Every finding on record at Woodlands Place Rehabilitation Suites

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 residents (Resident #47, Resident #66, Resident #84, and Resident #55) of 20 residents reviewed for ADLs.The facility failed to ensure Resident #s 47, 66, and 84 had their fingernails trimmed on 2/24/26.The facility failed to provide timely incontinent care for Resident #55 on 2/24/26.These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.Findings include:Record Review of Resident # 47 Annual MDS dated [DATE] reflected, Resident #47 was a [AGE] year-old female with initial admission date of 2/17/2025 to the facility. Her pertinent diagnoses included: Hypertension (high blood pressure), Diabetes mellitus (elevated blood glucose levels) , Hyperlipidemia (elevated lipid levels in blood), Age related cognitive decline. Her BIMS score was 5, which indicated Resident #47 had severe cognitive impairment. Resident # 47 needed supervision from staff for her personal hygiene.Review of Resident #47 's Comprehensive Care Plan, revised 2/12/2026 reflected, Category: ADLs Functional Status/Rehabilitation Potential. [Resident #47] requires up to extensive assistance with ADL's related to poor balance, decreased mobility, weakness post hospital. Approach: . Provide assistance with hygiene and grooming and dressing as needed .In an interview and observation on 02/24/2026 at 10:25 AM with Resident #47 revealed she had long and jagged fingers nails on both hands measuring approximately 0.2 - 0.4 inches in length extending from the tip of her fingers. Resident #47 stated that she would like her fingernails clipped. She stated that she did not recall if the staff had offered her nailcare.Record Review of Resident #66's Annual MDS assessment dated [DATE] reflected, Resident #66 was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included the following: Hypertension (high blood pressure), peripheral vascular disease ( reduced blood flow to the limbs especially legs ), Unspecified Dementia. Her BIMS score was 15, which indicated Resident #66 had intact cognition. Resident # 66 needed supervision from staff for her personal hygiene. Review of Resident #66's Comprehensive Care Plan, revised 12/18/2025 reflected, Category: [Resident #66] Requires extensive assistance with ADLs related to poor balance, decreased mobility. Approach: Provide assistance with hygiene and grooming and dressing as needed.In an interview and observation on 02/24/2026 at 10:47 AM with Resident #66 revealed Resident #66 had long, jagged nails on both hands, measuring approximately 0.4 inches in length extending from the tip of her fingers. Resident #66 stated she would like her nails clipped and staff had not offered to clip her nails for a long time. She stated that she was unable to trim her own nails.Record Review of Resident #84's admission MDS dated [DATE] reflected, Resident #84 was an [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included the following: Hypertension (high blood pressure), coronary artery disease (thickening of the heart arteries related to plaque buildup), Septicemia, (blood stream infection), Hyperlipidemia (elevated blood lipid levels). Her BIMS score was 15, which indicated Resident #84 had intact cognition. Resident # 84 needed moderate assistance from staff for her personal hygiene.Review of Resident #84 's Comprehensive Care Plan, revised 2/24/2026 reflected, Category: [Resident #84] Requires extensive assistance with ADL's related to poor balance, decreased mobility, weakness post hospital . Approach: . Provide assistance with hygiene and grooming and dressing as needed .In an interview and observation on 02/24/2026 at 11:25 AM with Resident #84 revealed Resident #84 was scratching with her nails on her left forehand. The left forehand had a skin tear. Resident # 84 had long and jagged fingernails on both hands, measuring approximately 0.3 inches in length extending from the tip of her fingers. Resident stated that she had fragile skin and often scratched herself. She stated that she would like her fingernails to be trimmed but was unable to do so by herself since she was admitted in the facility. She stated that staff had not offered her fingernail care in the facility.In an interview on 02/25/2026 at 10:03 AM with CNA C she stated that CNAs were responsible for nail care including trimming and cleaning them, unless the resident had diabetes. She stated that nailcare should be provided on shower days and as needed. She stated that some residents had their nails done during Activities, once a week. She stated that risks of long, jagged fingernails were potential skin tears and loss of dignity. In an interview on 2/25/26 at 10:10 AM with LVN D stated that Nurses and CNAs were responsible for clipping fingernails. She stated that for diabetic residents, Nurses should clip their fingernails. She stated that the expectation was CNAs performed nail care on residents on shower days and as needed. She stated the risks of long and jagged fingernails were skin tears and possibility of infections.In an interview on 2/26/26 at 10:40 AM with the DON revealed her expectation was that nail care should be provided as needed, especially during shower time. She stated that CNAs were responsible for doing nail care unless the resident had diagnosis of diabetes. She stated the charge nurses were supposed to monitor. She stated that some residents do participate in Nail care activity with the Activities coordinator but that does not replace grooming and ADL care that nursing staff were expected to provide to residents. The DON stated residents having long and jagged fingernails could cause lapses in infection control and dignity concerns. The DON stated that she will ensure that residents will receive nailcare soon after the interview. The DON stated that in order to maintain quality of life for residents in the facility, she and management staff conducted daily rounds on all residents.Record review of Resident #55's face sheet dated 2/25/26 reflected he was a [AGE] year-old male with an original admission date of 11/22/16 and a readmission date of 2/21/26. Resident #55 had the following active diagnoses: cerebral palsy (a neurological disorder that affects movement, muscle tone and posture), need for assistance with personal care, contracture of knee (loss of motion where the joint is fixed in a bent position), mixed receptive-expressive disorder (a communication disorder where individuals struggle to both understand and produce spoken language), unspecified lack of coordination and Anxiety Disorder (a mental health condition characterized by persistent, excessive and uncontrollable fear or worry that interferes with daily life).Record review of Resident #55's Quarterly MDS assessment dated [DATE] reflected Resident #55 was rarely understood and therefore could not complete the BIMS interview. Resident #55 had impairments on both sides to his upper and lower extremities and used a wheelchair. Resident #55 was fully dependent on staff for toileting hygiene and was always incontinent of bowel and bladder.Record review of Resident #55's Care Plan dated 12/22/25 reflected .Problem Start Date: 02/21/2026 Requires assistance one to two person assist with ADL's related to poor balance, decreased mobility, weakness Edited: 02/24/2026. Approach Start Date: 02/21/2026 Provide assistance of one with hygiene and grooming and dressing as neededEdited: 02/22/2026 Approach Start Date: 02/21/2026 Nursing Provide assistance of one with incontinent care as needed Edited: 02/22/2026. Problem Start Date: 02/21/2026 Category: Continence Status (Bowel/Bladder) Resident #55 is incontinent of bladder R/T: Cerebral Palsy Edited: 02/24/2026 Long Term Goal Target Date: 03/24/2026 Resident #55 will remain clean, dry, and odor free with no occurrence of skin breakdown over the next review period Edited: 02/24/2026 Approach Start Date: 02/21/2026 Monitor for incontinent episodes frequently. Change promptly and apply a skin barrier to skin. Edited: 02/22/2026 Approach Start Date: 02/21/2026 Monitor for S/S skin breakdown - report to MD and responsible party. Edited: 02/22/2026 Approach Start Date: 02/21/2026 Urinary Incontinence Type: Stress Edited: 02/22/2026.Record review of Resident #55's Point of Care History from 2/19/26 to 2/25/26 dated 2/25/26 reflected toileting hygiene was performed the following times on 2/24/26: 1:13am, 1:20pm, 9:32pm and 10:54pm.During an observation and interview with LVN A on 02/24/2026 12:55 PM revealed Resident #55 was sitting in his wheelchair at the nurses' station with LVN A. Resident #55 was observed wet on the front of his pants and on his t-shirt in the shape of an incontinent brief. Surveyor made LVN A aware Resident #55 was soiled LVN A displayed a surprised look and stated Oh Yes, he is! We need to get him changed. LVN A stated Resident #55 was not wet a bit ago. LVN A had not known the last time Resident #55 was changed. Resident #55 was with LVN A at the end of the observation.An interview with CNA J 02/25/2026 at 10:15 AM revealed she was the CNA J assigned to Resident #55 on 2/24/26 and 2/25/26. CNA J stated Resident #55 liked riding around the facility, and he only came to his room during the day when he needed incontinent care or wasn't feeling well. CNA J stated Resident #55 could have been found in his room around 2pm every day because that was when he would take a nap. CNA J stated Resident #55 was not on a specific schedule for incontinent care, however she typically checked him every 2-3 hours. CNA J stated she looked Resident 55 over when she saw him and checked for incontinence. CNA J stated Resident #55 was able to tell the staff when he was incontinent if they asked him. CNA J stated on 2/24/26 she changed Resident #55 at around 7am and checked him around lunch time, which was about 11am. CNA J stated his brief had a yellow strip that would turn blue if he was wet. She stated he was dry at 11am. CNA J stated she had not checked Resident #55 for incontinence after 11am. CNA J stated Resident #55 was in the activity room when she checked to see if he needed changing. CNA J stated she had not taken Resident #55 back to his room after she changed him at 7am. CNA J stated Resident #55 was changed before the end of her shift at 2pm on 2/24/25. She changed him yesterday at 7am. CNA J stated it was impossible for her to check Resident #55 every two hour because he was riding around the whole facility, however he was typically with staff, and they kept an eye on him and notified her if he needed to be changed. CNA J stated the risk to the resident of not being changed timely was he could have gotten a wound or something, but he had not had a wound. An interview with LVN G on 02/25/2026 at 10:42 am revealed she was not a regular employee of the facility but had worked with Resident #55 several times. LVN G stated Resident #55 was typically out and about throughout the facility and was never in his room. LVN G stated everyone tended to monitor Resident #55 and if they saw something wrong with him they would have taken him to his nurse or CNA. LVN G stated she checked Resident #55 every hour due to his medical condition. LVN G stated Resident #55 could not verbalize when he was wet and was unsure if he typically came back to his room when he was wet. LVN G stated the risk to the residents of not being checked regularly for incontinence was possible skin integrity issues.An interview with ADON K on 02/26/2026 at 11:08 AM revealed Resident #55 was not in his room very often and therefore the CNAs should have gotten him and checked him for incontinence at least every 2 hours throughout the day. ADON K stated she was unsure how the facility staff were monitoring whether Resident #55 had gotten checked for incontinent care. An interview with the DON on 02/26/2026 at 11:19 AM revealed when Resident #55 was observed wet by the surveyor on 2/24/26 it was ice and water and not urine on his clothing. The DON stated her staff was checking Resident #55 at least every 2 hours and stated checking him included taking him to his room and checking his brief. The DON stated the Point of Care History was inaccurate because it was not done in real time rather it was done at the end of the CNA's shift. The DON stated it was the responsibility of the charge nurses to ensure Resident #55 was rounded every two hours. The charge nurses were making sure the rounding was done. The DON stated if the wetness on the Resident #55 was urine the risk to the resident would have been dignity and a lot of other issues. Record review of the facility policy titled Activities of Daily Living revised on 5/5/2023 reflected, .The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food safety for the facility's only kitchen in that:The facility failed to ensure food items in the walk-in refrigerator were covered and sealed on 2/24/2026.This failure could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, if consumed and food contamination.Finding included:Observation on 2/24/26 at 9:38 AM of the walk-in refrigerator revealed two gallon-size Ziplock bags having 8-10 grilled sandwiches in them were left open and not sealed shut. The Ziplock bags had a date of 2/23/26 written on them. In an interview on 02/25/2026 at 12:32 PM with the Dietary Manager revealed that the grilled cheese sandwiches were made on 2/23/26 for dinner service and leftovers were stored in the refrigerator for later use. She stated that the Dietary Aide E left the bags open after she had completed helping serve dinner on 2/25/2026. She stated that everyone in the kitchen, including dietary aides and cooks, were responsible for covering food items. She stated she expected all kitchen staff to cover all food items. She stated that risk of not appropriately covering food items was food contamination and could make the residents sick. She stated that she provided frequent in-services to all kitchen staff on appropriate food storage. In an interview on 02/26/2026 at 11:45 AM with Dietary Aide E revealed she had been working in the facility for about 6 months. She stated that everyone in the kitchen was responsible for covering food items She stated that the grilled cheese sandwiches were prepared the day before and stored in the refrigerator. She stated she used some sandwiches for dinner on 2/25/26 and did not close the zip lock bags all the way. She stated that risk of not appropriately covering food items was food contamination and food borne illness.In an interview on 2/26/26 at 11:51 AM with [NAME] F, she stated all food items in the kitchen should be covered appropriately. She stated that everyone in the kitchen was responsible for covering food items. She stated that if the food was not covered, it needed to be discarded since it posed a risk of cross contamination and food borne illness. Record Review of the facility policy titled Food Storage revised 7/21/2023, reflected, .Always cover, label and date leftovers that are to be stored. They should be date marked with the use by date.Review of the Food and Drug Administration Food Code, dated 2022, reflected, 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review the facility failed to ensure residents had a safe, clean, comfortable and homelike environment including clean bed linen in good condition for seven (Resident #55, Resident #11, and 5 confidential residents in group interview) of 16 residents and 4 of 4 bed linen closets reviewed for resident rights and homelike environment. 1. The facility failed to ensure Resident #55 and #11's and 5 confidential residents' in group interview fitted bed sheets were in good condition free of holes, tears and threadbare areas. 2. The facility failed to ensure 4 of 4 bed linen closets on resident halls did not have clean fitted bed sheets with holes, tears and threadbare areas. These failures place residents at risk of an unsanitary environment and a decline in quality of life.Findings included: Review of Resident #55's face sheet reflected Resident #55 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses of cerebral palsy (brain disorder permanently affects body movement and muscle coordination), mixed receptive-expressive language disorder (neurodevelopmental condition that affects person's ability to understand and produce language), dysphagia (difficulty swallowing), cognitive communication deficit and ataxia (poor muscle control resulting in shaky, clumsy or unsteady movements). Review of Resident #55's Annual MDS dated [DATE] reflected Resident #55 was severely impaired in cognitive skills for daily decision making. Observation on 02/25/2026 at 8:32 AM of Resident #55 was in bed with his toes sticking out of a large hole in the top sheet. Resident #15's fitted sheet was very thin and threadbare in places. In a confidential group interview on 02/25/26 at 2:15 PM revealed 5 of 13 residents stated their bed linen at times was torn and had holes in them. They stated the facility would run out of bed linen. Review of Resident #11's face sheet reflected Resident #11 was a [AGE] year-old female readmitted to the facility on [DATE] with included diagnoses of sclerosis (hardening and stiffening of tissues commonly caused by disease, inflammation or the replacement of normal cells with fibrous connective tissue) and chronic obstructive pulmonary disease (progressive, chronic inflammatory lung disease causing obstructed airflow, making it difficult to breathe). Review of Resident #11's Annual MDS assessment dated [DATE] reflected Resident #11 had a BIMS score of 15 , indicating she was cognitively intact. Observation and interview on 02/25/26 at 3:13 PM with Resident #11 revealed she requested surveyor to go with her to look at her bed linen that was in poor condition. Observation revealed Resident #11's bed fitted sheet appeared to have large areas that were threadbare. Observations on 02/26/2026 from 12:58 PM to 1:09 PM with Contract Housekeeping Supervisor revealed 4 of 4 linen closets had the following:-100 hall linen closet had 1 fitted bed sheet with tears.-200 hall linen closet had 2 fitted bed sheets with holes and tears and large thinned areas that were threadbare.-300 hall linen closet had 2 fitted bed sheets with holes and tears.-400 hall linen closet had 1 fitted bed sheet with large thinned areas were threadbare and stained. Interview on 02/25/2026 at 1:12 PM with Contract Housekeeping Supervisor revealed she expected housekeeping to put linen in closets that were free of holes, tears and stains. She stated she had ordered 12 bed fitted sheets last week and needed to order more bed linen to replace the ones not in good condition. She stated residents should have fitted bed sheets that are free of holes and tears. Interview on 02/26/2026 at 1:57 PM with Administrator revealed that any time there are holes in resident bed linen they should be replaced. He stated he expected staff to use bed linen without holes. He expected housekeeping staff to ensure there were no holes in fitted sheets put in the linen closet for staff to use on resident beds. He stated the residents have the right to have bed linen without holes or tears and be in good condition. He stated direct care staff should not be putting fitted bed sheets on resident beds that have holes or are torn. Review of facility's policy Maintenance/Housekeeping Policies and Procedures Subject: Laundry dated 03/2006 reflected under all linens .4. Linens are examined for wear and tear and are to be replaced when in disrepair.

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 4 of 10 residents (Resident #15, Resident #51, Resident #55 and Resident #86) observed for infection control. 1. The facility failed to ensure Agency RN H prevented cross contamination of the multi-resident use glucometer test strips and failed to maintain a clean and dirty side of diabetic caddy used for supplies to obtain fingerstick blood for Resident #15 on 02/24/26, when she placed the contaminated glucometer back in the clean side of the caddy next to the bottle of glucose test strips. 2. The facility failed to ensure MA I prepared Resident #51's medication without cross contaminating her medications on 02/25/26. 3. The facility failed to ensure Agency LVN G utilized Enhanced Barrier Precautions while performing G tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) medication administration for Resident # 55 on 02/25/26. 4. The facility failed to ensure CNA B and hospice RN used the required Personal protective Equipment (PPE) for Resident #86 who was on enhanced barrier precautions (EBP) due to her wounds, while performing a mechanical lift transfer on 02/24/2026. These failures could place the residents at risk of cross-contamination and development of infection.Findings included: 1. In a medication administration observation on 02/24/26 at 11:05 a.m. with Agency RN H revealed her at the medication cart obtaining supplies needed to check Resident #15's fingerstick blood sugar. Agency RN H pulled out a caddy which had a sharps container on one side, and she placed her disinfected glucometer, a bottle of test strips and several lancets, and alcohol prep pads on the other side. Agency RN H entered Resident #15's room, opened an alcohol prep pad, cleaned the resident's finger and discarded the used alcohol prep pad in a cup in the caddy by the sharp's container. Agency RN H then handed the resident her own personal lancet device and pricked her finger to obtain a sample of blood. Agency RN H opened the test strips and placed a test strip in the glucometer and obtained a blood sugar reading of 214. Agency RN H discarded the test strip in the sharps container and then placed the soiled glucometer back on the clean side of the caddy, next to the bottle of test strips. Agency RN H returned the caddy to the top of the medication cart and pulled out a bottle of bleach wipes with a disinfectant time of 3 minutes. Agency RN H wiped down the glucometer and placed it back in the caddy beside the bottle of test strips, without disinfecting the inside of the caddy or the bottle of test strips. Agency RN H then removed her gloves, performed hand hygiene. In an interview on 02/24/26 at 11:10 a.m. with Agency RN H she stated she knew there was supposed to be a clean side and a dirty side of the caddy, and she stated she should have placed the glucometer in the cup by the sharps container since that side would be considered dirty. She stated by placing the glucometer on the side with the bottle of test strips after she had used it, it was no longer considered the clean side, and she had contaminated the test strips as well as the caddy. She stated the risk was the spread of blood borne pathogens to other residents. In an interview with the DON on 02/24/26 at 4:00 p.m. she stated the staff had all been in-serviced on the use of the caddy when obtaining blood sugars. She stated the caddy was supposed to have a clean side and dirty side. She stated the sharps container was on the dirty side with a plastic cup for the used for the glucometer after it was used and they were to discard the test strips, lancets and alcohol prep pad in the sharp's container. She stated the clean side was for the disinfected glucometer, a few test strips, not the whole bottle, and lancets and alcohol prep pads. She stated once the blood sugar was completed the glucometer needed to be placed on the dirty side until it was disinfected, and any remaining supplies not used should be discarded and not returned to the medication cart. She stated they had serviced the staff on numerous occasions but stated she was not sure if they had reviewed it with the Agency staff. She stated they do have an orientation packet the agency staff review and sign and stated they would be including the procedure for the use of diabetic caddy. She stated she was also going to label each side of the caddy to clearly state clean side and dirty side. She stated the risk of not following the proper steps was cross contamination of the caddy, as well as any supplies placed in the caddy. 2. A medication pass observation on 02/25/26 at 7:40 a.m. revealed MA I at the medication cart. MA I began to pull Resident # 51's morning medications. MA I placed 2 gel caps of coenzyme Q10 (vitamin) 50 mg and 1 capsule of Lactobacillus acidoph-L.bulgar (probiotic) in a separate medication cup and the remaining morning medication tablets in a separate cup. MA I crushed the tablets and added them to a small medicine cup of protein supplement. MA I then opened the capsule of Lactobacillus with her bare hands and placed the content of the capsule in with the other crushed medications. She then retrieved a pair of scissors and cut the gel capsules of coenzyme Q10 and extracted the contents of the gel caps into the cup containing the other crushed medications and mixed them up. MA I then wiped the scissors off with a tissue. MA I entered Resident #51's room and administered the medications. In an interview with MA I on 02/25/26 at 8:05 a.m. she stated she was supposed to wear gloves when separating the capsules and stated it was a risk of infections when she touched them with her bare hands. She stated she should have sanitized the scissors with a sanitizing cloth instead of a tissue. She stated she was sorry she stated she just forgot. 3. In an observation of G-tube medication administration on 02/25/2026 at 8:32 a.m. Agency LVN G was at the medication cart preparing Resident #55's morning medication. A sign was posted outside of room which indicated he was on EBP. Agency LVN G entered room, washed her hands and put on gloves but no gown. Agency LVN G checked residual with air auscultation and drew back to check for residual. Agency LVN G then flushed the G-Tube with 30 cc of water and then administered medications one at a time with 10 cc of water flushes between each medication and finished with 30 cc of water. In an interview with Agency LVN G on 02/25/2026 at 08:50 a.m. she stated residents who had G-tubes were on EBP which meant staff were to wear gloves and gowns. She stated she just forgot about the gown. She stated the risk was spreading infections from residents to residents. 4. Record Review of Resident #86's physician order dated 2/20/2026 reflected EBP related to wound . In an observation on 02/24/2026 at 2:06 p.m. revealed EBP signage outside Resident #86's room and PPE kit with gloves, gowns and hand sanitizer placed outside the room. Resident #86 was observed sitting in her wheelchair in her room. CNA B and Hospice RN J were present inside Resident #86's room. Both CNA B and Hospice RN J performed hand hygiene and put on gloves but did not put on a gown. Both staff maneuvered the lift around Resident #86's chair and hooked the sling to the lift. They transferred the Resident to her bed by lowering the mechanical lift onto the bed. Hospice RN J adjusted Resident #86 legs in her bed. Hospice RN J proceeded to check Resident # 86's wound on her right heel. CNA B performed hand hygiene and took the mechanical lift and left the room. In an interview on 2/24/26 at 2:34 p.m. with CNA B revealed Resident #86 had wounds and she stated she was aware that EBP required wearing appropriate PPE which included gowns and gloves while providing close contact care for residents. She stated she should have worn a gown and gloves while transferring the resident to the bed with the mechanical lift. She stated the risk of not using appropriate PPE for EBP could cause spread of infection. In an interview on 02/24/2026 at 2:37 p.m. with Hospice RN J revealed she was aware Resident # 86 had stage three pressure ulcers on right heel. She stated EBP was used for residents with wounds, catheters, or any other infections while providing care including transfers. She stated she did not wear appropriate PPE including a gown before transferring the resident and examining her wound. She stated the risk of not using appropriate PPE for EBP could cause spread of infection. In an interview on 02/24/2026 at 2:52 p.m. with LVN A stated Resident #86 had orders for EBP related to wounds. She stated any resident on EBP required the use of appropriate PPE which included gowns and gloves while providing close contact care such as transfers. She stated the risk of not using appropriate PPE for EBP resident can cause lapses in infection control. In an interview on 02/26/26 at 10:35 a.m. with the DON she stated staff had been taught to use gloves when they had to separate capsules and never touch medications with their bare hands to prevent cross contamination plus prevent the risk of the staff absorbing the medication onto their skin. She stated MA I was a new medication aid and they needed to do a little more training with her. She stated they had done multiple trainings on the use of Enhanced Barrier precautions and what PPE was required and when. She stated the signage also tells them every situation they are required to wear PPE for. She stated she expected the hospice staff to adhere to the protocol just like the facility staff. She stated she and the ADONs do spot checks to ensure compliance with infection control. She stated the staff had no excuse for not following the protocol. Record Review of the facility's undated protocol titled, Using Diabetic Caddy, reflected, .Ensure caddy is clean and disinfected. 