #3 stated he hit his head on the table, trying to go to the restroom. LVN A assessed R #3. R #3 was in pain and was administered pain medication. R #3 had a 0.2 X 3.5 X 0.2 laceration to his right temple with slight swelling. On [DATE] at 3:35 p.m., R #3 stated it took a long time to get help to go to the bathroom. R #3 stated he tried to take himself to the bathroom. R #16 On [DATE] at 3:38 p.m., R #16 stated on the 10:00 p.m. to 6:00 a.m. shift there was a shortage of staff. R #16 stated when the call light is turned on the staff were very slow answering the calling. R #16 stated at times it takes one hour for the staff to answer the call light. R #16 stated R #3 had fallen several times trying to go to the bathroom alone. On [DATE] at 7:15 a.m., LVN A stated the biggest issue is there is not enough staff. LVN A stated in [DATE] there were seven times she worked with only one other LVN and two CNAs for four halls. LVN A stated there were over a hundred residents. LVN A stated on [DATE] there were only two CNAs working. LVN A stated on [DATE] R #3's bed alarm was sounding and there was not enough staff to get to R #3 in time. LVN A stated R #3 sustained a laceration to his head. LVN A said she called the DON and told her they were short staffed. The DON never got back with her. LVN A stated she called the Administrator and told her they were short staff on [DATE]. LVN A stated the Administrator told her she would bring it up in the morning meeting. LVN A stated the next day on [DATE] the DON told her the Administrator was upset because she (LVN A) had called her (Administrator) the previous night. LVN A stated R #3's fall could have been prevented. LVN A stated the Administrator and the DON were aware of the shortage of staffing, things go in one ear and out the other. LVN A stated residents were not being turned every two hours, being administered medications timely, having more falls, obtaining pressure sores, and not getting water during the 10:00 p.m. to 6:00 a.m. shift. LVN A stated, most of the time Hall 300 is neglected because there is not a nurse assigned to the hall. LVN A stated, after 5:00 p.m., during the evening shift, Halls 100, 200 and 400 have a nurse. LVN A stated after the nurses completed rounds on their assigned hall, the nurse would attend to Hall 300. LVN A stated finger sticks and medication administration were not conducted timely. LVN A stated in the past before leaving her shift at 6:00 a.m. she had heard the CNAs who worked the 6:00 a.m. to 2:00 p.m. shift state, no one showed up, we are too short staffed to feed (residents' breakfast). The Daily Position Sheet dated Monday, [DATE] revealed LVN A, LVN C, CNA N and CNA M worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. The Enhanced Time Card Report dated [DATE] revealed [DATE] revealed LVN A, LVN C, CNA N and CNA M worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. R #6 R #6's Face Sheet dated [DATE] indicated R #6 was admitted to the facility on [DATE]. R #6 was [AGE] years old. R #6's [DIAGNOSES REDACTED]. R #6's Quarterly MDS dated [DATE] revealed R #6 had adequate hearing (no difficulty hearing normal conversation, social interact), impaired vision, (sees large print) clear speech, was able to make herself understood and understood others. R #6 was cognitively aware and capable of making her own decisions. R #6 did not exhibit behaviors, hallucinations or delusions. R #6 was totally dependent on two or more staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. R #6 required extensive assistance from one staff person for eating. R #6 utilized a wheelchair and required assistance with wheelchair locomotion. R #6's upper and lower extremities were impaired. R #6 was continent of urine and frequently incontinent of bowels. R #6 had a [DIAGNOSES REDACTED]. R #6's Care Plan dated [DATE] revealed R #6 required assistance from one staff person with dressing, toileting, and bed mobility due to paralysis/[MEDICAL CONDITION]. R #6 stated on [DATE] at 9:40 a.m., Hall 300 was short staffed. R #6 stated CNAs will work one day and quit the next day. R #6 stated Monday through Friday, Hall 300 had a nurse that worked 8:00 a.m. to 5:00 p.m. R #6 stated after 5:00 p.m. Hall 300 did not have a nurse. R #6 stated there was not a nurse assigned Hall 300 on the weekends for any shift. R #6 stated on the 10:00 p.m. to 6:00 a.m. shift the two nurses each had two halls to work, but had to help the CNAs because there was not enough CNAs. R #6 stated she was able to tell when her blood sugar was high or low and used her call light to get help. R #6 stated it was often one or two hours before a nurse would get to her room on the evening or night shifts to take her blood sugar. R #6 stated she had to remind the LVNs it was time for her medication. R #6 stated on [DATE] she had her call light on for three hours. R #6 stated she was screaming hello, hello. R #6 stated she heard a laundry barrel going down the hall. R #6 stated she said hello and was told by CNA P I will get someone. R #6 stated her call light was on from 10:10 p.m. to 1:15 p.m. before CNA L arrived in her room. R #6 stated, all I needed was my air conditioner turned down and my television turned off. R #6 stated water was not passed out at night to the residents. R #6 stated when she asked for water the CNAs would fill the water pitcher from the bathroom sink. R #6 stated one night CNA N repositioned her on her side and left the room. R #6 stated CNA N did not pull the covers back over her. R #6 stated her call light was left out of her reach. R #6 stated I was cold and started screaming for help. R #6 said she yelled for help about one hour. R #6 stated one night on the 10:00 p.m. to 6:00 a.m. shift she heard a woman in the room next to hers yelling very low, help, help. R #6 stated it took approximately one hour for staff to get to her room. R #7 R #7's Face Sheet dated [DATE] indicated R #7 was admitted to the facility on [DATE]. R #7 was [AGE] years old. R #7's [DIAGNOSES REDACTED]. R #7's 14 Day Scheduled Minimum Data Set ((MDS) dated [DATE] indicated R #7 had no difficulty hearing in a normal conversation, had clear speech, understood others and was able to understand others. R #7 was cognitively aware and able to make decisions. R #7 required extensive assistance from one staff person for transferring, ambulating, personal hygiene and was totally depended from one staff person for bathing. R #7 had an Ostomy (an operation-to create an artificial passage for bodily elimination). R #7's Care Plan dated [DATE] revealed there was not a [MEDICAL CONDITION] care plan. Observation of facility call lights on [DATE] at 5:20 a.m. revealed room [ROOM NUMBER] hall light was on and not answered until 5:55 a.m. Surveyor observed one Certified Nurse Aide (CNA) P on Hall 400. CNA P was in room [ROOM NUMBER]. There were not any other staff observed on Hall 400. During an interview on [DATE] at 5:25 a.m., and subsequent observation R #7 stated he needed water and his [MEDICAL CONDITION] bag changed. R #7 stated my light has been on at least one hour. R #7 stated, my mouth is so dry, I can hardly talk and my [MEDICAL CONDITION] bag (removable, disposable bag that attaches to the exterior opening of a [MEDICAL CONDITION] to permit sanitary collection and disposal of bodily wastes) is full. If they (staff) don't hurry and change it, it is going to burst all over me and they (staff) will have to clean it up. It takes longer to clean up then to change it. R #7 stated, I can't ever get anyone to help me. R #7 stated if you can get them in the room they (staff) are very nice. Surveyor observed R #7's lips were dry and cracked. R #7 stated when he was given water it was out of the bathroom sink, where the urinal was emptied. Observation on [DATE] at 5:55 a.m. revealed R #7's call light was answered by Licensed Vocational Nurse (LVN) A. LVN A filled R #7's water pitcher in the bathroom sink. On [DATE] at 6:45 a.m., CNA P stated he worked part time and he worked all the shifts. CNA P stated he mainly worked on Hall 400 and was working on Hall 400 the 10:00 p.m. to 6:00 a.m. shift [DATE]. CNA P stated when he was in a resident's room for incontinent care and personal hygiene and other resident's lights were on, it would take him 30 to 40 minutes to answer call lights. CNA P stated he was called one evening and told their was a 10:00 p.m. to 6:00 a.m. slot available to work. CNA P stated when he arrived at the facility there was only one other CNA working and two LVNs. CNA P stated residents turned on their call lights, but would get tired of waiting and attempt to transfer themselves and fall. CNA P stated in the past he had found two residents on the floor because he could not answer their call lights timely. CNA P stated he did not like working on Hall 300 because there was not an assigned nurse and you are just left on your own. R #15 R #15's Face Sheet dated [DATE] indicated R #15 was admitted to the facility on [DATE]. R #15 was [AGE] years old. R #15's [DIAGNOSES REDACTED]. R #15 Significant Change of Status MDS dated [DATE] revealed R #15 minimal difficulty hearing (difficulty when person speaks softly or noisy environment), clear speech, understood others and made himself understood. R #15 was cognitively aware and able to make some decisions. R #15 did not have hallucinations, delusions or behavioral symptoms. R #15 required extensive assistance fr

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for two Residents (R #1 and R#2) of 17 residents who were reviewed for provision of care and services. The facility did not have staff available for residents when needed for over one hour to meet resident needs. The facility did not have staff available to intervene and provide timely assessments when a resident was in a medical crisis. Hall 300 was left unattended for over an hour and R #1 was found with her call light on and unresponsive. R #1 was pronounced dead. R #2 complained of shortness of breath and the facility failed to assess and ensure R #2's oxygen concentrator and [MEDICAL CONDITION] machine were operational. R #2 could not breathe, called 911 and was transported to the hospital where he remained at the time of this investigation. The Administrator failed to: 1) Implement policies and procedures for provision of care. 2) Implement abuse and neglect policies and procedures to include protecting residents, and investigating and reporting incidents. 3) Supervise the Director Of Nurses (DON). 4) Employ sufficient staff to provide care and services to all residents to meet the residents' needs and to conform with physician's orders [REDACTED]. The DON failed to: 1) Develop and implement policies and procedures for provision of care and services to ensure nurses' were competent in the administration of oxygen and the [MEDICAL CONDITION] machine. 2) Provide in-services to nurses regarding oxygen a [MEDICAL CONDITION] machine. 3) Ensure sufficient staff on all shifts to meet the needs of residents and to conform with physician's orders [REDACTED]. 4) Supervise the nursing staff to ensure that the nursing staff were consistently assessing R #1 and #2 and consistently documenting those assessments. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of widespread and severity level of actual harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures placed one resident in the hospital and likely contributed to the death for one resident in the facility and could place the 109 residents who reside in the facility at a higher risk of neglect and delay medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #1's Face Sheet dated [DATE] indicated R #1 was admitted to the facility on [DATE]. R #1 was [AGE] years old. R #1's History and Physical dated [DATE] indicated R #1's admission into the facility was for skilled care. R #1 had high blood pressure, [MEDICAL CONDITION], Vascular Multi-infarction (stroke), Dementia, and [MEDICAL CONDITION] that were all well-controlled. R #1's Physician's Progress Notes dated [DATE] and completed by Physician Assistant (PA) VV revealed R #1 was eating well and had a seven pound weight gain in one month; R #1 was awake and able to voice her needs, vital signs were within normal limits. PA VV ordered R #1 [MEDICATION NAME] treatment (breathing treatment) every six hours, times one week and then as needed (PRN) for Shortness of Breath/cough. Chest x-ray one week after nebulizer treatments. R #1's Physician's Consolidated Orders dated [DATE] indicated R #1's current [DIAGNOSES REDACTED]. R #1 was a Full Code. R #1 was ordered: -PRN Oxygen (O2) at 2 liters per minute per nasal canula to relieve signs and symptoms of [MEDICAL CONDITION] (oxygen supply is insufficient) related to shortness of breath. -[MEDICATION NAME] (nebulizer)-one unit dose per nebulizer every six hours PRN Shortness of Breath/Cough. Monitor Respirations, Pulse, O2 Saturations (SAT) and lung sounds. R #1's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] indicated R #1 was placed on Hospice for [MEDICAL CONDITION]. R #1 had clear speech and was able to make herself understood and understood others. R #1 was cognitively aware and able to make decisions. R #1's Hospice Nursing Summary dated [DATE] and completed by Hospice Nurse (HN) PP revealed HN PP was called to the facility the evening of [DATE] by R #1's Family Member (FM) TT. FM TT was concerned that when she arrived earlier to the facility she (FM TT) found R #1's feet were hanging off the chair and swollen. R #1's vital signs were within normal limits. R #1's Departmental Notes/Nurse's Notes dated [DATE] at 8:25 a.m. and completed by LVN A revealed upon making rounds R #1 was found unresponsive at 2:50 a.m. Full Code called. Staff called to aide. Cardio [MEDICAL CONDITION] Resuscitation (CPR) initiated. Unable to obtain vital signs. No response with CPR. On [DATE] at 3:35 a.m. the Hospice nurse arrived to pronounce death. On [DATE] at 11:15 a.m., CNA T stated she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. CNA T stated she and CNA V went to put R #1 into bed on [DATE] before 10:00 p.m. R #1 did not want to go to bed and CNA T told HN PP. HN PP and FM TT talked R #1 into going to bed. CNA T and CNA V put R #1 to bed right before getting off their shift. CNA T stated R #1's head of bed was elevated and R #1 was joking around. CNA T stated R #1 was very coherent. CNA T stated, I could not believe the next day when I was told she (R #1) was dead. On [DATE] at 6:37 p.m., CNA V stated she and CNA T put R #1 to bed between 9:50 p.m. to 10:00 p.m. on [DATE]. CNA V stated FM TT and HN PP was in R #1's room. CNA V stated R #1 was elevated in her bed and had the call light within reach. CNA V sated R #1 was able to state her needs. On [DATE] at 2:37 p.m., HN PP stated she had visited with R #1 and FM TT between 10:00 p.m. and 11:00 p.m. on [DATE]. HN PP stated FM TT had requested a Hospice nurse to speak to regarding concerns that the facility was not providing care to R #1. HN PP stated when she arrived in R #1's room she observed R #1 in a recliner chair with her feet propped up. HN PP stated FM TT told her earlier in the evening she (FM TT) had found R #1 in the room with her feet hanging and very swollen. HN PP stated at the time of her visit R #1's right ankle bone and feet were swollen. HN PP stated R #1's vital signs were within normal limits. HN PP stated R #1's humidifier bottle located on oxygen concentrator was low. HN PP stated there were no red flags indicating anything was wrong. HN PP stated R #1's lungs were clear and she had not heard wheezing. HN PP stated heck yeah I was surprised. I would have never dreamed she would pass away in less than eight hours. I was shocked. Just shocked. On [DATE] at 6:05 a.m., CNA N stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. CNA N stated CNA U was assigned Hall 300 on [DATE]. CNA N stated CNA U did not tell her Charge Nurse, she was leaving for break and no one was assigned to watch out for Hall 300. CNA N stated LVN A told her and CNA CC to check the hall lights after midnight that were turned on for Hall 300. CNA N stated R #1's call light was on and when CNA N and CNA CC entered R #1 was unresponsive. CNA N stated she yelled to LVN A for help. On [DATE] at 7:00 a.m., Licensed Vocational Nurse (LVN) B stated he worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and after 12:00 a.m. CNA U told him she was going to take a break, CNA U never returned to the facility. LVN B stated he did not notify anyone CNA U was going on break. LVN B stated CNA U was working on Hall 300 prior to leaving and the charge nurse for Hall 300 was LVN A. On [DATE] at 7:15 a.m. LVN A stated she had worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. LVN A stated CNA U was assigned to work Hall 300 and LVN A was the Charge Nurse for Halls 300 and 400. LVN A stated she was working on Hall 400 and at approximately 2:15 a.m. she walked to the nurse's station located in the middle of the facility. LVN A stated she observed two call lights lit outside the doors on Hall 300. LVN A stated she asked CNA N to look for CNA U. CNA N stated she could not find CNA U. LVN B overheard CNA N and LVN A talking and stated CNA U had told him she was going on break. LVN A stated at approximately 2:15 a.m. to 2:30 a.m., she told CNA CC and CNA N to go and answer the call lights on Hall 300. LVN A stated CNA N and CNA CC found R #1 unresponsive. CNA N yelled for LVN A to help. LVN A stated she did not feel a pulse on R #1 but initiated Cardio [MEDICAL CONDITION] Resuscitation because R #1 was a full code. LVN A stated R #1's call light was turned on in the room and lit up outside of the room. LVN A stated R #1's roommate was not capable of using the call light. LVN A stated R #1 was supposed to be elevated when in bed, never lying flat. LVN A stated R #1 was lying flat in the bed. LVN A stated R #1 had been coherent, capable of turning the call light on and had used the call light on many occasions in the past to request oxygen. LVN A stated R #1 had O2 ordered PRN for Shortness of Breath. R #1's Mortician's Receipt/Death Report dated [DATE] revealed R #1 was pronounced dead by HN PP on [DATE] at 4:45 a.m., after being fully coded by the Emergency Medical Team. The cause of death was not documented on the form. R #1's Discharge Summary dated [DATE] revealed there was not a cause of death documented on the form. On [DATE] at 2:55 p.m., CNA U stated she had left the facility to go on break at 1:30 a.m. on [DATE]. CNA U stated she was pulled over by the police and her car was towed. CNA U stated she did not call and notify the facility but called the Lead CNA (CNA Z who was not working) and told her she would not return. CNA U stated at about 11:30 p.m. she did rounds and R #1 was dry and in her bed. CNA U stated I honestly can not remember how much, but her (R #1's) bed was elevated and the call light was not on. CNA U stated she told CNA N on Hall 400 she was going on break. On [DATE] at 11:45 a.m., CNA Z stated CNA U did not call and report to her on [DATE] that CNA U's car had been towed and CNA U would not be returning to work. CNA Z stated CNA U messaged her cell phone her at 1:44 a.m., and CNA Z did not read the text until 6:00 a.m. on [DATE]. CNA Z stated she was the Lead CNA and CNAs were to notify her when they were not going to come in. CNA Z stated she was responsible for finding another CNA to cover for the call in. On [DATE] at 9:55 a.m. the DON stated she had not investigated the death of R #1 because R #1 was on Hospice. The DON stated even if she (CNA U) had been on Hall 300 it does not mean she (R #1) would have lived. The DON stated in [DATE] the facility changed the staffing model. The new staffing model only required two nurses on the 10:00 p.m. to 6:00 a.m. shift, and each nurse split two halls. The DON stated there had been several doctors and nurses who were upset over Hall 300 not having nursing coverage. The DON stated there was not an incident form completed regarding the death of R #1. On [DATE] at 11:15 a.m., PA VV stated she was very familiar with R #1. PA VV stated R #1 was very capable of voicing her needs. PA VV stated R #1 did not have a history of [MEDICAL CONDITION] nor any [DIAGNOSES REDACTED]. PA VV stated she last assessed R #1 on [DATE] and R #1 did not have complaints of shortness of breath on [DATE]. PA VV stated R #1 had a chest x-ray [DATE] that indicated consolidations were present (lung tissue that becomes engorged with fluid or tissue). PA VV stated she had ordered the resident [MEDICATION NAME] treatments every six hours while awake, times one week, then every six hours PRN for Shortness of Breath and cough. PA VV stated she ordered a repeat chest x-ray one week after R #1 received the [MEDICATION NAME] treatments to see if R #1's lungs had cleared up. PA VV reviewed the resident's record with surveyor present and was not able to locate the chest x-ray. PA VV stated she had observed R #1 sitting in the facility the afternoon of [DATE]. PA VV stated R #1 looked great. PA VV stated R #1 had been put on Hospice and was gaining weight. PA VV stated I was very shocked to hear the next day she (R #1) was deceased . PA VV stated she had voiced her concerns to the facility regarding a nurse not being assigned to Hall 300. R #1's Medication Administration Record [REDACTED] [DATE]-at 6:00 a.m. and 6:00 p.m., [DATE]-at 6:00 a.m., [DATE]-at 6:00 p.m., [DATE]-at 6:00 p.m. R #1's Laboratory Record dated [DATE] through [DATE] revealed Repeat chest x-ray on [DATE]. The Laboratory Record was not initialed indicating R #1 did not receive the Chest x-ray on [DATE]. Review of R #1's entire medical folder revealed there was not a follow-up chest x-ray. On [DATE] at 4:30 p.m., the Administrator stated she was not aware of any concerns over R #1's death. The Administrator stated she had not been notified that at the time R #1 was found unresponsive, R #1's call light was turned on and CNA U had not notified LVN A she was taking a break, leaving Hall 300 unattended. The Administrator stated she did not know the cause of death for R #1. The Administrator stated she did not know why R #1's follow-up chest x-ray was not completed. The Administrator stated she had documented R #1 was due for a chest x-ray in her daily morning meeting notes, but the chest x-ray had not been completed. On [DATE] at 9:35 a.m., FM TT stated on [DATE] she was at the facility with R #1. FM TT stated, I don't know why I left. FM TT stated when she arrived on [DATE] before 6:30 p.m. and R #1 was wheezing and asking for a breathing treatment. FM TT stated she requested a breathing treatment for [REDACTED]. FM TT stated R #1 had breathing treatments ordered as needed. FM TT stated R #1 had not received the breathing treatment by 6:30 p.m. and FM TT was too afraid to go and ask the nurse again to administer R #1 a breathing treatment. FM TT stated I was afraid to ask for more things for (R #1). I felt threatened. FM TT stated R #1 had been neglected many times since she had been admitted and FM TT had made many complaints to the Director of Nursing and the Administrator. FM TT stated she had previously been told by management she could move her mother (R #1) if she was not happy at the facility. FM TT stated she had been told by the DON that staff were afraid of her and the facility had to have two staff go into the room as witnesses when she was visiting R #1. FM TT stated the DON told her the facility could not be pulling staff. FM TT stated you never knew who the nurse was for the 300 Hall because the hall was split up between so many nurses. FM TT stated the nurses were assigned halls and after they finished rounds on their assigned halls they (nurses) would go to Hall 300. FM TT stated on [DATE] she notified the Hospice Social Worker who told her to call the Hospice Nurse and tell her to come immediately. FM TT stated HN PP arrived to R #1's room at approximately 8:00 p.m. and HN PP requested the facility nurse to give R #1 a breathing treatment. FM TT stated the breathing treatment was given to R #1 between 8:00 and 10:00 p.m. FM TT stated HN PP requested for the humidifier to be replaced on the oxygen concentrator because it was out of water. FM TT stated when she left the facility at 10:00 p.m. the humidifier still had not been replaced on the oxygen concentrator. FM TT stated when she left the facility at 10:00 p.m. on [DATE]. R #1 was in bed and the bed was elevated. FM TT stated, When I left ([DATE]) she was fine. On [DATE] at 5:38 p.m., the DON stated R #1 was on Hospice and was going down. The DON stated even if R #1 had been found in time R #1 would have still expired because she was a Do Not Resuscitate. R #2 R #2's Face Sheet dated [DATE] indicated R #2 was admitted to the facility at 2:30 p.m. on [DATE]. R #2 was [AGE] years old. R #2's admission orders [REDACTED] -continuous O2 at 3 liters (L) per nasal canula for signs and symptoms of [MEDICAL CONDITION] due to shortness of breath, -[MEDICAL CONDITION]-(Continuous Positive Airway Pressure, respiratory ventilation primarily used in the treatment of [REDACTED]. -[MEDICATION NAME] 3 milliliters (ml), PRN ever six hours for [DIAGNOSES REDACTED]. R #2's Medicare Nurses Note dated [DATE] revealed R #2's [DIAGNOSES REDACTED]. R #2's O2 SAT level was 96%, Blood Pressure ,[DATE], Respirations 22 and Pulse 81. R #2 had Shortness of Breath/trouble breathing/lying flat. R #2 had [MEDICAL CONDITION] (paralysis). R #2 received O2 Therapy. Depression and Pleural Effusion. R #2 was alert and oriented to person, place and time. R #2's respirations were even and unlabored with O2 at 3 liters per nasal canula. [MEDICAL CONDITION] at bs (bedside), head of bed up 45 degrees for comfort. Requires max assistance with care. Medications verified with Physician MM and faxed to the pharmacy. Call light within reach. Monitor for changes. R #2's Initial Plan of Care dated [DATE] revealed R #2 was alert and his vision, hearing and speech were normal. R #2 was continent of bowel and bladder and utilized a bedpan for toileting. R #2 utilized a wheelchair and required a mechanical lift for transfers. Additional notes on the bottom of the Initial Plan of Care indicated R #2 required two staff persons for Activities of Daily Living (ADLs, hygiene, bathing, showers, incontinent care and transfers) and utilized a mechanical lift. R #2 could verbalize his needs. R #2's required continuous O2, [MEDICAL CONDITION] at night or PRN breathing treatments were not included in R #2's Initial Plan of Care. R #2's admission orders [REDACTED]. There was not any documentation R #2 received O2 on: [DATE]-2:00 p.m. to 10:00 p.m. shift, [DATE]-6:00 a.m. to 2:00 p.m. shift, [DATE]-2:00 p.m. to 10:00 p.m. shift, [DATE]-6:00 a.m. to 2:00 p.m. shift, [DATE]-2:00 p.m. to 10:00 p.m. shift. There was not any documentation on the admission orders [REDACTED]. There was not any documentation on the admission orders [REDACTED]. Medicare Nurse's Notes dated [DATE] and completed by LVN G revealed: -5:00 p.m.