Every finding on record at Woodway Nursing & Rehab

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 5 (CR #1) reviewed for laboratory services. The facility failed to obtain CR #1's lipid panel (a blood test used to measure fats to assess cardiovascular health and the risk of heart disease, stroke, and other heart-related conditions) as ordered by the physician to be drawn on 05/26/26.This failure could place residents at risk of not receiving timely services ordered by the physician and a decline in health status.Record review of CR #1's face sheet dated 07/02/26 revealed a [AGE] year-old admitted to the facility on [DATE] and discharged to an acute care hospital on [DATE]. CR #1's diagnoses included schizoaffective disorder bipolar type (a mental health condition), elevated blood pressure, hypothyroidism (a condition where the thyroid gland does not produce sufficient thyroid hormone), hyperlipidemia (a condition that causes high levels of lipids, or fats in the blood), vitamin D deficiency and moderate intellectual disabilities.Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 8 out of 15 indicating moderate cognitive impairment. CR #1 required supervision for oral hygiene, dressing, and personal hygiene. CR #1 required moderate assistance with toileting hygiene and required set up assistance with eating. CR #1 was frequently incontinent of bowel and bladder. Active diagnoses included hyperlipidemia.Record review of CR #1's physician orders as of 06/07/26 revealed an order to monitor Vitamin D levels and lipid panel every 6 months in May and November. Dx: Vitamin D deficiency, TSH (thyroid stimulating hormone) elevated in February - follow up one time a day every 6 months starting on the 26th for 3 days. The order date was 5/24/26 and the start date was 05/26/26. Further review revealed an order for Fenofibrate Oral Capsule 200mg, give 1 capsule by mouth one time a day for hyperlipidemia, date ordered was 120/09/2025. Record review of CR#1's undated care plan revealed no plan of care related to hyperlipidemia.Record review of CR#1's lab results report with date received on 05/26/26 at 4:22PM revealed labs were collected on 05/26/26 at 5:07AM. Lab results included TSH and Vitamin D results only and no lipid panel results.Record review of the facility's daily phlebotomy collection log dated 5/26/26 revealed the tests drawn were Vitamin D and TSH. Further review revealed no lipid panel was drawn and LVN B signed the collection log on 5/26/26.Record review of CR#1's lab results report dated 8/11/25 revealed the following lipid panel: cholesterol, HDL (high density lipoprotein) cholesterol (often referred to as good cholesterol), triglycerides (a type of fat in the blood that stores unused calories) and LDL (low density lipoprotein) cholesterol (often referred to as bad cholesterol because high levels can lead to plaque buildup in the arteries) were all within the normal reference range. In an interview on 07/03/26 at 11:05AM, the DON stated she was the one who took the order from the doctor to draw labs for Vitamin D, TSH and lipid panel to be drawn on the 26th of May and November of 2026 for CR#1. The DON stated when the order was placed in the electronic health records the order was linked to the lab electronically and this is how the lab would know to draw Vitamin D, TSH and lipid panel. The DON stated the lipid panel was not drawn as physician ordered. The DON stated that when the lab results came back without the lipid panel then the nurses should have caught this and ensured the lipid panel was completed. The DON stated the nurse who received the results should have known to follow up on the lipid panel that was not drawn. The DON stated during morning meetings resident lab results were reviewed. The DON stated she could not recollect if the ordered lipid panel for CR#1 was discussed at the meeting.On 7/03/26 at 11:30AM, an attempt to contact CR#1's PCP was made. Unable to leave a message d/t a continuous busy signal on the phone.In a telephone interview on 07/03/26 at 12:17 PM, LVN B stated the phlebotomists would have drawn labs before she came to work on 05/26/26. LVN B stated she would have received report from the night nurse and then she would mark the daily phlebotomy collection log after the blood draw. LVN B stated the reason for checking a lipid panel would be to monitor CR#1's hyperlipidemia. LVN B stated she did not know anything about the order for the lipid panel and that missing labs did not happen all the time in her hall.On 07/03/26 at 1:00PM, an attempt to contact the lab was made. No answer and unable to leave a message.In a telephone interview on 07/03/26 at 1:05PM the NP stated she was familiar with CR#1 and she could not remember whether or not she received the lab results because she did not have her chart in front of her to check. The NP stated it would be important to check a lipid panel because generally speaking, routine labs were ordered for the residents, and the focus would be on preventative healthcare such as heart health. In an interview on 07/03/26 at 1:12 PM, the DON stated she called the lab (on 07/03/26) to verify the orders for CR#1 that were drawn on 5/26/26 and stated that there was a disconnect with the lab and the lab did not receive an order to include lipid panel. The DON stated the lipid panel was to monitor levels to ensure they were within the limits for the medications CR#1 was receiving. The DON stated, moving forward she started conducting staff inservices regarding lab work orders.Record review of CR#1's Nurse Note effective date 05/27/26 at 11:26AM and written by LVN B revealed labs were reviewed and sent to NP.Record review of the facility in-service training report dated 5/4/26 for all nurses read in part: .Topic: Labs.Nurses need to follow up on daily blood/lab draws and report results to provider as soon as they receive them.Nurses chart in PCC - progress notes.Go to labs/results and click on mark review once they are done.Management.f/u - have nursing staff accountable.Record review of the facility policy for Laboratory Serves and Reporting, date reviewed/revised 5/16/25, read in part: Policy: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law.1. The facility must provide or obtain laboratory services to meet the needs of its residents 7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range.

Based on observation, interview, and record review, the facility failed to develop a base-line person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (CR #1) reviewed for base-line care plans. The facility failed to provide CR #1 with a base-line personal-centered care that addressed, monitored, and managed the development of wounds to CR #1's posterior area. This failure places residents at risk for appropriate care, treatment, monitoring, and timely assessment for the development of infections, resulting in hospitalization, a decline in health, or death. Findings included: Record review of CR #1's face sheet dated 06/03/2026, revealed that he was a [AGE] year-old male who originally admitted on [DATE] and discharged on 06/02/2026 with diagnoses including injury of head, displaced comminuted fracture (several breaks where the bone shatters into three or more pieces and the fragments are pushed out of their normal alignment) of shaft (break along the long, straight section of a major long bone) of left tibia (shinbone), traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering) with loss of consciousness, multiple fractures of pelvis with unstable disruption of pelvic ring (two or breaks in pelvis with loss of ability to support weight), fracture of part of neck or left femur (longest, heaviest, and strongest bone in the human body), fracture (bone break) of facial bones, major depressive disorder (persistent sadness, emptiness, and loss of interest), and bipolar disorder (MI that causes mood, energy, and activity level). Record review of CR #1's Hospital Records, reflected on 03/24/2026, an active pressure injury to coccyx medial. On 05/04/2026, wound, DTPI, deep purple, maroon: red, no closure, no odor, and cleaned. On 05/05/2026, no symptoms of infection. On 05/08/2026, new dressing interventions. On 05/11/2026, wound dressing status: area clean, dry and intact. Record review of CR #1's Baseline Care Plan dated 05/15/2026, reflected, CR #1 was dependent on staff for all his ADL's, lethargic level of consciousness, impaired cognition, and incapacitated, with skin integrity documented as an external fixator to pelvis (an emergency and temporary medical device used to stabilize severe, unstable pelvic fractures), and no documentation of any posterior wounds. Record review of CR #1's MD A order dated 05/16/2026 at 01:11 a.m., reflected, perform head to toe assessment of all areas of skin every day shift every 7-days. Record review of CR #1's Skin and Nutrition IDT Review dated 05/20/2026 at 06:43 a.m., reflected revealed, CR #1 was a new admit on 05/16/2026, with a score and risk category left blank and recorded as N/A. Wound Summary category indicated no active wounds upon admission and recorded as N/A. Record review of CR #1's Skin and Nutrition IDT Review dated 05/26/2026 at 02:43 p.m., reflected weekly review noting no wound summary/selection of wound locations. Record review of CR #1's IDT Care Conference dated 06/01/2026, reflected nurse's summary and evaluation/goals: free from infections. Record review of CR #1's Hospital Discharge Transfer Form dated 06/02/2026 at 08:30 a.m., reflected CR #1 had no skin/wound care/pressure ulcers/injures. Other wounds: surgical wound to abdomen. Dependent for all ADLs. Record review of CR #1's Discharge MDS dated [DATE], reflected CR #1 had no BIM score indicated the resident was unable to answer the assessment questions. Record review of CR #1's Hospital Records dated 06/02/2026, reflected it was unclear if the NF had evaluated or treated the resident's deteriorating skin and emerging skin breakdown. Record review of CR #1's Care Plan date initiated on 06/03/2026, reflected (non-pressure) incision site to anterior with unstable disruption of the pelvic ring. CR #1 at risk for infection, delayed wound healing, pain, and impaired mobility with Interventions: Assess, monitor, clean and report abnormalities to physicians. CR #1 had current skin concerns and was at risk for further skin breakdown, infection and pressure ulcer formation (specific skin concerns not documented) initiated on 06/03/2026, with no risk interventions. No documentation of an air mattress. Record review of CR #1's hospital dated 06/04/2026, reflected, CR #1 presented to the acute care hospital with a Stage IV sacral decubitus ulcer. Observation on 06/03/2026 06:01 p.m., CR #1, appeared groomed and clean with no odors. CR #1 verbally identified pain to his buttock while at the facility at a 4 out of 5. CR #1 observed using only one word responses to questions, and requests. During an interview on 06/03/2026 at 12:20 p.m., with FM B and FM C, FM B stated that the NF completely neglected CR #1's provided wound care and infection prevention care to CR #1 had pressure ulcers and skin injuries to his back. FM C stated FM A had provided photographs detailing the condition of CR #1s wounds upon readmission to the hospital on [DATE]. She stated that CR #1 had pressure ulcers on his buttocks and back with no bandages and active bleeding and an odor. She stated it appeared CR #1 had no wound care management while admitted at the NF. During an interview on 06/03/2026 at 02:29 p.m., the WCN stated that she performed CR #1's first weekly head-to-toe assessed on 05/20/2026. She stated his skin looked real good at that time. She stated due to his severe risk, his cognitive inability to articulate basic toileting needs, and his status as a heavy wetter with extra-large bowel movements, the NF standards required staff to turn and reposition him every 2-hours and provide incontinent care every 1 - 2 hours. She stated based on her physical assessment of CR #1, his Braden Score rated at a 9 (a severe, maximum clinical risk for developing pressure wounds). She stated she completed CR #1's 05/26/2026, weekly head-to-toe assessed finding no changes to his skin and no posterior wounds. She stated she had performed his 06/01/2026, weekly head-to-toe assessed finding no skin changes or posterior wounds. She stated CR #1 had an external pelvic hardware and did not hinder her or staff's ability to repositing, provide incontinent care and wound care. She stated after observing photographic evidence of CR #1's skin status upon admission to the ER on [DATE], she identified CR #1's left-side sacral with maceration and redness, which she stated was a direct result of being wet too long, with slough, and necrosis (dead tissue) on the right side of the sacrum, and skin breakdown on his shoulder blade. She stated advanced, necrotic tissue damage was caused directly by a resident laying in one spot for too long over bony prominences. She stated that sloughs occur after being exposed to feces and urine. She stated that the wounds pictured appeared to be a failure of systemic monitoring. She stated the NF failure to document required skin assessments and daily treatments to CR #1's exterior surgical wounds on 5/25/2026 and 05/26/2026 when she was off-shift. During an interview on 06/03/2026 at 03:05 p.m., FM B stated that on 05/23/2026, he and Family C visited CR #1 at the NF and found CR #1's room smelled like an [NAME], staff were hateful, and the bedbound resident was left in these hot, unpowered room conditions for an entire week without the ability to move or contact staff, until they filed a formal complaint with the SW, and the NF finally moved CR #1 on 05/26/2026, to another room. During an interview on 06/03/2026 at 3:10 p.m., FM C stated on 06/02/2026, she was present when CR #1 arrival at the ER for a scheduled surgery, and observed his incontinent brief soaking wet, like he had been that way a while, forcing her to immediately alert the ER staff. She stated that when the ER staff shifted and turned CR #1, she observed horrible buttock and back wounds with active bleeding. She stated the NF had placed no padding or dressing on those wounds, leaving his open, bleeding sores directly sitting in his urine saturated brief. She stated on 05/23/2026, during a visit to CR #1, her and Family B found the CR #1's room had no electricity and no functioning air conditioning (A/C) despite the resident being really hot natured. She stated that the room smelled like an [NAME], staff were hateful, when their concerns were expressed about CR #1 a bedbound resident left in these hot, unpowered room. She stated on 05/26/2026, CR #1 was moved to another room. During an interview on 06/03/2026 at 06:30 p.m., On-Call Hospital MD A stated it was clinically impossible during a brief 2-hour transport ride from the NF, for pressure ulcer/wounds to deteriorate or reach the severe condition observed on CR #1's upon admission to the hospital on [DATE]. During an interview on 06/04/2026 at 09:03 a.m., LVN B stated she was responsible for CR #1's admission head-to-toe skin and wound assessment immediately upon CR #1's 05/16/2026 admission. She stated she received and reviewed CR #1's hospital discharge summary and had not solely relied on that record when completing assessment and incorporated her visual assessment of both CR #1's front, back and head-to-toe observation as contributing findings to add to the assessment. She stated CR #1 had no wounds or skin integrity issues up admission. During an interview on 06/04/2026 at 10:22 a.m., MD B stated according to his MD notes he had not reflected the residents' needs for ADL and could not recall CR #1's ADL condition. He evaluated the CR #1 on 05/21/2026, and performed a thorough initial physical evaluation, discovered CR #1 had a superficial sacral wound. He stated on 05/28/2026, during a following examined found CR #1's sacrum wound remained the same, superficial, and no breakdown or anything serious of a stage 2, 3, or 4. He stated during rounding on both 05/12/2026 and 05/28/2026, he emphasized his verbal orders to the NF nurses, CR #1 was a dependent resident who required repositioning every 2 hours, wounds to receive daily cleaning, dressings, and attention to prevent infection and worsening. He stated he had been his expectation that those verbal orders were charted immediately so that subsequent shifts knew the exact care plan. He stated that had the NF been properly monitoring CR #1 as requested, severe wound degradation should never have occurred. He stated that no facility staff had ever contacted him to report CR #1's skin had worsened. During an interview on 06/04/2026 at 11:31 a.m., LVN Q stated she had not rounded with MD B, the WCD on 05/21/2026 and 05/28/2026 when CR #1 was assessed. She stated there were no orders and was not aware of sacrum or posterior wounds of CR #1. She stated that CR #1 required mandatory 2-hour turning schedules due to him having a rotator/metal external fixator on his pelvic area. She stated she had reviewed CR #1's clinicals dated 05/06/2026, and found that he had a weekly skin assessment, and his 05/20/2026, SBAR and found no tracking of skin deterioration or mention of a sacral wound. She stated as CR #1's nurse she monitored his pelvic area external fixator pins and no CNAs reported to her he had skin issues. She stated that she was responsible for performing weekend wound care but had not provided CR #1 any wound care on any weekends for CR #1. She stated had she witnessed skin trauma on CR #1, facility protocol required her to generate an change of condition SBAR report, update the skin assessment/progress notes, notify the FM, MD A, and the DON of which would have trigger the need for CR #1's care plan to be updated and include his skin changes and required interventions. During an interview on 06/04/2026 at 12:07 p.m., the WCN stated that she had not rounded with CR #1's MD B. During an interview on 06/04/2026 at 12:21 p.m., the DON stated CNAs were required to inspect resident's skin during daily incontinence care and weekly showers, document findings on shower sheets, and report findings to the nurses immediately. She stated once reported, the nurse was assess, notify the MD for new orders, FM, reported to the DON, the generation of a change of condition SBAR report, update a skin and pain assessment/progress note, which would trigger the need for the resident's care plan to be updated and include the changes and required interventions. She stated CR #1 admitted to the facility with only two clean surgical sites from fixator hardware, required total assist: staff to assist with absolutely everything, including eating/feeding, incontinence care, and all movement. She stated due to an extensive MVA, he suffered multiple fractures and had an external pelvic fixator. She stated that the external fixator did not interfere with skin assessments or showers/bed baths. She stated if CR 1's MDS reflected he needed maximum assistance from staff for showers/baths, CR #1 was allowed to shower. She stated CR #1 would scream out in pain with any involuntary arm movement. She stated his cognitive status was alert but varied. She stated she had no knowledge; CR #1 had any skin changes over time. She stated that MD B found a wound, a progress note and order should have been in the system. The DON stated that even for a DTPI, expectations are clear: it must be noted on the skin assessment, monitored closely, verbal orders must be entered into the system, tracked on the TAR and both the FM and MD B must be notified. During an interview on 06/04/2026 at 03:49 p.m., LVN B stated she had not rounded with MD B or received orders for CR #1 and a sacrum wound. She stated she performed CR #1's initial physical admissions assessment, a head-to-toe skin assessment, and had not observed a sacrum or back skin integrity issues. She stated that had CR #1 had any skin changes, CNAs A, B, C, D, E, F were responsible for CR #1's daily repositioning, identifying the development of foul smells, pressure wounds, and need for ADL care and reporting to her any changes in his skin condition. Had she received a change of condition report, she would have evaluated the resident, reported the changes to the MD, notified the DON and FA, completed an SBAR change of condition report, which would have triggered the need to update the resident's care plan and add interventions. During an interview on 06/04/2026 at 04:04 p.m., CNA C stated she was responsible for proving CR #1 with basic ADLs and reporting changes of condition to the nurse immediately. She stated CR #1 had a sacral wound already present when she began working with him. She stated the area had no drainage, redness, and bandage covering, and she was not aware if the area had worsened, and had she known, would have reported that immediately to his nurse. During an interview on 06/04/2026 at 04:19 p.m., CNA E stated she provided CR #1 with his ADL care: incontinence care and had she observed any redness or changes to CR #1's sacrum she would have reported to the changes to the nurse immediately. During an interview on 06/05/2026 at 11:23 a.m., CNA D stated he had visual knowledge of a 2 inches scratch with light redness to CR #1's sacrum when providing incontinent care assistance with CNA C. He stated he reported the scratch to a floor nurse, whom he could not recall on 05/26/2026 on the 2:00 p.m. to 10:00 p.m., shift, his first day working with the resident, and after his return from vacation. He stated all the nurses were already aware of CR #1's scratch and severe pain. He stated that was the reason he had not reported it to the nurse. He stated had they not been aware, he would have reported the scratch and any other skin issues to the nurse immediately. During an interview on 06/05/2026 at 12:06 p.m., CNA G stated she provided direct care to CR #1 and had direct visualization of a wound that was not that big, just small with no color and no drainage to CR #1's sacrum during incontinent care. She stated that the floor nurses knew about CR #1's wound and could not verify the name of the specific nurses who knew. She stated had the nurse's not known, she would have reported it to the nurses immediately. During an During an interview onthe ADM on 06/06/2026 at 1:55 p.m., he stated that the facility's expectation upon a resident's admission were that a full head-to-toe assessments and care directives were completed to ensure skin integrity, and that any changes in skin condition must be immediately identified and reported. He stated that the NF enforces a zero-tolerance policy regarding ANE, and that all staff had responsibility to maintain vigilance, immediately document, and protect residents. He stated the failure to properly develop, capture, and execute proper assessments and care planning protocols could affect all residents who reside at the facility. Record review of NF policy titled, Notification of Changes dated 5/16/2025, reflected, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Definition:. Clinical Complications: Examples - Development of stage 2 pressure injury.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 4 residents (CR #1) reviewed for ADLs. The facility failed to ensure CR #1, a resident with wounds, was provided with personal grooming, showers, and bed baths on the 2:00 p.m. to 10:00 p.m. shift. These failures could place residents at risk for skin breakdown, offensive odors, or infections, resulting in a decline in health, hospitalization, or dealth. Findings included: Record review of CR #1's face sheet dated 06/03/2026, revealed a [AGE] year-old male who originally admitted on [DATE] and discharged on 06/02/2026 with diagnoses including traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering) with loss of consciousness, injury of head, displaced comminuted fracture (several breaks where the bone shatters into three or more pieces and the fragments are pushed out of their normal alignment) of shaft (break along the long, straight section of a major long bone) to left tibia (shinbone), fracture of part of neck or left femur(longest, heaviest, and strongest bone in the human body), multiple fractures of pelvis with unstable disruption of pelvic ring (two or breaks in pelvis with loss of ability to support weight), fracture (bone break) of facial bones, bipolar disorder, (MI that causes mood, energy, and activity level), and major depressive disorder (persistent sadness, emptiness, and loss of interest). Record review of CR #1's Baseline Care Plan dated 05/15/2026, reflected, CR #1 was dependent on staff for all ADL's: eating, oral hygiene, toileting, shower/baths, upper/lower/footwear dressing, personal hygiene, left/right rolling mobility, shower/tub transfers, and always incontinent for bowel and bladder. Skin integrity documented as an external fixator to pelvis (an emergency and temporary medical device used to stabilize severe, unstable pelvic fractures). CR #1 was a lethargic level of consciousness, impaired cognition, and documented as incapacitated. Record review of CR#1's Pain assessment dated [DATE] at 5:43 a.m., revealed CR #1 was unable to answer pain Frequency, pain interference with therapy activities. Record review of CR #1's Discharge MDS assessment dated [DATE] reflected CR #1 had no BIMS score, which indicated the resident was unable to answer the assessment questions. Record review of CR #1's Hospital Records date 06/02/2026, reflected, CR #1 was admitted [DATE], with severe clinical concerns stemming from care received at the NF over the preceding two weeks. The documentation reflected a significant lack of routine bathing, the development of new pressure ulcers, and active skin breakdown, irritation, with potential infection surrounding the resident's surgical hardware sites. The records reflected a post-surgical wound infection, identifying concern for infection at the surgical sites secondary to delayed hardware removal. Removal of hardware was originally planned at 8 weeks, later changed to 12 weeks, but had not occurred due to transfer between facilities and difficulty returning to the original surgical team. Record review of CR #1's Care Plan date initiated on 06/03/2026, reflected multiple fractures of the pelvis with unstable disruption of the pelvic ring (fractured bone segments and stabilizing ligaments to separate) fixation sites following a MVA, placing CR #1 at risk for infection, delayed wound healing, and impaired mobility. Non-Pressure (surgical): Clean non-pressure incision site to anterior pelvic ring fixator. Interventions included: Assess, monitor, clean and report abnormalities to physicians. CR #1 had current skin concerns and was at risk for further skin breakdown, infection and pressure ulcer formation (specific skin concerns not documented) initiated on 06/03/2026, with no risk interventions and documentation of an air mattress. Record review of CR #1's Hospital Records dated 06/04/2026, reflected, CR #1 had a stage IV sacral decubitus ulcer (a severe, full-thickness wound extending through the skin and fat into muscle, tendons, or bone). During an observation on 06/03/2026 at 06:01 p.m., CR #1 appeared groomed and bathed sitting in the hospital bed. CR #1 verbally identified his rate of pain to his buttock while at the NF at a 4 out of 5 (with 5 being the worst pain). FM B was observed actively rubbing CR #1's right hand to provide comfort. CR #1 expressed a desire for fluid, and FM B was observed to be administering a drink to CR #1. During an interview on 06/03/2026 at 12:20 p.m., FM A stated that the NF completely neglected CR #1's grooming and hygiene. She stated on 06/03/2026, EMS transported CR #1 from the NF to a hospital for a planned surgery to remove CR #1's fixator pins. She stated at the hospital, hospital staff had to spend 2 to 3 hours using specialized soaps and lotions to get the resident clean in preparation for surgery because CR #1 was filthy like he had not had a bath the entire time he was at the NF. She stated CR #1 never refused showers or bed baths at the hospital and was fully cooperative with all hygiene care. She stated the lack of bathing CR # 1 directly affected the development and worsening of his wounds. She stated that CR #1 was able to communicate clearly when and where he was hurting. She stated she presented photographic evidence showing of his wound. She stated that she called the NF on 06/02/2026, reporting these concerns, speaking to both the ADM and DON who both brushed off her concerns and told her RN A had looked CR #1 over before EMS transported the resident out of the facility, and he looked fine. During an interview on 06/03/2026 at 01:37 p.m., DON stated CR #1 admitted to the NF following a MVA (struck while riding a bicycle) resulting in multiple fractures. She stated CR #1 had a pelvic fracture with external fixation hardware (a hallo shaped rod, fixated to the outside of the lower abdomen/pelvis area). She stated CR #1 discharged the morning of 06/02/2026, for a prescheduled surgery to remove the fixator hardware. She stated CR #1's assigned CNAs were CNA A and CNA B and were responsible for giving CR #1 his baths on the 2:00 p.m. to 10:00 p.m. shift M/W/F. She stated on 06/01/2026, in preparation for transport for CR #1's scheduled surgery, CNA B and RN A provided CR #1 a bath. She stated she spoke to FM A on 06/02/2026, and no complaints were made about CR #1 hair being dirty and falling out or made a formal complaint. She stated that CR #1's family subsequently decided to relocate him closer to home 2-hours away. During an interview on 06/03/2026 at 01:57 p.m., CNA B stated that CR #1 was a totally dependent resident, required two-person assistance for feeding, turning, repositing, and incontinent care. He stated CR #1 laid flat on his back consistently and he had observed slight redness to CR #1's backs due to the pelvic hardware screwed into CR #1's waist keeping him in that position. He stated that CR #1 could not say he needed his brief changed. He stated on 06/01/2026, he found CR #1 soaked through the brief with urine and bed linen was soaked. He stated the volume of urine was so heavy they had to change CR #1's gown and wipe down the actual bed frame/mattress before replacing the linen. He stated during CR #1's incontinent care, he had not observed open redness or wounds on CR #1's buttock, back, or shoulders, and had he would have reported to the nurse immediately. During an interview on 06/03/2026 at 02:29 p.m., the WCN stated that CR #1 was assessed upon admission with a Braden Score of 9, indicating a severe, maximum clinical risk for developing pressure injuries. She stated due to his severe risk, the cognitive inability to articulate basic toileting needs, and his status as a heavy wetter with extra-large bowel movements, the NF standards required staff to turn and reposition him every 2-hours and provide incontinent care every 1 - 2 hours. She stated CR #1 had an external pelvic hardware and did not hinder staff's ability to reposition and turn him. She stated after observing photographic evidence provided by FM A of CR #1's skin status upon admission to the ER on [DATE], she identified left-side sacral maceration (softening and breakdown of skin caused by prolonged exposure to excessive moisture) and redness, which she stated was a direct result of being wet too long, with slough, maceration, and necrosis (dead tissue) on the right side of the sacrum, and skin breakdown on his shoulder blade. She stated advanced, necrotic tissue damage was caused directly by a resident laying in one spot for too long over bony prominences and being left exposed to feces and urine, noting that slough takes hours to form. She stated that the wounds pictured appeared to be a failure of systemic monitoring, and failure to document required skin assessments and daily treatments from 5/25/2026 and 05/26/2026 when she was off-shift, concluding that if it is not here, it was not done. During an interview on 06/03/2026 at 03:05 p.m., FM B stated that on 05/23/2026, he and Family C visited CR #1 at the NF and found CR #1's room smelled like an [NAME], staff were hateful, and the bedbound resident was left in these hot, unpowered room conditions for an entire week without the ability to move or contact staff, until they voiced their concerns with the SW, and the NF finally moved CR #1 on 05/26/2026, to another room. During an interview on 06/03/2026 at 3:10 p.m., FM C stated on 06/02/2026, CR #1 arrival at the ER for a scheduled surgery, his incontinent brief was soaking wet and it appeared like he had been there for a while, forcing her to immediately alert the ER staff. She stated that when the ER staff shifted and turned CR #1, she observed horrible buttock and back wounds with active bleeding. She stated when CR #1 arrived at the hospital, she seen that the NF had placed no padding or dressing on those wounds, leaving his open, bleeding sores directly sitting in his urine saturated brief. She stated on 05/23/2026, during a visit to CR #1, her and FM B found the CR #1's room had no electricity and no functioning air conditioning (A/C) despite the resident being really hot natured. She stated that the room smelled like an [NAME], staff were hateful, when their concerns were expressed about CR #1 a bedbound resident left in the hot room, unpowered room. She stated on 05/26/2026, CR #1 was moved to another room. During an interview on 06/03/2026 at 06:01 p.m., FM B stated on 06/02/2026, CR #1 arrived at the ER with an overwhelming, foul body odor. He stated that he rubbed CR #1's leg and the smell remained on his hands even after washing. He stated CR #1 had not had a bathe in some time, having crusted, dry, flaking skin had heavily accumulated inside the resident's foot-drop boots and across his feet. He stated that the ER staff had to fully clean and wash CR #1 upon admission due to the accumulation of filth. He stated he observed CR #1's completely soaked brief, urine soaked, and prominent, dried brown stains visible on the bedding, indicating to him the linens had not been changed for an extended period. He stated CR #1 had dried food crumbs and debris on his back that he wiped off CR #1 with his hand. He stated that CR #1 experienced severe pain and cried out whenever his leg was moved. During an interview on 06/03/2026 at 06:01 p.m., FM C stated when CR #1 arrived at the ER, his odor was so severe that she was unable to touch/massage his leg as she usually did. During an interview on 06/03/2026 at 06:01 p.m., Hospital RN stated she was CR #1 RN during his 03/07/2026 to 05/15/2026 hospital stay. She stated that when CR #1 discharged to the NF, his legs were straight, was cooperative with all care, could communicate his needs, and did not resist hygiene changes or wound care. She stated on 06/02/2026, CR #1 had a strong smell, unwashed hair, and filthy skin that immediately revealed he had not been groomed or bathed for an extended period. She stated she had to scrub the callus of CR #1's feet and had to tag team with another RN to get CR #1 clean. She stated his legs had contracted back up and he yelled in pain when attempting to move his legs straight. During an interview on 06/04/2026 at 10:22 a.m., MD B stated according to his MD notes, he evaluated CR #1 on 05/21/2026, and CR #1 could not reliably provide his own medical history, a complex background of a recent admission, external orthopedic fixator, and a bipolar diagnosis. MD B stated his notes had not reflected the residents' needs for ADL and could not recall CR #1's ADL condition. He stated that if the NF had been properly monitoring and providing CR #1 with adequate showers/bed baths, the severe wound degradation should have never happened. During an interview on 06/04/2026 at 11:31 a.m., LVN Q stated CR #1 required a two-person physical assist for incontinent care, and repositioning, and consistently requested water. She stated she had not rounded with CR #1's MD B or his WCD on 05/21/2026 and 05/28/2026. She stated there were no orders and she was not aware of CR #1's need for mandatory 2-hour turning schedules. She stated she had reviewed CR #1's clinicals, his 05/06/2026 Weekly Skin Assessment, and his 05/20/2026, SBAR and found no tracking on skin deterioration or mention of a sacral wound. She stated she was not aware of CR #1's condition on 06/02/2026, discharged to the ER. She stated as CR #1's nurse she monitored his pelvic area external fixator pins. She stated that she was responsible for performing weekend wound care but had not provided CR #1 any wound care when she worked the weekends. She stated that if she had witnessed skin trauma, facility protocol required her to generate an SBAR, update the skin assessment/progress notes, notify the FM, MD A, and the DON. During an interview on 06/04/2026 at 12:07 p.m., the WCN stated that she had not rounded with CR #1's MD B. During an interview on 06/04/2026 at 12:21 p.m., the DON stated CNAs must visually inspect the skin during daily incontinence care and weekly showers, document findings on shower sheets, and report them to the nurses. She stated CR #1 admitted to the facility with two clean surgical sites, required total assist: staff to assist with absolutely everything, including eating/feeding, incontinence care, and all movement. She stated due to an extensive MVA, he suffered multiple fractures and had an external pelvic fixator. She stated that the external fixator did not interfere with skin assessments or showers/bed baths. She stated if CR #1's MDS reflected he required maximum assistance from staff for showers/baths. She stated CR #1 would scream out in pain with any involuntary arm movement. She stated his cognitive status was alert but varied. She stated she had no knowledge; CR #1 had any skin changes over time. She stated had MD B found a wound, a progress note and that order should have been in the system. The DON stated that even for a DTPI, expectations were clear: it must be noted on the skin assessment, monitored closely, verbal orders must be entered into the system, tracked on the TAR and both the FM and MD B must be notified. During an interview on 06/04/2026 at 03:49 p.m., LVN B stated CR #1 was completely dependent for care and had a rotator/metal external fixator on his pelvic area. She stated she had not rounded with MD B. She stated she performed CR #1's initial physical admissions assessment, a head-to-toe skin assessment. She stated CR #1 had no sacrum or back skin integrity issues. She stated that CNAs A, B, C, D, E, F were responsible for CR #1's daily repositioning, identifying the development of foul smells, pressure wounds, and need for ADL care. During an interview on 06/04/2026 at 04:04 p.m. CNA C stated she was responsible for proving CR #1 with basic ADLs, including feeding, providing water, and incontinent care. She stated she had not provided CR #1 with a bath or a shower during all her shifts and never noticed a body odor, or dirty skin. She stated incontinent care always required a two-person physical assistance protocol. She stated that when she began working with CR #1, she was told to be very careful and that staff devised a plan on how to physically hold and lift the resident to avoid interrupting the integrity of a sacrum wound. She stated she had frequently found CR #1 would shift and completely move out of position and she had to locate another staff to assist with his repositing. She stated CR #1's sacral wound was already present when she began working with him. She stated the area had no drainage, redness, or bandages covering, and was not aware if the area had worsened. She stated that CNA A and CNA D were the staff who provided the most direct line care to CR #1. During an interview on 06/04/2026 at 04:19 p.m., CNA E stated she provided CR #1 with his ADL care: incontinence care, who required two-person protocol. She stated she had not provided CR #1 with a bath or a shower during any of her shifts. She stated she had observed redness to CR 1's sacrum but denied seeing any open wounds. She stated had she seen a wound; she would have reported it to his nurse immediately. During an interview on 06/05/2026 at 11:23 a.m., CNA D stated due to the severe staffing shortage on every shift, he was forced to cover three of the four halls at the NF, managing to complete baths for only one or two residents total per shift. He stated as CR #1 required two-personal assist for bed bath or showers, there was never enough time to complete bathing for CR #1 and had never known CR #1 to receive a shower or bath on any of the shifts he worked. He stated that managing multiple halls required a massive amount of physical strength and severely restricted his ability to complete basic care tasks, and He can't do it, he is not a machine. He stated that he had visual knowledge of a 2-inchs scratch with light redness to CR #1's sacrum when providing incontinent care assistance with CNA C. He stated he reported the scratch to a floor nurse, whom he could not recall on 05/26/2026 on the 2:00 p.m. to 10:00 p.m., shift, his first day working with the resident. During an interview on 06/05/2026 at 12:05 p.m., CNA F stated she only worked in the secure memory care unit and had not provided CR #1 with ADL care or a shower or bed bath. During an interview on 06/05/2026 at 12:06 p.m., CNA G stated she provided direct care to CR #1 who had an external pelvic hardware that made him turning difficult and painful for him. She stated to maneuver CR #1 to prevent active physical harm, 3-staff were required to repositing him. She stated she had not provided him with a shower or bed bath on any shift while CR #1 was admitted to the facility. She stated she had direct visualization of a wound that was not that big, just small with no color and no drainage to CR #1's sacrum during incontinent care. She stated that the floor nurses knew about CR #1's wound and could not verify or name the specific nurses who knew. During an interview on 06/05/2026 at 02:58 p.m., Maintenance Director stated when he was informed the FA had concerns with CR #1's outlets and A/C, CR #1 was moved into another room. During an interview on 06/06/2026 at 01:55 p.m., ADM stated it had been his expectations that residents were to receive showers 3-times a week and those showers were to be completed according to residents' needs and preferences. He stated it was all staff responsible for identifying and reporting, and the nursing staff were to complete assessments and interventions. He stated it was all the staff's responsibility, the DON/designee ensures compliance, and the ADM ensures systems and regulatory requirements are met. Record review of the CNAs staff scheduled and actual staff who worked with CR #1 reflected, CNA A, CNA B CNA C, CNA D, CNA F, and CNA G. Record review of NF's in-service training report dated 05/15/2026, topic tiled. Residents Rights, ANE, Caution when Reporting and Providing Personal Care conducted by DON. Record review of NF's in-service training report dated 05/15/2026, topic tiled. ANE Reporting, Bathes/Showers and Providing Personal Care conducted by DON. Record review of NF's in-service training report dated 06/03/2026, topic tiled, Rounding and ANE conducted by DON. Record review of NF policy titled, Perineal Care dated 05/12/2025, reflected, Policy: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Always note any skin changes such as rash, red or pink areas or any discolorations to skin. Report to nurse when applicable .