1. On clean side you place 1 small drinking cup in which you put your supplies into 2 strips, prep and lancet. 2 Assure glucometer is clean and disinfected and place on clean side. 3. On dirty side you have a Sharps and a Blue top wipe (germicidal wipe) in bottom to put dirty glucometer on after blood sugar. 4. All dirty supplies lance, strip and bloody pad goes in sharps.DO NOT PLACE DIRTY GLUCOMETER ON CLEAN CART PUT ON BLUE TOP WIPE. Record review of the facility's policy titled, Medication Management Program, dated January 2025, reflected, .Administering the Medication pass.Perform hand hygiene.Do not touch the mediation when opening a bottle or unit dose package. Record review of the facility's policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, dated May 2023, reflected, Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP will be implemented for All resident with the following.Wounds and/or indwelling medical devices (urinary catheter, feeding tube.)regardless of MDRO colonization status.EBP will be implemented during the following high-contact resident care activities.Transferring.Device care or use.feeding tube.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 (Resident #7) of 5 residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #7's contracture to his left hand upon discharge from therapy services on 9/3/25. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Review of Resident #7's Face sheet dated 2/26/26 reflected a [AGE] year-old male with an initial admission date of 10/20/22 and readmission date of 9/9/25. The resident had the following active diagnoses: unspecified dementia, parkinsonism ( a syndrome characterized by a combination of motor symptoms, slowness of movement along with tremor, rigidity and balance issues), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) and muscle weakness. Review of Resident #7's quarterly MDS assessment, dated 12/11/25, reflected lno impairment in cognition with a BIMS of 15. The resident had upper and lower extremity impairment on one side and used a wheelchair. Resident #7 was coded as not having had any therapy. Review of Resident #7's physician orders on 2/26/25 revealed an active order dated 9/10/25 Contractures (Location): Left hand and Left Elbow with no interventions listed. Review of Resident #7's comprehensive care plan revised on 2/2/26, reflected, .Problem Start Date: 9/9/25 Resident #7 has a history of Cerebrovascular Accident (Stroke) with Hemiplegia edited 2/2/26. Long Term Goal Target date: 5/2/26 Resident #7 will maintain current levels of ADLs and not have another Cerebrovascular Accident over the next 90 days edited 2/2/26 Approach Start Date: 9/9/25 Therapy referral as needed edited 9/10/25. Review of Resident #7's Occupation Therapy Discharge summary dated [DATE] revealed .Discharge Recommendations: Nursing to assess for Restorative Nursing Program. Restorative Program Established / Trained = Not Indicated at This Time. Function Maintenance Program Established/Trained = Not indicated at this time. An interview and observation with Resident #7 on 2/24/26 at 1:51pm revealed resident was unable to open and close his left hand. Resident #7 stated he used a roll at times, however he was unsure how often he needed to use it or for how long. He stated staff had not been prompting him to use the roll but he would put it on at night when his hand bothered him. An interview with CNA L on 02/25/2026 at 10:30 revealed she had never seen Resident #7 with objects in his left hand. She stated he could not use his left hand. CNA L stated she had not done any exercises with him nor put any splint or object in his left hand. An interview with Agency LVN G on 02/25/2026 at 10:42 AM revealed she was not aware of any splints or devices for Resident #7's contracture. Agency LVN G reviewed Resident #7's medical record and stated he had not had any orders for management of his contracture. Agency LVN G stated she had not found in his medical record any exercises or anything she should have been doing with Resident #7 to manage his contracture. An interview with the Assistant Director of Rehab on 02/25/2026 at 1:42 PM revealed Resident #7 was not on therapy services. Resident #7 was last on physical therapy on 11/17/25 and occupational therapy 9/3/25. The Assistant Director of Rehab stated Resident #7 was discharged from therapy due to him having reached his highest potential. The Assistant Director of Rehab stated Resident #7 had no recommendations for Restorative services and there were no orders for contracture management. The Assistant Director of Rehab stated if the resident had needed a splint there would have been an order and the CNAs would have been trained to put the splint on the resident. An interview with the Director of Rehab on 02/26/2026 at 9:08 AM revealed Resident #7 had physical therapy until about 10/25/25. The Director of Rehab stated Resident #7 had not gotten as much therapy as before because he was on Hospice. The Director of Rehab stated Resident #7 was discharged from Occupational therapy in September of 2025 with a hand roll as tolerated. The Director of Rehab stated she was unsure of who was monitoring whether he was using the hand roll and she had not talked to any CNAs about the need for the resident to use the hand roll. The Director of Rehab stated she believed the Restorative Aid might have picked him up for services, but she was unsure. The handroll was to prevent any further contracture. The Director of Rehab stated she typically had not written orders for handrolls. The risk to the residents of not having had interventions in place for the contracture would have been the contracture could have gotten worse. The Director of Rehab stated although Resident #7 had no written contracture interventions the Rehab Department screened him every 90 days from his last service to assess him for needs and changes. An interview with Restorative Aid M on 02/26/2026 11:03 AM revealed Resident #7 was not on restorative services with her and he had never been referred to her. Restorative Aid M stated rehab had referred residents with contractures so she could do stretches and help monitor any devices the resident had such as a splint. Restorative Aid M stated if a resident needed a hand roll, rehab typically wrote an order, it was entered in the medical file and she was provided with a copy of it. She had never been provided with an order for Resident #7. An interview with ADON K on 02/26/2026 at 11:13 AM revealed Resident #7 had a contracture, and she remembered him having a brace on in the past week. ADON K stated braces and handrolls required an order so that staff were aware of their need to use them. ADON K stated if a resident hadn't worn their brace or handroll as prescribed by a doctor or therapist they would have been at risk for more damage to the contracted area. An interview with the DON on 02/26/2026 at 11:32 AM revealed it was the responsibility of therapy to ensure residents with contractions had the appropriate interventions. The DON reviewed Resident #7's orders and was unable to find any orders regarding contracture interventions. The DON stated if rehab made a recommendation for a splint or other intervention resident needed to have an order for it. The DON stated she was unable to say what the risks were of not having had interventions in place for Resident #7's contracture because that was a rehab thing. Record review of the facility's policy Restorative Nursing Policies and Procedures revised 10/25/24 .Patients/residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually and with significant changes through the comprehensive nursing assessment. A restorative program will be implemented through the care plan to increase, maintain or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated or upon discharge from skilled therapy.Appropriate candidates for the Nursing Restorative Range of Motion Program may include, but are not limited to patients/residents with the following conditions: Contractures.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of six residents (Resident #15) reviewed for pharmacy services. The facility failed to ensure Agency RN H followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #15. These failures placed residents at risk of not receiving full dosage of medication. Findings included: Record review of Resident #15's, Face sheet, dated 02/26/26 reflected a [AGE] year-old female with an admission date of 02/05/26. Resident #15 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) Record review of Resident #15's Physician's Order for February 2026, reflected, Insulin lispro insulin pen: 100 unit/ml; amt: Per Sliding Scale; If blood sugar is. 181 to 220, give 4 units.before meals and at bedtime. with a start date of 02/05/26. An observation on 02/24/26 at 11:05 a.m. revealed Agency RN H performed hand hygiene and put on gloves and entered Resident #15's room to obtain a fingerstick blood sugar. The blood sugar reading was 214. Agency RN H returned to the medication cart and checked the computer to determine the amount of insulin per sliding scale was 4 units of Lispro insulin. Agency RN H retrieved the insulin pen from the medication cart and retrieved a needle for the insulin pen and re-entered Resident #15's room. Agency RN H removed the cap from the insulin pen, attached the needle and dialed in 4 units without priming the pen to ensure all air was expelled, and administered the insulin to Resident #15. In an interview with Agency RN H on 02/24/26 at 11:10 a.m. she stated she was unaware the she was required to prime the insulin pen before each injection. She stated she had been a nurse for 6 years and had never been told she had to prime the pen. She stated it made sense, because otherwise you do not know if the pen was functioning or didn't have air in the chamber. She stated going forward she would prime the pen before each time. In an interview with the DON on 02/26/26 at 10:30 a.m. she stated the insulin pen was to be primed with 2 units before each injection to ensure the air was out of the pen and to determine it was working correctly. She stated failure to do so could result in the resident receiving too little medication which could result in ineffective treatments and uncontrolled blood sugars. She stated all of the facility staff had been trained on the proper protocol but stated they will In-service the staff again as well as the Agency staff to ensure compliance. Record review of the facility's reference material titled, Insulin Pen Quick Reference Guide, dated 2021, reflected, Humalog (lispro) U100 Kwikpen .Air shot before each use-2 units hold dose knob for 5 seconds.References: Manufacturer Full Prescribing information and/or instructions for use. Review of the manufacture instructions for Lispro obtained from https://www.lillyinsulinlispro.com/ searched on 02/28/26 reflected, .Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle, and repeat priming steps.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's one (hall 300 cart) of four medication carts reviewed for storage. The facility failed to ensure Resident # 15's Lispro Insulin (Hormone) Pen, that was used on [DATE], was dated when opened. These failures could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications. The findings included: Record review of Resident #15's, Face sheet, dated [DATE] reflected a [AGE] year-old female with an admission date of [DATE]. Resident #15 had a diagnosis which included Type 2 diabetes (condition where the body cannot control blood sugar and use it for energy) An observation on [DATE] at 11:05 a.m. revealed Agency RN H performed hand hygiene and put on gloves and entered Resident #15's room to obtain a fingerstick blood sugar. The blood sugar reading was 214. Agency RN H returned to the medication cart and checked the computer to determine the amount of insulin per sliding scale was 4 units of Lispro insulin. Agency RN H retrieved the insulin pen from the medication cart. Observation of the insulin pen revealed no date on the pen indicating when it was opened. Agency RN H retrieved a needle for the insulin pen and re-entered Resident #15's room, removed the cap from the insulin pen, attached the needle and dialed in 4 units and administered the insulin to Resident #15. In an interview with Agency RN H on [DATE] at 11:10 a.m. she stated the Insulin pen was supposed to be dated when they opened a new pen. She stated she was not sure who opened the pen or when it was opened. She stated they were to discard Insulin 28 days after it was opened. She stated by not dating it could result in giving a resident expired insulin which could make it ineffective. In an interview with the DON on [DATE] at 10:30 a.m. she stated the insulin pen was to be dated once it was opened. She stated failure to do so could result in the resident receiving an expired medication which could result in ineffective treatments and uncontrolled blood sugars. She stated the nurses are responsible for dating the pens once they are opened. She stated the ADONs are responsible for checking the medication carts daily and she stated she does a weekly random check of medication carts. She stated they will In-service the staff again as well as the Agency staff to ensure compliance. Record review of the facility's policy titled, Medication Management Program, dated [DATE], reflected, .Prior to administering medications, the nurse is responsible for .Checking for expiration dates and removing any expired products.once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose package with the date opened and follow guidelines for expiration dates.Humalog (lispro) U100 Kwik pen.in use storage.room temp 28 days.

Based on observation, interview and record review the facility failed to ensure resident call system was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area from each resident's beside and toilet and bathing facilities for one (Resident #23) of six residents reviewed for physical environment. The facility failed to ensure Resident #23's toilet and shower call button were working in resident's bathroom. This failure placed residents at risk of a delay in resident getting assistance from staff.Findings included: Review of Resident #23's face sheet undated reflected Resident #23 was an [AGE] year old female admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language and problem solving, thinking abilities severe enough to interfere with daily life), type 2 diabetes (chronic condition in which the body resists insulin or fails to produce enough, causing high blood sugar), heart disease and abnormalities of gait and mobility. Review of Resident #23's MDS assessment dated [DATE] reflected Resident #23 had a BIMS score of 15 indicating she was cognitively intact. Resident #23 required substantial/maximal assistance with ADLs. Observation and Interview on 02/24/2026 at 10:02 AM of Resident #23's emergency shower and toilet revealed the call light in bathroom did not work. The call lights did not light up when pulled down. The shower call light in bathroom had tape on it. Resident #23 stated the shower call light had been out for a couple of weeks and the Administrator along with Maintenance were aware of it. She was not aware the toilet call light was not working. Observation and Interview on 02/24/26 at 10:11 AM Aide C stated both the shower and toilet call lights in Resident #23's bathroom were not working. She was not aware of it until now. Interview on 02/25/2026 at 11:36 AM with Administrator revealed Maintenance Supervisor had been on leave for about 3 weeks and he was assisting while Maintenance was out. He stated he was not aware of any issues with Resident #23's shower and toilet call lights not working until yesterday when it was brought to his attention after surveyor notified his staff. He stated contract company came to look at Resident #23's call light in shower and toilet yesterday afternoon. He stated they had to order a part in order to fix it. He stated the risk to a resident is he or she could fall and there could be a delay in getting assistance. Review of facility's policy Safety and health Policies and Procedures last revised 12/20/24 reflected Call-light is to be easily accessible to the patient. It did not specify the working condition of the call lights.

Based on interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #7) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #7 was care planned for limited range of motion related to his contracture. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Review of Resident #7's Face sheet dated 2/26/26 reflected a [AGE] year-old male with an initial admission date of 10/20/22 and readmission date of 9/9/25. The resident had the following active diagnoses: unspecified dementia, parkinsonism ( a syndrome characterized by a combination of motor symptoms, slowness of movement along with tremor, rigidity and balance issues), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) and muscle weakness. Review of Resident #7's quarterly MDS assessment, dated 12/11/25, reflected no impairment in cognition with a BIMS score of 15. The resident had upper and lower extremity impairment on one side and used a wheelchair. Resident #7 was coded as not having had any therapy. Review of Resident #7's physician orders on 2/26/25 revealed an active order dated 9/10/25 Contractures (Location): Left hand and Left Elbow Review of Resident #7's comprehensive care plan revised on 2/2/26, reflected, .Problem Start Date: 9/9/25 Resident #7 has a history of Cerebrovascular Accident (Stroke) with Hemiplegia edited 2/2/26. Long Term Goal Target date: 5/2/26 Resident #7 will maintain current levels of ADLs and not have another Cerebrovascular Accident over the next 90 days edited 2/2/26 Approach Start Date: 9/9/25 Therapy referral as needed edited 9/10/25. An interview with ADON K on 02/26/2026 on 11:13 AM revealed the Resident #7 had a contracture and believed he had a brace on yesterday. ADON K stated the contracture, and interventions should have been in his care plan. ADON K stated it was the responsibility of ADONs and DON to update the care plans. An interview with the DON on 02/26/2026 at 11:32 revealed it was the MDS Nurse Coordinator's responsibility to put information in the care plan related to contractures and interventions. The DON stated a splint or any interventions for a contracture should have been put in a care plan. The DON stated she was unable to say what the risks to the resident would have been if his contracture was not in the care plan because it was a rehab thing. An interview with the MDS Nurse Coordinator on 02/26/2026 at 11:55 AM revealed he completed care plans for long term residents and completed Resident #7's care plan. The MDS Nurse Coordinator stated the resident had a contracture but had no splint. The MDS Nurse stated Resident #7's care plan had no interventions for his contracture. The MDS Nurse Coordinator reported he typically entered contracture interventions on resident care plans when rehab discussed them at their Interdisciplinary meetings or when a doctor's order was entered in their medical record. The MDS Nurse Coordinator stated Resident #7 had no interventions for his contracture in place, however he had entered the contracture to the care plan earlier that day under the portion related to Cerebrovascular Accident. The MDS Nurse Coordinator stated staff still monitored residents in the same way, thus not having it on the care plan would not affect his care. The MDS Nurse Coordinator stated the care plan was developed for staff as a guideline and items on the Care Plan were related to residents' needs and concerns. The MDS Nurse Coordinator stated not having had contracture interventions in the care plan did not affect the care of the residents because the residents would have gotten the same care and their needs were met regardless. Review of facility's policy Care Plan Process, Person-Centered Care revised May 5, 2023 reflected .11.The person-centered care plan includes.e. interventions, discipline specific services and frequency.h. resolution/goal analysis.

Based on interview and record review, the facility failed to ensure the resident's responsible party had the right to exercise the resident's rights for one (Resident #2) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #2's representative was involved in the decision making before inserting a catheter. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Included:Record review of Resident #2's face sheet revealed Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's face sheet identified his representatives were family members. Diagnosis included: Acute Prostatitis (painful bacterial infection and inflammation of the prostate gland causing pelvic pain, urgent, frequent or painful urination), Lack of Coordination, Cognitive Communication Deficit, Benign Prostatic Hyperplasia (pain and discomfort while urinating and inability to empty the bladder completely), Muscle Weakness and Mild Cognitive Impairment. Resident #2's face sheet revealed family members were listed as emergency contacts but they were not listed as POA. Record Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 08 which meant he had moderate cognitive impairment. The MDS revealed Resident #2 had difficulty communicating when he tried to make himself understood. Resident #2 missed some part or intent of message regarding his ability to understand others. Resident #2's MDS revealed it was very important to have family involved in discussions about his care. Record Review of Resident #2's Care Plan dated 11/11/25, revealed he had the need to urinate frequently and had decreased cognition. The resident's care plan revealed he had mild cognitive impairment. He yelled out for momma and please help me frequently which required frequent monitoring and redirection. The facility's approach was to determine if the resident was considered to have or not to have capacity to make medical decisions as evidenced by physician's order, psychological assessment, capacity declaration, or guardianship paperwork. The approach also included to encourage Resident #2's decision making when able with simple task, such as choice in clothing, snacks, and activities. Record Review of Resident #2's progress notes on 12/21/25 at 11:00 a.m. by RN-A revealed he was having difficulty in voiding and hollering that he needed to go pee despite going to the bathroom and not voiding. RN-A spoke with doctor and received an order to insert a catheter. Resident #2 continued stating he had to go pee even after catheter insertion. Interview on 12/23/25 at 11:06 a.m. with the DON revealed RN-A stated the nurse aide said Resident #2 had been saying he needed to void several times but was not putting out anything. RN-A got an order from the doctor for an in and out catheter. RN-A sent a text message to LVN-B letting her know about the order. DON stated Resident #2 told LVN-B no to having the catheter put in. RN-A went and explained the procedure to Resident #2, and he allowed her to proceed. DON stated Resident #2 had an enlarged prostrate which would have caused bleeding. Interview on 12/23/25 at 11:16 a.m. with the Admin revealed Resident #2 told LVN-B no to the catheter. RN-A explained the process to Resident #2, and he allowed her to insert the catheter. RN-A said Resident #2 said it was hurting, but she explained it would hurt due to his enlarged prostrate. Admin stated they normally would have called the family before placing a catheter. He stated a family member was in the other family member's room on the next hall. He stated the family member was POA. Admin stated both RN-A and LVN-B were written up for not contacting the family. Interview on 12/23/25 at 11:58 a.m. with Resident #2 stated he had no problems with any staff. He shook his head yes when asked if he was going home today and then he fell asleep. Interview on 12/23/25 at 12:03 p.m. with the RP revealed Resident #2 had felt like he had to use the restroom the entire time he had been at the facility due to his enlarged prostrate. She did not understand why the facility did not call them to let them know before they placed the catheter. RP stated she and another family member had POA. She stated Resident #2 had dementia and did not remember a lot of things. Interview on 12/23/25 at 12:15 p.m. with the FM revealed the facility did not call any of the family. FM stated RP and another family member had power of attorney over Resident #2. Attempted interview with Physician on 12/23/25 at 3:25 p.m. a voice message was left on his office phone requesting a return call. Attempted interview with Physician on 12/23/25 at 3:37 p.m. to his cell phone number, a voice and text message were sent requesting a return call. Interview on 12/23/25 at 3:41 p.m. with RN-A, she stated she was the on-duty nurse on the weekend. She stated Resident #2 always yelled he had to go to the bathroom. She stated he had been taken to the bathroom [ROOM NUMBER] times in 30 minutes. She had called the Doctor and received orders for Resident #2 for an in and out catheter. She said she delegated to LVN-B to do it since the resident was on her hall. RN-A went to check on Resident #2 and LVN-B had not placed the catheter. She explained the process to Resident #2 and started to insert the catheter. RN-A stated one thing they did wrong was nobody called the family first. RN-A stated she assumed LVN-B had called the family and vice versa. RN-A stated they should have called the family. RN-A stated she would usually call the family after she got an order but did not usually call to get permission to insert a catheter. RN-A stated she assumed LVN-B called the family because it was her resident. She stated Resident #2's family was always in the building. Interview on 12/23/25 at 4:18 p.m. with LVN-B, she stated she received a text from RN-A which stated Resident #2's doctor gave orders for a catheter to be placed. LVN-B stated RN-A had come in and placed the catheter. LVN-B stated she was told 12/22/25 that she was written up for not informing the family of the orders for the catheter. She stated she was not the nurse who requested the order and did not put the catheter in, so she did not feel she was responsible for notifying the family. Interview on 12/23/25 at 5:55 p.m. with the Admin, he stated Resident #2's family should have been called regarding the doctor's order. Record Review of the facility's Nursing Policies and Procedures with subject Physician and Other Communication/Change in Condition dated 5/5/23, reflected under policy was to provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Under Procedures: 1. Complete assessment of the patient/resident which may include but is not limited to: .K. Patient/resident/family wishes.5. The patient/resident and patient's/resident's family member/legal representative will be notified of any changes in medical condition or treatment plan as indicated by HIPPA directives. Record Review of Resident Rights in the facility's Admissions Handbook, dated March 2023, revealed under 18. Notice of Changes in Condition. The facility must.notify.resident representative or interested family member when: .it is necessary to alter treatments significantly (that is, a need to discontinue or change an existing form of treatment).