-scheduled medications given, resident voices no concerns at this time. -6:00 p.m.-Noted Emergency Medical Services (EMS) 911 enter facility and ask for room [ROOM NUMBER] A, upon entrance to room noted resident (R #2) with [MEDICAL CONDITION] on. R #2 stated, I called them, I'm short of breath. EMS asked R #2 how long had he been like this, R #2 responded all day. R #2's O2 SATS 93% with 3 liters O2 via nasal canula. R #2 informed EMS he wanted to go to the hospital. Resident transferred on stretcher and out of facility alert and oriented. R #2's Fire Department Patient Care Report dated [DATE] and completed by the EMT indicated the EMTs were dispatched to the facility on [DATE] due to R #2 having difficulty breathing. The Report indicated the EMTs arrived in R #2's room at 5:30 p.m. on [DATE]. R #2 was sitting in a bed and oriented to person, place, time and events. Complained of difficulty breathing. Patient stated he had difficulty breathing since this morning at 5:00 a.m. ([DATE]). Patient stated at 6:00 a.m. he received a breathing treatment from the staff. After treatment was finished, patient was placed on [MEDICAL CONDITION] machine. Patient stated that he did not receive any relief from his [MEDICAL CONDITION] machine all day. Patient stated that he was constantly calling for nurses to help him and they never did. His condition gradually worsened. Vital signs were taken and noted. Room Air O2 sat was at 76 percent, lung sounds diminished bilaterally. Patient was still on the [MEDICAL CONDITION] mask at this time. It was noticed that the [MEDICAL CONDITION] machine was not turned on or connected to any oxygen. Patient was placed on NRB (non re-breather, device used in medical emergencies that requires oxygen therapy) immediately. No cyanosis was noted and patient did not seem to be in any respiratory distress. Nursing staff at facility stated they were not aware of the current situation. Patient was moved to ambulance. IV access was unable to be obtained. Male stated he had immense relief from O2. O2 SATS were noted to go up to 99 percent. En route patient was much improved. EMTs arrived at the local hospital at 5:54 p.m. on [DATE]. On [DATE] at 1:10 p.m. EMT RR stated he and EMT SS arrived at the facility at approximately 5:00 p.m. on [DATE]. EMT RR stated when he and EMT SS arrived at the Nurse's Station the nurses standing at the Nurse's Station were surprised. EMT RR stated none of the staff knew who had called 911. EMT RR stated when he entered R #2's room R #2 had a [MEDICAL CONDITION] mask on his face. EMT RR stated he (R #2) was making an effort to breathe. R #2 told EMT RR he used the [MEDICAL CONDITION] when he had difficulty breathing. EMT RR stated typically a [MEDICAL CONDITION] is loud and he realized the [MEDICAL CONDITION] was not turned on. EMT RR stated R #2's O2 SAT was 78% initially and his lungs sounded diminished bilaterally. EMT RR stated he placed a non re-breather (a mask used in medical emergencies that requires O2 therapy) on R #2 at 15 liters per minute and R #2's O2 SATS went to 99%. EMT RR stated he asked R #2 how long this had been going on and R #2 told EMT RR since this morning. EMT RR stated R #2 said he told the nurse he was having trouble breathing and the nurse said to R #2 to breathe in oxygen. EMT RR stated R #2 told him he put the [MEDICAL CONDITION] mask on himself at 6:00 a.m. to try and get more O2. EMT RR said R #2 told him I got fed up and called 911. EMT RR stated there was not any O2 connected to the [MEDICAL CONDITION] mask or on R #2. EMT RR stated the O2 concentrator was turned on but the tubing was not connected to anything. EMT RR stated there were several nurses in the room and someone walked over and turned on the [MEDICAL CONDITION] machine. EMT RR stated, no-one (staff) knew what was going on. EMT RR stated if R #2 had gone to sleep with the mask on he may not have awakened. EMT RR stated it is like putting a plastic bag over your head (meaning the [MEDICAL CONDITION] mask) and suffocating because you are not getting oxygen. EMT RR stated it was really shocking no one at the facility knew what was going on. On [DATE] at 1:45 p.m., EMT SS stated on [DATE] she assisted EMT RR with a call to the facility. EMT SS stated when she and EMT RR arrived no one at the desk knew of anyone short of breath. EMT SS stated they (staff) said (R #2) must have called. EMT SS stated when she arrived in R #2's room R #1's [MEDICAL CONDITION] mask was on his face. EMT SS stated she took R #2's O2 SAT and it was below 80%. EMT SS stated she tried a different finger and the O2 SAT was still below 80%. EMT SS stated she took R #2's O2 SAT on a different hand and the O2 SAT was still below 80%. R #2 stated to EMT SS and EMT RR he had been that way a couple of hours. EMT SS stated R #2's [MEDICAL CONDITION] mask was strapped on R #2's face and the O2 tubing was not hooked to the [MEDICAL CONDITION]. EMT SS said I followed the O2 tubing connected to the O2 concentrator and the O2 tubing was lying on the floor. EMT SS stated R #2's O2 concentrator was turned on but the nasal canula was not connected to anything. EMT SS stated R #2 told them he had lifted up the [MEDICAL CONDITION] mask a couple of times to take breaths. EMT SS stated there were four nurses and CNAs in the room and EMT RR asked nurses who knew how to work the [MEDICAL CONDITION] machine and the O2 concentrator? EMT SS stated no one could say how to work the O2 or [MEDICAL CONDITION] machine. EMT SS stated without the oxygen turned on or connected R #2 was breathing his own air back inside and was getting Carbon [MEDICATION NAME] poisoning. EMT SS said R #2 was given the EMT's O2 and R #2's O2 SATs went up to 100%. Emergency Physician Record dated [DATE] revealed R #2's chief complaint was shortness of breath with an onset of one day. R #2 was alert and oriented. R #2's Arterial Blood Gas (measurement of how much oxygen and carbon [MEDICATION NAME] are in the blood) in the emergency room were: -77.3-pCO2 (Partial pressure of carbon [MEDICATION NAME]). The within normal range of pC02 was ,[DATE] mm hg. -PO2- (Partial pressure of oxygen). The normal range of oxygen saturation level is 95% to 99%. According to http://www.webmd.com dated [DATE], -pCO2-measures the pressure of carbon [MEDICATION NAME] dissolved in the blood and how well carbon [MEDICATION NAME] is able to move out of the body. -pO2 measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. On [DATE] at 9:20 a.m., surveyor attempted to call ER Physician OO. Surveyor left a message. During an interview with Hospital Physician ZZ on [DATE] at 10:30 a.m. surveyor requested Physician ZZ to review the emergency room Laboratory Report dated [DATE] at 7:17 p.m. Physician ZZ reviewed the report and stated R #2's, pO2 was ok but not good and the pCO2 77.3% could cause unconsciousness and could cause death. The laboratory Report had a handwritten note that indicated R #2 was at the nursing facility, had difficulty breathing since 6:00 a.m., [MEDICAL CONDITION] was completely off and no O2 was connected. According to http://www.ncbi.nlm.nih.gov/ Carbon [MEDICATION NAME] main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level.At higher concentrations it leads to an increased respiratory rate, [MEDICAL CONDITION] cardic arrhythmia and impaired consciousness. Concentrations greater than 10% may cause convulsions, coma and death. According to http://www.merriam-webster.com Asphyxia is a lack of oxygen or excess of carbon [MEDICATION NAME] in the body that is usually caused by interruption of breathing and that causes unconsciousness. R #2's chest x-ray dated [DATE] indicated R #2 had moderate to large right pleural effusion with right lower lobe consolidation and mild central [MEDICAL CONDITION] vascularity. According to http://www.nlm.nih.gov obtained [DATE] pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an abnormal, excessive collection of this fluid. Symptoms of Pleural effusion include.cough, rapid breathing, shortness of breath. Observation and subsequent interview with R #2 in the Hospital on [DATE] at 9:35 a.m., revealed R #2 lying in a hospital bed. R #2 had O2 nasal canula. R #2 stated, I would say I was neglected by the facility. R #2 stated he was told prior to being admitted to the facility that the facility was equipped to handle a [MEDICAL CONDITION] machine. R #2 stated he was admitted to the facility on [DATE] and his room was on Hall 300. R #2 said he was told that evening by an unknown lady there is not enough staff, once we leave the hall it will be a while till we get back. R #2 stated on [DATE] he would turn on the call light and it would take an hour or two for anyone to get to his room. R #2 stated at 5:00 a.m. on [DATE] he could not breathe and he was given a nebulizer treatment. R #2 stated he felt better for a while. R #2 stated his wife and son arrived at approximately 9:00 a.m. and R #2 said he could not snap out of it. R #2 stated his wife went and told a nurse he was having trouble breathing. R #2 said a nurse came in and gave him a pain pill ([MEDICATION NAME]) and an anxiety medication ([MEDICATION NAME]). R #2 stated his wife tried to wake him up in the afternoon but he was out of it. R #2 stated his wife left around 3:00 p.m. and the CNAs told him once we leave the hallway it will be a while before we are back. You can't be yelling. You have to wait. R #2 stated he did yell for help and someone came in and said you cannot be yelling there is other residents. R #2 stated a nurse came in around 5:00 p.m. on [DATE] and he told her something is not right, I can't breath. R #2 stated the nurse did not say anything, just left him hanging. R #2 stated he called 911. R #2 stated he had turned on his call light many times during the day and it took a long time to be answered. R #2 stated he did not turn on his call light at the time he called 911. R #2 stated I could not handle it. R #2 stated, I may be ignorant to things but I thought they (EMTs) said I was not even hooked up to oxygen. R #2 stated the EMTs got his O2 level back up and asked him if he wanted to stay or go to the emergency room . R #2 stated he could tell by the tone of the EMTs voice it would be better for him to go to the emergency room . R #2 stated when he was in the emergency room his CO2 levels were high and he was told the CO2 levels being high was from him not getting O2. On [DATE] at 12:30 p.m. FM MM stated she and her son visited R #2 on [DATE]. FM MM stated R #2 was very groggy and she could not wake R #2 up. FM MM stated R #2 was swollen and looked like a blow fish. FM MM stated she went to the nurse's station and told someone R #2 was having a hard time breathing. FM MM stated R #2 was given his pain medication by an unknown nurse. FM MM stated R #2 had turned on the call light and it took 1-,[DATE] hours to get answered. FM MM stated when she was in R #2's room visiting she heard a CNA tell R #2 they did not have enough staff to put him on the bedpan. FM MM stated she left the facility to run errands and was called back to the facility by Staff Person Q to sign R #2's admission papers. FM MM stated Staff Person Q told her to tell R #2 tell him (R #2) to bear with us, not to call 911. FM MM stated after she signed the admission papers she went back to R #2's room and still could not wake R #2 up. FM MM stated it was not normal but she thought R #2 was resting. FM MM stated she left the facility at approximately 3:00 p.m. on [DATE]. FM MM stated a little later she received a phone call from R #2 and he told her he could not breathe. FM MM stated R #2 was gasping. FM MM stated R #2 told her he had called 911. FM MM stated she called the nursing facility and they told her the EMTs were in the room with R #2. FM MM stated in the emergency room she heard the doctor say R #2 had Carbon [MEDICATION NAME] poisoning that was dangerously high. On [DATE] at 2:30 p.m. CNA T stated she was in R #2's room on [DATE] to assist the EMTs with transferring R #2 and she overheard the EMTs say R #2's [MEDICAL CONDITION] machine and O2 concentrator were off. On [DATE] at 3:00 p.m., CNA X stated she worked the 2:00 p.m. to 10:00 p.m. shift on Hall 300 on [DATE]. CNA X stated she was not assigned R #2 but had checked R #2 at the beginning of the shift for incontin

Based on interview and record review the facility failed to protect, investigate and immediately report a death with unknown cause to Department of Aging and Disability Services for one Resident (R #1) of 13 residents reviewed for neglect. The facility did not initiate an investigation or report the allegation of an unusual death on [DATE] after Hall 300 was left unattended for one hour. R #1's call light was on and R #1 was found unresponsive and pronounced dead. The facility did not ensure a system was in place to protect residents who resided on Hall 300 when staff were not present. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures could place the 24 residents who reside on Hall 300 at a higher risk of neglect and delay medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #1's Face Sheet dated [DATE] indicated R #1 was admitted to the facility on [DATE]. R #1 was [AGE] years old. R #1's History and Physical dated [DATE] indicated R #1's admission into the facility was for skilled care. R #1 had high blood pressure, [MEDICAL CONDITION], Vascular Multi-infarction (stroke), Dementia, and [MEDICAL CONDITION] that were all well-controlled. R #1's Physician's Progress Notes dated [DATE] and completed by Physician Assistant (PA) VV revealed R #1 was eating well and had a seven pound weight gain in one month; R #1 was awake and able to voice her needs, vital signs were within normal limits. PA VV ordered R #1 [MEDICATION NAME] treatment (breathing treatment) every six hours, times one week and then as needed (PRN) for Shortness of Breath/cough. Chest x-ray one week after nebulizer treatments. R #1's Physician's Consolidated Orders dated [DATE] indicated R #1's current [DIAGNOSES REDACTED]. R #1 was a Full Code. R #1 was ordered: -PRN Oxygen (O2) at 2 liters per minute per nasal canula to relieve signs and symptoms of [MEDICAL CONDITION] (oxygen supply is insufficient) related to shortness of breath. -[MEDICATION NAME] (nebulizer)-one unit dose per nebulizer every six hours PRN Shortness of Breath/Cough. Monitor Respirations, Pulse, O2 Saturations (SAT) and lung sounds. R #1's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] indicated R #1 was placed on Hospice for [MEDICAL CONDITION]. R #1 had clear speech and was able to make herself understood and understood others. R #1 was cognitively aware and able to make decisions. R #1's Hospice Nursing Summary dated [DATE] and completed by Hospice Nurse (HN) PP revealed HN PP was called to the facility the evening of [DATE] by R #1's Family Member (FM) TT. FM TT was concerned that when she arrived earlier to the facility she (FM TT) found R #1's feet were hanging off the chair and swollen. R #1's vital signs were within normal limits. R #1's Departmental Notes/Nurse's Notes dated [DATE] at 8:25 a.m. and completed by LVN A revealed upon making rounds R #1 was found unresponsive at 2:50 a.m. Full Code called. Staff called to aide. Cardio [MEDICAL CONDITION] Resuscitation (CPR) initiated. Unable to obtain vital signs. No response with CPR. On [DATE] at 3:35 a.m. the Hospice nurse arrived to pronounce death. On [DATE] at 11:15 a.m., CNA T stated she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. CNA T stated she and CNA V went to put R #1 into bed on [DATE] before 10:00 p.m. R #1 did not want to go to bed and CNA T told HN PP. HN PP and FM TT talked R #1 into going to bed. CNA T and CNA V put R #1 to bed right before getting off their shift. CNA T stated R #1's head of bed was elevated and R #1 was joking around. CNA T stated R #1 was very coherent. CNA T stated, I could not believe the next day when I was told she (R #1) was dead. On [DATE] at 6:37 p.m., CNA V stated she and CNA T put R #1 to bed between 9:50 p.m. to 10:00 p.m. on [DATE]. CNA V stated FM TT and HN PP was in R #1's room. CNA V stated R #1 was elevated in her bed and had the call light within reach. CNA V sated R #1 was able to state her needs. On [DATE] at 2:37 p.m., HN PP stated she had visited with R #1 and FM TT between 10:00 p.m. and 11:00 p.m. on [DATE]. HN PP stated FM TT had requested a Hospice nurse to speak to regarding concerns that the facility was not providing care to R #1. HN PP stated when she arrived in R #1's room she observed R #1 in a recliner chair with her feet propped up. HN PP stated FM TT told her earlier in the evening she (FM TT) had found R #1 in the room with her feet hanging and very swollen. HN PP stated at the time of her visit R #1's right ankle bone and feet were swollen. HN PP stated R #1's vital signs were within normal limits. HN PP stated R #1's humidifier bottle located on oxygen concentrator was low. HN PP stated there were no red flags indicating anything was wrong. HN PP stated R #1's lungs were clear and she had not heard wheezing. HN PP stated heck yeah I was surprised. I would have never dreamed she would pass away in less than eight hours. I was shocked. Just shocked. On [DATE] at 6:05 a.m., CNA N stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. CNA N stated CNA U was assigned Hall 300 on [DATE]. CNA N stated CNA U did not tell her Charge Nurse, she was leaving for break and no one was assigned to watch out for Hall 300. CNA N stated LVN A told her and CNA CC to check the hall lights after midnight that were turned on for Hall 300. CNA N stated R #1's call light was on and when CNA N and CNA CC entered R #1 was unresponsive. CNA N stated she yelled to LVN A for help. On [DATE] at 7:00 a.m., Licensed Vocational Nurse (LVN) B stated he worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and after 12:00 a.m. CNA U told him she was going to take a break, CNA U never returned to the facility. LVN B stated he did not notify anyone CNA U was going on break. LVN B stated CNA U was working on Hall 300 prior to leaving and the charge nurse for Hall 300 was LVN A. On [DATE] at 7:15 a.m. LVN A stated she had worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. LVN A stated CNA U was assigned to work Hall 300 and LVN A was the Charge Nurse for Halls 300 and 400. LVN A stated she was working on Hall 400 and at approximately 2:15 a.m. she walked to the nurse's station located in the middle of the facility. LVN A stated she observed two call lights lit outside the doors on Hall 300. LVN A stated she asked CNA N to look for CNA U. CNA N stated she could not find CNA U. LVN B overheard CNA N and LVN A talking and stated CNA U had told him she was going on break. LVN A stated at approximately 2:15 a.m. to 2:30 a.m., she told CNA CC and CNA N to go and answer the call lights on Hall 300. LVN A stated CNA N and CNA CC found R #1 unresponsive. CNA N yelled for LVN A to help. LVN A stated she did not feel a pulse on R #1 but initiated Cardio [MEDICAL CONDITION] Resuscitation because R #1 was a full code. LVN A stated R #1's call light was turned on in the room and lit up outside of the room. LVN A stated R #1's roommate was not capable of using the call light. LVN A stated R #1 was supposed to be elevated when in bed, never lying flat. LVN A stated R #1 was lying flat in the bed. LVN A stated R #1 had been coherent, capable of turning the call light on and had used the call light on many occasions in the past to request oxygen. LVN A stated R #1 had O2 ordered PRN for Shortness of Breath. R #1's Mortician's Receipt/Death Report dated [DATE] revealed R #1 was pronounced dead by HN PP on [DATE] at 4:45 a.m., after being fully coded by the Emergency Medical Team. The cause of death was not documented on the form. R #1's Discharge Summary dated [DATE] revealed there was not a cause of death documented on the form. The facility's Daily Position Sheet dated [DATE] for the 10:00 p.m. to 6:00 a.m. shift indicted CNA U was assigned Hall 300. CNA U's Enhanced Time Care Report dated [DATE] revealed CNA U clocked out of the facility at 1:25 a.m. and did not return. On [DATE] at 2:55 p.m., CNA U stated she had left the facility to go on break at 1:30 a.m. on [DATE]. CNA U stated she was pulled over by the police and her car was towed. CNA U stated she did not call and notify the facility but called the Lead CNA (CNA Z who was not working) and told her she would not return. CNA U stated at about 11:30 p.m. she did rounds and R #1 was dry and in her bed. CNA U stated I honestly can not remember how much, but her (R #1's) bed was elevated and the call light was not on. CNA U stated she told CNA N on Hall 400 she was going on break. On [DATE] at 11:45 a.m., CNA Z stated CNA U did not call and report to her on [DATE] that CNA U's car had been towed and CNA U would not be returning to work. CNA Z stated CNA U messaged her cell phone her at 1:44 a.m., and CNA Z did not read the text until 6:00 a.m. on [DATE]. CNA Z stated she was the Lead CNA and CNAs were to notify her when they were not going to come in. CNA Z stated she was responsible for finding another CNA to cover for the call in. On [DATE] at 9:45 a.m., Hospice Physician WW stated he was not familiar with R #1 and Facility Physician was the attending Physician for R #1. On [DATE] at 10:40 a.m. Facility Physician stated she had seen R #1 when she was admitted ([DATE]) but had not seen R #1 recently. Facility Physician stated PA VV was familiar with R #1. On [DATE] at 1:05 p.m. Hospice Physician YY stated she had not attended to R #1 but had heard R #1 discussed by the Hospice nursing. Hospice Physician YY stated she was aware of R #1's death and that the Hospice nursing staff were shocked by R #1's death. Hospice Physician YY stated she was not aware of the cause of R #1's death. On [DATE] at 9:55 a.m. the DON stated she had not investigated the death of R #1 because R #1 was on Hospice. The DON stated even if she (CNA U) had been on Hall 300 it does not mean she (R #1) would have lived. The DON stated in [DATE] the facility changed the staffing model. The new staffing model only required two nurses on the 10:00 p.m. to 6:00 a.m. shift, and each nurse split two halls. The DON stated there had been several doctors and nurses who were upset over Hall 300 not having nursing coverage. The DON stated there was not an incident form completed regarding the death of R #1. On [DATE] at 11:15 a.m., PA VV stated she was very familiar with R #1. PA VV stated R #1 was very capable of voicing her needs. PA VV stated R #1 did not have a history of [MEDICAL CONDITION] nor any [DIAGNOSES REDACTED]. PA VV stated she last assessed R #1 on [DATE] and R #1 did not have complaints of shortness of breath on [DATE]. PA VV stated R #1 had a chest x-ray [DATE] that indicated consolidations were present (lung tissue that becomes engorged with fluid or tissue). PA VV stated she had ordered the resident [MEDICATION NAME] treatments every six hours while awake, times one week, then every six hours PRN for Shortness of Breath and cough. PA VV stated she ordered a repeat chest x-ray one week after R #1 received the [MEDICATION NAME] treatments to see if R #1's lungs had cleared up. PA VV reviewed the resident's record with surveyor present and was not able to locate the chest x-ray. PA VV stated she had observed R #1 sitting in the facility the afternoon of [DATE]. PA VV stated R #1 looked great. PA VV stated R #1 had been put on Hospice and was gaining weight. PA VV stated I was very shocked to hear the next day she (R #1) was deceased . PA VV stated she had voiced her concerns to the facility regarding a nurse not being assigned to Hall 300. R #1's Medication Administration Record [REDACTED] [DATE]-at 6:00 a.m. and 6:00 p.m., [DATE]-at 6:00 a.m., [DATE]-at 6:00 p.m., [DATE]-at 6:00 p.m. R #1's Laboratory Record dated [DATE] through [DATE] revealed Repeat chest x-ray on [DATE]. The Laboratory Record was not initialed indicating R #1 did not receive the Chest x-ray on [DATE]. Review of R #1's entire medical folder revealed there was not a follow-up chest x-ray. On [DATE] at 4:30 p.m., the Administrator stated she was not aware of any concerns over R #1's death. The Administrator stated she had not been notified that at the time R #1 was found unresponsive, R #1's call light was turned on and CNA U had not notified LVN A she was taking a break, leaving Hall 300 unattended. The Administrator stated she did not know the cause of death for R #1. The Administrator stated she did not know why R #1's follow-up chest x-ray was not completed. The Administrator stated she had documented R #1 was due for a chest x-ray in her daily morning meeting notes, but the chest x-ray had not been completed. On [DATE] at 9:35 a.m., FM TT stated on [DATE] she was at the facility with R #1. FM TT stated, I don't know why I left. FM TT stated when she arrived on [DATE] before 6:30 p.m. and R #1 was wheezing and asking for a breathing treatment. FM TT stated she requested a breathing treatment for [REDACTED]. FM TT stated R #1 had breathing treatments ordered as needed. FM TT stated R #1 had not received the breathing treatment by 6:30 p.m. and FM TT was too afraid to go and ask the nurse again to administer R #1 a breathing treatment. FM TT stated I was afraid to ask for more things for (R #1). I felt threatened. FM TT stated R #1 had been neglected many times since she had been admitted and FM TT had made many complaints to the Director of Nursing and the Administrator. FM TT stated she had previously been told by management she could move her mother (R #1) if she was not happy at the facility. FM TT stated she had been told by the DON that staff were afraid of her and the facility had to have two staff go into the room as witnesses when she was visiting R #1. FM TT stated the DON told her the facility could not be pulling staff. FM TT stated you never knew who the nurse was for the 300 Hall because the hall was split up between so many nurses. FM TT stated the nurses were assigned halls and after they finished rounds on their assigned halls they (nurses) would go to Hall 300. FM TT stated on [DATE] she notified the Hospice Social Worker who told her to call the Hospice Nurse and tell her to come immediately. FM TT stated HN PP arrived to R #1's room at approximately 8:00 p.m. and HN PP requested the facility nurse to give R #1 a breathing treatment. FM TT stated the breathing treatment was given to R #1 between 8:00 and 10:00 p.m. FM TT stated HN PP requested for the humidifier to be replaced on the oxygen concentrator because it was out of water. FM TT stated when she left the facility at 10:00 p.m. the humidifier still had not been replaced on the oxygen concentrator. FM TT stated when she left the facility at 10:00 p.m. on [DATE]. R #1 was in bed and the bed was elevated. FM TT stated, When I left ([DATE]) she was fine. On [DATE] at 5:38 p.m., the DON stated she verbally counseled CNA U for leaving the facility and not returning or calling the facility on [DATE]. The DON stated R #1 was on Hospice and was going down. The DON stated even if R #1 had been found in time R #1 would have still expired because she was a Do Not Resuscitate. The facility's undated Accident and Incidents-Investigating and Reporting policies and procedures revealed, all accidents or incidents involving residents., occurring on our premises should be investigated and reported to the administrator.Reporting of Accidents/incidents d. An Accident or Incident Report Form should be completed for all reported accident or incidents.Obtain handwritten statements from witnesses to the incident. Interview all those with knowledge to the incident. e. We will follow the Guidelines of Reporting Incidents as outlined in the most current provider letter issued by the Texas Department of Aging and Disability Services if there is a suspicion of .neglect, death. 