Based on observation, interview and record review, the facility failed to ensure that a resident with pressure ulcers receives necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 9 residents (CR #1) reviewed.The facility failed to ensure CR #1, received orders, monitoring, and interventions to an existing wound and development of new wounds resulting in the lack of wound care management and hospitalization. These failures could place residents at risk of developing, reopening and worsening of pressure ulcers Findings included: Record review of CR #1's face sheet dated 06/03/2026, revealed that he was a [AGE] year-old male originally admitted on [DATE] and discharged on 06/02/2026 with diagnoses included traumatic subarachnoid hemorrhage (bleeding into the fluid-filled space between the brain and the protective tissue covering) with loss of consciousness, injury of head, displaced comminuted fracture of shaft (break along the long, straight section of a major long bone), of left tibia (shinbone), multiple fractures of pelvis with unstable disruption of pelvic ring (two or breaks in pelvis with loss of ability to support weight), fracture (bone break) of facial bones, major depressive disorder (persistent sadness, emptiness, and loss of interest), and bipolar disorder (MI that causes mood, energy, and activity level). Record review of CR #1's Hospital Records, reflected on 03/24/2026, CR #1 had an active pressure injury to his coccyx medial. On 05/04/2026, the wound was stated as a deep purple, maroon: red coloration, no closure, no odor, and clean. On 05/05/2026, no symptoms of infection. On 05/08/2026, new dressing interventions. On 05/11/2026, wound dressing status: area clean, dry and intact. Record review of CR #1's Baseline Care Plan dated 05/15/2026, reflected, CR #1 had skin integrity documentation related to an external fixator to pelvis (an emergency and temporary medical device used to stabilize severe, unstable pelvic fractures), and no documentation of any posterior wounds. CR #1 was dependent on staff for all his ADL's, lethargic level of consciousness, impaired cognition, and incapacitation. Record review of CR #1's MD A order dated 05/16/2026 at 01:11 a.m., reflected, perform head-to-toe assessment of all areas of skin every day shift every 7-days. Record review of CR #1's Skin and Nutrition IDT Assessment (used to proactively identify, prevent and manage pressure ulcers) dated 05/20/26 at 6:43 a.m., revealed, CR #1 was a new admit, with a Braden (assessment tool to determine the risk of developing pressure ulcers) score of 9. CR #1's score and risk category was left blank and recorded as N/A, and Wound Summary category indicated N/A for no active wounds upon admission. Record review of CR #1's Care plan had not reflected CR #1 had an active pressure wound or an air mattress with no wound interventions. Record review of CR #1's Skin and Nutrition IDT Review dated 05/26/2026 at 02:43 p.m., reflected weekly review noting no wound summary/selection of wound locations. Record review of CR #1's IDT Care Conference dated 06/01/2026, reflected nurse's summary and evaluation/goals: free from infections. Record review of CR #1's Hospital Discharge Transfer Form dated 06/02/2026 at 08:30 a.m., reflected CR #1 had no skin/wound care/pressure ulcers/injures. Other wounds: surgical wound to abdomen. Dependent for all ADLs. Record review of CR #1's Discharge MDS dated [DATE] reflected CR #1 had no BIM score which indicated CR #1 was unable to answer the assessment questions. Record review of CR #1's Care Plan date initiated on 06/03/2026, reflected CR #1 had current skin concerns and was at risk for further skin breakdown, infection and pressure ulcer formation (specific skin concerns not documented) initiated on 06/03/2026, with no risk interventions. No documentation of an air mattress. Record review of CR #1's Hospital Records dated 06/04/2026, reflected CR #1 was assessed upon admission to the hospital as having a Stage IV sacral decubitus ulcer (full-thickness tissue loss with exposed fascia, muscle, tendon, or bone). Observation on 06/03/2026 at 06:01 p.m., CR #1, sat in the hospital bed and appeared groomed and bathed. He verbally identified pain to his buttock while at the facility at a 4 out of 5. CR #1 observed using only one word responses to questions, and requests. During an interview on 06/03/2026 at 12:20 p.m., FM A stated that the NF completely neglected and directly affected the development and worsening of CR #1's wounds. She stated CR #1 admitted to the NF on 05/16/2026, with hospital discharge instructions for his surgical wound care. She stated there were no wound care instructions of an active pressure sore to his buttocks. She stated on 06/02/2026, CR #1 was discharged from the NF and readmitted to the hospital for a scheduled surgery. She stated when CR #1 arrived at the hospital, he had unmanaged, actively bleeding wounds on his buttocks and back, severe hygiene neglect, unkempt hair and acute pain to the wounds. She stated the Hospital RN who received CR #1, was literally in tears at how bad CR #1's appearance, foul smell, and wound mismanagement. She stated on that same day, she immediately addressed her concerns with the ADM and DON about their failure in executing wound care. She stated the staff, brushing off her concerns as if they had no care and concerns for CR #1's condition. She stated she had provided photographs detailing the condition of CR #1's pressure ulcers on his back and buttocks. During an interview on 06/03/2026 at 02:29 p.m., the WCN stated she performed CR #1's first weekly head-to-toe skin assessment on 05/20/2026 and found his skin looked real good at that time. She stated that due to the resident's severe risk factors, cognitive inability to verbalize toileting needs, and status as a heavy wetter with extra-large bowel movements, facility standards required staff to turn and reposition him every 2 hours and provide intensive incontinence care every 1 to 2 hours. She stated her initial assessment yielded a Braden Score of 9, signifying a severe, maximum clinical risk for developing pressure wounds. She stated she completed subsequent weekly assessments on 05/26/2026 and 06/01/2026, documenting no posterior wounds, though she noted she could not enter the 06/01/2026 assessment into the clinical record due to facility computer issues. She explicitly stated that the resident's external pelvic hardware did not hinder staff's ability to properly reposition and turn him. She stated after review of CR #1's photographic evidence documenting CR #1's skin status upon his readmission to the hospital on [DATE], she identified extensive left-sided sacral maceration (the softening and breakdown of skin caused by prolonged exposure to excessive moisture) and redness, which was the direct result of the resident being wet too long, identified slough (buildup of pale yellow, stringy, or soggy dead tissue on the wound bed), maceration, and necrosis (dead tissue) on the right side of the sacrum, alongside active skin breakdown on his shoulder blade. She stated that the advanced, necrotic tissue damage was caused directly by a resident laying in one spot for too long over bony prominences and being left exposed to feces and urine, noting that slough takes hours to form. During an interview on 06/03/2026 at 3:10 p.m., FM C stated on 06/02/2026, CR #1 arrival at the ER for a scheduled surgery, his incontinent brief was soaking wet, and it appeared like he had been there for a while, forcing her to immediately alert the ER staff. She stated that when the ER staff shifted and turned CR #1, she observed horrible buttock and back wounds with active bleeding. She stated the NF had placed no padding or dressing on those wounds, leaving his open, bleeding sores directly sitting in his urine saturated brief. During an interview on 06/03/2026 at 06:01 p.m., FM B stated on 06/02/2026, CR #1 originally discharged from the hospital to the NF with only one pressure ulcer that was clean and covered. He stated on readmission to the hospital on [DATE], CR #1's diaper was soaked, with active bedding and wet and old brown stained sheets. He stated CR #1 smelled so bad that FM C could not provide CR #1 with her usual therapeutic leg massages. He stated he apologized for his visibly emotional state of weeping during the interview, while recounting what he observed, and the need to wash his hands several times to get the foul smell off his hands after touching CR #1's legs. He stated the Hospital RN had to spend hours deep-cleaning CR #1's crusted feet and neglected skin. During an interview on 06/03/2026 at 06:21 p.m., Hospital RN stated she was CR #1's Hospital RN during his 03/07/2026 to 05/15/2026 hospital stay. She stated CR #1's had a documented sacrum wound that had not actually broken the skin, and was not bad. She stated she was present when FM C had taken the photographic evidence of CR #1's skin status upon admission to the ER on [DATE]. She stated that CR #1 had left-side sacral maceration and redness, from being in a wet too long. She stated the left-side had slough, maceration, and the right side had necrosis, and the shoulder blade had skin breakdown. She stated advanced, necrotic tissue damage was caused directly by a resident laying in one spot for too long over bony prominences and being left exposed to feces and urine,. She stated slough developed over days and weeks of skin trauma and lack of care. During an interview on 06/03/2026 at 06:30 p.m., On-Call Hospital MD A stated CR #1's advanced skin breakdown, left-side sacral maceration, right-side sacral necrosis (dead tissue), and shoulder blade breakdown to a prolonged, systemic lack of preventative care within the NF, and clinically impossible during a brief 2-hour transport from the NF to the hospital for such skin breakdown. During an interview on 06/04/2026 at 09:03 a.m., LVN B stated on 05/16/2026, she performed CR #1's initial admissions comprehensive, head-to-toe skin and wound assessment. She stated she received and reviewed CR #1's hospital discharge summary finding no notes or orders for pressure wounds and completed the comprehensive assessment and used her visual assessment of a front, back and head-to-toe observation of CR #1 to complete her findings. She stated CR #1 had no wounds or skin integrity issues upon admission. During an interview on 06/04/2026 at 10:22 a.m., MD stated he evaluated CR #1 on 05/21/2026, and CR #1 could not reliably provide his own medical history, a complex background of a recent admission, external orthopedic fixator, and a bipolar diagnosis. MD B stated he took the initiative to conduct a thorough initial physical evaluation, where he discovered a superficial sacral wound. He stated he had not recalled any admission orders for the sacral wound. He stated he provided verbal orders to the rounding nurse to prevent infection and worsening of the wound, CR #1, a dependent residents must be repositioned every 2 hours, and wound must receive daily cleaning, dressing, and attention, and educate the resident on avoiding scratching and touching the area to avoid opening and infecting the area. He stated it was the responsibility of the rounding nurse to add his verbal orders into CR #1's clinicals and his expectation, the orders were followed. He stated on 05/28/2026, he re-examined CR #1 and found the sacrum wound remained the same, superficial breakdown, and nothing serious of a stage 2, 3, or 4 at that time. He stated when he rounded at the NF a nurse always accompanied him. He stated and emphasized the rounding nurse was to chart his verbal orders immediately so that subsequent shifts knew the exact care plan. He stated that if the NF had been properly monitoring CR #1 as requested, the severe wound degradation should have never happened. He stated that no facility staff ever contacted him to report the worsening or development of any wounds to CR #1. During an interview on 06/04/2026 at 11:31 a.m., LVN A stated she was responsible for monitoring CR #1's pelvic area external fixator with pins and was unaware of sacrum pressure sore or postural wounds. She stated the standard protocol when obtaining verbal order from a physician must be formally entered into the resident's clinicals to trigger an immediate, comprehensive skin care assessment. She stated she was completely unaware of any sacral wound orders upon CR #1's admission or from MD B, and stating she received no new orders regarding the sacrum. She stated she reviewed CR #1's clinicals and found zero tracking of any skin deterioration. During an interview on 06/04/2026 at 12:07 p.m., WCN stated that she had not received orders from MD B for monitoring of a wound CR #1's sacrum. During an interview on 06/04/2026 at 12:21 p.m., DON stated CR #1 was a total-assist resident admitted with complex injuries, including an external fixator. She stated she was not aware CR #1 had a DTPI and had no sacrum wound care order upon admission. She stated CNAs must visually inspect resident's skin during daily incontinence care and weekly showers and report changes to the skin immediately to the nurses. She stated had a wound been identified, nurses were required to immediately notify the physician and obtain a specific order for new and pre-existing wounds, with consistent monitoring. She stated failures in this protocol, combined with a lack of admission wound care orders, created severe risks of further breakdown, infection, and sepsis. During an interview on 06/04/2026 at 03:49 p.m., LVN B stated she had not rounded with MD B. She stated she performed CR #1's initial physical admissions assessment, and head-to-toe skin assessment. She stated CR #1 had no sacrum or back skin integrity issues and had he, per policy, she would have notified the physician immediately and obtained wound care orders, documented and identified the wound on a skin, pain, and change of condition report. She stated that CNAs A, B, C, D, E, F were responsible for CR #1's daily repositioning, and incontinent care and would have been the front line staff in identifying the development of foul smells, and pressure wounds. She stated she had not been made aware of any reports that CR #1 had skin integrity issues. During an interview on 06/04/2026 at 04:04 p.m., CNA C stated she was responsible for proving CR #1 with basic ADLs, including incontinent care and repositioning. She stated CR #1 had a sacral wound already present when he admitted with no drainage, redness, or bandages. She stated she was not aware of the wound worsening. She stated that CNA A and CNA D were the staff who provided the most direct care to CR #1. She stated that when she began working with CR #1, she was told to be very careful and that staff devised a plan on how to physically hold and lift the resident to avoid interrupting the integrity of a sacrum wound. She stated she had not reported the wound, because he admitted with the wound and the nurses were aware of the wound. During an interview on 06/04/2026 at 04:19 p.m., CNA E stated she provided CR #1 with incontinence care and had observed redness to CR #1's sacrum and reported the redness to a floor nurse of whom she could not recall. She stated she denied seeing any wounds. She stated had she seen an open wound or development of a wound; she would have reported it to the resident's nurse immediately. She stated she had not provided CR #1 with a shower or bed bath. During an interview on 06/05/2026 at 11:23 a.m., CNA D stated that he had visual knowledge of a 2 inches scratch with light redness to CR #1's sacrum observed during incontinent care assistance with CNA C. He stated he reported the scratch to a floor nurse, whom he could not recall on 05/26/2026 on the 2:00 p.m. to 10:00 p.m., shift, his first day working with the resident returning from vacation. He stated all the nurses were already aware of the scratch to the residents' back and stated CR #1 had severe pain in that area but had never worsened. He stated she had not provided CR #1 with a shower or bed bath. During an interview on 06/05/2026 at 12:06 p.m., CNA G stated she provided direct care to CR #1 who had an external pelvic hardware that made him turning difficult and painful for him. She stated to maneuver CR #1 to prevent active physical harm, 3-staff were required to repositing him. She stated she had not provided him with a shower or bed bath. She stated she had direct visualization of a wound that was not that big, just small with no color and no drainage to CR #1's sacrum area during incontinent care. She stated the wound was present when CR #1 admitted . She stated that the floor nurses knew about CR #1's wound and could not verify or name the specific nurses who knew. During an interview on 06/06/2026 at 1:55 p.m. ADM stated that the facility's expectation upon a resident's admission were that a full head-to-toe assessments and care directives were completed to ensure skin integrity, and that any changes in skin condition must be immediately identified and reported. He stated staff were expected to identify and report all changes in condition, skin integrity and these changes should be reported to physician, DON, ADM, and resident's responsible party immediately. He stated that the NF enforces a zero-tolerance policy regarding ANE, and that all staff had responsibility to maintain vigilance, immediately document, and protect residents. He stated the failure to properly develop, capture, and execute proper assessments and care planning protocols could affect all residents who reside at the facility. He stated the alleged deficient practice could affect all residents who resided at the facility. Record review of photos received from FM A of CR #1s dated 06/02/2026, and times reflected,11:58 a.m., right and left buttock/sacrum with slough, maceration and redness12:02 p.m., right and left buttock/sacrum wound, left shoulder blade, and from blood on white linen.12:02 p.m., left over bony prominences (shoulder blade) with skin breakdown, tissue damage, and redness12:02 p.m., right and left buttock/sacrum wound with slough, maceration, and redness12:03 p.m., under right shoulder blade with skin breakdown, tissue damage, and redness04:59 p.m., right plantar surface (and ball of foot) and heel yellowed with dry crust (2 of 2 pictures)04:59 p.m., left plantar surface (ball of foot) yellowed with dry crustRecord review of NF policy titled, Wound Treatment Management dated 05/15/2025, reflected, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Treatment selection will consider wound etiology, condition, resident preferences, and risk factors. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .

Based on observation, record reviews and interviews, the facility failed to ensure resident environment remained as free of accident hazards as was possible for 1 of 4 shower rooms (A Hall shower room) reviewed for accidents. The facility failed to ensure the A Hall shower room was locked and sharps in the shower room were secured and not accessible to residents on 06/02/2026 and on 06/03/2026. This failure could place residents at risk of entering the shower room that and could harm themselves due to the presence of unsecured sharp items. During observations on 06/02/2026 at 10:02 a.m., and on 06/03/2026 at 3:10 p.m., the A Hall shower room door was ajar and accessible to residents. No residents or staff were in the hallway or inside the shower room at that time. Further observation on both days revealed staff stored 14 unopened disposable razors on an unsecured shelf inside the shower room. The razors were scattered and not inside a box or a container. The shower room did not contain a locked box or cabinet. In an interview on 06.03.3026 at 9:47 a.m., the Maintenance Director stated he was unaware the shower room door was broken. He stated staff did not report that to him verbally or wrote it on the Maintenance book. He stated he did Maintenance rounds every morning on all the facility halls for any visible problems which needed repairs. He stated he did not look at locked doors to determine if they worked as part of his rounds, but expected staff to let him know verbally or in the maintenance log book when those locks were broken. He stated residents could slip and hurt themselves if they entered the shower room unsupervised. In an interview on 06.03.2026 at 3:15 p.m., RN Q stated the A Hall shower room door did not lock because the keypad did not work. She said the keypad worked in the past and had a code to use in order to access the shower room but did not have a code anymore which caused the door to be unsecured. She stated she was unaware who opened the door and left it open. RN Q stated she was unaware if staff reported the broken keypad to maintenance. She stated if the shower room door was unsecured, residents could get in the room and slip on a wet floor or hurt themselves if they decided to use the stored razors unsupervised. She stated she checked the shower room at the beginning of her shift, and it was closed but not locked. In an interview on 06.03.2026 at 3:23 p.m., CNA Q stated he was aware of the shower room door keypad problem and reported it only to the Maintenance Director verbally a while ago who said he would fix it. CNA Q stated he did not follow up on the matter after that. CNA Q stated staff could log maintenance issues in the maintenance book but he did not do that this time. He stated if residents entered the opened shower room, they could cut themselves. He stated he rounded at the beginning of his shift and the shower room door was closed but not locked. In an interview on 06.03.3026 at 3:35 p.m., the DON stated she was unaware the shower room door lock did not work. She stated she did round the whole facility every day and did not notice if the door was open or closed. She stated residents could slip or cut themselves if they accessed the shower room unsupervised. The DON stated she expected staff to report the broken shower room door to maintenance and to log it in the maintenance book and let her know as well. In an interview on 06.03.3026 at 3:53 p.m., the Administrator stated he was unaware the shower room door lock did not work. He stated residents could slip or cut themselves if they accessed the shower room unsupervised. The Administrator stated he expected staff to report the broken shower room door to maintenance and to log it in the maintenance book. Record review of the Maintenance Log, dated between 07/22/2025 through 05/27/2026, showed staff did not report the broken shower room door lock to the Maintenance Director. Record review of the facility's Safe-and-Homelike-Environment-Policy, dated 06/15/2026, revealed, .Staff should .e. Report any furniture in disrepair to Maintenance promptly. f. Report any unresolved environmental concerns to the Administrator.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals), to meet the needs of each resident 1 of 1 medical supply reviewed for medication storage and labeling. The facility failed to ensure the medication cart was free from expired medical supplies on 06/05/2026. This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition and could cause infections due to compromised sterile equipment.Findings included: During an observation of C hall's medication cart and interview on 06/05/2026 at 9:36 a.m., revealed staff stored unopened expired Selan zinc oxide barrier cream (a medical and skincare topical ointment designed to form a protective layer on the skin, shielding it from moisture, irritants, and friction) count 17, all expired on 12/2025. In an interview on 06/05/2026 at 9:40 a.m., LVN Q stated she checked the medication cart for expired medications and supplies every day and before each use but overlooked the barrier cream. She stated if staff used expired barrier cream it could harm residents' skin. She stated she should have noticed the expired barrier cream and discarded them. In an interview on 06/05/2026 at 10:08 a.m., the Regional Nurse stated using expired barrier cream could cause the cream to not work as indicated. She stated she expected nurses to check the medication cart for expired medications and supplies every day and before each use. The DON was not available for an interview. Record reviews of the facility's Perineal Care policy dated 05/02/2025, revealed .Policy explanation and compliance guidelines.14. Apply skin protectant as needed. The policy did not mention checking the item's expiration date.

Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 5 residents reviewed for wound prevention. The facility failed to provide Resident #1 wound care every day shift as ordered on 2/23/26, 2/24/26, and 2/25/26 for his 6 documented wounds. Pressure wound on Resident #1's left hip developed a strong odor with moderate serosanguinous fluid. Wound Care Doctor (WCD) diagnosed the wound as infected on 2/27/26. An IJ was identified on 03/01/256. The IJ template was provided to the facility on [DATE] at 3:30 p.m. While the IJ was removed on 03/02/26, the facility remained out of compliance at a scope of pattern and a severity level of not actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor the implementation of the plan of removal. These failures could place residents at risk for infection, pain, hospitalization, and death. Findings included:Record review of Resident #1's facesheet revealed a seventy-five-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were severe protein-calorie malnutrition, metabolic encephalopathy (acute brain dysfunction caused by systemic illness), peripheral vascular disease, and the presence of pressure ulcers with unspecified stages for the sacral region and right heel, and osteomyelitis of the right ankle and foot upon admission. Record review of Resident #1's MDS assessment dated [DATE] revealed that he was admitted with a pressure injury and treatments included nonsurgical dressings, ointments/medications, and application of dressings. Record review of his baseline care plan completed 12/31/25 by the DON documented that Resident #1 had a sacral PU and bilateral heels were red and boggy with skin excoriations. Record review of Resident #1's Care Plan revised 2/11/26 documented that the facility was to keep the MD informed of the resident's wound progress, inform the MD of signs and symptoms of infection, and perform treatments per order. Care plan identified a wound to the coccyx/sacral region and a wound to the right heel. Record review of Resident #1's Orders, start date 2/11/26 reflected that each wound was to be treated every day shift with normal saline, pat dry, and apply Santyl/calcium alginate/border foam dressing the wound on the left hip, right hip, left posterior shoulder, coccyx, and left medial lateral foot every day shift. DTPI to the 5th toe was ordered to be treated with betadine and iota every day shift. Record overview of Resident #1's progress notes documented the following:*On 02/06/26 at 9:38 a.m., RN B documented that Resident #1 was sent out to the hospital by request of his family to have his suprapubic catheter replaced.*On 02/10/26 at 7:00 p.m., LVN B documented that Resident #1 was readmitted to the facility alert and oriented x3 (person, place, time) with noted forgetfulness and intermittent confusion. A wound was found on his right ischium (hip) and treatment orders were in place for daily care and wound care orders were confirmed with the on-call MD upon return.*On 02/11/26 at 1:26 p.m., the WCN assessed Resident #1's skin and identified the following:Unstageable pressure ulcer to right hip with 100% eschar, small serosanguinous exudate, no odor, no s/s of infection with surrounding skin dry and intact. It was noted that resident had a stage 2 pressure ulcer to right hip before transfer to hospital and wound changed to unstageable upon return with increase in size.Unstageable pressure ulcer to left hip with 100% eschar, moderate serosanguinous exudate, no odor, no s/s of infection with surrounding skin dry and intact.Resident has a stage 4 pressure ulcer to left posterior shoulder with 50% granulation tissue, 50% slough, small serosanguinous exudate, no odor, no s/s of infection with surrounding skin dry and intact.There is a stage 3 pressure ulcer to coccyx with 60% slough, 40% granulation tissue, small serosanguinous exudate, no odor, no s/s of infection with surrounding skin dry and intact.There is an unstageable pressure ulcer to left medial lateral foot with 100% slough, rolled edges, small serosanguinous exudate, no odor, no s/s of infection with surrounding skin dry and intact.Resident has a DTPI to left foot lateral 5th toe with no exudate, no odor, no s/s of infection with surrounding skin dry and intact.The WCN wrote that the MD was at the facility and had new orders for Santyl/calcium alginate/dry dressing to right and left hip, left posterior shoulder, coccyx, and left medial lateral foot and paint with betadine and lota to left lateral foot, 5th toe. Resident verbalized no c/o pain or discomfort before, during, or after treatment. Resident turned and repositioned in bed with call light in reach. Resident on hospice services. No other issues noted. *On 02/11/26 at 1:31 p.m., DON noted that Resident #1 had a consistent decline in condition and weight loss and was under the care of Hospice A and they were to continue their plan of care.*On 02/17/26 at 6:46 p.m., RN A wrote that she reached out to Hospice A to clarify coverage and authorization status due to a change in hospice admission. Hospice team stated that Resident #1's previous RP had not been reachable and was needed to sign his hospice paperwork for readmission.*On 02/22/26 at 6:33 p.m., RN A documented that she provided wound care to Resident #1.*On 02/23/26 at 10:15 a.m., RN A wrote that she was still waiting for feedback from management about Resident #1's hospice status. Record review of Resident #1's TAR reflected that wound care was documented completed on 2/22/26 by RN A. All wound care documentation was left blank for 2/23/26, 2/24/26, and 2/25/26. Record review of Resident #1's change in condition assessments did not provide any documentation of a change in condition on 02/26/26 Record review of the facility's Wound Tracking report updated 02/18/26 documented that the wound on his left hip was unstageable and measured 8.4 x.5.9 cm and had moderate serosanguineous drainage and eschar tissue. In an observation on 2/27/26 at 1:22 p.m., Resident #1 was in bed at the lowest position and the room was engulfed with a pungent smell of feces. He mouthed that he was ok and was informed that an aide would come in shortly to preform peri care. He could not communicate to answer any further questions. In an interview on 02/27/26 at 1:23 p.m., CNA C was asked to provide peri care for Resident #1 and she stated that she just checked his brief and he was clean. She explained that room smelled the way it did because of his wounds. In an interview on 02/27/26 at 1:28 p.m., RN A stated that she last dressed Resident #1's wound on 02/23/26 and there was no odor. On 02/26/26, she accompanied LVN D during wound care for Resident #1 and noticed that the bandages on his wounds had her initials on it from the last time she did wound care. She stated the wound on his left hip smelled really bad because it had not been dressed in 2-3 days. In an interview on 02/27/26 at 1:31 p.m., LVN D stated that her first time seeing Resident #1 was on 02/26/26 when she provided wound care. She stated the odor from the wound on his left hip was very bad, so bad that the RT across the hall had to spray inside her office. The wound on his left hip had a lot of serosanguineous drainage and the drainage seeped outside of bandage. She could not remember the date on the bandage. In an interview on 02/27/26 at 1:42 p.m., the DON stated that the WCN was on leave from the facility due to a family emergency and she had assigned floor nurses to provide wound care for the 5 residents with wounds. She explained that the WCD was scheduled to come every Tuesday at 1 p.m. but he could not come that Tuesday and he had rescheduled today (Friday 02/27/26). She initially told him that she was not available to round with him and wanted to reschedule, but she reached back out to the WCD and asked him to come in and check the wounds. In an observation and interview on 02/27/26 at 3:43 p.m., the WCD arrived to the facility and stated that Resident #1 was not on his list to provide wound care because he did not have documented consent, but he would provide a courtesy look, measurement, and treatment update. During wound care, the WCD stated the following:*the wound on his right hip was very dark and measured 11.5x8.5 cm, with 90% eschar and 10% granulation tissue on the edges. WCD stated the wound had a mild odor and moderate drainage and updated treatment orders to include Santyl.*the wound on his left hip, he stated that the wound looked infected, was very smelly, and his purlin and serosanguinous drainage looked gnarly. He described the wound as unstageable with an undetermined depth and measured 13 x 8.5 cm. When he pushed the wound, a yellow tinged drainage identified as purlin oozed out and the WCD stated that that worried him because it indicated the wound was deep. Treatment orders were updated to include Daikon's wash, which he described as bleach.*The wound to the left shoulder measured 2.3x3.5 cm with a dept of .1;*the coccyx wound was described as sacral coccyx and measured 3x 1 cm;*left lateral foot had an undetermined depth and measured 8x 2 cm; and*the left 5th toe had a wound in between the toes and measured 2x 1.5 cm with an undetermined depth.The WCD stated that Resident #1 was sticks and stones and his pressure ulcers were unavoidable because he did not have the nutrition. The WCD stated that if Resident #1 would have received wound care on 02/23/26, 02/24/26, 02/25/26 it could have helped prevent the decline of the left hip because some wound care was better than no wound care but because of his comorbidities, lack of nourishment, and thin frame, he could not say that an infection was unavoidable. In an interview on 02/27/26 at 2:49 p.m., CNA D stated that when she assisted LVN E with wound care on 02/26/26, the bandage on Resident #1 had a date from a few days prior to 02/26/26. She thought the bandaged was labeled 02/23/26 but she was not sure but she did know that the wound smelled bad and it leaked blood. CNA D stated that she knew the bandages had not been changed in 2-3 days because she discussed it with RN A and LVN D during Resident #1's wound care. In an interview on 02/27/26 at 4:33 p.m., the DON stated that Resident #1 arrived back to the facility on [DATE] and was taken off hospice because the hospital usually removed patients from Hospice to provide care. Hospice could not put Resident #1 back on hospice because Resident #1's RP could not be reached to sign the consent forms. DON stated that there was an open APS case with Resident #1's RP and the facility was told not to contact his RP anymore regarding his care. The facility was currently in the process of getting guardianship for Resident #1 and the facility was trying to get his paperwork expedited. Due to the WCN's emergency leave on 02/23/26, wound care was assigned to RN A. On 02/24/26, LVN E was called in PRN to complete wound care and LVN D was assigned wound care on 02/25/26. In an interview on 02/27/26 at 5:05 p.m., LVN E stated she was PRN and worked on 02/24/26 to perform wound care for the Residents. LVN E stated that she performed wound care for Resident #1 but did not document it in the TAR because she could not find his name. She stated that not documenting was a mistake she made and she planned to ask the DON for assistance but she did not answer the phone when she called her and she did not ask any other nurses on shift for assistance. After she stated that she could not locate Resident #1's profile and orders inside the facility's TAR, she was asked how she knew what his treatment orders were. There was a 30 second pause and LVN E stated that she cleaned the wound with calcium alginate. LVN E also stated that when she performed wound care, Resident #1's roommate was not in the room. Record review of LVN E employee time punches on 02/24/26 revealed that LVN E worked from 2:15pm to 6:15 pm. In an interview on 02/27/26 at 5:37 p.m., the DON stated that she received orders from Resident #1's PCP to start him on Clindamycin 450 mg to take 3 times a day for 14 days to treat a wound infection. The WCD had picked up Resident #1 and he would be seen weekly. The DON oversaw wound care completion and delegated wound care to the floor nurses and could not speak to why the nurses did not perform wound care for Resident #1 as she had instructed and all documentation should be recorded in the TAR and progress notes. In an interview on 02/27/26 at 5:43 p.m. with RN A, she stated that she performed wound care to Resident #1 on 02/23/26 but she could not explain why it was not documented and no staff were able to corroborate wound care completion for Resident #1 on 2/23/26. In an interview on 02/28/26 at 11:14 a.m. with Hospice B DON, she stated that Resident #1's wounds were unavoidable due to his comorbidities and his poor nutrition. His wounds escalated quickly, where the left hip went from a stage 2 PU to an unstageable wound. She stated that although his wounds may not get better, it did not mean that they had to be infected. She stated having an unavoidable wound is one thing, but having wounds that are not being treated is neglect. Infections are avoidable. A call attempt was made to Resident #1's PCP on 03/01/26 at 10:45 a.m. and 12:14 p.m. No answer. Voicemail was left requesting call back. A follow-up attempt was made on 03/02/26 at 4:19 p.m. with no answer. In an interview on 03/01/26 at 12:15 p.m., the DON stated that wound cultures had not been captured for Resident #1's wound at that time. She stated that she would inform staff to capture them immediately. Record review of the facility's policy Wound Treatment Management revised 5/15/25 documented that wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The Administrator, DON, and ADON were notified of the IJ on 03/01/26 at 3:30 p.m. and given the IJ template due to the above failures and a POR was requested. On 03/02/256 at 11:36 a.m., the POR was accepted. It was documented as follows:Tag: F686 - Treatment/Services to Prevent/Heal Pressure UlcersDate of IJ Identification: 3/1/26Date IJ Removed: _03/02/26_________________1. Immediate Corrective Actions for Resident #1 Resident #1 was immediately assessed by the Wound Care Doctor on 02/27/26 and diagnosed with an infected unstageable pressure ulcer to the left hip. Physician orders obtained for Clindamycin 450 mg three times daily for 14 days. Wound care resumed immediately per physician order (daily day shift treatment). Wound cultures ordered 03/01/26 and obtained. DON initiated direct oversight of wound care completion and documentation.2. Identification of Other Residents at Risk Facility census reviewed; all residents with wounds identified. 100% audit completed of all wound treatment orders and TAR documentation. Head-to-toe skin assessments completed for all current residents, 03/01/26. Any identified documentation gaps were immediately corrected, 03/01/26 and treatments provided.3. Systemic Changes to Prevent Recurrence All licensed nurses re-educated on wound care policy, including treatment frequency, dressing type, and documentation requirements. Education included expectations for notifying the physician of any changes in wound condition. Daily wound care assignment sheet implemented to ensure accountability. DON or designee to perform daily spot checks of wound treatments4. Monitoring Plan Daily audit of all wound treatments for 14 days. Weekly audits thereafter for 30 days. Audit results to be reviewed in QAPI meeting. Staff failing to follow wound care procedures will receive immediate counseling and retraining5. Date of ComplianceThe Immediate Jeopardy will be considered removed when the facility has verified that the following is completed by 3/2/2026: All residents are receiving wound care as ordered. All licensed nurses have completed re-education. Monitoring systems are in place and functioning to ensure ongoing compliance. Monitoring/Verification of Plan of removalThe POR was reviewed as followed. The facility created a binder and numbered each tab in the binder with the completed documentation necessary to fulfill the plan. Record review of the facility's comprehensive resident TAR dated 02/23/26- 03/01/26 revealed that no adverse effects were noted from other residents with wounds. Skin assessments for 42 residents dated 03/01/26 were reviewed and no adverse effects were noted. All skin was intact and no new open areas were identified on skin shower sheets. Weekly wound care tracking log dated 03/01/26 was provided and reviewed. No adverse progression or infections documented out of Resident #1. An interview was conducted on 03/02/26 at 12:54 p.m. with the DON. She stated that on 03/01/26 the DCO completed an audit of all wound treatment orders and the TAR. The DON reported that no negative findings related to wound presence were identified during the audit; however, omissions in TAR documentation were identified, staff were in-serviced, and the physician/primary care providers were notified. The DON stated that 43 resident skin assessments were completed, which identified minor scratches or redness but no pressure injuries, and physicians were notified with orders obtained as indicated. The DON stated that an in-service regarding the facility's wound care policy was conducted on 03/01/26, which included review of daily medication audit reports, physician notification procedures, monitoring for significant changes in condition, care plan updates, daily rounding, and ensuring dressings are dated, initialed, and consistent with treatment orders. The DON also stated that CNAs were educated to monitor resident skin during bathing and personal care, report any new skin issues, foul odors, missing or soiled dressings, pain complaints, or other changes in condition immediately to nursing staff, and to complete skin/shower documentation sheets when changes were identified. Licensed nursing staff were educated regarding assessment responsibilities, documentation, physician notification, ensuring treatments are completed according to orders, and addressing significant changes in condition promptly. The DON further stated staff were reminded that failure to follow physician orders for wound care could constitute neglect. Interviews were conducted on 03/02/26 between 1:15 p.m. and 3:06 p.m. with CNAs B, C, H, I, J, K, L, M, Q, and R who worked the 6:00 a.m.- 2:00 p.m. and 2:00 p.m. - 10:00 p.m. shift. The CNAs stated that the in-service covered monitoring residents' skin and reporting any abnormalities to nursing staff. Staff reported that if they observed bruising, skin tears, wounds, blisters, redness, drainage, foul odors, bleeding, or leaking dressings, they would immediately report the findings to the nurse and complete a skin/shower documentation sheet. Staff also stated that during showers, incontinent care, dressing changes, or resident transfers, they monitored the skin for abnormalities. The CNAs stated that they were instructed to report missing, soiled, or incorrectly dated dressings, as well as dressings that appeared leaking, bleeding, or producing odor, to nursing staff for further assessment. CNA's also stated that dressings should be dated and initialed, and staff were expected to notify the nurse if the dressing appeared outdated or inconsistent with treatment orders. At 1:15 p.m., CNA H stated that during the in-service, aides were instructed that the facility operated under a see something, say something expectation, which meant that if staff observed any change in a resident's condition they should immediately notify the charge nurse, ADON, or DON if the nurse was unavailable. Interviews were conducted on 3/2/26 between 2:36 p.m. and 2:46 p.m. with licensed nursing staff who worked the 6:00 a.m. - 6:00 p.m. shift, including RN A, RN B, LVN D, and LVN E. During the interviews, licensed nursing staff stated that the in-service covered procedures for identifying, reporting, and treating resident wounds and skin conditions. Licensed nursing staff stated that if a new wound or skin issue was identified, the nurse assessed the resident, notified the physician and the WCN, and initiated wound care until physician orders were received so the wound would not remain untreated. Nursing staff stated that CNAs were expected to report any new wounds, redness, skin breakdown, drainage, odor, or changes in existing wounds immediately to nursing staff, and to document findings on the skin observation or shower sheet so the nurse could assess the resident. Licensed nursing staff also stated that if a dressing was missing, uncovered, soiled, or incorrectly dated, staff notified nursing immediately. Nursing staff stated that when the WCN was not present in the facility, the assigned nurse completed wound care treatments and documented the treatment in the TAR, including dating and initialing the dressing and documenting the treatment provided. Nursing staff also stated that new skin conditions or worsening wounds were reported to the physician and a skin assessment was completed, with treatment orders implemented and documented accordingly. Licensed nursing staff stated that the in-service also addressed that failure to report, document, or treat wounds in accordance with physician orders could be considered neglect. Telephone interviews were conducted on 03/02/26 between 9:21 p.m. and 9:37 p.m. with LVN B and LVN F who worked the 6:00 p.m. - 6:00 a.m. shift. The LVNs stated that the in-service included education regarding proper wound care practices, neglect prevention, and ensuring dressings are dated, timed, and initialed according to physician orders. Licensed nurses reported that if skin issues were reported by aides, they would assess the resident, initiate treatment such as applying a dressing if indicated, notify the physician and wound care nurse, and obtain treatment order LVN B and LVN F stated they would document wound findings in the resident assessment and progress notes and ensure treatments were documented in the TAR. Nurses also stated that CNAs documented skin issues on shower or skin observation sheets, which were reviewed by nursing staff. CNAs were expected to notify nursing staff immediately when drainage, odor, or removed dressings were observed. Telephone interviews were conducted on 03/02/26 between 9:45 p.m. and 10:07 p.m. with CNA N and CNA O who worked the night shift from10:00 p.m.-6:00 a.m. CNAs reported that during the in-service they were instructed to document any skin abnormalities, including bruising, scratches, wounds, or other unusual skin findings, on a skin observation or shower sheet and notify nursing staff immediately. Staff further stated they monitor dressings for drainage, odor, or soiling, and report if a dressing appears missing, dirty, or incorrectly dated. During the interview conducted on 03/05/26 at 11:01 a.m., the DON and Administrator stated that Resident #1 was sent to the hospital on [DATE] for further evaluation and treatment. An interview was conducted on 03/05/26 at 11:07 a.m. with LVN H, who stated she worked PRN on the 6:00 p.m.-6:00 a.m. shift as needed. LVN H stated that during the in-service staff reviewed procedures to follow when a new skin issue or missing dressing was identified. She stated that if a CNA reported a skin tear or if a dressing was missing, the nurse assessed the resident, contacted the physician for orders, assessed the resident for pain, and implemented treatment according to physician orders. LVN H also stated that wound care treatments were dated and initialed on the dressing and documented in the nurse's notes and the TAR, and that a skin assessment was completed. CNAs documented skin issues on the shower sheet, which was reviewed and signed by nursing staff and submitted to the DON. An interview was conducted on 3/5/26 at 11:22 a.m. with the WCN, who stated she worked from 8:00 a.m. to 5:00 p.m. Monday - Friday. The WCN stated that in-services conducted for staff included pressure injury prevention, turning and repositioning, bathing, offloading heels, and use of barrier creams following incontinent care. The WCN stated that nurses were educated to notify the physician when skin issues were identified and to implement treatment orders, and that nursing staff were expected to complete wound care treatments when the WCN was not present in the facility. The WCN stated she reviewed the TAR and dressings to verify wound care treatments were completed, and if treatments were not completed, she addressed the concern with nursing staff and notified the DON for further education if necessary. The WCN stated that CNAs were expected to monitor resident skin during care, reposition residents every two hours, and document observations on the shower sheets, which she reviewed to identify new skin concerns. The WCN further stated that on 3/4/26 she assessed Resident #1's wound and observed signs and symptoms of infection, including redness, warmth, and copious purulent drainage from the left hip wound. The WCN stated the resident was already receiving antibiotics, however the wound appeared worsened compared to the prior assessment on 03/03/26. The WCN stated she notified his PCP, who assessed the resident and ordered the resident to be sent to the hospital for further evaluation due to concerns for infection. The WCN stated culture results were pending at the time of the interview and would take a few days because they were initially collected on a Sunday. The ADM, DON and ADON were notified that the IJ was removed on 03/02/26 at 10:22 p.m., however the facility remained out of compliance at a scope of pattern and a level of minimal harm due to the facility's need to monitor the implementation of the plan of removal.

Based on interview, and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders for 1 (CR#1) of 45esidents reviewed for advanced directives. CR #1 was found unresponsive on [DATE]. LVN A failed to perform CPR on resident or contact Hospice A for further instruction. CR#1 was pronounced deceased on [DATE] at 6:20 p.m. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. The failure could place residents at risk of experiencing a diminished quality of life and death. The findings included:Record review of CR#1's facesheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses were dementia, cerebral infraction (stroke), and COPD (Chronic Obstructive Pulmonary Disease). Advance directives stated that he was a FULL CODE- CPR (when care team will initiate CPR and all resuscitation efforts if a patient's heart or breathing stops). Record review of CR#1's MDS assessment dated [DATE] did not document his code status. Record review of CR#1's care plan initiated [DATE] revealed no documentation that he was FULL CODE- CPR. Record review of CR#1's Orders started [DATE] revealed that he was admitted under Hospice A and they were to be notified of any change in condition. CR#1 was a FULL CODE- CPR with an ordered start date on [DATE]. Record review of CR#1's weights and vitals on [DATE] revealed no documentation on his BP, temperature, pulse, and respirations. At 3:57 p.m., CR#1's oxygen saturation was documented at 99% via nasal canula by LVN A. Record review of CR#1's BIMS score completed [DATE] revealed a score of 99, staff assessed. Record review of CR#1's Progress note dated [DATE] at 8:04 a.m. documented that his BIMS test could not be completed and CR#1 seemed to recall after 5 minutes. CR#1 made decisions regarding tasks of daily life and was moderately impaired. Record review of CR#1's progress note documented on [DATE] at 6:20 p.m. by LVN A revealed that at 5:25 p.m., CR#1 was noted unresponsive with eyes closed and unable to obtain vitals. Upon assessments, body was warm to touch with absence of respiration and no detectable airway movement. Findings were reported to the MD and DON. Documentation did not note that CPR was administered. In an interview on [DATE] at 11:50 a.m., CNA B stated that on [DATE], she noticed CR#1 unresponsive in B bed around 5 p.m. while she passed out dinner trays. She stated that his skin looked yellow and he did not respond when she touched his hand and called out to him. She informed LVN A, who checked his pulse and pulled the covers back. CR#1 was not breathing. In an interview on [DATE] at 1:06 p.m. with LVN A, she stated that she had noticed increased weakness from CR#1 throughout her shift on [DATE] and she was notified by CNA B that CR#1 was unresponsive. LVN A immediately entered the room and took his pulse and BP, but forgot to document it and could not recall the reading. She explained that she did not administer CPR to CR#1 because in the code status binder at the nurse's station, CR#1's code status stated he was a DNR. After she found CR#1 unresponsive, LVN A stated she contacted the NP and the DON about his expiration. LVN A was unfamiliar of anything related to Resident #1 and stated that she could not recall telling the DON Resident #1's name instead of CR#1. LVN A explained that she was PRN and the last time she worked at the facility was in [DATE]. In an interview on [DATE] at 10:18 a.m. with the DON, she stated that she was first notified that a resident had passed on [DATE] around 5:45 p.m. LVN A informed her that Resident #1 had passed and she needed additional information on who to contact since Resident #1 was in the process of obtaining guardianship. On the morning of [DATE], the DON inquired about Resident #1's passing during the morning meeting and she was informed that CR#1 was the expired client and not Resident #1, who was still alive and well inside the facility. DON stated that LVN A was PRN and she requested her to come to the facility for additional information. DON asked LVN A if she initiated CPR twice. LVN A paused and stated she did not initiate CPR and that she had been a nurse for several years and could not say what happened. DON stated that if a resident was found unresponsive, the pulse and heart rate should be checked, someone should check the code status, and if Full Code, perform CPR but 911 should be contacted first. In an interview on [DATE] at 12:35 a.m., Hospice A Rep stated that CR#1 had always been a full code with their hospice company and he signed the documentation to be full code himself. She stated that the facility never notified them that CR#1 had expired and they found out about his expiration because the facility needed funeral home information because CR#1 was sent to a funeral home . Hospice A Rep explained that even if a patient was on hospice, they should still receive CPR if they were coded to do so. A call attempt was made to CR#1's NP on [DATE] at 2:59 p.m. Voicemail was left requesting call back Record review of the facility's policy titled Cardiopulmonary Resuscitation- CPR revised [DATE] stated that it is the facility's policy to adhere to resident rights to formulate advance directives and CPR will be performed if the resident does not show obvious sign of clinical death (rigor mortis, decomposition, decapitation). On [DATE] at 3:52 p.m., the facility's Administrator, DON, and Regional Nurse were notified of the past noncompliance IT. A plan of removal was not requested. An IT template was provided to the Administrator on [DATE] at 3:52 p.m. Verification of PNCRecord review of CR#1's code status completed [DATE] confirmed him as Full Code, and a root cause analysis was initiated by the ADM, DON, and MD. The staff involved were removed from direct resident care pending investigation, and the physician and responsible party were notified. LVN A was terminated on [DATE]. Record review of a facility audit date [DATE] by the DON confirmed that the status orders were current and accurately reflected in the EMR, care plans, face sheets, and code status identification tools. Record review of the facility's discharge and significant change reports completed [DATE] reviewed the previous 30 days of resident events involving significant change or death to ensure CPR had been initiated appropriately when indicated. No issues were indicated due to know changes in condition in the last 30 days. Record review of the facility's code binder updated [DATE] revealed 42 residents who were full code were identified and facesheets and care plans were reviewed for accuracy. Three residents were identified as DNR and all documentation was accurate. Records review of in-service education dated [DATE] revealed100% of licensed nurses, CNAs, and agency staff were in-serviced on CPR policy, code status verification, emergency response procedures, AED use (a portable, life-saving medical device used to treat sudden cardiac arrest by analyzing the heart's rhythm and delivering an electric shock to restore normal function), and CPR competency validation. Documentation confirmed current BLS certification for licensed nurses and implementation of mock code drills on all shifts. The facility implemented monitoring which included weekly mock code drills for four weeks, then monthly for three months, and weekly audits of resident code status documentation, with results reviewed through QAPI oversight. The DON, Staff Development Coordinator, and Administrator were identified as responsible for ongoing monitoring and compliance. In an interview on [DATE] at 10:36 a.m., the DON stated staff received post-incident in-service which included review of the facility protocol for responding to unresponsive residents, verification of resident code status, and use of the AED machine. The DON stated staff were also educated on abuse and neglect reporting procedures. The ADM was identified as the facility's abuse coordinator and stated staff were instructed to report suspected abuse immediately to the ADM, or to the DON or ADON if the ADM was unavailable. She stated the CPR training included review of the steps staff should take when a resident is found unresponsive, including calling for help, verifying responsiveness and pulse, activating 911, and initiating CPR if the resident was Full Code. The DON stated staff received hands-on CPR training with return demonstration, and both licensed nurses and CNAs participated in the training. She stated that during an emergency response, staff would call EMS, obtain the crash cart, apply AED pads, and continue CPR until EMS arrived, while another staff member documented the timeline of events.The DON also stated that following an emergency event, staff were expected to complete documentation, notify the physician and resident's family, and complete required follow-up reporting. The facility completed an audit of residents who experienced a change in condition, and a 30-day review did not identify additional adverse events. The facility planned to implement mock code drills on all shifts for nursing staff and CNAs to reinforce emergency response procedures. In an interview on [DATE] at 12:14 p.m., CNA F stated she had been employed at the facility since [DATE] and worked the 6:00 a.m. - 2:00 p.m. shift. CNA F stated that if she found a resident unresponsive, she would call for help, check if the resident was breathing and had a pulse, and begin CPR with chest compressions and rescue breaths while another staff member contacted 911. She stated staff would also notify the charge nurse and other available staff to assist. CAN F stated resident code status could be located in the Kardex (tool used to locate summarized patient care) in PCC or in the resident information binder. CNA F stated she maintained current CPR certification and identified the ADM, as the abuse coordinator, stating abuse or neglect would be reported immediately. In an interview on [DATE] at 12:21 p.m., CNA C stated she had been employed at the facility for seven months and worked the 6:00 a.m. - 2:00 p.m. shift. CNA C stated that if a resident was found unresponsive, she would call for help, assess responsiveness, and notify the nurse immediately. She stated CPR could be initiated by staff while another employee called 911. CNA C stated she had received CPR training and understood the procedures, including observing the resident's chest for breathing an identified the ADM as the abuse coordinator and stated abuse should be reported immediately.In an interview on [DATE] at 11:23 a.m., CNA E stated she had been employed at the facility since [DATE]. CNA E stated that if a resident was found unresponsive, she would call for the nurse, clear the area, and request assistance, including having someone call 911 and obtain the AED, which she stated was located near the front nurses' station. CNA E stated resident code status could be located on the resident door, in the MAR, or in the computer system. CNA E stated she felt confident in the CPR training provided and identified the ADM as the abuse coordinator. In an interview on [DATE] at 11:41 a.m., LVN D stated she had been employed at the facility for approximately one month and worked the 6:00 a.m. - 6:00 p.m. shift. LVN D stated that if a resident was found unresponsive, she would assess the resident for responsiveness and pulse, call for help, initiate CPR, and instruct another staff member to call 911 and obtain the crash cart and AED. LVN D stated CPR would continue until emergency services arrived, and staff would document the event and times accordingly. LVN D identified the ADM, as the abuse coordinator and stated abuse would be reported immediately. In an interview on [DATE] at 11:47 a.m., CNA M stated he had been employed at the facility for nine years and worked the 6:00 a.m. - 2:00 p.m. shift. CNA M stated that if a resident was found unresponsive, staff would call for help, assess the resident, initiate CPR, and have another staff member contact 911. CNA M identified the ADM, as the abuse coordinator and stated abuse would be reported immediately. In an interview on [DATE] at 11:51 a.m., CNA G stated she had been employed at the facility since [DATE] and worked the 2:00 p.m. - 10:00 p.m. shift. CNA G stated that if a resident was found unresponsive, she would remain with the resident, call for help, and assist nursing staff as needed, including calling 911 or obtaining emergency supplies. CNA G stated her CPR certification had recently expired but she was scheduled to complete a CPR course the following week and stated she felt comfortable performing CPR. CNA G identified ADM as the abuse coordinator and stated abuse or neglect would be reported immediately. In an interview on [DATE] at 11:56 a.m., CNA D stated she had been employed at the facility for six months and worked the 6:00 a.m. - 2:00 p.m. shift. CNA D stated that if a resident was found unresponsive, staff would ensure the environment was safe, call for help, assess the resident, and notify the nurse. CNA D stated the nurse would then direct staff to obtain the crash cart or call 911 as needed. CNA D stated resident code status could be verified in the resident care binder or through nursing staff. CNA D identified the ADM, as the abuse coordinator and stated abuse would be reported immediately following the chain of command. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records or safeguard medical record information against loss, destruction, or unauthorized use for 1 (Hall C) of 2 halls observed for privacy and failed to keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is to the individual, or their resident representative where permitted by applicable law or required by law for 1 (CR#1) of 1 residents reviewed for medical records. -CNA B left a computer logged into the medical record system unattended on 1/16/2025 at 10:52am.-The facility failed to respond to CR #1's representative's attempts for medical records requests on 5/21/2025, 6/24/2025, 7/9/2025, 7/22/2025 and 09/12/2025. This failure could place residents at risk of their personal health information being exposed to unauthorized personnel and could place residents and their representatives at risk of not being informed about their health status. Findings included:Observation and interview with OT A on 1/16/2026 at 10:52am, there was an unattended computer screen mounted to the wall of Hall C on which CNA B's name was shown on the top right of the screen and showed he was logged into the medical records system. OT A was walking by and was stopped and said CNA B should not have logged onto the computer and left it unattended because the medical records system contained private information with resident records and orders. OT A was observed logging out of CNA's account on the computer. There was no resident information on the screen.Interview with the ADON on 1/16/2026 at 10:58am, she said the computer should not have been left logged in and that she would start on verbal training for CNA B and then a facility-wide full-blown education later.Interview with the ADON on 1/16/2026 at 12:44pm, the ADON said that CNA B was hired three days ago and underwent all training before working. The ADON said that an unauthorized person could have gotten resident social security numbers, home address and diagnoses.Interview with the DON on 1/16/2026 at 12:26pm, she said CNA B should not have left the computer without logging out of the system, as unauthorized individuals could access resident information. The DON said staff get initial training and quarterly in-services on privacy.Interview with CNA B on 1/16/2026 at 1:20pm, CNA B said he left the computer to tell the ADON that his password worked. CNA B said he should not have done that, and someone could have located residents' home address or their diagnoses. CNA B said he received training on privacy at the facility.Interview with the Administrator, DON and ADON on 1/16/2026 at 1:35pm, the Administrator said the home screen CNA B logged into could not have given access to residents' medical records. The DON and ADON agreed to go back to the computer on Hall C and have a staff log in.Observation and interview with the DON and ADON on 1/16/2026 at 1:40pm, CNA M went back to the computer in Hall C and logged in. Once the screen was in the main screen, DON confirmed that from the home screen, staff did not need an additional password to access records. CR #1 Record review of letters addressed to the facility's President/CEO with a different facility name and the same address as this facility:-Letter 1 was dated 05/21/2025 and contained certified mail and first-class mail from an entity representing CR#1 requesting medical records to be sent within 45 days. It contained an authorization form for protected health information requesting CR#1's entire record from 08/01/2024 to present and electronically signed by CR #1's RP. It listed CR #1's Certificate of Death dated 01/05/2025. It had CR #1's RP's state ID.-Letter 2 was dated 6/24/2025 with the same information. It was certified mail and first class mail.-Letter 3 was dated 7/9/2025 with the same information. It was certified mail and first class mail. Letter 3 had a scan of the certified mail envelope also dated 7/9/2025 addressed to this facility's physical address. When verified on USPS' website, it stated this letter had not reached its destination.-Letter 4 was dated 7/22/2025 with the same information. The PDF was labelled addressed and sent to the facility's Corporate Office; there was a scan of the certified mail envelope dated 07/22/2025. When verified on USPS' website, it stated this letter was returned to sender. -Letter 5 was dated 09/12/2025 with the same information. It also had a scan of the certified mail dated 09/21/2025 addressed to the facility's parent company. When verified on USPS' website, it stated this letter was received and signed by an individual at the postal facility. Record review of the facility's TULIP profile, on 4/1/2025 the facility had a name change. Per the Facility Summary Report, there was no change to the facility's parent company. The facility's status was effective 08/15/2025.Record review of CR #1's face sheet dated 1/16/2026, he was a [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. His most recent hospitalization was 10/10/2024 to 11/29/2024. His medical diagnoses included: anemia, Parkinsonism, pressure ulcer of left hip (9/27/24), Alzheimer's Disease, quadriplegia, pressure ulcer of sacral region stage 4 (6/26/24), dysphagia, acute respiratory failure with hypoxia (11/29/2024) and pneumonia (11/29/2024). It listed CR #1's RP in the contacts section.Record review of the resident's progress notes, there were no notes documented before 09/27/2024.Record review of the resident's discharge MDS dated [DATE], he was discharged to the hospital on that date. CR #1's most recent Quarterly MDS dated [DATE] reflected CR#1 was rarely or never understood and a BIMS was not conducted. CR #1 was coded as having short-term and long-term memory problems and was totally dependent on staff for all ADLs.Interview with the SW on 1/16/2026 at 12:28pm, she had been at the facility since August 2022, and no one complained about not getting medical records. The process to request medical records was to speak to the medical records person, DON, Administrator. Then the facility would get a release form and let the resident or their representative sign it to get their medical record and that they're entitled to it.Interview with MR on 1/16/2026 at she came back to work in September 2025, and she did not hear about residents not getting requested documents. Residents and their representatives could verbally request from her, and she would just need to confirm the correct RP is making the request. There is also a form that residents and RPs could fill out. She said she was still in the process of learning about this position and if she had questions, she would ask the Administrator.Interview with BOM A on 1/16/2026 at 1:03pm, she said she oversaw accounts and authorizations and verifying eligibility. She denied receiving any medical records requests. BOM A said the new management took over on 4/1/2025, and they had a different name. BOM A did not remember CR #1.Interview with the former management company's BOM B on 1/16/2026 at 1:08pm, she looked into CR #1's records and found that he was admitted to the facility under the old company on 11/7/2023 and discharged [DATE]. She started working on 11/23/2024 and was not assigned to this facility until February 2025. She said she did not know this resident and had not received any medical records request from this resident or their RP. BOM B said if it was a former resident, she would send the request to whoever requested records to the local nursing homes' medical records.Interview with the Administrator, he said he started in his position one month ago. He said the process is for the DON to send medical records requests to the BOM. After some questioning, the Administrator stated a law firm did call him sometime in December 2025 and it was related to another resident under a different facility under the same management and it was not for this resident. He did not write down the name of the person he spoke to or their number. The Administrator said he did not know or recognize CR #1 and did not have the phone number of the former manager or the previous Administrator, He said if mail was addressed to the previous company, he would not sign the letters and that the letters would be sent back. He said the facility did not receive any mail or letters related to CR #1.Record review of the facility's policy on electronic medical records dated 2018, it read in part, 1. Electronic records are an acceptable form of medical record management. 2. The Administrator, in conjunction with the Quality Assessment and Assurance Committee, shall review requests for and the implementation of our electronic medical records system. 3. Only authorized people who have been issued a password and user ID code will be permitted access to the electronic medical records system. 4. The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure .Record review of the facility's policy on electronic medical records dated Qtr. 3, 2018 read in part, Policy Interpretation and Implementation 1. Electronic records are an acceptable form of medical record management. 2. The Administrator, in conjunction with the Quality Assessment and Assurance Committee, shall review requests for and the implementation of our electronic medical records system.Record review of the Texas Civil Practice and Remedies Code Section 74.051 verified on 05/26/2025 (found on https://texas.public.law/statutes/tex._civ._practice_and_remedies_code_section_74.051) read in part, .(a)Any person or his authorized agent asserting a health care liability claim shall give written notice of such claim by certified mail, return receipt requested, to each physician or health care provider against whom such claim is being made at least 60 days before the filing of a suit in any court of this state based upon a health care liability claim. The notice must be accompanied by the authorization form for release of protected health information as required under Section 74.052 (Authorization Form for Release of Protected Health Information) (d)All parties shall be entitled to obtain complete and unaltered copies of the patient's medical records from any other party within 45 days from the date of receipt of a written request for such records; provided, however, that the receipt of a medical authorization in the form required by Section 74.052 (Authorization Form for Release of Protected Health Information) executed by the claimant herein shall be considered compliance by the claimant with this subsection.Record review of the Texas Civil Practice and Remedies Code Section 74.052 verified on 05/26/2025 (found on https://texas.public.law/statutes/tex._civ._practice_and_remedies_code_section_74.052) read in part, (a) Notice of a health care claim under Section 74.051 (Notice) must be accompanied by a medical authorization in the form specified by this section .