Based on observation, interview, and record review, the facility failed to ensure that residents with indwelling urinary catheters receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #4) of three residents reviewed for Urinary Catheter or Urinary Tract Infection.-The facility failed to ensure that Resident #4 received care and services to avoid catheter-associated urinary tract infections to the extent possible as evidenced by not demonstrating sterile technique during indwelling urinary catheterization of Resident #4. This failure could place all residents requiring indwelling urinary catheters and catheter care at risk for catheter associated urinary tract infections or complications that could lead to serious harm.Record review of Resident #4's face sheet dated 12.23.2025 at 12:30 p.m. indicated he was a [AGE] year-old male admitted to this facility on 12.08.2025 with a diagnosis of obstructive and reflux uropathy (blockage of the passing of urine from the bladder), hyperlipidemia (high cholesterol level), muscle weakness, type two diabetes with hyperglycemia (high level of sugar in the blood), gastroesophageal reflux disease (relating to stomach acid), a fall, and encounter for orthopedic (related to bone or muscle) aftercare. Interview on 12.23.2025 at 2:58 p.m. with Resident #4 indicated an alert and oriented elderly male who stated he was admitted for physical therapy after a fall that required right knee surgery. He said he must have a catheter to help him urinate. He said the nurses removed his catheter earlier that day. He said he was uncomfortable and wanted to take a nap. He said, I wish they would hurry up and put the catheter back in I need to pee. [sic] Interview on 12.23.2025 at 3:45 p.m. with LVN E indicated she had worked at this facility for five years. She stated verbal orders from the NP had been received on 12.23.2025 to re-insert an indwelling urinary catheter for Resident #4. Observation for 12.23.2025 at 3:48 p.m., LVN E gathered supplies to include a sterile kit for the indwelling urinary catheter insertion for Resident #4. She explained the procedure to the resident and cleaned the surface of the bedside table to place supplies for the procedure. She washed her hands, put on PPE, and proceeded with the procedure. After LVN E opened the sterile indwelling urinary catheter kit, she stopped and looked down at the contents of the box. She stated, I can't remember how to proceed. [sic]. After approximately two minutes, LVN E turned to the surveyor and asked how to continue with the procedure. The surveyor asked how the facility policy and procedure guided the process. LVN E continued to stare at the contents of the indwelling urinary catheter box. LVN E was observed to pick up a drape used to protect skin, linens, and resident clothing against urine. She stated, I don't need this [sic] and was observed to lay the drape aside. LVN E took out two individually wrapped pairs of sterile gloves and put on one pair without washing her hands after removing dirty gloves. She was observed to not connect the urine drainage bag to the sterile indwelling urinary catheter tube prior to inserting the sterile tube into the urinary meatus (the opening leading to the interior of the urinary system). The drainage bag was not noted to be pre-connected. Interview with LVN E on 12.23.2025 at 4:16 p.m. indicated she realized she failed to maintain sterile technique by not washing her hands after removing dirty gloves to put on sterile gloves. She realized she failed to connect the urinary drainage bag to the end of the sterile catheter tube prior to inserting tube into the urinary meatus. LVN E stated her future expectation would be to review and follow policy and procedures to prevent the risk of introducing bacteria into a resident's bladder and causing a CAUTI. Interview with the DON on 12.23.2025 at 4:30 p.m. indicated the facility did not use written policies and procedures for inserting indwelling urinary catheters to male or female residents. The DON stated a Lippincott Manual; 9th Edition printed in 2023 was used for standards of nursing care. Skill check off for all nursing staff is done annually. Review of the Lippincott Manual instructions for Indwelling Urinary Catheter Insertion indicated these areas were not followed. To use sterile techniques when inserting, manipulating, and maintaining the indwelling urinary catheter.Maintain a sterile, continuously closed drainage system.Place a fluid-impermeable pad on the bed between the resident's legs and under the hips.Using sterile no-touch technique to open the insertion kit wrap.Wash hands prior to donning (putting on) sterile gloves.If the urine drainage bag is not preconnected, attach it to the other end of the catheter using sterile gloves.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate assistance devices to prevent accidents for 2 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure CNA A and the dietary staff checked the temperature and sealed Resident #1's cup of hot tea, which resulted in Resident #1 spilling tea in her lap on 10/13/25 acquiring a second-degree burn (partial thickness burn, damages the outer and middle layers of skin. Characterized by blistering-typically heal in 7 to 21 days) to her left upper thigh. The noncompliance was identified as PNC. The non-compliance began on 10/13/25 and ended on 10/14/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, or harm.Findings include: Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old female with an admission date of 07/17/23. Resident #1 had a BIMS of 15 indicating she was cognitively intact. She had no functional limitation in range of motion to her upper and lower extremities. She required only set up assistance with eating and was able to carry out the task unassisted. She utilized a wheelchair for mobility. Active diagnoses diabetes and cerebral vascular accident affecting left non-dominant side (stroke). Record review of Resident #1's progress notes by LVN B dated 10/13/25 at 1:00 p.m. reflected, when resident being assisted with clothing and brief change staff noticed red and blistered area to upper left thigh. Resident says she spilled hot liquid on herself. Upon examination note 3 cm x 6 cm reddened area with approximately 25 % of surface blistered. Resident says she spilled hot tea on herself at lunch. Record review of Resident #1's incident report dated 10/13/25 at 1:00 p.m., completed by ADON C reflected, .Type of incident/accident.blister/burn.location of injury. upper left thigh.Notifications.MD and Family notified, DON notified.Follow up steps to prevent reoccurrence.Temperature to be checked on food/drinks before given to residents.Resident health condition at the conclusion of the investigation.Vital signs Blood pressure-140/80, Pulse-64-Temperature-98.2-Respirations-18. No distress noted, denies pain, Bandage in place. Record review of Resident #1's General order sheet received by ADON C dated 10/13/25 from Resident #1's MD reflected, Daily wound treatment: xeroform to burn with a dry dressing daily. with a start date of 10/13/25. Record review of Resident #1's care plan dated on 10/14/25 reflected, [Resident #1] has a current wound/disruption of skin surface: blister like area on thigh from beverage.Short term goal.wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained.Approaches.Occupational therapy to evaluate for hot liquids assessment.Wound care as ordered. Record review of Resident #1's therapy screening form completed by Occupational Therapist D on 10/14/25 at 12:33 p.m. reflected, .Diagnosis: burn to thigh from hot liquid.Indicate all areas reflecting a change in condition or an area with a deficit that my warrant therapy.No Recent Change/Deficits Noted.Comments: Patient with no tremors or weakness. Patient had a mishap where she was reaching for food item while cup still in hand, and spill of hot liquid occurred with burn to thigh. Therapy services suggested. Record Review of Resident #1's Treatment Administration History from 10/01/2025 through 10/21/2025 reflected, Daily wound treatment: xeroform to burn with a dry dressing daily.start date of 10/13/25. Treatment was provided daily from 10/13/25 through 10/21/25. Record Review of the facility PIR initiated on 10/13/25 reflected, .CNA A was walking down the hall to fix herself a cup of tea, Resident #1 asked her what she had, and Resident #1 asked if she could have some. CNA A went to the kitchen and made Resident #1 a half of cup of tea and took it to her. She (Resident #1) was sitting in her wheelchair.Resident #1 spilled some of her hot tea on her leg but did not realize she had spilled it until hours later when being changed.She experienced no pain according to resident.Small blister to leg of Resident #1. Contacted MD and given order to treat with xeroform (petrolatum-based gauze dressing with antimicrobial properties). Wound care physician saw as well with no new orders. Keep clean and treat with xeroform daily.Provider response.Immediate treatment to the resident. In-service to all staff regarding hot beverages given to resident, therapy did assessment on all resident that drink hot beverages, all residents to be given hot beverage by staff, no resident self-serve, hot beverage mugs with lids ordered.Post action.Beverage cups with lids provided to residents, all residents to be served hot beverages, residents not allowed to self-serve, in-service to staff. In an interview with CNA A on 10/21/25 at 9:49 a.m. she stated on 10/13/25 around 8:50 a.m. she was walking down the hall from the skilled unit to the kitchen to make herself a cup of hot tea. She stated she had two tea bags with her. She stated Resident #1 was sitting in the hallway across from the living room area with the vending machines, when she stopped her and asked her what she was doing. She stated she told Resident #1 she was going to make her some tea and Resident #1 asked her if she would make her some tea as well. She stated she went into the kitchen area where the coffee maker was located and used the hot water dispenser from the coffee maker to make the tea. She stated she made her a cup of tea and filled the second cup half full for Resident #1. She stated she handed the cup of tea to Resident #1 who was still sitting in the hallway across from the vending machines. She told the resident the tea was hot, and to be careful. She stated she knew Resident #1 very well and stated she had taken care of her often since her admission to the facility. She stated the resident had always been independent with eating and drinking. She stated she was so upset when she heard Resident #1 had spilled the tea and burned herself. She stated she should have had the resident roll to one of the nearby tables and placed the tea on the table for her. She stated since the incident she had been in-serviced, and they were instructed to never obtain hot water from the coffee maker. She stated they now have carafe of hot water and hot coffee in each of the nutrition rooms that the kitchen staff prepare for the staff to be able to serve the residents from. She stated they had been instructed on temperature checking hot liquids with the thermometer provided in the nutrition room and it was not to exceed 150. She stated the facility had provided the residents who like to carry their coffee around with lidded cups. She stated any resident who traveled with hot coffee or tea had to have a lidded cup. She stated any resident who had tremors or weakness had to have a lidded cup and they were to sit the coffee or tea down on a table for the residents. In an interview and observation of Resident #1 on 10/21/25 at 9:05 a.m. she stated last Monday (10/13/25) she was headed to the snack machine to get her a snack when one of the CNAs walked by with something that smelled so good. She stated she asked her what it was, and she told her it was tea with cinnamon. She stated she asked her if she could have some. She stated the aide told her she would make her a cup and brought her a cup of tea. She stated she does not remember how full the cup was and stated she knew the tea was hot. She stated she rolled herself to the vending machine while holding her cup of tea in her left hand. She stated she placed her money in the machine and when she bent forward to get her snack out of the vending machine, she accidently tipped the cup of tea in her lap. She stated it stung for a little bit when she first did it. She stated she went on about her day and went to her room for lunch and an aide came in to help her put on some dry pants. She stated when they removed her pants her leg was red with a few little blisters, but by the next day it had blistered up and filled up with fluid. She stated the area was still puffed up, but not as much. She stated it did not hurt. She stated the staff immediately put a bandage on it and had been treating the area every day. She stated some doctor came by and looked at the area one day last week, but stated she was not sure what day that was. She stated she had not had any pain from the burn, just had generalized pain in her back and legs. In an interview with CNA G on 10/21/25 at 12:04 p.m. she stated she was the CNA assigned to Resident #1 on 10/13/25. She had gotten the resident up that morning and as usual the resident was out of her room wandering about the facility in her wheelchair. She stated the Nurse had told her the resident needed her pants changed, stating they were wet. She stated she went to the resident's room around 12:45 p.m. to change her and when she pulled the residents' pants off she noticed the reddened, blistered area on her left thigh. The resident told her she had spilled hot tea on herself. She stated she had no idea who had made her hot tea. She stated she notified the nurse immediately about the spot on the resident's leg. She stated Resident #1 was independent with eating and drinking and always ate in her room. She stated she went to the snack machine daily and would get herself a coke and chips. She stated they did receive In-service and were told they were not to prepare hot beverage that the kitchen had to make it. She stated they were also in-serviced on temperature checking any food or drink they were asked to reheat for a resident and stated they had the temperatures posted in the nutrition room and had a thermometer they were to use. She stated they also were provided with lidded cups for the residents. In an interview with LVN B on 10/21/25 at 12:20 p.m. she stated the day of the incident with Resident #1 she was in the hallway performing her blood sugar checks, when the resident rolled past her in the hall around 11:30 a.m. She stated the resident told her she had a spill and was headed to her room to get changed and get ready for lunch. She stated she never said anything about spilling hot tea or indicated she was in pain. She stated she did not have a cup in her hand at that time. She stated the resident always ate all of her meals in her room but stated after her meals she wheeled about throughout the facility and frequently went to the vending machine for cokes and chips. She stated the CNA alerted her about the red spot on her leg and she went to assess it. She stated she alerted ADON A and she came and assessed it as well. She stated this was when the resident told them she had spilled hot tea on herself. She stated since the incident they implemented several changes. She stated they were screening any resident who had tremors, vision impairments, behaviors and weakness to determine who needed to have lidded cups for hot beverages and supervision. She stated nursing staff had to serve the residents their beverages and residents cannot self-serve coffee in the dining room. She stated the kitchen brings fresh coffee and hot water three times a day to the nourishment room, and only the staff have access to those rooms. She stated they were discouraged from reheating any coffee, instead pour fresh. For reheating food, they have a thermometer to be able to check the temperature. She stated the food temperature was not to exceed 160 degrees and any resident who had been deemed independent and wanted to carry their hot beverage with them had to be in a lidded cup or travel mug with a lid. In an observation on 10/21/25 at 9:15 a.m. LVN E prepared wound care supplies for Resident #1's wound care. LVN E performed hand hygiene, put on gown and gloves and entered Resident #1's room to provide wound care. LVN E assisted the resident to a standing position to pull down her pants, revealing a dressing on the upper portion of her left thigh right below her brief line. LVN E removed the old dressing revealing a fluid filled blister approximately the size of a half dollar on her left upper thigh. There was no redness noted surrounding the blister. LVN E performed hand hygiene, put on clean gloves and cleaned the blister with wound cleanser and applied xeroform gauze and covered with dry dressing. The resident did not express any pain or show signs of pain during the procedure. In an interview with LVN E on 10/21/25 at 9:25 a.m. she stated she was not working on the day of the incident with Resident #1. She stated Resident #1 was independent with eating and drinking and always ate her meals in her room. She stated she wheels herself in her wheelchair throughout the facility most of the day and returns to her room for meals. She stated since the incident they had received in-service which required the staff to pour coffee or hot water from the carafe provided from the kitchen. She stated the carafes were stored in the nutrition rooms and only the staff had keys to the nutrition rooms. She stated they were also instructed that any resident who traveled with their hot beverage had to have a lidded cup. She stated if food or beverages were reheated in the microwave they had to check the temperature prior to giving it to the resident. She stated hot coffee was not served if it was over 150 degrees. In an observation and interview with CNA A of the nutrition room on the skilled unit side of the facility on 10/21/25 at 9:55 a.m., two carafes were revealed. One was labeled coffee the other was labeled hot water. CNA A retrieved the thermometer, wiped it with an alcohol wipe and tested the carafe with coffee which registered 139 degrees. She wiped the thermometer with another alcohol wipe and tested the carafe with hot water which registered 150 degrees. She stated they do not reheat coffee for residents but instead get them a fresh cup of coffee. She stated the kitchen replenished the coffee carafes three times a day or when they run out they will go to the kitchen to have them fill the carafes. In an interview and observation with the Dietary Manager on 10/21/25 at 10:05 a.m. the kitchen area was revealed to be divided. The entrance contains a commercial coffee urn. Observation of the twin coffee brewing system revealed between the two coffee tanks was a hot water dispenser. The coffee brewing system had 3 settings, high, medium and low. The system was set on medium. Interview with the Dietary manager revealed this had been the setting the machine had been set on upon its installation, which was a top setting of about 175 degrees, which was needed to brew coffee. She stated the kitchen staff had always filled the coffee carafes for serving on the halls and the dining room for the residents. She stated they had very few residents who drank hot tea, but if they requested the kitchen staff would make it, and temperature check before giving it to the staff. She stated she had been here 10 years, and they had never had a Hot-beverage incident. She stated since the incident the nursing staff had assessed all of the residents who had dementia, tremors, behaviors, poor vision and poor hand control and they were provided with a list of those residents. She stated those residents had to have a lidded coffee mug for hot beverages. She stated she went one step further and for all the hall trays they all had lidded coffee mugs. She stated they only use open coffee cups in the dining room under supervision and if the resident had been deemed safe with hot beverages. She stated they also had stopped setting the coffee carafes out for the residents to self-serve. She stated staff had to serve the residents. She stated her staff temperature check the coffee carafes before putting out for service. She stated carafes will cool off about 10 degrees. She stated they brew coffee at least three times a day. She stated the first pot was brewed at about 5:30 a.m. for breakfast so by the time they start plating for breakfast the coffee has cooled. In observation of the long-term care unit's nutrition room with ADON C on 10/21/25 at 11:10 a.m. revealed signs posted for the correct serving temperature for any food and drink to be reheated in the microwave. Temperatures for food were not to exceed 160 degrees and drinks 150 degrees. ADON C wiped the thermometer with an alcohol wipe, poured a cup of coffee and tested the temperature. The coffee registered 130 degrees. She stated they had sent for a carafe of hot water and stated the kitchen would replenish the carafes around lunchtime. Observation of the long-term care dining room on 10/21/25 at 11:15 a.m. revealed CNA F serving drinks to the resident prior to lunch service. Two residents were observed with lidded coffee mugs. CNA F went into the kitchen serving area to refill one of the residents' coffee mugs from a coffee carafe. ADON A temperature checked the carafe, and it registered 130 degrees. Hall carts for hall 100 and Hall 200 were also being loaded. The coffee carafes were filled. Temperature checks completed by ADON A on hall cart 200 registered 143.8 degrees. Hall 100 registered 141 degrees. In an interview with CNA F on 10/21/25 at 11:25 a.m. she stated they had all been in-serviced about the new process for serving hot beverages. She stated they were not allowed to make any resident a hot beverage, but instead the kitchen had to make it to make sure it was the correct temperature. She stated they had also moved the coffee carafes out of the dining room, and they had to serve the residents their coffee. She stated they had been instructed to have any resident who had behaviors, tremors, weaknesses, or poor vision had to have a lidded cup and be supervised. She stated they were to place the coffee on the table away from the edge of the table for any resident they served a hot beverage too. She stated for residents who like to wheel around or want to take their coffee with them they had to place it in a lidded cup. She stated a lot of those residents have their own lidded coffee mugs. In an interview with ADON A on 10/21/25 at 11:30 a.m. she stated the day of incident with Resident #1 she was alerted by LVN B about the burn to the resident's leg. She stated she went to assess the area and stated it was slightly red with some small, raised blisters. She stated the resident told her she had spilled her hot tea on herself. She stated they first thought she had just gotten the hot tea but later found out it was much earlier in the day, and she had not said anything to anyone. She stated she immediately called the doctor and received treatment orders, notified the family and notified the DON. She stated they started reviewing the incident and immediately stopped the staff from preparing any hot beverages for a resident. She stated they started in-servicing right away. She stated therapy evaluated the at-risk residents to determine who was safe with hot beverages. She stated they had always had coffee carafes in the nutrition room for the residents use, but now the rooms were locked, and the staff had to serve the residents and ensure the temperature was checked. She stated they also posted the safe temperatures for reheating food or drinks. She stated food did not exceed 160 degrees and hot beverage 150 degrees. She stated any resident who was alert and wanted to take their coffee with them had to have a lidded cup or travel mug with a lid. She stated they had several residents who liked to take their coffee with them as they went around the facility. In an interview with the Maintenance Director on 10/21/25 at 11:40 a.m. he stated the facility's commercial coffee maker had always been set on its lowest setting that will effectively brew coffee. He stated the water tank only keeps water warm so when they start brewing it does not have to heat cold water. He stated the water will heat up during the brewing process. He stated the hottest temperature test he had found was when the water was going into the brewing basket and it registered at 175 degrees. He stated they had always had it set to the midpoint and never to the high point. He stated he tested the hot water holding tank the day of the incident it was testing at 135 degrees when he tested it. He stated the temperature will fluctuate when the machine starts to brew coffee but will then decrease after the brewing process was complete. He stated it depended on the timing of when you get hot water out of it and on what the temperature will be. A second observation on 10/22/25 at 8:35 a.m. of the coffee brewing system with the Dietary manager revealed the right coffee pot had been brewed approximately 15 minutes earlier. The Dietary manger drew up a cup of coffee directly from the brew station and the temperature check registered 150.9 degrees. The left coffee pot was brewed approximately an hour ago and the temperature check registered 149 degrees. A cup of hot water was poured from the holding tank, and it registered 135.5 degrees. The Dietary manager stated this was the range of temperatures they were getting each time they tempt the coffee and water. She stated their policy was coffee was to be consumed at temperatures between 155 to 175 degrees. She stated powdered creamer will not dissolve in coffee below 150 degrees. In an interview with Occupational Therapist D on 10/22/25 at 11:15 a.m. she stated she had provided therapy to Resident #1 several times since her admission to the facility. She stated she never had any issues with upper or lower range of motion and had always been independent for eating and drinking. She stated her main issues were poor core strength and balance when standing or ambulating. She stated it was simply a fluke accident. She stated she re-screened her after the incident and there were no changes from her previous base line. She stated the facility had them screen all residents with dementia, ataxia (lack of muscle control and balance) tremors, rheumatoid arthritis (causes inflammation and damage to the joints) and decrease range of motion for hot liquid safety. She stated any of those residents would require a lidded cup and supervision while drinking. She stated any resident who wanted to travel with their hot beverage would also need a lidded cup. In an interview with the DON on 10/22/25 at 12:05 p.m she stated CNA A was given a verbal warning for getting hot tea for a resident without checking the temperature. She stated secondly, she should had never hand the resident hot tea while in her wheelchair and should