4. Investigative Action: a. The nurse supervisor/charge nurse and/or the department director or supervisor should conduct an immediate investigation of the accident or incident. 5. Accident/Incident Report: a. The nurse supervisor/charge nurse, department director and/or administrator should: 1. Complete an Accident and Incident Report Form and submit it to the director of nursing services and/or administrator along with the Accident Investigation Report Form. The facility's policy and procedures for Abuse Prevention Program dated [DATE] revealed This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law. As with other resident protection and care protocols and policies, it is important to use common sense and reason when carrying out this policy. Since.neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. On [DATE] at 6:30 p.m., an IJ was identified and the DON and Administrator were informed at 7:14 p.m. on [DATE] of the IJ due to the above failures. On [DATE] at 10:30 p.m., the facility's fourth Plan of Removal was accepted and contained the following: Issues: 1. Facility failed to identify a change in respiratory status and failed to provide services for monitoring O2 administration. 2. Facility failed to have sufficient staff to meet the needs of the residents. Interventions Issue #2: 1. Facility will ensure we have appropriate staff on each shift to meet the needs of the residents. 6:00 a.m. to 2:00 p.m. shift (minimum of 2 aides per hall)/ 2:00 p.m. to 10:00 p.m. shift (minimum of 2 aides per hall)/ 10:00 p.m. to 6:00 a.m. shift (minimum of one aide per hall). Initiated: [DATE] Completion: Ongoing 2. Aides will be in-serviced on proper call in procedures. 1st call in-verbal warning, 2nd call in-written counseling, 3rd call in suspension and possible termination. Initiated: [DATE] Completion: Ongoing 3. Charge Nurses will notify on-call nurse and Administrator if scheduled staff do not report to duty or if nurse aides leave their assigned floor without notifying supervisory charge nurse. Initiated: [DATE] Completion: Ongoing 4. On call nurse will attempt to find replacements of staff; should staff not be available on-call nurse will work as a nurse aide on the floor and notify the DON and Administrator. Initiated: [DATE] Completion: Ongoing 5. Facility will continue to recruit for staff: advertise, connect with local schools and request assistance from Corporate recruiting department. Initiated: [DATE] Completion: Ongoing 6. Advertisement will be run in local newspaper weekly until nurse aide positions are filled to complete schedule as stated in #1 to meet the needs of the residents. Initiated: [DATE] Completion: Ongoing Monitoring: 1. Nurse Management will monitor compliance of skilled MAR indicated [REDACTED] 2. Nurse Managers will monitor residents with special needs and equipment during morning rounds. 3. Administrator and DON will monitor staffing patterns daily during morning rounds to ensure appropriate staff is scheduled to meet the needs of the residents. 4. The facility Medical Director will be notified of the immediate jeopardy and interventions that have been put into place. 5. The facility QA committee will be responsible for monitoring status for staffing issues and making revisions as indicated. 6. Department Heads will monitor the response time for answering call lights during their daily rounds. Charge Nurses will monitor the response time for answering call lights during evening and night shifts on rounds. End of Plan of Removal. Through observations, interviews and record reviews, the survey team determined that in-servicing was initiated and staff followed the residents at risk for O2/special needs and ensured sufficient staffing that was documented in the facility's Plan of Removal were implemented. On [DATE] at 5:15 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for potential for more than minimal harm with a scope identified as pattern. The facility was still implementing the Plan of Removal. The facility's 802 provided on [DATE] revealed there were 24 residents who resided on Hall 300. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to care and services to prevent neglect. As of exit on [DATE] at 5:15 p.m., the facility provided no further information. Refer to F224 and F226

Based on observation, interview and record review the facility failed to implement policies and procedures that prohibit neglect for two Residents (R #1 and R #2) of seven residents who resided on Hall 300 and were reviewed for provision of care and services. The facility did not have staff available for residents when needed for over one hour to meet resident needs. The facility did not have staff available to intervene and provide timely assessments when a resident was in a medical crisis. Hall 300 was left unattended for over an hour and R #1 was found with her call light on and unresponsive. R #1 was pronounced dead. R #2 complained of shortness of breath and the facility failed to assess and ensure R #2's oxygen concentrator and [MEDICAL CONDITION] machine were operational. R #2 could not breathe, called 911 and was transported to the hospital where he remained at the time of this investigation. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of actual harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures placed one resident in the hospital and resulted in death for one resident in the facility and could place the 24 residents who resided on Hall 300 and the three residents who were ordered continuous oxygen at a risk of neglect and delay medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #1's Face Sheet dated [DATE] indicated R #1 was admitted to the facility on [DATE]. R #1 was [AGE] years old. R #1's History and Physical dated [DATE] indicated R #1's admission into the facility was for skilled care. R #1 had high blood pressure, [MEDICAL CONDITION], Vascular Multi-infarction (stroke), Dementia, and [MEDICAL CONDITION] that were all well-controlled. R #1's Physician's Progress Notes dated [DATE] and completed by Physician Assistant (PA) VV revealed R #1 was eating well and had a seven pound weight gain in one month; R #1 was awake and able to voice her needs, vital signs were within normal limits. PA VV ordered R #1 [MEDICATION NAME] treatment (breathing treatment) every six hours, times one week and then as needed (PRN) for Shortness of Breath/cough. Chest x-ray one week after nebulizer treatments. R #1's Physician's Consolidated Orders dated [DATE] indicated R #1's current [DIAGNOSES REDACTED]. R #1 was a Full Code. R #1 was ordered: -PRN Oxygen (O2) at 2 liters per minute per nasal canula to relieve signs and symptoms of [MEDICAL CONDITION] (oxygen supply is insufficient) related to shortness of breath. -[MEDICATION NAME] (nebulizer)-one unit dose per nebulizer every six hours PRN Shortness of Breath/Cough. Monitor Respirations, Pulse, O2 Saturations (SAT) and lung sounds. R #1's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] indicated R #1 was placed on Hospice for [MEDICAL CONDITION]. R #1 had clear speech and was able to make herself understood and understood others. R #1 was cognitively aware and able to make decisions. R #1's Hospice Nursing Summary dated [DATE] and completed by Hospice Nurse (HN) PP revealed HN PP was called to the facility the evening of [DATE] by R #1's Family Member (FM) TT. FM TT was concerned that when she arrived earlier to the facility she (FM TT) found R #1's feet were hanging off the chair and swollen. R #1's vital signs were within normal limits. R #1's Departmental Notes/Nurse's Notes dated [DATE] at 8:25 a.m. and completed by LVN A revealed upon making rounds R #1 was found unresponsive at 2:50 a.m. Full Code called. Staff called to aide. Cardio [MEDICAL CONDITION] Resuscitation (CPR) initiated. Unable to obtain vital signs. No response with CPR. On [DATE] at 3:35 a.m. the Hospice nurse arrived to pronounce death. On [DATE] at 11:15 a.m., CNA T stated she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. CNA T stated she and CNA V went to put R #1 into bed on [DATE] before 10:00 p.m. R #1 did not want to go to bed and CNA T told HN PP. HN PP and FM TT talked R #1 into going to bed. CNA T and CNA V put R #1 to bed right before getting off their shift. CNA T stated R #1's head of bed was elevated and R #1 was joking around. CNA T stated R #1 was very coherent. CNA T stated, I could not believe the next day when I was told she (R #1) was dead. On [DATE] at 6:37 p.m., CNA V stated she and CNA T put R #1 to bed between 9:50 p.m. to 10:00 p.m. on [DATE]. CNA V stated FM TT and HN PP was in R #1's room. CNA V stated R #1 was elevated in her bed and had the call light within reach. CNA V sated R #1 was able to state her needs. On [DATE] at 2:37 p.m., HN PP stated she had visited with R #1 and FM TT between 10:00 p.m. and 11:00 p.m. on [DATE]. HN PP stated FM TT had requested a Hospice nurse to speak to regarding concerns that the facility was not providing care to R #1. HN PP stated when she arrived in R #1's room she observed R #1 in a recliner chair with her feet propped up. HN PP stated FM TT told her earlier in the evening she (FM TT) had found R #1 in the room with her feet hanging and very swollen. HN PP stated at the time of her visit R #1's right ankle bone and feet were swollen. HN PP stated R #1's vital signs were within normal limits. HN PP stated R #1's humidifier bottle located on oxygen concentrator was low. HN PP stated there were no red flags indicating anything was wrong. HN PP stated R #1's lungs were clear and she had not heard wheezing. HN PP stated heck yeah I was surprised. I would have never dreamed she would pass away in less than eight hours. I was shocked. Just shocked. On [DATE] at 6:05 a.m., CNA N stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. CNA N stated CNA U was assigned Hall 300 on [DATE]. CNA N stated CNA U did not tell her Charge Nurse, she was leaving for break and no one was assigned to watch out for Hall 300. CNA N stated LVN A told her and CNA CC to check the hall lights after midnight that were turned on for Hall 300. CNA N stated R #1's call light was on and when CNA N and CNA CC entered R #1 was unresponsive. CNA N stated she yelled to LVN A for help. On [DATE] at 7:00 a.m., Licensed Vocational Nurse (LVN) B stated he worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and after 12:00 a.m. CNA U told him she was going to take a break, CNA U never returned to the facility. LVN B stated he did not notify anyone CNA U was going on break. LVN B stated CNA U was working on Hall 300 prior to leaving and the charge nurse for Hall 300 was LVN A. On [DATE] at 7:15 a.m. LVN A stated she had worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. LVN A stated CNA U was assigned to work Hall 300 and LVN A was the Charge Nurse for Halls 300 and 400. LVN A stated she was working on Hall 400 and at approximately 2:15 a.m. she walked to the nurse's station located in the middle of the facility. LVN A stated she observed two call lights lit outside the doors on Hall 300. LVN A stated she asked CNA N to look for CNA U. CNA N stated she could not find CNA U. LVN B overheard CNA N and LVN A talking and stated CNA U had told him she was going on break. LVN A stated at approximately 2:15 a.m. to 2:30 a.m., she told CNA CC and CNA N to go and answer the call lights on Hall 300. LVN A stated CNA N and CNA CC found R #1 unresponsive. CNA N yelled for LVN A to help. LVN A stated she did not feel a pulse on R #1 but initiated Cardio [MEDICAL CONDITION] Resuscitation because R #1 was a full code. LVN A stated R #1's call light was turned on in the room and lit up outside of the room. LVN A stated R #1's roommate was not capable of using the call light. LVN A stated R #1 was supposed to be elevated when in bed, never lying flat. LVN A stated R #1 was lying flat in the bed. LVN A stated R #1 had been coherent, capable of turning the call light on and had used the call light on many occasions in the past to request oxygen. LVN A stated R #1 had O2 ordered PRN for Shortness of Breath. R #1's Mortician's Receipt/Death Report dated [DATE] revealed R #1 was pronounced dead by HN PP on [DATE] at 4:45 a.m., after being fully coded by the Emergency Medical Team. The cause of death was not documented on the form. R #1's Discharge Summary dated [DATE] revealed there was not a cause of death documented on the form. The facility's Daily Position Sheet dated [DATE] for the 10:00 p.m. to 6:00 a.m. shift indicted CNA U was assigned Hall 300. CNA U's Enhanced Time Care Report dated [DATE] revealed CNA U clocked out of the facility at 1:25 a.m. and did not return. On [DATE] at 2:55 p.m., CNA U stated she had left the facility to go on break at 1:30 a.m. on [DATE]. CNA U stated she was pulled over by the police and her car was towed. CNA U stated she did not call and notify the facility but called the Lead CNA (CNA Z who was not working) and told her she would not return. CNA U stated at about 11:30 p.m. she did rounds and R #1 was dry and in her bed. CNA U stated I honestly can not remember how much, but her (R #1's) bed was elevated and the call light was not on. CNA U stated she told CNA N on Hall 400 she was going on break. On [DATE] at 11:45 a.m., CNA Z stated CNA U did not call and report to her on [DATE] that CNA U's car had been towed and CNA U would not be returning to work. CNA Z stated CNA U messaged her cell phone her at 1:44 a.m., and CNA Z did not read the text until 6:00 a.m. on [DATE]. CNA Z stated she was the Lead CNA and CNAs were to notify her when they were not going to come in. CNA Z stated she was responsible for finding another CNA to cover for the call in. On [DATE] at 9:45 a.m., Hospice Physician WW stated he was not familiar with R #1 and Facility Physician was the attending Physician for R #1. On [DATE] at 10:40 a.m. Facility Physician stated she had seen R #1 when she was admitted ([DATE]) but had not seen R #1 recently. Facility Physician stated PA VV was familiar with R #1. On [DATE] at 1:05 p.m. Hospice Physician YY stated she had not attended to R #1 but had heard R #1 discussed by the Hospice nursing. Hospice Physician YY stated she was aware of R #1's death and that the Hospice nursing staff were shocked by R #1's death. Hospice Physician YY stated she was not aware of the cause of R #1's death. On [DATE] at 9:55 a.m. the DON stated she had not investigated the death of R #1 because R #1 was on Hospice. The DON stated even if she (CNA U) had been on Hall 300 it does not mean she (R #1) would have lived. The DON stated in [DATE] the facility changed the staffing model. The new staffing model only required two nurses on the 10:00 p.m. to 6:00 a.m. shift, and each nurse split two halls. The DON stated there had been several doctors and nurses who were upset over Hall 300 not having nursing coverage. The DON stated there was not an incident form completed regarding the death of R #1. On [DATE] at 11:15 a.m., PA VV stated she was very familiar with R #1. PA VV stated R #1 was very capable of voicing her needs. PA VV stated R #1 did not have a history of [MEDICAL CONDITION] nor any [DIAGNOSES REDACTED]. PA VV stated she last assessed R #1 on [DATE] and R #1 did not have complaints of shortness of breath on [DATE]. PA VV stated R #1 had a chest x-ray [DATE] that indicated consolidations were present (lung tissue that becomes engorged with fluid or tissue). PA VV stated she had ordered the resident [MEDICATION NAME] treatments every six hours while awake, times one week, then every six hours PRN for Shortness of Breath and cough. PA VV stated she ordered a repeat chest x-ray one week after R #1 received the [MEDICATION NAME] treatments to see if R #1's lungs had cleared up. PA VV reviewed the resident's record with surveyor present and was not able to locate the chest x-ray. PA VV stated she had observed R #1 sitting in the facility the afternoon of [DATE]. PA VV stated R #1 looked great. PA VV stated R #1 had been put on Hospice and was gaining weight. PA VV stated I was very shocked to hear the next day she (R #1) was deceased . PA VV stated she had voiced her concerns to the facility regarding a nurse not being assigned to Hall 300. R #1's Medication Administration Record [REDACTED] [DATE]-at 6:00 a.m. and 6:00 p.m., [DATE]-at 6:00 a.m., [DATE]-at 6:00 p.m., [DATE]-at 6:00 p.m. R #1's Laboratory Record dated [DATE] through [DATE] revealed Repeat chest x-ray on [DATE]. The Laboratory Record was not initialed indicating R #1 did not receive the Chest x-ray on [DATE]. Review of R #1's entire medical folder revealed there was not a follow-up chest x-ray. On [DATE] at 4:30 p.m., the Administrator stated she was not aware of any concerns over R #1's death. The Administrator stated she had not been notified that at the time R #1 was found unresponsive, R #1's call light was turned on and CNA U had not notified LVN A she was taking a break, leaving Hall 300 unattended. The Administrator stated she did not know the cause of death for R #1. The Administrator stated she did not know why R #1's follow-up chest x-ray was not completed. The Administrator stated she had documented R #1 was due for a chest x-ray in her daily morning meeting notes, but the chest x-ray had not been completed. On [DATE] at 9:35 a.m., FM TT stated on [DATE] she was at the facility with R #1. FM TT stated, I don't know why I left. FM TT stated when she arrived on [DATE] before 6:30 p.m. and R #1 was wheezing and asking for a breathing treatment. FM TT stated she requested a breathing treatment for [REDACTED]. FM TT stated R #1 had breathing treatments ordered as needed. FM TT stated R #1 had not received the breathing treatment by 6:30 p.m. and FM TT was too afraid to go and ask the nurse again to administer R #1 a breathing treatment. FM TT stated I was afraid to ask for more things for (R #1). I felt threatened. FM TT stated R #1 had been neglected many times since she had been admitted and FM TT had made many complaints to the Director of Nursing and the Administrator. FM TT stated she had previously been told by management she could move her mother (R #1) if she was not happy at the facility. FM TT stated she had been told by the DON that staff were afraid of her and the facility had to have two staff go into the room as witnesses when she was visiting R #1. FM TT stated the DON told her the facility could not be pulling staff. FM TT stated you never knew who the nurse was for the 300 Hall because the hall was split up between so many nurses. FM TT stated the nurses were assigned halls and after they finished rounds on their assigned halls they (nurses) would go to Hall 300. FM TT stated on [DATE] she notified the Hospice Social Worker who told her to call the Hospice Nurse and tell her to come immediately. FM TT stated HN PP arrived to R #1's room at approximately 8:00 p.m. and HN PP requested the facility nurse to give R #1 a breathing treatment. FM TT stated the breathing treatment was given to R #1 between 8:00 and 10:00 p.m. FM TT stated HN PP requested for the humidifier to be replaced on the oxygen concentrator because it was out of water. FM TT stated when she left the facility at 10:00 p.m. the humidifier still had not been replaced on the oxygen concentrator. FM TT stated when she left the facility at 10:00 p.m. on [DATE]. R #1 was in bed and the bed was elevated. FM TT stated, When I left ([DATE]) she was fine. On [DATE] at 5:38 p.m., the DON stated she verbally counseled CNA U for leaving the facility and not returning or calling the facility on [DATE]. The DON stated R #1 was on Hospice and was going down. The DON stated even if R #1 had been found in time R #1 would have still expired because she was a Do Not Resuscitate. R #2 R #2's Face Sheet dated [DATE] indicated R #2 was admitted to the facility at 2:30 p.m. on [DATE]. R #2 was [AGE] years old. R #2's admission orders [REDACTED] -continuous O2 at 3 liters (L) per nasal canula for signs and symptoms of [MEDICAL CONDITION] due to shortness of breath, -[MEDICAL CONDITION]-(Continuous Positive Airway Pressure, respiratory ventilation primarily used in the treatment of [REDACTED]. -[MEDICATION NAME] 3 milliliters (ml), PRN ever six hours for [DIAGNOSES REDACTED]. R #2's Medicare Nurses Note dated [DATE] revealed R #2's [DIAGNOSES REDACTED]. R #2's O2 SAT level was 96%, Blood Pressure ,[DATE], Respirations 22 and Pulse 81. R #2 had Shortness of Breath/trouble breathing/lying flat. R #2 had [MEDICAL CONDITION] (paralysis). R #2 received O2 Therapy. Depression and Pleural Effusion. R #2 was alert and oriented to person, place and time. R #2's respirations were even and unlabored with O2 at 3 liters per nasal canula. [MEDICAL CONDITION] at bs (bedside), head of bed up 45 degrees for comfort. Requires max assistance with care. Medications verified with Physician MM and faxed to the pharmacy. Call light within reach. Monitor for changes. R #2's Initial Plan of Care dated [DATE] revealed R #2 was alert and his vision, hearing and speech were normal. R #2 was continent of bowel and bladder and utilized a bedpan for toileting. R #2 utilized a wheelchair and required a mechanical lift for transfers. Additional notes on the bottom of the Initial Plan of Care indicated R #2 required two staff persons for Activities of Daily Living (ADLs, hygiene, bathing, showers, incontinent care and transfers) and utilized a mechanical lift. R #2 could verbalize his needs. R #2's required continuous O2, [MEDICAL CONDITION] at night or PRN breathing treatments were not included in R #2's Initial Plan of Care. R #2's admission orders [REDACTED]. There was not any documentation R #2 received O2 on: [DATE]-2:00 p.m. to 10:00 p.m. shift, [DATE]-6:00 a.m. to 2:00 p.m. shift, [DATE]-2:00 p.m. to 10:00 p.m. shift, [DATE]-6:00 a.m. to 2:00 p.m. shift, [DATE]-2:00 p.m. to 10:00 p.m. shift. There was not any documentation on the admission orders [REDACTED]. There was not any documentation on the admission orders [REDACTED]. Medicare Nurse's Notes dated [DATE] and completed by LVN G revealed: -5:00 p.m.-scheduled medications given, resident voices no concerns at this time. -6:00 p.m.