Based on observation, interview, and record review the facility failed to ensure that its residents are free of any significant medication errors for 1 (Resident #1) of 4 residents reviewed for medication administration. RN B failed to call the hospital, ADON, and Administrator on 11/04/25 when she did not receive report from the hospital when Resident #1 returned to the facility from the hospital on [DATE]. The facility failed to administer Resident #1's IV Vancomycin 1gm evening dose on 11/04/25 and morning dose on 11/5/25. The facility failed to administer Resident #1's IV Meropenem 500mg every 4 hours when he returned to the NF on 11/04/25 from the hospital. The facility did not initiate the medication until 11/05/25 at 8:00PM. Resident #1 missed a total of 4 doses. This failure could place residents at risk of prescribed antibiotics not working effectively to treat residents' infections. Findings: Record review of Resident #1's face sheet dated 11/05/25 revealed a [AGE] year-old-male admitted to the NF initially on 05/07/25 and again on 11/04/25. Resident #1's diagnoses included the following: respiratory failure with hypoxia (low oxygen levels in the body), cerebral infarction (blood flow to a part of the brain is blocked), sepsis (bacterial infection in the body that could lead to organ failure and death), type 2 diabetes mellitus (when blood sugar in the body is too high), pneumonia (infection of the lungs), muscle wasting and atrophy (shrinking and weaking of muscle tissue when not being used enough), traumatic subarachnoid hemorrhage (bleeding in the space around the brain due to an injury), hypertension (elevated blood pressure), heart disease, neuromuscular dysfunction of the bladder (when the nerves and muscles that control the bladder is not working properly causing the bladder to not empty adequately), altered mental status, restlessness and agitation, tracheostomy (surgical opening made in the front of the neck directly into the windpipe and a small tube is inserted to help one breathe), and gastrostomy (surgical opening made directly into the stomach to allow for feeding through a tube). Record review of Resident #1's quarterly MDS dated [DATE] reflected that resident had a BIMS score of 3 indicating that Resident #1's cognition was severely impaired. Further review section H (Bladder and Bowel) revealed that Resident #1 had an indwelling catheter and feeding tube. Section O (Special Treatments) revealed that Resident #1 was receiving oxygen therapy, suctioning, and tracheostomy care, but was not on isolation or quarantined for active infections. Record review of Resident #1's Comprehensive Care Plan dated 10/24/25 reflected that Resident #1 was being care planned for being at risk for frequent infection with an intervention that included administering medication as order by the physician. Record review of Resident #1's hospital records dated 10/28/25 revealed that Resident #1 was receiving IV antibiotic vancomycin and Meropenem. The hospital physician electronically signed on 11/03/25 for Resident #1 to continue IV meropenem for pneumonia bacteremia and IV vancomycin for MRSA, final duration of antibiotic through 11/07/25. Record review of Resident #1's NF active Physician orders for the month of November 2025 included the following orders: Dated 11/05/25 Vancomycin 1gm IV every 12 hours for pneumonia and bacteremia.Dated 11/05/25 Meropenem 500mg IV 4 (four) times a day for MDRO Dated 11/05/25 Isolation for MDRO Record review of Resident #1's MAR for November 2025 reflected that Resident #1 did not receive his 1st dose of Vancomycin 1gm IV until 7pm on 11/05/25 at 7pm. The medication times on the MAR for the medication Vancomycin were 7:00AM and 7PM. The times for the meropenem was 10:00AM, 3:00PM, 8:00PM, and 2:00AM. Interview on 11/04/25 at 4:33PM with the RP of Resident #1 said Resident #1 was at the hospital and still receiving IV antibiotics to treat his infection. The RP said the hospital would be discharging Resident #1 back to the NF on 11/04/25. The RP said the hospital doctor wanted resident to continue on the IV antibiotics for several more days. Observation on 11/05/25 at 10:45AM revealed Resident #1 was resting in bed with his eyes closed to his left side with a pillow wedge to his back. Resident had a tracheostomy that was connected to continuous oxygen. There was no IV antibiotics being administered. Interview on 11/05/25 at 11:30AM with RN B, she said she worked at the facility on the morning shift from 6AM to 6PM. RN B said she was the nurse that admitted Resident #1 when he returned from the hospital on [DATE]. Interview on 11/05/25 at 3:18PM with RN B, she said when Resident #1 returned to the facility on [DATE] she did not know who took report on resident. RN B said she did not administer any antibiotics to Resident #1 due to no antibiotics being listed on Resident #1's medication list when he returned to the NF. RN B said she had informed the ADON about this around 2:00PM on 11/05/25. RN B said she learned on 11/05/25 that resident was supposed to be on the antibiotic Meropenem (antibiotic used to treat a variety of severe bacterial infections, particularly those caused by multidrug-resistant bacteria) 4 times a day. RN B said she needed to clarify the orders with the NP . Interview on 11/05/25 at 4:11PM with LVN C via phone. LVN C said he worked at the facility full time on the night shift from 6PM-6AM. LVN C said he had been working at the facility for 4 to 5 months. LVN C said he worked on 11/04/25 and received report from nurse RN B who did not tell him much about Resident #1's return from the hospital to the NF. Interview on 11/05/25 at 4:26PM with the ADON, she said the NF did not have a DON but that the facility's new DON would be starting on 11/17/25. The ADON said the NF was waiting for an update from the hospital when Resident #1 would be returning to the NF. ADON said when resident returned to the NF on 11/04/25, the hospital did not call to give a report on resident. The ADON said when resident returned via EMS the staff did not receive a full medication list with the initial paperwork. The ADON said she did not review the 2nd clinical records regarding resident antibiotics for Resident #1 until 11/05/25. The ADON said she received the 2nd clinical record via e-mail. The ADON said the hospital sent over the 1st set of clinical records via email on 11/04/25 and did not send the 2nd set of clinical records until later on 11/04/25. The ADON said she was doing the best she could and that it must have been an oversight on her part. Interview on 11/06/25 at 8:50AM with the Administrator, she said there was a gap in communication regarding Resident #1's return from the hospital to the facility. The Administrator said EMS just showed up at the facility on 11/04/25 toward the end of the day shift. The Administrator said the nursing staff was in-serviced on 11/05/25 on the importance of getting a report from the hospital when a resident is discharging back to the NF. The Administrator said nurse RN B could have called the ADON to tell her what had taken place, and they could have come up with a solution on how to handle the situation. The Administrator said she could not say what system the NF had in place if the nurse did not receive report on a resident because that had never happened before. The Administrator said the NF did not have a Clinical Marketer. The Administrator said the last Clinical Marketer would communicate with the hospital and let the NF know when a resident was due to return to the facility. The Administrator said this was done to ensure the NF had all necessary orders at the time of discharge. The Administrator said the NF had morning meetings discussing admissions and the resident clinicals. The Administrator said on 11/05/25 the NF only had a brief morning meeting due to State surveyor being at the facility as well as the Rapid Response being at the facility. The Administrator said the RRT had been coming to the facility on a weekly basis for several weeks reviewing the NF systems that were in place and communicating with the NF areas that needed to be corrected. The Administrator said the staff that normally participated in the morning meetings included herself, DON, ADON, MDS Coordinator, Clinical Marketer, and Rehab Department. The Administrator said she would have to ask the ADON when she reviewed Resident #1's clinical records. Interview with ADON on 11/06/25 10:05AM, she said it was nurse RN B that transcribed Resident #1's Physician Orders on 11/05/25. The ADON said Resident #1 was on the antibiotic Vancomycin IV and had missed two doses. The ADON said resident was also on the antibiotic Meropenem IV and had missed 3 doses. The ADON said RN B did not call her about the hospital not giving a report on Resident #1 on 11/04/25. The ADON said normally the Clinical Marketer communicated with the hospital Case Manager regarding resident care and the anticipated date of discharge. The ADON said the facility no longer had a Clinical Marketer. The ADON said prior to Resident #1 being readmitted to the facility, it was the NF Business Office Manager that was communicating with the hospital and sending a group email to herself, Corporate MDS Coordinator, Administrator, Social Worker, Wound Care Nurse, and Rehab Director regarding a resident's plan of care. The ADON said the Case Manager at the hospital had informed her that the hospital called to give report on Resident #1 on 11/04/25 and no one at the facility answered the phone. The ADON said when an admission comes to the NF, the admitting nurse did the initial assessment, contacted the doctor or NP to do a medication reconciliation with the doctor or NP. The ADON said it was discovered on 11/05/25 around 4:30PM by herself that Resident #1 was supposed to be on IV antibiotic therapy and the antibiotics had not been initiated. The ADON said when resident medications were transcribed by RN B on 11/04/25 there were no antibiotics included on resident MAR. The ADON said she did not see the 2nd list of resident medications that was sent on 11/04/25 until 4:30PM on 11/05/25. The ADON said although the NF was utilizing the Corporate Regional Nurse who was easily available by phone and email, it was still a challenge due to the facility not having a Clinical Marketer. The ADON said she was being pulled in so many different directions and therefore it made it a challenge to try and keep up with everything. The ADON said the Business Office Manager was doing the best that she could while learning the process. The ADON said the Business Office Manager was emailing her Resident #1's clinical records while resident was still at the hospital and emailed her the updated email on 11/04/25 around 4:10PM. The ADON said ultimately, she missed the email. The ADON said RN B did not inform her on 11/04/25 that she did not get report from the hospital on Resident #1's return to the NF. The ADON said she in-serviced the staff that if they do not get a report on a resident being admitted to the facility from the hospital to call the hospital to get a thorough report even if they have to speak to hospital supervisor to confirm the residents' medication list was correct and that the facility had received all of residents' clinical hospital records. The ADON said after the nurse did this, he or she would call the NF doctor to do a medication reconciliation. The ADON said it was the MDS Nurse that reviewed the residents' records to ensure that they met the medical necessity prior to admission and that it was herself and the DON that was responsible in reviewing clinical records on all admissions to ensure everything was correct. Interview on 11/06/25 at 11:06AM via phone with Business Office Manager, she said she had been working at the facility since July 7th 2025. The Business Office Manager said she had been communicating with the hospital regarding the care of Resident #1 the computer referral portal. The Business Office Manager said when a resident was getting close to being discharged from the hospital, the hospital started sending clinical records to the NF. The Business Office Manager said she started receiving clinical records on Resident #1 on 10/31/25 from the hospital case manager. The Business Office Manager said she received records again on 11/03/25 that resident was expected to be discharged back to the NF in 1 - 2 days and the hospital case manager sent over resident clinical records. The Business Office Manager said on 11/04/25 resident was clear to be discharged from the hospital to the NF and that Resident #1 needed antibiotics through 11/07/25. She said she gave the hospital case manager the mode of transportation and what room resident would be admitted to. She said she also gave the hospital case manager the ADON's phone number because she knew the hospital would be calling to give report and the nurses could be away from the nurse station on the halls providing care for the residents. She said due to the NF not having a Clinical Marketer, she was asked by the COO if she could assist with referrals. She said she was familiar with the referral process from prior experience. Attempted interview on 11/06/25 at 11:27AM via phone with the NP, no answer, left voicemail with call back number. Interview on 11/06/25 at 11:55AM with LVN F, she said she worked the morning shift from 6AM-6PM full time. LVN F said she had been working at the NF for almost a year. LVN F said if a resident was admitted to the NF without the NF receiving a report on the resident, she would immediately call the hospital to get a full report on the resident. LVN F said she would inform the doctor, Administrator and the ADON since the facility did not have a DON at present what had taken place. LVN F said whenever a resident missed a scheduled dose of their antibiotic therapy, it placed the resident at risk of the infection developing resistance to the antibiotic causing the resident to be given a stronger antibiotic to treat the infection. LVN F said it also placed other residents at risk of encountering that same bacteria. Interview on 11/06/25 at 2:03PM with Resident #1's Doctor, he said he was notified on 11/06/25 by the ADON that Resident #1 had missed several doses of his IV antibiotic therapy. Dr. said because resident was already receiving frequent scheduled doses at the hospital, he was not concerned about the missed doses and would extend the length of days for resident to receive the IV antibiotic therapy and continue to have the staff monitor resident vital signs and order labs as needed. The doctor said more than likely the infection had resolved itself, but antibiotic therapy was extended a little longer for precautionary measure due to resident having the following tubes (tracheostomy, gastrostomy, and Foley catheter). The Dr. said it was the NP that the facility would first call upon admission and then he would follow-up. The Doctor said the NP had sent him a message on 11/06/25 in the morning informing him that Resident #1 had returned to the facility and what antibiotics he was receiving for diagnosis of pneumonia and what bacteria was being treated. The Doctor said Resident #1 had a history of sepsis and going in and out of the hospital. The Doctor said Resident #1 would continue to get infections due to having tubes inside of his body which the body looks at as a foreign object and would begin to attack. The Doctor said it was an ongoing process. The Doctor said the infection would go away until another infection occurred and had to be treated. The Doctor said eventually no antibiotic would help and Resident #1 would eventually pass away. The Administrator was asked for the NF policy on Pharmacy Services on 11/06/25 at 4:30PMRecord review of the NF policy on Resident Rights revised June 06, 2025 reflected in part: .Resident has the right to receive the services and /or items included in the plan of care.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety for 1 (Resident #1) of 4 residents observed for cleanliness of rooms. Housekeeping failed to clean Resident #1's room prior to being admitted from the hospital to facility on 11/04/25. This failure placed residents at risk for cross contamination. Findings: Record review of Resident #1's face sheet dated 11/05/25 revealed a [AGE] year-old-male admitted to the NF initially on 05/07/25 and again on 11/04/25. Resident #1's diagnoses included the following: respiratory failure with hypoxia (low oxygen levels in the body), cerebral infarction (blood flow to a part of the brain is blocked), sepsis (bacterial infection in the body that could lead to organ failure and death), type 2 diabetes mellitus (when blood sugar in the body is too high), pneumonia (infection of the lungs), muscle wasting and atrophy (shrinking and weaking of muscle tissue when not being used enough), traumatic subarachnoid hemorrhage (bleeding in the space around the brain due to an injury), hypertension (elevated blood pressure), heart disease, neuromuscular dysfunction of the bladder (when the nerves and muscles that control the bladder is not working properly causing the bladder to not empty adequately), altered mental status, restlessness and agitation, tracheostomy (surgical opening made in the front of the neck directly into the windpipe and a small tube is inserted to help one breathe), and gastrostomy (surgical opening made directly into the stomach to allow for feeding through a tube). Record review of Resident #1's quarterly MDS dated [DATE] reflected that resident had a BIMS score of 3 indicating that resident[VT1] cognition was severely impaired. Further review section H (Bladder and Bowel) revealed that resident had an indwelling catheter and feeding tube. Section O (Special Treatments) revealed that resident was receiving oxygen therapy, suctioning, and tracheostomy care. Record review of Resident #1's Comprehensive Care Plan revised 10/24/25 reflected that resident was being care planned for risk of infection and recurrent infections. Record review of Resident #1's Physician Order Summary Report for November 1015 reflected the following orders: -Dated 05/31/25 Enhanced Barrier Precautions-Dated 11/05/25 Isolation for MDRO in sputum every shift Interview on 11/05/25 at 11:30AM with Housekeeping Director, she said she had been working at the facility since mid-April of 2025. She said the residents' rooms were cleaned once a day and as needed by sweeping and mopping the residents' floors, cleaning the light switches, counter tops of the bedside tables and nightstands. She said the trash was emptied as well. She said there was 1 housekeeper assigned to 2 halls and the facility had 4 halls. She said housekeeping did not strip the linen from the beds and that the nursing department did this and made the residents' beds. Observation on 11/05/25 at 10:45AM Resident #1 resting in bed to left side with eyes closed on scoop mattress. There was a used bottle of enteral feeding (Osmolite 1.2 cal) sitting on the night stand on the left side of resident bed dated 11/05/25 along with respiratory supplies. On top of the nightstand was white sand like debris. There was a purple top container of disinfectant sani-wipes sitting on the nightstand. Resident nightstand drawer was ajar with a used suctioning catheter size 14 French (unit measurement used to describe the outer diameter of the catheter) that was not enclosed but laying in drawer. Further observation was made of Resident #1's floors not clean with debris on the floor and underneath the bed. Bed B by the window was not made. The bed had a fitted sheet on the mattress with red brownish spots on the sheet and a used alcohol swab on the bed. Interview on 11/05/25 at 11:25AM with CNA G, she said she had been working at the facility for 2 months and worked the morning shift. CNA G said Resident #1 did not have a roommate. CNA G said resident room did not appear clean and organized and there was stuff all over resident room. CNA G said resident floor was dirty. CNA G said she did not know who placed the disinfectant sani-wipes in resident room and did not notice that earlier in resident room. CNA G said she had been off work for several days and worked another hall and therefore could not say when the last time resident room had been cleaned. Interview on 11/05/25 at 11:30AM with RN B, she said she worked at the facility on the morning shift from 6a-6p full time. RN B said Resident #1's room was not clean, the floor in resident room was dirty, and B bed was not clean or made. RN B said resident nightstand was cluttered and did not appear to be cleaned. RN B said she did not know who placed the disinfectant sani-wipes in resident room on the nightstand. RN B said she could not explain why there was a used suction catheter laying inside of resident nightstand drawer. RN B said she did not handle the respiratory supplies, but the respiratory therapist did. Further interview with RN B said she was the nurse that admitted Resident #1 back to the facility on [DATE]. RN B said she was not aware that Resident #1 was being admitted back to the facility on [DATE]. RN B said had she known that Resident #1 was returning to the facility on [DATE], she would have called housekeeping to come and clean resident room. RN B said she just saw resident being wheeled down the hallway on a stretcher. RN B said resident room had not been cleaned when resident returned from the hospital on [DATE]. RN B said resident did not have any sheets on his bed and that she was trying to clean the room as best as she could by disinfecting resident bed. RN B said she had to remove linens from the other bed in the room (bed B) and placed them on Resident #1's bed (Bed A). RN B said she would remove the sani-wipes from resident room and place them in the trash because the sani-wipes should not be in the resident's room. RN B said Resident #1 had been discharged from the facility for several days and did not answer why resident room was not cleaned. RN B said whenever a resident was discharged from the facility to the hospital, it was the Nursing department that stripped the sheets off the bed, disinfected all residents' care equipment such as feeding pumps, IV poles, etc. and bagged all residents' care equipment placing them in the storage room. RN B said this was done to prevent cross contamination and for infection control. Interview on 11/05/25 at 11:40AM with Respiratory Therapist, she said she worked at the facility from 7a-7p three times a week and every other weekend. She said she had not checked Resident #1's drawer where respiratory equipment was stored. After checking resident drawer, she said the used suction tubing should have been trashed. Interview on 1:03PM 11/05/25 with Housekeeping Director said the housekeeper assigned to Resident #1's room was Housekeeper E. She said she ensured that the housekeepers were cleaning the residents' rooms daily, and that the residents' rooms were clean and presentable by performing random rounds on residents' rooms but not all the rooms. She said when a resident was admitted or readmitted to the facility, the room had to be cleaned prior to the resident being placed in the room. She said when a resident was discharged from the facility, the room had to be deep cleaned and disinfected. She said it was the DON, ADON, Social Worker, and sometimes the Nursing staff that communicated with Housekeeping that a residents' room needed to be cleaned prior to any admissions. Interview on 11/05/25 at 1:14PM with Housekeeper E said she was assigned to Resident #1's room. She said the last time Resident #1's room was cleaned was on 11/04/25. She said it was herself and another housekeeper that was cleaning and that she did not know if the other housekeeper had cleaned resident room thoroughly. She said it was important for the residents' rooms to remain clean prior to admission and discharge to prevent the spread of bacteria. Interview on 11/06/25 at 8:50AM with the Administrator, she said the NF had started an in-service on Infection Control with the staff on 11/05/25 due to Resident #1's room not being cleaned. The Administrator said the residents' rooms should be cleaned every day. The Administrator said if a resident is discharged from the facility the resident's room should be deep cleaned, and everything should be removed from the room and placed in the storage room. The Administrator said before a resident is admitted to a room, the room had to be cleaned to prevent infections. The Administrator said there was a gap in communication with the housekeeping department regarding the cleaning of Resident #1's room. The Administrator was asked to provide the facility policy on Physical Environment. The Administrator was asked to provide the facility policy on Physical Environment on 11/06/25 at 4:30PM. Record review of the NF policy on Resident Rights revised June 10, 2025, reflected in part: .The resident has a right to a safe, clean, comfortable environment and homelike environment including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review, the facility failed to maintain an infection control program to provide a safe, sanitary, and comfortable environment to help prevent the transmission of infection for 1 of 4 residents (Resident # 2,) reviewed for infection control in that: CNA D failed to don (to put on) disposable gown when providing direct care for Resident #2 who was on Enhanced Barrier Precautions on 11/05/25. This failure could place residents at risk for cross-contamination and unwanted infections. Findings include: Record review of Resident #2's face sheet dated 11/06/25 revealed a [AGE] year-old-female admitted to the NF originally on 06/29/24 and again on 07/02/25. Resident #2's diagnoses consisted of the following: heart disease, type 2 diabetes mellitus (high blood sugar levels), pneumonia (infection in the lungs), dysphagia (difficulty swallowing), gastrostomy (surgical procedure to insert a feeding tube in to the stomach to allow liquid nutrition and medicine), end stage renal disease (irreversible kidney disease where the kidneys are no longer able to function on their own), renal dialysis (medical procedure to remove waste from the blood), and cerebral infarction (blockage in the brain that cuts off blood flow to the brain). Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating that Resident #2's cognition was severely impaired. Record review of Resident #2's Comprehensive Care Plan dated 06/06/25 revealed that resident was being care planned for feeding tube being in place with intervention to wear abdominal binder. Record review of Resident #2's Physician Order Summary Report for the month November 2025 reflected the following orders: -Dated 05/31/25 Enhanced Barrier Precaution every day and night shift.-Dated 08/11/25 Every shift Nepro continuous pump assist via peg at 55ml/hr x 22 hours to provide a total 1946 ml/day, may give Glucerna 1.5 pending Nepro available. Observation on 11/05/25 at 10:18AM on Resident #2's door entrance was an EBP signage on the door with the door closed. The signage instructed staff to don PPE gown and gloves. There was a 3-drawer plastic storage bin by resident door entrance with gloves and blue disposable gowns inside of the drawers. Coming out of Resident # 2's room was CNA D with clear plastic bags in her hand. Inside of bag the surveyor did not see a blue disposable gown in the bag. Interview 11/05/25 at 10:18AM with CNA D, she said she had just finished providing incontinent care for Resident #2. CNA D said she did not put on a disposable gown while providing direct care for Resident #2. CNA D said she was supposed to do this for infection control and got in a hurry to get resident ready to go to dialysis. CNA D said she placed resident and herself at risk for infections. Observation on 11/05/25 at 10:20AM of Resident #2 resting in bed awake with feeding pump on the left of bed with feeding disconnected from resident. CNA D said she was about to transfer resident from bed to chair. Resident had a gastrostomy tube with dressing around gastrostomy site dated 11/05/25. Interview on 11/06/25 at 2:50PM the ADON said she was the facility's Infection Control Preventionist. The ADON said all nursing staff should be practicing Enhanced Barrier Precaution when providing direct care for a resident that had the following: gastrotomy tubes, Foley catheter tube, tracheostomy, IV lines, etc. ADON said the staff should be wearing gloves and gowns. The ADON said when the staff was not donning correct PPE there was risk for cross contamination. Record of the NF policy on Infection Prevention and Control Prevention revised April 04, 2025 reflected in part: .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .

Based on observation, interview, and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the entire facility which included: 2 residents who experienced abuse (Resident #113 & Resident #114), 3 residents who experienced problems with services for treatment and services for mental and psychosocial concerns (Resident #30, Resident #42 & Resident #52); 2 resident who experienced repeated G-tube dislodgement (Resident #18 & Resident #33); 2 residents who experience problems with ADL care (Resident #28 & Resident #109), 3 residents who experienced significant medication errors and problems with quality of care (Resident #161, Resident #162, Resident #163); pharmacy services & physical environment reviewed for administration. - Facility administration failed to have an effective system that identified and put interventions in place to address residents with escalating behaviors leaving residents in distress, suffering from suicidal ideation, attempting suicide, fighting police officers and staff, having guns drawn on them by police, attempting to pull police officers guns and being forcefully restrained by police and removed from the facility. - Facility administration failed to have an effective system that identified and put interventions in place to address residents with repetitive behaviors of pulling on and out their gtube that resulted in dislodgment, hospitalization for replacement and head injury from an IV pole falling on their head. - Facility administration failed to have an effective system that identified and put interventions in place to address residents with repetitive verbal aggression, physical aggression, and sexually inappropriate behaviors. - Facility administration failed to have an effective system in place to ensure that critical supplies needed for CPR were maintained and staff were provided CPR to residents per the facility policy. - Facility administration failed to have an effective system that identified: medication errors, delay in care after critical labs were reported incorrectly, delayed administration of medications upon readmission; and failed to put in interventions in place to prevent such occurrences from repeating. - Facility administration failed to have an effective system that ensured plan of corrections from previously cited visits were followed which resulted in residents not receiving proper ADL care, delay in resident laundry services and the facility left unsafe/disrepair with loose floor tiles, unsecure toilets, and sinks. - Facility administration failed to have a system in place to ensure there was a RN on duty to provide care to the residents every day between 10/2024 and 03/2025. - Facility administration failed to maintain vendor services for drug destruction due to non-payment resulting in expired medications building up in the medication rooms and being mixed in with current medications. An IJ was Identified on 05/06/25 was called on 06/03/25 . The template was provided to the facility Administrator on 06/03/25 at 11:51 PM. While the IJ was removed on 06/19/25 the facility remained out of compliance at a scope of widespread and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Resident #30 Record review of Resident #30's Face Sheet dated 05/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: spinal cord injury, anemia, nicotine dependence, Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar disorder (mental health condition characterized by extreme mood swings, ranging from periods of intense happiness or irritability (mania or hypomania) to periods of deep sadness or despair) with sever psychotic features (hallucinations (seeing or hearing things that aren't real), delusions (false beliefs), and disorganized thinking) and paraplegia( paralysis of the legs and lower body, typically caused by a spinal cord injury). Record review of Resident #30's previous facility Progress Notes dated 12/26/24 at 02:21 PM revealed, Resident says she is hearing things and people talking about her. She is under mental distress. She is wanting to go to the psych hospital. Resident stated she no longer wanted to be here. Record review of the Resident #30's Quarterly MDS revealed, intact cognition as indicated by a BIMS score of 14 and use of antipsychotic medications during last 7 days. There were no evidence of an acute change in mental status, and no behaviors present. She had no potential indicators of psychosis such as hallucinations or delusions. Record review of Resident #30's undated Care Plan revealed, focus- history of being resistant to care at times and is at risk for injury; intervention- approach in a calm manner, talk while giving care. Focus- taking psychotropic medications and is at risk of adverse reactions and (depression, anxiety, and/or psychosis driven behaviors; interventions- monitor for psychosis driven behaviors such as aggressiveness, combativeness, manic episodes, observe and record any displayed behaviors or mood problems. Focus- Resident #30 verbalized suicidal ideations and became physically aggressive with police related to her diagnosis of bipolar and or anxiety, date initiated 04/13/25; interventions- provide medications as ordered, resident will be assisted with discharge planning as when needed, resident will be referred to inpatient geri psych placement as when needed, call 911 with request for the mental health team as/when needed. Record review of Resident #30's Progress Notes from 12/31/24 to 05/02/25 revealed : 01/01/25- EMS arrived at facility stating they received phone call from facility. This nurse was notified by CMA that this resident called EMS. Resident states that she is not feeling well and wants to go to the Hospital. Resident did not notify this nurse that she was not feeling well prior. Resident called EMS instead. EMS assessed resident. No abnormal findings. EMS spoke with resident about receiving care in facility before calling 911. Resident continues to state that she wants to go to the hospital. 01/02/25- Resident called 911 for pain pill when her pain was just due to be given to her, every effort to advise her to take her pain pill yield no result as she wants to go to hospital, NP made aware, administrator made aware, resident insisted on going to hospital, picked up in stable condition. 01/12/25- Note Text : On rounds at 7:04am resident did not complain of any discomfort, distress, or concerns, noted vaping in the room, was educated by this nurse that vaping is not proper and not allowed in the room, resident did not listen, but continue vaping. At about 7:54am, 911 ambulance arrived facility stated resident called them, complained of pain to lower back, sediment in urine, and brown urine output. Resident has UA result and labs pending ,this explained to resident Norco 5-325mg offered, resident refused, and still insisted going with 911 to the hospital, transferred by 911 to hospital ,per resident request. Resident is self-RP.NP notified. 01/22/25- SW informed nurse that resident was seen by Psych services today and was told that resident may be going through a manic episode. Resident is currently in bed with NAD. Given PRN pain medication. resident has no plan to harm herself stayed she is just little down today. MD informed stated to monitor for now and call her for any changes. 01/24/25- Resident informed SN that she called 911 due to pain on her lower back. Education provided on pain management such as other ways to manage pain without medications such as deep breathing, exercise , music therapy and others , resident verbalized understanding but still want to get stronger medication . NP notified . patient has been medicated with Norco Tablet 5-325 MG every 4 hours as needed, last one was at 1034am. Sn will continue to monitor. 01/31/25- Resident signed herself out after requesting (2) cigarettes. Resident was then transported to the ER by ambulance. Family notified. DON Notified. 02/01/25 at 08:01 AM- Resident requested cigarette, received her cigarette, signed out to go smoke out front where she then called 911 and requested transport. Resident would not specify where she wanted to be transported to. 911 arrived around 0710 and took resident on a stretcher to the ER. 02/01/25 at 03:15 PM- Resident returned from the hospital . Resident still appears anxious upon return and immediately returned to nurses' station to sign out with (4) cigarettes as of 0325 resident is signed out of the facility. 02/13/25 at 10:49 PM- Resident called 911 by herself twice this evening at 7:30pm and 9:40pm stating that she wants to go to the hospital because she is having spasms. Charge nurse informed her that he can notify her doctor and see if she can be given some new orders, but she refused. EMS arrived the first time and resident refused to go to the hospital they intended to transport her to. The second time the EMS arrived and took resident to Hospital at 10:00pm. 02/24/25- Note Text: At 21:30 hrs (09:30 PM), resident called the EMS via 911, requesting to be taken to the emergency room due to spasm and pain. Resident had already received her scheduled pain medication (Norco) at 20:00 hrs. Resident had not complained to Charge Nurse about being in pain prior to her calling 911, and charge nurse was not aware that she had called EMS 911 until the emergency personnel showed up in the unit. Resident was taken to the emergency room as she requested by the EMS technicians at 21:40 hrs. 03/02/25- Resident complains of hearing voices making fun of her, she said had been going on for a while now, she stated that she did not complain initially because she thought they might go away, but they getting louder, depriving her sleep. This morning observed resident in her sleep saying, stop stop stop. Resident also have diagnosis of schizophrenia and mild sleep disorder.NP notified, order received to consult psych. Order carry out. 03/08-25- Resident called EMS via 911, and they took her to the hospital at 18:45 hours for complaint of pain. Resident's emergency contact family member' and facility DON notified. 03/19/25- Resident came to Charge nurse and requested for her nightly medication to be administered to her, which was done. After taking her medications, she informed the Charge Nurse that she had called 911 so she can be taken to the hospital due to pain. Charge Nurse advised resident to give her pain pill (Norco) which she just took, time to become effective but she refused, insisting to go to the hospital. Charge nurse noted ant acute distress on resident both in her speech and behavior. Resident then wheeled herself in her wheelchair to the reception area awaiting the arrival of EMS ambulance. Upon arrival to the facility, the EMS personnel spoke briefly with resident and loaded her on their stretcher without asking the charge nurse any questions or informing him where they were taking resident to. When charge nurse inquired from them where they were taking resident to, they simply told him the hospital name and continued on. Facility Director of Nursing was notified. 03/22/25 T 05:53 AM- Behavioral Note-Resident removed her brief after ADL change claimed is too big despite the brief been her size and the large size that could be used for her. 03/22/25 at 10:09 AM- : Resident was observed alert and oriented with behavior, screamed , yelled, took clothes off. Attempted to talked to resident several times with no effect. NP. was notified order given Alprazolam 0.5mh twice a day for fourteen days for anxiety. 04/13/25 at 01:39 AM signed by LVN H- Patient called 911 at 11:00pm and had been disturbing other patients from sleeping. The two EMS that came refused to take her to hospital stated she has no good reason to go to hospital. Patient received all her pain med and other prescribed med, throwing stuff on the floor including her phone. Patient is threatening to kill herself. Nurse notified the physician, DON, and Administrator. 04/13/25 signed by SW- SW informed per staff that this resident had verbalized wanting to kill herself. SW visited with this resident, and she verbalized I tied something around my neck but, I could still breathe. I want my Xanax back. I want my Xanax back. I am going to get my Xanax back. SW attempted to contact resident's [family member], , unable to reach and voicemail full. Resident began to yell and scream as she exited the office. Staff was present to maintain visual of her per SW request while 911 contacted with a request for the Mental Health Response team. Upon 911 arriving officer was provided with the aforementioned information. He spoke with resident, and she informed him that she wanted to kill herself. He called for assistance and another officer arrived whom also spoke with resident and then SW observed resident began to hit the officers resulting in them restraining her until approximately 4 more officers arrived. SW was informed per that she was being transported to Hospital and that the District Attorney would be contacted but they were doubtful any criminal charges would be filed against her. SW informed the DON and LNFA and was able to contact her [family member] and informed him. He verbalized understanding. Care Plan updated to reflect. Record review of Resident #30's Hospital Progress note dated 04/22/25 at 01:22 PM revealed, Resident #30 continued to throw tantrums and screamed, covering her face with her pillow. The resident was requesting IV pain medication. Record review of Resident #30's Hospital Progress note dated 04/23/25 at 12:01 PM revealed, Resident #30 continued to throw tantrums and requested IV pain medication despite being notified that she was on oral pain medication. Record review of Resident #30's Hospital Psychiatric Consultation note dated 04/24/25 at 12:00 AM, revealed Resident #30 had bipolar disorder with discrete periods of mania and discreet periods of depression. She had poor impulse control and a history of PTSD and had attempted fake suicide in the past on multiple occasions by either choking herself or overdosing on medications. Resident #30 had a history of ideas of persecution, thinking that people were going to hurt her or that something negative was going to happen to her. Resident #30 had a history of auditory hallucinations commanding her to wrap a cord around her neck or to overdose on Seroquel. In the past Resident #30 contemplated starting a fire in her apartment following the command of the voices she heard, and she wished she had a weapon to hurt hospital or nursing staff. Resident #30 was admitted to a behavioral hospital in February of 2021 and in November of 2023 she was admitted to the hospital after typing a collar on her neck to kill herself. Record review of Resident #30's Hospital Progress note dated 04/24/25 at 11:52 AM revealed, Resident #30 called 911 from her hospital room and pretend to sleep when the MD entered her room. Record review of Resident #30's Progress Notes on 05/01/25 at 02:48 AM revealed, Note Text : Resident called EMS and requested to be taken back to the hospital for evaluation. Resident indicated to EMS personnel that she feels nauseated, dehydrated, and is not getting enough pain medications. Resident had not complained to Charge Nurse about any of these concerns tonight. Resident had received her nightly medications as ordered, including her PRN Norco pain medication. Charge Nurse offered to call resident's PCP to see if there may be any new orders, but she refused, stating her preference to go to the hospital. Upon resident's insistence to go to the hospital, EMS personnel took her to hospital. Record review of Resident #30's Order Summary Report that included all orders since admission on [DATE] and printed 05/02/25 at 01:50 PM revealed, Resident #30 had no behavior monitoring and behavior intervention orders. Record review of a 30-day lookback of Resident #30's Behavior Monitoring and Interventions dated 05/09/25 revealed, no documented behaviors observed prior to 05/09/25. On 05/09/25 at 10:30 AM Resident #30 was screaming and expressed frustration and angers at others. An observation an interview on 05/02/25 at 01:12 PM revealed, Resident #30 sitting in a wheelchair at the nursing station. There were other residents around her and no nursing staff within 15 feet on both sides of the nursing station. The resident said she just returned to the facility from the hospital, and she felt better now. Resident #30 said the voices got too loud so she hit herself in the face and tied a pillowcase around her neck to harm herself to stop the voices, but she could still breathe. As Resident #30 talked to the surveyors she swayed left to right & back and forth in her wheelchair. Resident #30 said she did not notify any staff of the voices prior to trying to harm herself but when she went to the hospital, they fixed her meds, so she did not hear the voices anymore and she did not want to harm herself. In an interview on 05/02/25 at 12:33 PM, the SW said Resident #30 was young and had obsessive drug seeking behaviors r/t to complaints of significant pain. She said the resident would call the police 1-2 times a week and had been hospitalized at least 6-7 times since admission. The SW said Resident #30 always yelled at staff and yelled to go to the hospital. The SW said in April she was notified that Resident #30 wanted to hurt herself. She said she first talked to the resident on the phone and then again when she arrived at the facility. The SW said Resident # 30 told her she tried to hurt herself by tying something around her neck, but she could still breathe, the resident became loud and said she was going to hurt herself, so she called 911 for a mental health response team. She said when the police arrived Resident #30 wheeled herself away from them down the hallway as they spoke to her and when both police officers approached her, Resident #30 started to scream and fought the police. The SW said Resident #30 attacked the police, the police tried to restrain her, the police drew then their guns and pointed them at the resident and Resident #30 was eventually handcuffed. She said Resident #30 was a risk to other patients because of her unpredict ableness. In an interview on 05/02/25 at 01:05 PM, MA C said Resident #30's normal behaviors included verbal aggression/yelling towards staff and other residents. She said the resident propels herself around the facility in her wheelchair cursing and yelling. She said the resident was not on any increased behavioral monitoring, not on 1-on-1 monitoring and was not safe to be in a room with others. In an interview on 05/02/25 at 01:21 PM, LVN J said Resident #30's regular behaviors included yelling and screaming at others. She said Resident #30's former roommate, Resident #22, was scared of her because of her yelling and screaming In an interview on 05/02/25 at 01:27 PM, Resident #22 said she was scared by her former roommates yelling and screaming, She said Resident #30 yelled and screamed at night, startling her. In an interview on 05/02/25 at 01:27 PM, Anonymous A said Resident #30's regular behaviors included yelling/screaming and calling Anonymous A out of her name. Anonymous A staff said Resident #30's behaviors were towards anyone including residents and staff. Anonymous A said in one incident Resident #30 was screaming and she came down the hallway in her wheelchair with no clothes on. Anonymous A said last April, the social worker called the authorities because of Resident #30's behaviors and when they arrived, Anonymous A saw the resident attempt to pull the police officer's firearm. Anonymous A said Resident #30 liked to yell, scream and throw stuff at people and it makes Anonymous A antsy. In an interview on 05/02/25 at 01:36 PM, the MDS Nurse said she did not know Resident #30 had a history of attempted suicide or aggressive behaviors. She said the resident was always nice, but she liked to go to the ER on a weekly basis since arriving in the facility. The MDS nurse had she known of the resident's behaviors she would have included it in her care plan. In an interview on 05/02/25 at 02:04 PM, the Psychiatric NP said Resident #30 had a lot of anxiety and would call 911 often. She said the resident seemed hyper-manic and had racing thoughts. The Psychiatric NP said no one notified her that the resident was aggressive, she was unaware that the resident yelled at others, but she could believe Resident #30 rolled down the hall naked because the resident was always inappropriately dressed in her room. The Psychiatric Nurse said the resident had never shown any signs of suicidal ideation, or that she heard voices, but Resident #30 expressed anxiety and depression. She said she was unaware of Resident #30's previous history of suicide attempts, and she would have to review the hospital notes because based on what was discussed the resident's behaviors were more severe. The Psychiatric NP said Resident #30 should have a lot more monitoring by the staff and she did not know why the resident never communicated any of these issues with her. She said she had not read Resident #30's readmission clinicals from 04/3025 but she assumes the resident is safe since she was discharged . The Psychiatric NP said based on Resident #30's behaviors she was not a safe person, and she expected the resident to have frequent assessments, close monitoring, increased therapy visits and should be encouraged to verbalize her feelings. She said Resident #30 needed additional monitoring to make sure nothing occurs. In an interview on 05/02/25 at 02:22 PM, the DON said prior to readmission she or her designee are supposed to receive and review the resident's hospital clinicals, but she did not, she said she thought the admitting nurse did. The DON said to her knowledge Resident #30 was not having behaviors in the hospital and since her return there had been no medication changes. She said since the resident returned to the facility there have been no interventions in place beyond the standard shift monitoring and based on her documented history of behaviors Resident #30 was not safe to be in a room with Resident #18 who was unable to communicate. In an interview on 05/02/25 at 02:27 PM, the Administrator said she did not know about Resident #30's aggressive behaviors or significant history of suicide, all she knew was that the resident would go to the hospital often. She said now that she knew the contents of the hospital psych consult notes and the resident's history of attempted suicide, the resident should be placed on 1on1 monitoring for at least 72 hours, because she was a resident safety risk having her unsupervised and ambulating in her wheelchair around the facility. In an interview on 05/02/25 at 02:37 PM, CNA T said in April she saw the police go towards the SWs office and then Resident #30 came down the hallway in her wheelchair. She said at first the police were talking to Resident #30, when she started yelling and screaming so the police tried to restrain the resident at which point Resident #30 attempted to pull the police officers firearm. CNA T said prior to the incident in April, Resident #30's regular behaviors included rolling around the facility in her wheelchair yelling/screaming/cursing at other residents and staff. In an interview on 05/02/25 at 02:46 PM, LVN T said she was the nurse scheduled when Resident #30 arrived at the facility, but she was on break, so the resident was already in the room when she returned. She said upon readmission Resident #30 had been roaming the facility unattended asking for cigarettes and pain medications. LVN T said in April she observed Resident #30 come out of SWs office screaming fuck you and the SW called 911 mental health. She said when the police talked to Resident #30, she said she was not suicidal but had attempted suicide the night before. LVN T said Resident #30 rolled away from the police, started fighting the police and when they attempted to restrain the resident grabbed their handcuffs and she heard the police say, let go of the gun. She said the SW thought they were going to shoot Resident #30, so she told her to get out of the way for safety. LVN T said more police arrived and then the ambulance took the resident away. LVN T said Resident #30's behaviors included hollering/yelling at people, calling people out of their name, calling Black people the n word, and she did all of this sometimes while going down the hall but the incident in April was the first time it had escalated to this point. LVN T said Resident #30, propelled herself freely in the facility down the halls, always yelling at others. She said when the resident returned on 04/30/25 , she did not receive the discharge clinicals that listed Resident #30's extensive suicide history and the resident was not ordered or placed on 1on1 observation or suicide watch. In an interview on 05/02/25 at 02:57 PM, the ADON said Resident #30 can be extremely aggressive. She said the resident goes in and out of the hospital and calls 911 when she wants her pain medications, and the provider is aware of her behaviors. The ADON said she heard the resident was aggressive especially during night shift. She said everyone was aware of Resident #30's behaviors including social services, and it was documented in the resident's chart. The ADON said while she does not think Resident #30 is a threat to herself or others, she possibly made other residents feel scared. The ADON said when a resident has made threats of or attempted suicide interventions like 1on1 monitoring should be in place when they readmitted to the facility, but she did not know if Resident #30 had any others for this. The ADON said the IDT/Managers/Administration had not discussed interventions needed to ensure Resident #30's safety but management should absolutely have had that conversation. In an interview on 05//02/25 at 03;41 PM, the DON said she did not know Resident #30 had a history of attempted fake suicide, suicide attempts by tying a cord around her neck, auditory hallucinations telling her to harm herself by tying something around her neck or overdose on medications, wished to have a weapon to harm hospital and nursing staff or attempted suicide in November 2023. The DON said did not read the hospital discharge record sent to the facility prior to the resident readmitting that had the psychiatric consult notes describing all of Resident #30's previous behavioral issues and she honestly does not know why she did not. The DON said now that she knows Resident #30 had this history of behaviors the resident should have been somewhere more appropriate and based on the new information the facility had not provided Resident #30 adequate care. She said prior to today (05/02/25) Resident #30's behaviors placed the safety of herself and other residents in jeopardy. In an interview on 05/03/25 at 01:37 PM, the DON said since the surveyor alerted the facility of Resident #30's extensive history of fake suicide attempts, actual suicide attempts, auditory hallucinations, desire to harm others the resident was placed on 1on1 observation. She said the resident has had a sitter at all times, had not had any new behaviors and was doing well today. An observation and interview on 05/03/25 at 01:38 PM revealed, Resident #30 sitting in her wheelchair, writing in a notebook with headphones on. Resident #30 said she now had a sitter with her and has had no behaviors. She said she no longer heard voices since they put her on her proper meds in the hospital, but the doctor will take her off the medication in 10 days, and that is what keeps her calm. She said her Xanax helps her anxiety and bipolar and she was not drug seeking. Resident #30 said she was collating a list of songs for her online music store. In an interview on 05/03/25 at 01:42 PM, the DON said since Resident #30 had behaviors, received antidepressants and antipsychotic medications she should have had behavior monitoring orders. The DON said behavior monitoring orders are important for residents with behaviors in order to monitor for side effects or changes, and failure to have behavior monitoring orders would result in missed behaviors or change of condition. The DON looked through the resident's chart and said nope Resident #30 had no orders from her admission up until her suicide attempt on 04/13/25, and there were no orders entered when she returned to the facility on [DATE]. The DON said the lack of behavior monitoring played a part in the missed behavior monitoring and the missed residents change of condition. Resident #52 Record review of Resident #52's Face Sheet dated 04/24/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: schizophrenia ( mental disorder characterized by a breakdown in thought process, making it difficult to distinguish between reality and fantasy), and anxiety disorder. Record review of Resident # 52's Significant change in status MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15. Active diagnosis of anxiety disorder and schizophrenia, no presence of any behavioral symptoms such as physical (hitting, kicking, pushing), verbal (threatening, screaming, or cursing at others) and no other behavioral symptoms not directed toward others. Antipsychotics were received on a daily basis; no gradual dose reduction was attempted and there was no physician documentation indicating a GDR was clinically contraindicated. Record review of Resident #52's undated Care Plan revealed, focus- signs and symptoms of anxiety like hypersensitivity, paranoid, nervousness and is at risk for further episodes of anxiety and injury; intervention- medication as ordered. Focus initiated 01/07/25- psychotropic medications and is at risk for adverse reactions and behaviors; interventions- monitor for adverse reactions and hypnotic driven behaviors such as tiredness and weakness, monitor for psychosis driven behaviors such as aggressiveness, combativeness, and manic episodes. There was no focus areas addressing suicidal behavior or suicide threats. Record review of Resident #52's Progress Notes from 01/06/25 to 05/06/25 revealed: 01/19/25 at 04:53 PM signed by RN G- Resident has been very rude to RT she does not like her to enter room to give care to her roommate. She yells/curse and shout. Education given to resident that her room needs assistance and staff will provide assistance without bothering her, but resident stated now. Resident also continue to ask staff for cups thorough the shift. Education given to resident that she is currently NPO and cannot consume anything by mouth at this time for her safety. Education did not work. She continue to ask anyone walking pass her room. 02/01/25 at 09:46 PM signed by RN G- Resident is currently crying and screaming she would like to go the hospital due to pain in her left legs. Resident was given all of her scheduled medication and Tylenol PRN. She also received her pain cream diclofenac cream applied to her ankle. Resident also propels herself around the facility not crying screaming she became very aggressive with staff. Screaming cursing and grabbing of laptop and other staff equipment she is not able to be redirected. 02/08/25 at 05:42 PM signed by RN G- Resident throw a cup a writer on this shift then later came and apologize. she also snatched the phone causing the cords to come undone and later apologize for that she sta[TRUNCATED]

Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from abuse, neglect, and exploitation for two residents (Resident #111, #113 and #114) out of seven reviewed for abuse. The facility failed to protect Resident #113 and #114 from a physical altercation on 3/23/25. Resident #114 sustained redness and pain to the left eye and sent to the ER. The facility failed to address Resident # 114's continued threatening and aggressive behavior towards residents and staff. The facility failed to address Resident #113's inappropriate sexual behavior on 5/03/2024 towards an unknown female resident as documented in the medical records. An Immediate Jeopardy (IJ) was identified on 05/03/2025. The IJ template was provided to the facility on [DATE] at 1:58 PM. While the immediacy was removed on 05/08/2025 at 1:24 PM, the facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. Failures outside IJ -The facility failed to ensure CNA A properly repositioned Resident #111 CNA A shuffling and adjusting his head on the pillow. these failures could place residents at risk of physical or psychosocial harm as a result of the abuse. Findings included: 1. Record review of Resident #113's face sheet dated 04/22/25 reflected a [AGE] year-old male first admitted to the facility on [DATE] and discharged on 03/28/25 to another facility. His diagnoses included dementia, persistent mood disorders, hypertension, chronic pain syndrome and muscle weakness. Record review of Resident #113's quarterly MDS dated [DATE] reflected he had a BIMS score of 6 out of 15 indicating severe impaired cognition. Section E revealed he had no behaviors or refusals of care. He used a wheelchair for mobility. He required supervision to moderate assistance with all ADLs. Record review of Resident #113's care plan with the closed date of 03/31/25 included: Focus - resident had moods that were not easily altered by staff intervention as evidenced by persistent mood disorder, symptoms and signs involving appearance and behavior. Date initiated as 05/06/24. Interventions included - document staff interventions, notify physician, psych referrals. Focus - Resident was taking psychotropic medications and at risk for adverse reactions and behaviors. Date initiated was 05/06/24. Interventions included - monitor for anxiety driven behaviors and report to physician. Monitor for psychosis driven behaviors such as aggressiveness, combativeness, and report to physician. Focus - he was resistant to care and at risk of injury as evidenced by refusal of baths at times. Date initiated was 09/06/24. Focus - He had episodes of inappropriate behaviors and at risk for future episodes and injuries as evidenced by not allowing housekeeping to clean room, refusing care (becoming aggressive at times). Date initiated was 11/27/24. Interventions included - give medications as ordered, monitor and chart behaviors every shift and report progress to physician. Provide psych consult per order. Focus - Resident reportedly hit his roommate in the eye. Date initiated was 03/23/25. Interventions included - refer to Medical Behavioral Hospital for inpatient geri psych placement. Immediately inform resident to stop and separate from others when resident becomes aggressive. Further review of Resident #113's care plan revealed sexually inappropriate behavior was not addressed. Record review of Resident #113's progress note on 5/3/24 at 2:26 PM written by LVN U read in part: Resident #113 was observed by the nurse inappropriately touching on a female resident while she was on her bed resting. The female resident had long pants and a top on. The resident was redirected back to his room .and stated, I will not do it again. The RP was notified .NP notified; orders received for psych consult. Record review of Resident #113's progress note on 5/04/24 at 3:20 AM written by LVN V indicated the resident was verbally and physically abusive to anyone in his path while trying to go into another residents room. The only intervention was to let his aggression run its course and keep other residents safe. Resident #113 proceeded to constantly hit/bang/kick the window and door of the secure door. The activity continued for 2 hours. Resident #113 was going room to room waking other residents by banging on doors and opening or closing doors. Interventions were attempted to redirect Resident #113 failed. At 3:20 AM Resident #113 finally went to bed and slept. Record review of Resident #113's Psychological Services progress note dated 5/12/24 at 10:24 AM indicated the focus of the session was emotional withdrawal, communication, and physical decline. Further review revealed sexually inappropriate behavior, or aggressive behavior was not addressed. Record review of Resident #113's Psychological Services progress note dated 8/21/24 at 11:32 AM written by the LCSW indicated the resident was agitated when another resident wandered into his room. Further review indicated the resident did not like shared space and liked his privacy. Record review of a progress note on 11/24/24 at 6:05 PM written by LVN T indicated Resident #113 was following and yelling at his roommate calling him names as well as yelling at staff. Resident #113 would be upset when staff entered his room. He was redirected, told to calm down then continued to yell. Record review of Resident #113's progress note on 11/26/24 at 9:42 AM written by the Social Services Assistant indicated a care plan meeting with the RP was scheduled for 11/26/24 at 11:00 AM. Further review revealed there were no details regarding the outcome of the meeting. Record review of Resident #113's Psychological Services progress note dated 11/27/24 at 6:43 AM written by LCSW indicated he was agitated, frustrated with staff and another resident. Record review of Resident #113's Psychiatric progress note dated 2/6/25 written by the Psychiatric NP indicated the resident was improving but remained isolated and unable to tolerate a new roommate. Record review of progress note on 3/18/25 at 5:02 PM written by the ADON indicated Resident #113 was yelling, screaming and vocally aggressive to the nursing staff as he refused a shower. The ADON de-escalated the situation, and the resident later continued to refuse. The RP was notified. Record review of Resident #113's progress note on 3/23/25 at 12:07 PM written by RN F indicated at 12:45 PM the resident was observed threatening, grasping roommate in his wheelchair, telling roommate to leave the room. Record review of a progress note on 3/23/25 at 12:58 PM written by RN F indicated Resident #113 refused shower care and was reported to be hitting the staff. The resident was reoriented. Record review of Resident #113's progress note on 3/23/25 at 5:22 PM written by the SW indicated the SW left messages for the RP to report resident's increasingly aggressive behaviors. Further review indicated Resident #113 hit his roommate in the eye and they were immediately separated. Resident #113 remained in the office with SW while reaching out to a behavioral hospital for evaluation. Record review of Resident #113's progress note on 3/23/25 at 6:32 PM written by RN F indicated Resident #113 was reported by a CNA to be physically aggressive towards the roommate, verbally threatening and pushing the other resident's wheelchair. Record review of Resident #113's progress note on 3/23/25 at 7:47 PM written by RN F indicated the resident was kept separated from the roommate while waiting for transportation to behavioral center. Record review Resident #113's progress note on 3/23/25 at 9:44 PM written by LVN L indicated the resident was transported to the hospital at 9:00 PM accompanied by the RP. Record review of Resident #113's progress note on 3/23/25 at 11:40 PM written by the SW indicated the resident returned from the hospital. He was alert and calm and placed in a room alone. The resident was referred to Mental Health. Record review of Resident #113's progress note on 3/28/25 at 8:33 AM written by LVN L indicated the resident was transferred to another nursing facility. Record review of Resident #113's order summary report dated 04/22/25 indicated an order for behavior monitoring which included agitation, hitting, increasing complaints, kicking, cussing, aggression and refusing care every shift for use of Depakote starting 06/04/24. An order for Depakote 125mg tablet every 8 hours for mood disorder was started on 05/03/24. The last order change was on 02/26/25 for Depakote 250mg TID. An order for Memantine 5mg tablet twice a day for dementia was started on 5/16/24. An order for Melatonin 5mg at bedtime for insomnia was started on 5/20/24. In a telephone interview on 4/22/25 at 1:45 PM, LVN U stated the incident on 5/3/2024 when Resident #113 was inappropriately touching a female resident was reported to the Administrator at the time. LVN U did not recall the name of the female resident nor the details of what happened when asked about the inappropriate touching. In an interview on 4/22/25 at 2:25 PM the interim Administrator stated if a resident inappropriately touched another resident, they would be placed on 1:1 monitoring until sent out for evaluation, and that they did not need to be at the facility. In an interview on 4/23/25 at 9:20 AM, the Psychiatric NP stated it was concerning that Resident #113 even left his room. Had she known of Resident #113's sexual interaction with another resident, she would have assessed him and adjusted meds, have a talk with him and involve social services. He knew what he was doing, he was agitated and aggressive. The Psychiatric NP stated, he would have gotten away with it if he wasn't caught. If there were further events, he would have been discharged . Psychiatric NP stated she was not at the facility on 5/3/24 and did not start covering the facility until October 2024. The risks of having no interventions for behaviors would be residents could walk up to other residents, repeating the aggressive behavior and no one seeing it, and there would be risk of sexual abuse as well. She stated in the secure unit, every resident was supposed to be monitored, and there should not be residents with low BIMS scores wandering around. In an interview on 4/23/25 at 12:25 PM The DON stated sexual behavior should have been in the care plan for Resident #113. The MD should have been notified and the resident should have been transferred out for evaluation. The DON stated she was not at employee of the facility at the time of sexually inappropriate incident on 5/3/24. In a telephone interview on 4/23/25 at 3:20 PM, the SW revealed she was unaware of Resident #113 inappropriately touching a female resident on 5/3/2024. SW stated had she been notified, she would have talked to both residents involved. In an interview on 5/1/25 at 12:58PM, the Social Service Assistant stated she was not aware of Resident #113's sexual inappropriate behavior on 5/3/24. The Social Service Assistant stated if she had been aware then she would have immediately separated the residents, refer to psychologist and psychiatric services, and he would have to be removed from the facility. 2. Record review of Resident #114's face sheet dated 05/06/24 reflected a [AGE] year-old male first admitted to the facility on [DATE] and discharged on 03/26/25 to acute care hospital. His diagnoses included depression, personal history of suicidal behavior, dementia, tension headaches, hypertension, and hemiplegia (one sided paralysis). Record review of Resident #114's quarterly MDS dated [DATE] indicated he had a BIMS score of 9 out of 15 indicating moderate impaired cognition. Section E indicated he had no behaviors or refusals of care. He had impairment to one side of the upper body. He used a wheelchair for mobility. He required substantial assistance with most ADLs. Record review of Resident #114's undated care plan included: Focus - Resident had moods not easily altered by staff as evidenced by - history of suicidal behavior. Interventions included - notify physician if mood interferes with physical functioning, psych referral as needed. Focus - resident at risk for increased confusion and decline in ADLs as dementia progresses. Date initiated was 08/05/24. Interventions included - administer medications as ordered. Reorient resident daily as needed. Further review revealed verbal and physical aggressive behavior was not addressed nor was the physical altercation with the roommate Resident #113 on 03/23/25 addressed. Record review of Resident #114's chart revealed a progress note on 8/04/24 at 2:52 PM written by the SW indicated the Resident #114 reported a verbal altercation with another male resident resulting in an exchange of curse words. A referral to Psychiatry (Medication Management) was made on 8/4/24 by SW for anger outburst. Record review of Resident #114's Psychological Services progress note dated 8/27/24 at 4:55 PM written by the LCSW indicated a diagnosis of adjustment disorder with anxiety. Further review revealed anger outburst was not addressed. Record review of Resident #114's progress note on 11/12/24 at 2:07 PM written by The Social Service Assistant indicated he had agitation and verbal aggression towards his roommate. Resident #114 was then moved to a different room. Record review of Resident #114's Psychological Services progress note dated 11/21/24 at 5:12 PM written by the LCSW revealed verbal aggressive behavior was not addressed. Record review of Resident #114's progress note on 3/13/25 at 5:51 PM written by RN F indicated the resident was physically aggressive towards roommate and staff, threatening to kill the roommate. The resident refused collection of urine for test. The NP, DON and ADON were notified. Record review of Resident #114's progress note on 3/13/25 at 6:35 PM written by the DON indicated the resident was throwing drink containers out the door and at passing residents, yelling, cursing, and threatening staff. The resident was transferred to the ER for evaluation and the RP was notified. The resident returned to facility on 3/14/25. Record review of Resident #114's facility Behavioral Health note on 3/14/25 written by the Psychiatric NP for Medication follow up for dementia indicated Resident #114's medications were not adjusted at the ER visit, and he was tolerating medications with no problems. Further review indicated the resident expressed frustration regarding recent medical experiences including visit to the hospital. Further review indicated Resident #114 had psychiatric history of: combative, physical aggression, and confusion. Record review of Resident #114's progress note on 3/23/25 at 6:02 PM written by RN F indicated the resident told the nurse he was hit in his eyes by the roommate. Further review indicated he had discoloration to the left eye and the NP, RP, Administrator, DON and SW was notified. Record review of Resident #114's progress note on 3/23/25 at 7:35 PM written by SW indicated that Resident #114 verbally reported that his roommate hit him in the eye. Record review of the facility PIR (Provider Investigation Report) dated on 03/31/25 and signed by the acting Administrator at the time, indicated the incident of abuse by resident-to-resident altercation occurred on 03/23/25 at 4:30 PM involving Resident #113 and #114. The PIR indicated the incident was reported to the State on 3/24/25 at 5:00 PM. The report indicated Resident #114 alleged that the roommate, Resident #113 hit him in the eye and that it was not witnessed by any staff member. Resident #114 had redness to the left eye lid, denied pain and Resident #113 was unable to be interviewed to recall the incident. Each resident was sent out to the ER for evaluation. There were no delayed injuries for Resident #114 and Resident #113 was returned from psych hospital. The PIR indicated the incident occurred in the secure unit and that Resident #114 did not have capacity to make informed decisions and had the history of verbal and physical aggression as well as wandering. The PIR indicated that Resident #113 had a history of verbal and physical aggression as well as wandering. The PIR indicated the investigation findings were unconfirmed and the facility planned to find alternate placement for Resident #113 due to increasing behaviors. Further review indicated an emailed progress note dated 03/24/25 at 10:39 PM indicating Resident #114 was evaluated by the facility's LMSW and LCSW Therapists on 3/24/25. The progress note indicated Resident #114 reported that the roommate would sometimes become confused and agitated. Further review of the progress note indicated Resident #114 was calm and in no distress during the session. The PIR included the facility incident report dated 3/23/25 at 12:58 PM written by RN F. The incident report indicated RN F was notified by the CNA of Resident #113's physical aggression towards his roommate and that RN F observed Resident #113 verbally threatening and pushing the other resident's wheelchair in the hallway. The immediate actions taken residents were separated, kept away from each other by RN F and the attending staff in the unit. The DON and SW were notified. Further review of the PIR revealed no indication as to whether or not the Ombudsman and Law Enforcement were notified. The PIR did not include any statements by staff members. Record review of Resident #114's Order Summary Report dated 04/22/25 indicated an order for Venlafaxine extended release 37.5mg capsule daily for depression was started on 11/27/24. The most recent dose change was Venlafaxine extended release 75mg on 03/01/25. An order for Memantine 5mg tablet daily for dementia was started on 08/13/24. An order to monitor for side effects of antidepressant medication use every shift started on 11/27/24. Resident #113 had bronchitis and was treated with an antibiotic Azithromycin 500mg tablet every 8 hours beginning on 03/14/25 and ending on 3/19/25. In an interview on 4/20/25 at 9:30 AM, MA D said she recalled the incident between Resident #113 and #114. MA D stated Resident #113 originally was in the room by himself, and Resident #114 had a roommate that was discharged . MA D stated both residents resided in the same room on the secure unit. MA D stated the main cause of the incident was that Resident #113 would not allow Resident #114 to get into the room. MA D stated she knew they were not a good match because they would have arguments. MA D stated room changes do not work well with residents in the secure unit. Interview on 4/20/25 at 10:00 AM, CNA T stated that on 3/23/25 the altercation between Residents #113 and #114 took place in the secure unit hallway just outside the dining room. Resident #113 said to Resident #114 why are you going into my room!. Resident #113 grabbed Resident #114, there was a scuffle between the two men. CNA T stated they were swinging at each other, and she was in the middle trying to separate them. She stated she could not see if Resident #113 struck Resident #114 in the eye but that Resident #114's eye was red, and it was not red prior to that. CNA T stated Resident #114 had a pair of fingernail clippers in his hand. He was not supposed to have it; she did not know how he got hold of one. CNA T stated Resident #114 was afraid of Resident #113 because he would call him names; CNA T stated she reported to the nurse on duty. CNA T stated Resident #113 had taken swings at her in the past due to refusal of care. CNA T stated she would document and report to nursing but did not provide dates or names of staff. CNA T A stated Resident #113 and #114 should not have been put together as roommates due to their aggressive behavior towards one another which included arguing with one another. CNA T stated Resident #113 would get upset thinking the roommate was taking his stuff. CNA T stated she did not get a chance to write a witness statement regarding the altercation on 3/23/25. In an interview on 4/21/25 at 11:20 AM, the Social Service Assistant stated since Resident #114 did not want to get out of bed, he was a good roommate for Resident #113 and facility census increased so the two had to become roommates. The Social Service Assistant stated Resident #113 would be aggressive to other roommates in the past but never physical prior to the incident with Resident #114. Resident #113 had 2-3 roommates prior, and it always ended up not working because he would block roommates from getting into the room. The Social Service Assistant stated it was all documented in his chart and had multiple care plans with the family; he just did not want a roommate. In an interview on 04/22/25 at 10:06 AM, RN F stated MA D notified her about the incident between Resident #113 and #114. RN F stated she immediately notified the SW, ADON, DON she then walked into the secure unit and in the hallway, she saw both residents. RN F stated Resident #113 was upset, he pushed Resident #114's wheelchair and Resident #113 said to Resident #114, you cannot do that! RN F stated Resident #113 would often talk loudly when upset. RN F stated she heard about Resident #113 going into Resident #114's things but she did not witness that. RN F stated before they were roommates, they were friends talking and visiting with each other. RN F stated this was why they thought they would be compatible. Interview on 4/22/25 at 11:50 AM, MA D stated she heard the commotion in the hallway and saw CNA T separating the Residents #113 and #114. She heard Resident #113 say Trash, trash! and usually when he says these things she knows he was very agitated. She did see Resident #114 with fingernail clippers and heard Resident #114 say he was going to use it as he waved it in his hand. A nurse took the clippers away but she did not have the name of the nurse. She did provide a statement to Administrator for the incident. MA D stated there were other incidents where Resident #113 would block the door with his bed and not allow his roommates to enter, saying it was his room. Resident #113 would curse out the staff as well. Incidents like that were reported to administration. MA D could not recall dates or who it was reported to. In an interview on 4/22/25 at 2:25 PM with the interim Administrator and the DON, the interim Administrator stated that combative residents should not be put together and that they would agitate and possibly beat each other up. The interim Administrator stated nail clippers would not be allowed as they could cut themselves, or someone could wander into room, pick it up and use it as a weapon. The interim Administrator stated families may not always comply and if aware then the rooms would be searched. The DON stated she was not notified of the nail clippers. The DON stated she was aware Resident #114 was threatening to kill his previous roommate (before Resident #113 was roommate) and he was then transferred to hospital for observations and returned to the facility. The interim Administrator stated she would not have accepted him back if she were the Administrator at the time. The interim Administrator stated she was unable to locate the completed facility investigation for the resident-to-resident altercation on 3/23/25. In a telephone interview on 4/23/25 at 7:25 AM, the previous Administrator stated an internal investigation was completed for the resident-to-resident altercation incident on 3/23/25 and that she did conduct staff interviews. She stated the incident was unwitnessed and did not report to law enforcement because it was a verbal altercation, and the residents had dementia and were confused. She stated later that day, it was reported that Resident #114 had been struck by Resident #113 in the eye and that was when she sent Resident #114 out to hospital for evaluation. In an interview on 4/23/25 at 9:20 AM, the Psychiatric NP stated Resident #113 did not want to have roommates and would block the door. The Psychiatric NP stated she also followed Resident #114 and was not notified of Resident #114 threatening to kill the roommate. She learned about it much later. Resident #114 had an increase in antidepressant medication Venlafaxine on 2/27/25, and probably was not appropriate to be in the same room as Resident #113 due to behaviors. The risk would be that one day they would get on each other's nerves, and someone could get hurt especially if they were physical. In a telephone interview on 4/23/25 at 9:21 AM, The Psychiatric NP stated that she was the Psychiatric NP for both Resident #113 and #114. The Psychiatric NP stated Resident #114 was not aggressive, didn't bother anybody, and stayed in bed depressed. Resident #114 was more with it and that he did not have anything in common with anyone in the secure unit. She stated, at one time in January 2025, Resident #113 had a roommate and had witnessed he was annoyed with the roommate who was in bed and nonverbal. Resident #113 would accuse that roommate of taking his belongings. This behavior was discussed with her by the SW and DON. Prior to that, Resident #113 was fine with the curtain between his bed and the roommate's bed. Resident #113 would remain on his side. By February 2025, Resident #113 was in a room by himself. Resident #113 and Resident #114 seemed like they got along well and would be fine as roommates. In an interview on 4/23/25 at 12:25 PM the DON stated after altercation on 3/23/25, Residents #113 and #114 were placed in separate rooms and no increase in staff were made, when asked how the other residents were protected. The DON stated there were no further incidents. In a telephone interview on 4/23/25 at 3:20 PM the SW stated she was notified of the resident-to-resident altercation between Resident #113 and #114 on 3/23/25. The SW stated they were immediately separated and then she worked on trying to find a different place for Resident #113. The SW stated Resident #113 did not do well with roommates. In an interview on 4/24/25 at 9:05 AM, the DON stated Resident #114 would be verbal with staff and refuse care and that Resident #113 would stay in his room, and she did not know much about him but knew he refused care. The DON stated behaviors, whether verbal or physical, should be in care plan and MDS, so everybody knows about the behaviors. DON stated they should not have been roommates. The DON stated Resident #113 and Resident #114 had never been roommates in the past and that the decision to put them together was made by a previous Administrator. DON stated she was not notified of verbal or physical behaviors from either resident prior to the incident on 3/23/25. She stated Resident #113 was placed on 1:1 until transport to hospital and upon return was back to a room by himself. The DON stated Resident #113 had no behaviors while in hospital but should have been placed on 1:1 monitoring until he was transferred out for good. In an interview on 5/1/25 at 12:58PM the Social Service Assistant stated Resident #113 did not like it when staff would come into the room to clean up the roommate and would then be pretty aggressive towards staff. The Social Service Assistant stated after any incidents Resident #113 would have, the Social Service Assistant would call family every day for family to try and calm down Resident #113. It would work for a few days and then aggression would repeat. The Social Service Assistant stated other interventions were psych services, adjustment to meds and emergency visits. It was discussed with the family about transferring him out, but he needed a secure unit. There was never a concern about other residents' safety around Resident #113 as he didn't come out of his room. The Social Service Assistant stated having a roommate would be a risk because Resident #113 could cause chaos, agitation, and this would be more harmful to other residents. The Social Service Assistant stated, in reality the facility could not meet his needs, he needed his own room because anyone put into his room would be a disaster. This was shared with previous management but there was a time the facility was bed locked except for his room and the Administrator or Owner placed Resident #113 with another resident. The Social Service Assistant stated Resident #113 had three different roommates on different occasions. The Social Service Assistant stated the concerns about Resident #113 having a roommate to the Administrator/Owner and was told it was not a private room. The Social Service Assistant stated it was unsafe to have another resident room with him because the roommate would not get the needed care when Resident #113 would deny staff from entering. The Social Service Assistant stated after the first roommate, Resident #113 was by himself for about 6 months before he had roommates. Resident #114 was his last roommate. All staff were responsible for non-allowable items and cannot search a resident room without cause and consent. Record review of the facility policy for Abuse and Neglect, effective date of October 2022 read in part: .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations Types of abuse: 1. Physical, 2. Verbal . Record review of the facility policy for Behavioral Assessment, Intervention and Monitoring, dated in 2001, read in part: .Policy Statement .5. Residents will have minimal complications associated with the management of altered or impaired behavior .Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm 11. The director of nursing, or designee, will evaluate whether the staffing needs have changed based on acuity of the residents and their plans of care. Additional staff and/or staff training will be provided if it is determined that the needs of the residents cannot be met with the current level of staff or staff training . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/03/25. The Administrator was informed and was provided the IJ template on 05/03/25 at 1:58 PM. Plan of Removal (POR) was requested. The following Plan of Removal was submitted by the facility and was accepted on 5/06/25 at 7:19 PM: F600 Introduction: On 5/3/2025 at 01:58PM, the surveyor issued an Immediate Jeopardy F600 (IJ) template notification stating Regulatory Services had determined that the facility failed to protect the resident's right for Resident #113 and Resident #114 to be free from abuse. The facility failed to protect Resident #114 from a physical altercation on 3/23/25 where Resident #114 was sent to the ER for a red eye. The facility failed to address sexual behaviors in the care plan for Resident #113. All current residents could be at risk because of the failure to provide supervision. At the Time of the IJ it was noted that: 1. Both residents #113 and #114 were discharged prior to the change in ownership of the facility. Access to resident records that were closed prior to the change are not accessible by the current provider. 2. Resident #113 has been discharged safely from the facility on 3/26/2025. 3. Resident #114 has been discharged safely from the facility on 3/28/2025 . 4. Neither resident has returned to the facility. As a result of the IJ

Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 7 of 10 Residents (Resident #18, Resident #28, Resident #30, Resident #33 , Resident #52, Resident #113 & Resident #114 ) reviewed for care plans. - The facility failed to develop and implement a care plan that addressed Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in the resident pulling out her G-tube in 11/12/24, 03/28/25 and 04/15/25 which required hospitalization to place a new tube. - The facility failed to develop and implement a care plan that addressed Resident #33's behaviors of pulling out his G-tube which resulted in the resident pulling out his G-tube on 02/04/25, 02/12/25, 02/23/25 and 04/15/25 which required hospitalization to place a new tube. - The facility failed to develop and implement a plan of care that addressed Resident #30's escalating behaviors which resulted in a suicide attempt on 04/13/25 and the resident attempting to draw a police officer's firearm when she had to be forcefully restrained and removed from the facility. - The facility failed to develop and implement a care plan that addressed interventions that would be in place when Resident #30 returned to the facility on [DATE] following her suicide attempt. - The facility failed to develop and implement a plan of care that addressed Resident #52's escalating behaviors which resulted in suicide threats and an incident on 05/03/25 when the resident had to be forcefully restrained and removed from the facility. - The facility failed to address inappropriate sexual behaviors in the care plan for Resident #113. - The facility failed to address physical, verbal aggressive behaviors in the care plan for Resident #114 prior to the resident-to-resident altercation on 3/23/25. An IJ was Identified on 04/17/25 . The template was provided to the facility on [DATE] at 12:33 PM. While the IJ was removed on 04/22/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. A second IJ was identified on 05/05/25. The template was provided to the facility on [DATE] at 04:00 PM. While the IJ was removed on 05/08/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having their needs met, escalating behaviors, mental breakdowns, dislodged g-tube, hospitalization, pain, and injury. Non-IJ Findings - The facility failed to implement interventions in Resident #28's care plan addressing nail care, leaving the resident with his left thumb fingernail greater than 1/3rd inch, with thick skin. Findings Included: Resident #18 Record review of Resident #18's Face Sheet dated 04/15/25 revealed, a [AGE] year-old female who admitted to the facility 01/14/21 with diagnoses which included: dysphagia (difficulty swallowing), high blood pressure, contracture of the right hand/ left hand and left food. Dementia with other behavioral disturbance and anxiety disorder. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, upper and lower extremity functional limitations in range of motion, dependent on staff for all aspects of self-care( eating, oral hygiene, toileting hygiene, shower/bathing, dressing), dependent on staff for all aspects of mobility, no physical/verbal behavioral symptoms directed towards others and no behavioral symptoms not directed towards others. Record review of Resident #18's Care Plan printed 04/15/25 revealed, focus- requires the use of feeding tube and is at risk of aspiration(accidental inhalation of food/fluids into the airway), weight loss and dehydration. Feeding tube is related to dysphagia; intervention- administer tube feeding and water flushes as ordered, monitor/document/report to the physician as needed for the following complications related to tube feedings . tube dislodged. Focus initiated 12/29/22- inappropriate behaviors: resident has episodes of inappropriate behaviors of an causing her oxygen tubing from constantly falling off her face onto the floor. Interventions- monitor and chart behaviors every shift and report progress to MD. Focus- history of spitting and crying out at times according to staff and chart review ; intervention- referred to mental health services as needed. Focus initiated 02/07/21- resident has impaired communication, family member reports he is the only one that can get resident to verbally communicate; intervention- will assist with translation when needed, staff will monitor for facial grimaces and body language. , focus- signs and symptoms of anxiety like hypersensitivity, paranoid, nervousness and is at risk for further episodes of anxiety and injury; intervention- medication as ordered, redirect resident from source of anxiety. Resident #18's care plan did not include the resident pulling on or pulling out her G-tube. Further review indicated EBP was not included as an intervention. Record review of Resident #18's Progress Notes from to 04/15/25 revealed: 11/12/24 at 11:56 PM- CNA informed nurse during care that resident had pulled her G Tube from her abdomen. Nurse went to assess resident and she was found with tube laying on her abdomen without any s/s of pain or distress. DON and Attending notified 11/13/24 at 01:03 AM- EMS arrived to transport resident to hospital 03/27/25 at 05:32 PM- Resident #18 pulled her feeding tube and IV pole fell on her head. The resident had no bumps and bruises, and the NP was notified 03/28/25 at 09:40 AM- From incident yesterday evening pole fell on resident head right eye and forehead bruises was noted this morning, resident is already on neuro checks. NP was notified A.DON as well resident medication was administered. 04/15/25 at 05:47 PM- Patient pulled her G-tube out. Nurse sent patient to hospital for replacement An observation and interview on 04/15/25 at 09:50 AM revealed, Resident #18 in bed with contracted feet and hands. The resident had a bruise with a scab and dry blood on her forehead, with her bed low to the ground and fall mat on the left side of the bed. The resident had a firm grip on her G-tube tubing, pulling it tightly and her abdomen was observed to rise as she tugged on the tubing. The surveyor immediately exited the room to notify facility staff. When the surveyor returned to the room with MA A the resident was no longer pulling on her tube but continued to pull her legs up and move her hands. MA A said the resident returned to the facility that morning from the hospital. The resident had large tan bandage strips loosely placed on top of the site where her G-tube entered her abdomen, there was no abdominal binder or other assistive device preventing Resident #18 from pulling out her G-tube. An observation and interview with LVN J on 04/15/25 at 11:15 AM revealed, Resident #18 squirming/fidgety/restless in bed, with her legs pulled up. There was tube feeding residue, not previously seen, on the resident's sheets and incontinent brief. LVN J said Resident #18 readmitted to the facility in the morning she pulled out her G-tube. She said the resident did not have an order for an abdominal binder, and a binder was not used to protect Resident #30 from dislodging her G-tube. LVN J said, she can have an abdominal binder. In an interview on 04/15/25 at 11:23 AM, the NP said she started following Resident #18 6 weeks ago. She said the residents restless, fidgety, and squirming behavior is what she considered her baseline. The NP said she originally thought the resident's behaviors were due to a UTI so Resident #30 was treated with a course of antibiotics, but the behaviors remained when the medication was completed so she now believed she needed psych services. The NP said residents with excessive restlessness and continuous activity were at risk of pulling out their G-tube, so they should have an abdominal binder covering the tube which would prevent them from easily pulling out the tube. The NP said the resident did not have an order for an abdominal binder because she had not received any reports that the resident consistently pulled on her G-tube. She said the failure to have an abdominal binder on a G-tube resident with excessive movement and restlessness placed the resident at risk for the G-tube dislodgement, danger if the IV pole holding the feed falls leading to injuries. In an interview on 04/15/25 at 12:27 PM, MA B said Resident #18 always moved around and was restless. She said the resident had never had an abdominal binder put she probably could. In an interview on 04/15/25 at 12:30 PM, MA A said he had worked at the facility for 8 years and Resident #18's normal behaviors included: agitation and trying to pull out her G-tube. He said the resident did not have an abdominal binder, so he put a sheet on top her G-tube to prevent her from pulling on it. In an interview on 04/15/25 at 12:35 PM, the DON said Resident #18 was non-verbal. She said the resident had always been grabby and fidgety and received psych services. In an interview on 04/15/25 at 12:38 PM, LVN J said Resident #18 just returned from the facility after she pulled out her G-tube and the IV pole fell and hit her head. She said she received an order for an abdominal binder from the NP and was waiting for central supply to deliver the binder. An observation on 04/16/25 at 07:47 AM revealed, Resident #18 in bed, with no abdominal binder in place. The resident was restless and taking off her clothing. In an interview on 04/16/25 at 07:48 AM, MA A said there was an order for an abdominal binder for Resident #18, but she did not have one on because it had not arrived at the facility. In an interview on 041/16/25 at 07:50 AM, LVN J said Resident #18 did not have an abdominal binder on. She put in an order for an abdominal binder for Resident #18 yesterday, but it had not arrived. In an interview on 04/16/25 at 11:27 AM, LVN H said Resident #18 was one of her residents. She said even though the resident was bedbound, she did not stay in one place, moved her arms and legs around a lot, and was very fidgety. LVN H said she worked with Resident #52 for the past two years and off-course she pulls out her G-tube but the staff could not restrict her. She said she previously notified nursing management of the resident pulling on and out her g-tube, but no changes were made. She said on 04/15/25 at around 4 AM when she checked on the resident, she saw that Resident #18's G-tube was dislodged and the IV pole was on the floor. In an interview on 04/16/25 at 08:27 AM, the DON said she started her position in February and Resident #18 always had behaviors that included pulling on her G-tube. She said in March the resident pulled on her tubing which caused the IV pole holding her feed to fall and hit her in the head leading to an injury. After the incident, the resident had neuro checks in place to confirm she didn't have a change in condition and the IV pole was moved to the other side of the bed. The DON said Resident #18's behaviors were discussed in an IDT meeting, and it was decided a GDR was contraindicated and the only thing in place after the incident in March was the NP ordering labs. In an interview on 04/16/25 at 02:18 PM, RN A said Resident #18 was always fidgety and liked to play and pull on her G-tube. She said Resident #18 did not have an abdominal binder on the night 04/15/25, and she was never educated or informed about any interventions that should be in place to protect Resident #18. RN A said due to resident's movement and preference to pull on her G-tube she had communicated her concerns with nursing management and thought the resident needed an abdominal binder, but nothing was done. In an interview on 04/16/25 at 03:48 PM, the DON said an abdominal binder was ordered from their vendor, but it had not arrived yet, so the staff were monitoring Resident #18's behaviors. She said Resident #18's abdominal binder was expected to arrive on 04/17/25. Resident #33 Record review of Resident #33's Face Sheet dated 04/17/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: chronic respiratory failure, asthma, bipolar disorder, severe with psychotic features, paraplegia (paralysis of legs and lower injury), Gastrostomy and Tracheostomy (opening in neck to access the windpipe). Record review of Resident #33's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The resident had no behavioral symptoms present including physical or verbal behavioral symptoms towards others and no other behavioral symptoms towards others (hitting or scratching self, pacing, rummaging or disruptive sounds) Record review of Resident #33's undated Care Plan printed 04/17/25 revealed, Focus- risk of aspiration r/t feeding tube in place; intervention- report N/V, absent bowel sounds to MD and RP. Focus- history of depression and is at risk of episodes of depression, adverse reactions and depression driven behaviors; intervention- monitor for impeding episodes of depression- document any noted in clinical record, prove psych consult per order. Record review of Resident #33's Progress Notes from 01/16/25 to 04/17/25 revealed, Resident #33 pulled out or pulled on his G-tube on the following days: 02/04/25- Residents G-tube was dislodged 02/12/25- Residents G-tube was dislodged and he was sent out to the Hospital 02/23/25- Resident pulled out his G-tube and was sent out to the hospital ER for G-tube placement. 02/25/25- Resident was found pulling on G-tube around 9 am. Resident was cleaned up and abdominal binder was applied. 04/15/25- Residents G-tube became dislodged and he was sent out to the hospital ER of G-tube placement. In an interview on 04/16/25 at 09:18 AM, the MDS Nurse said she had been in her current position for 8 to 9 years but worked in the facility for 19 years. In an interview on 04/16/25 at 11:40 AM, the MDS Nurse said she was responsible for completing resident care plans. She said the care plan functioned as a plan of how to care for a resident. The MDS nurse said everything needed to care for a resident should be included, day to day tasks/care, wound status, behaviors, diagnosis, code status, and weight management. She said if a resident had behaviors, those behaviors should be included in their care plan with specific details that include the type of behaviors and should include goals and interventions. The MDS Nurse said incorrect care plans posed no risks to residents because nobody looks at the care plan except state. She said staff do not look at resident care plans to determine how to care for residents but received care information from reports, documentation, and verbal communications. The MDS nurse said she did not know about Resident #18's continuous behaviors of pulling at and on her G-tube and she only knew that the resident had once pulled on her IV pole causing it to fall and injury her. She said based on the behaviors she knows Resident #18 displayed, the resident's care plan should have had a focus area addressing them. In an interview on 04/17/25 at 12:50 PM, the DON said she took the role at the facility in February. She said the purpose of the care plan is to provide guidance for patient care and resident needs. The DON said she was responsible for the accuracy and completion of the care plan, but the MDS nurse is the person who actually completes the care plan. She said each resident's care plan should address their: diet, code status, diagnoses, treatments received and behaviors. The DON said the care plan triggers everything the nurses did for the residents and let them know what interventions to implement. She said inaccuracies in the care plan can result in missed treatments or interventions and in Resident #18's case it led to the resident pulling out her G-tube, injury, and hospitalization to replace her G-tube. The DON said she was not aware of Resident #18's behaviors of pulling on and out her G-tube, and she was not aware those behaviors were not in the resident's care plan, but it should have been . An IJ was Identified on 04/17/2025 . The template was provided to the Administrator on 04/17/25 at 12:33 PM. The following Plan of Removal submitted by the facility was accepted on 04/18/2025 at 07:52 PM. Plan of Removal F656 On 4/17/2025 at 12;33 PM, the surveyor provided an Immediate Jeopardy (IJ) template notification stating the Regulatory Services had determined the facility failed to develop and implement a comprehensive care plan. The facility failed to develop and implement a comprehensive care plan that addressed Redients#18's behaviors of pulling her G-tube which resulted in injury after the IV pose fell and hit resident in the head and her G-tube being dislodged on 2 occasions. 1. Immediate Action: oThe Director of Nursing immediately reassessed Resident #18 to validate the resident's G-tube was in place, patent, and medication/nutrition was being administered per provider orders. An abdominal binder ordered on 4/15/2025 after displacement was received 4/17/2025 and applied per provider orders. No other concerns were identified. Resident #18 tolerated the application of device well and exhibits no distress. Resident #18 injury to forehead is resolving without complications. oThe MDS Coordinator revised the care plan to include interventions related to the incident occurring on 3/27/2025 where Resident #18 pulled feeding tube causing the IV pole to fall on her head. Interventions included changing the positioning of the IV pole to reduce ability to pull feeding tube and IV pole. Occupational Therapy evaluation was ordered and completed. New occupational therapy plan of care for Resident #18 includes, range of motion, joint proprioception, to decrease restlessness with bilateral upper extremities. oThe MDS Coordinator updated and revised Resident#18 care plan to include provider orders for G-tube, any current/historical behaviors including agitation, fidgeting, and attempts to remove or dislodge the G-tube. Care plan revisions include interventions to prevent/reduce displacement of G-tube and requirement of documenting provider notification of any changes in behavior specifically related risk of G-tube displacement. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Plan of Removal F656 Immediate Action: oThe Director of Nursing/Designee conducted a review of all facility residents and determined 13 residents were currently receiving nutritional feeding through a G-tube/Peg Tubes. All 13 residents were immediately assessed to validate tubes were secure and patent. Further assessment included a 7 day look back record review to determine that there are no new changes in behavior, increased agitation, or fidgeting related to potential risk of G-tube/Peg Tube displacement. oThe Director of Nursing determined that 4 of the 13 residents receiving nutritional supplements via G-tubes/Peg Tubes, including Resident #18, would potentially benefit from the use of an abdominal binder. The abdominal binders were previously ordered from the supply vendor and received, provider orders were obtained, and all abdominal binders have been applied to applicable residents and applicable residents are tolerating well with reduced risk of displacement. oThe MDS Coordinator completed updates/revisions for the 13 resident care plans that included noting any current or historical behaviors (7 day look back) related to potential displacement of G-Tube/Peg tube and validated that if behaviors were identified, interventions included actions to take to reduce risk of displacement and documentation of provider notification. New orders for abdominal binders and monitoring for 4 of the 13 residents, have been added to care plan interventions to assist in potential displacement of G-Tubes/Peg Tubes as applicable. oThe MDS Coordinator/designee completed an audit to validate that all 13 residents who receive nutritional feeding through tube have updated care plans. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Plan of Removal F656 Immediate Actions: oThe QAPI Committee reviewed the policies and procedures regarding Care Plans, Comprehensive Person-Centered, to validate accuracy of the policy. oThe Director of Nursing/Designee provided training to all nursing staff who provide care to residents who receive nutritional feeding via a tube prior to providing direct patient care. oIf resident is exhibiting restlessness, agitation, or changes in behaviors related to obstruction/removal of a G-tube will be documented in the resident record which pulls to the 24 hour report and the Provider/Director of Nursing are to be promptly notified and increased supervision is implemented to maintain tube replacement and patency until root cause of increased restlessness, agitation, changes in behavior are determined. oCompleted a return determination with nursing staff on proper placement of G-tube and securing abdominal [NAME] to validate skill set. oThe Administrator provided training to the MDS Coordinator regarding the requirement to collaborate with the Interdisciplinary Team (IDT) to update and revise the resident care plans timely with resident changes in condition including behaviors that might put the resident at risk for displacement of G-tubes/Peg Tubes, compliance with provider orders. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Plan of Removal F656 Immediate Actions: oThe Director of Nursing/Designee will monitor residents with G-Tubes/Peg Tubes including those that require supportive devices such as abdominal binders that reduce the risk of tube displacement q shift and as needed to validate correct placement and patency of tubes for residents who currently have provider orders. If concerns are identified, immediate corrective action will be implemented, provider notified, and applicable staff re-educated. oThe Director of Nursing/Designee will monitor changes in behavior including increased agitation and restlessness daily to promptly determine a root cause and ensure appropriate interventions have been implemented timely on the care plan to reduce potential negative outcomes, including displacement of G-Tube/Peg Tube. oAn ad-hoc QAPI meeting was held, and the facility medical director was notified of the deficient practice and plan of removal. The Plan of Correction will be reviewed monthly during the QAPI meeting for the next 3 months and as needed until a lesser frequency is deemed appropriate. Meeting minutes will be taken and maintained for 12 months. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Monitoring of the POR . An observation on 04/19/25 at 12:25 revealed, Resident #18 in bed with an abdominal binder on. An observation on 04/19/25 at 12:29 PM revealed, Resident #33 with an abdominal binder on. In an interview on 04/19/25 at 01:01 PM, MA B said she received training on G-tube safety on 04/16/25. She said the training addressed how to address active/agitated residents with G-tube, ensuring interventions like abdominal binders are in place, ensuring the resident is safe and administering medications as ordered if necessary. MA B said the training reinforced that G-tube residents with increased agitation could be at risk of dislodgement and the IV pole falling on them. In an interview on 04/20/25 at 06:45 AM, LVN H said she was trained on 04/17/25 about G-tube safety. She said Resident #18 moved around a lot and had a tendency to pull on and out her G-tube, so she had asked for a binder to be used on the resident in the past, but no action was taken. In an interview on 04/20/25 at 08:55 AM, MA A said he had not received any training on G-tubes, Care Plans or Accidents/Supervision. An observation on 04/20/25 at 08:57 AM revealed, Resident #22 in bed with an abdominal binder in place. An observation on 04/20/25 at 09:05 AM revealed , Resident #18 in bed with an abdominal binder in place. The resident was calm, in no immediate distress and did not have concerning body movement In an interview on 04/20/25 at 09:00 AM, CNA K said she received training on G-tube safety in the previous week. She said if a resident with a G-tube was agitated they were expected to report it to the nurse and ensure an abdominal binder was on if there was an order. In an interview on 04/20/25 at 09:05 AM, LVN J could not answer what in-services she received and had to be prompted by the surveyor. She said she received training on G-tubes and care plans on 04/17/25 and 04/20/25. LVN J said when a resident on a G-tube had behaviors nurses were expected to document the incident in the chart, and report it to management, while CNAs document behaviors in the POC and report it to their nurse. She said when residents with G-tubes become agitated, they are at risk of dislodgment so nursing staff should initiate interventions like an abdominal binder if there is an order for one and notifications should be sent out. In an interview on 04/20/25 at 09:07 AM, the ADON said she completed training with staff on 04/17/25 regarding G-tube Placement, Behaviors and Abdominal binders. She said staff were educated that residents who are agitated, fidgety, constantly moving/irritated should be documents on having behaviors in the POC or the progress notes. The ADON said staff were trained that these residents are at risk of dislodgement and can also pull-down equipment. She said the training addressed reporting and documenting behaviors that increase risk of G-tube dislodgement, sending notifications and interventions that should be in place. The ADON said she also did training on resident care plans and how documentations played into the development of care plans, where to find a resident's care plan and how to review the interventions in place. She said this training was provided to CNAs, CMAs, Nurses, RTs, and anyone who provided care to residents, In an interview on 04/20/25 at 01:10 PM, the MDS Nurse said she received a 1-on-1 training from the Interim Administrator regarding care plan timing & accidents, incidents on 04/17/25 and training regarding G-tubes on 04/18/25. She said the training reinforced that she should know about resident behaviors such as pulling on and pulling out their G-tube and make sure there is the appropriate documentation. The MDS Nurse said behaviors should be tracked, orders should be in place for a binder, the binder must actually be used/in place on the resident and such orders must be in the resident's plan of care. The MDS nurse said even though the MDS is only a 7 day look back the behaviors should be documented in the resident's plan of care. The MDS nurse said she was educated that all behaviors should be documented in the care plan even if it were the resident's baseline behaviors because agitated residents are at risk of pulling out their G-tube which could result in rupture, injury, trauma, infection, and hospitalization. In an interview on 04/22/25 at 04:56 AM, RN A said she received training on G-tube safety the previous week and on 04/21/25. She said the training focused on preventing G-tube dislodgement with the use of a binder. RN A said when a resident with a g-tube is agitated or has increased movement, nursing staff are expected to assess the resident, and if needed, apply an abdominal binder or get an order for an abdominal binder. She said resident behaviors are to be documented in the resident's chart and interventions such as repositioning, medications administered as ordered, and notification sent to the MD/NP because increased behaviors/movement can place residents at risk of dislodgement, bleeding, bloating and infection. RN A said documenting any incidents that occur is important because it plays into the resident's care plan. In an interview on 04/22/25 at 05:01 PM, RN E said he received training on G-tube safety on 04/21/25. He said if a resident with a G-tube had behaviors such as fidgeting and pulling on the tube they should not be ignored, they should be assessed and interventions such as abdominal binders or PRN meds should be in place. RN E said if a resident even if these behaviors are continuous staff should document it whenever they see it because it plays into the care plan. In an interview on 04/22/25 at 05:05 AM, CNA X said he did not receive any training on G-tubes, care plans or behaviors in residents with behaviors but if a resident is observed pulling on their G-tube staff should ensure interventions like abdominal binders are in place, notify their nurse and document the behaviors in the POC to prevent dislodgement. In an interview on 04/22/25 at 05:09, RT A said he had not received in-person training on G-tube safety but had received a text message on some trainings and asked if he could pull it up. RT A was not able to verbalize independently what the training he received was but read from his text that residents with increased agitation were at risk of dislodgement or injury so the nurse should be notified and the behaviors document. An observation on 04/22/25 at 05:20 AM revealed, Resident #18 in bed, with no abdominal binder on. In an interview on 04/22/25 at 05:25 AM, CNA A said she received training regarding G-tube safety on 04/20/25. She said when a resident with a G-tube was agitated or fidgety she is expected to observe them and document it in the POC. CNA A said Resident #18 did not have an abdominal binder on because it was only required when the resident was agitated which she was not at this time . In an interview on 04/22/25 at 05:29 AM LVN B said he received training on G-tube safety on 04/21/25. He said residents with G-tubes that experienced behaviors were at risk for dislodgement, so they must notify the MD to receive an order for an abdominal binder or use one if order was in place. LVN B said Resident #18 did not have an abdominal binder in place because she only required one when she was agitated. In an interview on 04/22/25 at 08:50 AM, LVN D said she received training on G-tube safety on 04/21/25. She said residents with G-tubes that are fidgety are considered as having behaviors and that should be documented. In an interview on 04/22/25 at 09:18 AM, MA C said she had not received any training on G-tube safety. In an interview on 04/22/25 at 01:55 PM, MA C said she received training that day regarding residents with G-tubes displaying behaviors, communication & notifications of behaviors and the application of abdominal binders as ordered. She said if a resident with a G-tube was agitated they were at risk of G-tube dislodgement so interventions should be in place as ordered, nurse notified, and observations document ed in the residents POC. MA C said residents with behaviors like Resident #18 should have binders in place at all times except when care is provided. An observation on 04/22/25 at 02:00 PM revealed, Resident #22 sleeping in bed with her [family member] by her bedside. The said the resident currently had an abdominal binder on and had extra ones in her nightstand. In an interview on 04/22/25 at 02:18 PM with the Interim Administrator and the DON, the Administrator said the facility performed an audit and identified 5 residents with a history of behaviors associated with pulling out their Gtube. She said those resident's care plans have been updated, every

Based on observation, interviews, and record reviews the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 ( Resident #161) residents and 2 out of 2 Crash Carts in that: - RN D failed to use the AED when providing CPR to Resident #161 when he was found unresponsive on [DATE]. - The facility failed to ensure the facility had pads for use with the AED in case a resident was in need of CPR. - The facility failed to ensure the facility crash carts had oxygen available. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 02:12 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. This facility failure could place residents at risk of experiencing worsening of condition, severe injury, brain damage, hospitalization, and death. Findings include: Record review of the facility list of Residents with full code status provided on [DATE] at 02:00 PM revealed, 46 out of 50 residents in the facility were full code, which signified that they requested to receive all possible medical interventions to save their lives in the event of cardiac or respiratory arrest. Resident #161 Record review of Resident #161's Face Sheet dated [DATE] at 04:45 PM revealed, the resident admitted to the facility on [DATE] with diagnosis which included: respiratory failure, mild protein-calorie malnutrition, epilepsy (brain disorder characterized by unprovoked seizures), heart failure, low blood pressure, inability to sleep and the presence of a prosthetic heart valve. The resident had advanced directives of Full Code CPR when he discharged to the hospital on [DATE]. Record review of Resident #161's Discharge MDS dated [DATE] revealed, the resident had an unplanned discharge to a short-term general hospital. He received continuous oxygen and tracheostomy (a surgical procedure where a hole is created in the neck, directly into the windpipe to allow air to enter the lungs) care, had no acute mental status change and had severely impaired cognitive skills for daily decision making. Record review of Resident #161's undated care plan revealed, focus: advance directive choice of FULL CODE status; interventions- staff will initiate CPR and notify EMS for transport to a hospital. The full code status for Resident #161 was initiated on the resident's care plan on 05/27.25. Focus- episodes of inappropriate behaviors and risk of injury due to self-dislodgement of trach; interventions- observe for early warning signs of behavior; date initiated [DATE]. Focus- resident has a tracheostomy; intervention- provide tracheostomy care per order. Record review of Resident #161's Progress Note dated [DATE] at 06:15 PM signed by RN D revealed, approximately 05:30 PM , SN went to check blood pressure and noticed resident unresponsive with no pulse , Code blue activated, and resident placed on floor CPR started immediately for 3 minutes resident become responsive , placed on non-breather mask with 15 liters. blood pressure 165/101, heart rate 105 , oxygen 98% , temperature 99.2, blood sugar 131. 911 was called and transferred resident to hospital . MD notified . RP and caregiver also notified of the CIC and transfer. Record review of Resident #161's Change in Condition Evaluation dated [DATE] at 06:26 PM revealed, the residents change of condition was abnormal vital signs and unresponsiveness that started in the afternoon. Resident #161 was unresponsive, code blue activated, resident sent to ER via ambulance. Record review of Resident #161's Hospital Record revealed, he admitted to the ED with altered mental status. Resident #161 admitted from a nursing facility in which the staff states he was in cardiac arrest and did 1 round of CPR. The fire department stated the resident had pulses and breathing on scene, with eyes open with a gaze and he was unresponsive to pain. According to EMS, they were called to the patient's nursing home due to cardiopulmonary arrest. They state that staff at the facility had told him that they found the patient unresponsive without a pulse. It is unclear what time this was or when the patient was last seen normal. According to EMS, staff had performed chest compressions for 3 minutes and had ventilated the patient with the BVM (a manual technique to deliver positive pressure ventilation to a patient who is not breathing or is not breathing adequately). No medications or defibrillation/cardioversion was performed. When EMS arrived, patient was awake and confused. In an interview on [DATE] at 09:25 AM, RN D said on [DATE] Resident #161 was found unresponsive without a pulse in his room. She said facility staff immediately started CPR on the resident and after 1 round of CPR (30 compressions to 2 breaths) the resident came back (responsive and with a pulse). RN D said when a resident is found unresponsive nursing staff are expected to check the residents pulse and activate code blue and the crash cart is brought to the resident. She said when the cart arrives, the staff are to apply the AED and then follow the prompts. RN D said she last received training on AED use with the previous management company at the end of 2024. She said she did not use the AED on Resident #161 because he came back pretty fast (after 1-2 minutes of CPR). RN D said the AED was supposed to be applied after 1 round of CPR was completed. In observation on [DATE] at 09:26 AM with RN D, inventory of the A & B hall crash cart revealed, the contents of the crash cart were unsecured. There were no pads for the AED, the oxygen tank was empty and there were 2 sealed syringes with needles in one of the drawers. The cart was signed off as being fully stocked from [DATE] to [DATE] by different staff on Crash Cart Check List was signed off . RN D said the crash cart had not had any pads for the AED for an unknown period in time , she opened the valve on the oxygen tank and confirmed the oxygen tank was empty. In an interview on [DATE] at 09:30 AM, the DON said Resident #161 was found unresponsive so facility staff-initiated CPR, 911 was called but he was responsive when the EMS arrived. She said when a resident who is full code is unresponsive nursing staff must initiate CPR while someone calls 911. She said once CPR is started staff are expected to grab the crash cart and immediately apply the AED and follow the prompts and there should be no delay in the use of the AED. The DON said if a resident did not have a pulse the AED should have been used. She said she was notified that there were no AED pads during the previous week, and she attempted to order them, but she was unsuccessful due to the facility's new vendor, so she sent the order form to the medical director. The DON said failure to have AED pads would result in staff being unable to defibrillate a resident, but the resident would not die because they could still perform CPR without it. The DON would not answer what the risk to residents was if the facility crash cart did not have oxygen. An observation and interview on [DATE] at 09:38 am revealed, the Station C & D of the crash cart was unlocked. There were no AED on the station C & D Hall Crash Cart and there was no oxygen tank. LVN J said the crash cart had an AED but did not know where to find it, she checked the cart and the supply closet, but the AED could not be located. An observation on [DATE] at 10:11 AM revealed, an empty box that read AED/defibrillator located in the front hallway on the way to the station A & B hall after the door to the DONs office. In an interview on [DATE] at 10:30 AM, the DON said she did not know exactly how long the facility had been without AED pads, but she notified the Medical Director on [DATE]. She said the facility's supplier sent her a form to order the AED pads, so she forwarded it to the Medical Director, but she had not received a response from the Medical Director or the supplier. The DON said going forward she would order the AED pads herself from an online marketplace. She said she did not have record of the last reorder for the AED pads as it was with the older management company (new management of the facility started on [DATE]) and she did not have any records available. In an interview on [DATE] at 01:27 PM, the Administrator said the nursing designee is responsible for ensuring the crash carts were stocked. He said he was unaware that the facility did not have pads for the AEDs, but he saw an email he was copied on regarding AED pads, but he did not know what the difficulty was. The Administrator said the facility only had 1 AED in the building and failure to have a functional AED in the facility could place residents at risk of a delay in care up to death. He said he was not aware that the oxygen tanks on the crash carts were empty or absent and failure to have oxygen on the crash cart could place resident at risk for a delay in care and negative outcomes. The Administrator said he was not aware that nursing staff were not checking the contents of the crash cart correctly and he did not know how long the facility had gone without AED pads. He said as the administrator he expected the crash carts to be fully stocked, timely restocked after use, and locked to maintain the integrity of the contents and for patient safety. In an interview on [DATE] at 01:45 PM, RN D said she only knew about the lack of AED pads and no back up AED this morning when the state surveyor brought it up. She said when Resident #161 coded and they performed CPR they brought the entire crash cart to the residents room, but she did not get to connect the AED and did not look inside. RN D checked the facility EMR system and said the last time the AED was used was on [DATE] and the night shift was responsible for checking the crash cart/AED. RN D said lack of supplies for the AED or lack of a back up AED placed residents at risk of a bad situation but the EMTs always have their own AEDs so facility staff would have continued with CPR until they arrived. In an interview on [DATE] at 02:38 PM, the Medical Director said she expected nursing staff to know how to perform CPR including when to use the AED. When asked the expectation for AED use the Medical Director said she could not answer because it was a hypothetical question. When asked what expectations she had for nursing staff regarding CPR the medical director said she would not answer because it was a hypothetical situation. The Medical Director said the AED should be used when a resident had pulseless electrical activity and a fibrillation pattern, but she would not answer how the staff would be able to determine if the resident was in these states without first attaching the AED because it was a hypothetical situation. She said the Medical Director, DON and Central Supply were responsible for ensuring that the facility crash carts were fully stocked and she was unaware that the facility did not have pads for the AED or that the O2 tanks on the crash carts were empty. The Medical Director said she received an email on [DATE] from the DON regarding the ordering of the AED pads but she did not read it until recently. She said as the Medical Director she meets with facility administration every week when she comes in and she also had a QAPI meeting last week but they did not discuss the facility's need of AED pads. When asked the risk to residents if the facility did not have functional AEDs or O2 on the crash cart, the Medical Director said she couldn't say because it was a hypothetical situation. Record review of RN D's BLS Provider Certificate dated [DATE] revealed, RN D BLS training expired on 10/2026. Record review of the facility policy titled Automatic External Defibrillator, Use and Care of revised 03/2015 revealed, personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden cardiac arrest. arrest. 1- During a sudden cardiac arrest event, follow guidelines outlined in the procedure for CPR and BLS. 2- if an individual is found unresponsive and not breathing normally, a staff member who is trained in CPR/BLS shall initiate CPR unless- the resident has a DNR order that prohibits CPR or external defibrillation exist for that individual or there are obvious signs of irreversible death. 3- The AED will be used to try and restore normal cardiac rhythm when arrythmia is strongly suspected. 4- In general, SCA should be suspected if; the victim's symptoms appeared very suddenly; he or she is unresponsive; and his or her breathing has stopped. 5- If an individual is found unconscious and SCA is suspected, begin AED protocol. Initial Assessment and Safety Precautions: 1- Call or direct someone to call 911; 2- Apply PPE; 3- Assess the victim- if unresponsive, retrieve (or direct someone to retrieve) the AED from its location and bring to the victim. Open airway and look, listen, feel for breathing. If breathing is absent, deliver 2 rescue breaths. If signs of circulation are absent, begin CPR until the AED is available Devise Setup: remove device from case. remove the film [NAME] from pads, turn on the device and follow the prompts Defibrillation . The AED will analyze the heart rhythm and indicate whether a shock is needed. Storing the AED- 1- replace used accessories, including pads; 2- check and inspect device. Maintaining the AED: keep spare battery and adhesive pads in the case as instructed. 3- document checks, maintenance steps and date performed on maintenance log and store log with the device. Record review of the facility policy titled Emergency Procedure- Cardiopulmonary Resuscitation and Basic Life Support revised 10/2024 revealed, personnel have completed training on the initiation of CPR and BLS, including defibrillation, for victims of sudden cardiac arrest. General Guidelines: 1- if an individual is found unresponsive and not breathing normally, a staff member who is trained in CPR/BLS shall initiate CPR unless- the resident has a DNR order that prohibits CPR or external defibrillation exist for that individual or there are obvious signs of irreversible death. Preparation for CPR: 1- obtain and/or maintain certification in BLS/CPR that adheres to the AHA guidelines for all clinical staff members, including non-licensed personnel . 4- maintain equipment and supplies necessary for CPR/BLS in the facility at all times. AHA guidelines for CPR and ECC: 10 staff are trained to follow current AHA guidelines and recommendation for sequence of resuscitation including: Recognition or cardiac arrest; initiation of resuscitation; opening the airway; metrics for high-quality CPR; ventilation and compression-to-ventilation ratio; defibrillation . An IJ was Identified on [DATE]. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 02:12 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 02:13 PM. [DATE], F678 Introduction: On [DATE], at 2:12pm, an Immediate Jeopardy was identified due to: The facility failed to use an AED when Resident #161 coded on [DATE]. The facility failed to have a functional crash cart. The station A&B crash cart did not have pads for the AED and the oxygen tank was empty. Nurse Station C&D did not have an AED or oxygen tank available. As a result of the IJ the facility has implemented the following: 1. All current residents could be at risk of having a change of condition and have the potential to be impacted by this deficient practice. 2. The facility completed an ad-hoc QAPI, on [DATE], at 3:30pm, F678 was reviewed as it pertained to the incident resulting in the IJ and reviewed the its CPR Policy, AED policy and Code procedures. 3. All residents' code status (Full Code/DNR) confirmed and verified in the electronic health record (EHR). Completed [DATE]. 2025 by DON/ADON. 4. All residents' oxygen orders were confirmed and verified in the electronic health record (EHR). All residents use oxygen concentrators, residents who are on concentrators will have their concentrators plugged into outlets that are powered by the facility generator. Oxygen tanks will be used should a concentrator fail, for resident transportation on facility bus, and for use during emergent situations, such as a resident code. Facility is able to contact the supplier for additional tanks as needed. Completed [DATE]. 2025 by DON/ADON. 5. An audit was conducted on the crash carts, identified missing equipment replaced, or reordered, as necessary. If the crash cart is used, the on-duty nurse will restock the cart as soon as possible after it use, no later than the end of the current shift. The restocking will be verified by the second nurse on duty in the facility. The cart will be audited by the DON/ADON/Designee no later than 24 hours after its use and restocking. Completed [DATE]. 2025 by DON/ADON 6. The audit sheet will serve as the guide and system for checking and re-stocking the crash cart. DON/ADON will in-service the RNs and LVNs on the use of the audit sheet to re-stock the crash cart. This training will be completed on [DATE]. 7. On [DATE], replacement pads for the AEDs were obtained and placed on the crash carts. 8. An audit is being conducted by DON/ADON/Designee of RN and LVN CPR training and certifications. Audit will be completed [DATE]. Any staff member found not current will be removed from the schedule and will be required to update their certification prior to being placed back on the schedule. The facility will make Annual training available. Initial annual training will be offered to all staff by [DATE]. 9. All nursing staff; RN, LVN, CMA, and CNA's in-service on the facilities resident code policy and procedures. All staff must complete this training prior to the start of their next shift. All staff will sign off on the training. Training will be completed [DATE]. 10. Facility will complete daily audits for 14 days to ensure that Staff can locate and interpret code status, That emergency equipment, (i.e., .crash cart, AED is accessible and functional. 11. Random resident code drills will be conducted at least once on all shifts during the next 30 days. These codes will be performed by DON/ADON. Staff members will be retrained on any deficiencies observed during the drills. 12. The Administrator, DON/ADON will monitor this plan of removal and correction daily during morning meeting for the next 30 days. Monitoring of the POR In an observation and Interview on [DATE] at 05:50 AM, LVN R said he had not received an in-service regarding CPR and the use of the AED recently. His BLS/CPR card was observed to have an expiration date of 05/2025. An observation on [DATE] at 05:56 AM revealed, the ADON asking nursing staff to sign in-service documentation. Review of the document signed was training addressing crash cart audits . In an interview on [DATE] at 08:56 AM, RN F said she did not have CPR/BLS certification, and she last received an in-service on CPR/BLS last week. She said a resident's code status is documented in the EMR and it is also on the 24-hour report. RN F said her training emphasized when a resident was found unresponsive nursing staff must check on them, check vitals, listen for breathing and if there is none, call help and start CPR. She said the AED was located on the crash cart and it should be used while doing chest compressions which should start once the resident was found unresponsive. In an interview on [DATE] at 09:14 AM, RN D said she was last CPR/BLS certified in 10/2024 and she was current until 10/2026. She said the last inservice she received was with the previous company and a residents code status was found on their profile. She said her training on running a code emphasized, yelling for help, bringing the crash cart to the resident, assigning duties to each person including calling 911 and starting CPR on a resident immediately if there is no pulse. RN D said there is an AED on the crash cart, and it should be used if the resident still does not have a pulse after 1 round of CPR is completed. In an interview on [DATE] at 09:40 AM, MA A said she completed her BLS certification on [DATE] and it expires in 2026. She said she received an in-services about CPR 2 weeks ago and the AED was located on the A Hall on the wall. MA C said the AED is used when they do compressions to restart the resident and when a code is called staff bring the AED and the crash cart into the residents room. In an interview on [DATE] at 09:55 AM, LVN O said she was last certified in BLS a few days ago and does not remember the last time she received an in-service from the facility about CPR/BLS. She said a resident's code status can be found on their profile and she had no training to run a code. LVN O said if she saw an unresponsive resident she would check their code status, then go grab the crash cart and activate the response team to ask for help. She said nursing staff with help, and they will start CPR, check if the resident is breathing or not and if not, the resident is placed on the floor and 2 nursing giving CPR while they call 911. LVN O corrected herself and said she would never leave the resident and she said the AED is used when they shock the resident after giving 15 breaths. In an interview on [DATE] at 10:15 AM, the Wound Care Nurse said she was last BLS certified in 10/2024. She said she had not received an in-service on CPR/BLS, and she had only worked in the facility for 3 weeks. The Wound Care Nurse said she was showed the location of the AED and crash carts, and she knew where to find the residents code status on the EMR. She said if a resident were found unresponsive, she would check for breathing ensuring there was no obstruction, check carotid pulse and immediately start CPR. The Wound Care Nurse said when the AED is applied it would tell her when to do CPR and the pads must be put on immediately when CPR starts. In an interview on [DATE] at 11:08 AM, MA D said she was last BLS certified when she was hired in 10/2024 and the last time, she received an in-service was a month ago, but she could not remember. She said a resident code status is located in the EMR she said as a MA she does not do assessments so she will call for the nurse of a CNA. MA D said the AED was located at the nurses station ad she was not involved in using the AED so she would just help the nurses with whatever they need. In an interview on [DATE] at 11:20 AM, CNA H said she was last BLS certified in 01/2025. She said if a resident was unresponsive, she would run to the nurses station to get the crash cart, then continue doing compressions while someone calls 911. She said she would follow the nurses instructions to perform CPR. In an interview on [DATE] at 11:36 AM, RT D said her BLS certification will expire in 08/2025. She said she last received an in-service on BLS/CPR a few months ago before the facility management company changed. RT D said a residents code status can be found in PCC and if a resident was not responsive, she would check their pulse, run to get help, ask the nurse to call a code blue, get the crash cart and go to the resident. She clarified that she would call the code and someone else would bring the crash cart so she would not leave the resident. RT D said the nurses will check on the resident and place the AED pads on the resident, start chest compressions and have the bag set up. She said there was an AED on the crash cart by the nursing station. In an interview on [DATE] at 12:19 PM, RN A said she was last BLS certified in 11/2024 and she received an in-service addressing CPR approximately 3 weeks ago. She said the AED was part of the crash cart and after the resident is connected to the AED the device would tell them what to do. RN A said the AED pads should be applied as soon as the crash cart arrived. In an interview on [DATE] at 03:48 PM. LVN R said he was last BLS certified on 09/2023 and his last in-service on CPR was yesterday ([DATE]). He said if a resident is found unresponsive, with full code status, code blue will be called, and the nurses will help start CPR. LVN R said the AED is located in the crash cart by the nursing station and it should be used when a resident is unresponsive and after it arrives. In an interview on [DATE] at 05:48 PM, the DON stated they had IJ because in the documentation it did not show that the nurses used the AED for the resident. After interviewing the nurse and finding out what happened he did not need the AED because he got 3 min of CPR. They got the AED, opened the pads but did not need to apply them . They in serviced the nursing staff on documentation following the incident. In an interview on [DATE] at 06:15 PM, the ADON stated that there was an IJ in AED because the AED was used prior, and pads were not ordered between there. Things that are missing, there are always 2 sets. The time frame from the time they replaced the AED pads. She stated if they did CPR that is a true code. She stated the resident had hypoxia because they did not get potassium. The IJ was because it was an AED issue that was not used. They need to analyze heart rate is with the defibrillator. There was teaching and orientation done. There was no pads and any CPR patient they use the AED because it tells them what they need. It was a failure on the nurse In an interview on [DATE] at 06:30 PM, the Administrator said the facility had an IJ in CPR because the facility failed to ensure the proper items were available for use and in stock. The facility failed to follow up on audits to verify for completeness. Going forward the facility will ensure the audits were done appropriately with all the supplies were ready and available on the crash carts. Record review completed on [DATE] revealed: - The facility held an ad-hoc QAPI meeting with the Administrator, DON, ADON and medical director on [DATE]. - The Administrator, DON and ADON were in-serviced by the CNO on CIC, follow-up, staff reporting of incidents and CIC and notifying the medical director and or designated on call provider. The document was dated [DATE] and the training was completed over phone and email. - The facility provided training to staff on CPR- Crash Cart/AED un an unspecified date. - The facility provided training to staff on CPR- Crash Cart/AED on [DATE]. - The facility completed a CPR training audit on an unspecified dated and the following discrepancies were noted: LVN R was documented as expiration date 09/25 when the observed BLS card was 05/2025. - The facility audited the crash cart on [DATE] and [DATE] and all items where in working order. - The facility completed an audit of the number of O2 tanks in the building on [DATE] through [DATE]. - The facility ordered a new AED and Pads on [DATE]. The supplies were shipped to an address located in a different city from the facility and the AED pads purchased were replacement adult training pads for training only. The facility was informed that the immediacy was removed on [DATE] at 06:40 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 3 of 9 residents (Resident #161, Resident #162 and Resident #163) reviewed for quality of care. - LVN T failed to enter orders for potassium to treat Resident #161's critically low potassium of 2.7 correctly which resulted in Resident #161 receiving his first dose of potassium over 12 hours after the lab notified LVN T of the critical lab result and Resident #162 receiving 2 doses of Potassium in error. - RN E failed to notify Resident #163's physician of his critically high BUN of 93 correctly by sending a picture to the incorrect provider after hours instead of notifying the on-call physician and failed to conduct a CIC evaluation for the resident. These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 04:36 PM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of pattern and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. Findings include: Resident #161 Record review of Resident #161's Face Sheet dated [DATE] at 04:45 PM revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: respiratory failure, mild protein-calorie malnutrition, epilepsy (brain disorder characterized by unprovoked seizures), heart failure, low blood pressure, inability to sleep and the presence of a prosthetic heart valve . The resident had advanced directives of Full Code CPR when he discharged to the hospital on [DATE] at 06:01 PM. Record review of Resident #161's Discharge MDS dated [DATE] revealed, the resident had an unplanned discharge to a short-term general hospital. He received continuous oxygen and tracheostomy (a surgical procedure where a hole is created in the neck, directly into the windpipe to allow air to enter the lungs )care, had no acute mental status change and had severely impaired cognitive skills for daily decision making. Record review of Resident #161's undated care plan revealed, focus: advance directive choice of FULL CODE status; interventions- staff will initiate CPR and notify EMS for transport to a hospital. The full code status for Resident #161 was initiated on the resident's care plan on 05/27.25. Focus- episodes of inappropriate behaviors and risk of injury due to self-dislodgement of trach; interventions- observe for early warning signs of behavior; date initiated [DATE]. Focus- resident has a tracheostomy; intervention- provide tracheostomy care per order. Focus- Potential for seizure activity, injury related to seizure activity and epilepsy; Goal- maintain lab values WNL through therapeutic range per MD order and be free of seizure activity through next review date; Interventions- administer medications as ordered. Record review of Resident #161's Lab Result Results dated [DATE] at 04:41 PM revealed, the facility collected a blood sample for a complete blood count, lipid panel and comprehensive metabolic panel on [DATE] at 05:55 AM; the sample was received by the lab on [DATE] at 10:26 AM; the lab reported the results on [DATE] at 04:41 PM. Resident #161's Potassium was tested to be 2.7 mmol/L and flagged as a critically low since the normal range for potassium was 3.6-5.5 mmol/L. The results were verified, called to and red back by [LVN T] on [DATE] at 04:37 PM regarding the residents potassium. Record review of Resident #161's Progress Notes dated [DATE] at 06:34 AM signed by RN D revealed, Critical lab potassium noted 2.7 and reported to the MD . New order received to give stat potassium chloride 40mEq , then another at night and give 40 mEq for the next 3 days. RP called ; phone went to Voice mail, administered the medication as ordered . Resident vital signs are wnl, nurse will continue to monitor . Record review of Resident #161's Change in Condition Evaluation dated [DATE] at 03:06 PM signed by RN D revealed it was a follow up CIC evaluation. The residents change of condition was critical potassium level of 2.7 that stated in the afternoon on [DATE]. There was no repeat lab ordered, treatment was in place for 3 days and the physician was notified on [DATE] at. 06:34 AM. Abnormal chemistry values of K less than 3.0 at 2.7 from [DATE]. Record review of Resident #161's Progress Note dated [DATE] at 06:15 PM signed by RN D revealed, approximately 05:30 PM , SN went to check blood pressure and noticed resident unresponsive with no pulse , Code blue activated, and resident placed on floor CPR started immediately for 3 minutes resident become responsive , placed on non-breather mask with 15 liters. blood pressure 165/101, heart rate 105 , oxygen 98% , temperature 99.2, blood sugar 131. 911 was called and transferred resident to hospital . MD notified . RP and caregiver also notified of the CIC and transfer. Record review of Resident #161's Change in Condition Evaluation dated [DATE] at 06:26 PM revealed, the residents change of condition was abnormal vital signs and unresponsiveness that started in the afternoon. Resident #161 was unresponsive, code blue activated, resident sent to ER via ambulance. Record review of the facility Unreviewed Laboratory records on [DATE] at 01:33 PM revealed, Resident #161 had critical lab result that were reported to the facility on [DATE] at 04:41 PM. Record review of the Resident #131's Lab Results in his EMR dated [DATE] at 02:02 PM revealed, his critical lab results were reported on [DATE] at 04:41 PM but the review status read To Be Reviewed. Record review of Resident #161's Order Summary Report dated [DATE] at 02:06 PM revealed: - Potassium 20 mEq- Give 40 mEq by mouth one time only for critical potassium 2.7 for 1 Day - Potassium 20 mEq- give 40 mEq by mouth one time only for low potassium level 2.7 for 1 day. - Potassium 20 mEq- give 40 mEq by mouth one time only for low potassium level 2.7 for 3 days. Record review of Resident #161's Hospital Record printed [DATE] at 03:48 PM revealed, Resident #161's Potassium level upon admission to the hospital was abnormal. His potassium level was 3.1 mEq/L with a reference range of 3.4-4.5. Record review of Resident #161's May MAR dated [DATE] revealed, RN D administered only 1 dose of Potassium 40 mEq to Resident #161 on [DATE] at 07:19 AM (over 12 hours after the critical lab value was reported). Record review of Resident #161's Hospital Record revealed, he admitted to the ED with altered mental status. Resident #161 admitted from a nursing facility in which the staff states he was in cardiac arrest and did 1 round of CPR. The fire department stated the resident had pulses and breathing on scene, with eyes open with a gaze and he was unresponsive to pain. According to EMS, they were called to the patient's nursing home due to cardiopulmonary arrest. They state that staff at the facility had told him that they found the patient unresponsive without a pulse. It is unclear what time this was or when the patient was last seen normal. According to EMS, staff had performed chest compressions for 3 minutes and had ventilated the patient with the BVM (a manual technique to deliver positive pressure ventilation to a patient who is not breathing or is not breathing adequately). No medications or defibrillation/cardioversion was performed. When EMS arrived, patient was awake and confused. In an anonymous interview on [DATE], They said Resident #161 coded in the facility in May due to a delay in treatment of a critical lab because the lab was called in under an incorrect resident who received Resident #161's critical treatment in error resulting in Resident #161 receiving delayed treatment for his critical lab value. The anonymous person said this was not the only critical lab missed but this particular incident bothered them. In an interview on [DATE] at 02:45 PM, the Hospital Nurse A said Resident #161 was not in his room because he was undergoing a procedure in a different building. She said the resident initially admitted to the facility because he was unresponsive and had admitting diagnosis of heart valve replacement and cardiac issues. Hospital Nurse B said the resident was unresponsive with no pulse in the facility but once he was conscious, he had seizure like activity. In an interview on [DATE] at 09:36 AM, RN D said when she came in on her morning shift on [DATE] the nurse who gave her a verbal report said Resident #162 had a critically low potassium, so he was administered potassium. She said in her experience when a resident had a critically low result the MD ordered a retest, but the reporting nurse said no such report was received, so she reviewed Resident #162's medical record and determined that the resident did not have a critical lab result for potassium but Resident #161 did. She said after further investigation she learned that both LVN T and RN A administered 40 mEq to Resident #162. RN D said she immediately called the doctor and received orders for Potassium for Resident #161 which she administered, and she notified the DON who asked for a STAT lab for Resident #161 and Resident #162. RN D said throughout the day Resident #161 was not his usual self, he was very lethargic, had slightly elevated BP, decreased O2 stats, was not trying to get out of bed and was spacing out. She said Resident #161 only ate a little bit of his lunch and around 04:00 PM when staff went to check on him, he was found unresponsive. RN D said she and her trainee nurse, RN H, immediately initiated CPR, Resident #161 recovered and was then sent out to the hospital which he remains. She said a resident potassium level was important because potassium controlled how the heart contracts. RN D said if a resident had low potassium they could go into cardiac arrest, and while she cannot say that is exactly why Resident #161 was found unresponsive the chance was high that the critically low potassium caused the resident to code. In an interview on [DATE] at 09:25 AM, RN D said on [DATE] Resident #161 was found unresponsive without a pulse in his room. She said facility staff immediately started CPR on the resident and after 1 round of CPR (30 compressions to 2 breaths) the resident came back (responsive and with a pulse). RN D said when a resident is found unresponsive nursing staff are expected to check the residents pulse and activate code blue and the crash cart is brought to the resident. She said when the cart arrives, the staff are to apply the AED and then follow the prompts. RN D said she last received training on AED use with the previous management company at the end of 2024. She said she did not use the AED on Resident #161 because he came back pretty fast (after 1-2 minutes of CPR). RN D said the AED was supposed to be applied after 1 round of CPR was completed. Resident #162 Record review of Resident #162's Face Sheet dated [DATE] at 01:58 PM revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: traumatic brain hemorrhage , respiratory failure, type 2 diabetes, brain injury, anxiety disorder, g-tube, and dependence on a ventilator. Record review of Resident #162's Admissions MDS dated [DATE] revealed, active diagnoses included: coronary artery disease, anemia, a CVA, TIA or stroke and traumatic brain injury. Record review of Resident #162's undated Care Plan revealed, Focus- risk of aspiration due to feeding tube and episodes of inappropriate behaviors of rolling himself from the bed to floor mat pulling out his feeding tube. Record review of Resident #162 Change in Condition Evaluation dated [DATE] at 05:00 PM signed by LVN T revealed, change of condition was critical potassium level of 2.7 that started on [DATE] in the afternoon. LVN T received a call from the clinical laboratory with a critical potassium value of 2.7 and she reported the result to the Medical Director. LVNT received new orders to give 40 mEq of potassium now, another dose at night and then daily for 3 days. LVN T entered the orders into the EMR and administered the initial dose of potassium 40 mEq. Abnormal results- potassium level 2.7. Record review of Resident #162's Progress Note dated [DATE] at 06:57 AM signed by LVN T revealed, LVN T received a call from the clinical laboratory with a critical potassium value of 2.7 and she reported the result to the Medical Director. LVN T received new orders to give 40 mEq of potassium now, another dose at night and then daily for 3 days. LVN T entered the orders into the EMR and administered the initial dose of potassium 40 mEq. Record review of Resident #162's Lab Results Report dated [DATE] at 04:00 PM revealed, the result was reviewed by NP B on [DATE] at 11:11 PM. A blood sample for BMP testing was collected on [DATE] at 02:20 PM and Resident #162's potassium level was 4.5 mmol/L with a reference range of 3.5-5.2 [NAME]/L. Record review of Resident #162 Order Summary Report dated [DATE] revealed: - Potassium give 40 mEq via G-tube one time only for critical potassium level for 1 day. - Potassium give 40 mEq via G-tube at bedtime for critical potassium level - Potassium give 40 mEq via G-tube one time a day for critical potassium level for 3 days. Record review of Resident #162 May [DATE] dated [DATE] at 01:59 PM revealed, Resident #162 received Potassium 40 mEq on: - [DATE] at 06:33 PM administered by LVN T. - [DATE] at 09:00 PM administered by RN A. Record review of Resident #162's Clinical Results on [DATE] at 02:01 PM revealed, Resident #162 had no labs were collected on [DATE] and no results for critical potassium were reported on [DATE]. In an interview on [DATE] at 03:50 PM, RN A said she did not administer Potassium 40 mEq to Resident #162. In an interview on [DATE] at 07:28 PM, LVN T said she was not aware she made a med error with Resident #161 and Resident #162. She said when nurses received a critical lab result, they are expected to notify the NP in order to receive new orders for treatment. LVN T said she would report the CIC to the RP, enter the new orders into the EMR and notify the ADON. She said critically low potassium could place residents at risk for a cardiac event and all critical lab result should have immediate interventions in place because the resident could experience an adverse event, or the resident could die. After LVN T looked through the EMR she confirmed that she was documented as receiving the critical lab call from the lab on [DATE], she entered the order for potassium into Resident #162's chart and she administered potassium to Resident #162. LVN T said she did not remember a med error incident on [DATE] as that was her first day working over here, no one ever talked to her about the incident, and she never received any re-training or in-service related to this incident. In an interview on [DATE] at 05:06 PM, the DON said there was a medication error when Resident #161's labs were attributed to Resident #162 and the wrong resident was treated for critically low potassium. She said the facility investigation revealed LVN T made the med error. The DON said when a resident has a critical lab value nursing staff must follow the critical labs pathway, notify the MD/NP, and follow through as ordered. She said low potassium can impact heart muscle contraction, leading to cardiac arrest if response is delayed. An observation on [DATE] at 06:15 PM revealed, Resident #162 in bed in no immediate distress. He was connected to a ventilator and received continuous enteral feeding via a G-tube. In an interview on [DATE] at 11:42 AM, NP A said she was unaware that Resident #161 coded in May nor was she aware that Resident #162 received potassium in error. She said when the facility is notified of critical labs, nursing staff are expected to call them into the MD/NP as soon as possible but sometimes she did not receive a call but instead found out about resident abnormal labs during chart review. NP A said critically low potassium can present as elevated heart rate, lethargy, seizures, and result in cardiac arrest. In an interview on [DATE] at 10:53 AM, the DON said she completed an investigation into the incident, discussed the incident with LVN T and completed an incident report. She said she did not remember if she in-serviced nursing staff in regards to medication errors and handling critical labs. The DON said she did not remember if any interventions were put into place after [DATE] to ensure the medication error incident would not occur again. In an interview on [DATE] at 12:04 PM, the Medical Director said she does not remember if LVN T associated the critical lab with the wrong resident when she was notified of the incident. She just remembered she was notified that potassium was given to the incorrect patient, so she gave orders for labs, but she could not say which resident received potassium in error or which resident was supposed to receive the medication. The Medical Director said she was sure she discussed the medication error with the facility administration, but she did not know what interventions were put into place following the incident. The Medical Director would not say what a delay in care of critically low potassium would place residents at risk of as she would not attest to hypothetical situation. She said she would like notification and treatment immediately when a resident had a critical lab, but she could not say what the expected time was because it was a hypothetical situation. In an interview on [DATE] at 06:28 PM, NP B said she worked with the facility contracted medical practice. She said when nursing staff received notification of a critical lab, they are expected to notify the provider and initiate treatment immediately. NP B said critical potassium could present differently in residents, but the resident could be confused, have flaccid muscles (muscles that are weak and lacking firmness) and/or cardiac arrest. She said a relay in treatment of critically low potassium with oral potassium could result in arrythmia and cardiac arrest so treatment should be immediate within minutes. NP B said administration of potassium over 12 hours after staff were notified of a critically low potassium level would not be acceptable because of all the symptoms previously discussed. Resident #163 Record review of Resident #163's Face Sheet dated [DATE] at 08:20 AM revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: blood infection, acute kidney failure, heart failure, irregular heartbeat, and dependence on ventilator. Record review of Resident #163's admission MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, total dependence for all ADLs, an indwelling catheter, history of stroke and respiratory failure. He received oxygen therapy, suctioning, tracheostomy care, and a non-invasive machinal ventilator. Record review of Resident #163's Lab Results Report dated [DATE] at 12:33 AM revealed, a sample for a comprehensive metabolic panel was collected on [DATE] at 07:30 PM, the sample was received by the lab at 11:27 PM and the results were verified, called to and read back by [RN E] on [DATE] at 12:25 AM. Resident #163's lab reported a critically high BUN of 93 mg/dL with a reference range of 3-23. Record review of a text sent on [DATE] at 01:01 AM revealed, pictures of Resident #163's Critical BUN of 93 were sent to NP C who was not listed on Resident #163's Face Sheet. Record review of Resident #163's Progress Notes printed [DATE] at 08:32 AM revealed, - on [DATE] Resident #163's lab results from [DATE] came back with a critical BUN of 91, the NP was notified, and a STAT redraw for the CMP was ordered. - [DATE] at 03:04 PM signed by RN E, Resident had his 8 hourly Amoxicillin 500mg at 2200, other medications were administered , well tolerated. Result of the CMP is ready, doctor notified. Indwelling catheter is in place, draining well. No SOB or any adverse reaction observed during the shift. Vital signs are wnl. Record review of Resident #163's EMR on [DATE] at 08:30 AM revealed, no CIC evaluation was completed for Resident #163's elevated BUN, no new orders from the provider after notification of the critical Lab. An observation on [DATE] at 08:05 AM revealed, Resident #163 in bed in no immediate distress. The resident was connected to a ventilator and continuous enteral feeding. In an interview on [DATE] at 08:09 AM, RN H said she was the 6 AM- 6 PM nurse for Resident #163. She said when she received report from RN E, she was not notified of any critical lab results reported by the lab early this morning. In an interview on [DATE] at 08:11 AM, RN E said the lab called lab results to her early this morning for an elevated BUN of 93 for Resident #163. She said immediately after she received the results, she took a picture and sent the results to NP A, but NP A just responded, thank you, without any additional orders. RN E said when the facility received critical lab report they must immediately notify the doctor by phone and if they do not respond they send a picture. She said the facility had an on-call doctor, but they will not pick up calls, so staff take pictures and send them to the resident's provider. RN E said she notified RN H when she gave report this morning, but she had not notified the RP yet because it was too early. She said immediate notification of critical BUN levels was very important and a failure to get an immediate response from a provide could result in a delay in treatment. An observation and interview on [DATE] at 08:32 AM revealed, the DON sitting in her office as she reviewed the facility 24-hour report and took notes on residents. The DON said Resident #163 had a critical BUN on [DATE] and the provider ordered a retest, but she was unaware the results came back early yesterday morning because she had not been notified and the facility had not had their morning meeting. She said when a staff member received a critical lab result, they must call the residents provider or the on-call physician if the lab report is released after hours. The DON said nursing staff should document the lab results, who they notified and what the new orders are. She said sending text pictures of lab results was not their facility policy because it is a violation of patient confidentiality. The DON said failure to properly notify a provider of a resident's critical lab result can place a resident at risk of delay in care and untreated health conditions. Record review of the facility document Laboratory Notification Parameters with no revision date revealed, Test/Procedure: K(potassium) any value outside reference range should be reported immediately. BUN > 60 mg/dl should be reported immediately. An IJ was Identified on [DATE]. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 04:36 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 03:39 PM. [DATE] F684 Introduction: On [DATE], at 4:36pm, an Immediate Jeopardy was identified due to a critically low potassium of 2.7 by reporting it under an incorrect resident, resulting in a delay in treatment. All current residents could be at risk of having a change of condition and have the potential to be impacted by this deficient practice. As a result of the IJ the facility has implemented the following. 1. Administrator, DON and ADON were in-serviced by Chief Nursing Officer on the following Healthcare regarding resident changes in condition, follow-up, staff reporting of incidents and changes in condition and notifying the medical director and or designated on call provider Admin, DON and ADON in-serviced on the need for increased staff education and monitoring including new hires and agency staff. All verbalized understanding. In service completed on [DATE]. The facility nurse receiving the results will ensure that the correct resident and medical provider have been identified, a second nursing staff member will double-check that the correct results have been attached to the correct resident. Facility will contact the correct physician and communicate the results, and obtain orders. RNs and LVNs were trained on this process on [DATE]. Additional training is in process and will be completed [DATE]. Staff will not be allowed to work if they do not complete the training. 2. Facility reviewed polices and procedures prior to in-services. Polices reviewed include medication pass, change in condition, clinical lab protocol. No changes were made to policies, as a result of the initial review. 3. Administrator, DON and ADON completed the following: a. The facility DON and ADON on [DATE] at 5:00pm implemented the following: All on duty nurses staff were in-serviced on the following by DON and ADON. i. MD notification of change in condition, including change in mental status/alertness to include critical labs, ii. Notification of DON/ Administrator of any change in condition. iii. Resident follow-up monitoring iv. Monitoring residents for change in conditions. b. Signs/Symptoms of Resident change of condition to include but not limited to: i. mental status, ii. critical lab values iii. changes in breathing iv. unarousable while sleeping, v. changes to pupils vi. inability to/or refusing to eat, drink or take medications. vii. Documentation 4. Facility also conducted additional in-services on the following topics: a Abuse, neglect, and exploitation. b Documentation c. Medication administration and medication error training, d. Physician notification. Staff will verify that the correct provider is being notified as per the resident chart. Staff will make phone notifications and will not use other methods of communication such as text or email. Facility will continue to in-service as needed. Initial trainings will be completed by [DATE]. All staff must complete the trainings prior to working their next scheduled shift. 5. All other nurses will be in-serviced prior to starting their next scheduled shift. The DON, ADON or designee will in-service the nursing staff. 6. Administrator, DON and or Designee will review all residents who have had a lab draw in the past 7 days, [DATE] forward/ An audit will be conducted on residents with a lab draw change in condition to ensure compliance with the policy. The audit was completed by the ADON and completed [DATE]. 7. An Audit was conducted on [DATE]. for residents having a current change in condition, residents who were identified as having a change of condition in the past 14 days were reviewed. a. The facility Identified no other residents with change of condition due to critical labs during the review period. b. The facility reviews all labs and results from [DATE] to [DATE]. 8. Administrator, DON/ADON will monitor this plan of removal and correction daily during morning meeting for the next 30 days. 9. The facility completed an ad-hoc QAPI, on [DATE], regarding the incident resulting in the IJ. QAPI Committee will add residents with change of condition to the agenda and will review data for 8 weeks. Additionally, any change of conditions will be reviewed in morning meeting. Monitoring of POR In an interview on [DATE] at 08:56 AM, RN F said she received training on ANE, CIC and physician notification on Monday [DATE]. She said a change in condition was anything that new with a resident that they did not have before like: high temperature, respiratory distress, no bowel movement for 2 days and blood sugar above normal. RN F said when a resident had a CIC nursing staff should notify the doctor, document, and follow whatever orders they received from the DON. She said she also received training on critical labs which addressed notifying the MD immediately. RN F said providers can be notified via text of critical labs but if they do not respond in 2 to 5 minutes, she would call them, and an on-call physician is available after hours. RN F said once the orders from the physician were received and implemented, nursing staff must follow the resident to ensure there are no further acute changes. She said she had access to the automated dispensing system and when a resident readmitted to the facility, staff would take pictures of the medication list and send it to the MD for approval. She said when a medication is unavailable nursing staff must check the automated system or get the medication expedited from the pharmacy. RN F said if a medication was unavailable, she must notify the MD, who will give orders for action to take. She said the training also address attaching labs to the correct medical record by linking the lab to the progress note. In an interview on [DATE] at 09:14 AM, RN D revealed she received training on ANE, CIC, physician notification last week and she was the staff who trained new nurses. She said when a resident had a CIC nursing staff are expected to check their vitals, notify the doctors, and await new orders like medication changes or labs. RN D said the lab calls to notify the facility of critical labs. She said she had to go into the facility lab system and looked through everyone's labs to figure out was ordered and what happened. RN F said the facility needs to do better, but when she saw a critical lab, she is expected to notify the MD and the family of the CIC as well. RN F said after hours providers should be notified of critical labs through the on-call system and documentation should include what the lab result was, and interventions in place. RN F said she received training on med errors and readmission/admission medication reconciliation on [DATE]. She said when a resident arrived at the facility, nursing staff send the admissions orders to the physician immediately, who approved the orders after review. RN F said if a medication was not available, the medication can be retrieved from the automated dispensing system if available and the physician must be notified if the medication was unavailable. In an interview on [DATE] at 09:40 AM, MA A said she was trained on ANE, CIC, and physician notification last week and this week. She said if a patient experienced a change of condition, she must notify the nurse. MA A said she was trained on medication administration, medication errors and admission/readmission medication reconciliation on [DATE] and the pharmacy and nurse must be notified if medications were unavailable for newly admitted residents. In an interview on [DATE] at 09:55 AM, LVN O said she was trained on ANE, CIC, and physician notification on [DATE] and a CIC was any type of change in a resident. She said if a resident experienced a CIC the DON, family and MD must be notified, and the change documented in the EMR. LVN O said the lab called the facility immediately after a critical lab and nursing start are expected to notify the MD immediately to receive orders for treatment. She said if a lab resulted after hours nursing staff were expected to send notification to the on-call physician, and implement any orders received immediately. LVN