have taken it to her room for her or placed it on a nearby table. She stated Resident #1 was independent with eating and drinking. She stated the CNA was simply providing the resident with what she asked for but stated should have thought it through. She stated it was a pure and simple accident. She stated the resident never alerted them until hours later she had spilled hot tea on her. She stated they did have the wound care physician evaluate her and he would continue to see her until the area was healed. She stated all the staff were told to immediately stop preparing any hot beverage for residents and only have the kitchen staff prepare it. She stated they told the staff they were to serve the residents coffee or obtain hot water from the carafes the kitchen staff provided, because they had been temperature checked for safety. She stated they had placed thermometer and safe temperature notices in the nourishment rooms in case the staff were reheating food and drinks, and they had all been in-serviced on checking temperatures and knowing the appropriate temperature for food and coffee. She stated the Dietary Manager had conducted in-service and training with all the dietary staff. She stated they also screened and updated resident's care plan for resident who required a lidded cup for hot beverages. She stated they met with all of the alert residents and informed them going forward the staff would have to serve them coffee instead of them having access to the coffee carafes. She stated any alert resident who wanted to go around the facility with their coffee also had to have it in a lidded cup or lidded travel mug. She stated several of the residents had their own coffee mugs with lids. In an interview with the Administrator on 10/22/25 at 07:55 p.m. He stated the incident with Resident #1 was the result of CNA A preparing her a cup of tea and not knowing how hot it was. He stated they immediately stopped all the nursing staff from preparing any hot beverage for a resident, and instead were instructed to request if from dietary, so they can properly test the temperature. He stated the coffee was checked by kitchen staff every time they put it into the carafes and was to be within the proper temperature range and staff were to ensure when poured it did not exceed 150. He stated staff were instructed to lock the nourishment rooms because they were expected to serve the residents anytime they requested coffee. He stated they had also implemented lidded cups for all of the residents that ate on the hall and any resident who wanted to move about the facility with their coffee had to have it in a lidded cup. He stated in the 10 years he had been here this was the first and only hot liquid burn they had. He stated it was just an unfortunate accident, but stated he felt with all the measures they had put in place it should never happen again. He stated they had an Ad-hoc QA meeting with the Medical director on 10/14/25 and reviewed their mitigation plan. He stated they covered every possible scenario and had put measure in place to ensure all staff were aware of safe temperatures and safe interventions to prevent future accidents. Record review of the facility's Nutrition Policies and Procedures Guidelines to Reduce The Risk of Burns From Hot Beverages revised August 2020, reflected, Precautions shall be implemented to limit the risk of burns from hot beverage (coffee, tea, etc.,) .Hot beverages should be consumed at temperatures between 155 degrees Fahrenheit and 175 degrees Fahrenheit. Palatability is affected by temperature and varies from person to person.Pots or urns containing hot liquids should not be left unattended. Facility staff should pour all hot beverages. Locations where hot beverages may be prepared and/or reheated such as employee break rooms or nourishment rooms should be safeguarded. Patients or residents should not carry hot beverages without a lid while walking or moving in a wheelchair.When serving hot beverages to patients or residents: Transfer the beverage from its brewing urn to a serving container. Beverages served directly from the brewing urn will be hotter. Do not overfill cups. Explain to the patient/resident that a hot beverage is being served. Place cup away from the edge of the table and within patient's/resident's field of vision and reach of dominant hand. Remove lids to allow beverage to cool faster.When serving hot beverage to patients or resident with behaviors or medical conditions that put them at risk for spills.Evaluate the patient's/resident's ability to manage hot beverages independently. Provide assistance and/or supervision as needed. Consider providing a lid for the coffee cup or a travel mug. Allow hot beverage to coo before serving. Ensure all appropriate staff is aware of those residents need supervision. Patients/resident who may be at greater risk may include, but are not limited to, those with: Tremors, Poor hand Control, Visual Impairments, Behavioral issues. The facility implemented the following Mitigation plan on 10/14/25-1. Hot beverage injury has been thoroughly investigated by facility administration. 2. Treatment was ordered and implemented3. An updated list of Residents who drink coffee/hot liquids was proved to Dietary Department for reference. List will be updated weekly. 4. Resident that consumes hot beverages while mobile throughout the facility have the potential to be affected by this alleged deficient practice.5. Skin audits of residents that consume hot liquids from dispenser were completed by the Licensed Nurses: no other concerns were identified.6. Facility will have additional cups with lids on hand for residents who are identified as at risk for hot spills.7. A Therapy referral was initiated for the affected Resident for adaptive equipment and management of eating/drinking ADLs.8. A Therapy referral will be initiated for any resident that may be at risk for hot beverage spills. 9. CSD provided education to Administrator, DON and Dietary Manager on appropriate notification if there is a hot liquids injury identified. Also, procedures for proper temping of hot liquids and keeping hot liquids in a secured locations available to resident with assistance from staff. 10. Licensed nurses and certified nursing assistants and Dietary Manager and dietary staff were re-educated regarding serving hot liquids for those residents that normally use the carafes to obtain hot liquids in cups with lids and stored in nourishment room where they must get assistance from staff t pour hot liquids. 11. This re-education will be completed by 10/14/25. Any Staff member not receiving this re-education by this date will receive prior to next scheduled shift. This will be provided for agency staff and new hire orientation. 12. The Administrator or Designee will validate that residents who desire hot liquids and are mobile through the facility have hot liquids in a cup with a lid and hot liquids is available in nourishment room with assistance from staff for 5 days and then weekly for 3 months and re-evaluate for further supervision if needed. 13. Ad-hoc QA with Medical Director, Administrator, and DON was conducted on 10/14/25. Record review of in-services dated 10/14/25 reflected the Administrator, DON, ADON C and the Dietary Manager were in-serviced by the Clinical Service Director on the facility's Nutrition Polices to reduce the risk of Burns from hot beverages. Record review of in-services dated 10/14/25 reflected the Nursing staff were in-serviced by the DON on the facility's Nutrition Polices to reduce the risk of Burns from hot beverages. Record review of in-services dated 10/14/25 reflected the Dietary staff were in-serviced by the Dietary Manger on the facility's Nutrition Polices to reduce the risk of Burns from hot beverages. Record review of the Coffee Temperature log, for October 2025 reflected Temperatures were taken at breakfast, lunch, and dinner. Temperatures were within the facility guidelines for transfer to serving pots. Record review of the facility's Quality Assurance meeting minutes reflected an AD Hoc meeting was held with the Medical Director, Administrator, DON, Dietary Manager, and ADON's on 10/14/25 about the mitigation plan for hot beverages. Record review of the resident roster list provided to the dietary department on 10/14/25 and 10/21/25 indicated which residents were high risk travelers for hot beverages and residents who had vision, tremors, poor hand control and behaviors. Record review of CNA A personnel file reflected she received a verbal warning and education from the DON on 10/14/25 to always have dietary prepare hot beverages for residents, ensure the beverages were placed safely on a table to prevent the potential for a spill. In interviews covering all three shifts (6 AM- 2PM, 2 PM-10 PM, and 10 PM- 6 AM), revealed they had been in-serviced that all hot beverages had to be prepared by the kitchen staff. Hot beverage was to be served by the staff from carafes provided by dietary. All hot beverages were stored in the nutrition room under lock and key and only staff could pour hot liquids for residents. Staff were in serviced on ensuring mobile residents who were independent with food and drink had a travel mug with a lid in use with hot beverages. Staff were taught any resident with vision impairment, tremors, weakness, or behaviors required a lidded cup and supervision while consuming. Staff were also trained on appropriate temperature for reheating of food and coffee. Food 160 degrees and Coffee 150 d

Based on observations, interviews and record review, the facility failed to store and label food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility failed to ensure food items in the facility refrigerator and freezer were dated or labeled. The facility failed to take the temperature of the soup after re-heating the soup in the microwave. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: *At 8:45am revealed an opened box of slice smoked ham had two plastic 3-pound bags of sliced smoked ham without a date received or date used by. *At 8:49am revealed an unopened loaf of white sliced bread in non-labeled clear bag without a date used by or label of contents. Observation of facility's kitchen walk-in freezer on [DATE] revealed the following: *At 8:49am revealed 2 apple lattice pies in individual boxes that were opened to the air and not securely closed. *At 8:49am revealed an opened bag of about 35 unidentified frozen little squares was in a box labeled 10 pounds of chicken breast tenders had no label of what it was or date used by. Interview with Dietary Manager on [DATE] at 8:49am revealed her expectation was that everything be labeled with date received and that the items had to be used within 14 days of receipt. She stated once an item was opened, they must write the date of open and it had to be used within 3 days of opening. She stated she could not find a date on the box of smoked ham or a date and label of what the item was on the bag that looked like bread. She stated the loaf must have been the last one in the box and they took it out and threw the box away. She stated not labeling items appropriately posed a risk by possibly making a resident sick due to them being expired. She indicated the pies should have been securely covered so they would not get freezer burn; she grabbed them to discard them. She identified the bag of small squares in the box of chicken strips as tater tots and stated that because they were not labeled it would put the residents at risk, as they would be served the wrong items. Observation of food preparations on [DATE] at 11:10am revealed the Dietary Manager had warmed an individual cup of soup in the microwave, she took the temperature and rewarmed it. Observation revealed the Dietary Manager took the temperature of the soup after reheating it in the microwave. She then told the rest of the staff they needed to warm individual servings of soup for 2 minutes to ensure it was warmed to the appropriate temperature. Observation revealed 3 more individually served soups were served by kitchen staff without temperatures taken. Interview with Dietary Manager on [DATE] 12:34 PM revealed she had temped the individually served soup at 180 degrees after reheating it in the microwave. Interview revealed the Dietary Manager warmed the soup for 2 minutes in the microwave and instructed the rest of the staff to warm all the individually served soups at 2 minutes in the microwave after that. She stated the expectation was for all food to be temped before being served and that included the individually served soups. She stated not having the appropriate temperature on the soups would not kill all possible bacteria. Record review of Nutritional Policies and Procedures revised [DATE] reflected, General Food Storage Guidelines .12. Refrigerated, ready to eat Time/Temperature Control (TCS) for Safety Foods are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage Review of the facility policy Food Safety in Receiving and Storage dated [DATE] revealed Refrigerated Storage Guideline 4. Maintain the ambient temperature of refrigerator to 34 to 40 degrees Fahrenheit Review of the Food and Drug Administration Food Code, dated 2022, reflected, XXX,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food ,d+[DATE].11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Review of the Food and Drug Administration Code, dated 2022, reflected ,d+[DATE].11 Reheating for Hot Holding (A) . Time/temperature Control for Safety food that is cooked, cooled , an reheated for hot holding shall be reheated so that all parts of the food reaches a temperature of at least 74 degrees Celsius (165 degrees Fahrenheit) and the food is rotated or stirred, covered and allowed to stand covered for 2 minutes after reheating . Review of the Food and Drug Administration Code, dated 2022, reflected XXX,d+[DATE].12 Time/Temperature Control for Safety Food, Slacking. Frozen Time/Temperature Control for Safety Food that is slacked to moderate the temperature shall be held: (A) Under refrigeration that maintains the FOOD temperature at 50C (41F) or less; XXX,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding. Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5oC to 57oC (41F to 135F) too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #21, Resident #63, and Resident #45) observed for infection control. 1. The facility failed to ensure RN B prepared Resident 21's medication without cross contaminating her medications on 12/04/24 2. The facility failed to ensure that CNA D performed hand hygiene after providing dressing assistance and transfer of Resident # 63 and before leaving the resident's room on 12/04/24. 3. The facility failed to ensure that CNA F changed her gloves and performed hand hygiene while providing incontinence care to Resident #45 on 12/04/24 and failed to ensure CNA F and CNA E performed hand hygiene after completion of incontinence care on Resident #45, before leaving the room on 12/04/24 These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. During medication observation on 12/04/24 at 08:30 a.m. RN B was observed at the medication cart. RN B performed hand hygiene without putting on gloves and entered Resident #21's room to obtain her blood pressure, temperature, and Oxygen saturation levels. RN B returned to the medication cart, put on a pair of gloves, and sanitized the equipment with a germicidal wipe. RN B then removed her gloves and returned to the resident's room to wash her hands. RN B then put on a glove on her right hand and opened the medication cart with her gloved hand and pulled out the resident's each of the required over the counter supplements and poured the medication into the top of the supplement bottle and then placed them in a plastic medication cup. RN B then pulled out seven blister packs, and proceeded to pop the medication into her gloved hand and then placed each tablet into the medication cup with her gloved hand. RN B stated she had to go to the medication room to pull one of the resident's medications. RN B placed the medication cup in the top drawer of the medication cart, locked it and started walking down the hall, still wearing the glove on her right hand. RN B then removed the gloved, entered the Medication room, disposed the glove, and opened the refrigerator and the lock box inside of the refrigerator and retrieved 1 tablet of Dronabinol (cannabinoids used for nausea and loss of appetite). She then searched the cabinet for a multi vitamin and then returned to the medication cart. RN B then put on another glove on her right hand without performing hand hygiene and opened the medication cart and pulled out the plastic cup containing the resident's medications and continued popping the Dronabinol and one other medication from the blister pack into her gloved hand and placed them into the medication cup. In an interview on 12/04/24 at 08:55 a.m. with RN B she stated she thought she was being extra cautious on infection control by using the glove. She stated she had been told during Inservice to be sure they did not touch the top of the medication cup while popping the meds out of the blister pack to prevent cross contamination. She stated it was so hard to pop the pills out of the pack without touching the top of the cup, so she thought popping it into her gloved hand would prevent that problem. She stated after the thought about that process, she realized she had cross contaminated the glove once she touched other items on and in the medication cart. She stated she today (12/04/24) was the first time she had punched the medications into her gloved hand. RN B entered the resident's room and administered the medication. Removed her glove and performed hand hygiene. In an interview on 12/05/24 at 11:10 a.m. with the DON she stated staff had never been taught to punched meds into a gloved hand. She stated they were taught to punch the medication directly into the med cup without touching the medication to prevent cross contamination. She stated she saw RN B with the glove on her hand and could not figure out why she would be wearing a glove. She stated the go over and over infection control practice with the staff. She stated she had never seen RN B pass medications the way she had during the observation and stated it was certainly not the facility policy or procedure. Record review of RN B's staff education/orientation check list dated 10/15/24 reflected she had met the performance criteria for medication administration. Record review of the facility's policy titled, Medication Management Program, dated May 2023, reflected, .The authorized staff member or licensed nurse will retrieve refrigerated items needed for administration prior to initiate the medication pass .Administering the Medication pass .Perform hand hygiene .Do not touch the mediation when opening a bottle or unit dose package . 2. An observation on 12/04/24 at 11:10 a.m. revealed CNA D entered Resident #63's room to transfer him to the wheelchair. CNA D performed hand hygiene and put on gloves and a gown. CNA D removed the residents hospital gown and placed the resident's leg urinary drainage bag into the leg of his pants and then placed the resident's other leg into his pants. CNA D then put on the resident's shirt and assist him to sit up on the side of the bed. CNA D placed a gait belt around the resident and transferred him to the wheelchair. CNA D then placed the dirty gown into a plastic bag and then pushed the resident toward the door, stopped to remove his gown and gloves and left the resident's room without performing hand hygiene. He then pushed the resident while holding the plastic bag which contained soiled clothing, to the front office for his care plan conference. In an interview on 12/04/24 at 11:25 a.m. with CNA D he stated he was supposed to perform hand hygiene after he removed his gloves and gown and before he left the room. He stated he just forgot since he knew the residents care plan was scheduled for 11:30 a.m. and he was trying to get him there on time. He stated the risk of not performing hand hygiene was the spread of germs. 3. In an observation on 12/04/24 at 03:40 p.m. CNA E and CNA F put on a gown and entered Resident #45's to provide incontinence care. Both staff entered the resident's room and washed their hands and put on gloves. Both staff unfastened the resident's brief, CNA F cleaned the resident from front to back, changing her wipes with each stroke. CNA F then removed her gloves and washed her hands. Both staff assisted the resident onto her side and CNA F cleaned the residents' anal area from front to back revealing she had a small soft bowel movement. CNA F wiped several times changing out the wipe each time. CNA F then placed the clean brief under the resident without changing her gloves or performing hand hygiene. CNA E removed her gloves and washed her hands, put on gloves and then assisted to roll the resident back onto her other side to remove the soiled brief and pull the clean brief under the resident. Both staff adjusted the resident covers and lowered her bed. Both staff removed their gowns and gloves and placed them in the plastic bag with the soiled briefs and wipes and left room without preforming hand hygiene. In an interview at 12/04/24 at 04:00 p.m. with CNA E and CNA F they both stated they were supposed to perform hand hygiene when they went from dirty to clean and were supposed to wash their hands before they left the room. Both staff members stated they had failed to do that. Both staff members stated the risk of not performing hand hygiene was the spread of infection to other residents. In an interview with ADON A on 12/05/24 at 09:47 a.m. she stated she was the infection preventionist. She stated staff were always taught to sanitize their hands when they enter a resident's room, when going from dirty to clean and before leaving the resident's room. She stated the do skills checks at time of hire, annually and as needed if they determine an issue. She stated the Charge nurse are also expected to observe staff for compliance with infection control practices. In an interview on 12/05/24 at 11:10 a.m. with the DON she stated staff were supposed to wash hands and change gloves before, and after completion of cleaning a resident and after completion of care. She stated they had worked so hard with the staff on skills and stated they were all aware of what they were supposed to be doing. She stated the risk of failing to perform hand hygiene was increased infections and cross contamination. Record review of CNA E's competency check off for peri-care revealed she was proficient in care as of 11/04/24. Record review of CNA F's competency check off for peri-care revealed she was proficient in care as of 11/04/24. Record review of the facility's policy titled, Hand Hygiene/Handwashing, dated May 2023, reflected, .Hand Hygiene/Hand washing is the most important component for preventing the spread of infection .Hand hygiene/hand washing is done before .patient/resident contact .before taking part in a medical or surgical procedure .After contact with soiled or contaminated articles, such as articles that are contaminated body fluids .After patient/resident contact . After removal of medical/surgical gloves or utility gloves .Contact with environmental surfaces in the immediate vicinity of patients/residents .

Based on interview, observation and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of six residents (Residents #8) reviewed for pharmacy services. The facility failed to ensure LVN C followed the Physician orders and facility procedures for checking residual before administering Resident #8's medication through his g-tube on 12/04/24. This failure placed the residents at risk of aspiration, vomiting or incomplete administration of medication if tube was blocked or obstructed. Findings included: Record review of Resident #8's quarterly MDS assessment dated [DATE], reflected a [AGE] year-old male with an admitted [DATE]. Staff assessment for mental status reflected resident was moderately cognitively impaired. The resident received 51% or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone or posture due to abnormal brain development). Record review of Resident #8's physician order report dated 11/05/24 through 12/05/24, reflected, .Placement Verification by aspiration of stomach residual volume . with a start date of 08/01/24. Record review of Resident #8's care plan updated on 11/07/24 reflected, [Resident #8] is at nutrition and dehydration risk related to tube feeding .Approach .Medications as ordered via g tube .Monitor for signs/symptoms of tube feeding intolerance . A medication pass observation on 12/04/24 at 08:55 a.m. revealed LVN C at the medication cart preparing Resident #8's medication for g-tube administration. LVN C prepared 4 medications placing each of the medications into separate plastic medication cups and diluted the 2 non-liquid medications with 5 ml of water. LVN C entered the resident's room and obtained a cup of water from the resident's bathroom and turned off the G-tube pump. LVN C then checked placement of the G-tube through air auscultation but did not pull back to check for residual. LVN C flushed the G-tube with 30 ml of water and administered the 4 medications, flushed with water between each medication and then flushed with 30 ml after the last medication. LVN C then re-connected the Enteral feeding line and turned the pump back on. In an interview on 12/04/24 at 09:15 a.m. LVN C stated she was supposed to check placement with air auscultation. She stated they no longer had to check residual. LVN C then reviewed the orders and stated she had gotten it backwards; she was supposed to check residual for placement not air auscultation. She stated the risk for not checking residual was if the resident had too much residual, they would need to hold the mediations and let the physician know. She stated it could cause aspiration if the stomach was overfilled. In an interview on 12/05/24 at 11:15 a.m. with the DON stated the nurse just got it backwards. She stated LVN C was one of the best nurses for G-tube medication administration. She stated she was an old school nurse who was taught to check with air auscultation, but stated they also had to check residual to determine if they needed to hold the feeding or mediation. She stated the risk of not checking was aspiration. She stated they did skills checks on all the staff annually or if they determine they need additional training or procedures. Record review of LVN C Staff Education/Orientation check off list dated 10/16/24 reflected she had met the performance criteria for Gastrostomy tube management. Record review of the Facilities undated procedure, Enteral Tube Drug instillation, reflected, .Verify enteral tube placement using at least two of the following. Observe for a change in the external tube length or the incremental marking at the exit site .Aspirate tube contents and inspect the visual characteristics of the tube aspirate .Notify the practitioner if tube placement is in doubt .