-Noted Emergency Medical Services (EMS) 911 enter facility and ask for room [ROOM NUMBER] A, upon entrance to room noted resident (R #2) with [MEDICAL CONDITION] on. R #2 stated, I called them, I'm short of breath. EMS asked R #2 how long had he been like this, R #2 responded all day. R #2's O2 SATS 93% with 3 liters O2 via nasal canula. R #2 informed EMS he wanted to go to the hospital. Resident transferred on stretcher and out of facility alert and oriented. R #2's Fire Department Patient Care Report dated [DATE] and completed by the EMT indicated the EMTs were dispatched to the facility on [DATE] due to R #2 having difficulty breathing. The Report indicated the EMTs arrived in R #2's room at 5:30 p.m. on [DATE]. R #2 was sitting in a bed and oriented to person, place, time and events. Complained of difficulty breathing. Patient stated he had difficulty breathing since this morning at 5:00 a.m. ([DATE]). Patient stated at 6:00 a.m. he received a breathing treatment from the staff. After treatment was finished, patient was placed on [MEDICAL CONDITION] machine. Patient stated that he did not receive any relief from his [MEDICAL CONDITION] machine all day. Patient stated that he was constantly calling for nurses to help him and they never did. His condition gradually worsened. Vital signs were taken and noted. Room Air O2 sat was at 76 percent, lung sounds diminished bilaterally. Patient was still on the [MEDICAL CONDITION] mask at this time. It was noticed that the [MEDICAL CONDITION] machine was not turned on or connected to any oxygen. Patient was placed on NRB (non re-breather, device used in medical emergencies that requires oxygen therapy) immediately. No cyanosis was noted and patient did not seem to be in any respiratory distress. Nursing staff at facility stated they were not aware of the current situation. Patient was moved to ambulance. IV access was unable to be obtained. Male stated he had immense relief from O2. O2 SATS were noted to go up to 99 percent. En route patient was much improved. EMTs arrived at the local hospital at 5:54 p.m. on [DATE]. On [DATE] at 1:10 p.m. EMT RR stated he and EMT SS arrived at the facility at approximately 5:00 p.m. on [DATE]. EMT RR stated when he and EMT SS arrived at the Nurse's Station the nurses standing at the Nurse's Station were surprised. EMT RR stated none of the staff knew who had called 911. EMT RR stated when he entered R #2's room R #2 had a [MEDICAL CONDITION] mask on his face. EMT RR stated he (R #2) was making an effort to breathe. R #2 told EMT RR he used the [MEDICAL CONDITION] when he had difficulty breathing. EMT RR stated typically a [MEDICAL CONDITION] is loud and he realized the [MEDICAL CONDITION] was not turned on. EMT RR stated R #2's O2 SAT was 78% initially and his lungs sounded diminished bilaterally. EMT RR stated he placed a non re-breather (a mask used in medical emergencies that requires O2 therapy) on R #2 at 15 liters per minute and R #2's O2 SATS went to 99%. EMT RR stated he asked R #2 how long this had been going on and R #2 told EMT RR since this morning. EMT RR stated R #2 said he told the nurse he was having trouble breathing and the nurse said to R #2 to breathe in oxygen. EMT RR stated R #2 told him he put the [MEDICAL CONDITION] mask on himself at 6:00 a.m. to try and get more O2. EMT RR said R #2 told him I got fed up and called 911. EMT RR stated there was not any O2 connected to the [MEDICAL CONDITION] mask or on R #2. EMT RR stated the O2 concentrator was turned on but the tubing was not connected to anything. EMT RR stated there were several nurses in the room and someone walked over and turned on the [MEDICAL CONDITION] machine. EMT RR stated, no-one (staff) knew what was going on. EMT RR stated if R #2 had gone to sleep with the mask on he may not have awakened. EMT RR stated it is like putting a plastic bag over your head (meaning the [MEDICAL CONDITION] mask) and suffocating because you are not getting oxygen. EMT RR stated it was really shocking no one at the facility knew what was going on. On [DATE] at 1:45 p.m., EMT SS stated on [DATE] she assisted EMT RR with a call to the facility. EMT SS stated when she and EMT RR arrived no one at the desk knew of anyone short of breath. EMT SS stated they (staff) said (R #2) must have called. EMT SS stated when she arrived in R #2's room R #1's [MEDICAL CONDITION] mask was on his face. EMT SS stated she took R #2's O2 SAT and it was below 80%. EMT SS stated she tried a different finger and the O2 SAT was still below 80%. EMT SS stated she took R #2's O2 SAT on a different hand and the O2 SAT was still below 80%. R #2 stated to EMT SS and EMT RR he had been that way a couple of hours. EMT SS stated R #2's [MEDICAL CONDITION] mask was strapped on R #2's face and the O2 tubing was not hooked to the [MEDICAL CONDITION]. EMT SS said I followed the O2 tubing connected to the O2 concentrator and the O2 tubing was lying on the floor. EMT SS stated R #2's O2 concentrator was turned on but the nasal canula was not connected to anything. EMT SS stated R #2 told them he had lifted up the [MEDICAL CONDITION] mask a couple of times to take breaths. EMT SS stated there were four nurses and CNAs in the room and EMT RR asked nurses who knew how to work the [MEDICAL CONDITION] machine and the O2 concentrator? EMT SS stated no one could say how to work the O2 or [MEDICAL CONDITION] machine. EMT SS stated without the oxygen turned on or connected R #2 was breathing his own air back inside and was getting Carbon [MEDICATION NAME] poisoning. EMT SS said R #2 was given the EMT's O2 and R #2's O2 SATs went up to 100%. Emergency Physician Record dated [DATE] revealed R #2's chief complaint was shortness of breath with an onset of one day. R #2 was alert and oriented. R #2's Arterial Blood Gas (ABG-measurement of how much oxygen and carbon [MEDICATION NAME] are in the blood) in the emergency room were: -77.3-pCO2 (Partial pressure of carbon [MEDICATION NAME]). The within normal range of pC02 was ,[DATE] mm hg. -PO2- (Partial pressure of oxygen). The normal range of oxygen saturation level is 95% to 99%. According to http://www.webmd.com dated [DATE], -pCO2-measures the pressure of carbon [MEDICATION NAME] dissolved in the blood and how well carbon [MEDICATION NAME] is able to move out of the body. -pO2 measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. On [DATE] at 9:20 a.m., surveyor attempted to call ER Physician OO. Surveyor left a message. During an interview with Hospital Physician ZZ on [DATE] at 10:30 a.m. surveyor requested Physician ZZ to review the emergency room Laboratory Report dated [DATE] at 7:17 p.m. Physician ZZ reviewed the report and stated R #2's, pO2 was ok but not good and the pCO2 77.3% could cause unconsciousness and could cause death. The laboratory Report had a handwritten note that indicated R #2 was at the nursing facility, had difficulty breathing since 6:00 a.m., [MEDICAL CONDITION] was completely off and no O2 was connected. According to http://www.ncbi.nlm.nih.gov/ Carbon [MEDICATION NAME] main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level.At higher concentrations it leads to an increased respiratory rate, [MEDICAL CONDITION] cardic arrhythmia and impaired consciousness. Concentrations greater than 10% may cause convulsions, coma and death. According to http://www.merriam-webster.com Asphyxia is a lack of oxygen or excess of carbon [MEDICATION NAME] in the body that is usually caused by interruption of breathing and that causes unconsciousness. R #2's chest x-ray dated [DATE] indicated R #2 had moderate to large right pleural effusion with right lower lobe consolidation and mild central [MEDICAL CONDITION] vascularity. According to http://www.nlm.nih.gov obtained [DATE] pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an abnormal, excessive collection of this fluid. Symptoms of Pleural effusion include.cough, rapid breathing, shortness of breath. Observation and subsequent interview with R #2 in the Hospital on [DATE] at 9:35 a.m., revealed R #2 lying in a hospital bed. R #2 had O2 nasal canula. R #2 stated, I would say I was neglected by the facility. R #2 stated he was told prior to being admitted to the facility that the facility was equipped to handle a [MEDICAL CONDITION] machine. R #2 stated he was admitted to the facility on [DATE] and his room was on Hall 300. R #2 said he was told that evening by an unknown lady there is not enough staff, once we leave the hall it will be a while till we get back. R #2 stated on [DATE] he would turn on the call light and it would take an hour or two for anyone to get to his room. R #2 stated at 5:00 a.m. on [DATE] he could not breathe and he was given a nebulizer treatment. R #2 stated he felt better for a while. R #2 stated his wife and son arrived at approximately 9:00 a.m. and R #2 said he could not snap out of it. R #2 stated his wife went and told a nurse he was having trouble breathing. R #2 said a nurse came in and gave him a pain pill ([MEDICATION NAME]) and an anxiety medication ([MEDICATION NAME]). R #2 stated his wife tried to wake him up in the afternoon but he was out of it. R #2 stated his wife left around 3:00 p.m. and the CNAs told him once we leave the hallway it will be a while before we are back. You can't be yelling. You have to wait. R #2 stated he did yell for help and someone came in and said you cannot be yelling there is other residents. R #2 stated a nurse came in around 5:00 p.m. on [DATE] and he told her something is not right, I can't breath. R #2 stated the nurse did not say anything, just left him hanging. R #2 stated he called 911. R #2 stated he had turned on his call light many times during the day and it took a long time to be answered. R #2 stated he did not turn on his call light at the time he called 911. R #2 stated I could not handle it. R #2 stated, I may be ignorant to things but I thought they (EMTs) said I was not even hooked up to oxygen. R #2 stated the EMTs got his O2 level back up and asked him if he wanted to stay or go to the emergency room . R #2 stated he could tell by the tone of the EMTs voice it would be better for him to go to the emergency room . R #2 stated when he was in the emergency room his CO2 levels were high and he was told the CO2 levels being high was from him not getting O2. On [DATE] at 12:30 p.m. FM MM stated she and her son visited R #2 on [DATE]. FM MM stated R #2 was very groggy and she could not wake R #2 up. FM MM stated R #2 was swollen and looked like a blow fish. FM MM stated she went to the nurse's station and told someone R #2 was having a hard time breathing. FM MM stated R #2 was given his pain medication by an unknown nurse. FM MM stated R #2 had turned on the call light and it took 1-,[DATE] hours to get answered. FM MM stated when she was in R #2's room visiting she heard a CNA tell R #2 they did not have enough staff to put him on the bedpan. FM MM stated she left the facility to run errands and was called back to the facility by Staff Person Q to sign R #2's admission papers. FM MM stated Staff Person Q told her to tell R #2 tell him (R #2) to bear with us, not to call 911. FM MM stated after she signed the admission papers she went back to R #2's room and still could not wake R #2 up. FM MM stated it was not normal but she thought R #2 was resting. FM MM stated she left the facility at approximately 3:00 p.m. on [DATE]. FM MM stated a little later she received a phone call from R #2 and he told her he could not breathe. FM MM stated R #2 was gasping. FM MM stated R #2 told her he had called 911. FM MM stated she called the nursing facility and they told her the EMTs were in the room with R #2. FM MM stated in the emergency room she heard the doctor say R #2 had Carbon [MEDICATION NAME] poisoning that was dangerously high. On [DATE] at 2:30 p.m. CNA T stated she was in R #2's room on [DATE] to assist the EMTs with transferring R #2 and she overheard the EMTs say R #2's [MEDICAL CONDITION] machine and O2 concentrator were off. On [DATE] at 3:00 p.m., CNA X stated she worked the 2:00 p.m. to 10:00 p.m. shift on Hall 300 on [DATE]. CNA X stated she was not assigned R #2 but had checked R #2 at the beginning of

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect for two Residents (R #1 and R #2) of seven residents who resided on Hall 300 and were reviewed for provision of care and services. The facility did not have staff available for residents when needed for over one hour to meet resident needs. The facility did not have staff available to intervene and provide timely assessments when a resident was in a medical crisis. Hall 300 was left unattended for over an hour and R #1 was found with her call light on and unresponsive. R #1 was pronounced dead. R #2 complained of shortness of breath and the facility failed to assess and ensure R #2's oxygen concentrator and [MEDICAL CONDITION] machine were operational. R #2 could not breathe, called 911 and was transported to the hospital where he remained at the time of this investigation. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of actual harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures placed one resident in the hospital and resulted in death for one resident in the facility and could place the 24 residents who resided on Hall 300 and the three residents who were ordered continuous oxygen at a risk of neglect and delay medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #1's Face Sheet dated [DATE] indicated R #1 was admitted to the facility on [DATE]. R #1 was [AGE] years old. R #1's History and Physical dated [DATE] indicated R #1's admission into the facility was for skilled care. R #1 had high blood pressure, [MEDICAL CONDITION], Vascular Multi-infarction (stroke), Dementia, and [MEDICAL CONDITION] that were all well-controlled. R #1's Physician's Progress Notes dated [DATE] and completed by Physician Assistant (PA) VV revealed R #1 was eating well and had a seven pound weight gain in one month; R #1 was awake and able to voice her needs, vital signs were within normal limits. PA VV ordered R #1 [MEDICATION NAME] treatment (breathing treatment) every six hours, times one week and then as needed (PRN) for Shortness of Breath/cough. Chest x-ray one week after nebulizer treatments. R #1's Physician's Consolidated Orders dated [DATE] indicated R #1's current [DIAGNOSES REDACTED]. R #1 was a Full Code. R #1 was ordered: -PRN Oxygen (O2) at 2 liters per minute per nasal canula to relieve signs and symptoms of [MEDICAL CONDITION] (oxygen supply is insufficient) related to shortness of breath. -[MEDICATION NAME] (nebulizer)-one unit dose per nebulizer every six hours PRN Shortness of Breath/Cough. Monitor Respirations, Pulse, O2 Saturations (SAT) and lung sounds. R #1's Significant Change in Status Minimum Data Set ((MDS) dated [DATE] indicated R #1 was placed on Hospice for [MEDICAL CONDITION]. R #1 had clear speech and was able to make herself understood and understood others. R #1 was cognitively aware and able to make decisions. R #1's Hospice Nursing Summary dated [DATE] and completed by Hospice Nurse (HN) PP revealed HN PP was called to the facility the evening of [DATE] by R #1's Family Member (FM) TT. FM TT was concerned that when she arrived earlier to the facility she (FM TT) found R #1's feet were hanging off the chair and swollen. R #1's vital signs were within normal limits. R #1's Departmental Notes/Nurse's Notes dated [DATE] at 8:25 a.m. and completed by LVN A revealed upon making rounds R #1 was found unresponsive at 2:50 a.m. Full Code called. Staff called to aide. Cardio [MEDICAL CONDITION] Resuscitation (CPR) initiated. Unable to obtain vital signs. No response with CPR. On [DATE] at 3:35 a.m. the Hospice nurse arrived to pronounce death. On [DATE] at 11:15 a.m., CNA T stated she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE]. CNA T stated she and CNA V went to put R #1 into bed on [DATE] before 10:00 p.m. R #1 did not want to go to bed and CNA T told HN PP. HN PP and FM TT talked R #1 into going to bed. CNA T and CNA V put R #1 to bed right before getting off their shift. CNA T stated R #1's head of bed was elevated and R #1 was joking around. CNA T stated R #1 was very coherent. CNA T stated, I could not believe the next day when I was told she (R #1) was dead. On [DATE] at 6:37 p.m., CNA V stated she and CNA T put R #1 to bed between 9:50 p.m. to 10:00 p.m. on [DATE]. CNA V stated FM TT and HN PP was in R #1's room. CNA V stated R #1 was elevated in her bed and had the call light within reach. CNA V sated R #1 was able to state her needs. On [DATE] at 2:37 p.m., HN PP stated she had visited with R #1 and FM TT between 10:00 p.m. and 11:00 p.m. on [DATE]. HN PP stated FM TT had requested a Hospice nurse to speak to regarding concerns that the facility was not providing care to R #1. HN PP stated when she arrived in R #1's room she observed R #1 in a recliner chair with her feet propped up. HN PP stated FM TT told her earlier in the evening she (FM TT) had found R #1 in the room with her feet hanging and very swollen. HN PP stated at the time of her visit R #1's right ankle bone and feet were swollen. HN PP stated R #1's vital signs were within normal limits. HN PP stated R #1's humidifier bottle located on oxygen concentrator was low. HN PP stated there were no red flags indicating anything was wrong. HN PP stated R #1's lungs were clear and she had not heard wheezing. HN PP stated heck yeah I was surprised. I would have never dreamed she would pass away in less than eight hours. I was shocked. Just shocked. On [DATE] at 6:05 a.m., CNA N stated she worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. CNA N stated CNA U was assigned Hall 300 on [DATE]. CNA N stated CNA U did not tell her Charge Nurse, she was leaving for break and no one was assigned to watch out for Hall 300. CNA N stated LVN A told her and CNA CC to check the hall lights after midnight that were turned on for Hall 300. CNA N stated R #1's call light was on and when CNA N and CNA CC entered R #1 was unresponsive. CNA N stated she yelled to LVN A for help. On [DATE] at 7:00 a.m., Licensed Vocational Nurse (LVN) B stated he worked the 10:00 p.m. to 6:00 a.m. shift on [DATE] and after 12:00 a.m. CNA U told him she was going to take a break, CNA U never returned to the facility. LVN B stated he did not notify anyone CNA U was going on break. LVN B stated CNA U was working on Hall 300 prior to leaving and the charge nurse for Hall 300 was LVN A. On [DATE] at 7:15 a.m. LVN A stated she had worked the 10:00 p.m. to 6:00 a.m. shift on [DATE]. LVN A stated CNA U was assigned to work Hall 300 and LVN A was the Charge Nurse for Halls 300 and 400. LVN A stated she was working on Hall 400 and at approximately 2:15 a.m. she walked to the nurse's station located in the middle of the facility. LVN A stated she observed two call lights lit outside the doors on Hall 300. LVN A stated she asked CNA N to look for CNA U. CNA N stated she could not find CNA U. LVN B overheard CNA N and LVN A talking and stated CNA U had told him she was going on break. LVN A stated at approximately 2:15 a.m. to 2:30 a.m., she told CNA CC and CNA N to go and answer the call lights on Hall 300. LVN A stated CNA N and CNA CC found R #1 unresponsive. CNA N yelled for LVN A to help. LVN A stated she did not feel a pulse on R #1 but initiated Cardio [MEDICAL CONDITION] Resuscitation because R #1 was a full code. LVN A stated R #1's call light was turned on in the room and lit up outside of the room. LVN A stated R #1's roommate was not capable of using the call light. LVN A stated R #1 was supposed to be elevated when in bed, never lying flat. LVN A stated R #1 was lying flat in the bed. LVN A stated R #1 had been coherent, capable of turning the call light on and had used the call light on many occasions in the past to request oxygen. LVN A stated R #1 had O2 ordered PRN for Shortness of Breath. R #1's Mortician's Receipt/Death Report dated [DATE] revealed R #1 was pronounced dead by HN PP on [DATE] at 4:45 a.m., after being fully coded by the Emergency Medical Team. The cause of death was not documented on the form. R #1's Discharge Summary dated [DATE] revealed there was not a cause of death documented on the form. The facility's Daily Position Sheet dated [DATE] for the 10:00 p.m. to 6:00 a.m. shift indicted CNA U was assigned Hall 300. CNA U's Enhanced Time Care Report dated [DATE] revealed CNA U clocked out of the facility at 1:25 a.m. and did not return. On [DATE] at 2:55 p.m., CNA U stated she had left the facility to go on break at 1:30 a.m. on [DATE]. CNA U stated she was pulled over by the police and her car was towed. CNA U stated she did not call and notify the facility but called the Lead CNA (CNA Z who was not working) and told her she would not return. CNA U stated at about 11:30 p.m. she did rounds and R #1 was dry and in her bed. CNA U stated I honestly can not remember how much, but her (R #1's) bed was elevated and the call light was not on. CNA U stated she told CNA N on Hall 400 she was going on break. On [DATE] at 11:45 a.m., CNA Z stated CNA U did not call and report to her on [DATE] that CNA U's car had been towed and CNA U would not be returning to work. CNA Z stated CNA U messaged her cell phone her at 1:44 a.m., and CNA Z did not read the text until 6:00 a.m. on [DATE]. CNA Z stated she was the Lead CNA and CNAs were to notify her when they were not going to come in. CNA Z stated she was responsible for finding another CNA to cover for the call in. On [DATE] at 9:45 a.m., Hospice Physician WW stated he was not familiar with R #1 and Facility Physician was the attending Physician for R #1. On [DATE] at 10:40 a.m. Facility Physician stated she had seen R #1 when she was admitted ([DATE]) but had not seen R #1 recently. Facility Physician stated PA VV was familiar with R #1. On [DATE] at 1:05 p.m. Hospice Physician YY stated she had not attended to R #1 but had heard R #1 discussed by the Hospice nursing. Hospice Physician YY stated she was aware of R #1's death and that the Hospice nursing staff were shocked by R #1's death. Hospice Physician YY stated she was not aware of the cause of R #1's death. On [DATE] at 9:55 a.m. the DON stated she had not investigated the death of R #1 because R #1 was on Hospice. The DON stated even if she (CNA U) had been on Hall 300 it does not mean she (R #1) would have lived. The DON stated in [DATE] the facility changed the staffing model. The new staffing model only required two nurses on the 10:00 p.m. to 6:00 a.m. shift, and each nurse split two halls. The DON stated there had been several doctors and nurses who were upset over Hall 300 not having nursing coverage. The DON stated there was not an incident form completed regarding the death of R #1. On [DATE] at 11:15 a.m., PA VV stated she was very familiar with R #1. PA VV stated R #1 was very capable of voicing her needs. PA VV stated R #1 did not have a history of [MEDICAL CONDITION] nor any [DIAGNOSES REDACTED]. PA VV stated she last assessed R #1 on [DATE] and R #1 did not have complaints of shortness of breath on [DATE]. PA VV stated R #1 had a chest x-ray [DATE] that indicated consolidations were present (lung tissue that becomes engorged with fluid or tissue). PA VV stated she had ordered the resident [MEDICATION NAME] treatments every six hours while awake, times one week, then every six hours PRN for Shortness of Breath and cough. PA VV stated she ordered a repeat chest x-ray one week after R #1 received the [MEDICATION NAME] treatments to see if R #1's lungs had cleared up. PA VV reviewed the resident's record with surveyor present and was not able to locate the chest x-ray. PA VV stated she had observed R #1 sitting in the facility the afternoon of [DATE]. PA VV stated R #1 looked great. PA VV stated R #1 had been put on Hospice and was gaining weight. PA VV stated I was very shocked to hear the next day she (R #1) was deceased . PA VV stated she had voiced her concerns to the facility regarding a nurse not being assigned to Hall 300. R #1's Medication Administration Record [REDACTED] [DATE]-at 6:00 a.m. and 6:00 p.m., [DATE]-at 6:00 a.m., [DATE]-at 6:00 p.m., [DATE]-at 6:00 p.m. R #1's Laboratory Record dated [DATE] through [DATE] revealed Repeat chest x-ray on [DATE]. The Laboratory Record was not initialed indicating R #1 did not receive the Chest x-ray on [DATE]. Review of R #1's entire medical folder revealed there was not a follow-up chest x-ray. On [DATE] at 4:30 p.m., the Administrator stated she was not aware of any concerns over R #1's death. The Administrator stated she had not been notified that at the time R #1 was found unresponsive, R #1's call light was turned on and CNA U had not notified LVN A she was taking a break, leaving Hall 300 unattended. The Administrator stated she did not know the cause of death for R #1. The Administrator stated she did not know why R #1's follow-up chest x-ray was not completed. The Administrator stated she had documented R #1 was due for a chest x-ray in her daily morning meeting notes, but the chest x-ray had not been completed. On [DATE] at 9:35 a.m., FM TT stated on [DATE] she was at the facility with R #1. FM TT stated, I don't know why I left. FM TT stated when she arrived on [DATE] before 6:30 p.m. and R #1 was wheezing and asking for a breathing treatment. FM TT stated she requested a breathing treatment for [REDACTED]. FM TT stated R #1 had breathing treatments ordered as needed. FM TT stated R #1 had not received the breathing treatment by 6:30 p.m. and FM TT was too afraid to go and ask the nurse again to administer R #1 a breathing treatment. FM TT stated I was afraid to ask for more things for (R #1). I felt threatened. FM TT stated R #1 had been neglected many times since she had been admitted and FM TT had made many complaints to the Director of Nursing and the Administrator. FM TT stated she had previously been told by management she could move her mother (R #1) if she was not happy at the facility. FM TT stated she had been told by the DON that staff were afraid of her and the facility had to have two staff go into the room as witnesses when she was visiting R #1. FM TT stated the DON told her the facility could not be pulling staff. FM TT stated you never knew who the nurse was for the 300 Hall because the hall was split up between so many nurses. FM TT stated the nurses were assigned halls and after they finished rounds on their assigned halls they (nurses) would go to Hall 300. FM TT stated on [DATE] she notified the Hospice Social Worker who told her to call the Hospice Nurse and tell her to come immediately. FM TT stated HN PP arrived to R #1's room at approximately 8:00 p.m. and HN PP requested the facility nurse to give R #1 a breathing treatment. FM TT stated the breathing treatment was given to R #1 between 8:00 and 10:00 p.m. FM TT stated HN PP requested for the humidifier to be replaced on the oxygen concentrator because it was out of water. FM TT stated when she left the facility at 10:00 p.m. the humidifier still had not been replaced on the oxygen concentrator. FM TT stated when she left the facility at 10:00 p.m. on [DATE]. R #1 was in bed and the bed was elevated. FM TT stated, When I left ([DATE]) she was fine. On [DATE] at 5:38 p.m., the DON stated she verbally counseled CNA U for leaving the facility and not returning or calling the facility on [DATE]. The DON stated R #1 was on Hospice and was going down. The DON stated even if R #1 had been found in time R #1 would have still expired because she was a Do Not Resuscitate. R #2 R #2's Face Sheet dated [DATE] indicated R #2 was admitted to the facility at 2:30 p.m. on [DATE]. R #2 was [AGE] years old. R #2's admission orders [REDACTED] -continuous O2 at 3 liters (L) per nasal canula for signs and symptoms of [MEDICAL CONDITION] due to shortness of breath, -[MEDICAL CONDITION]-(Continuous Positive Airway Pressure, respiratory ventilation primarily used in the treatment of [REDACTED]. -[MEDICATION NAME] 3 milliliters (ml), PRN ever six hours for [DIAGNOSES REDACTED]. R #2's Medicare Nurses Note dated [DATE] revealed R #2's [DIAGNOSES REDACTED]. R #2's O2 SAT level was 96%, Blood Pressure ,[DATE], Respirations 22 and Pulse 81. R #2 had Shortness of Breath/trouble breathing/lying flat. R #2 had [MEDICAL CONDITION] (paralysis). R #2 received O2 Therapy. Depression and Pleural Effusion. R #2 was alert and oriented to person, place and time. R #2's respirations were even and unlabored with O2 at 3 liters per nasal canula. [MEDICAL CONDITION] at bs (bedside), head of bed up 45 degrees for comfort. Requires max assistance with care. Medications verified with Physician MM and faxed to the pharmacy. Call light within reach. Monitor for changes. R #2's Initial Plan of Care dated [DATE] revealed R #2 was alert and his vision, hearing and speech were normal. R #2 was continent of bowel and bladder and utilized a bedpan for toileting. R #2 utilized a wheelchair and required a mechanical lift for transfers. Additional notes on the bottom of the Initial Plan of Care indicated R #2 required two staff persons for Activities of Daily Living (ADLs, hygiene, bathing, showers, incontinent care and transfers) and utilized a mechanical lift. R #2 could verbalize his needs. R #2's required continuous O2, [MEDICAL CONDITION] at night or PRN breathing treatments were not included in R #2's Initial Plan of Care. R #2's admission orders [REDACTED]. There was not any documentation R #2 received O2 on: [DATE]-2:00 p.m. to 10:00 p.m. shift, [DATE]-6:00 a.m. to 2:00 p.m. shift, [DATE]-2:00 p.m. to 10:00 p.m. shift, [DATE]-6:00 a.m. to 2:00 p.m. shift, [DATE]-2:00 p.m. to 10:00 p.m. shift. There was not any documentation on the admission orders [REDACTED]. There was not any documentation on the admission orders [REDACTED]. Medicare Nurse's Notes dated [DATE] and completed by LVN G revealed: -5:00 p.m.