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #18 and Resident #33 ) of 7 residents reviewed for enteral nutrition. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #18's behaviors of pulling on and pulling out her G-tube which resulted in: the resident pulling out her G-tube on 2 occasions (11/12/24 and 04/15/25) which required hospitalization to place a new tube; and on 1 occasion (03/27/25) the resident pulling on her G-tube and an IV pole falling on her head on. - The facility failed to provide treatment and services, which included an abdominal binder, to prevent complications of enteral feeding due to Resident #33's behaviors of pulling out his G-tube which resulted in the resident pulling out his G-tube on 3 occasions (02/04/25, 02/12/25, 02/23/25 and 04/15/25) which required hospitalization to place a new tube. An IJ was Identified on 04/17/25. The template was provided to the facility on [DATE] at 12:33 PM. While the IJ was removed on 04/22/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of injuries, hospitalization, and death. Findings Include: Resident #18 Record review of Resident #18's Face Sheet dated 04/15/25 revealed, a [AGE] year-old female who admitted to the facility 01/14/21 with diagnoses which included: dysphagia (difficulty swallowing), high blood pressure, contracture of the right hand/ left hand and left foot, Dementia with other behavioral disturbance and anxiety disorder. Record review of Resident #18's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making, upper and lower extremity functional limitations in range of motion, dependent on staff for all aspects of self-care (eating, oral hygiene, toileting hygiene, shower/bathing, dressing), dependent on staff for all aspects of mobility, no physical/verbal behavioral symptoms directed towards others and no behavioral symptoms not directed towards others. Record review of Resident #18's Care Plan printed 04/15/25 revealed, focus- requires the use of feeding tube and is at risk of aspiration (accidental inhalation of food/fluids into the airway), weight loss and dehydration. Feeding tube is related to dysphagia; intervention- administer tube feeding and water flushes as ordered, monitor/document/report to the physician as needed for the following complications related to tube feedings . tube dislodged. Focus initiated 12/29/22- inappropriate behaviors: resident has episodes of inappropriate behaviors of an causing her oxygen tubing from constantly falling off her face onto the floor. Interventions- monitor and chart behaviors every shift and report progress to MD. Focus- history of spitting and crying out at times according to staff and chary review; intervention- referred to mental health services as needed. Focus initiated 02/07/21- resident has impaired communication,[family]reports he is the only one that can get resident to verbally communicate; intervention-[family]will assist with translation when needed, staff will monitor for facial grimaces and body language. , focus- signs and symptoms of anxiety like hypersensitivity, paranoid, nervousness and is at risk for further episodes of anxiety and injury; intervention- medication as ordered, redirect resident from source of anxiety. Resident #18's care plan did not include the resident pulling on or pulling out her G-tube. Record review of Resident #18's Order Summary dated 04/15/25 revealed, she did not have an order for an abdominal binder, or orders for monitoring of increased movement, restlessness, or agitation. Record review of Resident #18's Progress Notes from to 04/15/25 revealed: *11/12/24 at 11:56 PM- CNA informed nurse during care that resident had pulled her G Tube from her abdomen. Nurse went to assess resident and she was found with tube laying on her abdomen without any s/s of pain or distress. DON and Attending notified *11/13/24 at 01:03 AM- EMS arrived to transport resident to hospital *03/27/25 at 05:32 PM- Resident #18 pulled her feeding tube and IV pole fell on her head. The resident had no bumps and bruises, and the NP was notified *03/28/25 at 09:40 AM- From incident yesterday evening pole fell on resident head right eye and forehead bruises was noted this morning, resident is already on neuro checks. NP was notified A.DON as well resident medication was administered. *04/15/25 at 05:47 PM- Patient pulled her G-tube out. Nurse sent patient to hospital for replacement . Record review of Resident #18's EMR revealed, no orders for monitoring of behaviors associated with Resident #18 pulling on and pulling out her G-tube. An observation and interview on 04/15/25 at 09:50 AM revealed, Resident #18 in bed with contracted feet and hands. The resident had a bruise with a scab and dry blood on her forehead, with her bed low to the ground and fall mat on the left side of the bed. The resident had a firm grip on her G-tube tubing, pulling it tightly and her abdomen was observed to rise as she tugged on the tubing. The surveyor immediately exited the room to notify facility staff. When the surveyor returned to the room with MA A the resident was no longer pulling on her tube but continued to pull her legs up and move her hands. MA A said the resident returned to the facility that morning from the hospital. The resident had large tan bandage strips loosely placed on top of the site where her G-tube entered her abdomen, there was no abdominal binder or other assistive device preventing Resident #18 from pulling out her G-tube. An observation and interview with LVN J on 04/15/25 at 11:15 AM revealed, Resident #18 squirming/fidgety/restless in bed, with her legs pulled up. There was tube feeding residue, not previously seen, on the resident's sheets and incontinent brief. LVN J said Resident #18 readmitted to the facility in the morning she pulled out her G-tube. She said the resident did not have an order for an abdominal binder, and a binder was not used to protect Resident #30 from dislodging her G-tube. LVN J said, she can have an abdominal binder. In an interview on 04/15/25 at 11:23 AM, the NP said she started following Resident #18, 6 weeks ago. She said the residents restless, fidgety, and squirming behavior is what she considered her baseline. The NP said she originally thought the resident's behaviors were due to a UTI so Resident #18 was treated with a course of antibiotics, but the behaviors remained when the medication was completed so she now believed she needed psych services. The NP said residents with excessive restlessness and continuous activity were at risk of pulling out their G-tube, so they should have an abdominal binder covering the tube which would prevent them from easily pulling out the tube. The NP said the resident did not have an order for an abdominal binder because she had not received any reports that the resident consistently pulled on her G-tube. She said the failure to have an abdominal binder on a G-tube resident with excessive movement and restlessness placed the resident at risk for the G-tube dislodgement, danger if the IV pole holding the feed falls leading to injuries. In an interview on 04/15/25 at 12:27 PM, MA B said Resident #18 always moved around and was restless. She said the resident had never had an abdominal binder, but she probably could use it. In an interview on 04/15/25 at 12:30 PM, MA A said he had worked at the facility for 8 years and Resident #18's normal behaviors included: agitation and trying to pull out her G-tube. He said the resident did not have an abdominal binder, so he put a sheet on top her G-tube to prevent her from pulling on it. In an interview on 04/15/25 at 12:35 PM, the DON said Resident #18 was non-verbal. She said the resident had always been grabby and fidgety and received psych services. In an interview on 04/15/25 at 12:38 PM, LVN J said Resident #18 just returned from the facility after she pulled out her G-tube and the IV pole fell and hit her head. She said she received an order for an abdominal binder from the NP and was waiting for central supply to deliver the binder. An observation on 04/16/25 at 07:47 AM revealed, Resident #18 in bed, with no abdominal binder in place. The resident was restless and taking off her clothing. In an interview on 04/16/25 at 07:48 AM, MA A said there was an order for an abdominal binder for Resident #18, but she did not have one on because it had not arrived at the facility. In an interview on 4/16/25 at 07:50 AM, LVN J said Resident #18 did not have an abdominal binder on. She put in an order for an abdominal binder for Resident #18 yesterday, but it had not arrived. In an interview on 04/16/25 at 11:27 AM, LVN H said Resident #18 was one of her residents. She said even though the resident is bedbound she did not stay in one place, moved her arms and legs around a lot and is very fidgety. LVN H said she worked with Resident #2 for the past two years and off-course she pulls out her G-tube but the staff could not restrict her. She said she had previously notified nursing management of the resident pulling on and out her g-tube, but no changes were made. She said on 04/15/25 at around 4 AM when she checked on the resident, she saw that Resident #18's G-tube was dislodged and the IV pole was on the floor. In an interview on 04/16/25 at 02:18 PM, RN A said Resident #18 was always fidgety and liked to play and pull on her G-tube. She said Resident #18 did not have an abdominal binder on the night 04/15/25, and she was never educated or informed about any interventions that should be in place to protect Resident #18. RN A said due to resident's movement and preference to pull on her G-tube she had communicated her concerns with nursing management and thought the resident needed an abdominal binder, but nothing was done. In an interview on 04/16/25 at 08:27 AM, the DON said she started her position in February 2025 and Resident #18 always had behaviors that included pulling on her G-tube. She said in March 2025 the resident pulled on her tubing which caused the IV pole holding her feeding to fall and hit her in the head leading to an injury. After the incident, the resident had neuro checks in place to confirm she did not have a change in condition and the IV pole was moved to the other side of the bed. The DON said Resident #18's behaviors were discussed in an IDT meeting, and it was decided a GDR was contraindicated and the only intervention in place after the incident in March was the NP ordering labs. In an interview on 4/16/25 at 03:48 PM, the DON said an abdominal binder was ordered from their vendor, but it had not arrived yet, so the staff were monitoring Resident #18's behaviors. She said Resident #18's abdominal binder was expected to arrive on 04/17/25 . Resident #33 Record review of Resident #33's Face Sheet dated 04/17/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: chronic respiratory failure, asthma. Bipolar disorder, severe with psychotic features, paraplegia(paralysis of legs and lower injury), Gastrostomy and Tracheostomy (opening in neck to access the windpipe). Record review of Resident #33's Quarterly MDS dated [DATE] revealed, severely impaired cognitive skills for daily decision making. The resident had no behavioral symptoms present including physical or verbal behavioral symptoms towards others and no other behavioral symptoms towards others (hitting or scratching self, pacing, rummaging or disruptive sounds) Record review of Resident #33's undated Care Plan printed 04/17/25 revealed, Focus- risk of aspiration r/t feeding tube in place; intervention- report N/V, absent bowel sounds to MD and RP. Focus- history of depression and is at risk of episodes of depression, adverse reactions and depression driven behaviors; intervention- monitor for impeding episodes of depression- document any noted in clinical record, prove psych consult per order. Record review of Resident #33's Order Summary dated 04/17/25 revealed, she did not have an order for an abdominal binder prior to 04/15/25. Record review of Resident #33's Progress Notes from 01/16/25 to 04/17/25 revealed, Resident #33 pulled out or pulled on his G-tube on the following days: 02/04/25- Residents G-tube was dislodged 02/12/25- Residents G-tube was dislodged and he was sent out to the Hospital 02/23/25- Resident pulled out his G-tube and was sent out to the hospital ER for G-tube placement. 02/25/25- Resident was found pulling on G-tube around 9 am. Resident was cleaned up and abdominal binder was applied. 04/15/25- Residents G-tube became dislodged and he was sent out to the hospital ER of G-tube placement. In an interview on 04/16/25 at 09:18 AM, the MDS Nurse said she had been in her current position for 8 to 9 years but worked in the facility for 19 years. In an interview on 04/17/25 at 11:31 AM, the DON said Resident #18's abdominal binder had not arrived at the facility yet. In an interview on 04/16/25 at 11:40 AM, the MDS Nurse said she was responsible for completing resident care plans. She said the care plan functioned as a plan of how to care for a resident. The MDS nurse said everything needed to care for a resident should be included, day to day tasks/care, wound status, behaviors, diagnosis, code status, and weight management. She said if a resident had behaviors, those behaviors should be included in their care plan with specific details that include the type of behaviors and should include goals and interventions. The MDS Nurse said incorrect care plans posed no risks to residents because nobody looks at the care plan except state. She said staff do not look at resident care plans to determine how to care for residents but received care information from reports, documentation, and verbal communications. The MDS nurse said she did not know about Resident #18's continuous behaviors of pulling at and on her G-tube and she only knew that the resident had once pulled on her IV pole causing it to fall and injury her. She said based on the behaviors she now knows Resident #18 displayed, the resident's care plan should have had a focus area addressing them. In an interview on 04/17/25 at 12:50 PM, the DON said she took the role at the facility in February. She said the purpose of the care plan is to provide guidance for patient care and resident needs. The DON said she was responsible for the accuracy and completion of the care plan, but the MDS nurse is the person who actually completes the care plan. She said each resident's care plan should address their: diet, code status, diagnoses, treatments received and behaviors. The DON said the care plan triggers everything the nurses do for the residents and lets them know what interventions they need to implement. She said inaccuracies in the care plan can result in missed treatments or interventions and in Resident #18's case it led to the resident pulling out her G-tube, injury, and hospitalization to replace her G-tube. The DON said she was not aware of Resident #18's behaviors of pulling on and out her G-tube, she was not aware those behaviors were not in the resident's care plan, but it should have been. Record review of the facility policy Assistive Devices and Equipment with no revision date revealed, our facility provides, maintains, train s and supervises the use of assistive devices and equipment for residents. 1- devices and equipment that assist with resident mobility, safety and independence are provided for residents. 2- recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's record. An IJ was Identified on 04/17/2025. The template was provided to the facility on [DATE] at 12:33 PM. The following Plan of Removal submitted by the facility was accepted on 04/18/2025 at 07:52 PM and the Administrator was notified on 04/18/25 at 08:01 PM. {Facility Name] 4/18/2025 Plan of Removal F689 On 4/17/2025 at 12:33 PM, the surveyor provided an Immediate Jeopardy (IJ) template notification stating Regulatory Services had determined the facility failed to provide adequate supervision and assistance devices to prevent accidents. The facility failed to provide supervision and/or devices to prevent Resident #18 from pulling her G-tube which resulted in: an injury after the IV pole fell and hit her in the head and her G-tube being dislodged on 2 occasions. 1. Immediate Action: o The Director of Nursing immediately reassessed Resident #18 to validate the resident's G-tube was in place, patent, and medication/nutrition was being administered per provider orders. An abdominal binder ordered on 4/15/2025 after displacement was received 4/17/2025 and applied per provider orders. No other concerns were identified. Resident #18 tolerated the application of device well and exhibits no distress . o The MDS Coordinator updated and revised Resident #18 care plan to include provider orders for G-tube, any current/historical behaviors including agitation, fidgeting, and attempts to remove or dislodge the G-tube. Care plan revisions include interventions to prevent/reduce displacement of G-tube and requirement of documenting provider notification of any changes in behavior specifically related risk of G-tube displacement. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Immediate Action: o The Director of Nursing/Designee immediately conducted a review of all facility residents and determined 13 residents were currently receiving nutritional feeding through a G-Tube/Peg Tube. All 13 residents were immediately assessed to validate tubes were secure and patent. Further assessment included a 7 day look back record review to determine that there are no new changes in behavior, increased agitation, or fidgeting related to potential risk of G-Tube/Peg Tube displacement. o The Director of Nursing determined that 4 of the 13 residents receiving nutritional supplements via G-Tubes/Peg Tubes, including Resident #18, would potentially benefit from the use of an abdominal binder. The abdominal binders were previously ordered from the supply vendor and received, provider orders were obtained, and all abdominal binders have been applied to applicable residents and applicable residents are tolerating well with reduced risk of displacement. o It was identified in the expanded sample that 1 of the 13 residents [Resident #33] receiving nutrition via G-tube/Peg Tube had also displaced feeding tube on 2/4/25, 2/12/25, 2/23/25, and 4/15/25. After interview with staff, it was determined that residents is restless, and fidgets and these behaviors have been noted in a progress note dated 4/18/25. The MDS was opened with an ARD (Assessment Review Date) of 4/21/25 to capture these behaviors. The care plan has been revised. The resident is currently receiving physical therapy for range of motion and bed mobility. An occupational therapy eval has been requested. o The MDS Coordinator completed updates/revisions for the 13 resident care plans that included noting any current or historical behaviors (7 day look back) related to potential displacement of G-Tube/Peg tube and validated that if behaviors were identified, interventions included actions to take to reduce risk of displacement and documentation of provider notification. New orders for abdominal binders and monitoring for 4 of the 13 residents have been added to care plan interventions to assist in reducing the potential displacement of G-Tubes/Peg Tubes as applicable. Start Date: 4/17/2025 Completion Date: 4/18/2025 Responsible: Administrator Immediate Actions: o The QAPI Committee reviewed the policies and procedures regarding enteral feeding, safety precautions to validate accuracy. Added to the policy were recommendations to assist nursing staff when residents exhibit behaviors of attempts to remove tube i.e.: pulling, fidgeting, restlessness. o The Director of Nursing/Designee provided training to nursing staff who provide care to residents who receive nutritional feeding via a tube. Staff will not be allowed to provide direct resident care until training has been provided. o Training included validating G-Tube/Peg Tube is secure, patent, and provider orders for med/nutrition are administered per orders. o If resident is exhibiting restlessness, agitation, or changes in behaviors related to obstruction/removal of a G-tube will be documented in the resident record which pulls to the 24 hour report and the Provider/Director of Nursing are to be promptly notified and increased supervision is implemented to maintain tube replacement and patency until root cause of increased restlessness, agitation, changes in behavior are determined. o Completed a return determination with nursing staff on proper placement of G-tube and securing abdominal binder to validate competency. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Immediate Actions: o The Director of Nursing/Designee will monitor residents with G-Tubes/Peg Tubes including those that require supportive devices such as abdominal binders that reduce the risk of tube displacement q shift and as needed to validate correct placement and patency of tubes for residents who currently have provider orders. If concerns are identified, immediate corrective action will be implemented, provider notified, and applicable staff re-educated. o The Director of Nursing/Designee will monitor changes in behavior including increased agitation and restlessness daily to promptly determine a root cause and ensure appropriate interventions have been implemented timely on the care plan to reduce potential negative outcomes, including displacement of G-Tube/Peg Tube. o An ad-hoc QAPI meeting was held, and the facility medical director was notified of the deficient practice and plan of removal. The Plan of Correction will be reviewed monthly during the QAPI meeting for the next 3 months and as needed until a lesser frequency is deemed appropriate. Meeting minutes will be taken and maintained for 12 months. Start Date: 4/17/2025 Completion Date: 4/17/2025 Responsible: Administrator Monitoring of the POR. An observation on 04/19/25 at 12:25 PM revealed, Resident #18 in bed with an abdominal binder on. An observation on 04/19/25 at 12:29 PM revealed, Resident #33 with an abdominal binder on. In an interview on 04/19/25 at 01:01 PM, MA B said she received training on G-tube safety on 04/16/25. She said the training addressed how to address active/agitated residents with G-tube, ensuring interventions like abdominal binders are in place, ensuring the resident is safe and administering medications as ordered if necessary. MA B said the training reinforced that G-tube residents with increased agitation could be at risk of dislodgement and the IV pole falling on them. In an interview on 04/20/25 at 06:45 AM, LVN H said she was trained on 04/17/25 about G-tube safety. She said Resident #18 moved around a lot and had a tendency to pull on and out her G-tube, . In an interview on 04/20/25 at 08:55 AM, MA A said he had not received any training on G-tubes, Care Plans or Accidents/Supervision. An observation on 04/20/25 at 08:57 AM revealed, Resident #22 in bed with an abdominal binder in place. An observation on 04/20/25 at 09:05 AM, revealed Resident #18 in bed with an abdominal binder in place. The resident was calm, in no immediate distress and did not have concerning body movement. In an interview on 04/20/25 at 09:00 AM, CNA K said she received training on G-tube safety in the previous week. She said if a resident with a G-tube was agitated they were expected to report it to the nurse and ensure an abdominal binder was on if there was an order. In an interview on 04/20/25 at 09:05 AM, LVN J could not answer what in-services she received and had to be prompted by the surveyor. She said she received training on G-tubes and care plans on 04/17/25 and 04/20/25. LVN J said when a resident on a G-tube has behaviors nurses are expected to document the incident in the chart and report it to management, while CNAs document behaviors in the POC and report it to their nurse. She said when residents with G-tubes become agitated they are at risk of dislodgment so nursing staff should initiate interventions like an abdominal binder if there is an order for one and notifications should be sent out. In an interview on 04/20/25 at 09:07 AM, the ADON said she completed training with staff on 04/17/25 regarding G-tube Placement, Behaviors and Abdominal binders. She said staff were educated that residents who are agitated, fidgety, constantly moving/irritated should be documents on having behaviors in the POC or the progress notes. The ADON said staff were trained that these residents are at risk of dislodgement and can also pull-down equipment. She said the training addressed reporting and documenting behaviors that increase risk of G-tube dislodgement, sending notifications and interventions that should be in place. The ADON said she also did training on resident care plans and how documentations played into the development of care plans, where to find a resident's care plan and how to review the interventions in place. She said this training was provided to CNAs, CMAs, Nurses, RTs, and anyone who provided care to residents., In an interview on 04/20/25 at 10:21 AM, LVN B said he had not received any training about G-tube safety and his knowledge was based on basic nursing. In an interview on 04/20/25 at 01:10 PM, the MDS Nurse said she received a 1-on-1 training from the Interim Administrator regarding care plan timing & accidents, incidents on 04/17/25 and training regarding G-tubes on 04/18/25. She said the training reinforced that she should know about resident behaviors such as pulling on and pulling out their G-tube and make sure there is the appropriate documentation. The MDS Nurse said behaviors should be tracked, orders should be in place for a binder, the binder must actually be used/in place on the resident and such orders must be in the resident's plan of care. The MDS nurse said even though the MDS is only a 7 day look back the behaviors should be documented in the resident's plan of care. The MDS nurse said she was educated that all behaviors should be documented in the care plan even if it were the resident's baseline behaviors because agitated residents are at risk of pulling out their G-tube which could result in rupture, injury, trauma, infection, and hospitalization. In an interview on 04/22/25 at 04:56 AM, RN A said she received training on G-tube safety the previous week and on 04/21/25. She said the training focused on preventing G-tube dislodgement with the use of a binder. RN A said when a resident with a g-tube is agitated or has increased movement nursing staff are expected assess the resident and if needed apply an abdominal binder or get an order for an abdominal binder. She said resident behaviors are to be documented in the resident's chart and interventions such as repositioning, medications administered as ordered, and notification sent to the MD/NP because increased behaviors/movement can place residents at risk of dislodgement, bleeding, bloating and infection. RN A said documenting any incidents that occur is important because it plays into the resident's care plan. In an interview on 04/22/25 at 05:01 PM, RN E said he received training on G-tube safety on 04/21/25. He said if a resident with a G-tube had behaviors such as fidgeting and pulling on the tube they should not be ignored, they should be assessed and interventions such as abdominal binders or PRN meds should be in place. RN E said if a resident even if these behaviors are continuous staff should document it whenever they see it because it plays into the care plan. In an interview on 04/22/25 at 05:05 AM, CNA X said he did not receive any training on G-tubes, care plans or behaviors in residents with behaviors but if a resident was observed pulling on their G-tube staff should ensure interventions like abdominal binders are in place, notification should be sent to their nurse and document the behaviors in the POC to prevent dislodgement. In an interview on 04/22/25 at 05:09, RT A said he had not received in-person training on G-tube safety but had received a text message on some trainings and asked if he could pull it up. RT A was not able to verbalize independently what the training he received was but read from his text that residents with increased agitation were at risk of dislodgement or injury so the nurse should be notified and the behaviors document. An observation on 04/22/25 at 05:20 AM revealed, Resident #18 in bed, with no abdominal binder on. In an interview on 04/22/25 at 05:25 AM, CNA A said she received training regarding G-tube safety on 04/20/25. She said when a resident with a G-tube was agitated or fidgety she is expected to observe them and document it in the POC. CNA A said Resident #18 did not have an abdominal binder on because it was only required when the resident was agitated which she was not at this time. In an interview on 04/22/25 at 05:29 AM, LVN B said he received training on G-tube safety on 04/21/25. He said residents with G-tubes that experienced behaviors were at risk for dislodgement, so they must notify the MD to receive an order for an abdominal binder or use one if order was in place. LVN B said Resident #18 did not have an abdominal binder in place because she only required one when she was agitated. In an interview on 04/22/25 at 08:50 AM, LVN D said she received training on G-tube safety on 04/21/25. She said residents with G-tubes that are fidgety are considered as having behaviors and that should be documented. In an interview on 04/22/25 at 09:18 AM, MA C said she had not received any training on G-tube safety. In an interview on 04/22/25 at 01:55 PM, MA C said she received training that day regarding residents with G-tubes displaying behaviors, communication & notifications of behaviors and the application of abdominal binders as ordered. She said if a resident with a G-tube was agitated they were at risk of G-tube dislodgement so interventions should be in place as ordered, nurse notified, and observations document ed in the residents POC. MA C said residents with behaviors like Resident #18 should have binders in place at all times except when care is provided. An observation on 04/22/25 at 02:00 PM, revealed Resident #22 sleeping in bed with her family member at her bedside. The family member said the resident currently had an abdominal binder on and had extra ones in her nightstand. In an interview on 04/22/25 at 02:18 PM, with the Interim Administrator and the DON, the Administrator said the facility performed an audit and identified 5 residents with a history of behaviors associated with pulling out their G tube. She said those resident's care plans have been updated, every shift monitoring has put in place and signs to have abdominal binders in place are located above the resident's beds. The Administrator said the facility failed to have a structure in place to track residents with behaviors. The DON said prior to the IJ notification the facility did not have interventions in place for G-tube residents with behaviors but now training was provided to CNAs, Nurses, RT about these behaviors, documenting behaviors, the use of abdominal binders and signage placed above the bed of residents that require abdominal binders. The DON said since the IJ notification the MDS nurse and