Based on interview and record review the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for one of six residents (Resident #1) reviewed for diagnostic services in that. 1.ADON A failed to read Resident #1's x-ray results received at the facility on 01/18/24 and failed to notify/consult the Physician about the resident's femur (thigh bone) fracture and change of condition using the facility's approved notification methods leaving Resident #1 with an undiagnosed /untreated fracture for 29 days (01/18/24 to 02/13/24). 2. The facility failed to have a system in place to ensure verbal notification was promptly received from the contracted Radiology company. Resident #1 fell on [DATE] at 03:15 a.m. with no apparent injury, but when attempting to get up, the resident's legs kept giving way. Resident #1 transported to the hospital and returned to the facility on [DATE] with no known fractures. On 01/15/24 Resident #1 complained of excruciating pain to her left leg and reported having an additional fall to PT R and the DOR/OT during their assessments. An X-ray was completed on 01/15/24 which was negative. On 01/18/24 another X-ray was obtained which showed a left intertrochanteric femoral fracture (type of hip fracture). The physician or family were never notified. Resident #1 was transferred to Facility X on 02/05/24 due to needing a Medicaid pending bed. Resident #1 continued to receive physical therapy at Facility X. On 02/13/24 Resident #1 was sent to the hospital due to continued hip pain and an X-ray confirmed a left hip fracture. Resident #1 received surgery to repair the hip fracture on 02/15/24, 29 days after the initial X-ray which showed the fracture. An Immediate Jeopardy (IJ) was identified on 04/16/24 at 04:45 p.m. The IJ template was provided to the facility on [DATE] at 05:02 p.m. and signed by the Administrator. While the IJ was removed on 04/18/24 at 01:15 p.m. the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in delayed medical treatment, ongoing pain, delay in rehabilitation, hospitalization and placed the resident at risk of death, bleeding, and increased severity of the initial fracture. Findings include: Record review of Resident #1's 5-day MDS assessment, dated 01/20/24, reflected a [AGE] year-old female admitted to the facility on [DATE] and a re-admission on 01/14/24. Resident #1 had a BIMS of 12 which indicated her cognition was moderately impaired. Resident #1 required partial to substantial assistance with ADLs. Her diagnoses included coronary artery disease, myocardial infarction (heart attack), COVID-19, and unspecified fall. The assessment indicated the resident had zero fall since re-admission and had no pain. She had received PT and OT services with a start date of 01/15/24. Record review of Resident #1's base line care plan dated 01/09/24, reflected, Resident is a new admission .post cardiac stents and COVID positive .Goals .Resident's immediate health and safety needs will be identified .Approach .Fall Risk .Minimize falls .Encourage use of call eight .Pain Management .Monitor Pain .Verbal/descriptor .Location .General Treatment-see Physician orders . Record review of Resident #1's PT evaluation and Plan of treatment completed by PT R, dated 01/15/24 reflected, .Patient subsequently was originally admitted to the [facility] on 1/09/24 in order to participate with rehab. However, she had experienced a backward fall after her admittance hitting her posterior (back) aspect of the head on the floor. She was returned to [Hospital name] for evaluation on 1/10/24. Following all of the routine tests at the hospital patient was diagnosed with NSTEMI (type of partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart). She was treated and eventually deemed clinically stabilized sufficiently to be returned to the [Facility] on 1/14/24 to resume her rehab. On the morning of 1/15/24 patient apparently transferred herself from the bed and possibly was attempting to walk toward the bathroom when she lost her balance and experienced another fall. There was ensuing pain in the left hip and along the full length of the lateral (outside) left femur prompting the order for a X-ray of the LLE (left lower extremity). The results were NEG(-) for showing any acute fracture or dislocation. However, patient is experiencing significant pain in the left hip which radiates along the tensor fascia [NAME] (muscle located in the upper outer thigh and hip) in distally to the lateral (outside) left knee. The pain is intense and increases with any attempt to move the left LE actively or passively from the current angulation (angle) described as left hip flexion (pulling the knee close to the chest), excessive across-midline adduction ( brining the hip towards the midline of the body), and internal rotation (happens when you twist your thigh inward from your hip joint). Pt's therapy will be addressing her declines in mobility and performance of ADLs due to her decreases in endurance, strength, and balance for upright positioning .History of Falls .The most recent fall on the morning of 01/15/24 resulting in strains/contusion to the lateral left hip/thigh/knee causing pain and challenges for movement (whether active or passive) for left hip. Attempts to passive move the left leg is met with protective guarding and resistance .Pain assessment .Pain at rest-4/10 (scale used where 0 is no pain 10 is most severe pain); frequency-constant, daily, location-left hip, Description-gnawing, heavy, throbbing, dull ache and burning .Pain with movement-9/10-Frequency- Daily, intermittent- location- Left hip/thigh/knee laterally. Pain description-Burning, aching, cramping and sharp, quick . Record review of Resident #1's OT evaluation and plan of treatment completed by the DOR, dated 01/15/24 reflected, .Once admitted , patient had a fall and was sent back out to hospital and was dx (diagnosed ) with NSTEMI. She has returned to this facility with therapy eval orders in place. She has already had another fall at this facility, c/o L hip pain, and was ordered Xray, which was negative for fracture. Upon eval, pt was unable to straighten LE, and remained in severe IR (internal rotation) to L hip. Nursing notified, and patient was assisted for improved positioning of LLE. She still complains 9/10 pain to L hip .Pain Assessment- Patient verbalized pain level .Paint at rest-4/10 .Pain with movement .9/10 .What relieves pain .sitting down, remaining still .What exacerbates pain .sitting, standing, bending, prolonged activity . Record review of the facility's falls summary report from 01/14/24 through 04/15/24 did not indicate a fall for Resident #1 on 01/14/24 or 01/15/24. Record Review of Resident #1's physician's orders for January 2024 did not reflect an order for X-ray for 01/15/24 or 01/18/24. Resident #1 did have Tramadol 50 mg 1 tablet every 6 hours as needed for pain with a start date of 01/14/24. Record review of Resident #1's Narcotic disposition form dated 01/18/24 for Tramadol 50 mg 1 tab every 6 hours as needed for pain, reflected the resident was treated for pain on 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24 (2x), 01/24/24, 01/25/24 (2x), 01/26/24, 01/27/24, 01/28/24 (2x), 01/29/24, 01/30/24(2x), 01/31/24, 02/01/24, 02/02/24, 02/03/24 (2x), and 02/04/24. Record review of Resident #1's TAR from 01/14/24 through 02/04/24 reflected, Every shift check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale mild, moderate, severe, very severe. Shift 1 from 01/14/24 through 02/04/24 indicated no pain. Shift 2 indicated- no pain from 01/14/24-01/17/24, 01/18/24-01/20/21- moderate pain, 01/21/24- no pain, 01/22/24-moderate, 01/23/24-no pain, 01/24/24- moderate pain, 01/25/24- no pain, 01/26/24-01/28/24-moderate pain, 01/29/24-no pain, 01/30/24-02/01/24 moderate pain, 02/02/24-02/04/24- no pain. Record review of the Radiology report dated 01/15/24 completed at 11:25 a.m. reflected, Femur min 2 views, left- Results .Negative left hip. Atherosclerotic vascular disease (buildup of plaque in arteries). The report was signed by the MD and noted by Agency LVN P as reviewed on 01/15/24. Record review of Resident #1's Nurse Progress note completed by Agency LVN P on 01/15/2024 at 02:01 p.m. reflected, residents femur x-ray report: conclusion: negative left hip, atherosclerotic vascular disease. There were no indications the responsible party were notified. Record review of the Radiology report dated 01/18/24 completed at 02:41 p.m. reflected, Conclusion: Interval increase in angulation (alteration of aliment) of the intertrochanteric left femoral (type of thigh bone fracture) fracture as noted. Compare with 01/15/24. Record review of the e-mail provided to the facility from the contracted radiology company on 04/17/24 reflected the following timeline: X-ray Ordered: 01/18/24 at 01:04 p.m.- completed on 01/18/24 at 02:20 p.m. Resulted on 01/18/24 at 02:41 p.m. Faxed to the facility on [DATE] at 02:45 p.m. Unsuccessful attempts called to facility at 01/18/24 at 04:59 p.m. and 05:47 p.m. Record review of Resident #1's NP's note dated 01/18/24 at 01:01 p.m. reflected, .Seen today without issues or concerns .Status post fall. No reports of syncope (dizziness). CT of the brain was negative. Fall precautions .plan of care reviewed and discussed with [MD] . Record review of the Facility's 24-hour report for 01/18/24 and 01/19/24 did not reflect any follow up for X-Ray and indicated no change in Resident #1. Record review of Resident #1's Nurse Progress notes and daily observation note for 01/18/24 did not indicate an order was received to repeat Resident #1's X-ray. No indication of pain or complaints. Record review of Resident #1's hospital record dated 02/13/24 reflected, admitted to Facility X on 02/05/24 from Facility Y with left hip pain. Patient requested repeat X-ray today due to pain not getting any better. X-Ray showing left femoral neck fracture. Alert and oriented x 4, incontinent due to pain. Surgical repair of her left hip fracture was completed on 02/14/24. In an interview with LVN F on 04/16/24 at 10:15 p.m. she stated she worked the 06:00 a.m. to 06:00 p.m. shift. She stated she worked on 01/14/24 when Resident #1 was readmitted to the facility. She stated she did not recall her having any additional falls on her return to the facility. She stated she was off from 01/15/24 through 01/27/28. She stated the process when they received an order for an x-ray was to place the order in the resident's electronic record, place the order in the radiology request portal, place it on the 24-hour report and make a note in the progress note of the pending request and any assessment needed that resulted in the request. She stated once the results were received, they were to notify the family and MD and document in the progress note the notification was completed and sign off on the X-ray result and place it in the MD's box for their review. LVN F searched Resident #1's electronic record and stated there were no X-Ray results uploaded into the record. She stated the progress note dated 01/15/24 reflected an X-ray had been completed and was negative. LVN F searched the radiology portal and stated there were copies of the X-ray results for 01/15/24 and stated there was another report for 01/18/24. She stated the X-ray request for 01/18/24 was put into the system by ADON A. She stated the X-ray for 01/18/24 showed a fracture. She stated she was unaware the resident had a fracture. She stated that surprised her since the resident had not complained of pain to her. She stated the X-ray company would fax the results but would also call if the X-ray was positive for a fracture. In an interview with PTA S on 04/16/24 at 10:30 a.m. he stated Resident #1 had expressed to PT R during his assessment she had fallen again, but stated there was some confusion if she had fallen on the re-admission or if it was the fall, she had on her first admission on 01/09/24. He stated she was expressing pain the first day of therapy on 01/15/24, but after that she did not complain and was progressing slowly with therapy. He stated he knew the X-ray on 01/15/24 was negative for a fracture, so they proceeded forward with therapy. He stated he was unaware of the X-Ray completed on 01/18/24 and was shocked she had a fracture. In an interview with the NP on 04/16/24 at 10:40 p.m. she stated she vaguely remembered Resident #1. She stated she saw the resident 3 x week during her stay at the facility and she did not recall her ever complaining to her about pain in her hip. She stated she did not recall ordering an X-ray for the resident on 01/15/24 or 01/18/24. She stated she would usually place anything like that in her notes to ensure she followed up. She stated the nurse's may have mentioned it to her in passing and she gave a verbal OK for the X-Ray. She stated the facility would call her or the MD with the results of the X-ray and they placed a copy of the report in the MD's communication box for her and the MD to review. She stated she did not ever see an X-ray that showed a fracture to the resident's femur. She stated if she had she seen it they would have sent her out to the hospital for further evaluation and treatment immediately. In an interview with ADON A on 04/16/24 at 11:30 a.m. she stated she was covering for the DON on the week of 01/15/24. She stated it was a crazy week, stating she had family who were also in the hospital during that time. She stated in addition they were using a lot of agency nurses. She stated she did not recall what prompted her to request the X-ray on 01/18/24 for Resident #1. She stated she did not recall being notified from PT or OT that Resident #1 had reported another fall on 01/15/24. She stated she should have placed an order in the resident's chart for the X-ray on 01/18/24 and should have placed it on the 24-hour report for follow up. She stated the nursing staff should have documented in the progress notes any complaints of pain the resident had and if PT had indicated a fall, and an incident report should have been completed. She stated she was unsure how the X-ray report was never reviewed by nursing or the physician. Attempted to reach Agency LVN O on 04/16/24 at 12:14 p.m. by phone. No answer. Agency LVN O worked at the facility on 01/18/24 and was assigned to Resident #1's hall. In an interview with Facility X's DON on 04/16/24 at 12:20 p.m. she stated Resident #1 transferred to their facility on 02/05/24. She stated the resident had received therapy since her admission to their facility. She stated on 02/13/24 the resident requested a repeat X-ray of her left hip because she did not think Facility Y's X-rays were done correctly, since her left hip had continued to hurt. She stated they ordered an X-ray, which showed a left femur fracture. She stated the resident was sent to the hospital 02/13/24 and underwent surgical repair to her left hip. She stated the resident had since returned to the facility and was doing well. In an interview with PT R on 04/16/24 at 12:20 p.m. he stated he had reported to nursing on 01/15/24 about the resident's complaints of pain to her left hip, which was why an X-ray was ordered. He stated he did not recall if he reported to them about the resident's comments about falling that morning. He stated the X-Ray on 01/15/24 was negative, so they proceeded with therapy, but stated if a resident presented with symptoms or discomfort, they would back off therapy. He stated the resident did not present as someone with a hip fracture and was able to stand and ambulate for short distances. He stated it was not uncommon for a new admission to have more pain at first because they were sometimes waiting for the resident's pain medication to arrive. He stated the resident did not complain of pain after the first initial day and was making some progress in her therapy. He stated they will frequently ask nursing to request an X-ray if they have concerns about a possible fracture, but stated he did not request a second X-ray on 01/18/24. In an interview with the MD on 01/18/24 at 12:40 p.m. he stated he did not recall any calls from the facility regarding the results of an X-ray which showed a femur fracture for Resident #1. He stated had he been notified he would have sent her to the hospital immediately for treatment. He stated they would repeat an X-Ray if a resident continued to complain of pain and the initial X-ray was negative to make sure there was not a fracture. He stated the NP was in the facility three times a week and would update him of any changes in his patients. He stated he did not know why the radiology company did not contact him directly when they were unable to reach the facility. He stated an untreated fracture could result in death, increased pain, bleeding, and blood clots. In an interview with the DON on 04/16/24 at 1:10 p.m. she stated she was on family medical leave during the week of 01/15/24 and ADON A was covering for her. She stated she had not been able to locate any incident report of a fall for Resident #1 since her readmission on 01/14/24. She stated agency staff do not have access to the radiology portal so a facility staff member would had to have put in the request for any X-ray. She stated the facility staff should ensure the X-ray order was placed in the electronic record and placed on the 24-hour report for follow up. She stated the agency staff were oriented to the electronic record and were provided access. She stated they should document any assessment of pain or notification to the family and physician. She stated she suspected when the fax copy of the X-ray report came in it was placed in the box to be scanned instead of the MD's box for review and when the Medical Records clerk picked up the reports, she did not notice it had not been reviewed by the physician or nursing. She stated she would be doing education with the Medical Records clerk to ensure those reports were placed back into the MD's box to ensure proper review. She stated the failure started with ADON A when she did not ensure an order was placed in the electronic record, a progress note notifying the family of the requested X-Ray and failing to place it on the 24-hour report. She stated had the ADON followed up even with the misplacement of the report, they would have been aware of the results of the X-Ray. In a telephone interview with Resident #1 on 04/16/24 at 1:50 p.m. she stated she was finally on the road to recovery. She stated she remembered very little about her stay at Facility Y. She stated she did not recall falling and was not sure if she fell more than once. She stated she did not know if she was having a lot of pain. She stated she remembered in February 2024 having pain in her left hip when she moved a certain way. She stated she just remembered her stay at Facility Y was not pleasant. She stated since she had her hip repaired, she was walking with a walker and getting much stronger. In an interview with Agency LVN P on 04/16/24 at 3:10 p.m. she stated she worked at the facility on 01/15/24, 01/16/24 and 01/17/24. She stated she did recall Resident #1 and remembered the physician had requested an X-ray on 01/15/24 due to hip pain. She stated she did not recall being told she had fallen. She stated she remembered Resident #1's family was with her most of the time, and would ask for pain medication for her, but stated when she assessed her for pain the resident would deny being in pain. She stated if she got an order for an X-ray, she would have to get one of the facility staff to place the request in the portal since she did not have access. She stated she would place the information about the X-ray on the 24-hour report and any notifications she made in the progress notes. Attempted to contact Agency LVN M on 04/16/24 at 4:22 p.m. who worked on 01/18/24. Unable to leave a message-voice mail was full. Record review of the facility policy titled Laboratory Testing, revised May 2023 reflected . Requests for diagnostic services must be ordered by the patient/resident's attending physician or physician extender .Orders for diagnostic services must be entered into the resident's medical record and signed by the attending physician or physician extender .Results of laboratory, radiological, and diagnostic tests shell be reported in writing to the resident's attending physician or physician extender or to the facility via fax or electronic reporting .The attending physician or physician extender shall be promptly notified of abnormal, critical, or stat test results. The charge nurse receiving the test results shall be responsible for notify the physician or physician extender of such test results in a timely manner . Record review of the facility's policy, Physician and other communication/change in condition revised May 2023, revealed To improve communication between physician and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decision regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/resident's and their responsible party regarding change in condition .Complete assessment of the patient/resident which may include but is not limited to .Patient's/resident's previous condition .Recent labs, x-ray results .Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record .The patient/resident and patient's /resident's family member/legal representative will be notified of any changes in medical condition or treatment plan . The Administrator was notified on 04/16/24 at 05:02 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 04/17/24 at 05:22 p.m. The accepted plan of removal for the Immediate Jeopardy included the following: [Resident #1] is not currently in the facility. A house wide audit will be completed of x-rays completed since 1/1/24 to validate that any abnormal results have been reported to the physician for further direction, physician orders for the x-ray are in the medical record and responsible party has been notified. This will be completed by the Director of Nursing/Designee by 4/16/24. The facility activity report and the 24hour report for the past 14 days will be audited by the Director of Nursing/Designee to identify any x-rays ordered and validate that the physician has been contacted with results for further direction and the responsible party notified. This will be completed by 4/16/24. [Radiology company] will be notified on 4/17/24 by Administrator on process for notification of abnormal x-rays which includes notification to Administrator and Director of Nursing by cell phone if unable to contact facility staff in the building. Licensed nurses will be reeducated by the Director of Nursing/Designee on radiology orders including. Requests for diagnostic services must be ordered by the resident's physician. Orders for diagnostic services will be promptly carried out as directed in the physician's order. Shift to shift report will be given to oncoming nurse for effective communication regarding resident care and treatment, including changes of condition, new orders, incidents/accidents and follow up for diagnostic services. Physician and responsible party will be promptly notified of a change of condition, including falls. Physician will be notified for additional injury, including pain for further orders. Responsible party will be notified for additional injuries. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction. Any licensed nurse not receiving this education by 4/16/24 will receive prior to their next scheduled shift. This will be presented in new hire and agency orientation. The next 6 shift changes a member of nursing management (Nurse Assessment Coordinator, RN Supervisor, Director of Nursing, Assistant Director of Nursing) will attend shift to shift report to validate that any resident that has had a change of condition has been assessed appropriately, any diagnostic testing completed, physician notified, orders implemented promptly, and responsible party notified. The Director of Nursing/Designee and/or Manager on Duty will review the 24-hour report and the facility activity report to identify any documentation regarding a change of condition, including falls, and validate that the resident has been assessed appropriately, physician notified, RP/Family notified, and orders implemented promptly. This includes diagnostic testing and results. This will be completed Monday -Friday in the Clinical Meeting and Charge Nurse on weekends. Facility Medical Director will be notified of the Immediate Jeopardy and the contents of this plan on 4/16/24 and will be given progress updates. Monitoring The facility's implementation of the IJ Plan of Removal was verified through the following: Record Review of an e-mail dated 04/17/24 sent to the radiology company indicated the facility's request for any X-ray outside of the normal parameters were to the Administrator, DON, the Medical Director, or The Attending physician. Cell phone numbers were provided to the company. Record review of the facility's Summary Utilization Report dated 01/01/24 through 04/16/24 reflected a 100% audit of all radiology requests made had been reviewed and verified physician notification was made on all request except for Resident #1 on 01/18/24. Record review of facility's in-service initiated on 04/16/24 by the Clinical Service Director reflected the DON was in-serviced on the facility's policy on Abuse and Neglect, fall management and assessment of the resident post fall, significant changes of condition and the facility's lab and radiology procedure for notification to physician. In an interview with the DON on 04/18/24 at 9:30 a.m. she stated the root cause of this failure was the ADON's failure to follow procedure and failure to follow up. She stated it was her expectation for any nurse who received an order due to a change of condition to follow up on the resident, notify the physician and family. She stated staff must report from shift to shift when there had been a change so ongoing follow up could continue. She stated she monitored for this by making daily rounds, following up after daily stand-up meetings and review of the 24-hour report. She stated going forward therapy had been instructed to notify her as well as the nursing staff on any changes in a resident's condition so she will be assured required follow up is completed. Record review of the Shift-to-Shift verification report reflected on 04/16/24 the DON participated in the 6 p.m. to 6 a.m. shift report and ADON B participated in the shift-to-shift report for the 6 a.m. to 6 p.m. shift changes. Record review of the facility's inservice initiated on 04/16/24 by the Clinical Service Director reflected the Administrator was in serviced on the facility policy for abuse and neglect. In an interview with the MD on 04/18/24 at 10:54 a.m. he stated the facility had provided his contact information to the radiology company so he could be contacted directly if an X-ray was outside the normal parameters. He stated it was the expectation if the radiology company had not been able to reach anyone at the facility, they should had contacted him directly since he was the ordering physician of the X-ray request. He stated had they done that, the resident would have received timely care. He verified he had reviewed the facilities Plan of removal and stated he had reviewed with his NP his expectation for follow up on any of their residents for X-ray results. In an interview with the Administrator on 04/18/24 at 11:14 a.m. he stated he had been re-educated on abuse and neglect on 04/16/24. He stated he had self-reported the allegation of neglect involving Resident #1 and they had suspended ADON A until the completed investigation. He stated he felt the failure of the ADON resulted in neglect related to the failure to follow up on the X-ray which resulted in the physician never becoming aware of the results and the resident not receiving necessary treatment. He stated it was an unfortunate time since he was also off during that time frame as well. He stated he made daily rounds especially on the rehab hall, so residents know who to report any concerns to. He stated he had reached out to Resident #1's responsible party on 04/17/24 to inform them of the X-ray results and to let them know they were taking this failure very seriously and doing everything possible to ensure this never occurred again. He stated they had a conversation with the Radiology company and contact numbers were provided to them. He stated that way, even if he or the DON were not at the facility, they would be notified of any X-ray outside of the normal parameters so they could ensure proper notifications and follow up were completed. Record Review of the facility's Inservice Records dated 04/17/24 reflected staff were educated on Fall management, Abuse and neglect, signification changes in condition, physician notification and verification of Radiology request. Interviews conducted on 04/17/27 from 3:30 p.m. to 4:00 p.m. with 2nd shift charge nurses RN E and RN C revealed they had received in-service training and were able to verbalize understanding of the in-service training regarding x-rays to be completed in timely manner and to follow up to physician and responsible party. They were knowledgeable of the documentation process for placing the orders in the electronic record, notation on the X-ray results of their review and notification to the physician. The were aware of the fall and incident reporting criteria and communication to oncoming shifts of any changes through the 24-hour report. They were all knowledgeable of abuse/neglect policy on reporting, neglect definition including a delay in treatment and to report any allegations immediately. Interviews conducted on 04/18/24 from 08:34 a.m. to 10:05 a.m. with 1st and 2 shift staff, LVN H, LVN I, LVN F, LVN J, LVN K, and LVN G revealed they had received in-service training and were able to verbalize understanding of the in-service training regarding x-rays to be completed in timely manner and to follow up to physician and responsible party. They were knowledgeable of the documentation process for placing the orders in the electronic record, notation on the X-ray results of their review and notification to the physician. They were aware of the fall and incident reporting criteria and communication to oncoming shifts of any changes through the 24-hour report. They were all knowledgeable of abuse/neglect policy on reporting, neglect definition including a delay in treatment and to report any allegations immediately. Interviews conducted on 04/18/24 from 10:10 a.m. to 10:40 a.m. with therapy staff COTA Q, PT R, PTA S, PTA T, and COTA W revealed they had received inservice training on fall management which included the reporting to the DON as well as nursing staff any self-reported fall from a resident, and any change in condition related to pain and inability to bear weight. The staff w [TRUNCATED]