-scheduled medications given, resident voices no concerns at this time. -6:00 p.m.-Noted Emergency Medical Services (EMS) 911 enter facility and ask for room [ROOM NUMBER] A, upon entrance to room noted resident (R #2) with [MEDICAL CONDITION] on. R #2 stated, I called them, I'm short of breath. EMS asked R #2 how long had he been like this, R #2 responded all day. R #2's O2 SATS 93% with 3 liters O2 via nasal canula. R #2 informed EMS he wanted to go to the hospital. Resident transferred on stretcher and out of facility alert and oriented. R #2's Fire Department Patient Care Report dated [DATE] and completed by the EMT indicated the EMTs were dispatched to the facility on [DATE] due to R #2 having difficulty breathing. The Report indicated the EMTs arrived in R #2's room at 5:30 p.m. on [DATE]. R #2 was sitting in a bed and oriented to person, place, time and events. Complained of difficulty breathing. Patient stated he had difficulty breathing since this morning at 5:00 a.m. ([DATE]). Patient stated at 6:00 a.m. he received a breathing treatment from the staff. After treatment was finished, patient was placed on [MEDICAL CONDITION] machine. Patient stated that he did not receive any relief from his [MEDICAL CONDITION] machine all day. Patient stated that he was constantly calling for nurses to help him and they never did. His condition gradually worsened. Vital signs were taken and noted. Room Air O2 sat was at 76 percent, lung sounds diminished bilaterally. Patient was still on the [MEDICAL CONDITION] mask at this time. It was noticed that the [MEDICAL CONDITION] machine was not turned on or connected to any oxygen. Patient was placed on NRB (non re-breather, device used in medical emergencies that requires oxygen therapy) immediately. No cyanosis was noted and patient did not seem to be in any respiratory distress. Nursing staff at facility stated they were not aware of the current situation. Patient was moved to ambulance. IV access was unable to be obtained. Male stated he had immense relief from O2. O2 SATS were noted to go up to 99 percent. En route patient was much improved. EMTs arrived at the local hospital at 5:54 p.m. on [DATE]. On [DATE] at 1:10 p.m. EMT RR stated he and EMT SS arrived at the facility at approximately 5:00 p.m. on [DATE]. EMT RR stated when he and EMT SS arrived at the Nurse's Station the nurses standing at the Nurse's Station were surprised. EMT RR stated none of the staff knew who had called 911. EMT RR stated when he entered R #2's room R #2 had a [MEDICAL CONDITION] mask on his face. EMT RR stated he (R #2) was making an effort to breathe. R #2 told EMT RR he used the [MEDICAL CONDITION] when he had difficulty breathing. EMT RR stated typically a [MEDICAL CONDITION] is loud and he realized the [MEDICAL CONDITION] was not turned on. EMT RR stated R #2's O2 SAT was 78% initially and his lungs sounded diminished bilaterally. EMT RR stated he placed a non re-breather (a mask used in medical emergencies that requires O2 therapy) on R #2 at 15 liters per minute and R #2's O2 SATS went to 99%. EMT RR stated he asked R #2 how long this had been going on and R #2 told EMT RR since this morning. EMT RR stated R #2 said he told the nurse he was having trouble breathing and the nurse said to R #2 to breathe in oxygen. EMT RR stated R #2 told him he put the [MEDICAL CONDITION] mask on himself at 6:00 a.m. to try and get more O2. EMT RR said R #2 told him I got fed up and called 911. EMT RR stated there was not any O2 connected to the [MEDICAL CONDITION] mask or on R #2. EMT RR stated the O2 concentrator was turned on but the tubing was not connected to anything. EMT RR stated there were several nurses in the room and someone walked over and turned on the [MEDICAL CONDITION] machine. EMT RR stated, no-one (staff) knew what was going on. EMT RR stated if R #2 had gone to sleep with the mask on he may not have awakened. EMT RR stated it is like putting a plastic bag over your head (meaning the [MEDICAL CONDITION] mask) and suffocating because you are not getting oxygen. EMT RR stated it was really shocking no one at the facility knew what was going on. On [DATE] at 1:45 p.m., EMT SS stated on [DATE] she assisted EMT RR with a call to the facility. EMT SS stated when she and EMT RR arrived no one at the desk knew of anyone short of breath. EMT SS stated they (staff) said (R #2) must have called. EMT SS stated when she arrived in R #2's room R #1's [MEDICAL CONDITION] mask was on his face. EMT SS stated she took R #2's O2 SAT and it was below 80%. EMT SS stated she tried a different finger and the O2 SAT was still below 80%. EMT SS stated she took R #2's O2 SAT on a different hand and the O2 SAT was still below 80%. R #2 stated to EMT SS and EMT RR he had been that way a couple of hours. EMT SS stated R #2's [MEDICAL CONDITION] mask was strapped on R #2's face and the O2 tubing was not hooked to the [MEDICAL CONDITION]. EMT SS said I followed the O2 tubing connected to the O2 concentrator and the O2 tubing was lying on the floor. EMT SS stated R #2's O2 concentrator was turned on but the nasal canula was not connected to anything. EMT SS stated R #2 told them he had lifted up the [MEDICAL CONDITION] mask a couple of times to take breaths. EMT SS stated there were four nurses and CNAs in the room and EMT RR asked nurses who knew how to work the [MEDICAL CONDITION] machine and the O2 concentrator? EMT SS stated no one could say how to work the O2 or [MEDICAL CONDITION] machine. EMT SS stated without the oxygen turned on or connected R #2 was breathing his own air back inside and was getting Carbon [MEDICATION NAME] poisoning. EMT SS said R #2 was given the EMT's O2 and R #2's O2 SATs went up to 100%. Emergency Physician Record dated [DATE] revealed R #2's chief complaint was shortness of breath with an onset of one day. R #2 was alert and oriented. R #2's Arterial Blood Gas (ABG-measurement of how much oxygen and carbon [MEDICATION NAME] are in the blood) in the emergency room were: -77.3-pCO2 (Partial pressure of carbon [MEDICATION NAME]). The within normal range of pC02 was ,[DATE] mm hg. -PO2- (Partial pressure of oxygen). The normal range of oxygen saturation level is 95% to 99%. According to http://www.webmd.com dated [DATE], -pCO2-measures the pressure of carbon [MEDICATION NAME] dissolved in the blood and how well carbon [MEDICATION NAME] is able to move out of the body. -pO2 measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. On [DATE] at 9:20 a.m., surveyor attempted to call ER Physician OO. Surveyor left a message. During an interview with Hospital Physician ZZ on [DATE] at 10:30 a.m. surveyor requested Physician ZZ to review the emergency room Laboratory Report dated [DATE] at 7:17 p.m. Physician ZZ reviewed the report and stated R #2's, pO2 was ok but not good and the pCO2 77.3% could cause unconsciousness and could cause death. The laboratory Report had a handwritten note that indicated R #2 was at the nursing facility, had difficulty breathing since 6:00 a.m., [MEDICAL CONDITION] was completely off and no O2 was connected. According to http://www.ncbi.nlm.nih.gov/ Carbon [MEDICATION NAME] main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level.At higher concentrations it leads to an increased respiratory rate, [MEDICAL CONDITION] cardic arrhythmia and impaired consciousness. Concentrations greater than 10% may cause convulsions, coma and death. According to http://www.merriam-webster.com Asphyxia is a lack of oxygen or excess of carbon [MEDICATION NAME] in the body that is usually caused by interruption of breathing and that causes unconsciousness. R #2's chest x-ray dated [DATE] indicated R #2 had moderate to large right pleural effusion with right lower lobe consolidation and mild central [MEDICAL CONDITION] vascularity. According to http://www.nlm.nih.gov obtained [DATE] pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an abnormal, excessive collection of this fluid. Symptoms of Pleural effusion include.cough, rapid breathing, shortness of breath. Observation and subsequent interview with R #2 in the Hospital on [DATE] at 9:35 a.m., revealed R #2 lying in a hospital bed. R #2 had O2 nasal canula. R #2 stated, I would say I was neglected by the facility. R #2 stated he was told prior to being admitted to the facility that the facility was equipped to handle a [MEDICAL CONDITION] machine. R #2 stated he was admitted to the facility on [DATE] and his room was on Hall 300. R #2 said he was told that evening by an unknown lady there is not enough staff, once we leave the hall it will be a while till we get back. R #2 stated on [DATE] he would turn on the call light and it would take an hour or two for anyone to get to his room. R #2 stated at 5:00 a.m. on [DATE] he could not breathe and he was given a nebulizer treatment. R #2 stated he felt better for a while. R #2 stated his wife and son arrived at approximately 9:00 a.m. and R #2 said he could not snap out of it. R #2 stated his wife went and told a nurse he was having trouble breathing. R #2 said a nurse came in and gave him a pain pill ([MEDICATION NAME]) and an anxiety medication ([MEDICATION NAME]). R #2 stated his wife tried to wake him up in the afternoon but he was out of it. R #2 stated his wife left around 3:00 p.m. and the CNAs told him once we leave the hallway it will be a while before we are back. You can't be yelling. You have to wait. R #2 stated he did yell for help and someone came in and said you cannot be yelling there is other residents. R #2 stated a nurse came in around 5:00 p.m. on [DATE] and he told her something is not right, I can't breath. R #2 stated the nurse did not say anything, just left him hanging. R #2 stated he called 911. R #2 stated he had turned on his call light many times during the day and it took a long time to be answered. R #2 stated he did not turn on his call light at the time he called 911. R #2 stated I could not handle it. R #2 stated, I may be ignorant to things but I thought they (EMTs) said I was not even hooked up to oxygen. R #2 stated the EMTs got his O2 level back up and asked him if he wanted to stay or go to the emergency room . R #2 stated he could tell by the tone of the EMTs voice it would be better for him to go to the emergency room . R #2 stated when he was in the emergency room his CO2 levels were high and he was told the CO2 levels being high was from him not getting O2. On [DATE] at 12:30 p.m. FM MM stated she and her son visited R #2 on [DATE]. FM MM stated R #2 was very groggy and she could not wake R #2 up. FM MM stated R #2 was swollen and looked like a blow fish. FM MM stated she went to the nurse's station and told someone R #2 was having a hard time breathing. FM MM stated R #2 was given his pain medication by an unknown nurse. FM MM stated R #2 had turned on the call light and it took 1-,[DATE] hours to get answered. FM MM stated when she was in R #2's room visiting she heard a CNA tell R #2 they did not have enough staff to put him on the bedpan. FM MM stated she left the facility to run errands and was called back to the facility by Staff Person Q to sign R #2's admission papers. FM MM stated Staff Person Q told her to tell R #2 tell him (R #2) to bear with us, not to call 911. FM MM stated after she signed the admission papers she went back to R #2's room and still could not wake R #2 up. FM MM stated it was not normal but she thought R #2 was resting. FM MM stated she left the facility at approximately 3:00 p.m. on [DATE]. FM MM stated a little later she received a phone call from R #2 and he told her he could not breathe. FM MM stated R #2 was gasping. FM MM stated R #2 told her he had called 911. FM MM stated she called the nursing facility and they told her the EMTs were in the room with R #2. FM MM stated in the emergency room she heard the doctor say R #2 had Carbon [MEDICATION NAME] poisoning that was dangerously high. On [DATE] at 2:30 p.m. CNA T stated she was in R #2's room on [DATE] to assist the EMTs with transferring R #2 and she overheard the EMTs say R #2's [MEDICAL CONDITION] machine and O2 concentrator were off. On [DATE] at 3:00 p.m., CNA X stated she worked the 2:00 p.m. to 10:00 p.m. shift on Hall 300 on [DATE]. CNA X stated she was not assigned R #2 but had checked R #2 at the begin

Based on observation, interview and record review the facility failed to ensure proper treatment and care for one Resident (R #2) of five residents reviewed for respiratory care. R #2 complained of shortness of breathe and the facility failed to assess and ensure R #2's oxygen concentrator and [MEDICAL CONDITION] machine were operational. R #2 could not breathe, called 911 and was transported to the hospital where he remained at the time of this investigation. These failures resulted in identification of an Immediate Jeopardy (IJ) on 02/18/15. While the IJ was removed on 02/20/15, the facility remained out of compliance at a scope of isolated and severity level of actual harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures placed R #1 in the hospital and could place the three residents who were ordered continuous oxygen at a higher risk of a delay in medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #2's Face Sheet dated 02/18/15 indicated R #2 was admitted to the facility at 2:30 p.m. on 02/06/15. R #2 was [AGE] years old. R #2's admission orders [REDACTED] -continuous O2 at 3 liters (L) per nasal canula for signs and symptoms of [MEDICAL CONDITION] due to shortness of breath, -[MEDICAL CONDITION]-(Continuous Positive Airway Pressure, respiratory ventilation primarily used in the treatment of [REDACTED]. -[MEDICATION NAME] 3 milliliters (ml), PRN ever six hours for [DIAGNOSES REDACTED]. R #2's Medicare Nurses Note dated 02/06/15 revealed R #2's [DIAGNOSES REDACTED]. R #2's O2 SAT level was 96%, Blood Pressure 115/77, Respirations 22 and Pulse 81. R #2 had Shortness of Breath/trouble breathing/lying flat. R #2 had [MEDICAL CONDITION] (paralysis). R #2 received O2 Therapy. Depression and Pleural Effusion. R #2 was alert and oriented to person, place and time. R #2's respirations were even and unlabored with O2 at 3 liters per nasal canula. [MEDICAL CONDITION] at bs (bedside), head of bed up 45 degrees for comfort. Requires max assistance with care. Medications verified with Physician MM and faxed to the pharmacy. Call light within reach. Monitor for changes. R #2's Initial Plan of Care dated 02/06/15 revealed R #2 was alert and his vision, hearing and speech were normal. R #2 was continent of bowel and bladder and utilized a bedpan for toileting. R #2 utilized a wheelchair and required a mechanical lift for transfers. Additional notes on the bottom of the Initial Plan of Care indicated R #2 required two staff persons for Activities of Daily Living (ADLs, hygiene, bathing, showers, incontinent care and transfers) and utilized a mechanical lift. R #2 could verbalize his needs. R #2's required continuous O2, [MEDICAL CONDITION] at night or PRN breathing treatments were not included in R #2's Initial Plan of Care. R #2's admission orders [REDACTED]. There was not any documentation R #2 received O2 on: 02/06/15-2:00 p.m. to 10:00 p.m. shift, 02/07/15-6:00 a.m. to 2:00 p.m. shift, 02/07/15-2:00 p.m. to 10:00 p.m. shift, 02/08/15-6:00 a.m. to 2:00 p.m. shift, 02/08/15-2:00 p.m. to 10:00 p.m. shift. There was not any documentation on the admission orders [REDACTED]. There was not any documentation on the admission orders [REDACTED]. Medicare Nurse's Notes dated 02/08/15 and completed by LVN G revealed: -5:00 p.m.-scheduled medications given, resident voices no concerns at this time. -6:00 p.m.-Noted Emergency Medical Services (EMS) 911 enter facility and ask for room [ROOM NUMBER] A, upon entrance to room noted resident (R #2) with [MEDICAL CONDITION] on. R #2 stated, I called them, I'm short of breath. EMS asked R #2 how long had he been like this, R #2 responded all day. R #2's O2 SATS 93% with 3 liters O2 via nasal canula. R #2 informed EMS he wanted to go to the hospital. Resident transferred on stretcher and out of facility alert and oriented. R #2's Fire Department Patient Care Report dated 02/08/15 and completed by the EMT indicated the EMTs were dispatched to the facility on [DATE] due to R #2 having difficulty breathing. The Report indicated the EMTs arrived in R #2's room at 5:30 p.m. on 02/08/15. R #2 was sitting in a bed and oriented to person, place, time and events. Complained of difficulty breathing. Patient stated he had difficulty breathing since this morning at 5:00 a.m. (02/08/15). Patient stated at 6:00 a.m. he received a breathing treatment from the staff. After treatment was finished, patient was placed on [MEDICAL CONDITION] machine. Patient stated that he did not receive any relief from his [MEDICAL CONDITION] machine all day. Patient stated that he was constantly calling for nurses to help him and they never did. His condition gradually worsened. Vital signs were taken and noted. Room Air O2 sat was at 76 percent, lung sounds diminished bilaterally. Patient was still on the [MEDICAL CONDITION] mask at this time. It was noticed that the [MEDICAL CONDITION] machine was not turned on or connected to any oxygen. Patient was placed on NRB (non re-breather, device used in medical emergencies that requires oxygen therapy) immediately. No cyanosis was noted and patient did not seem to be in any respiratory distress. Nursing staff at facility stated they were not aware of the current situation. Patient was moved to ambulance. IV access was unable to be obtained. Male stated he had immense relief from O2. O2 SATS were noted to go up to 99 percent. En route patient was much improved. EMTs arrived at the local hospital at 5:54 p.m. on 02/08/15. On 02/17/15 at 1:10 p.m. EMT RR stated he and EMT SS arrived at the facility at approximately 5:00 p.m. on 02/08/15. EMT RR stated when he and EMT SS arrived at the Nurse's Station the nurses standing at the Nurse's Station were surprised. EMT RR stated none of the staff knew who had called 911. EMT RR stated when he entered R #2's room R #2 had a [MEDICAL CONDITION] mask on his face. EMT RR stated he (R #2) was making an effort to breathe. R #2 told EMT RR he used the [MEDICAL CONDITION] when he had difficulty breathing. EMT RR stated typically a [MEDICAL CONDITION] is loud and he realized the [MEDICAL CONDITION] was not turned on. EMT RR stated R #2's O2 SAT was 78% initially and his lungs sounded diminished bilaterally. EMT RR stated he placed a non re-breather (a mask used in medical emergencies that requires O2 therapy) on R #2 at 15 liters per minute and R #2's O2 SATS went to 99%. EMT RR stated he asked R #2 how long this had been going on and R #2 told EMT RR since this morning. EMT RR stated R #2 said he told the nurse he was having trouble breathing and the nurse said to R #2 to breathe in oxygen. EMT RR stated R #2 told him he put the [MEDICAL CONDITION] mask on himself at 6:00 a.m. to try and get more O2. EMT RR said R #2 told him I got fed up and called 911. EMT RR stated there was not any O2 connected to the [MEDICAL CONDITION] mask or on R #2. EMT RR stated the O2 concentrator was turned on but the tubing was not connected to anything. EMT RR stated there were several nurses in the room and someone walked over and turned on the [MEDICAL CONDITION] machine. EMT RR stated, no-one (staff) knew what was going on. EMT RR stated if R #2 had gone to sleep with the mask on he may not have awakened. EMT RR stated it is like putting a plastic bag over your head (meaning the [MEDICAL CONDITION] mask) and suffocating because you are not getting oxygen. EMT RR stated it was really shocking no one at the facility knew what was going on. On 02/17/15 at 1:45 p.m., EMT SS stated on 02/08/15 she assisted EMT RR with a call to the facility. EMT SS stated when she and EMT RR arrived no one at the desk knew of anyone short of breath. EMT SS stated they (staff) said (R #2) must have called. EMT SS stated when she arrived in R #2's room R #1's [MEDICAL CONDITION] mask was on his face. EMT SS stated she took R #2's O2 SAT and it was below 80%. EMT SS stated she tried a different finger and the O2 SAT was still below 80%. EMT SS stated she took R #2's O2 SAT on a different hand and the O2 SAT was still below 80%. R #2 stated to EMT SS and EMT RR he had been that way a couple of hours. EMT SS stated R #2's [MEDICAL CONDITION] mask was strapped on R #2's face and the O2 tubing was not hooked to the [MEDICAL CONDITION]. EMT SS said I followed the O2 tubing connected to the O2 concentrator and the O2 tubing was lying on the floor. EMT SS stated R #2's O2 concentrator was turned on but the nasal canula was not connected to anything. EMT SS stated R #2 told them he had lifted up the [MEDICAL CONDITION] mask a couple of times to take breaths. EMT SS stated there were four nurses and CNAs in the room and EMT RR asked nurses who knew how to work the [MEDICAL CONDITION] machine and the O2 concentrator? EMT SS stated no one could say how to work the O2 or [MEDICAL CONDITION] machine. EMT SS stated without the oxygen turned on or connected R #2 was breathing his own air back inside and was getting Carbon [MEDICATION NAME] poisoning. EMT SS said R #2 was given the EMT's O2 and R #2's O2 SATs went up to 100%. Emergency Physician Record dated 02/08/15 revealed R #2's chief complaint was shortness of breath with an onset of one day. R #2 was alert and oriented. R #2's Arterial Blood Gas (ABG-measurement of how much oxygen and carbon [MEDICATION NAME] are in the blood) in the emergency room were: -77.3-pCO2 (Partial pressure of carbon [MEDICATION NAME]). The within normal range of pC02 was 35-45 mm hg. -PO2- (Partial pressure of oxygen). The normal range of oxygen saturation level is 95% to 99%. According to http://www.webmd.com dated 02/24/15, -pCO2-measures the pressure of carbon [MEDICATION NAME] dissolved in the blood and how well carbon [MEDICATION NAME] is able to move out of the body. -pO2 measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. On 02/16/15 at 9:20 a.m., surveyor attempted to call ER Physician OO. Surveyor left a message. During an interview with Hospital Physician ZZ on 02/13/15 at 10:30 a.m. surveyor requested Physician ZZ to review the emergency room Laboratory Report dated 02/08/15 at 7:17 p.m. Physician ZZ reviewed the report and stated R #2's, pO2 was ok but not good and the pCO2 77.3% could cause unconsciousness and could cause death. The laboratory Report had a handwritten note that indicated R #2 was at the nursing facility, had difficulty breathing since 6:00 a.m., [MEDICAL CONDITION] was completely off and no O2 was connected. According to http://www.ncbi.nlm.nih.gov/ Carbon [MEDICATION NAME] main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level.At higher concentrations it leads to an increased respiratory rate, [MEDICAL CONDITION] cardic arrhythmia and impaired consciousness. Concentrations greater than 10% may cause convulsions, coma and death. According to http://www.merriam-webster.com Asphyxia is a lack of oxygen or excess of carbon [MEDICATION NAME] in the body that is usually caused by interruption of breathing and that causes unconsciousness. R #2's chest x-ray dated 02/08/15 indicated R #2 had moderate to large right pleural effusion with right lower lobe consolidation and mild central [MEDICAL CONDITION] vascularity. According to http://www.nlm.nih.gov obtained 02/24/15 pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an abnormal, excessive collection of this fluid. Symptoms of Pleural effusion include.cough, rapid breathing, shortness of breath. Observation and subsequent interview with R #2 in the hospital on [DATE] at 9:35 a.m., revealed R #2 lying in a hospital bed. R #2 had O2 nasal canula. R #2 stated, I would say I was neglected by the facility. R #2 stated he was told prior to being admitted to the facility that the facility was equipped to handle a [MEDICAL CONDITION] machine. R #2 stated he was admitted to the facility on [DATE] and his room was on Hall 300. R #2 said he was told that evening by an unknown lady there is not enough staff, once we leave the hall it will be a while till we get back. R #2 stated on 02/07/15 he would turn on the call light and it would take an hour or two for anyone to get to his room. R #2 stated at 5:00 a.m. on 02/08/15 he could not breathe and he was given a nebulizer treatment. R #2 stated he felt better for a while. R #2 stated his wife and son arrived at approximately 9:00 a.m. and R #2 said he could not snap out of it. R #2 stated his wife went and told a nurse he was having trouble breathing. R #2 said a nurse came in and gave him a pain pill ([MEDICATION NAME]) and an anxiety medication ([MEDICATION NAME]). R #2 stated his wife tried to wake him up in the afternoon but he was out of it. R #2 stated his wife left around 3:00 p.m. and the CNAs told him once we leave the hallway it will be a while before we are back. You can't be yelling. You have to wait. R #2 stated he did yell for help and someone came in and said you cannot be yelling there is other residents. R #2 stated a nurse came in around 5:00 p.m. on 02/08/15 and he told her something is not right, I can't breath. R #2 stated the nurse did not say anything, just left him hanging. R #2 stated he called 911. R #2 stated he had turned on his call light many times during the day and it took a long time to be answered. R #2 stated he did not turn on his call light at the time he called 911. R #2 stated I could not handle it. R #2 stated, I may be ignorant to things but I thought they (EMTs) said I was not even hooked up to oxygen. R #2 stated the EMTs got his O2 level back up and asked him if he wanted to stay or go to the emergency room . R #2 stated he could tell by the tone of the EMTs voice it would be better for him to go to the emergency room . R #2 stated when he was in the emergency room his CO2 levels were high and he was told the CO2 levels being high was from him not getting O2. On 02/13/15 at 12:30 p.m. FM MM stated she and her