Based on observations, interviews, and record reviews the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment disorder received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 3 of 8 residents (Resident # 30, Resident #42 Resident #52) reviewed for treatment and services for mental and psychosocial concerns. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #30's escalating behaviors which resulted in a suicide attempt on 04/13/25 and the resident attempting to draw a police officer's firearm when she had to be forcefully restrained and removed from the facility. - The facility failed to provide appropriate treatment and services to prevent and correct Resident #52's escalating behaviors which resulted in suicide threats and an incident on 05/03/25 when the resident had to be forcefully restrained and removed from the facility. - The facility failed to provide treatment and services to correct Resident #42's continuous behaviors of pacing up and down the secure unit, banging on the doors, getting in residents and staff faces, touching their shoulder while asking if his RP was dead. An IJ was identified on 05/03/25. The template was provided to the facility on [DATE] at 01:58 PM. While the IJ was removed on 05/08/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. The IJ was called again on 06/07/25. The template was provided to the facility on [DATE] at 07:03 AM. While the IJ was removed on 06/19/25 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of minor and major injuries, suicide threats, attempted suicide, hospitalization, and death. Resident #30 Record review of Resident #30's Face Sheet dated 05/02/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: spinal cord injury, anemia, nicotine dependence, Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), bipolar disorder (mental health condition characterized by extreme mood swings, ranging from periods of intense happiness or irritability (mania or hypomania) to periods of deep sadness or despair) with sever psychotic features (hallucinations (seeing or hearing things that aren't real), delusions (false beliefs), and disorganized thinking) and paraplegia( paralysis of the legs and lower body, typically caused by a spinal cord injury). Record review of Resident #30's previous facility Progress Notes dated 12/26/24 at 02:21 PM revealed, Resident says she is hearing things and people talking about her. She is under mental distress. She is wanting to go to the psych hospital. Resident stated she no longer wanted to be here. Record review of the Resident #30's Quarterly MDS revealed, intact cognition as indicated by a BIMS score of 14 and use of antipsychotic medications during last 7 days. There were no evidence of an acute change in mental status, and no behaviors present. She had no potential indicators of psychosis such as hallucinations or delusions. Record review of Resident #30's undated Care Plan revealed, focus- history of being resistant to care at times and is at risk for injury; intervention- approach in a calm manner, talk while giving care. Focus- taking psychotropic medications and is at risk of adverse reactions and (depression, anxiety, and/or psychosis driven behaviors; interventions- monitor for psychosis driven behaviors such as aggressiveness, combativeness, manic episodes, observe and record any displayed behaviors or mood problems. Focus- Resident #30 verbalized suicidal ideations and became physically aggressive with police related to her diagnosis of bipolar and or anxiety, date initiated 04/13/25; interventions- provide medications as ordered, resident will be assisted with discharge planning as when needed, resident will be referred to inpatient geri psych placement as when needed, call 911 with request for the mental health team as/when needed. Record review of Resident #30's Progress Notes from 12/31/24 to 05/02/25 revealed : 01/01/25- EMS arrived at facility stating they received phone call from facility. This nurse was notified by CMA that this resident called EMS. Resident states that she is not feeling well and wants to go to the Hospital. Resident did not notify this nurse that she was not feeling well prior. Resident called EMS instead. EMS assessed resident. No abnormal findings. EMS spoke with resident about receiving care in facility before calling 911. Resident continues to state that she wants to go to the hospital. 01/02/25- Resident called 911 for pain pill when her pain was just due to be given to her, every effort to advise her to take her pain pill yield no result as she wants to go to hospital, NP made aware, administrator made aware, resident insisted on going to hospital, picked up in stable condition. 01/12/25- Note Text : On rounds at 7:04am resident did not complain of any discomfort, distress, or concerns, noted vaping in the room, was educated by this nurse that vaping is not proper and not allowed in the room, resident did not listen, but continue vaping. At about 7:54am, 911 ambulance arrived facility stated resident called them, complained of pain to lower back, sediment in urine, and brown urine output. Resident has UA result and labs pending ,this explained to resident Norco 5-325mg offered, resident refused, and still insisted going with 911 to the hospital, transferred by 911 to hospital ,per resident request. Resident is self-RP.NP notified. 01/22/25- SW informed nurse that resident was seen by Psych services today and was told that resident may be going through a manic episode. Resident is currently in bed with NAD. Given PRN pain medication. resident has no plan to harm herself stayed she is just little down today. MD informed stated to monitor for now and call her for any changes. 01/24/25- Resident informed SN that she called 911 due to pain on her lower back. Education provided on pain management such as other ways to manage pain without medications such as deep breathing, exercise , music therapy and others , resident verbalized understanding but still want to get stronger medication . NP notified . patient has been medicated with Norco Tablet 5-325 MG every 4 hours as needed, last one was at 1034am. Sn will continue to monitor. 01/31/25- Resident signed herself out after requesting (2) cigarettes. Resident was then transported to the ER by ambulance. Family notified. DON Notified. 02/01/25 at 08:01 AM- Resident requested cigarette, received her cigarette, signed out to go smoke out front where she then called 911 and requested transport. Resident would not specify where she wanted to be transported to. 911 arrived around 0710 and took resident on a stretcher to the ER. 02/01/25 at 03:15 PM- Resident returned from the hospital . Resident still appears anxious upon return and immediately returned to nurses' station to sign out with (4) cigarettes as of 0325 resident is signed out of the facility. 02/13/25 at 10:49 PM- Resident called 911 by herself twice this evening at 7:30pm and 9:40pm stating that she wants to go to the hospital because she is having spasms. Charge nurse informed her that he can notify her doctor and see if she can be given some new orders, but she refused. EMS arrived the first time and resident refused to go to the hospital they intended to transport her to. The second time the EMS arrived and took resident to Hospital at 10:00pm. 02/24/25- Note Text: At 21:30 hrs (09:30 PM), resident called the EMS via 911, requesting to be taken to the emergency room due to spasm and pain. Resident had already received her scheduled pain medication (Norco) at 20:00 hrs. Resident had not complained to Charge Nurse about being in pain prior to her calling 911, and charge nurse was not aware that she had called EMS 911 until the emergency personnel showed up in the unit. Resident was taken to the emergency room as she requested by the EMS technicians at 21:40 hrs. 03/02/25- Resident complains of hearing voices making fun of her, she said had been going on for a while now, she stated that she did not complain initially because she thought they might go away, but they getting louder, depriving her sleep. This morning observed resident in her sleep saying, stop stop stop. Resident also have diagnosis of schizophrenia and mild sleep disorder.NP notified, order received to consult psych. Order carry out. 03/08-25- Resident called EMS via 911, and they took her to the hospital at 18:45 hours for complaint of pain. Resident's emergency contact (family member)' and facility DON notified. 03/19/25- Resident came to Charge nurse and requested for her nightly medication to be administered to her, which was done. After taking her medications, she informed the Charge Nurse that she had called 911 so she can be taken to the hospital due to pain. Charge Nurse advised resident to give her pain pill (Norco) which she just took, time to become effective but she refused, insisting to go to the hospital. Charge nurse noted ant acute distress on resident both in her speech and behavior. Resident then wheeled herself in her wheelchair to the reception area awaiting the arrival of EMS ambulance. Upon arrival to the facility, the EMS personnel spoke briefly with resident and loaded her on their stretcher without asking the charge nurse any questions or informing him where they were taking resident to. When charge nurse inquired from them where they were taking resident to, they simply told him the hospital name and continued on. Facility Director of Nursing was notified. 03/22/25 T 05:53 AM- Behavioral Note-Resident removed her brief after ADL change claimed is too big despite the brief been her size and the large size that could be used for her. 03/22/25 at 10:09 AM- : Resident was observed alert and oriented with behavior, screamed , yelled, took clothes off. Attempted to talked to resident several times with no effect. NP. was notified order given Alprazolam 0.5mh twice a day for fourteen days for anxiety. 04/13/25 at 01:39 AM signed by LVN H- Patient called 911 at 11:00pm and had been disturbing other patients from sleeping. The two EMS that came refused to take her to hospital stated she has no good reason to go to hospital. Patient received all her pain med and other prescribed med, throwing stuff on the floor including her phone. Patient is threatening to kill herself. Nurse notified the physician, DON, and Administrator. 04/13/25 signed by SW- SW informed per staff that this resident had verbalized wanting to kill herself. SW visited with this resident, and she verbalized I tied something around my neck but, I could still breathe. I want my Xanax back. I want my Xanax back. I am going to get my Xanax back. SW attempted to contact resident's [family member], , unable to reach and voicemail full. Resident began to yell and scream as she exited the office. Staff was present to maintain visual of her per SW request while 911 contacted with a request for the Mental Health Response team. Upon 911 arriving officer was provided with the aforementioned information. He spoke with resident, and she informed him that she wanted to kill herself. He called for assistance and another officer arrived whom also spoke with resident and then SW observed resident began to hit the officers resulting in them restraining her until approximately 4 more officers arrived. SW was informed per that she was being transported to Hospital and that the District Attorney would be contacted but they were doubtful any criminal charges would be filed against her. SW informed the DON and LNFA and was able to contact her [family member] and informed him. He verbalized understanding. Care Plan updated to reflect. Record review of Resident #30's Hospital Progress note dated 04/22/25 at 01:22 PM revealed, Resident #30 continued to throw tantrums and screamed, covering her face with her pillow. The resident was requesting IV pain medication. Record review of Resident #30's Hospital Progress note dated 04/23/25 at 12:01 PM revealed, Resident #30 continued to throw tantrums and requested IV pain medication despite being notified that she was on oral pain medication. Record review of Resident #30's Hospital Progress note dated 04/24/25 at 11:52 AM revealed, Resident #30 called 911 from her hospital room and pretend to sleep when the MD entered her room. Record review of Resident #30's Hospital Psychiatric Consultation note dated 04/24/25 at 12:00 AM, revealed Resident #30 had bipolar disorder with discrete periods of mania and discreet periods of depression. She had poor impulse control and a history of PTSD and had attempted fake suicide in the past on multiple occasions by either choking herself or overdosing on medications. Resident #30 had a history of ideas of persecution, thinking that people were going to hurt her or that something negative was going to happen to her. Resident #30 had a history of auditory hallucinations commanding her to wrap a cord around her neck or to overdose on Seroquel. In the past Resident #30 contemplated starting a fire in her apartment following the command of the voices she heard, and she wished she had a weapon to hurt hospital or nursing staff. Resident #30 was admitted to a behavioral hospital in February of 2021 and in November of 2023 she was admitted to the hospital after typing a collar on her neck to kill herself. Record review of Resident #30's Progress Notes on 05/01/25 at 02:48 AM revealed, Note Text : Resident called EMS and requested to be taken back to the hospital for evaluation. Resident indicated to EMS personnel that she feels nauseated, dehydrated, and is not getting enough pain medications. Resident had not complained to Charge Nurse about any of these concerns tonight. Resident had received her nightly medications as ordered, including her PRN Norco pain medication. Charge Nurse offered to call resident's PCP to see if there may be any new orders, but she refused, stating her preference to go to the hospital. Upon resident's insistence to go to the hospital, EMS personnel took her to hospital. Record review of Resident #30's Order Summary Report that included all orders since admission on [DATE] and printed 05/02/25 at 01:50 PM revealed, Resident #30 had no behavior monitoring and behavior intervention orders. Record review of a 30-day lookback of Resident #30's Behavior Monitoring and Interventions dated 05/09/25 revealed, no documented behaviors observed prior to 05/09/25. On 05/09/25 at 10:30 AM Resident #30 was screaming and expressed frustration and angers at others. An observation an interview on 05/02/25 at 01:12 PM revealed, Resident #30 sitting in a wheelchair at the nursing station. There were other residents around her and no nursing staff within 15 feet on both sides of the nursing station. The resident said she just returned to the facility from the hospital, and she felt better now. Resident #30 said the voices got too loud so she hit herself in the face and tied a pillowcase around her neck to harm herself to stop the voices, but she could still breathe. As Resident #30 talked to the surveyors she swayed left to right & back and forth in her wheelchair. Resident #30 said she did not notify any staff of the voices prior to trying to harm herself but when she went to the hospital, they fixed her meds, so she did not hear the voices anymore and she did not want to harm herself. In an interview on 05/02/25 at 12:33 PM, the SW said Resident #30 was young and had obsessive drug seeking behaviors r/t to complaints of significant pain. She said the resident would call the police 1-2 times a week and had been hospitalized at least 6-7 times since admission. The SW said Resident #30 always yelled at staff and yelled to go to the hospital. The SW said in April she was notified that Resident #30 wanted to hurt herself. She said she first talked to the resident on the phone and then again when she arrived at the facility. The SW said Resident # 30 told her she tried to hurt herself by tying something around her neck, but she could still breathe, the resident became loud and said she was going to hurt herself, so she called 911 for a mental health response team. She said when the police arrived Resident #30 wheeled herself away from them down the hallway as they spoke to her and when both police officers approached her, Resident #30 started to scream and fought the police. The SW said Resident #30 attacked the police, the police tried to restrain her, the police drew then their guns and pointed them at the resident and Resident #30 was eventually handcuffed. She said Resident #30 was a risk to other patients because of her unpredict ableness. In an interview on 05/02/25 at 01:05 PM, MA C said Resident #30's normal behaviors included verbal aggression/yelling towards staff and other residents. She said the resident propels herself around the facility in her wheelchair cursing and yelling. She said the resident was not on any increased behavioral monitoring, not on 1-on-1 monitoring and was not safe to be in a room with others. In an interview on 05/02/25 at 01:21 PM, LVN J said Resident #30's regular behaviors included yelling and screaming at others. She said Resident #30's former roommate, Resident #22, was scared of her because of her yelling and screaming In an interview on 05/02/25 at 01:27 PM, Resident #22 said she was scared by her former roommates yelling and screaming, She said Resident #30 yelled and screamed at night, startling her. In an interview on 05/02/25, Anonymous A said Resident #30's regular behaviors included yelling/screaming and calling Anonymous A out of her name. Anonymous A staff said Resident #30's behaviors were towards anyone including residents and staff. Anonymous A said in one incident Resident #30 was screaming and she came down the hallway in her wheelchair with no clothes on. Anonymous A said last April, the social worker called the authorities because of Resident #30's behaviors and when they arrived, Anonymous A saw the resident attempt to pull the police officer's firearm. Anonymous A said Resident #30 liked to yell, scream and throw stuff at people and it makes Anonymous A antsy. In an interview on 05/02/25 at 01:36 PM, the MDS Nurse said she did not know Resident #30 had a history of attempted suicide or aggressive behaviors. She said the resident was always nice, but she liked to go to the ER on a weekly basis since arriving in the facility. The MDS nurse had she known of the resident's behaviors she would have included it in her care plan. In an interview on 05/02/25 at 02:04 PM, the Psychiatric NP said Resident #30 had a lot of anxiety and would call 911 often. She said the resident seemed hyper-manic and had racing thoughts. The Psychiatric NP said no one notified her that the resident was aggressive, she was unaware that the resident yelled at others, but she could believe Resident #30 rolled down the hall naked because the resident was always inappropriately dressed in her room. The Psychiatric Nurse said the resident had never shown any signs of suicidal ideation, or that she heard voices, but Resident #30 expressed anxiety and depression. She said she was unaware of Resident #30's previous history of suicide attempts, and she would have to review the hospital notes because based on what was discussed the resident's behaviors were more severe. The Psychiatric NP said Resident #30 should have a lot more monitoring by the staff and she did not know why the resident never communicated any of these issues with her. She said she had not read Resident #30's readmission clinicals from 04/30/25 but she assumes the resident is safe since she was discharged . The Psychiatric NP said based on Resident #30's behaviors she was not a safe person, and she expected the resident to have frequent assessments, close monitoring, increased therapy visits and should be encouraged to verbalize her feelings. She said Resident #30 needed additional monitoring to make sure nothing occurs. In an interview on 05/02/25 at 02:22 PM, the DON said prior to readmission she or her designee are supposed to receive and review the resident's hospital clinicals, but she did not, she said she thought the admitting nurse did. The DON said to her knowledge Resident #30 was not having behaviors in the hospital and since her return there had been no medication changes. She said since the resident returned to the facility there have been no interventions in place beyond the standard shift monitoring and based on her documented history of behaviors Resident #30 was not safe to be in a room with Resident #18 who was unable to communicate. In an interview on 05/02/25 at 02:27 PM, the Administrator said she did not know about Resident #30's aggressive behaviors or significant history of suicide, all she knew was that the resident would go to the hospital often. She said now that she knew the contents of the hospital psych consult notes and the resident's history of attempted suicide, the resident should be placed on 1on1 monitoring for at least 72 hours, because she was a resident safety risk having her unsupervised and ambulating in her wheelchair around the facility. In an interview on 05/02/25 at 02:37 PM, CNA T said in April she saw the police go towards the SWs office and then Resident #30 came down the hallway in her wheelchair. She said at first the police were talking to Resident #30, when she started yelling and screaming so the police tried to restrain the resident at which point Resident #30 attempted to pull the police officers firearm. CNA T said prior to the incident in April, Resident #30's regular behaviors included rolling around the facility in her wheelchair yelling/screaming/cursing at other residents and staff. In an interview on 05/02/25 at 02:46 PM, LVN T said she was the nurse scheduled when Resident #30 arrived at the facility, but she was on break, so the resident was already in the room when she returned. She said upon readmission Resident #30 had been roaming the facility unattended asking for cigarettes and pain medications. LVN T said in April she observed Resident #30 come out of SWs office screaming fuck you and the SW called 911 mental health. She said when the police talked to Resident #30, she said she was not suicidal but had attempted suicide the night before. LVN T said Resident #30 rolled away from the police, started fighting the police and when they attempted to restrain the resident grabbed their handcuffs and she heard the police say, let go of the gun. She said the SW thought they were going to shoot Resident #30, so she told her to get out of the way for safety. LVN T said more police arrived and then the ambulance took the resident away. LVN T said Resident #30's behaviors included hollering/yelling at people, calling people out of their name, calling Black people the n word, and she did all of this sometimes while going down the hall but the incident in April was the first time it had escalated to this point. LVN T said Resident #30, propelled herself freely in the facility down the halls, always yelling at others. She said when the resident returned on 04/30/25 , she did not receive the discharge clinicals that listed Resident #30's extensive suicide history, and the resident was not ordered or placed on 1on1 observation or suicide watch. In an interview on 05/02/25 at 02:57 PM, the ADON said Resident #30 can be extremely aggressive. She said the resident goes in and out of the hospital and calls 911 when she wants her pain medications, and the provider is aware of her behaviors. The ADON said she heard the resident was aggressive especially during night shift. She said everyone was aware of Resident #30's behaviors including social services, and it was documented in the resident's chart. The ADON said while she does not think Resident #30 is a threat to herself or others, she possibly made other residents feel scared. The ADON said when a resident has made threats of or attempted suicide interventions like 1on1 monitoring should be in place when they readmitted to the facility, but she did not know if Resident #30 had any others for this. The ADON said the IDT/Managers/Administration had not discussed interventions needed to ensure Resident #30's safety but management should absolutely have had that conversation. In an interview on 05//02/25 at 03;41 PM, the DON said she did not know Resident #30 had a history of attempted fake suicide, suicide attempts by tying a cord around her neck, auditory hallucinations telling her to harm herself by tying something around her neck or overdose on medications, wished to have a weapon to harm hospital and nursing staff or attempted suicide in November 2023. The DON said did not read the hospital discharge record sent to the facility prior to the resident readmitting that had the psychiatric consult notes describing all of Resident #30's previous behavioral issues and she honestly does not know why she did not. The DON said now that she knows Resident #30 had this history of behaviors the resident should have been somewhere more appropriate and based on the new information the facility had not provided Resident #30 adequate care. She said prior to today (05/02/25) Resident #30's behaviors placed the safety of herself and other residents in jeopardy. In an interview on 05/03/25 at 01:37 PM, the DON said since the surveyor alerted the facility of Resident #30's extensive history of fake suicide attempts, actual suicide attempts, auditory hallucinations, desire to harm others the resident was placed on 1on1 observation. She said the resident has had a sitter at all times, had not had any new behaviors and was doing well today. An observation and interview on 05/03/25 at 01:38 PM revealed, Resident #30 sitting in her wheelchair, writing in a notebook with headphones on. Resident #30 said she now had a sitter with her and has had no behaviors. She said she no longer heard voices since they put her on her proper meds in the hospital, but the doctor will take her off the medication in 10 days, and that is what keeps her calm. She said her Xanax helps her anxiety and bipolar and she was not drug seeking. Resident #30 said she was collating a list of songs for her online music store. In an interview on 05/03/25 at 01:42 PM, the DON said since Resident #30 had behaviors, received antidepressants and antipsychotic medications she should have had behavior monitoring orders. The DON said behavior monitoring orders are important for residents with behaviors in order to monitor for side effects or changes, and failure to have behavior monitoring orders would result in missed behaviors or change of condition. The DON looked through the resident's chart and said nope Resident #30 had no orders from her admission up until her suicide attempt on 04/13/25, and there were no orders entered when she returned to the facility on [DATE]. The DON said the lack of behavior monitoring played a part in the missed behavior monitoring and the missed residents change of condition. Resident #52 Record review of Resident #52's Face Sheet dated 04/24/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: schizophrenia ( mental disorder characterized by a breakdown in thought process, making it difficult to distinguish between reality and fantasy), and anxiety disorder. Record review of Resident # 52's Significant change in status MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 05 out of 15. Active diagnosis of anxiety disorder and schizophrenia, no presence of any behavioral symptoms such as physical (hitting, kicking, pushing), verbal (threatening, screaming, or cursing at others) and no other behavioral symptoms not directed toward others. Antipsychotics were received on a daily basis; no gradual dose reduction was attempted and there was no physician documentation indicating a GDR was clinically contraindicated. Record review of Resident #52's undated Care Plan revealed, focus- signs and symptoms of anxiety like hypersensitivity, paranoid, nervousness and is at risk for further episodes of anxiety and injury; intervention- medication as ordered. Focus initiated 01/07/25- psychotropic medications and is at risk for adverse reactions and behaviors; interventions- monitor for adverse reactions and hypnotic driven behaviors such as tiredness and weakness, monitor for psychosis driven behaviors such as aggressiveness, combativeness, and manic episodes. There was no focus areas addressing suicidal behavior or suicide threats. Record review of Resident #52's Progress Notes from 01/06/25 to 05/06/25 revealed: 01/19/25 at 04:53 PM signed by RN G- Resident has been very rude to RT she does not like her to enter room to give care to her roommate. She yells/curse and shout. Education given to resident that her room needs assistance and staff will provide assistance without bothering her, but resident stated now. Resident also continue to ask staff for cups thorough the shift. Education given to resident that she is currently NPO and cannot consume anything by mouth at this time for her safety. Education did not work. She continue to ask anyone walking pass her room. 02/01/25 at 09:46 PM signed by RN G- Resident is currently crying and screaming she would like to go the hospital due to pain in her left legs. Resident was given all of her scheduled medication and Tylenol PRN. She also received her pain cream diclofenac cream applied to her ankle. Resident also propels herself around the facility not crying screaming she became very aggressive with staff. Screaming cursing and grabbing of laptop and other staff equipment she is not able to be redirected. 02/08/25 at 05:42 PM signed by RN G- Resident throw a cup a writer on this shift then later came and apologize. she also snatched the phone causing the cords to come undone and later apologize for that she stated she was in a bad mood due to her mother and boyfriend not answering the phone. She was educated not to throw things at staff or at all. She stated okay. 02/08/25 a6 06:56 PM signed by RN G- Resident still present with behaviors she snatched all of the cords and laptop and phone off the nurse station. She Started hitting another nurse on duty throwing stuff and cruising. Resident shouting, she will kill herself. 911 called at this time social worker present. 02/08/25 at 07:19 PM signed by the SW- This resident became physically aggressive with nursing staff by hitting, kicking, grabbing, and attempting to bite them. She then began to yell and scream I'm going to kill myself. I am going to kill myself. Attempts to verbally redirect unsuccessful. SW contacted her r/p, and she informed SW that she was having one of her episodes and in the past, she was sent to a Behavioral Hospital. SW contacted Behavioral hospital intake Dept via and was informed that they have no available beds till Monday. Recommended that she be sent to ER for assessment due to her aggression. 02/08/25 at 07:25 PM signed by the SW- Note Text : Resident was able to talk with her r/p and also to one of her male friends. They were able to get her to calm down and she again began to apologize for her behavior. She denied [TRUNCATED]

Based on observations, interviews, and record reviews the facility failed to ensure residents were free of significant medication error for 3 of 7 residents (Resident #31, Resident #161, and Resident #162) reviewed for significant medication errors. - The facility failed to administer Potassium 40 mEq immediately to Resident #161 after he had a critical potassium lab value of 2.7. - The facility failed to ensure Resident #162 was not administered Potassium 40 mEq in error. -The facility failed to administer Resident #31's seizure medications (Lacosamide and Clonazepam) and IV antibiotic (Meropenem) after he readmitted to the facility from a short-term hospital stay even though the medication was in the facility. This failure could place residents at risk of side effects of medications, worsening of health conditions, increased chance of seizures, cardiovascular arrest, brain damage and death. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 04:36 PM. While the IJ was removed on [DATE] at 06:40 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. Findings include: Resident #161 Record review of Resident #161's Face Sheet dated [DATE] at 04:45 PM revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: respiratory failure, mild protein-calorie malnutrition, epilepsy, heart failure, low blood pressure, inability to sleep and the presence of a prosthetic heart valve. The resident had advanced directives of Full Code CPR when he discharged to the hospital on [DATE] at 06:01 PM. Record review of Resident #161's Discharge MDS dated [DATE] revealed, the resident had an unplanned discharge to a short-term general hospital. He received continuous oxygen and tracheostomy (a surgical procedure where a hole is created in the neck, directly into the windpipe to allow air to enter the lungs care, had no acute mental status change and had severely impaired cognitive skills for daily decision making. Record review of Resident #161's undated care plan revealed, focus: advance directive choice of FULL CODE status; interventions- staff will initiate CPR and notify EMS for transport to a hospital. The full code status for Resident #161 was initiated on the resident's care plan on 05/27.25. Focus- episodes of inappropriate behaviors and risk of injury due to self-dislodgement of trach; interventions- observe for early warning signs of behavior; date initiated [DATE]. Focus- resident has a tracheostomy; intervention- provide tracheostomy care per order. Focus- Potential for seizure activity, injury related to seizure activity and epilepsy; Goal- maintain lab values WNL through therapeutic range per MD order and be free of seizure activity through next review date; Interventions- administer medications as ordered. Record review of Resident #161's Lab Result dated [DATE] at 04:41 PM revealed, the facility collected a blood sample for a complete blood count, lipid panel and comprehensive metabolic panel on [DATE] at 05:55 AM; the sample was received by the lab on [DATE] at 10:26 AM; the lab reported the results on [DATE] at 04:41 PM. Resident #161's Potassium was tested to be 2.7 mmol/L and flagged as a critically low since the normal range for potassium was 3.6-5.5 mmol/L. The results were verified, called to and red back by [LVN T] on [DATE] at 04:37 PM regarding the residents potassium. Record review of Resident #161's Progress Notes dated [DATE] at 06:34 AM signed by RN D revealed, Critical lab potassium noted 2.7 and reported to the MD. New order received to give stat potassium chloride 40mEq , then another at night and give 40 mEq for the next 3 days. RP called ; phone went to Voice mail, administered the medication as ordered . Resident vital signs are WNL, nurse will continue to monitor. Record review of Resident #161's Progress Note dated [DATE] at 06:15 PM signed by RN D revealed, approximately 05:30 PM , SN went to check blood pressure and noticed resident unresponsive with no pulse , Code blue activated, and resident placed on floor CPR started immediately for 3 minutes resident become responsive , placed on non-breather mask with 15 liters. blood pressure 165/101, heart rate 105 , oxygen 98% , temperature 99.2, blood sugar 131. 911 was called and transferred resident to hospital . MD notified . RP and caregiver also notified of the CIC and transfer. Record review of Resident #161's Change in Condition Evaluation dated [DATE] at 06:06 PM signed by RN D revealed it was a follow up CIC evaluation. The residents change of condition was critical potassium level of 2.7 that stated in the afternoon on [DATE]. There was no repeat lab ordered, treatment was in place for 3 days and the physician was notified on [DATE] at. 06:34 AM. Abnormal chemistry values of K less than 3.0 at 2.7 from [DATE]. Record review of Resident #161's Change in Condition Evaluation dated [DATE] at 06:26 PM revealed, the residents change of condition was abnormal vital signs and unresponsiveness that started in the afternoon. Resident #161 was unresponsive, code blue activated, resident sent to ER via ambulance. Record review of the facility Unreviewed Laboratory records on [DATE] at 01:33 PM revealed, Resident #161 had critical lab result that were reported to the facility on [DATE] at 04:41 PM. Record review of the Resident #161's Lab Results in his EMR dated [DATE] at 02:02 PM revealed, his critical lab results were reported on [DATE] at 04:41 PM but the review status read To Be Reviewed. Record review of Resident #161's Order Summary Report dated [DATE] at 02:06 PM revealed: - Potassium 20 mEq- Give 40 mEq by mouth one time only for critical potassium 2.7 for 1 Day - Potassium 20 mEq- give 40 mEq by mouth one time only for low potassium level 2.7 for 1 day. - Potassium 20 mEq- give 40 mEq by mouth one time only for low potassium level 2.7 for 3 days. Record review of Resident #161's Hospital Record printed [DATE] at 03:48 PM revealed, Resident #161's Potassium level upon admission to the hospital was abnormal. His potassium level was 3.1 mEq/L with a reference range of 3.4-4.5. Record review of Resident #161's [DATE] MAR dated [DATE] revealed, RN D administered only 1 dose of Potassium 40 mEq to Resident #161 on [DATE] at 07:19 AM (over 12 hours after the critical lab value was reported). Record review of Resident #161's Hospital Record revealed, he admitted to the ED with altered mental status. Resident #161 admitted from a nursing facility in which the staff states he was in cardiac arrest and did 1 round of CPR. The fire department stated the resident had pulses and breathing on scene, with eyes open with a gaze and he was unresponsive to pain. According to EMS, they were called to the patient's nursing home due to cardiopulmonary arrest. They state that staff at the facility had told him that they found the patient unresponsive without a pulse. It is unclear what time this was or when the patient was last seen normal. According to EMS, staff had performed chest compressions for 3 minutes and had ventilated the patient with the BVM (a manual technique to deliver positive pressure ventilation to a patient who is not breathing or is not breathing adequately). No medications or defibrillation/cardioversion was performed. When EMS arrived, patient was awake and confused. In an anonymous interview on [DATE], They said Resident #161 coded in the facility in May due to a delay in treatment of a critical lab because the lab was called in under an incorrect resident who received Resident #161's critical treatment in error resulting in Resident #161 receiving delayed treatment for his critical lab value. The anonymous person said this was not the only critical lab missed but this particular incident bothered them. In an interview on [DATE] at 02:45 PM, Hospital Nurse A said Resident #161 was not in his room because he was undergoing a procedure in a different building. She said the resident initially admitted to the facility because he was unresponsive and had admitting diagnosis of heart valve replacement and cardiac issues. Hospital Nurse B said the resident was unresponsive with no pulse in the facility but once he was conscious he had seizure like activity. In an interview on [DATE] at 09:36 AM, RN D said when she came in on her morning shift on [DATE] the nurse who gave her a verbal report said Resident #162 had a critically low potassium, so he was administered potassium. She said in her experience when a resident had a critically low result the MD ordered a retest, but the reporting nurse said no such report was received, so she reviewed Resident #162's medical record and determined that the resident did not have a critical lab result for potassium but Resident #161 did. She said after further investigation she learned that both LVN T and RN A administered 40 mEq to Resident #162. RN D said she immediately called the doctor and received orders for Potassium for Resident #161 which she administered, and she notified the DON who asked for a STAT lab for Resident #161 and Resident #162. RN D said throughout the day Resident #161 was not his usual self, he was very lethargic, had slightly elevated BP, decreased O2 stats, was not trying to get out of bed and was spacing out. She said Resident #161 only ate a little bit of his lunch and around 04:00 PM when staff went to check on him, he was found unresponsive. RN D said she and her trainee nurse, RN H, immediately initiated CPR, Resident #161 recovered and was then sent out to the hospital which he remains. She said a resident potassium level was important because potassium controlled how the heart contracts. RN D said if a resident had low potassium they could go into cardiac arrest, and while she cannot say that is exactly why Resident #161 was found unresponsive the chance was high that the critically low potassium caused the resident to code. In an interview on [DATE] at 09:25 AM, RN D said on [DATE] Resident #161 was found unresponsive without a pulse in his room. She said facility staff immediately started CPR on the resident and after 1 round of CPR (30 compressions to 2 breaths) the resident came back (responsive and with a pulse). RN D said when a resident is found unresponsive nursing staff are expected to check the residents pulse and activate code blue and the crash cart is brought to the resident. She said when the cart arrives, the staff are to apply the AED and then follow the prompts. RN D said she last received training on AED use with the previous management company at the end of 2024. She said she did not use the AED on Resident #161 because he came back pretty fast (after 1-2 minutes of CPR). RN D said the AED was supposed to be applied after 1 round of CPR was completed. Resident #162 Record review of Resident #162's Face Sheet dated [DATE] at 01:58 PM revealed, a [AGE] year-old man who admitted to the facility on [DATE] with diagnosis which included: traumatic brain hemorrhage, respiratory failure, type 2 diabetes, brain injury, anxiety disorder, g-tube and dependence on a ventilator. Record review of Resident #162's Admissions MDS dated [DATE] revealed, active diagnoses included: coronary artery disease, anemia, a CVA, TIA or stroke and traumatic brain injury. Record review of Resident #162's undated Care Plan revealed, Focus- risk of aspiration due to feeding tube and episodes of inappropriate behaviors of rolling himself from the bed to floor mat pulling out his feeding tube. Record review of Resident #162 Change in Condition Evaluation dated [DATE] at 05:00 PM signed by LVN T revealed, change of condition was critical potassium level of 2.7 that started on [DATE] in the afternoon. LVN T received a call from the clinical laboratory with a critical potassium value of 2.7 and she reported the result to the Medical Director. LVNT received new orders to give 40 mEq of potassium now, another dose at night and then daily for 3 days. LVNT entered the orders into the EMR and administered the initial dose of potassium 40 mEq. Abnormal results- potassium level 2.7. Record review of Resident #162's Progress Note dated [DATE] at 06:57 AM signed by LVN T revealed, LVN T received a call from the clinical laboratory with a critical potassium value of 2.7 and she reported the result to the Medical Director. LVNT received new orders to give 40 mEq of potassium now, another dose at night and then daily for 3 days. LVNT entered the orders into the EMR and administered the initial dose of potassium 40 mEq. Record review of Resident #162's Lab Results Report dated [DATE] at 04:00 PM revealed, the result was reviewed by NP B on [DATE] at 11:11 PM. A blood sample for BMP testing was collected on [DATE] at 02:20 PM and Resident #162's potassium level was 4.5 mmol/L with a reference range of 3.5-5.2 [NAME]/L. Record review of Resident #162 Order Summary Report dated [DATE] revealed: - Potassium give 40 mEq via G-tube one time only for critical potassium level for 1 day. - Potassium give 40 mEq via G-tube at bedtime for critical potassium level - Potassium give 40 mEq via G-tube one time a day for critical potassium level for 3 days. Record review of Resident #162 May [DATE] dated [DATE] at 01:59 PM revealed, Resident #162 received Potassium 40 mEq on: - [DATE] at 06:33 PM administered by LVN T. - [DATE] at 09:00 PM administered by RN A. Record review of Resident #162's Clinical Results on [DATE] at 02:01 PM revealed, Resident #162 had no labs were collected on [DATE] and no results for critical potassium were reported on [DATE]. In an interview on [DATE] at 03:50 PM, RN A said she did not administer Potassium 40 mEq to Resident #162. In an interview on [DATE] at 07:28 PM, LVN T said she was not aware she made a med error with Resident #161 and Resident #162. She said when nurses received a critical lab result, they are expected to notify the NP in order to receive new orders for treatment. LVN T said she would report the CIC to the RP, enter the new orders into the EMR and notify the ADON. She said critically low potassium could place residents at risk for a cardiac event and all critical lab result should have immediate interventions in place because the resident could experience an adverse event, or the resident could die. After LVN T looked through the EMR she confirmed that she was documented as receiving the critical lab call from the lab on [DATE], she entered the order for potassium into Resident #162's chart and she administered potassium to Resident #162. LVN T said she did not remember a med error incident on [DATE] as that was her first day working over here, no one ever talked to her about the incident, and she never received any re-training or in-service related to this incident. In an interview on [DATE] at 05:06 PM, the DON said there was a medication error when Resident #161's labs were attributed to Resident #162 and the wrong resident was treated for critically low potassium. She said the facility investigation revealed LVN T made the med error. The DON said when a resident has a critical lab value nursing staff must follow the critical labs pathway, notify the MD/NP, and follow through as ordered. She said low potassium can impact heart muscle contraction, leading to cardiac arrest if response is delayed. In an interview on [DATE] at 11:42 AM, NP A said she was unaware that Resident #161 coded in May nor was she aware that Resident #162 received potassium in error. She said when the facility is notified of critical labs, nursing staff are expected to call them into the MD/NP as soon as possible but sometimes she did not receive a call but instead found out about resident abnormal labs during chart review. NP A said critically low potassium can present as elevated heart rate, lethargy, seizures, and result in cardiac arrest. In an interview on [DATE] at 10:53 AM, the DON said she completed an investigation into the incident, discussed the incident with LVN T and completed an incident report. She said she did not remember if she in-serviced nursing staff in regards to medication errors and handling critical labs. The DON said she did not remember if any interventions were put into place after [DATE] to ensure the medication error incident would not occur again. In an interview on [DATE] at 12:04 PM, the Medical Director said she does not remember if LVN T associated the critical lab with the wrong resident when she was notified of the incident. She just remembered she was notified that potassium was given to the incorrect patient, so she gave orders for labs, but she could not say which resident received potassium in error or which resident was supposed to receive the medication. The Medical Director said she was sure she discussed the medication error with the facility administration, but she did not know what interventions were put into place following the incident. The Medical Director would not say what a delay in care of critically low potassium would place residents at risk of as she would not attest to hypothetical situation. She said she would like notification and treatment immediately when a resident had a critical lab, but she could not say what the expected time was because it was a hypothetical situation. An observation on [DATE] at 06:15 PM revealed, Resident #162 in bed in no immediate distress. He was connected to a ventilator and received continuous enteral feeding via a G-tube. In an interview on [DATE] at 06:28 PM, NP B said she worked with the facility contracted medical practice. She said when nursing staff received notification of a critical lab, they are expected to notify the provider and initiate treatment immediately. NP B said critical potassium could present differently in residents, but the resident could be confused, have flaccid muscles (muscles that are weak and lacking firmness) and/or cardiac arrest. She said a relay in treatment of critically low potassium with oral potassium could result in arrythmia and cardiac arrest so treatment should be immediate within minutes. NP B said administration of potassium over 12 hours after staff were notified of a critically low potassium level would not be acceptable because of all the symptoms previously discussed. Resident #31 Record review of Resident #31's Face Sheet dated [DATE] revealed, a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE] after a short-term hospital stay with diagnosis which included: chronic respiratory failure, cardiac arrest, cerebral palsy, anxiety disorder, contracture and epilepsy ( a brain disorder characterized by recurring seizures due to abnormal electrical activity in the brain. Record review of Resident #31's Quarterly MDS dated [DATE] revealed, the resident had no speech, had severely impaired cognitive skills for daily decision making, had Aphasia (inability to speak), cerebral palsy, seizure disorder or epilepsy and traumatic brain injury. Record review of Resident #31's undated care plan revealed, focus- risk for increased episodes of seizure activity and injury due to his diagnosis of epilepsy; interventions- give medications per order. Record review of Resident #31's Progress Note dated [DATE] at 11:25 PM revealed, resident readmitted to the facility at 07:30 PM from a hospital. Medications were reconciled with the NP, and the DON was notified of the resident's arrival. There is no documentation of the resident not receiving his evening dose of medication. Record review and audit of the facility 24-hour Summary dated [DATE] at 08:15 AM revealed, Resident #31 admitted to the facility on [DATE] and exceptions were triggered for his medication order administration on [DATE] for: Clonazepam 0.5 mg at 09:37 PM, Clotrimazole 1% Cream at 09:38 PM, Lacosamide 100 mg at 09:38 PM and Midodrine 2.5 mg at 11:00 PM. Record review of Resident #31's Order Summary Report dated [DATE] revealed, Lacosamide 100 mg- give 100 mg via G-tube every 12 hours related to epilepsy; Clonazepam 0.5 mg- give 0.5 mg via G-tube every 12 hours for seizure management; meropenem IV solution- 500 mg IV every 6 hours for pneumonia. Record review of Resident #31's MAR for June printed [DATE] revealed, on [DATE] Resident #31 did not receive: - Meropenem 500 mg IV solution scheduled for 08:00 PM - Lacosamide 100 mg scheduled for 08:00 PM. - Clonazepam 0.5 mg scheduled for 08:00 PM. - Clotrimazole 1% cream to his stoma scheduled for 09:00 PM. - Midodrine 2.5 mg scheduled for 11:00 PM. Record review of Resident #31's MAR for June printed [DATE] revealed, on [DATE] Resident #31 did not receive: Meropenem 500 mg IV solution scheduled for 10:00 AM Record review of the facility provided audit of the 24-hr. report on [DATE] revealed, Resident #31 readmitted on [DATE] and he was to start meropenem antibiotics, there is no mention of the missed doses of medication. Record review of the pharmacy automated dispensing system Content List provided on [DATE] at 12:24 PM revealed the system contained: - Clonazepam 0.5 mg with a minimum quantity of 3 and maximum quantity of 8 - Meropenem 1 g and 500 mg. Record review of the pharmacy provided Transaction Report for the automated dispensing system dated [DATE] revealed, on [DATE] at 07:34 AM RN D retrieved a vial of Meropenem antibiotics for Resident #31. In an interview on [DATE] at12:28 PM, the DON said when a resident readmits to the facility from a hospital stay the admitting nurse performs medication reconciliation, enters the orders in the EMR and the pharmacy delivers the medications. She said if a resident's medication had not arrived from the pharmacy staff can pull the first dose from the automated dispensing system which contained both non-controlled and controlled substances. She said the resident's first dose of medication would be determined by the last dose that was given and documented in their hospital discharge medication list. The DON said Resident #31 readmitted to the facility yesterday ([DATE]) and returned on antibiotics, but when he was transferred to the hospital his narcotics were taken of the nursing cart and locked in her office. She said Resident #31 was diagnosed with pneumonia and ordered Meropenem antibiotics for 3 or 4 days. The DON said even though Resident #31 was discussed in the facility morning clinical meeting, she was unaware that he had not received his seizure and antibiotic medication last night or his antibiotic early this morning until it was mentioned by the surveyor. She said it is important that residents receive their seizure meds on time because it keeps the drug level in a safe range which prevents and controls seizures; and antibiotics frequency must be maintained to keep the concentration of the drug at the right level. The DON said Resident #31's missed doses of seizure and antibiotic medications could place him at risk of seizures, promote bacterial drug resistance and continued growth of bacteria, leaving his pneumonia untreated resulting in difficulty breathing. An observation on [DATE] at 12:45 PM revealed, Resident #31 in bed receiving breathing assistance via a tracheostomy and continuous enteral feeding via a g-tube. The resident was non-interviewable and appeared to be no immediate distress. In an interview on [DATE] at 12:48 PM, RN D said Resident #31 readmitted to the facility last night ([DATE]) with a diagnosis of pneumonia. She said Resident #31 did not receive his medications last night, his Lacosamide or Clonazepam was not administered last night because they were locked in the DONs office and his Meropenem was not administered during the 6PM to 6AM shift because RN A did not have access to the automated dispensing system. She said when she arrived this morning, she retrieve the IV antibiotic from the automated dispensing system and administered it to the resident. RN D said she contacted the DON at 07:12 AM to ask her about Resident #31's seizure meds and the DON said the medications were locked in her office, but she would be in the facility shortly. RN D said the DON arrived at the facility at approximately 08:00 AM and shortly thereafter she administered Resident #31 his Lacosamide and Clonazepam. RN D said failure to administer seizure medications timely is a critical error because it could cause seizures which can result in brain damage. In an interview on [DATE] at 03:50 PM, RN A said she became a full-time nurse at the facility 2 months ago. She said on [DATE] she received report that Resident #31 was readmitting back to the facility, but he arrived late. RN A said she was Resident #31's admitting nurse when he arrived at night on [DATE], she performed his admission assessment, called the doctor to reconcile medications and entered the orders into the chart. She said when Resident #31 arrived he was ordered IV antibiotics four times a day, but the medication had not arrived from the pharmacy. RN A said she checked the medication room for his controlled substances (Lacosamide & Clonazepam), but they were not there, so she administered his other medications and check his blood sugar. She said Resident #31 did not receive his seizure and antibiotic medications because she cannot borrow medications from another patient, and she did not get the IV antibiotics from the automated dispensing system because she does not have a code to access the system. RN A said she never received access to the automated dispensing system because she worked at night and would not answer what the facility's expectations were when resident medications were unavailable, but she did not notify the doctor because the resident was not new to the facility, and she did not contact the DON because it was late late. In an interview on [DATE] at 05:06 PM, the DON said the facility had an automated dispensing system that nursing staff should get first doses of medication prior to resident medication delivery from the pharmacy. She said the automated machine had a list of medications in the machine that are stocked by the pharmacist and when a nurse dispensed medications from the machine a pharmacist restocks it as needed and scheduled. The DON said all nurses and nurse management should have access to the automated dispensing system, but she just learned that RN A did not have access. She said RN A was never trained on how to use the automated system, all nurses working on the floor should have access and it was an oversight that RN A never had access. The DON said on [DATE] Resident #31 did not receive his meropenem or controlled substance seizure medications. Record review of the facility policy titled Reconciliation of Medications on admission revised 07/2017 revealed, General Guidelines 1.Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes, and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medicati9ns, routes and dosages have been accurately communicated to the Attending Physician and care team. An IJ was Identified on [DATE]. The Administrator was notified of the IJ, and the template was provided to the facility on [DATE] at 04:36 PM. The following Plan of Removal submitted by the facility was accepted on [DATE] at 03:39 PM. [DATE] F760 Introduction: On [DATE], at 4:36pm, an Immediate Jeopardy was identified due to a critically low potassium of 2.7 by reporting it under an incorrect resident, resulting in a medication error and delay in treatment. All current residents could be at risk of having a change of condition and have the potential to be impacted by this deficient practice. As a result of the IJ the facility has implemented the following. 1. Administrator, DON and ADON were in-serviced by Chief Nursing Officer on the following Healthcare regarding resident changes in condition, follow-up, staff reporting of incidents and changes in condition and notifying the medical director and or designated on call provider Admin, DON and ADON in-serviced on the need for increased staff education and monitoring including new hires and agency staff. All verbalized understanding. In service completed on [DATE]. The facility nurse receiving the results will ensure that the correct resident and medical provider have been identified, a second nursing staff member will double-check that the correct results have been attached to the correct resident. Facility will contact the correct physician and communicate the results, and obtain orders. RNs and LVNs were trained on this process on [DATE]. Additional training is in process and will be completed [DATE]. Staff will not be allowed to work if they do not complete the training. 2. Facility reviewed policies and procedures prior to in-services. Polices reviewed include medication pass, change in condition, clinical lab protocol. No changes were made to policies, as a result of the initial review. 3. Administrator, DON and ADON completed the following: a. The facility DON and ADON on [DATE] at 5:00pm implemented the following: All on duty nurses staff were in-serviced on the following by DON and ADON. i. MD notification of change in condition, including change in mental status/alertness to include critical labs, ii. Notification of DON/ Administrator of any change in condition. iii. Resident follow-up monitoring iv. Monitoring residents for change in conditions. b. Signs/Symptoms of Resident change of condition to include but not limited to: i. mental status, ii. critical lab values iii. changes in breathing iv. unarousable while sleeping, v. changes to pupils vi. inability to/or refusing to eat, drink or take medications. vii. Documentation 4. Facility also conducted additional in-services on Abuse, neglect, and exploitation. a. Abuse, neglect and exploitation. b. Documentation c. Medication administration and medication error training, d. Physician notification. Staff will verify that the correct provider is being notified as per the resident chart. Staff will make phone notifications and will not use other methods of communication such as text or email. Facility will continue to in-service as needed. Initial trainings will be