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a a significant change in the resident's physical status for one of six residents (Resident #1) reviewed for change of condition. ADON A failed to read Resident #1's x-ray results received at the facility on 01/18/24 and failed to notify/consult the Physician about the resident's femur (thigh bone) fracture and change of condition using the facility's approved notification methods leaving Resident #1 with an undiagnosed /untreated fracture for 29 days (01/18/24 to 02/13/24). Resident #1 fell on [DATE] at 03:15 a.m. with no apparent injury, but when attempting to get up, the resident's legs kept giving way. Resident #1 was transported to the hospital and returned to the facility on [DATE] with no known fractures. On 01/15/24 Resident #1 complained of excruciating pain to her left leg and reported having an additional fall to PT R and the DOR/OT during their assessments. An X-ray was completed on 01/15/24 which was negative. On 01/18/24 another X-ray was obtained which showed a left intertrochanteric femoral fracture (type of hip fracture). The physician or family were never notified. Resident #1 was transferred to Facility X on 02/05/24 due to needing a Medicaid pending bed. Resident #1 continued to receive physical therapy at Facility X. On 02/13/24 Resident #1 was sent to the hospital due to continued hip pain and an X-ray confirmed a left hip fracture. Resident #1 received surgery to repair the hip fracture on 02/15/24, 29 days after the initial X-ray which showed the fracture. An Immediate Jeopardy (IJ) was identified on 04/16/24 at 04:45 p.m. The IJ template was provided to the facility on [DATE] at 05:02 p.m. and signed by the Administrator. While the IJ was removed on 04/18/24 at 01:15 p.m. the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of a delay in medical treatment which could lead to worsening of their condition, hospitalization , and/or death. Findings include: Record review of Resident #1's 5-day MDS assessment, dated 01/20/24, reflected a [AGE] year-old female admitted to the facility on [DATE] and a re-admission on 01/14/24. Resident #1 had a BIMS of 12 which indicated her cognition was moderately impaired. Resident #1 required partial to substantial assistance with ADLs. Her diagnoses included coronary artery disease, myocardial infarction (heart attack), COVID-19, and unspecified fall. The assessment indicated the resident had zero fall since re-admission and had no pain. She had received PT and OT services with a start date of 01/15/24. Record review of Resident #1's base line care plan dated 01/09/24, reflected, Resident is a new admission .post cardiac stents and COVID positive .Goals .Resident's immediate health and safety needs will be identified .Approach .Fall Risk .Minimize falls .Encourage use of call eight .Pain Management .Monitor Pain .Verbal/descriptor .Location .General Treatment-see Physician orders . Record review of Resident #1's PT evaluation and Plan of treatment completed by PT R, dated 01/15/24 reflected, .Patient subsequently was originally admitted to the [facility] on 1/09/24 in order to participate with rehab. However, she had experienced a backward fall after her admittance hitting her posterior (back) aspect of the head on the floor. She was returned to [Hospital name] for evaluation on 1/10/24. Following all of the routine tests at the hospital patient was diagnosed with NSTEMI (type of partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart). She was treated and eventually deemed clinically stabilized sufficiently to be returned to the [Facility] on 1/14/24 to resume her rehab. On the morning of 1/15/24 patient apparently transferred herself from the bed and possibly was attempting to walk toward the bathroom when she lost her balance and experienced another fall. There was ensuing pain in the left hip and along the full length of the lateral (outside) left femur prompting the order for a X-ray of the LLE (left lower extremity). The results were NEG(-) for showing any acute fracture or dislocation. However, patient is experiencing significant pain in the left hip which radiates along the tensor fascia [NAME] (muscle located in the upper outer thigh and hip) in distally to the lateral (outside) left knee. The pain is intense and increases with any attempt to move the left LE actively or passively from the current angulation (angle) described as left hip flexion (pulling the knee close to the chest), excessive across-midline adduction ( brining the hip towards the midline of the body), and internal rotation (happens when you twist your thigh inward from your hip joint). Pt's therapy will be addressing her declines in mobility and performance of ADLs due to her decreases in endurance, strength, and balance for upright positioning .History of Falls .The most recent fall on the morning of 01/15/24 resulting in strains/contusion to the lateral left hip/thigh/knee causing pain and challenges for movement (whether active or passive) for left hip. Attempts to passive move the left leg is met with protective guarding and resistance .Pain assessment .Pain at rest-4/10 (scale used where 0 is no pain 10 is most severe pain); frequency-constant, daily, location-left hip, Description-gnawing, heavy, throbbing, dull ache and burning .Pain with movement-9/10-Frequency- Daily, intermittent- location- Left hip/thigh/knee laterally. Pain description-Burning, aching, cramping and sharp, quick . Record review of Resident #1's OT evaluation and plan of treatment completed by the DOR, dated 01/15/24 reflected, .Once admitted , patient had a fall and was sent back out to hospital and was dx (diagnosed ) with NSTEMI. She has returned to this facility with therapy eval orders in place. She has already had another fall at this facility, c/o L hip pain, and was ordered Xray, which was negative for fracture. Upon eval, pt was unable to straighten LE, and remained in severe IR (internal rotation) to L hip. Nursing notified, and patient was assisted for improved positioning of LLE. She still complains 9/10 pain to L hip .Pain Assessment- Patient verbalized pain level .Paint at rest-4/10 .Pain with movement .9/10 .What relieves pain .sitting down, remaining still .What exacerbates pain .sitting, standing, bending, prolonged activity . Record review of the facility's falls summary report from 01/14/24 through 04/15/24 did not indicate a fall for Resident #1 on 01/14/24 or 01/15/24. Record Review of Resident #1's physician's orders for January 2024 did not reflect an order for X-ray for 01/15/24 or 01/18/24. Resident #1 did have Tramadol 50 mg 1 tablet every 6 hours as needed for pain with a start date of 01/14/24. Record review of Resident #1's Narcotic disposition form dated 01/18/24 for Tramadol 50 mg 1 tab every 6 hours as needed for pain, reflected the resident was treated for pain on 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24 (2x), 01/24/24, 01/25/24 (2x), 01/26/24, 01/27/24, 01/28/24 (2x), 01/29/24, 01/30/24(2x), 01/31/24, 02/01/24, 02/02/24, 02/03/24 (2x), and 02/04/24. Record review of Resident #1's TAR from 01/14/24 through 02/04/24 reflected, Every shift check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale mild, moderate, severe, very severe. Shift 1 from 01/14/24 through 02/04/24 indicated no pain. Shift 2 indicated- no pain from 01/14/24-01/17/24, 01/18/24-01/20/21- moderate pain, 01/21/24- no pain, 01/22/24-moderate, 01/23/24-no pain, 01/24/24- moderate pain, 01/25/24- no pain, 01/26/24-01/28/24-moderate pain, 01/29/24-no pain, 01/30/24-02/01/24 moderate pain, 02/02/24-02/04/24- no pain. Record review of the Radiology report dated 01/18/24 completed at 02:41 p.m. reflected, Conclusion: Interval increase in angulation (alteration of aliment) of the intertrochanteric left femoral (type of thigh bone fracture) fracture as noted. Compare with 01/15/24. Record review of the e-mail provided to the facility from the contracted radiology company on 04/17/24 reflected the following timeline: X-ray Ordered: 01/18/24 at 01:04 p.m.- completed on 01/18/24 at 02:20 p.m. Resulted on 01/18/24 at 02:41 p.m. Faxed to the facility on [DATE] at 02:45 p.m. Unsuccessful attempts called to facility at 01/18/24 at 04:59 p.m. and 05:47 p.m. Record review of Resident #1's NP's note dated 01/18/24 at 01:01 p.m. reflected, .Seen today without issues or concerns .Status post fall. No reports of syncope (dizziness). CT of the brain was negative. Fall precautions .plan of care reviewed and discussed with [MD] . Record review of the facility's 24-hour report for 01/18/24 and 01/19/24 did not reflect any follow up for the X-Ray result and indicated no change in Resident #1. Record review of Resident #1's Nurse Progress notes and daily observation note for 01/18/24 did not indicate an order was received to repeat Resident #1's X-ray. No indication of pain or complaints. Record review of Resident #1's hospital record dated 02/13/24 reflected, admitted to [Facility X] on 02/05/24 from [Facility Y] with left hip pain. Patient requested repeat X-ray today due to pain not getting any better. X-Ray showing left femoral neck fracture. Alert and oriented x 4, incontinent due to pain. Surgical repair of her left hip fracture was completed on 02/14/24. In an interview with LVN F on 04/16/24 at 10:15 p.m. she stated she worked the 06:00 a.m. to 06:00 p.m. shift. She stated she worked on 01/14/24 when Resident #1 was readmitted to the facility. She stated she did not recall her having any additional falls on her return to the facility. She stated she was off from 01/15/24 through 01/27/28. She stated the process when they received an order for an x-ray was to place the order in the resident's electronic record, place the order in the radiology request portal, place it on the 24-hour report and make a note in the progress note of the pending request and any assessment needed that resulted in the request. She stated once the results were received, they were to notify the family and MD and document in the progress note the notification was completed and sign off on the X-ray result and place it in the MD's box for their review. LVN F searched Resident #1's electronic record and stated there were no X-Ray results uploaded into the record. She stated the progress note dated 01/15/24 reflected an X-ray had been completed and was negative. LVN F searched the radiology portal and stated there were copies of the X-ray results for 01/15/24 and stated there was another report for 01/18/24. She stated the X-ray request for 01/18/24 was put into the system by ADON A. She stated the X-ray for 01/18/24 showed a fracture. She stated she was unaware the resident had a fracture. She stated that surprised her since the resident had not complained of pain to her. She stated the X-ray company would fax the results but would also call if the X-ray was positive for a fracture. In an interview with PTA S on 04/16/24 at 10:30 a.m. he stated Resident #1 had expressed to PT R during his assessment she had fallen again, but stated there was some confusion if she had fallen on the re-admission or if it was the fall, she had on her first admission on 01/09/24. He stated she was expressing pain the first day of therapy on 01/15/24, but after that she did not complain and was progressing slowly with therapy. He stated he knew the X-ray on 01/15/24 was negative for a fracture, so they proceeded forward with therapy. He stated he was unaware of the X-Ray completed on 01/18/24 and was shocked she had a fracture. In an interview with the NP on 04/16/24 at 10:40 p.m. she stated she vaguely remembered Resident #1. She stated she saw the resident 3 x week during her stay at the facility and she did not recall her ever complaining to her about pain in her hip. She stated she did not recall ordering an X-ray for the resident on 01/15/24 or 01/18/24. She stated she would usually place anything like that in her notes to ensure she followed up. She stated the nurse's may have mentioned it to her in passing and she gave a verbal OK for the X-Ray. She stated the facility would call her or the MD with the results of the X-ray and they placed a copy of the report in the MD's communication box for her and the MD to review. She stated she did not ever see an X-ray that showed a fracture to the resident's femur. She stated if she had seen it they would have sent her out to the hospital for further evaluation and treatment immediately. In an interview with ADON A on 04/16/24 at 11:30 a.m. she stated she was covering for the DON on the week of 01/15/24. She stated it was a crazy week, stating she had family who were also in the hospital during that time. She stated in addition they were using a lot of agency nurses. She stated she did not recall what prompted her to request the X-ray on 01/18/24 for Resident #1. She stated she did not recall being notified from PT or OT that Resident #1 had reported another fall on 01/15/24. She stated she should have placed an order in the resident's chart for the X-ray on 01/18/24 and should have placed it on the 24-hour report for follow up. She stated the nursing staff should have documented in the progress notes any complaints of pain the resident had and if PT had indicated a fall, and an incident report should have been completed. She stated she was unsure how the X-ray report was never reviewed by nursing or the physician. Attempted to reach Agency LVN O on 04/16/24 at 12:14 p.m. by phone. No answer. Agency LVN O worked at the facility on 01/18/24 and was assigned to Resident #1's hall. In an interview with Facility X's DON on 04/16/24 at 12:20 p.m. she stated Resident #1 transferred to their facility on 02/05/24. She stated the resident had received therapy since her admission to their facility. She stated on 02/13/24 the resident requested a repeat X-ray of her left hip because she did not think Facility Y's X-rays were done correctly, since her left hip had continued to hurt. She stated they ordered an X-ray, which showed a left femur fracture. She stated the resident was sent to the hospital 02/13/24 and underwent surgical repair to her left hip. She stated the resident had since returned to the facility and was doing well. In an interview with PT R on 04/16/24 at 12:20 p.m. he stated he had reported to nursing on 01/15/24 about the resident's complaints of pain to her left hip, which was why an X-ray was ordered. He stated he did not recall if he reported to them about the resident's comments about falling that morning. He stated the X-Ray on 01/15/24 was negative, so they proceeded with therapy, but stated if a resident presented with symptoms or discomfort, they would back off therapy. He stated the resident did not present as someone with a hip fracture and was able to stand and ambulate for short distances. He stated it was not uncommon for a new admission to have more pain at first because they were sometimes waiting for the resident's pain medication to arrive. He stated the resident did not complain of pain after the first initial day and was making some progress in her therapy. He stated they will frequently ask nursing to request an X-ray if they have concerns about a possible fracture, but stated he did not request a second X-ray on 01/18/24. In an interview with the MD on 01/18/24 at 12:40 p.m. he stated he did not recall any calls from the facility regarding the results of an X-ray which showed a femur fracture for Resident #1. He stated had he been notified he would have sent her to the hospital immediately for treatment. He stated they would repeat an X-Ray if a resident continued to complain of pain and the initial X-ray was negative to make sure there was not a fracture. He stated the NP was in the facility three times a week and would update him of any changes in his patients. He stated he did not know why the radiology company did not contact him directly when they were unable to reach the facility. He stated an untreated fracture could result in death, increased pain, bleeding, and blood clots. In an interview with the DON on 04/16/24 at 1:10 p.m. she stated she was on family medical leave during the week of 01/15/24 and ADON A was covering for her. She stated she had not been able to locate any incident report of a fall for Resident #1 since her readmission on 01/14/24. She stated agency staff do not have access to the radiology portal so a facility staff member would had to have put in the request for any X-ray. She stated the facility staff should ensure the X-ray order was placed in the electronic record and placed on the 24-hour report for follow up. She stated the agency staff were oriented to the electronic record and were provided access. She stated they should document any assessment of pain or notification to the family and physician. She stated she suspected when the fax copy of the X-ray report came in it was placed in the box to be scanned instead of the MD's box for review and when the Medical Records clerk picked up the reports, she did not notice it had not been reviewed by the physician or nursing. She stated she would be doing education with the Medical Records clerk to ensure those reports were placed back into the MD's box to ensure proper review. She stated the failure started with ADON A when she did not ensure an order was placed in the electronic record, a progress note notifying the family of the requested X-Ray and failing to place it on the 24-hour report. She stated had the ADON followed up even with the misplacement of the report, they would have been aware of the results of the X-Ray. In a telephone interview with Resident #1 on 04/16/24 at 1:50 p.m. she stated she was finally on the road to recovery. She stated she remembered very little about her stay at Facility Y. She stated she did not recall falling and was not sure if she fell more than once. She stated she did not know if she was having a lot of pain. She stated she remembered in February 2024 having pain in her left hip when she moved a certain way. She stated she just remembered her stay at Facility Y was not pleasant. She stated since she had her hip repaired, she was walking with a walker and getting much stronger. In an interview with Agency LVN P on 04/16/24 at 3:10 p.m. she stated she worked at the facility on 01/15/24, 01/16/24 and 01/17/24. She stated she did recall Resident #1 and remembered the physician had requested an X-ray on 01/15/24 due to hip pain. She stated she did not recall being told she had fallen. She stated she remembered Resident #1's family was with her most of the time, and would ask for pain medication for her, but stated when she assessed her for pain the resident would deny being in pain. She stated if she got an order for an X-ray, she would have to get one of the facility staff to place the request in the portal since she did not have access. She stated she would place the information about the X-ray on the 24-hour report and any notifications she made in the progress notes. Attempted to contact Agency LVN M on 04/16/24 at 4:22 p.m. who worked on 01/18/24. Unable to leave a message-voice mail was full. Record review of the facility policy titled Laboratory Testing, revised May 2023 reflected . Requests for diagnostic services must be ordered by the patient/resident's attending physician or physician extender .Orders for diagnostic services must be entered into the resident's medical record and signed by the attending physician or physician extender .Results of laboratory, radiological, and diagnostic tests shell be reported in writing to the resident's attending physician or physician extender or to the facility via fax or electronic reporting .The attending physician or physician extender shall be promptly notified of abnormal, critical, or stat test results. The charge nurse receiving the test results shall be responsible for notify the physician or physician extender of such test results in a timely manner . Record review of the facility's policy, Physician and other communication/change in condition revised May 2023, revealed To improve communication between physician and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decision regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/resident's and their responsible party regarding change in condition .Complete assessment of the patient/resident which may include but is not limited to .Patient's/resident's previous condition .Recent labs, x-ray results .Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record .The patient/resident and patient's /resident's family member/legal representative will be notified of any changes in medical condition or treatment plan . The Administrator was notified on 04/16/24 at 05:02 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 04/17/24 at 05:22 p.m. The accepted plan of removal for the Immediate Jeopardy included the following: [Resident #1] is not currently in the facility. A house wide audit will be completed of x-rays completed since 1/1/24 to validate that any abnormal results has been reported to the physician for further direction and the responsible party. This will be completed by the Director of Nursing/Designee by 4/16/24. The facility activity report and the 24-hour report for the past 14 days will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 4/16/24. The facility activity report and the 24hour report for the past 14 days will be audited by the Director of Nursing/Designee to identify any x-ray ordered and validate that the physician has been contacted with results for further direction and the responsible party notified. This will be completed by 4/16/24. Licensed Nurses and Therapy Staff will be reeducated on 4/17/24 by the Director of Nursing/Designee on the fall management policy including reporting of falls, which includes self-reported falls which must include evaluation of the resident for injury and investigation using a fall investigation worksheet to determine what may have caused or contributed to the fall or self-reported fall, notification to physician for further orders and notification to the responsible party. Any member of the target audience not receiving this education by 4/17/24 will receive prior to their next scheduled shift. Licensed nurses will be reeducated by the Director of Nursing/Designee on Abuse, Neglect & Misappropriation of Property Policy, fall management and assessment of resident post fall that includes: If a fall occurs, licensed nurse will evaluate the resident for injury and determine what may have caused or contributed to the fall and determines appropriate interventions to prevent future falls and completed a fall investigation worksheet. Licensed Nurses will continue to evaluate the resident 72hours post fall to identify any possible delayed injuries. Physician and responsible party will be promptly notified of a change of condition, including falls. Physician will be notified for additional injury, including pain for further orders. Responsible party will be notified for additional injuries. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition, notify the physician for further direction, and notify the responsible party. Requests for diagnostic services must be ordered by the resident's physician. Orders for diagnostic services will be promptly carried out as directed in the physician's order. Shift to shift report will be given to oncoming nurse for effective communication regarding resident care and treatment, including changes of condition, new orders, incidents/accidents and follow up for diagnostic services. Licensed Nurses will be reeducated on 4/17/24 by the Director of Nursing/Designee on change of condition including: Residents showing signs of a change of condition will be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction. Assessment may include but not limited to a. Residents physical condition b. Residents previous condition c. Vital signs, including pain. d. Recent labs, x-rays e. Previous and current mental status f. Medications g. Resident wishes h. Any interventions provided to the resident. Licensed Nurse will notify responsible party of residents change in condition. Any licensed nurse not receiving this education by 4/17/24 will receive prior to their next scheduled shift. This will be presented in new hire and agency orientation. The next 6 shift changes a member of nursing management (Nurse Assessment Coordinator, RN Supervisor, Director of Nursing, Assistant Director of Nursing) will attend shift to shift report to validate that any resident that has had a change of condition has been assessed appropriately, physician notified, and orders implemented promptly, and responsible party notified. The Director of Nursing/Designee and/or Manager on Duty will review the 24-hour report and the facility activity report to identify any documentation regarding a change of condition, including falls, and validate that the resident has been assessed appropriately, physician notified, RP/Family notified, and orders implemented promptly. This includes diagnostic testing and results. This will be completed Monday -Friday in the Clinical Meeting and Charge Nurse on weekends. Facility Medical Director will be notified of the Immediate Jeopardy and the contents of this plan on 4/16/24 and will be given progress updates. Monitoring The facility's implementation of the IJ Plan of Removal was verified through the following: Record review of the facility's Summary Utilization Report dated 01/01/24 through 04/16/24 reflected a 100% audit of all radiology requests made had been reviewed and verified physician notification was made on all request except for Resident #1 on 01/18/24. Record review of the Shift-to-Shift verification report reflected on 04/16/24 the DON participated in the 6 p.m. to 6 a.m. shift report and ADON B participated in the shift-to-shift report for the 6 a.m. to 6 p.m. shift changes. Record review of facility's in-service initiated on 04/16/24 by the Clinical Service Director reflected the DON was in-serviced on the facility's policy on Abuse and Neglect, fall management and assessment of the resident post fall, significant changes of condition and the facility's lab and radiology procedure for notification to physician. In an interview with the DON on 04/18/24 at 9:30 a.m. she stated the root cause of the failure was the ADON's failure to follow procedure and failure to follow up. She stated it was her expectation for any nurse who received an order due to a change of condition to follow up on the resident, notify the physician and family. She stated staff must report from shift to shift when there had been a change so ongoing follow up could continue. She stated she monitored for that by making daily rounds, following up after daily stand-up meetings and review of the 24-hour report. She stated going forward therapy had been instructed to notify her as well as the nursing staff on any changes in a resident's condition so she will be assured required follow up is completed. Record review of the facility's in-service initiated on 04/16/24 by the Clinical Service Director reflected the Administrator was in-serviced on the facility policy for abuse and neglect. In an interview with the MD on 04/18/24 at 10:54 a.m. he verified he had reviewed the facilities Plan of removal and stated he had reviewed with his NP his expectation for follow up on any their residents for X-ray results. In an interview with the Administrator on 04/18/24 at 11:14 a.m. he stated he had been re-educated on abuse and neglect on 04/16/24. He stated he had self-reported the allegation of neglect involving Resident #1 and they had suspended ADON A until the completed investigation. He stated he felt the failure of the ADON resulted in neglect related to the failure to follow up on the X-ray which resulted in the physician never becoming aware of the results and the resident not receiving necessary treatment. He stated it was an unfortunate time since he was also off during that time frame as well. He stated he made daily rounds especially on the rehab hall, so residents knew who to report any concerns to. He stated he had reached out to Resident #1's responsible party on 04/17/24 to inform them of the X-ray results and to let them know they were taking the failure very seriously and doing everything possible to ensure this never occurred again. Record Review of the facility's Inservice Records dated 04/17/24 reflected staff were educated on Fall management, Abuse and neglect, signification changes in condition, physician notification and verification of Radiology request. Interviews conducted on 04/17/27 from 3:30 p.m. to 4:00 p.m. with 2nd shift charge nurses RN E and RN C revealed they had received in-service training and were able to verbalize understanding of the in-service training regarding x-rays to be completed in timely manner and to follow up to physician and responsible party. They were knowledgeable of the documentation process for placing the orders in the electronic record, notation on the X-ray results of their review and notification to the physician. The were aware of the fall and incident reporting criteria and communication to oncoming shifts of any changes through the 24-hour report. They were all knowledgeable of abuse/neglect policy on reporting, neglect definition including a delay in treatment and to report any allegations immediately. Interviews conducted on 04/18/24 from 08:34 a.m. to 10:05 a.m. with 1st and 2 shift staff, LVN H, LVN I, LVN F, LVN J, LVN K, and LVN G revealed they had received in-service training and were able to verbalize understanding of the in-service training regarding x-rays to be completed in timely manner and to follow up to physician and responsible party. They were knowledgeable of the documentation process for placing the orders in the electronic record, notation on the X-ray results of their review and notification to the physician. They were aware of the fall and incident reporting criteria and communication to oncoming shifts of any changes through the 24-hour report. They were all knowledgeable of abuse/neglect policy on reporting, neglect definition including a delay in treatment and to report any allegations immediately. Interviews conducted on 04/18/24 from 10:10 a.m. to 10:40 a.m. with therapy staff COTA Q, PT R, PTA S, PTA T, and COTA W revealed they had received in-service training on fall management which included the reporting to the DON as well as nursing staff any self-reported fall from a resident, and any change in condition related to pain and inability to bear weight. The sta [TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one of six residents(Resident #1) reviewed for neglect. 1. ADON A failed to follow the facility's process for documentation, transcription and notifications when she failed to transcribe the physician's order on 01/18/24 for an X-ray request for Resident #1's left femur (thigh bone), failed to document an assessment of Resident #1's pain to determine the location, duration, and scale of Resident #1's pain, failed to place the X-ray request for 01/18/24 on the 24-hour report for follow-up, and failed to notify the responsible party of the X-ray request and results. 2. The facility staff failed to follow the facility's process for communication, both verbal and in writing, to the physician, X-ray results obtained on 01/18/24 which identified a left femoral fracture for Resident #1. 