son visited R #2 on 02/08/15. FM MM stated R #2 was very groggy and she could not wake R #2 up. FM MM stated R #2 was swollen and looked like a blow fish. FM MM stated she went to the nurse's station and told someone R #2 was having a hard time breathing. FM MM stated R #2 was given his pain medication by an unknown nurse. FM MM stated R #2 had turned on the call light and it took 1-1/2 hours to get answered. FM MM stated when she was in R #2's room visiting she heard a CNA tell R #2 they did not have enough staff to put him on the bedpan. FM MM stated she left the facility to run errands and was called back to the facility by Staff Person Q to sign R #2's admission papers. FM MM stated Staff Person Q told her to tell R #2 tell him (R #2) to bear with us, not to call 911. FM MM stated after she signed the admission papers she went back to R #2's room and still could not wake R #2 up. FM MM stated it was not normal but she thought R #2 was resting. FM MM stated she left the facility at approximately 3:00 p.m. on 02/08/15. FM MM stated a little later she received a phone call from R #2 and he told her he could not breathe. FM MM stated R #2 was gasping. FM MM stated R #2 told her he had called 911. FM MM stated she called the nursing facility and they told her the EMTs were in the room with R #2. FM MM stated in the emergency room she heard the doctor say R #2 had Carbon [MEDICATION NAME] poisoning that was dangerously high. On 02/16/15 at 2:30 p.m. CNA T stated she was in R #2's room on 02/08/15 to assist the EMTs with transferring R #2 and she overheard the EMTs say R #2's [MEDICAL CONDITION] machine and O2 concentrator were off. On 02/16/15 at 3:00 p.m., CNA X stated she worked the 2:00 p.m. to 10:00 p.m. shift on Hall 300 on 02/08/15. CNA X stated she was not assigned R #2 but had checked R #2 at the beginning of the shift for incontinence. CNA X stated R #2 looked woozie. CNA X stated R #2 had his [MEDICAL CONDITION] mask on. CNA X stated she asked LVN G if R #2 was supposed to have on the [MEDICAL CONDITION] mask and LVN G said R #2 had put the [MEDICAL CONDITION] mask on himself. CNA X stated later R #6 who resided on Hall 300 told her R #2 had been yelling for help on the 10:00 p.m. to 6:00 a.m. shift. R #6 stated R #2 was yelling, does anyone work here? CNA X stated when the EMTs arrived she overheard LVN F say who called 911? CNA X stated, probably (R #2). CNA X stated she walked into R #2's room and saw one of the EMTs pick up [MEDICAL CONDITION] machine and say this is not even on and the O2 is not on. CNA X stated R #2 said I called 911, I could not breathe. On 02/17/15 at 9:55 a.m. the DON stated she had initially denied R #2's admission into the facility on [DATE] and 02/05/15. The DON stated she denied R #2 because she was told by the hospital R #2 was on 10 liters per minute of O2 and the facility did not accept anyone that was over 5 liters of O2. The DON stated R #2's weight was also a factor in the denials. The DON said R #2's weight was 356 pounds and the mechanical lift was maxed out at 360 pounds. The DON said on 02/06/15 she left the facility to go to lunch and when she returned R #2 was in building. The DON said the Administrator gave approval to admit R #2. The DON stated R #2 was to wear his [MEDICAL CONDITION] only at night and the oxygen was for the day at 3 liters. The DON said on 02/08/15 someone called 911. The DON said R #2 had reached over to the nightstand and put on his [MEDICAL CONDITION] mask. The DON said she did not know why R #2 put on his [MEDICAL CONDITION] mask. The DON said the EMTs took his O2 SATS and the SATS were 87%. The DON said the EMTs gave R #2 O2 and he stabilized. The DON said the EMTs ask R #2 if he wanted to stay at the facility or go to the hospital and R #2 said the hospital. On 02/18/15 at 11:05 a.m., LVN F stated she was the Manager on Duty on 02/08/15. LVN F stated at approximately 5:00 p.m. on 02/08/15 the EMTs entered the building and asked where R #2's room was located. LVN F stated she entered R #2's room with the EMTs and observed R #2 wearing his [MEDICAL CONDITION] mask and was resting in bed. LVN F stated R #2 did not have rapid breathing. LVN F stated she left R #2's room to get his chart and when she returned she heard the EMTs stated R #2's [MEDICAL CONDITION] machine was off. LVN F stated the [MEDICAL CONDITION] machine was plugged in to the electrical outlet but it was not turned on. LVN F stated an EMT picked up the nasal canula from the floor and asked R #2 if he got oxygen from the O2 nasal canula or the [MEDICAL CONDITION] machine and R #2 pointed to the O2 Canula. LVN F stated the EMT removed the [MEDICAL CONDITION] mask and placed a non re-breather mask on R #2. LVN F stated she did not remember what R #2's O2 SATs were. LVN F stated to R #2 O2 SAT was ok would you like to stay here and let these people take care of you? LVN F stated R #2 answered, no, I want to go to the hospital. On 02/17/15 at 2:15 p.m. LVN G stated she worked the 2:00 p.m. to 10:00 p.m. shift on 02/08/15. LVN G stated she was working on Hall 300 and R #2 never told her he was having trouble breathing. LVN G stated when she did her initial rounds after arriving at the facility R #2 had on his O2 nasal canula. LVN G stated R #2's [MEDICAL CONDITION] machine was on the nightstand next to his bed. LVN G stated she left Hall 300 after 5:00 p.m. to work on another hall. LVN G stated there was not a nurse on Hall 300 after she left. On 02/17/15 at 2:50 p.m., CNA AA stated she worked the 2:00 p.m. to 10:00 p.m. shift on 02/08/15. CNA AA stated R #2 used his call light several times because he had to urinate. CNA AA stated R #2 was urinating more than usual and she told LVN G who said she would check on R #2. CNA AA stated R #2 did not have on his [MEDICAL CONDITION] mask on his face and she did not remember if R #2 had on his O2. On 02/18/15 at 9:50 a.m. the DON reviewed R #2's admission orders [REDACTED]. The DON stated she could not read all of the order. The DON stated as a nurse she would consider the order as PRN. The DON stated she was not able to tell if the O2 was ordered continuously, but knowing him (R #2) she would considered the order as continuous. The DON stated the admitting nurse could have clarified the Admission Order. The DON stated if a resident had shortness of breath it would be expected for nursing to put on O2. The DON stated in this case they put on [MEDICAL CONDITION], don't know when. The DON stated the facility nurses do not chart O2 SATS, it is a nursing judgement as to when O2 SATS are obtained. The DON stated there were not any O2 SATs for R #2 prior to the EMTs entering the facility. The DON stated the Charge Nurse was responsible for assessing for signs and symptoms of [MEDICAL CONDITION]. The DON stated when EMTs arrived at approximately 5:00 p.m. she went with the EMTs to R #2's room. The DON said when they entered R #2's room, R #2 was cooperative, pleasant and his breathing was fine. The DON stated R #2 had his nasal canula on under his [MEDICAL CONDITION] mask and the nasal canula was connected to the O2 concentrator. The DON stated the EMTs obtained R #2's O2 SATS and the O2 SATS were at 87%. The DON stated the EMTs placed a non re-breather on R #2 and his O2 SATS went to 93 %. The DON said the EMTs stated to R #2 he was stable, but R #2 wanted to go to the hospital. The DON stated she had been at the facility for three months and there were a lot of things to fix here. On 02/18/15 at 3:35 p.m., CNA BB stated she worked the 6:00 a.m. to 2:00 p.m. shift on 02/08/15. CNA BB stated R #2 was on his call light all day. CNA BB stated R #2 wanted ice water, bed pan, and had complaints of shortness of breath. CNA BB stated she told the nurse. CNA BB stated R #2 had on the [MEDICAL CONDITION] mask but she did not know if R #2 had the nasal canula hooked to the O2 concentrator. On 02/18/15 at 3:50 p.m. LVN H stated he worked the 6:00 a.m. to 2:00 p.m. shift on 02/08/15. LVN H stated during the early hours of the shift R #2 told LVN H he was having discomfort with breathing. LVN H stated R #2 always had O2 on. LVN H stated before breakfast a CNA told him R #2 could not breathe good. LVN H stated he gave R #2 a nebulizer treatment at approximately 6:45 a.m. on 02/08/15. LVN H stated he went back to R #2's room later and R #2 stated he need a [MEDICATION NAME]. LVN H stated he administered R #2 a [MEDICATION NAME] at 8:00 a.m. and at 12:00 p.m. and administered R #2's [MEDICATION NAME] at the same time. LVN H stated he did not give R #2 any further nebulizer treatments during the shift. LVN H stated on the weekends Hall 300 does not have a nurse. LVN H stated nurses are pulled from other halls to cover Hall 300. LVN H reviewed R #2's admission orders [REDACTED]. LVN H stated he had not documented the [MEDICATION NAME] R #2 was administered. On 02/18/15 at 4:30 p.m., the Administrator stated she was not aware of the circumstances of R #1's death nor did she did know anything about R #2. The Administrator stated she knew the DON had initially denied R #2's admission into the facility because R #2 was on 10 liters per minute of O2 and the facility was not equipped to manage R #2's O2 needs. The Administrator stated the Admission Consultant accepted R #2 into the facility. Surveyor asked the Administrator what type of procedure is there to make sure the nursing needs of residents are being met? The Administrator stated, I am not clinical, the DON needs to answer this question. Nurses should be making rounds, documenting, charting and checking vitals. The Administrator stated she monitored the DON by having open conversations. The Administrator stated she was not aware the facility systems were not working and it is hard to get people to work. On 02/18/15 at 5:38 p.m., the DON stated she had denied R #2 twice because the facility could not meet his needs. The DON stated R #2 was admitted and yes, when he got here we had to try to meet his needs. The DON stated R #2's O2 SATS were good when he left the facility with the EMTs for transport to the hospital and something happened on the way to the hospital to result in R #2's ABG to be 77%. The DON stated R #2 had the [MEDICAL CONDITION] mask on all day. The DON stated R #2 did not want to be at the facility. The DON stated the system was not working for documentation. The DON stated R #2's Nurse's Notes were not reflective of what occurred on 02/08/15. The DON stated there was not any physician order to document resident's O2 SATS, the facility was not an acute care setting. On 02/18/15 at 10:30 p.m., the DON provided surveyor a copy of Departmental Notes/Nurse's Notes dated 02/18/15 at 10:07 p.m. The notes indicated, Late entry: On 02/08/15, at approximately 1645 (4:45 p.m.), writer was at the nurse's station when she noticed that EMS was entering the building. Writer asked EMS who called them and they stated that the resident in room [ROOM NUMBER]. Writer and two other nurses (LVN F and LVN G), quickly made our way into room [ROOM NUMBER] (R #2's room). While walking towards the resident's room, writer noticed the call light was not on. Upon entering the room, at about the same time as the EMS crew, writer noticed that the resident had his [MEDICAL CONDITIONS] mask on. The [MEDICAL CONDITION] machine was off and had been applied on top of his nasal canula. An EMS Crew member removed the mask. In the process, the O2 nasal canula, which was on the resident fell to the floor. EMS took an initial O2 SAT reading. Reading on room air was 87%. EMS applied a non-re-breather mask for approximately five minutes. The resident's O2 went up to 99%. Non-re-breather mask was removed and O2 nasal canula was re-applied at 3L/minute. O2 SAT was ranging from 93% to 95%; O2 SAT was taken by (LVN G), who was residents assigned nurse. EMS crew talked to the resident and EMS verbalized that the resident was stable. EMS asked the resident if he would stay since he was stable. The resident insisted on being taken to the hospital. Resident's skin color was within normal limits. No respiratory distress was noted. Resident speaking without difficulty. The facility's undated Change in a Resident's Condition or Status policy and procedure indicated, If a change in the resident's physical or mental condition occurs, an assessment of the resident's condition should be conducted. The facility's Oxygen Administration policy and procedures dated November 2014 indicated verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Oxygen is administered by way of an oxygen mask or nasal canula.The nasal canula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident head.Turn on the oxygen. Start the flow of oxygen at the prescribed rate. Place appropriate oxygen device on the resident.Observed the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. The facility's policy and procedures for Abuse Prevention Program dated January 2013 revealed This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law. As with other resident protection and care protocols and policies, it is important to use common sense and reason when carrying out this policy. Since.neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. The Health and Safety Code, Title 4, Subtitle B., Chapter 260A, Section 260A. 001 (6) defines Neglect as the failure to provide for the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caregiver to provide such goods or services. On 02/18/15 at 6:30 p.m., an IJ was identified and the DON and Administrator were informed at 7:14 p.m. on 02/18/15 of the IJ due to the above failures. On 02/18/15 at 10:30 p.m., the facility's fourth Plan of Removal was accepted and contained the following: Issues: 1. Facility failed to identify a change in respiratory status and failed to provide services for monitoring O2 administration. 2. Facility failed to have sufficient staff to meet the needs of the residents. Interventions Issue #1: 1. Skills checklist will be conducted with charge nurses and nurse management for respiratory training, assessment and appropriate intervention. Skills checklist training will begin 02/18/15 and continue with charge nurses prior to working next shift. Initiated: 02/18/15 Completion: 02/21/15 2. Charge Nurses will be educated on appropriate documentation of O2 administration. Education will begin 02/18/15 and continue with charge nurses prior to working next shift. Initiated: 02/18/15 Completion: 02/21/15 3. Nurse aides will be educated on how to identify changes in respiratory status and immediate notification to charge nurse. Education will begin 02/18/15. Initiated: 0218/15 Completion: 02/21/15 4. Assess every resident with special needs to ensure orders are correct and O2 concentrator/tanks are at the rate ordered. Initiated: 02/18/15 Completion: Ongoing 5. Nurse Managers will monitor that O2 orders are correct and O2 concentrators/tanks are at right rate daily and humidifiers have sufficient water. Initiated: 02/18/15 Completion: Ongoing 6. Nurse Managers include: DON, Staffing ADON (Assistant DON), QA (Quality Assurance) Nurse #1, Assessment Nurse #2, Medicare Coordinator and TX (Treatment) Nurse. Initiated: 02/18/15 Completion: Ongoing 7. Charge Nurses will follow MD (Medical Doctor) orders for residents with O2 and will document on skilled MARs. Initiated: 02/18/15 Completion: Ongoing Interventions Issue #2: 1. Facility will ensure we have appropriate staff on each shift to meet the needs of the residents. 6:00 a.m. to 2:00 p.m. shift (minimum of 2 aides per hall)/ 2:00 p.m. to 10:00 p.m. shift (minimum of 2 aides per hall)/ 10:00 p.m. to 6:00 a.m. shift (minimum of one aide per hall). Initiated: 02/18/15 Completion: Ongoing 2. Aides will be in-serviced on proper call in procedures. 1st call in-verbal warning, 2nd call in-written counseling, 3rd call in suspension and possible termination. Initiated: 02/18/15 Completion: Ongoing 3. Charge Nurses will notify on-call nurse and Administrator if scheduled staff do not report to duty or if nurse aides leave their assigned floor without notifying supervisory charge nurse. Initiated: 02/18/15 Completion: Ongoing 4. On call nurse will attempt to find replacements of staff; should staff not be available on-call nurse will work as a nurse aide on the floor and notify the DON and Administrator. Initiated: 02/18/15 Completion: Ongoing 5. Facility will continue to recruit for staff: advertise, connect with local schools and request as

Based on observation, interview and record review the facility failed to provide services in accordance with each residents written plan of care for one Resident (R #2) of five residents reviewed for respiratory care. The facility failed to follow the Physician's Plan of Care (Physician Orders) for R #2's administration of oxygen. R #2 was ordered continuous oxygen by nasal canula but did not received continuous oxygen and was admitted to the hospital. R #2 remained in the hospital during the time of this visit. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 02/18/15, while the IJ was removed on 02/20/15, the facility remained out of compliance at a scope of isolated and severity level of actual harm due to the facility continuing to in-service staff and implement the Plan of Removal. These failures placed R #2 in the hospital and could place the three residents who were ordered continuous oxygen at a higher risk of neglect and delay medical treatment, care, services, incurring complications and/or hospitalization or possible death. The findings were: R #2's Face Sheet dated 02/18/15 indicated R #2 was admitted to the facility at 2:30 p.m. on 02/06/15. R #2 was [AGE] years old. R #2's admission orders [REDACTED] -continuous O2 at 3 liters (L) per nasal canula for signs and symptoms of [MEDICAL CONDITION] due to shortness of breath, -[MEDICAL CONDITION]-(Continuous Positive Airway Pressure, respiratory ventilation primarily used in the treatment of [REDACTED]. -[MEDICATION NAME] 3 milliliters (ml), PRN ever six hours for [DIAGNOSES REDACTED]. R #2's Medicare Nurses Note dated 02/06/15 revealed R #2's [DIAGNOSES REDACTED]. R #2's O2 SAT level was 96%, Blood Pressure 115/77, Respirations 22 and Pulse 81. R #2 had Shortness of Breath/trouble breathing/lying flat. R #2 had [MEDICAL CONDITION] (paralysis). R #2 received O2 Therapy. Depression and Pleural Effusion. R #2 was alert and oriented to person, place and time. R #2's respirations were even and unlabored with O2 at 3 liters per nasal canula. [MEDICAL CONDITION] at bs (bedside), head of bed up 45 degrees for comfort. Requires max assistance with care. Medications verified with Physician MM and faxed to the pharmacy. Call light within reach. Monitor for changes. R #2's Initial Plan of Care dated 02/06/15 revealed R #2 was alert and his vision, hearing and speech were normal. R #2 was continent of bowel and bladder and utilized a bedpan for toileting. R #2 utilized a wheelchair and required a mechanical lift for transfers. Additional notes on the bottom of the Initial Plan of Care indicated R #2 required two staff persons for Activities of Daily Living (ADLs, hygiene, bathing, showers, incontinent care and transfers) and utilized a mechanical lift. R #2 could verbalize his needs. R #2's required continuous O2, [MEDICAL CONDITION] at night or PRN breathing treatments were not included in R #2's Initial Plan of Care. R #2's admission orders [REDACTED]. There was not any documentation R #2 received O2 on: 02/06/15-2:00 p.m. to 10:00 p.m. shift, 02/07/15-6:00 a.m. to 2:00 p.m. shift, 02/07/15-2:00 p.m. to 10:00 p.m. shift, 02/08/15-6:00 a.m. to 2:00 p.m. shift, 02/08/15-2:00 p.m. to 10:00 p.m. shift. There was not any documentation on the admission orders [REDACTED]. There was not any documentation on the admission orders [REDACTED]. Medicare Nurse's Notes dated 02/08/15 and completed by LVN G revealed: -5:00 p.m.-scheduled medications given, resident voices no concerns at this time. -6:00 p.m.-Noted Emergency Medical Services (EMS) 911 enter facility and ask for room [ROOM NUMBER] A, upon entrance to room noted resident (R #2) with [MEDICAL CONDITION] on. R #2 stated, I called them, I'm short of breath. EMS asked R #2 how long had he been like this, R #2 responded all day. R #2's O2 SATS 93% with 3 liters O2 via nasal canula. R #2 informed EMS he wanted to go to the hospital. Resident transferred on stretcher and out of facility alert and oriented. R #2's Fire Department Patient Care Report dated 02/08/15 and completed by the EMT indicated the EMTs were dispatched to the facility on [DATE] due to R #2 having difficulty breathing. The Report indicated the EMTs arrived in R #2's room at 5:30 p.m. on 02/08/15. R #2 was sitting in a bed and oriented to person, place, time and events. Complained of difficulty breathing. Patient stated he had difficulty breathing since this morning at 5:00 a.m. (02/08/15). Patient stated at 6:00 a.m. he received a breathing treatment from the staff. After treatment was finished, patient was placed on [MEDICAL CONDITION] machine. Patient stated that he did not receive any relief from his [MEDICAL CONDITION] machine all day. Patient stated that he was constantly calling for nurses to help him and they never did. His condition gradually worsened. Vital signs were taken and noted. Room Air O2 sat was at 76 percent, lung sounds diminished bilaterally. Patient was still on the [MEDICAL CONDITION] mask at this time. It was noticed that the [MEDICAL CONDITION] machine was not turned on or connected to any oxygen. Patient was placed on NRB (non re-breather, device used in medical emergencies that requires oxygen therapy) immediately. No cyanosis was noted and patient did not seem to be in any respiratory distress. Nursing staff at facility stated they were not aware of the current situation. Patient was moved to ambulance. IV access was unable to be obtained. Male stated he had immense relief from O2. O2 SATS were noted to go up to 99 percent. En route patient was much improved. EMTs arrived at the local hospital at 5:54 p.m. on 02/08/15. On 02/17/15 at 1:10 p.m. EMT RR stated he and EMT SS arrived at the facility at approximately 5:00 p.m. on 02/08/15. EMT RR stated when he and EMT SS arrived at the Nurse's Station the nurses standing at the Nurse's Station were surprised. EMT RR stated none of the staff knew who had called 911. EMT RR stated when he entered R #2's room R #2 had a [MEDICAL CONDITION] mask on his face. EMT RR stated he (R #2) was making an effort to breathe. R #2 told EMT RR he used the [MEDICAL CONDITION] when he had difficulty breathing. EMT RR stated typically a [MEDICAL CONDITION] is loud and he realized the [MEDICAL CONDITION] was not turned on. EMT RR stated R #2's O2 SAT was 78% initially and his lungs sounded diminished bilaterally. EMT RR stated he placed a non re-breather (a mask used in medical emergencies that requires O2 therapy) on R #2 at 15 liters per minute and R #2's O2 SATS went to 99%. EMT RR stated he asked R #2 how long this had been going on and R #2 told EMT RR since this morning. EMT RR stated R #2 said he told the nurse he was having trouble breathing and the nurse said to R #2 to breathe in oxygen. EMT RR stated R #2 told him he put the [MEDICAL CONDITION] mask on himself at 6:00 a.m. to try and get more O2. EMT RR said R #2 told him I got fed up and called 911. EMT RR stated there was not any O2 connected to the [MEDICAL CONDITION] mask or on R #2. EMT RR stated the O2 concentrator was turned on but the tubing was not connected to anything. EMT RR stated there were several nurses in the room and someone walked over and turned on the [MEDICAL CONDITION] machine. EMT RR stated, no-one (staff) knew what was going on. EMT RR stated if R #2 had gone to sleep with the mask on he may not have awakened. EMT RR stated it is like putting a plastic bag over your head (meaning the [MEDICAL CONDITION] mask) and suffocating because you are not getting oxygen. EMT RR stated it was really shocking no one at the facility knew what was going on. On 02/17/15 at 1:45 p.m., EMT SS stated on 02/08/15 she assisted EMT RR with a call to the facility. EMT SS stated when she and EMT RR arrived no one at the desk knew of anyone short of breath. EMT SS stated they (staff) said (R #2) must have called. EMT SS stated when she arrived in R #2's room R #1's [MEDICAL CONDITION] mask was on his face. EMT SS stated she took R #2's O2 SAT and it was below 80%. EMT SS stated she tried a different finger and the O2 SAT was still below 80%. EMT SS stated she took R #2's O2 SAT on a different hand and the O2 SAT was still below 80%. R #2 stated to EMT SS and EMT RR he had been that way a couple of hours. EMT SS stated R #2's [MEDICAL CONDITION] mask was strapped on R #2's face and the O2 tubing was not hooked to the [MEDICAL CONDITION]. EMT SS said I followed the O2 tubing connected to the O2 concentrator and the O2 tubing was lying on the floor. EMT SS stated R #2's O2 concentrator was turned on but the nasal canula was not connected to anything. EMT SS stated R #2 told them he had lifted up the [MEDICAL CONDITION] mask a couple of times to take breaths. EMT SS stated there were four nurses and CNAs in the room and EMT RR asked nurses who knew how to work the [MEDICAL CONDITION] machine and the O2 concentrator? EMT SS stated no one could say how to work the O2 or [MEDICAL CONDITION] machine. EMT SS stated without the oxygen turned on or connected R #2 was breathing his own air back inside and was getting Carbon [MEDICATION NAME] poisoning. EMT SS said R #2 was given the EMT's O2 and R #2's O2 SATs went up to 100%. Emergency Physician Record dated 02/08/15 revealed R #2's chief complaint was shortness of breath with an onset of one day. R #2 was alert and oriented. R #2's Arterial Blood Gas (ABG-measurement of how much oxygen and carbon [MEDICATION NAME] are in the blood) in the emergency room were: -77.3-pCO2 (Partial pressure of carbon [MEDICATION NAME]). The within normal range of pC02 was 35-45 mm hg. -PO2- (Partial pressure of oxygen). The normal range of oxygen saturation level is 95% to 99%. According to http://www.webmd.com dated 02/24/15, -pCO2-measures the pressure of carbon [MEDICATION NAME] dissolved in the blood and how well carbon [MEDICATION NAME] is able to move out of the body. -pO2 measures the pressure of oxygen dissolved in the blood and how well oxygen is able to move from the airspace of the lungs into the blood. On 02/16/15 at 9:20 a.m., surveyor attempted to call ER Physician OO. Surveyor left a message. During an interview with Hospital Physician ZZ on 02/13/15 at 10:30 a.m. surveyor requested Physician ZZ to review the emergency room Laboratory Report dated 02/08/15 at 7:17 p.m. Physician ZZ reviewed the report and stated R #2's, pO2 was ok but not good and the pCO2 77.3% could cause unconsciousness and could cause death. The laboratory Report had a handwritten note that indicated R #2 was at the nursing facility, had difficulty breathing since 6:00 a.m., [MEDICAL CONDITION] was completely off and no O2 was connected. According to http://www.ncbi.nlm.nih.gov/ Carbon [MEDICATION NAME] main mode of action is as an asphyxiant, although it also exerts toxic effects at cellular level.At higher concentrations it leads to an increased respiratory rate, [MEDICAL CONDITION] cardic arrhythmia and impaired consciousness. Concentrations greater than 10% may cause convulsions, coma and death. According to http://www.merriam-webster.com Asphyxia is a lack of oxygen or excess of carbon [MEDICATION NAME] in the body that is usually caused by interruption of breathing and that causes unconsciousness. R #2's chest x-ray dated 02/08/15 indicated R #2 had moderate to large right pleural effusion with right lower lobe consolidation and mild central [MEDICAL CONDITION] vascularity. According to http://www.nlm.nih.gov obtained 02/24/15 pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest cavity. The body produces pleural fluid in small amounts to lubricate the surfaces of the pleura. This is the thin tissue that lines the chest cavity and surrounds the lungs. Pleural effusion is an abnormal, excessive collection of this fluid. Symptoms of Pleural effusion include.cough, rapid breathing, shortness of breath. Observation and subsequent interview with R #2 in the hospital on [DATE] at 9:35 a.m., revealed R #2 lying in a hospital bed. R #2 had O2 nasal canula. R #2 stated, I would say I was neglected by the facility. R #2 stated he was told prior to being admitted to the facility that the facility was equipped to handle a [MEDICAL CONDITION] machine. R #2 stated he was admitted to the facility on [DATE] and his room was on Hall 300. R #2 said he was told that evening by an unknown lady there is not enough staff, once we leave the hall it will be a while till we get back. R #2 stated on 02/07/15 he would turn on the call light and it would take an hour or two for anyone to get to his room. R #2 stated at 5:00 a.m. on 02/08/15 he could not breathe and he was given a nebulizer treatment. R #2 stated he felt better for a while. R #2 stated his wife and son arrived at approximately 9:00 a.m. and R #2 said he could not snap out of it. R #2 stated his wife went and told a nurse he was having trouble breathing. R #2 said a nurse came in and gave him a pain pill ([MEDICATION NAME]) and an anxiety medication ([MEDICATION NAME]). R #2 stated his wife tried to wake him up in the afternoon but he was out of it. R #2 stated his wife left around 3:00 p.m. and the CNAs told him once we leave the hallway it will be a while before we are back. You can't be yelling. You have to wait. R #2 stated he did yell for help and someone came in and said you cannot be yelling there is other residents. R #2 stated a nurse came in around 5:00 p.m. on 02/08/15 and he told her something is not right, I can't breath. R #2 stated the nurse did not say anything, just left him hanging. R #2 stated he called 911. R #2 stated he had turned on his call light many times during the day and it took a long time to be answered. R #2 stated he did not turn on his call light at the time he called 911. R #2 stated I could not handle it. R #2 stated, I may be ignorant to things but I thought they (EMTs) said I was not even hooked up to oxygen. R #2 stated the EMTs got his O2 level back up and asked him if he wanted to stay or go to the emergency room . R #2 stated he could tell by the tone of the EMTs voice it would be better for him to go to the emergency room . R #2 stated when he was in the emergency room his CO2 levels were high and he was told the CO2 levels being high was from him not getting O2. On 02/13/15 at 12:30 p.m. FM MM stated she and her son visited R #2 on 02/08/15. FM MM stated R #2 was very groggy and she could not wake R #2 up. FM MM stated R #2 was swollen and looked like a blow fish. FM MM stated she went to the nurse's station and told someone R #2 was having a hard time breathing. FM MM stated R #2 was given his pain medication by an unknown nurse. FM MM stated R #2 had turned on the call light and it took 1-1/2 hours to get answered. FM MM stated when she was in R #2's room visiting she heard a CNA tell R #2 they did not have enough staff to put him on the bedpan. FM MM stated she left the facility to run errands and was called back to the facility by Staff Person Q to sign R #2's admission papers. FM MM stated Staff Person Q told her to tell R #2 tell him (R #2) to bear with us, not to call 911. FM MM stated after she signed the admission papers she went back to R #2's room and still could not wake R #2 up. FM MM stated it was not normal but she thought R #2 was resting. FM MM stated she left the facility at approximately 3:00 p.m. on 02/08/15. FM MM stated a little later she received a phone call from R #2 and he told her he could not breathe. FM MM stated R #2 was gasping. FM MM stated R #2 told her he had called 911. FM MM stated she called the nursing facility and they told her the EMTs were in the room with R #2. FM MM stated in the emergency room she heard the doctor say R #2 had Carbon [MEDICATION NAME] poisoning that was dangerously high. On 02/16/15 at 2:30 p.m. CNA T stated she was in R #2's room on 02/08/15 to assist the EMTs with transferring R #2 and she overheard the EMTs say R #2's [MEDICAL CONDITION] machine and O2 concentrator were off. On 02/16/15 at 3:00 p.m., CNA X stated she worked the 2:00 p.m. to 10:00 p.m. shift on Hall 300 on 02/08/15. CNA X stated she was not assigned R #2 but had checked R #2 at the beginning of the shift for incontinence. CNA X stated R #2 looked woozie. CNA X stated R #2 had his [MEDICAL CONDITION] mask on. CNA X stated she asked LVN G if R #2 was supposed to have on the [MEDICAL CONDITION] mask and LVN G said R #2 had put the [MEDICAL CONDITION] mask on himself. CNA X stated later R #6 who resided on Hall 300 told her R #2 had been yelling for help on the 10:00 p.m. to 6:00 a.m. shift. R #6 stated R #2 was yelling, does anyone work here? CNA X stated when the EMTs arrived she overheard LVN F say who called 911? CNA X stated, probably (R #2). CNA X stated she walked into R #2's room and saw one of the EMTs pick up [MEDICAL CONDITION] machine and say this is not even on and the O2 is not on. CNA X stated R #2 said I called 911, I could not breathe. On 02/17/15 at 9:55 a.m. the DON stated she had initially denied R #2's admission into the facility on [DATE] and 02/05/15. The DON stated she denied R #2 because she was told by the hospital R #2 was on 10 liters per minute of O2 and the facility did not accept anyone that was over 5 liters of O2. The DON stated R #2's weight was also a factor in the denials. The DON said R #2's weight was 356 pounds and the mechanical lift was maxed out at 360 pounds. The DON said on 02/06/15 she left the facility to go to lunch and when she returned R #2 was in building. The DON said the Administrator gave approval to admit R #2. The DON stated R #2 was to wear his [MEDICAL CONDITION] only at night and the oxygen was for the day at 3 liters. The DON said on 02/08/15 someone called 911. The DON said R #2 had reached over to the nightstand and put on his [MEDICAL CONDITION] mask. The DON said she did not know why R #2 put on his [MEDICAL CONDITION] mask. The DON said the EMTs took his O2 SATS and the SATS were 87%. The DON said the EMTs gave R #2 O2 and he stabilized. The DON said the EMTs ask R #2 if he wanted to stay at the facility or go to the hospital and R #2 said the hospital. On 02/18/15 at 11:05 a.m., LVN F stated she was the Manager on Duty on 02/08/15. LVN F stated at approximately 5:00 p.m. on 02/08/15 the EMTs entered the building and asked where R #2's room was located. LVN F stated she entered R #2's room with the EMTs and observed R #2 wearing his [MEDICAL CONDITION] mask and was resting in bed. LVN F stated R #2 did not have rapid breathing. LVN F stated she left R #2's room to get his chart and when she returned she heard the EMTs stated R #2's [MEDICAL CONDITION] machine was off. LVN F stated the [MEDICAL CONDITION] machine was plugged in to the electrical outlet but it was not turned on. LVN F stated an EMT picked up the nasal canula from the floor and asked R #2 if he got oxygen from the O2 nasal canula or the [MEDICAL CONDITION] machine and R #2 pointed to the O2 Canula. LVN F stated the EMT removed the [MEDICAL CONDITION] mask and placed a non re-breather mask on R #2. LVN F stated she did not remember what R #2's O2 SATs were. LVN F stated to R #2 O2 SAT was ok would you like to stay here and let these people take care of you? LVN F stated R #2 answered, no, I want to go to the hospital. On 02/17/15 at 2:15 p.m. LVN G stated she worked the 2:00 p.m. to 10:00 p.m. shift on 02/08/15. LVN G stated she was working on Hall 300 and R #2 never told her he was having trouble breathing. LVN G stated when she did her initial rounds after arriving at the facility R #2 had on his O2 nasal canula. LVN G stated R #2's [MEDICAL CONDITION] machine was on the nightstand next to his bed. LVN G stated she left Hall 300 after 5:00 p.m. to work on another hall. LVN G stated there was not a nurse on Hall 300 after she left. On 02/17/15 at 2:50 p.m., CNA AA stated she worked the 2:00 p.m. to 10:00 p.m. shift on 02/08/15. CNA AA stated R #2 used his call light several times because he had to urinate. CNA AA stated R #2 was urinating more than usual and she told LVN G who said she would check on R #2. CNA AA stated R #2 did not have on his [MEDICAL CONDITION] mask on his face and she did not remember if R #2 had on his O2. On 02/18/15 at 9:50 a.m. the DON reviewed R #2's admission orders [REDACTED]. The DON stated she could not read all of the order. The DON stated as a nurse she would consider the order as PRN. The DON stated she was not able to tell if the O2 was ordered continuously, but knowing him (R #2) she would considered the order as continuous. The DON stated the admitting nurse could have clarified the Admission Order. The DON stated if a resident had shortness of breath it would be expected for nursing to put on O2. The DON stated in this case they put on [MEDICAL CONDITION], don't know when. The DON stated the facility nurses do not chart O2 SATS, it is a nursing judgement as to when O2 SATS are obtained. The DON stated there were not any O2 SATs for R #2 prior to the EMTs entering the facility. The DON stated the Charge Nurse was responsible for assessing for signs and symptoms of [MEDICAL CONDITION]. The DON stated when EMTs arrived at approximately 5:00 p.m. she went with the EMTs to R #2's room. The DON said when they entered R #2's room, R #2 was cooperative, pleasant and his breathing was fine. The DON stated R #2 had his nasal canula on under his [MEDICAL CONDITION] mask and the nasal canula was connected to the O2 concentrator. The DON stated the EMTs obtained R #2's O2 SATS and the O2 SATS were at 87%. The DON stated the EMTs placed a non re-breather on R #2 and his O2 SATS went to 93 %. The DON said the EMTs stated to R #2 he was stable, but R #2 wanted to go to the hospital. The DON stated she had been at the facility for three months and there were a lot of things to fix here. On 02/18/15 at 3:35 p.m., CNA BB stated she worked the 6:00 a.m. to 2:00 p.m. shift on 02/08/15. CNA BB stated R #2 was on his call light all day. CNA BB stated R #2 wanted ice water, bed pan, and had complaints of shortness of breath. CNA BB stated she told the nurse. CNA BB stated R #2 had on the [MEDICAL CONDITION] mask but she did not know if R #2 had the nasal canula hooked to the O2 concentrator. On 02/18/15 at 3:50 p.m. LVN H stated he worked the 6:00 a.m. to 2:00 p.m. shift on 02/08/15. LVN H stated during the early hours of the shift R #2 told LVN H he was having discomfort with breathing. LVN H stated R #2 always had O2 on. LVN H stated before breakfast a CNA told him R #2 could not breathe good. LVN H stated he gave R #2 a nebulizer treatment at approximately 6:45 a.m. on 02/08/15. LVN H stated he went back to R #2's room later and R #2 stated he need a [MEDICATION NAME]. LVN H stated he administered R #2 a [MEDICATION NAME] at 8:00 a.m. and at 12:00 p.m. and administered R #2's [MEDICATION NAME] at the same time. LVN H stated he did not give R #2 any further nebulizer treatments during the shift. LVN H stated on the weekends Hall 300 does not have a nurse. LVN H stated nurses are pulled from other halls to cover Hall 300. LVN H reviewed R #2's admission orders [REDACTED]. LVN H stated he had not documented the [MEDICATION NAME] R #2 was administered. On 02/18/15 at 4:30 p.m., the Administrator stated she was not aware of the circumstances of R #1's death nor did she did know anything about R #2. The Administrator stated she knew the DON had initially denied R #2's admission into the facility because R #2 was on 10 liters per minute of O2 and the facility was not equipped to manage R #2's O2 needs. The Administrator stated the Admission Consultant accepted R #2 into the facility. Surveyor asked the Administrator what type of procedure is there to make sure the nursing needs of residents are being met? The Administrator stated, I am not clinical, the DON needs to answer this question. Nurses should be making rounds, documenting, charting and checking vitals. The Administrator stated she monitored the DON by having open conversations. The Administrator stated she was not aware the facility systems were not working and it is hard to get people to work. On 02/18/15 at 5:38 p.m., the DON stated she had denied R #2 twice because the facility could not meet his needs. The DON stated R #2 was admitted and yes, when he got here we had to try to meet his needs. The DON stated R #2's O2 SATS were good when he left the facility with the EMTs for transport to the hospital and something happened on the way to the hospital to result in R #2's ABG to be 77%. The DON stated R #2 had the [MEDICAL CONDITION] mask on all day. The DON stated R #2 did not want to be at the facility. The DON stated the system was not working for documentation. The DON stated R #2's Nurse's Notes were not reflective of what occurred on 02/08/15. The DON stated there was not any physician order to document resident's O2 SATS, the facility was not an acute care setting. On 02/18/15 at 10:30 p.m., the DON provided surveyor a copy of Departmental Notes/Nurse's Notes dated 02/18/15 at 10:07 p.m. The notes indicated, Late entry: On 02/08/15, at approximately 1645 (4:45 p.m.), writer was at the nurse's station when she noticed that EMS was entering the building. Writer asked EMS who called them and they stated that the resident in room [ROOM NUMBER]. Writer and two other nurses (LVN F and LVN G), quickly made our way into room [ROOM NUMBER] (R #2's room). While walking towards the resident's room, writer noticed the call light was not on. Upon entering the room, at about the same time as the EMS crew, writer noticed that the resident had his [MEDICAL CONDITIONS] mask on. The [MEDICAL CONDITION] machine was off and had been applied on top of his nasal canula. An EMS Crew member removed the mask. In the process, the O2 nasal canula, which was on the resident fell to the floor. EMS took an initial O2 SAT reading. Reading on room air was 87%. EMS applied a non-re-breather mask for approximately five minutes. The resident's O2 went up to 99%. Non-re-breather mask was removed and O2 nasal canula was re-applied at 3L/minute. O2 SAT was ranging from 93% to 95%; O2 SAT was taken by (LVN G), who was residents assigned nurse. EMS crew talked to the resident and EMS verbalized that the resident was stable. EMS asked the resident if he would stay since he was stable. The resident insisted on being taken to the hospital. Resident's skin color was within normal limits. No respiratory distress was noted. Resident speaking without difficulty. The facility's undated Change in a Resident's Condition or Status policy and procedure indicated, If a change in the resident's physical or mental condition occurs, an assessment of the resident's condition should be conducted. The facility's Oxygen Administration policy and procedures dated November 2014 indicated verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.Oxygen is administered by way of an oxygen mask or nasal canula.The nasal canula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident head.Turn on the oxygen. Start the flow of oxygen at the prescribed rate. Place appropriate oxygen device on the resident.Observed the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. The facility's policy and procedures for Abuse Prevention Program dated January 2013 revealed This policy is intended to set out practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law. As with other resident protection and care protocols and policies, it is important to use common sense and reason when carrying out this policy. Since.neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations. The Health and Safety Code, Title 4, Subtitle B., Chapter 260A, Section 260A. 001 (6) defines Neglect as the failure to provide for the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caregiver to provide such goods or services. On 02/18/15 at 6:30 p.m., an IJ was identified and the DON and Administrator were informed at 7:14 p.m. on 02/18/15 of the IJ due to the above failures. On 02/18/15 at 10:30 p.m., the facility's fourth Plan of Removal was accepted and contained the following: Issues: 1. Facility failed to identify a change in respiratory status and failed to provide services for monitoring O2 administration. 2. Facility failed to have sufficient staff to meet the needs of the residents. Interventions Issue #1: 1. Skills checklist will be conducted with charge nurses and nurse management for respiratory training, assessment and appropriate intervention. Skills checklist training will begin 02/18/15 and continue with charge nurses prior to working next shift. Initiated: 02/18/15 Completion: 02/21/15 2. Charge Nurses will be educated on appropriate documentation of O2 administration. Education will begin 02/18/15 and continue with charge nurses prior to working next shift. Initiated: 02/18/15 Completion: 02/21/15 3. Nurse aides will be educated on how to identify changes in respiratory status and immediate notification to charge nurse. Education will begin 02/18/15. Initiated: 0218/15 Completion: 02/21/15 4. Assess every resident with special needs to ensure orders are correct and O2 concentrator/tanks are at the rate ordered. Initiated: 02/18/15 Completion: Ongoing 5. Nurse Managers will monitor that O2 orders are correct and O2 concentrators/tanks are at right rate daily and humidifiers have sufficient water. Initiated: 02/18/15 Completion: Ongoing 6. Nurse Managers include: DON, Staffing ADON (Assistant DON), QA (Quality Assurance) Nurse #1, Assessment Nurse #2, Medicare Coordinator and TX (Treatment) Nurse. Initiated: 02/18/15 Completion: Ongoing 7. Charge Nurses will follow MD (Medical Doctor) orders for residents with O2 and will document on skilled MARs. Initiated: 02/18/15 Completion: Ongoing Interventions Issue #2: 1. Facility will ensure we have appropriate staff on each shift to meet the needs of the residents. 6:00 a.m. to 2:00 p.m. shift (minimum of 2 aides per hall)/ 2:00 p.m. to 10:00 p.m. shift (minimum of 2 aides per hall)/ 10:00 p.m. to 6:00 a.m. shift (minimum of one aide per hall). Initiated: 02/18/15 Completion: Ongoing 2. Aides will be in-serviced on proper call in procedures. 1st call in-verbal warning, 2nd call in-written counseling, 3rd call in suspension and possible termination. Initiated: 02/18/15 Completion: Ongoing 3. Charge Nurses will notify on-call nurse and Administrator if scheduled staff do not report to duty or if nurse aides leave their assigned floor without notifying supervisory charge nurse. Initiated: 02/18/15 Completion: Ongoing 4. On call nurse will attempt to find replacements of staff; should staff not be available on-call nurse will work as a nurse aide on the floor and notify the DON and Administrator. Initiated: 02/18/15 Completion: Ongoing 5. Facility w

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for one Resident (R #1) of five Residents reviewed for accidents and injuries. R #1 sustained a fracture of unknown origin to her right femur (thigh bone) and had surgery to repair the fracture. Staff provided one person assistance with care instead of two person assistance prior to the injury. This failure affected one resident and placed 26 residents who required two person staff assistance with activities of daily living at risk for injuries and a diminished quality of life. Findings were: R #1's Face Sheet dated 10/07/14 revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Care Plans dated 06/12/14 revealed R #1 had toileting, dressing, bed mobility and transfer ability deficits. Approaches included to provide "total assist x 1 staff member." R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 had no speech; rarely/never understood others or made herself understood; had highly impaired vision (object identification in question, but eyes appear to follow objects); had a severely impaired cognition (never/rarely made decisions); had continuous psychomotor [MEDICAL CONDITION] (consistently had an unusually decreased level of activity); had range of motion limitation to her upper extremities but no limitations to her lower extremities; was always incontinent of bowel and bladder; was totally dependent on two staff persons for bed mobility, transfers, dressing and toilet use; and was totally dependent on one staff person for eating and bathing. R #1's Care Plan dated 06/12/14 was not updated to reflect R #1 required the assistance of two staff persons for bed mobility, transfers, toileting and dressing. On 10/29/14 at 10:30 a.m., Licensed Vocational Nurse (LVN) "F" said she was responsible for R #1's MDS dated [DATE]. LVN "F" said R #1 required two person staff assistance with activities of daily living. After reviewing R #1's care plan with the investigator, LVN "F" said R #1's care plan was not accurate and "care plans are (used) to guide care." R #1's Activities of Daily Living Flowsheet dated October, 2014 revealed staff provided one person assistance instead of two person assistance with bed mobility, toileting and "dressing/grooming" on the 10:00 p.m. to 6:00 a.m. shifts from 10/01/14 through 10/11/14. (The 10/11/14 shift ended at 6:00 a.m. on 10/12/14.) The Activities of Daily Living Flowsheet indicated two staff were needed for bed mobility, toileting and "dressing/grooming." R #1's Incident Report dated 10/12/14 at 7:30 a.m. revealed: "... After assessment noted (R #1 with) groaning/grimacing on palpatation (sic) of (right lower extremity), head to toe assessment completed, (no) other (changes) noted, (no) visible abnormality of (right lower extremity) was visualized ... R #1's physician's orders [REDACTED].#1's right hip and femur. R #1's X-Ray Report from Radiology "AA" dated 10/12/14 revealed R #1 had a "comminuted" fracture of her right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, a comminuted fracture is a bone that "shatters into three or more pieces." R #1's physician's orders [REDACTED].#1 to the emergency room due to her fractured femur. R #1's Operative Report from Hospital "BB" dated 10/13/14 revealed R #1 was admitted on [DATE] and had an "open reduction, internal fixation" operation using a metal plate that was screwed into R #1's right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, open reduction internal fixation is an operation where "the bone fragments are first repositioned (reduced) in their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone..." R #1's Nurses Notes dated 10/16/14 revealed R #1 was readmitted to the facility. Observation of R #1 at the facility on 10/28/14 at 11:30 a.m. revealed R #1 lying in bed. R #1 did not respond to investigator's questions. On 10/28/14 at 12:15 p.m., Family Member (FM) "A" said the facility provided no explanation how R #1's right thigh was fractured. FM "A" said R #1's right thigh fracture "didn't happen by itself." On 10/28/14 at 2:50 p.m., Certified Nurse Aide (CNA) "C" said R #1 was totally dependent on two staff persons for care because of "her contractures. (You) would be pulling and pushing (on her legs) to clean her. A break could happen." CNA "C" said R #1 did not assist "in any way at all" with care because "her hands are contracted and crossed at her stomach." On 10/28/14 at 3:00 p.m., CNA "D" said R #1 was totally dependent on two staff persons for care because of R #1's "contractures. You need two people. Her legs are contracted. It could cause pain, stressful for (R #1) if only one staff did that (provide care)." CNA "D" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "D" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. On 10/28/14 at 3:20 p.m., CNA "E" said R #1 was totally dependent on two staff persons for care because "it would hurt her because of her contractures. You would have to put pressure on her contractures and it could cause pain" if only one staff person provided care. CNA "E" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "E" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. Observation of CNAs "I" and "J" on 10/29/14 at 2:15 p.m. providing incontinent care to R #1 revealed R #1's legs were drawn up at the knees towards her chest. R #1's hands and arms were rigid with her arms crossed over her abdomen. CNAs "I" and "J" attempted to extend R #1's thighs to provide incontinent care but were only able to partially extend them. CNA "J" kept R #1's thighs partially extended while CNA "I" provided incontinent care. Confidential Interviewee (CI) "CC" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift. CI "CC" did not know why only one staff person provided care for R #1. CI "DD" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift but could not recall how often. The facility's Provider Investigation Report dated 10/13/14 revealed: "... Conclusion: Radiology results indicated comminuted fracture to the right distal femur. Radiologist states x-ray shows demineralization of bones and this predisposes people to easy fractures and injury. The resident is assisted out of bed for all meals by two staff members and use of Hoyer lift due to requiring total assistance with all tasks. Interviews with staff did not reveal any adversities. Family visits often and had not noticed any abnormalities either. Investigation is inconclusive of any findings of abuse ..." The report indicated facility staff were inserviced on mechanical lift transfers and reporting abuse and neglect. The report did not indicate and included no evidence that the facility considered R #1's fracture could have been caused by trauma due to providing one person assistance with care instead of two person assistance and did not include interventions and precautions to minimize the risk of injury to other residents who required two person assistance. On 10/29/14 at 3:50 p.m., the Director of Nurses (DON) said she did not take into account R #1's fracture could have been caused by providing only one staff person for assistance. The facility's Abuse Prohibition Policy and Procedure dated 03/2012 revealed: "...This policy is intended to set our practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law ... Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations ... " Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported revealed: " ... 2. NEGLECT (as defined in 40 TAC 19.101(81)) 'The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness.' The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident ... 8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE ... 'An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.' ..." The facility's Resident Roster dated 10/29/14 revealed 26 residents who required two person assistance with activities of daily living. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to providing two person assistance. As of exit on 10/29/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R #1) of five Residents reviewed for accidents and injuries. R #1 sustained a fracture of unknown origin to her right femur (thigh bone) and had surgery to repair the fracture. Staff provided one person assistance with care instead of two person assistance prior to the injury. This failure affected one resident and placed 26 residents who required two person staff assistance with activities of daily living at risk for injuries and a diminished quality of life. Findings were: R #1's Face Sheet dated 10/07/14 revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Care Plans dated 06/12/14 revealed R #1 had toileting, dressing, bed mobility and transfer ability deficits. Approaches included to provide "total assist x 1 staff member." R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 had no speech; rarely/never understood others or made herself understood; had highly impaired vision (object identification in question, but eyes appear to follow objects); had a severely impaired cognition (never/rarely made decisions); had continuous psychomotor [MEDICAL CONDITION] (consistently had an unusually decreased level of activity); had range of motion limitation to her upper extremities but no limitations to her lower extremities; was always incontinent of bowel and bladder; was totally dependent on two staff persons for bed mobility, transfers, dressing and toilet use; and was totally dependent on one staff person for eating and bathing. R #1's Care Plan dated 06/12/14 was not updated to reflect R #1 required the assistance of two staff persons for bed mobility, transfers, toileting and dressing. On 10/29/14 at 10:30 a.m., Licensed Vocational Nurse (LVN) "F" said she was responsible for R #1's MDS dated [DATE]. LVN "F" said R #1 required two person staff assistance with activities of daily living. After reviewing R #1's care plan with the investigator, LVN "F" said R #1's care plan was not accurate and "care plans are (used) to guide care." R #1's Activities of Daily Living Flowsheet dated October, 2014 revealed staff provided one person assistance instead of two person assistance with bed mobility, toileting and "dressing/grooming" on the 10:00 p.m. to 6:00 a.m. shifts from 10/01/14 through 10/11/14. (The 10/11/14 shift ended at 6:00 a.m. on 10/12/14.) The Activities of Daily Living Flowsheet indicated two staff were needed for bed mobility, toileting and "dressing/grooming." R #1's Incident Report dated 10/12/14 at 7:30 a.m. revealed: "... After assessment noted (R #1 with) groaning/grimacing on palpatation (sic) of (right lower extremity), head to toe assessment completed, (no) other (changes) noted, (no) visible abnormality of (right lower extremity) was visualized ... R #1's physician's orders [REDACTED].#1's right hip and femur. R #1's X-Ray Report from Radiology "AA" dated 10/12/14 revealed R #1 had a "comminuted" fracture of her right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, a comminuted fracture is a bone that "shatters into three or more pieces." R #1's physician's orders [REDACTED].#1 to the emergency room due to her fractured femur. R #1's Operative Report from Hospital "BB" dated 10/13/14 revealed R #1 was admitted on [DATE] and had an "open reduction, internal fixation" operation using a metal plate that was screwed into R #1's right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, open reduction internal fixation is an operation where "the bone fragments are first repositioned (reduced) in their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone..." R #1's Nurses Notes dated 10/16/14 revealed R #1 was readmitted to the facility. Observation of R #1 at the facility on 10/28/14 at 11:30 a.m. revealed R #1 lying in bed. R #1 did not respond to investigator's questions. On 10/28/14 at 12:15 p.m., Family Member (FM) "A" said the facility provided no explanation how R #1's right thigh was fractured. FM "A" said R #1's right thigh fracture "didn't happen by itself." On 10/28/14 at 2:50 p.m., Certified Nurse Aide (CNA) "C" said R #1 was totally dependent on two staff persons for care because of "her contractures. (You) would be pulling and pushing (on her legs) to clean her. A break could happen." CNA "C" said R #1 did not assist "in any way at all" with care because "her hands are contracted and crossed at her stomach." On 10/28/14 at 3:00 p.m., CNA "D" said R #1 was totally dependent on two staff persons for care because of R #1's "contractures. You need two people. Her legs are contracted. It could cause pain, stressful for (R #1) if only one staff did that (provide care)." CNA "D" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "D" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. On 10/28/14 at 3:20 p.m., CNA "E" said R #1 was totally dependent on two staff persons for care because "it would hurt her because of her contractures. You would have to put pressure on her contractures and it could cause pain" if only one staff person provided care. CNA "E" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "E" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. Observation of CNAs "I" and "J" on 10/29/14 at 2:15 p.m. providing incontinent care to R #1 revealed R #1's legs were drawn up at the knees towards her chest. R #1's hands and arms were rigid with her arms crossed over her abdomen. CNAs "I" and "J" attempted to extend R #1's thighs to provide incontinent care but were only able to partially extend them. CNA "J" kept R #1's thighs partially extended while CNA "I" provided incontinent care. Confidential Interviewee (CI) "CC" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift. CI "CC" did not know why only one staff person provided care for R #1. CI "DD" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift but could not recall how often. The facility's Provider Investigation Report dated 10/13/14 revealed: "... Conclusion: Radiology results indicated comminuted fracture to the right distal femur. Radiologist states x-ray shows demineralization of bones and this predisposes people to easy fractures and injury. The resident is assisted out of bed for all meals by two staff members and use of Hoyer lift due to requiring total assistance with all tasks. Interviews with staff did not reveal any adversities. Family visits often and had not noticed any abnormalities either. Investigation is inconclusive of any findings of abuse ..." The report indicated facility staff were inserviced on mechanical lift transfers and reporting abuse and neglect. The report did not indicate and included no evidence that the facility considered R #1's fracture could have been caused by trauma due to providing one person assistance with care instead of two person assistance and did not include interventions and precautions to minimize the risk of injury to other residents who required two person assistance. On 10/29/14 at 3:50 p.m., the Director of Nurses (DON) said she did not take into account R #1's fracture could have been caused by providing only one staff person for assistance. The facility's Abuse Prohibition Policy and Procedure dated 03/2012 revealed: "...This policy is intended to set our practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law ... Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations ... " Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported revealed: " ... 2. NEGLECT (as defined in 40 TAC 19.101(81)) 'The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness.' The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident ... 8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE ... 'An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.' ..." The facility's Resident Roster dated 10/29/14 revealed 26 residents who required two person assistance with activities of daily living. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to neglect. As of exit on 10/29/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to thoroughly investigate an allegation of possible neglect and an injury of unknown source for one Resident (R #1) of five Residents reviewed for accidents and injuries. R #1 sustained a fracture of unknown origin to her right femur (thigh bone) and had surgery to repair the fracture. Staff provided one person assistance with care instead of two person assistance prior to the injury. The facility did not investigate one person assistance as a possible cause of the fracture. This failure affected one resident and placed 26 residents who required two person staff assistance with activities of daily living at risk for injuries and a diminished quality of life. Findings were: R #1's Face Sheet dated 10/07/14 revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Care Plans dated 06/12/14 revealed R #1 had toileting, dressing, bed mobility and transfer ability deficits. Approaches included to provide "total assist x 1 staff member." R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 had no speech; rarely/never understood others or made herself understood; had highly impaired vision (object identification in question, but eyes appear to follow objects); had a severely impaired cognition (never/rarely made decisions); had continuous psychomotor [MEDICAL CONDITION] (consistently had an unusually decreased level of activity); had range of motion limitation to her upper extremities but no limitations to her lower extremities; was always incontinent of bowel and bladder; was totally dependent on two staff persons for bed mobility, transfers, dressing and toilet use; and was totally dependent on one staff person for eating and bathing. R #1's Care Plan dated 06/12/14 was not updated to reflect R #1 required the assistance of two staff persons for bed mobility, transfers, toileting and dressing. On 10/29/14 at 10:30 a.m., Licensed Vocational Nurse (LVN) "F" said she was responsible for R #1's MDS dated [DATE]. LVN "F" said R #1 required two person staff assistance with activities of daily living. After reviewing R #1's care plan with the investigator, LVN "F" said R #1's care plan was not accurate and "care plans are (used) to guide care." R #1's Activities of Daily Living Flowsheet dated October, 2014 revealed staff provided one person assistance instead of two person assistance with bed mobility, toileting and "dressing/grooming" on the 10:00 p.m. to 6:00 a.m. shifts from 10/01/14 through 10/11/14. (The 10/11/14 shift ended at 6:00 a.m. on 10/12/14.) The Activities of Daily Living Flowsheet indicated two staff were needed for bed mobility, toileting and "dressing/grooming." R #1's Incident Report dated 10/12/14 at 7:30 a.m. revealed: "... After assessment noted (R #1 with) groaning/grimacing on palpatation (sic) of (right lower extremity), head to toe assessment completed, (no) other (changes) noted, (no) visible abnormality of (right lower extremity) was visualized ... R #1's physician's orders [REDACTED].#1's right hip and femur. R #1's X-Ray Report from Radiology "AA" dated 10/12/14 revealed R #1 had a "comminuted" fracture of her right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, a comminuted fracture is a bone that "shatters into three or more pieces." R #1's physician's orders [REDACTED].#1 to the emergency room due to her fractured femur. R #1's Operative Report from Hospital "BB" dated 10/13/14 revealed R #1 was admitted on [DATE] and had an "open reduction, internal fixation" operation using a metal plate that was screwed into R #1's right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, open reduction internal fixation is an operation where "the bone fragments are first repositioned (reduced) in their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone..." R #1's Nurses Notes dated 10/16/14 revealed R #1 was readmitted to the facility. Observation of R #1 at the facility on 10/28/14 at 11:30 a.m. revealed R #1 lying in bed. R #1 did not respond to investigator's questions. On 10/28/14 at 12:15 p.m., Family Member (FM) "A" said the facility provided no explanation how R #1's right thigh was fractured. FM "A" said R #1's right thigh fracture "didn't happen by itself." On 10/28/14 at 2:50 p.m., Certified Nurse Aide (CNA) "C" said R #1 was totally dependent on two staff persons for care because of "her contractures. (You) would be pulling and pushing (on her legs) to clean her. A break could happen." CNA "C" said R #1 did not assist "in any way at all" with care because "her hands are contracted and crossed at her stomach." On 10/28/14 at 3:00 p.m., CNA "D" said R #1 was totally dependent on two staff persons for care because of R #1's "contractures. You need two people. Her legs are contracted. It could cause pain, stressful for (R #1) if only one staff did that (provide care)." CNA "D" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "D" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. On 10/28/14 at 3:20 p.m., CNA "E" said R #1 was totally dependent on two staff persons for care because "it would hurt her because of her contractures. You would have to put pressure on her contractures and it could cause pain" if only one staff person provided care. CNA "E" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "E" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. Observation of CNAs "I" and "J" on 10/29/14 at 2:15 p.m. providing incontinent care to R #1 revealed R #1's legs were drawn up at the knees towards her chest. R #1's hands and arms were rigid with her arms crossed over her abdomen. CNAs "I" and "J" attempted to extend R #1's thighs to provide incontinent care but were only able to partially extend them. CNA "J" kept R #1's thighs partially extended while CNA "I" provided incontinent care. Confidential Interviewee (CI) "CC" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift. CI "CC" did not know why only one staff person provided care for R #1. CI "DD" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift but could not recall how often. The facility's Provider Investigation Report dated 10/13/14 revealed: "... Conclusion: Radiology results indicated comminuted fracture to the right distal femur. Radiologist states x-ray shows demineralization of bones and this predisposes people to easy fractures and injury. The resident is assisted out of bed for all meals by two staff members and use of Hoyer lift due to requiring total assistance with all tasks. Interviews with staff did not reveal any adversities. Family visits often and had not noticed any abnormalities either. Investigation is inconclusive of any findings of abuse ..." The report indicated facility staff were inserviced on mechanical lift transfers and reporting abuse and neglect. The report did not indicate and included no evidence that the facility considered R #1's fracture could have been caused by trauma due to providing one person assistance with care instead of two person assistance and did not include interventions and precautions to minimize the risk of injury to other residents who required two person assistance. On 10/29/14 at 3:50 p.m., the Director of Nurses (DON) said she did not take into account R #1's fracture could have been caused by providing only one staff person for assistance. The facility's Abuse Prohibition Policy and Procedure dated 03/2012 revealed: "...This policy is intended to set our practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law ... Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations ... " Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported revealed: " ... 2. NEGLECT (as defined in 40 TAC 19.101(81)) 'The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness.' The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident ... 8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE ... 'An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.' ..." The facility's Resident Roster dated 10/29/14 revealed 26 residents who required two person assistance with activities of daily living. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to conducting thorough investigations. As of exit on 10/29/14 at 4:10 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to implement their written policy and procedure that prohibits neglect for one Resident (R #1) of five Residents reviewed for accidents and injuries. R #1 sustained a fracture of unknown origin to her right femur (thigh bone) and had surgery to repair the fracture. Staff provided one person assistance with care instead of two person assistance prior to the injury. The facility did not investigate one person assistance as a possible cause of the fracture. This failure affected one resident and placed 26 residents who required two person staff assistance with activities of daily living at risk for injuries and a diminished quality of life. Findings were: The facility's Abuse Prohibition Policy and Procedure dated 03/2012 revealed: "...This policy is intended to set our practical guidelines to be followed in an overall effort to prevent or minimize abuse, neglect or other forms of mistreatment toward nursing home facility residents by any person, and to comply with applicable nursing home regulations as required by law ... Since abuse and neglect allegations can be based on many different fact situations, this policy will not be viewed as a rigid set of rules, but rather as guiding principles to be used with some flexibility and adapted to specific situations ... " Provider Letter 14-13 - Abuse, Neglect, Exploitation and Other Incidents that Must Be Reported revealed: " ... 2. NEGLECT (as defined in 40 TAC 19.101(81)) 'The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness.' The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident ... 8. SUSPICIOUS INJURIES OF UNKNOWN SOURCE ... 'An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.' ..." R #1's Face Sheet dated 10/07/14 revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Care Plans dated 06/12/14 revealed R #1 had toileting, dressing, bed mobility and transfer ability deficits. Approaches included to provide "total assist x 1 staff member." R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R #1 had no speech; rarely/never understood others or made herself understood; had highly impaired vision (object identification in question, but eyes appear to follow objects); had a severely impaired cognition (never/rarely made decisions); had continuous psychomotor [MEDICAL CONDITION] (consistently had an unusually decreased level of activity); had range of motion limitation to her upper extremities but no limitations to her lower extremities; was always incontinent of bowel and bladder; was totally dependent on two staff persons for bed mobility, transfers, dressing and toilet use; and was totally dependent on one staff person for eating and bathing. R #1's Care Plan dated 06/12/14 was not updated to reflect R #1 required the assistance of two staff persons for bed mobility, transfers, toileting and dressing. On 10/29/14 at 10:30 a.m., Licensed Vocational Nurse (LVN) "F" said she was responsible for R #1's MDS dated [DATE]. LVN "F" said R #1 required two person staff assistance with activities of daily living. After reviewing R #1's care plan with the investigator, LVN "F" said R #1's care plan was not accurate and "care plans are (used) to guide care." R #1's Activities of Daily Living Flowsheet dated October, 2014 revealed staff provided one person assistance instead of two person assistance with bed mobility, toileting and "dressing/grooming" on the 10:00 p.m. to 6:00 a.m. shifts from 10/01/14 through 10/11/14. (The 10/11/14 shift ended at 6:00 a.m. on 10/12/14.) The Activities of Daily Living Flowsheet indicated two staff were needed for bed mobility, toileting and "dressing/grooming." R #1's Incident Report dated 10/12/14 at 7:30 a.m. revealed: "... After assessment noted (R #1 with) groaning/grimacing on palpatation (sic) of (right lower extremity), head to toe assessment completed, (no) other (changes) noted, (no) visible abnormality of (right lower extremity) was visualized ... R #1's physician's orders [REDACTED].#1's right hip and femur. R #1's X-Ray Report from Radiology "AA" dated 10/12/14 revealed R #1 had a "comminuted" fracture of her right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, a comminuted fracture is a bone that "shatters into three or more pieces." R #1's physician's orders [REDACTED].#1 to the emergency room due to her fractured femur. R #1's Operative Report from Hospital "BB" dated 10/13/14 revealed R #1 was admitted on [DATE] and had an "open reduction, internal fixation" operation using a metal plate that was screwed into R #1's right femur. According to the American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/topic.cfm?topic=a on 11/03/14, open reduction internal fixation is an operation where "the bone fragments are first repositioned (reduced) in their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone..." R #1's Nurses Notes dated 10/16/14 revealed R #1 was readmitted to the facility. Observation of R #1 at the facility on 10/28/14 at 11:30 a.m. revealed R #1 lying in bed. R #1 did not respond to investigator's questions. On 10/28/14 at 12:15 p.m., Family Member (FM) "A" said the facility provided no explanation how R #1's right thigh was fractured. FM "A" said R #1's right thigh fracture "didn't happen by itself." On 10/28/14 at 2:50 p.m., Certified Nurse Aide (CNA) "C" said R #1 was totally dependent on two staff persons for care because of "her contractures. (You) would be pulling and pushing (on her legs) to clean her. A break could happen." CNA "C" said R #1 did not assist "in any way at all" with care because "her hands are contracted and crossed at her stomach." On 10/28/14 at 3:00 p.m., CNA "D" said R #1 was totally dependent on two staff persons for care because of R #1's "contractures. You need two people. Her legs are contracted. It could cause pain, stressful for (R #1) if only one staff did that (provide care)." CNA "D" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "D" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. On 10/28/14 at 3:20 p.m., CNA "E" said R #1 was totally dependent on two staff persons for care because "it would hurt her because of her contractures. You would have to put pressure on her contractures and it could cause pain" if only one staff person provided care. CNA "E" said residents' Activities of Daily Living Flowsheet guided staff regarding how many staff were needed to provide care. CNA "E" said it was the facility's policy to document on the Activities of Daily Living Flowsheet how many staff provided care on each shift, each day of the week. Observation of CNAs "I" and "J" on 10/29/14 at 2:15 p.m. providing incontinent care to R #1 revealed R #1's legs were drawn up at the knees towards her chest. R #1's hands and arms were rigid with her arms crossed over her abdomen. CNAs "I" and "J" attempted to extend R #1's thighs to provide incontinent care but were only able to partially extend them. CNA "J" kept R #1's thighs partially extended while CNA "I" provided incontinent care. Confidential Interviewee (CI) "CC" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift. CI "CC" did not know why only one staff person provided care for R #1. CI "DD" said only one staff person provided care for R #1 on the 10:00 p.m. to 6:00 a.m. shift but could not recall how often. The facility's Provider Investigation Report dated 10/13/14 revealed: "... Conclusion: Radiology results indicated comminuted fracture to the right distal femur. Radiologist states x-ray shows demineralization of bones and this predisposes people to easy fractures and injury. The resident is assisted out of bed for all meals by two staff members and use of Hoyer lift due to requiring total assistance with all tasks. Interviews with staff did not reveal any adversities. Family visits often and had not noticed any abnormalities either. Investigation is inconclusive of any findings of abuse ..." The report indicated facility staff were inserviced on mechanical lift transfers and reporting abuse and neglect. The report did not indicate and included no evidence that the facility considered R #1's fracture could have been caused by trauma due to providing one person assistance with care instead of two person assistance and did not include interventions and precautions to minimize the risk of injury to other residents who required two person assistance. On 10/29/14 at 3:50 p.m., the Director of Nurses (DON) said she did not take into account R #1's fracture could have been caused by providing only one staff person for assistance. The facility's Resident Roster dated 10/29/14 revealed 26 residents who required two person assistance with activities of daily living. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to neglect. As of exit on 10/29/14 at 4:10 p.m., the facility provided no further information.