3. The facility staff failed to follow the facility's process for investigating Resident #1's complaint of an additional fall and pain on 01/15/24. Resident #1 fell on [DATE] at 03:15 a.m. with no apparent injury, but when attempting to get up, the resident's legs kept giving way. Resident #1 transported to the hospital and returned to the facility on [DATE] with no known fractures. On 01/15/24 Resident #1 complained of excruciating pain to her left leg and reported having an additional fall to PT R and the DOR/OT during their assessments. An X-ray was completed on 01/15/24 which was negative. On 01/18/24 another X-ray was obtained which showed a left intertrochanteric femoral fracture (type of hip fracture). The physician or family were never notified. Resident #1 was transferred to Facility X on 02/05/24 due to needing a Medicaid pending bed. Resident #1 continued to receive physical therapy at Facility X. On 02/13/24 Resident #1 was sent to the hospital due to continued hip pain and an X-ray confirmed a left hip fracture. Resident #1 received surgery to repair the hip fracture on 02/15/24, 29 days after the initial X-ray which showed the fracture. An Immediate Jeopardy (IJ) was identified on 04/16/24 at 04:45 p.m. The IJ template was provided to the facility on [DATE] at 05:02 p.m. and signed by the Administrator. While the IJ was removed on 04/18/24 at 01:15 p.m. the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in delayed medical treatment, ongoing pain, delay in rehabilitation, hospitalization and placed the resident at risk of death, bleeding, and increased severity of the initial fracture. Findings include: Record review of Resident #1's 5-day MDS assessment, dated 01/20/24, reflected a [AGE] year-old female admitted to the facility on [DATE] and a re-admission on 01/14/24. Resident #1 had a BIMS of 12 which indicated her cognition was moderately impaired. Resident #1 required partial to substantial assistance with ADLs. Her diagnoses included coronary artery disease, myocardial infarction (heart attack), COVID-19, and unspecified fall. The assessment indicated the resident had zero fall since re-admission and had no pain. She had received PT and OT services with a start date of 01/15/24. Record review of Resident #1's base line care plan dated 01/09/24, reflected, Resident is a new admission .post cardiac stents and COVID positive .Goals .Resident's immediate health and safety needs will be identified .Approach .Fall Risk .Minimize falls .Encourage use of call eight .Pain Management .Monitor Pain .Verbal/descriptor .Location .General Treatment-see Physician orders . Record review of Resident #1's PT evaluation and Plan of treatment completed by PT R, dated 01/15/24 reflected, .Patient subsequently was originally admitted to the [facility] on 1/09/24 in order to participate with rehab. However, she had experienced a backward fall after her admittance hitting her posterior (back) aspect of the head on the floor. She was returned to [Hospital name] for evaluation on 1/10/24. Following all of the routine tests at the hospital patient was diagnosed with NSTEMI (type of partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart). She was treated and eventually deemed clinically stabilized sufficiently to be returned to the [Facility] on 1/14/24 to resume her rehab. On the morning of 1/15/24 patient apparently transferred herself from the bed and possibly was attempting to walk toward the bathroom when she lost her balance and experienced another fall. There was ensuing pain in the left hip and along the full length of the lateral (outside) left femur prompting the order for a X-ray of the LLE (left lower extremity). The results were NEG(-) for showing any acute fracture or dislocation. However, patient is experiencing significant pain in the left hip which radiates along the tensor fascia [NAME] (muscle located in the upper outer thigh and hip) in distally to the lateral (outside) left knee. The pain is intense and increases with any attempt to move the left LE actively or passively from the current angulation (angle) described as left hip flexion (pulling the knee close to the chest), excessive across-midline adduction ( brining the hip towards the midline of the body), and internal rotation (happens when you twist your thigh inward from your hip joint). Pt's therapy will be addressing her declines in mobility and performance of ADLs due to her decreases in endurance, strength, and balance for upright positioning .History of Falls .The most recent fall on the morning of 01/15/24 resulting in strains/contusion to the lateral left hip/thigh/knee causing pain and challenges for movement (whether active or passive) for left hip. Attempts to passive move the left leg is met with protective guarding and resistance .Pain assessment .Pain at rest-4/10 (scale used where 0 is no pain 10 is most severe pain); frequency-constant, daily, location-left hip, Description-gnawing, heavy, throbbing, dull ache and burning .Pain with movement-9/10-Frequency- Daily, intermittent- location- Left hip/thigh/knee laterally. Pain description-Burning, aching, cramping and sharp, quick . Record review of Resident #1's OT evaluation and plan of treatment completed by the DOR, dated 01/15/24 reflected, .Once admitted , patient had a fall and was sent back out to hospital and was dx (diagnosed ) with NSTEMI. She has returned to this facility with therapy eval orders in place. She has already had another fall at this facility, c/o L hip pain, and was ordered Xray, which was negative for fracture. Upon eval, pt was unable to straighten LE, and remained in severe IR (internal rotation) to L hip. Nursing notified, and patient was assisted for improved positioning of LLE. She still complains 9/10 pain to L hip .Pain Assessment- Patient verbalized pain level .Paint at rest-4/10 .Pain with movement .9/10 .What relieves pain .sitting down, remaining still .What exacerbates pain .sitting, standing, bending, prolonged activity . Record review of the facility's falls summary report from 01/14/24 through 04/15/24 did not indicate a fall for Resident #1 on 01/14/24 or 01/15/24. Record Review of Resident #1's physician's orders for January 2024 did not reflect an order for X-ray for 01/15/24 or 01/18/24. Resident #1 did have Tramadol 50 mg 1 tablet every 6 hours as needed for pain with a start date of 01/14/24. Record review of Resident #1's Narcotic disposition form dated 01/18/24 for Tramadol 50 mg 1 tab every 6 hours as needed for pain, reflected the resident was treated for pain on 01/18/24, 01/19/24, 01/20/24, 01/21/24, 01/22/24 (2x), 01/24/24, 01/25/24 (2x), 01/26/24, 01/27/24, 01/28/24 (2x), 01/29/24, 01/30/24(2x), 01/31/24, 02/01/24, 02/02/24, 02/03/24 (2x), and 02/04/24. Record review of Resident #1's TAR from 01/14/24 through 02/04/24 reflected, Every shift check resident for level of pain utilizing numeric rating scale 0-10 or verbal descriptor scale mild, moderate, severe, very severe. Shift 1 from 01/14/24 through 02/04/24 indicated no pain. Shift 2 indicated- no pain from 01/14/24-01/17/24, 01/18/24-01/20/21- moderate pain, 01/21/24- no pain, 01/22/24-moderate, 01/23/24-no pain, 01/24/24- moderate pain, 01/25/24- no pain, 01/26/24-01/28/24-moderate pain, 01/29/24-no pain, 01/30/24-02/01/24 moderate pain, 02/02/24-02/04/24- no pain. Record review of the Radiology report dated 01/15/24 completed at 11:25 a.m. reflected, Femur min 2 views, left- Results .Negative left hip. Atherosclerotic vascular disease (buildup of plaque in arteries). The report was signed by the MD and noted by Agency LVN P as reviewed on 01/15/24. Record review of Resident #1's Nurse Progress note completed by Agency LVN P on 01/15/2024 at 02:01 p.m. reflected, residents femur x-ray report: conclusion: negative left hip, atherosclerotic vascular disease. There were no indications the responsible party were notified. Record review of the Radiology report dated 01/18/24 completed at 02:41 p.m. reflected, Conclusion: Interval increase in angulation (alteration of aliment) of the intertrochanteric left femoral (type of thigh bone fracture) fracture as noted. Compare with 01/15/24. Record review of the e-mail provided to the facility from the contracted radiology company on 04/17/24 reflected the following timeline: X-ray Ordered: 01/18/24 at 01:04 p.m.- completed on 01/18/24 at 02:20 p.m. Resulted on 01/18/24 at 02:41 p.m. Faxed to the facility on [DATE] at 02:45 p.m. Unsuccessful attempts called to facility at 01/18/24 at 04:59 p.m. and 05:47 p.m. Record review of Resident #1's NP's note dated 01/18/24 at 01:01 p.m. reflected, .Seen today without issues or concerns .Status post fall. No reports of syncope (dizziness). CT of the brain was negative. Fall precautions .plan of care reviewed and discussed with [MD] . Record review of Resident #1's hospital record dated 02/13/24 reflected, admitted to [Facility X] on 02/05/24 from [Facility Y] with left hip pain. Patient requested repeat X-ray today due to pain not getting any better. X-Ray showing left femoral neck fracture. Alert and oriented x 4, incontinent due to pain. Surgical repair of her left hip fracture was completed on 02/14/24. In an interview with LVN F on 04/16/24 at 10:15 p.m. she stated she worked the 06:00 a.m. to 06:00 p.m. shift. She stated she worked on 01/14/24 when Resident #1 was readmitted to the facility. She stated she did not recall her having any additional falls on her return to the facility. She stated she was off from 01/15/24 through 01/27/28. She stated the process when they received an order for an x-ray was to place the order in the resident's electronic record, place the order in the radiology request portal, place it on the 24-hour report and make a note in the progress note of the pending request and any assessment needed that resulted in the request. She stated once the results were received, they were to notify the family and MD and document in the progress note the notification was completed and sign off on the X-ray result and place it in the MD's box for their review. LVN F searched Resident #1's electronic record and stated there were no X-Ray results uploaded into the record. She stated the progress note dated 01/15/24 reflected an X-ray had been completed and was negative. LVN F searched the radiology portal and stated there were copies of the X-ray results for 01/15/24 and stated there was another report for 01/18/24. She stated the X-ray request for 01/18/24 was put into the system by ADON A. She stated the X-ray for 01/18/24 showed a fracture. She stated she was unaware the resident had a fracture. She stated that surprised her since the resident had not complained of pain to her. She stated the X-ray company would fax the results but would also call if the X-ray was positive for a fracture. In an interview with PTA S on 04/16/24 at 10:30 a.m. he stated Resident #1 had expressed to PT R during his assessment she had fallen again, but stated there was some confusion if she had fallen on the re-admission or if it was the fall, she had on her first admission on 01/09/24. He stated she was expressing pain the first day of therapy on 01/15/24, but after that she did not complain and was progressing slowly with therapy. He stated he knew the X-ray on 01/15/24 was negative for a fracture, so they proceeded forward with therapy. He stated he was unaware of the X-Ray completed on 01/18/24 and was shocked she had a fracture. In an interview with the NP on 04/16/24 at 10:40 p.m. she stated she vaguely remembered Resident #1. She stated she saw the resident 3 x week during her stay at the facility and she did not recall her ever complaining to her about pain in her hip. She stated she did not recall ordering an X-ray for the resident on 01/15/24 or 01/18/24. She stated she would usually place anything like that in her notes to ensure she followed up. She stated the nurse's may have mentioned it to her in passing and she gave a verbal OK for the X-Ray. She stated the facility would call her or the MD with the results of the X-ray and they placed a copy of the report in the MD's communication box for her and the MD to review. She stated she did not ever see an X-ray that showed a fracture to the resident's femur. She stated if she had she seen it they would have sent her out to the hospital for further evaluation and treatment immediately. In an interview with COTA Q on 04/16/24 at 11:00 a.m. she stated the DOR was off until 04/18/24. She stated the DOR had assessed Resident #1 on 01/15/24 and the resident had expressed severe pain in her left hip. She stated it was reported to nursing and an X-ray was obtained, which showed to be negative. She stated they continued to provide OT services to the resident for the remainder of her stay at the facility. She stated the resident did not complain of pain after 01/16/24. In an interview with ADON A on 04/16/24 at 11:30 a.m. she stated she was covering for the DON on the week of 01/15/24. She stated it was a crazy week, stating she had family who were also in the hospital during that time. She stated in addition they were using a lot of agency nurses. She stated she did not recall what prompted her to request the X-ray on 01/18/24 for Resident #1. She stated she did not recall being notified from PT or OT that Resident #1 had reported another fall on 01/15/24. She stated she should have placed an order in the resident's chart for the X-ray on 01/18/24 and should have placed it on the 24-hour report for follow up. She stated the nursing staff should have documented in the progress notes any complaints of pain the resident had and if PT had indicated a fall, and an incident report should have been completed. She stated she was unsure how the X-ray report was never reviewed by nursing or the physician. In an interview with CNA L on 04/16/24 at 11:45 a.m. she stated she worked with Resident #1 when she returned to the facility on [DATE]. She stated she was not aware of any additional falls for Resident #1 and did not recall her complaining of pain. Attempted to reach Agency LVN O on 04/16/24 at 12:14 p.m. by phone. No answer. Agency LVN O worked at the facility on 01/18/24 and was assigned to Resident #1's hall. In an interview with Facility X's DON on 04/16/24 at 12:20 p.m. she stated Resident #1 transferred to their facility on 02/05/24. She stated the resident had received therapy since her admission to their facility. She stated on 02/13/24 the resident requested a repeat X-ray of her left hip because she did not think Facility Y's X-rays were done correctly, since her left hip had continued to hurt. She stated they ordered an X-ray, which showed a left femur fracture. She stated the resident was sent to the hospital 02/13/24 and underwent surgical repair to her left hip. She stated the resident had since returned to the facility and was doing well. In an interview with PT R on 04/16/24 at 12:20 p.m. he stated he had reported to nursing on 01/15/24 about the resident's complaints of pain to her left hip, which was why an X-ray was ordered. He stated he did not recall if he reported to them about the resident's comments about falling that morning. He stated the X-Ray on 01/15/24 was negative, so they proceeded with therapy, but stated if a resident presented with symptoms or discomfort, they would back off therapy. He stated the resident did not present as someone with a hip fracture and was able to stand and ambulate for short distances. He stated it was not uncommon for a new admission to have more pain at first because they were sometimes waiting for the resident's pain medication to arrive. He stated the resident did not complain of pain after the first initial day and was making some progress in her therapy. He stated they will frequently ask nursing to request an X-ray if they have concerns about a possible fracture, but stated he did not request a second X-ray on 01/18/24. In an interview with the MD on 01/18/24 at 12:40 p.m. he stated he did not recall any calls from the facility regarding the results of an X-ray which showed a femur fracture for Resident #1. He stated had he been notified he would have sent her to the hospital immediately for treatment. He stated they would repeat an X-Ray if a resident continued to complain of pain and the initial X-ray was negative to make sure there was not a fracture. He stated the NP was in the facility three times a week and would update him of any changes in his patients. He stated he did not know why the radiology company did not contact him directly when they were unable to reach the facility. He stated an untreated fracture could result in death, increased pain, bleeding, and blood clots. In an interview with the DON on 04/16/24 at 1:10 p.m. she stated she was on family medical leave during the week of 01/15/24 and ADON A was covering for her. She stated she had not been able to locate any incident report of a fall for Resident #1 since her readmission on 01/14/24. She stated agency staff do not have access to the radiology portal so a facility staff member would had to have put in the request for any X-ray. She stated the facility staff should ensure the X-ray order was placed in the electronic record and placed on the 24-hour report for follow up. She stated the agency staff were oriented to the electronic record and were provided access. She stated they should document any assessment of pain or notification to the family and physician. She stated she suspected when the fax copy of the X-ray report came in it was placed in the box to be scanned instead of the MD's box for review and when the Medical Records clerk picked up the reports, she did not notice it had not been reviewed by the physician or nursing. She stated she would be doing education with the Medical Records clerk to ensure those reports were placed back into the MD's box to ensure proper review. She stated the failure started with ADON A when she did not ensure an order was placed in the electronic record, a progress note notifying the family of the requested X-Ray and failing to place it on the 24-hour report. She stated had the ADON followed up even with the misplacement of the report, they would have been aware of the results of the X-Ray. In a telephone interview with Resident #1 on 04/16/24 at 1:50 p.m. she stated she was finally on the road to recovery. She stated she remembered very little about her stay at Facility Y. She stated she did not recall falling and was not sure if she fell more than once. She stated she did not know if she was having a lot of pain. She stated she remembered in February 2024 having pain in her left hip when she moved a certain way. She stated she just remembered her stay at Facility Y was not pleasant. She stated since she had her hip repaired, she was walking with a walker and getting much stronger. In an interview with Agency LVN P on 04/16/24 at 3:10 p.m. she stated she worked at the facility on 01/15/24, 01/16/24 and 01/17/24. She stated she did recall Resident #1 and remembered the physician had requested an X-ray on 01/15/24 due to hip pain. She stated she did not recall being told she had fallen. She stated she remembered Resident #1's family was with her most of the time, and would ask for pain medication for her, but stated when she assessed her for pain the resident would deny being in pain. She stated if she got an order for an X-ray, she would have to get one of the facility staff to place the request in the portal since she did not have access. She stated she would place the information about the X-ray on the 24-hour report and any notifications she made in the progress notes. Attempted to contact Agency LVN M on 04/16/24 at 4:22 p.m. who worked on 01/18/24. Unable to leave a message-voice mail was full. Record review of the facility policy titled Laboratory Testing, revised May 2023 reflected . Requests for diagnostic services must be ordered by the patient/resident's attending physician or physician extender .Orders for diagnostic services must be entered into the resident's medical record and signed by the attending physician or physician extender .Results of laboratory, radiological, and diagnostic tests shell be reported in writing to the resident's attending physician or physician extender or to the facility via fax or electronic reporting .The attending physician or physician extender shall be promptly notified of abnormal, critical, or stat test results. The charge nurse receiving the test results shall be responsible for notify the physician or physician extender of such test results in a timely manner . Record review of the facility's policy, Physician and other communication/change in condition revised May 2023, revealed To improve communication between physician and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decision regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/resident's and their responsible party regarding change in condition .Complete assessment of the patient/resident which may include but is not limited to .Patient's/resident's previous condition .Recent labs, x-ray results .Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record .The patient/resident and patient's /resident's family member/legal representative will be notified of any changes in medical condition or treatment plan . Review of facility's policy Abuse, neglect, exploitation, or mistreatment last revised October 2019 reflected The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition .and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .In the event an employee is accused of abuse/neglect, that employee will be suspended during the investigation process . The Administrator was notified on 04/16/24 at 05:02 p.m. that an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided at this time and plan of removal was requested. The facility's plan of removal was accepted on 04/17/24 at 05:22 p.m. The accepted plan of removal for the Immediate Jeopardy included the following: [Resident #1] is not currently in the facility. The allegation of neglect was reported to the state agency on 4/16/24 and is being thoroughly investigated. Appropriate actions will be taken as the investigation is conducted. The results of the investigation will be submitted to the state agency in 5 days. The responsible party of Resident #1 will be notified of the allegation 4/17/24 and subsequent investigation once completed. A house wide audit will be completed of x-rays completed since 1/1/24 to validate that any abnormal results have been reported to the physician for further direction, responsible parties have been notified and that physician orders for the x-ray are in the medical record. This will be completed by the Director of Nursing/Designee by 4/16/24. The facility activity report and the 24-hour report for the past 14 days will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 4/16/24. The facility activity report and the 24hour report for the past 14 days will be audited by the Director of Nursing/Designee to identify any x-ray ordered and validate that the physician has been contacted with results for further direction and the responsible party notified. This will be completed by 4/16/24. The Administrator and Director of Nursing were reeducated by the Clinical Consultant on 4/16/24 on Abuse, Neglect & Misappropriation Policy, fall management and assessment of resident post fall that included: If a fall occurs, licensed nurse will evaluate the resident for injury and determine what may have caused or contributed to the fall and determines appropriate interventions to prevent future falls and completed a fall investigation worksheet. Licensed Nurses will continue to evaluate the resident 72hours post fall to identify any possible delayed injuries. Physician and responsible party will be promptly notified of a change of condition, including falls. Physician will be notified for additional injury, including pain for further orders. Responsible party will be notified for additional injuries. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition, notify the physician for further direction, and notify the responsible party. Requests for diagnostic services must be ordered by the resident's physician. Orders for diagnostic services will be promptly carried out as directed in the physician's order. Shift to shift report will be given to oncoming nurse for effective communication regarding resident care and treatment, including changes of condition, new orders, incidents/accidents and follow up for diagnostic services. The Administrator and Director of Nursing were reeducated by the Clinical Consultant on 4/17/24 on change of condition including. Residents showing signs of a change of condition will be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction. Assessment may include but not limited to a. Residents physical condition b. Residents previous condition c. Vital signs, including pain. d. Recent labs, x-rays e. Previous and current mental status f. Medications g. Resident wishes h. Any interventions provided to the resident. Licensed Nurse will notify responsible party of residents change in condition. Identified Assistant Director of Nursing was reeducated by the Director of Nursing on 4/16/24 on Abuse, Neglect & Misappropriation Policy, fall management and assessment of resident post fall that included: If a fall occurs, licensed nurse will evaluate the resident for injury and determine what may have caused or contributed to the fall and determines appropriate interventions to prevent future falls and completed a fall investigation worksheet. Licensed Nurses will continue to evaluate the resident 72hours post fall to identify any possible delayed injuries. Physician and responsible party will be promptly notified of a change of condition, including falls. Physician will be notified for additional injury, including pain for further orders. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction. Requests for diagnostic services must be ordered by the resident's physician. Orders for diagnostic services will be promptly carried out as directed in the physician's order. Shift to shift report will be given to oncoming nurse for effective communication regarding resident care and treatment, including changes of condition, new orders, incidents/accidents and follow up for diagnostic services. Identified Assistant Director of Nursing was suspended on 4/16/24 pending investigation. Identified therapist was reeducated by the Director of Nursing on 4/17/24 regarding change in conditions that require notifications to the charge nurse including: Resident complaining of new or increased pain. Resident has a change in condition including the ability to bear weight. Licensed Nurses and Therapy Staff will be reeducated on 4/17/24 by the Director of Nursing/Designee on the fall management policy including reporting of falls, this includes self-reported falls which must include evaluation of the resident for injury and investigation using a fall investigation worksheet to determine what may have caused or contributed to the fall or self-reported fall, notification to physician for further orders and notification to the responsible party. Any member of the target audience not receiving this education by 4/17/24 will receive prior to their next scheduled shift. Licensed nurses will be reeducated by the Director of Nursing/Designee on Abuse, Neglect & Misappropriation of Property Policy, fall management and assessment of resident post fall that includes: If a fall occurs, licensed nurse will evaluate the resident for injury and determine what may have caused or contributed to the fall and determines appropriate interventions to prevent future falls and completed a fall investigation worksheet. Licensed Nurses will continue to evaluate the resident 72hours post fall to identify any possible delayed injuries. Physician and responsible party will be promptly notified of a change of condition, including falls. Physician will be notified for additional injury, including pain for further orders. Responsible party will be notified for additional injuries. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition, notify the physician for further direction, and notify the responsible party. Requests for diagnostic services must be ordered by the resident's physician. Orders for diagnostic services will be promptly carried out as directed in the physician's order. Shift to shift report will be given to oncoming nurse for effective communication regarding resident care and treatment, including changes of condition, new orders, incidents/accidents and follow up for diagnostic services. Licensed Nurses will be reeducated on 4/17/24 by the Director of Nursing/Designee on change of condition including: Residents showing signs of a change of condition will be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction. Assessment may include but not limited to i. Residents physical condition j. Residents previous condition k. Vital signs, including pain. l. Recent labs, x-rays m. Previous and current mental status n. Medications o. Resident wishes p. Any interventions provided to the resident. Licensed Nurse w [TRUNCATED]

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 three of six residents (Resident #39, Resident # 33, Resident # 385 and Resident # 336) and eight of 13 rooms (Rooms #201, #202, #203, #204, #205, #207, #208 and #209) reviewed for infection control. 1. LVN C failed to perform hand hygiene after completion of insulin injection on Resident # 39. 2. LVN D failed to clean Resident #33's administration site with an alcohol wipe prior to giving her an insulin injection. 3. CNA J failed to use hand hygiene while passing lunch trays on the 200 hall, Rooms #201, #202, #203, #204, #205, #207, #208 and #209. 4. MA F failed to sanitize the blood pressure cuff between uses on Resident # 385 and Resident # 336. Theses failure could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #39's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had a diagnosis which included type 2 diabetes mellitus. Observation during medication pass on 11/14/23 at 10:37 AM revealed LVN C placed numerous plastic cups on a tray with alcohol wipes, lancets, a whole bottle of test strips, gloves, glucometer, and Residents #39's Novolog insulin (in a vial) and her Lantus insulin Pen -both in plastic bag on a tray. LVN C entered Resident #39's room and placed the tray of supplies on the resident's bedside table. LVN C washed her hands and put on gloves and performed a fingerstick blood sugar check. LVN C removed her soiled gloves and placed them on tray beside the insulins and the bottle of test strips and left the room to go to the medication cart outside of the door without performing hand hygiene. LVN C determined the amount of Insulin the resident required returned to the room and washed her hands and re-gloved. LVN C removed the box of Novolog insulin out of plastic bag and drew up 4 units and administered insulin to the resident. LVN C removed her gloves and placed them on the tray and without performing hand hygiene placed the insulin back in the plastic bag and placed the dirty glucometer on the tray next to the bottle of test strips. LVN C returned to the medication cart with tray of supplies, put on gloves, and pulled out a germicidal disinfectant wipe and wiped down the glucometer and placed it back in the top drawer of the medications cart without letting it dry. LVN C then removed her gloves and placed the vial of test strips without sanitizing them, the remaining alcohol wipes, lancets, and the packages of insulin and placed them back in the medications cart. In an interview with LVN C on 11/14/23 at 10:55 AM, she stated she used the various cups to keep everything separate. She stated she was supposed to sanitize her hands before and after each procedure and she did not realize she had not sanitized her hands before she had touched the computer and placed the vial of insulin back in its plastic bag. She stated she should have only taken the supplies needed into the room to prevent the risk of cross contamination. Record review of LVN C's competency checks, dated 09/04/23, reflected she was competent in administering subcutaneous injections, blood glucose monitoring and hand washing. 2. Record review of Resident #33's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #33 had diagnoses which included type 2 diabetes mellitus. Observation during a medication pass on 11/14/23 at 11:00 AM revealed LVN D entered Resident #33's room to obtain a fingerstick blood sugar. After checking the resident's blood sugars LVN D removed her gloves performed hand hygiene and checked the computer to determine the amount of insulin required. LVN D primed the insulin pen and dialed in 5 units. LNV D then administered the insulin in the resident's abdomen without first cleaning the site with alcohol disinfectant. In an interview with LVN D on 11/14/23 at 11:10 AM, she stated she was supposed to clean the site with alcohol before administering the insulin. She stated failing to do this posed the risk of introducing germs into the resident. She stated she could not believe she forgot. She stated she just got nervous. In an interview with the DON on 11/14/23 at 11:15 AM, she stated staff were not following the facility procedure if they were carrying in multiple supplies to check a resident's blood sugars. She stated they were only to carry in the necessary supplies needed to check a blood sugar, then perform hand hygiene and retrieve the required insulin and perform hand hygiene before and after giving the insulin. She stated any injection required the nurse to clean the site with alcohol before giving the injection to prevent the introduction of germs into the resident. She stated that was nerves on the nurse's part. She stated failure to follow the correct procedures placed residents at risk of blood borne pathogens as well as infections and cross contamination. Record review of LVN D's competency checks, dated 09/01/23, reflected she was competent in administering subcutaneous injections. Record review of the facility's Staff Education/Orientation Policies and Procedure titled, Infection, subcutaneous, dated July 2013, reflected, .select site for administration .Cleanse site using circular motion from center outward about 2 inches and allow to dry 3. Observation on 11/14/23 at 11:45 AM at 12:08 PM revealed CNA J on hall 200, with the food cart that was pushed to the floor (hall 200). CNA J approached the food cart and proceeded down the hall (200). CNA J did not use hand hygiene prior to touching the food cart, prior to touching food trays, or while passing out lunch trays to residents on 200 Hall. CNA J approached the food cart on the hall and proceeded to remove the food tray for rooms beginning at #201 - #213, helping to set up trays for eating and assisting residents to sit up in bed. Interview on 11/14/23 at 1:00 PM with CNA J revealed she was working through agency at the facility. CNA J stated she had not received infection control or hand hygiene in-services. CNA J stated she was aware of using proper hand hygiene, she used hand hygiene before and after entering resident rooms and during before and after resident care. Observation on 11/15/23 at 11:45 AM at 12:08 PM revealed CNA I and CNA J on hall 200, the food cart was pushed to the floor (hall 200) by kitchen staff. CNA J approached the food cart and proceeded to pass out trays down the hall (200). CNA J did not use hand hygiene prior to touching the food cart, prior to touching food trays, or while passing out lunch trays to residents on 200 Hall. CNA J continued to assist on hall 200, passing lunch trays, without using proper hand hygiene. Interview on 11/15/23 at 1:05 PM with CNA I revealed she was working through an agency at the facility. CNA I state she completed training on infection control and use of proper hand hygiene. CNA I stated she was aware to use proper hand hygiene before and after entering resident rooms, before, after and sometimes during resident care. CNA I stated the facility continually expressed the importance of hand hygiene. CNA I stated it was important to use proper hand hygiene to prevent the spread of infection. Interview on 11/15/23 at 1:15 PM with CNA J revealed she was not using proper hand hygiene to pass out lunch trays. CNA J stated she knew to use hand hygiene while passing out trays, however, she was just trying to get the food trays passed out before they got cold. CNA J stated not using proper hand hygiene could spread infection and cause residents to become sick. Interview on 11/16/23 at 2:04 PM with LVN E revealed it was her expectation that staff were using proper hand hygiene, at all times. LVN E stated she was not aware CNA I was not using proper hand hygiene while passing food trays. LVN E stated she expected staff to use hand hygiene while passing food trays, before and after entering resident rooms and during resident care. LVN E stated not doing so put residents and staff at risk of spreading possible infection from one resident to another. Interview on 11/16/23 at 2:20 PM with the DON revealed all staff were to use proper hand hygiene while working. The DON stated there were several in-services completed on Infection Control and Hand Hygiene. The DON stated the last In-service was done about 2 weeks ago. The DON stated CNA J was reminded recently to ensure she was using proper hand hygiene while the state surveyors were in the facility. The DON stated it was her expectation for staff to use hand hygiene before and after entering resident rooms to prevent spread of disease and infection. The DON stated ultimately, she was responsible for ensuring staff followed facility protocols, however each staff was responsible to ensure they used proper hand hygiene at all times. Record review of the facility's policy titled, Hand Hygiene/ handwashing, dated May 2023, reflected, Hand hygiene/hand washing is done before patient/resident contact .Before taking part in a medical or surgical procedure .After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids .After contact with a contaminated object or source where there is a concentration of microorganisms .After removal of medical/surgical or utility gloves 4. Record review of Resident #385's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included hypertension ( high blood pressure) and urinary tract infection. Record review of Resident # 336's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #336 had diagnoses which included heart failure and urinary tract infection. Observation during medication pass on 11/15/23 at 09:00 AM revealed MA F entered Resident #385's room to obtain her blood pressure. After performing the blood pressure reading MA F returned to the medication cart and obtained the resident's morning medications and administered them. MA F returned to the cart and walked across the hall with the un-sanitized blood pressure cuff to take Resident # 336's blood pressure. After several attempts to get a reading, MA F went to the cart and retrieved a wrist blood cuff and obtained the resident's blood pressure. In an interview with MA F on 11/15/23 at 9:20 AM, she stated she was supposed to clean the blood pressure cuff with a germicidal wipe after each use. She stated she was trying to get Resident #336's medication to her before she went to therapy. She stated she knew she was supposed to clean all the equipment between residents to prevent the spread of infection. In an interview with the DON on 11/15/23 at 10:10 AM, she stated the staff were required to clean the equipment used after each use before using it another resident. She stated failure to do this could potentially spread germs. Record review of the facility's policy titled, Cleaning, disinfecting and sterilizing patient/resident care equipment. Dated May 2023 reflected, Equipment will be maintained and kept sanitized or disinfected in accord with acceptable polices .non-critical items are those that come in contact with intact skin but not mucous membranes. Such items include .blood pressure cuffs . Routine cleaning and disinfection of resident care equipment that is shared among residents will be completed. The items require cleaning followed by eighter low or intermediate level disinfection following manufacturer's instructions. Disinfection should be completed by an EPA-registered disinfectant labeled for use in healthcare settings . 48236

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 18 residents (Resident #79) reviewed for accommodation of needs. The facility failed to ensure Resident #79's call light was placed within his reach. This failure could place residents at risk of injuries and unmet needs. The findings include: Record review of Resident #79's face sheet, dated 11/16/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included multiple sclerosis (chronic disease of the central nervous system), unspecified fracture of right lower leg, subsequent encounter for closed fracture with routine healing (admission), essential hypertension (high blood pressure), muscle weakness. Record review of Resident #79's care plan, dated 09/28/23, reflected the following: Problem: [Resident #79] is at risk for falling R/T impaired balance and weakness as evidenced by a fall on 11/15/23. Goal: Resident will be free from injury from falls daily over the next review period. Approach: Keep call light in reach at all times. Problem: ADLs Functional Status/Rehabilitation Potential [Resident #79] requires use of U assist rails for positioning/transfer assist. Goal: Will maintain current level of independence with bed mobility/positioning next quarter. Approach: Keep call light in reach at all times. Record review of Resident #79's admission MDS Assessment, dated 10/29/23, reflected she had a BIMS score of 14, which indicated intact cognition. Observation and interview on 11/14/23 at 1:18 PM revealed Resident #79 lying in his bed and his call light was underneath the bed on the floor. Resident #79 stated he was doing well, when asked about his call light he stated it was somewhere in his bed. Resident #79 stated he did not need assistance at the time. Resident #79 was unaware of the location of his call. Resident #79 stated call light is usually next to him. Observation and interview on 11/14/23 at 2:29 PM revealed Resident #79 lying in his bed and his call light was underneath the bed on the floor. Resident #79 was sleeping. Observation and interview on 11/14/23 at 3:15 PM revealed Resident #79 lying in his bed and his call light was underneath the bed on the floor. Resident #79 was sleeping. Interview on 11/14/23 at 3:30 PM with CNA G revealed she was caring for Resident #79 and was last in his room around 2PM to change him. CNA G stated she placed the call light next to Resident #79. CNA G stated call lights were supposed to be within reach of the resident. CNA G went to Resident #79's room and observed the call light was underneath the bed on the floor. CNA G stated all staff were responsible, including her, to ensure a resident could reach their call light by placing it within their reach. CNA G stated the risk of not keeping the call light within reach could be a resident needing help and the call light was the only way to call for assistance . Interview on 11/14/23 at 3:35 PM with LVN K revealed she was the nurse assigned to Resident #79. She stated the last time she observed Resident #79 was around 2 PM when she provided him with his afternoon medications. She stated call lights should be within reach of the resident. She stated when she went to Resident #79 room she did not ensure if the call light was within reach. She stated there was not risk to Resident #79 because the resident was able to yell out for help. She stated call lights were needed for residents to call for assistance. Interview on 11/16/23 at 4:49 PM with the DON revealed her expectation was for call light to be within reach. She stated all staff were responsible for ensuring a resident's call light was within their reach. The DON said the purpose of having a call light within reach of the resident was so they could utilize it. A policy regarding Call light/Bells was requested; however, it was not provided upon exit.

Based on interviews and record reviews, the facility failed to ensure personnel provided basic life support, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED].#1) of seven residents reviewed for CPR. Facility staff failed to immediately call 911 to request emergency medical personnel and utilize the Automatic External Defibrillator (AED) when it was determined Resident #1 had no respirations or pulse on [DATE] at 3:45 p.m. Resident #1 expired at the facility on [DATE]. It was determined an Immediate Jeopardy (IJ) existed from [DATE] to [DATE]. The IJ was determined to have been removed on [DATE] due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. These failures could affect the residents by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] and a readmitted on [DATE]. Resident #1 was cognitively intact, required extensive two-person assist with ADLs, and had active [DIAGNOSES REDACTED]. Review of Resident #1's Face Sheet dated [DATE] reflected his advance directives were Full Code. Review of the Provider Investigation Report submitted by the facility on [DATE], reflected, On [DATE] (ADON A) reported to the Abuse coordinator that (RN B) reported to her that she had heard there was alleged lapse in CPR for (Resident #1) on [DATE]. (Resident #1) was checked on by the Nurse aide at approximately 3:40 p.m. and found lying in bed unresponsive. (no date indicated). The aide assigned to the resident got the nurse and when they entered the room the resident was unresponsive with no pulse or respiratory rate. Allegedly the nurse was not aware of whether the resident was a full code and he went to get the weekend RN to verify code status. According to the allegations received by the ADON, 15 minutes elapsed before starting CPR, 911 was called and resident was expired on arrival. The allegation category was neglect. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Care Plan dated [DATE] reflected: Advanced Care planning- Full Code with a start date of [DATE]. Review of Resident #1's Nurse Progress notes, dated [DATE], created by LVN C at 4:58 p.m. reflected, Resident noted unresponsive by CNA and notified Charged (sic) nurse around 3:45 p.m. This Nurse with Supervisor went in room and found pt (patient) lying on supine position. Upon assessment no breath sounds, BP (blood pressure) or pulse noted. Pt non-responsive to verbal/tactile stimuli. SPPO2 (oxygen saturation) 20% on O2 @ 2 LPM (liters per minute) via NC (nasal cannula). CPR immediately initiated around 3:50 p.m. for about 15-Paramedics notified about 4:20 p.m. and they arrived at 4:26 p.m. Resident was pronounced dead at 4:28 p.m. MD notified at 4:30 p.m . Review of the Emergency Medical Services (EMS) run report dated [DATE] reflected they were called at 4:17 p.m. and arrived at the facility at 4:24 p.m. First CPR was started at 4:00 p.m. by facility staff. CPR was being performed when EMS arrived. Initial ECG (electrocardiogram-electrical activity of the heartbeat) Rhythm was asystole (flat line- no signs of life) CPR was discontinued due to obvious signs of death. EMS notes reflected, .Upon arrival EMS found the PT laying (sic) in bed. Staff was performing CPR and using a BVM (manual resuscitator). EMS started to take over CPR and saw lividity (pooling of blood following death) on the pt.'s back. EKG (also known as ECG) was obtained and showed asystole. Staff stated his last known normal was around 1400 (2:00 p.m.) A staff member took him some water and ice and he was asleep. Pt has extensive medical history as noted. EMS talked to the RN. RN stated time of death was 1628 (4:28 p.m.). In an interview with CNA H on [DATE] at 1:30 p.m. she stated on [DATE] she had taken Resident #1 some crushed ice around 2 p.m., and he was lying in bed sleeping. She stated she checked on him again between 3:,[DATE]:00 p.m., found him unresponsive and immediately reported it to LVN C. CNA H stated she could not remember the exact time she found Resident #1 unresponsive. She stated she could not say whether CPR was performed on Resident #1, because she left the room after the nurse arrived. She stated the Weekend Supervisor (RN I) asked her and CNA G if they knew how to prepare a body for the funeral home and she told her yes. She stated she and CNA G were instructed to clean the resident up. She stated she and CNA G later told LVN F about the resident passing, and LVN F asked if CPR had been done. She stated that after they cleaned the body, EMS arrived later. Interview with LVN C on [DATE] at 10:25 a.m. revealed he had been at the nurse's station on [DATE] when he was alerted by a CNA (could not recall her name) that Resident #1 was non-responsive. He stated RN I was at the desk and followed him to the room. He stated he checked the resident and found the resident had no pulse or respirations. LVN C stated since he was not sure if Resident #1 had a full code status, he started CPR while RN I left to get the cart and check code status. He said she returned with the cart and LVN K. LVN C stated he was told by RN I that the resident was a full code, and LVN K aided with the code. He stated it was after RN I and LVN K got to the room that he was able to call 911. In a follow up interview on [DATE] at 1:25 p.m. LVN C revealed the AED was not used on Resident #1 after he was found unresponsive. LVN C stated the AED was not used because he was busy performing compressions and assessing the resident and did not think about it. LVN C confirmed the use of the AED was part of his CPR training. In an interview with CNA G on [DATE] at 2:00 p.m. she stated on [DATE] CNA H asked her to come and help with Resident #1. She stated RN I, CNA H, and she went to Resident #1's room. She stated RN I put a pulse oximeter on Resident #1's finger and confirmed he had no pulse. She stated RN I then instructed her and CNA H to clean the resident in preparation for the family and funeral home. CNA G stated she did not see them do CPR but stated she was certain they were asked to clean him up prior to them doing CPR. She stated after they cleaned him up she left and went back to the hall. She stated she saw the licensed nurses take the crash cart into the room. She could not recall when the paramedics came. In an interview with RN I (the Weekend Supervisor) on [DATE] at 3:40 p.m. she stated she and LVN C were alerted by one of the CNAs that Resident #1 was not responsive. She stated she and LVN C went to the resident's room where LVN C assessed the resident and found he had no pulse. She stated LVN C started CPR and she left the room to get the crash cart and get help. She stated LVN F returned with her to Resident #1's room and he started assisting LVN C, while she tried to get the other resident out of the room. She stated the CNAs were not in the room during CPR. She stated she though LVN C called 911 but was not sure. She stated she instructed the aides to prepare the body after the arrival of EMS. An interview with LVN K on [DATE] at 9:24 a.m. revealed he was working on hall 100 and was at the nurse's station when RN I asked him to come and assist with Resident #1. He stated RN I was pushing the crash cart to the resident's room. He stated LVN C was with the resident and in the process of getting the bed adjusted to perform CPR. LVN K stated he started doing ventilations with the manual respirator while LVN C did compressions. He stated he was not sure who called 911. He stated once EMS arrived and took over, he returned to his hall to check on his residents. In a follow up interview on [DATE] at 1:30 p.m. LVN K stated he could not remember seeing the AED in the room when he went to assist with CPR on Resident #1. He stated everything happened so quickly. He stated he assisted with ventilation until the paramedics arrived, which was not long after he got to the room. LVN K stated in the event of an unwitnessed arrest he was to stay with the patient, call code blue, and to direct someone to call 911 and get the crash cart and AED. He stated if the resident was full code, he was to start compressions until the AED arrived, and then follow the prompts from the AED until EMS arrived. Interview with LVN F on [DATE] at 1:20 p.m. revealed she was working the hall on [DATE] when CNAs H and G came up to her and told her Resident #1 had passed away. She stated she asked the CNAs if CPR had been started, and they said they did not know. She stated she told them to tell RN I he was a full code. She stated she saw the crash cart go into the room and about five minutes later, EMS arrived. She stated she did not go to the room to assist during that time, because she had to monitor the dining room. Interview with Cook D on [DATE] at 10:05 a.m. revealed on [DATE] she was in the dining area waiting for the staff to pick up meal tickets when someone stated EMS had arrived at the facility. She stated about 30 minutes later, CNA J told her the resident in room [ROOM NUMBER] had died and the nurses did not do a full code on him. Interview with RN B on [DATE] at 3:30 p.m. revealed she had received a call from Cook D on [DATE] around the evening meal time, stating Resident #1 had died and the staff did not do CPR. She stated she looked in the computer and did not see any documentation about staff performing CPR, so she called ADON [NAME] and told him he might want to check it out. She stated later, ADON [NAME] told her CPR had been done, so she let it drop. Interview with ADON [NAME] on [DATE] at 1:05 p.m. revealed on [DATE] he re-read Resident #1's nurses note from [DATE] and there was a delay in calling 911 when Resident #1 was found unresponsive. He stated 911 should have been called immediately. He stated the DON had him start in-services on [DATE] regarding abuse and neglect and reporting. Interview with the Administrator on [DATE] at 8:35 a.m. revealed he had been called by the DON on [DATE] to let him know that Resident #1 had passed away in the facility. The Administrator stated at that time nothing indicated the abuse and neglect protocol had not been followed. The Administrator stated when he returned to the facility on [DATE], he was called by the DON and was told they may have had a possible reportable incident regarding Resident #1's death. He stated he immediately started interviewing the staff involved in the incident. He stated he, the DON and ADON A called and spoke with CNAs G and H. The Administrator stated CNA H reported on [DATE] she had checked on Resident #1 between 2:,[DATE]:15 p.m. and he appeared to be okay, but when she went back between 3:40 to 3:45 p.m., she found Resident #1 unresponsive. The Administrator stated CNA H reported she alerted LVN C, who went to the room and checked on Resident #1. The Administrator stated he spoke with LVN C on [DATE] at around 6:45 p.m. He stated LVN C told him that after assessing the resident and finding him with no pulse or respirations, he immediately started CPR. The Administrator stated LVN C reported RN I brought in the crash cart, and LVN K came and assisted. The Administrator stated after he got off the phone with LVN C, he contacted the DON and they agreed to speak with the Clinical Services Director (CSD) the next morning. He stated he received a call from the Regional Vice President (RVP) and CSD around 9:00 p.m. on [DATE] and after reviewing the day's events it was agreed to call in the report that evening to the State Survey Agency. The Administrator stated when he returned to the facility on [DATE], he and the DON were suspended pending the investigation, and the investigation was taken over by the CSD at that time. He stated had the staff just called on [DATE] when they first thought something was not right, then all of this could have been avoided. Interview with the DON on [DATE] at 10:00 a.m. revealed she was notified of a possible case of neglect regarding Resident #1 on [DATE] by ADON [NAME] The DON stated she immediately notified the Administrator and had instructed the ADONs to start in-services on abuse and neglect. She stated the Administrator started making calls to the individuals who supposedly had information about the issue. She stated she had reviewed the nurse's progress note for [DATE], which indicated CPR had been done. She stated she did notice the gap of time it took from when CPR was started and when EMS arrived but had not had a chance to speak with any of the nurse's involved because return calls had not been received. She stated the Administrator had called her the evening of [DATE] to tell her what LVN C had said, and to let her know he had called the incident into the State Survey Agency. She stated when she arrived at the facility on [DATE], she was told she was suspended. She stated someone had called the Corporate hot line and reported that the incident was not being investigated. She stated she and the Administrator were removed from the investigation at that time. She stated when she returned on [DATE], in-services for Abuse/Neglect, reporting guidelines, 24-hour report and shift communications, HIPPA, Emergency 911, emergency cart and AED, CPR, DNR and Change of communication were scheduled for [DATE] and [DATE] by the CSD. She stated in-service were also scheduled for [DATE] to capture the weekend staff who had not yet attended. She stated she had also scheduled CPR classes for [DATE]. She stated she did not know why RN B did not alert her or the Administrator on [DATE] or why ADON A did not alert either of them on [DATE] when she first heard of the concern. Interview with the CSD on [DATE] at 11:22 a.m. revealed the facility's corporate office had received a call regarding a concern that an allegation of abuse was not investigated. She stated as per protocol the company suspended the Administrator and the DON, who would be responsible for investigating and she took over the investigation on [DATE]. She stated the allegation was that CPR had not been performed on Resident #1. She stated she had noticed the delay from the time CPR was started and when 911 arrived but stated she did not ask LVN C why there was a delay. She stated CNAs G and H had alleged they were asked to clean the resident by RN I, before CPR was started. In a follow up interview with the CSD on [DATE] at 1:20 p.m. revealed she did not ask LVN C, LVN K or RN I if they used the AED. She stated she just assumed they had, since that is a standard of care when providing CPR. Review of the facility's policy, Emergency -911, dated (MONTH) (YEAR), reflected, .The staff will call 911 for emergency situations. This policy only applies to resident who have been determined to be a full code .Qualified staff initiates the appropriate emergency procedures .CPR (with or without automatic external defibrillation (AED)), as appropriate, etc., In accordance with patient/resident Advance directives .Call 911 when the patients/resident's condition is life threatening .Qualified staff attempts to stabilize and monitor the patient/resident until the advance medical team arrives . Review of the facility's policy Cardiopulmonary Resuscitation, Emergency Code Blue revised [DATE], reflected, .The facility ensures provision of basic life support and CPR including: .Staff are directed to initiate CPR when cardiac or respiratory arrest occurs .Who have not formulated an advanced directive .Procedure .Follow practice guideline for CRP by initiating Resuscitation with and without Automatic External Defibrillator ( AED) , as appropriate .Page overhead Code Blue .Call 911 for emergency transfer to an acute care center .Continue CPR efforts as appropriate . Review of the American Heart association's guidelines for CPR reflected, . Cardiac Chain of Survival . To have the best chance of recovering from a [MEDICAL CONDITION] the ARC (American Red Cross) advises that individuals should follow the Cardiac Chain of Survival. The chain starts with early recognition of [MEDICAL CONDITION] and immediately upon recognition activation of Emergency Medical Services with a rapid response from them. The second link in the chain is CPR provided by those on scene with the victim immediately at the time of collapse. The third link is early defibrillation, when appropriate, by quick use of an AED by bystanders. The final link is early advanced care as provided by Emergency Medical Services and then a hospital with the capability of correcting the problem which led to the [MEDICAL CONDITION] . (retrieved on [DATE] from https://www.cprcertificationonlinehq.com/american-red-cross-official-guidelines-cpr-2014/-) Review of the Texas Board of Nursing Standards of Nursing Practice, reflected a nurse must, .(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications . (retrieved on [DATE] from http://www.bon.texas.gov/rr_current/,[DATE].asp) On [DATE] at 3:00 p.m. The Administrator was informed an Immediate Jeopardy was determined to have existed from [DATE] to [DATE]. Review of the facility's investigation report revealed the facility took the following actions to correct the noncompliance prior to the visit on [DATE]: Review of in-service documentation revealed Licensed Nurses were re-educated on [DATE] by the ADON on the Cardiopulmonary Resuscitation Policy and process to include the following: Change of condition, Crash Cart, Full code, DNR and coding procedures. Review if in-service documentation revealed Licensed Nurse and support staff were re-educated on [DATE] and [DATE] by the CSD on the following: Resuscitation Equipment will be maintained in designated crash carts in general nursing areas. Person finding the resident unresponsive will not leave the resident unattended but will call for help immediately. Licensed nurses will respond immediately to the emergency and evaluate resident and begin resuscitation effort if indicated. Nurse will direct nursing staff, either nurse or Certified Nursing Assistant to check the resident's code status found in the resident's chart. Must have the DNR on the chart if identified as a DNR. Nurse will direct Certified Nursing Assistants or other staff to gather equipment (crash cart) and bring to the resident room. Staff will call 911 and offer assistance to the nurse. Once resuscitation is initiated it must continue until Emergency Medical Services arrives and takes over, or residents' spontaneous efforts have returned and are adequate. Individual interviews with facility staff representing multiple shifts (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, and LVN Q) on [DATE] between 01:24 p.m. and 2:30 p.m. revealed they had received in-service training on [DATE] and [DATE] and understood to initiate CPR immediately on a resident with Full Code status when he or she was unresponsive with no pulse. The staff had sufficient knowledge of their roles in an emergency and the use of the AED and the need to call 911 immediately. Staff revealed they were trained to not leave an unresponsive resident or stop compressions until the paramedics were ready to take over. Staff were trained to identify the code status by use of the 24-hour report or the residents clinical record. No concerns were noted during the interviews.