Based on observations, interviews, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 18 of 18 residents reviewed (CR #1, Resident #2, #3, #4, #5, #6, #7, #10, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 4 of 4 Halls (A, B, C & D Halls) reviewed for clean, comfortable, homelike environment, and clean bed and bath linens. - The facility failed to maintain a clean and homelike environment for all residents across the facility. - The facility failed to provide adequate clean linens (towels & Sheets) to meet the needs of all residents across all units which resulted in residents (CR#1, Resident #2, #7, #5, #3) who reported they stuck to their mattress, felt cold, unclean, dirty, worthless, neglected, and left CR #1 in tears. - The facility failed to provide adequate clean linens as Residents #6, #10, #21, #22, #24, #25, #26, #27, #28, #29 & #30 were observed laying on bare mattresses. - The facility failed to ensure privacy curtains were in resident rooms (B-5, B-10, C-1, C-8, and D-11). - The facility failed to provide hot water which resulted in residents receiving cold showers or no showers at all. - The facility failed to provide hot water in resident rooms & showers ( Rooms C6- C8, C-13, D-1, D-10, C Hall showers/sinks and D Hall Shower). An IJ that began on 02/11/25 was Identified on 03/07/2025. The template was provided to the facility on [DATE] at 04:08 PM. While the IJ was removed on 03/12/25 the facility remained out of compliance at a scope of widespread and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of decreased feelings of self-worth, emotional destress, mental anguish, decline in health and infections. Findings included: Observations on 2/11/25 at 09:35 AM revealed, most residents in their rooms. Some residents were laying on bare mattresses due to the lack of linens in the facility. There was a total of six rooms observed. Observations on 2/11/25 at 11:28am revealed, the hallway and room closets at the end of A&B Hall and C&D Hall had no linen supplies. Water in the bathrooms were lukewarm; showers and sinks on C & D halls were lukewarm; sinks in the shower of the memory care unit had lukewarm water. Residents were laying on bare mattresses in rooms (B-4 & 5, B-12, C8, C6, D4). B-4, 5, & 10 had no privacy curtains. CR #1 Record review of CR #1's face sheet revealed CR #1 was initially admitted [DATE], readmitted [DATE], and discharged [DATE] with a diagnosis of anemia, coronary artery disease, congestive heart failure, hypertension, orthostatic, hypertension, renal failure, hepatitis, hyperlipidemia, COPD (lung disease), and respiratory failure. Resident was on dialysis. Record review of CR #1's MDS assessment revealed a BIMS Score of 13. CR #1 required supervision or touching assistance in the areas of eating and oral hygiene. CR #1 required partial, moderate assistance in toileting, and upper body dressing and personal hygiene. Record review of CR #1's Care Plan indicated the resident was at risk for skin break down. The goal was to remain clean, dry, intact without evidence of breakdown over the next 90 days. The target date was to 3/25. Interventions was to assess skin on a weekly basis and PRN (As needed) any breakdown, assist with repositioning as needed using padding between pressure areas. In an observation and interview on 02/12/25 at 08:30 AM, CR #1 was at a local hospital. He said while at the facility he was unable to take a bath every day because there was no hot water and no clean linens or towels. CR #1 stated that the facility washers were broken for the last two months and when his clothing went to the laundry, he could barely get all his items returned. CR #1 reported that he had an infection due to not having a shower and inadequate clean linens and not getting his IV bandage changed daily as ordered. CR#1 began to cry and said the situation in the facility was inhumane and it made him feel dirty and worthless. Resident #2 Record review of Resident #2's face sheet dated 02/12/25 revealed, a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, paraplegia (type of paralysis that affects the lower half of the body), depression, cognitive communication deficit and non-pressure chronic ulcer of the buttocks. Record review of Resident #2's annual MDS dated [DATE] revealed, a BIMS score of 9 indicating he had moderate cognitive impairment. He required moderate assistance from staff with shower/baths and footwear. Record review of Resident #2's care plan printed 02/12/25 revealed, focus- incontinent(bladder/bowel) and at risk for skin breakdown and pressure wound formation ; goal: clean, dry, odor free and dignity will be remained; intervention: check for incontinent episode during rounds, change promptly and apply protective skin barrier, observe for skin breakdown. In an interview on 2/11/25 at 10:00 AM, Resident #2 stated the facility's washing machines were not working and have not been working for over 2 weeks. Resident #2 stated his own clothes have been lost. Resident #2 also stated the hot water has been out since 1/25/25 and just started working yesterday, 2/10/25, but the heat or air condition still does not work. Resident #2 stated he feels helpless and neglected at times because this should not be happening. He stated he could not take a shower because the water was cold. He stated same with wash ups in the sink. Resident #2 said he was a human being and felt he should be treated with more respect. Resident #7 Record review of Resident #7's face sheet dated 03/12/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included diabetes, stroke, dementia, mild protein malnutrition, schizophrenia, bipolar disorder, anxiety, elevated blood pressure and non-pressure chronic ulcer of foot. Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 8 indicating she had moderate cognitive impairment. She required substantial assistance from staff for toileting, shower/baths, and lower body dressing. She required partial assistance with upper body dressing and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #7's undated care plan revealed she was bedfast most/all the time and at risk for skin breakdown. Interventions included use position devices to prevent skin break down. An observation and interview on 03/06/25 at 11:30 AM revealed, Resident #7 in bed with no fitted sheet or flat sheet. There was a draw sheet beneath her and blankets on top of her. Resident #7 said the previous night nursing staff removed her fitted sheet because it was wet, and it was never replaced. She said she preferred to have a fitted sheet because without it her skin would stick to the plastic mattress, and she did not like it. Resident #7 and she preferred to have a top sheet and that there was always a problem with linen supplies. She said the facility did not have enough towels, diaper s or wipes and she did not understand why the facility was always out of the supplies that were needed. Resident #5 Record review of Resident #5's face sheet dated 03/11/2025 revealed, a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body) d/t stroke, presence of prosthetic heart valve, depression, anxiety, diabetes, muscle weakness, dementia, high blood pressure and contractures of the left upper arm. An observation on 02/11/25 at 11:28 AM revealed, Resident #5 laying on a bare mattress in his room. In an observation and interview on 02/11/25 at 12:06 PM, Resident #5 stated there has not been warm or hot water in the facility for at least two weeks. Resident #5 stated he last showered on Sunday (2/9/25). Resident #5 stated the shower was still too cold. Resident #5 said most of the time he was unable to take a shower because there were no clean linens and the staff told him the linens were being washed at a local washeteria. He said the facility was supposed to be like home and the treatment he got did not make him feel good. An observation on 02/11/25 at 12:10 PM revealed, the water in Resident #5's bathroom was lukewarm. In an observation and interview on 03/07/25 between 9:55 AM and 10:25 AM, Resident #5 was observed in bed. He reported that his bed sheets had not been changed for a few days and prior to that he did not have sheets on his bed. Resident #5 said not having sheets was uncomfortable because his skin would stick to the mattress and on cold days the mattress made him cold. Resident #3 Record review of Resident #3's face sheet dated 03/11/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, cirrhosis of the liver (abnormal liver function), low blood pressures, muscle wasting and pain. Record review of Resident #3's annual MDS dated [DATE] revealed a BIMS Score of 12 indicating moderate cognitive impairment. An observation on 02/11/25 at 11:28 AM revealed, Resident #3 laying on a bare mattress in his room. In an observation and interview on 02/11/25 at 12:06 PM, Resident #3 said the facility's washing machine and dryer were not working so his family had to wash his clothing since the facility could not keep up with his clothes. He said the laundry room has lost his clothing items which was another reason his family washed his clothes. Resident #3 stated the last time he took a shower was last Sunday and it was cold. He stated he just couldn't wait any longer and had to bear with the uncomfortable shower to get clean. He stated the water was only lukewarm today, but for the last two weeks there has only been cold water. An observation on 02/11/25 at 12:10 PM revealed, the water in Resident #3's bathroom was lukewarm. In an observation and interview on 03/07/25 between 09:55 AM and 10:25 AM, Resident #3 was observed in bed. He reported that his sheets had not been changed for several days and prior to that he had no sheets. Resident # 3 said he felt unclean because he did not have clean sheets on his bed. Resident #6 Record review of Resident #6's face sheet dated 03/10/2025 revealed, a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), dependence on supplemental oxygen, Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, chronic obstructive pulmonary disease (a lung condition caused by damage to the airway), anemia (reduced number of red blood cells), depression, functional quadriplegia (inability to completely move), congestive heart failure (is a condition where the heart is unable to pump enough blood to meet the body's needs), hypertension (elevated blood pressure) and anxiety. Resident #6 was his own RP. Record review of Resident # 6's Quarterly MDS (minimum data set, resident assessment, and care screening) dated 02/11/2025 revealed, intact cognition as indicated by a BIMS score of 14 out of 15. He required total dependence on staff for lower body dressing and substantial maximum assist for upper body dressing and personal hygiene. He was always incontinent of urine and bowel. Record review of Resident #6's undated care plan revealed he was bedfast most/all the time and at risk for skin breakdown. Interventions included keep sheets clean and wrinkle free. An observation and interview on 3/6/2025 at 9:45 AM revealed, Resident #6 lying on an air mattress with a bath blanket and regular blanket. Resident #6 did not have a fitted sheet and his pillowcase was visibly dirty/soiled. He stated he did not have a fitted sheet because he was on an air mattress, so he was lying on a draw sheet. Resident #6 said he always had issues with clean linen. He stated there was never enough linen especially top sheets and the facility was always short on towels and blankets especially during a cold snap. Resident #4 Record review of Resident #4's face sheet revealed, a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, end stage renal disease, dialysis dependent, diabetes, heart failure, anxiety, and depression. Record review of Resident #4's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13. She had impairment to one side of upper and lower body that interfered with daily functions. She required substantial assistance from staff for showers/baths, and partial assistance with dressing and personal hygiene. Record review of Resident #4's undated care plan revealed, focus: risk for skin breakdown and injury due to decreased mobility; goal: skin will remain clean/dry, intact without evidence of breakdown; intervention- provide pressure reducing and positioning devices on resident bed/wheelchair as indicated. In an interview on 2/11/ 25 at 6:30 PM, Resident #4 stated she has not had a hot shower in 2-3 weeks. Resident #4 stated the water was either cold, cool, or lukewarm. Resident #4 stated the washing machine has been out for at least 3 weeks and the staff take dirty clothes, linens, and towels to the local washeteria. Resident #4 stated she was afraid to send her personal items to the laundry because items were often missing or lost. Resident #10 Record review of Resident #10's faces sheet dated 03/11/25 revealed, a [AGE] year-old male whose initial admission date was 05/07/21 and re-admitted on [DATE]. The resident's diagnosis included: Down Syndrome, moderate intellectual disabilities, need for assistance with personal care, cognitive communication deficit and retention of urine. An observation on 02/11/25 at 11:28 AM revealed, Resident #10 laying on a bare mattress in his room. An observation and interview on 3/7/2025 between 9:55 AM and 10 :25 AM in the secured unit revealed, Resident #10 was lying on the bare mattress. The resident was non-verbal and could not be interviewed so CNA G was asked why the resident's bed had no linens. CNA G said that the facility did not have enough clean linen on the unit. She said the laundry only had some sheets and bed pads, but it was not enough for every room. CNA G said it had been an ongoing issue and the facility did not have enough sheets and things for the residents. Residents #21-30 Observations on 02/11/25 at 11:28 AM revealed, the following additional residents not interviewed in their room laying on bare mattresses: 1. Resident #21 2. Resident #22 3. Resident #23 4. Resident #24 5. Resident #25 6. Resident #26 7. Resident #27 8. Resident #28 9. Resident #29 10. Resident #30 An observation on 02/11/25 at 06:45 PM revealed, Resident #29's bed did not have a privacy curtain. Observations on 03/06/25 at 10: 25 AM revealed, the following residents did not have sheets on their beds. 1. Resident #26 2. Resident #10 3. Resident #28 In an observation and Interview on 2/11/25 at 4:37 PM, Maintenance stated he got a complaint about the water issue on January 30th, 2025, that there was water coming out of the ceiling; however, when he came to the facility there was hot water running out of the ceiling. Maintenance stated the circulation pump busted on Sunday. Maintenance stated on Monday morning he ordered the pump which arrived on the 3rd of February 2025. It was installed the same day. Maintenance stated the policy for temperatures were important for environmental issues for residents, them maintaining their hygiene, and because it's important for their health. Walk through Water Temperature Observation with Maintenance in the following areas: Room D-1 Sink - 81 degrees Room D-10 Sink - 100 degrees D Hall shower sink - 105 degrees D Hall Shower - 93 degrees Rooms C6-C-8 Sinks - 92.7 Degrees Room C-13 - 100 Degrees C-Hall Shower - 93 degrees C Hall Sink - 93.6 Degrees. An observation on 02/12/25 at 7:05 PM revealed, enough linen for about 10 beds in the linen closet, dirty linen bags (waiting to be picked up and taken to the washeteria in the morning by laundry staff) at the end of each hall, and there were towels on staff carts in each hallway. An observation on 03/06/2025 at 9:00 AM revealed, there were no linens in linen closets in C Hall and D Hall. An observation on 03/06/25 at 10:38 AM revealed, there were no linens for beds on for Hall A. The linen closet was empty. An Observation on 03/06/25 at 11:00 AM revealed, the linen closet in C and D hall did not have linens. An observation and interview on 03/06/25 at 3:00 PM, 2 residential/standard size washing machines in use. An observation on 03/07/25 at 10:27 AM revealed, the linen closet on Hall A had no sheets, towels, or blankets. An observation on 03/07/25 at 11:02 AM revealed, the linen closet on Hall C had only 2 flat sheets on shelf. Observation on 3/6/25 at 10:38 AM of Hall A to check for linens on the bed. Rooms A6-8 did not have sheets on the bed. The linen closet for the hall was empty. In an interview on 2/11/25 at 10:15 AM, CW stated the residents were not being cared for. The CW stated residents were in soiled underwear or adult briefs a lot because the washing machines were broken and at certain times the staff were going to the washateria. The CW stated the trash outside of the facility hasn't been picked up in almost a month and it smelled and sometimes you could see rodents in the trash. The CW stated it was an eye sore for the neighborhood. In an Interview on 2/11/25 at 10:25 AM, LA stated his job was to do laundry. LA stated that the washing machines have been down since last Monday (2/3/25). LA stated the facility's dirty laundry was picked up daily and taken to the local washateria, where the linen, clothes, and towels were washed and returned to the facility. LA stated that the two domestic dryers in the facility were operable; however, the commercial dryer did not work. LA stated that the residents' clothes were organized by the resident's names that were labeled or marked on the inside of the clothes after being washed. He stated that the clothes without names came back to the laundry area and if a resident was missing clothing items or the CNAs knew that one of their residents were missing clothes, then they came here to the laundry area and retrieved the missing clothing items. LA stated that if a resident did not know or was not cognitive enough to know if they are missing clothes, then they probably would not be getting them. LA stated sometimes the CNAs would come get the residents clothes. When asked if he thought this was a good process, LA stated he did not know because he is only doing what he has been taught to do and at this point there has not been any complaining from the CNA's or residents. In an interview on 2/11/25 at 11:32 AM, CNA A stated there was no clean linen in the facility today. CNA A stated the last day of clean linen was Sunday (2/9/25) when she last stocked for second shift. CNA A stated the process for the MCU was to stock the clean linens for the second shift. CNA A stated when she came on to the MCU yesterday morning (2/10/25), there were no clean linens, and the residents were laying on their bare mattresses. CNA A stated she sanitized the mattresses to ensure cleanliness. In an interview on 2/11/25 at 12:00 PM, CNA B stated the A-Hall had hot water for approximately a week. However, prior to that, the water was cold and as the temperature changed outside to a little warmer, the inside showers and sinks in the rooms became lukewarm. CNA B stated without towels the showers have become interrupted and a lot of residents haven't received showers. CNA B stated the facility's commercial washing machines were out for the last two weeks. CNA B stated the first shift CNAs were hardly able to give the residents their baths or showers because there were no towels, or the water was too cold, and the residents refused. CNA B stated there were no face towels in the facility for the residents. The only towels, when they were clean, were bath towels. In an interview on 2/11/25 at 12:05 PM, the Housekeeper stated she was aware of the facility running short on linens because the washing machines have been broken for a while but could not give an exact timeline of how long the machines have been inoperable. The housekeeper stated that the trash outside had not been picked up in 2 weeks. In an interview on 2/11/25 at 12:15 PM, CNA C stated some of the residents were on bare mattresses because the facility did not have linens. CNA C stated she has only worked at the facility for a week, and it has been like this since she started. CNA C stated she just continue to check on resident and ensure when the washed linen return to facility she makes the beds up and ensure resident has clean towels and clothing. In an interview on 2/11/25 at 03:00 PM, CNA D who stated there was a problem with getting clean towels. CNA D stated it was difficult to do an adequate job caring for residents when there were no towels to clean residents, or the showers were too cold to bath them. CNA D stated this weekend (Sunday 2/9/2025) there were no briefs for residents, wipes, or gloves and some residents had to wear a towel for briefs. She stated it was like this on the morning and afternoon shifts. In an interview on 2/11/25 at 6:15 PM, CNA E stated he worked Sunday morning (2/9/25) from 6:00am to 2:00 PM. CNA E stated there were no linens or towels during his shift. CNA E stated that there were no briefs for residents on his hall and had to retrieve some briefs from other resident halls. CNA E stated that there were no gloves or wipes in the facility; however, did not offer any additional information on how the residents were cleaned. In an interview on 2/12/25 at 2:15 PM, CNA F stated the resident and facility laundry was picked up in the morning around 5:30am to be taken to the local washateria and usually returned in afternoon by 3:00 PM with clean linens. She stated she brought her own gloves when she worked because she was aware that there was a shortage of supplies and other items. In an interview on 2/12/25 at 2:25 PM, LVN A stated she has observed at times there was no clean linens in the facility. She stated the washer has been broken for a while, so the dirty clothes and laundry must go to the local washateria and return to the unit around 3:00 PM. She stated when there were no sheets, towels were used on residents temporarily for briefs or sheets. In an interview on 2/12/25 at 7:35 PM, the Administrator stated the facility's washing machines had been broken for 2 weeks. She stated parts have been ordered on 2/7/25. She stated until the parts arrive, the linens and towels had to be taken to the local washeteria for washing. The Administrator stated although the residents that were cognizant have stated they understand, she stated they should not have to be subjected to this because they were supposed to have linens and towels and not wait for them to be washed. She stated the facility has washed the private curtains and were in the process of hanging them in the rooms. In an interview on 3/6/25 at 12:55 PM, KL stated that sometimes clean linens were not available until the second shift, which started at 2:00 PM. They were always short on linens since last fall. It was not like that when KL first began working at the facility. KL reported that a complaint was made to management before, but KL felt being treated differently after reporting. KL did not report things much anymore afterwards because of fear of retaliation for reporting issues. KL ran out of briefs on the unit this morning but got some from another hall. KL stated normally we have briefs. KL stated that without necessary tools KL could not provide resident care fairly or not at all. In an interview on 3/6/25 at 3:00 PM, the Laundry Tech stated the washers were down one or two months ago and that was when he started taking the laundry to the washateria down the street. He stated his process was separating the linens from the towels and personal items were always bagged separately. He stated isolation bags would come in red or yellow bags and usually the nursing staff would hand deliver, so he knew whether to wash them or throw them away. He stated he would always wash contaminated isolation laundry last. There were 2 standard size washing machines in operation. He stated he washed the laundry the same way when using the machines at the washateria. He stated the transport driver would help him with transporting the laundry to washateria. He stated he never brought contaminated/isolation laundry to the washateria because he did not know how well they would be cleaned. He stated he did not know whether the nurses threw them away or not. In an interview on 3/7/25 at 11:49 AM, the Administrator stated that a shipment was received yesterday (03/06/2025) so that should have solved the problem of residents without any sheets or shortage of bed sheets. There should not be anyone without sheets today. Some CNAs are taking them to their hall and then another hall does not have enough until the next batch was washed. She stated that the facility was working on the distribution of linens. The laundry starts around 4:30 AM so that there are sheets available for each hall when the shift changes at 6am. She stated she was Not sure how the shortage happened but suspected that since the trash barrels and dirty linen barrels were the same color, someone may have been throwing out the sheets by mistake. She stated, the color of the barrels will be changed to prevent that from happening. The Administrator was asked the question if the company was experiencing financial problems that would prevent purchasing linens needed for the facility. She stated she was not aware of any problems and that the facility was very conscious of waste and did not want unnecessary purchases to be made. She stated that she did not think resident beds without bed sheets would affect the psychosocial well-being of the resident because the residents who were aware enough to understand that, know that it was us and not them. It was not their fault we were in short supply so they should not feel bad about themselves. When asked if there was a dignity issue, she stated nobody should be on a bare mattress and that the facility was working on the problem. She stated it was not a system failure with the linen process. She stated it was a hoarding thing because we were short for a long time and now the CNAs are worried, they will not have enough so they grab all they can. We have also found residents with extra linens in their room. When asked if the failure to provide services was neglect, she stated the facility had not failed to provide them, they are here, they are being moved by staff. Until we get an abundance, then they will stop doing it. It is a process of unlearning. She stated that neglect comes with intent and neglect was a willful act to not provide something. She stated Abuse and Neglect trainings for all new hires was part of the orientation and as coordinator, I make sure everyone was trained. We also do education multiple times a year. In an Interview on 3/7/25 at 2:17 PM, NP #2 stated the only health issue from not having sheets on the bed that she could think of was the skin rubbing on bare mattress could cause skin breakdown. For psychosocial affect, it would depend on if the resident had a preexisting mental health issue such as a phobia or an obsession with neatness. It may not affect some residents at all. It would be very individualized. In an interview on 3/7/25 at 2:24 PM, the DON said there was no health risk that she could think of regarding resident's not having linens on their beds. As far as dignity, some people prefer to have a sheet on them so that would bother them. She said she thought it only impacted how they thought about the facility staff, not how they think about themselves. The DON said she would be mad at the person that wasn't taking care of me if she was in the residents' situation. In an Interview on 3/7/25 at 2:35 PM, LVN A said I've seen residents without sheets on the bed sometimes. We wait for them to come around with fresh ones and then the bed gets made. I can't think of any health risks. Residents might get mad at us, but I have not seen anyone get upset with themselves. In an interview on 3/9/25 at 7:06 PM, TQ stated that it sucks that they don't have the supplies. TQ stated there were no gloves, no sheets, no briefs, no wipes, and no staff. TQ stated there were no gloves and cannot clean poop without them. TQ stated they need sheets, wipes, gloves, briefs, and staff. TQ stated they would scavenger hunt at night for these items. In the last couple of days, they have had supplies they need, and this was the first night they were fully staffed. Interview on 3/9/25 at 7:30 PM with Resident #8's RP, stated there had been times she visited, and they did not have sheets on the bed and the staff would go to look for sheets. Sometimes they found one and sometimes they said it was drying and could not put one on the bed. The RP stated Resident #8 had been wet during the evening of 3/9/25. She was going to try to move him because they need a system. Interview on 3/9/25 at 7:40 PM, RM stated most times they had problems with gloves, and they did not have the supplies. RM had to come to work bringing own supply of gloves to make sure gloves were available when needed. RM stated last week the CNA's complained about linen, wipes, and diapers. The CNA's tried to do what they could do. RM stated once they do not have the material to work with it affects the residents. The residents went without sheets. Some of the residents complained of being cold. They did not have enough things to cover them. Interview on 3/9/25 at 7:45 PM the Social Services stated she did not know what happened in the building. She stated all she knew was that the washer went out and the Administrator was taking the laundry aide to the laundromat/washeteria to wash the sheets. She stated she did not know what happened with the sheets. Record review of Facility provided invoice dated 02/04/25 revealed, the facility ordered linens and towels. Record review of Facility provided invoice dated 02/07/25 revealed, the facility ordered washing machine parts. Record review of the facility's undated policy on Abuse and Neglect - Clinical Protocol read in part: Definitions:2. Neglect as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Record Review of the facility's undated policy Quality of Life- Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The f[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure all residents were free from neglect for 18 of 18 residents (CR #1, Resident #2, #3, #4, #5, #6, #7, #10, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 4 of 4 Halls (A, B, C & D Halls) reviewed for neglect. - The facility failed to provide adequate clean linens (towels & Sheets) to meet the needs of all residents across all units which resulted in residents (CR#1, Resident #2, #7, #5, #3) who reported they stuck to their mattress, felt cold, unclean, dirty, worthless, neglected, and left CR #1 in tears. - The facility failed to provide adequate clean linens as Residents #6, #10, #21, #22, #24, #25, #26, #27, #28, #29 & #30 were observed laying on bare mattresses. - The facility failed to provide hot water in resident rooms & showers which resulted in residents receiving cold showers or no showers at all. - The facility failed to ensure there was hot water in rooms C6- C8, C-13, D-1, D-10, C Hall shower, C-Hall sink, and D Hall Shower. - The facility failed to provide sufficient supplies (briefs, gloves, wipes) for resident care. An IJ that began on 02/11/25 was Identified on 03/07/2025. The template was provided to the facility on [DATE] at 04:08 PM. While the IJ was removed on 03/12/25 the facility remained out of compliance at a scope of widespread and a severity level of no actual harm that was not immediate due to the to the facility's need to evaluate the effectiveness of the corrective systems. Failure outside of IJ; - The facility failed to provide nursing services to Resident #6 after he sustained a skin injury to his finger. These failures could place residents at risk of decline in health, infection, amputation, emotional distress, and mental anguish. Findings included: Observations on 2/11/25 at 09:35 AM revealed, most residents in their rooms. Some residents were laying on bare mattresses due to the lack of linens in the facility. There was a total of six rooms observed. Observations on 2/11/25 at 11:28am revealed, the hallway and room closets at the end of A&B Hall and C&D Hall had no linen supplies. Water in the bathrooms were lukewarm; showers and sinks on C & D halls were lukewarm; sinks in the shower of the memory care unit had lukewarm water. Residents were laying on bare mattresses in rooms (B-4 & 5, B-12, C8, C6, D4). B-4, 5, & 10 had no privacy curtains. CR #1 Record review of CR #1's face sheet revealed CR #1 was initially admitted [DATE], readmitted [DATE], and discharged [DATE] with a diagnosis of anemia, coronary artery disease, congestive heart failure, hypertension, orthostatic, hypertension, renal failure, hepatitis, hyperlipidemia, COPD (lung disease), and respiratory failure. Resident was on dialysis. Record review of CR #1's MDS assessment revealed a BIMS Score of 13. CR #1 required supervision or touching assistance in the areas of eating and oral hygiene. CR #1 required partial, moderate assistance in toileting, and upper body dressing and personal hygiene. Record review of CR #1's Care Plan indicated the resident was at risk for skin break down. The goal was to remain clean, dry, intact without evidence of breakdown over the next 90 days. The target date was to 3/25. Interventions was to assess skin on a weekly basis and PRN (As needed) any breakdown, assist with repositioning as needed using padding between pressure areas. In an observation and interview on 02/12/25 at 08:30 AM, CR #1 was at a local hospital. He said while at the facility he was unable to take a bath every day because there was no hot water and no clean linens or towels. CR #1 stated that the facility washers were broken for the last two months and when his clothing went to the laundry, he could barely get all his items returned. CR #1 reported that he had an infection due to not having a shower and inadequate clean linens and not getting his IV bandage changed daily as ordered. CR#1 began to cry and said the situation in the facility was inhumane and it made him feel dirty and worthless. Resident #2 Record review of Resident #2's face sheet dated 02/12/25 revealed, a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, paraplegia (type of paralysis that affects the lower half of the body), depression, cognitive communication deficit and non-pressure chronic ulcer of the buttocks. Record review of Resident #2's annual MDS dated [DATE] revealed, a BIMS score of 9 indicating he had moderate cognitive impairment. He required moderate assistance from staff with shower/baths and footwear. Record review of Resident #2's care plan printed 02/12/25 revealed, focus- incontinent(bladder/bowel) and at risk for skin breakdown and pressure wound formation ; goal: clean, dry, odor free and dignity will be remained; intervention: check for incontinent episode during rounds, change promptly and apply protective skin barrier, observe for skin breakdown. In an interview on 2/11/25 at 10:00 AM, Resident #2 stated the facility's washing machines were not working and have not been working for over 2 weeks. Resident #2 stated his own clothes have been lost. Resident #2 also stated the hot water has been out since 1/25/25 and just started working yesterday, 2/10/25, but the heat or air condition still does not work. Resident #2 stated he feels helpless and neglected at times because this should not be happening. He stated he could not take a shower because the water was cold. He stated same with wash ups in the sink. Resident #2 said he was a human being and felt he should be treated with more respect. Resident #7 Record review of Resident #7's face sheet dated 03/12/2025 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included diabetes, stroke, dementia, mild protein malnutrition, schizophrenia, bipolar disorder, anxiety, elevated blood pressure and non-pressure chronic ulcer of foot. Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 8 indicating she had moderate cognitive impairment. She required substantial assistance from staff for toileting, shower/baths, and lower body dressing. She required partial assistance with upper body dressing and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #7's undated care plan revealed she was bedfast most/all the time and at risk for skin breakdown. Interventions included use position devices to prevent skin break down. An observation and interview on 03/06/25 at 11:30 AM revealed, Resident #7 in bed with no fitted sheet or flat sheet. There was a draw sheet beneath her and blankets on top of her. Resident #7 said the previous night nursing staff removed her fitted sheet because it was wet, and it was never replaced. She said she preferred to have a fitted sheet because without it her skin would stick to the plastic mattress, and she did not like it. Resident #7 and she preferred to have a top sheet and that there was always a problem with linen supplies. She said the facility did not have enough towels, diaper s or wipes and she did not understand why the facility was always out of the supplies that were needed. Resident #5 Record review of Resident #5's face sheet dated 03/11/2025 revealed, a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body) d/t stroke, presence of prosthetic heart valve, depression, anxiety, diabetes, muscle weakness, dementia, high blood pressure and contractures of the left upper arm. An observation on 02/11/25 at 11:28 AM revealed, Resident #5 laying on a bare mattress in his room. In an observation and interview on 02/11/25 at 12:06 PM, Resident #5 stated there has not been warm or hot water in the facility for at least two weeks. Resident #5 stated he last showered on Sunday (2/9/25). Resident #5 stated the shower was still too cold. Resident #5 said most of the time he was unable to take a shower because there were no clean linens and the staff told him the linens were being washed at a local washeteria. He said the facility was supposed to be like home and the treatment he got did not make him feel good. An observation on 02/11/25 at 12:10 PM revealed, the water in Resident #5's bathroom was lukewarm. In an observation and interview on 03/07/25 between 9:55 AM and 10:25 AM, Resident #5 was observed in bed. He reported that his bed sheets had not been changed for a few days and prior to that he did not have sheets on his bed. Resident #5 said not having sheets was uncomfortable because his skin would stick to the mattress and on cold days the mattress made him cold. Resident #3 Record review of Resident #3's face sheet dated 03/11/2025 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, cirrhosis of the liver (abnormal liver function), low blood pressures, muscle wasting and pain. Record review of Resident #3's annual MDS dated [DATE] revealed a BIMS Score of 12 indicating moderate cognitive impairment. An observation on 02/11/25 at 11:28 AM revealed, Resident #3 laying on a bare mattress in his room. In an observation and interview on 02/11/25 at 12:06 PM, Resident #3 said the facility's washing machine and dryer were not working so his family had to wash his clothing since the facility could not keep up with his clothes. He said the laundry room has lost his clothing items which was another reason his family washed his clothes. Resident #3 stated the last time he took a shower was last Sunday and it was cold. He stated he just couldn't wait any longer and had to bear with the uncomfortable shower to get clean. He stated the water was only lukewarm today, but for the last two weeks there has only been cold water. An observation on 02/11/25 at 12:10 PM revealed, the water in Resident #3's bathroom was lukewarm In an observation and interview on 03/07/25 between 09:55 AM and 10:25 AM, Resident #3 was observed in bed. He reported that his sheets had not been changed for several days and prior to that he had no sheets. Resident # 3 said he felt unclean because he did not have clean sheets on his bed. Resident #6 Record review of Resident #6's face sheet dated 03/10/2025 revealed, a [AGE] year-old male admitted to the facility on [DATE] His initial admission was 11/21/2022 and his original admission was 02/26/2018. His diagnoses included acute respiratory failure with hypoxia (inadequate gas exchange by the respiratory system), dependence on supplemental oxygen, Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, chronic obstructive pulmonary disease (a lung condition caused by damage to the airway), anemia (reduced number of red blood cells), depression, functional quadriplegia (inability to completely move), congestive heart failure (is a condition where the heart is unable to pump enough blood to meet the body's needs), hypertension (elevated blood pressure) and anxiety. Resident #6 was his own RP. Record review of Resident # 6's Quarterly MDS (minimum data set, resident assessment, and care screening) dated 02/11/2025 revealed, intact cognition as indicated by a BIMS score of 14 out of 15. He required total dependence on staff for lower body dressing and substantial maximum assist for upper body dressing and personal hygiene. He was always incontinent of urine and bowel. Record review of Resident #6's undated care plan revealed he was bedfast most/all the time and at risk for skin breakdown. Interventions included keep sheets clean and wrinkle free. An observation and interview on 3/6/2025 at 9:45 AM revealed, Resident #6 lying on an air mattress with a bath blanket and regular blanket. Resident #6 did not have a fitted sheet and his pillowcase was visibly dirty/soiled. He stated he did not have a fitted sheet because he was on an air mattress, so he was lying on a draw sheet. Resident #6 said he always had issues with clean linen. He stated there was never enough linen especially top sheets and the facility was always short on towels and blankets especially during a cold snap. Resident #4 Record review of Resident #4's face sheet revealed, a [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included Hemiplegia (one sided paralysis), Hemiparesis (paralysis to one side of body), stroke, end stage renal disease, dialysis dependent, diabetes, heart failure, anxiety, and depression. Record review of Resident #4's quarterly MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 13. She had impairment to one side of upper and lower body that interfered with daily functions. She required substantial assistance from staff for showers/baths, and partial assistance with dressing and personal hygiene. Record review of Resident #4's undated care plan revealed, focus: risk for skin breakdown and injury due to decreased mobility; goal: skin will remain clean/dry, intact without evidence of breakdown; intervention- provide pressure reducing and positioning devices on resident bed/wheelchair as indicated. In an interview on 2/11/ 25 at 6:30 PM, Resident #4 stated she has not had a hot shower in 2-3 weeks. Resident #4 stated the water was either cold, cool, or lukewarm. Resident #4 stated the washing machine has been out for at least 3 weeks and the staff take dirty clothes, linens, and towels to the local washeteria. Resident #4 stated she was afraid to send her personal items to the laundry because items were often missing or lost. Resident #10 Record review of Resident #10's faces sheet dated 03/11/25 revealed, a [AGE] year-old male whose initial admission date was 05/07/21 and re-admitted on [DATE]. The resident's diagnosis included: Down Syndrome, moderate intellectual disabilities, need for assistance with personal care, cognitive communication deficit and retention of urine. An observation on 02/11/25 at 11:28 AM revealed, Resident #10 laying on a bare mattress in his room. An observation and interview on 3/7/2025 between 9:55 AM and 10 :25 AM in the secured unit revealed, Resident #10 was lying on the bare mattress. The resident was non-verbal and could not be interviewed so CNA G was asked why the resident's bed had no linens. CNA G said that the facility did not have enough clean linen on the unit. She said the laundry only had some sheets and bed pads, but it was not enough for every room. CNA G said it had been an ongoing issue and the facility did not have enough sheets and things for the residents. Residents #21-30 Observations on 02/11/25 at 11:28 AM revealed, the following additional residents not interviewed in their room laying on bare mattresses: 1. Resident #21 2. Resident #22 3. Resident #23 4. Resident #24 5. Resident #25 6. Resident #26 7. Resident #27 8. Resident #28 9. Resident #29 10. Resident #30 An observation on 02/11/25 at 06:45 PM revealed, Resident #29's bed did not have a privacy curtain. Observations on 03/06/25 at 10: 25 AM revealed, the following residents did not have sheets on their beds. 1. Resident #26 2. Resident #10 3. Resident #28 An observation on 02/12/25 at 7:05 PM revealed, enough linen for about 10 beds in the linen closet, dirty linen bags (waiting to be picked up and taken to the washeteria in the morning by laundry staff) at the end of each hall, and there were towels on staff carts in each hallway. An observation on 03/06/2025 at 9:00 AM revealed, there were no linens in linen closets in C Hall and D Hall. An observation on 03/06/25 at 10:38 AM revealed, there were no linens for beds on for Hall A. The linen closet was empty. An Observation on 03/06/25 at 11:00 AM revealed, the linen closet in C and D hall did not have linens. An observation and interview on 03/06/25 at 3:00 PM, 2 residential/standard size washing machines in use. An observation on 03/07/25 at 10:27 AM revealed, the linen closet on Hall A had no sheets, towels, or blankets. An observation on 03/07/25 at 11:02 AM revealed, the linen closet on Hall C had only 2 flat sheets on shelf. Observation on 3/6/25 at 10:38 AM of Hall A to check for linens on the bed. Rooms A6-8 did not have sheets on the bed. The linen closet for the hall was empty. In an interview on 2/11/25 at 10:15 AM, CW stated the residents were not being cared for. The CW stated residents were in soiled underwear or adult briefs a lot because the washing machines were broken and at certain times the staff were going to the washateria. The CW stated the trash outside of the facility hasn't been picked up in almost a month and it smelled and sometimes you could see rodents in the trash. The CW stated it was an eye sore for the neighborhood. . In an Interview on 2/11/25 at 10:25 AM, LA stated his job was to do laundry. LA stated that the washing machines have been down since last Monday (2/3/25). LA stated the facility's dirty laundry was picked up daily and taken to the local washateria, where the linen, clothes, and towels were washed and returned to the facility. LA stated that the two domestic dryers in the facility were operable; however, the commercial dryer did not work. LA stated that the residents' clothes were organized by the resident's names that were labeled or marked on the inside of the clothes after being washed. He stated that the clothes without names came back to the laundry area and if a resident was missing clothing items or the CNAs knew that one of their residents were missing clothes, then they came here to the laundry area and retrieved the missing clothing items. LA stated that if a resident did not know or was not cognitive enough to know if they are missing clothes, then they probably would not be getting them. LA stated sometimes the CNAs would come get the residents clothes. When asked if he thought this was a good process, LA stated he did not know because he is only doing what he has been taught to do and at this point there has not been any complaining from the CNA's or residents. In an interview on 2/11/25 at 11:32 AM, CNA A stated there was no clean linen in the facility today. CNA A stated the last day of clean linen was Sunday (2/9/25) when she last stocked for second shift. CNA A stated the process for the MCU was to stock the clean linens for the second shift. CNA A stated when she came on to the MCU yesterday morning (2/10/25), there were no clean linens, and the residents were laying on their bare mattresses. CNA A stated she sanitized the mattresses to ensure cleanliness. In an interview on 2/11/25 at 12:00 PM, CNA B stated the A-Hall had hot water for approximately a week. However, prior to that, the water was cold and as the temperature changed outside to a little warmer, the inside showers and sinks in the rooms became lukewarm. CNA B stated without towels the showers have become interrupted and a lot of residents haven't received showers. CNA B stated the facility's commercial washing machines were out for the last two weeks. CNA B stated the first shift CNAs were hardly able to give the residents their baths or showers because there were no towels, or the water was too cold, and the residents refused. CNA B stated there were no face towels in the facility for the residents. The only towels, when they were clean, were bath towels. In an interview on 2/11/25 at 12:05 PM, the Housekeeper stated she was aware of the facility running short on linens because the washing machines have been broken for a while but could not give an exact timeline of how long the machines have been inoperable. The housekeeper stated that the trash outside had not been picked up in 2 weeks. In an interview on 2/11/25 at 12:15 PM, CNA C stated some of the residents were on bare mattresses because the facility did not have linens. CNA C stated she has only worked at the facility for a week, and it has been like this since she started. CNA C stated she just continue to check on resident and ensure when the washed linen return to facility she makes the beds up and ensure resident has clean towels and clothing. In an interview on 2/11/25 at 03:00 PM, CNA D who stated there was a problem with getting clean towels. CNA D stated it was difficult to do an adequate job caring for residents when there were no towels to clean residents, or the showers were too cold to bath them. CNA D stated this weekend (Sunday 2/9/2025) there were no briefs for residents, wipes, or gloves and some residents had to wear a towel for briefs. She stated it was like this on the morning and afternoon shifts. In an observation and Interview on 2/11/25 at 4:37 PM, Maintenance stated he got a complaint about the water issue on January 30th, 2025, that there was water coming out of the ceiling; however, when he came to the facility there was hot water running out of the ceiling. Maintenance stated the circulation pump busted on Sunday. Maintenance stated on Monday morning he ordered the pump which arrived on the 3rd of February 2025. It was installed the same day. Maintenance stated the policy for temperatures were important for environmental issues for residents, them maintaining their hygiene, and because it's important for their health. Walk through Water Temperature Observation with Maintenance in the following areas: Room D-1 Sink - 81 degrees Room D-10 Sink - 100 degrees D Hall shower sink - 105 degrees D Hall Shower - 93 degrees Rooms C6-C-8 Sinks - 92.7 Degrees Room C-13 - 100 Degrees C-Hall Shower - 93 degrees C Hall Sink - 93.6 Degrees. In an interview on 2/11/25 at 6:15 PM, CNA E stated he worked Sunday morning (2/9/25) from 6:00am to 2:00 PM. CNA E stated there were no linens or towels during his shift. CNA E stated that there were no briefs for residents on his hall and had to retrieve some briefs from other resident halls. CNA E stated that there were no gloves or wipes in the facility; however, did not offer any additional information on how the residents were cleaned. In an interview on 2/12/25 at 2:15 PM, CNA F stated the resident and facility laundry was picked up in the morning around 5:30am to be taken to the local washateria and usually returned in afternoon by 3:00 PM with clean linens. She stated she brought her own gloves when she worked because she was aware that there was a shortage of supplies and other items. In an interview on 2/12/25 at 2:25 PM, LVN A stated she has observed at times there was no clean linens in the facility. She stated the washer has been broken for a while, so the dirty clothes and laundry must go to the local washateria and return to the unit around 3:00 PM. She stated when there were no sheets, towels were used on residents temporarily for briefs or sheets. In an interview on 2/12/25 at 7:35 PM, the Administrator stated the facility's washing machines had been broken for 2 weeks. She stated parts have been ordered on 2/7/25. She stated until the parts arrive, the linens and towels had to be taken to the local washeteria for washing. The Administrator stated although the residents that were cognizant have stated they understand, she stated they should not have to be subjected to this because they were supposed to have linens and towels and not wait for them to be washed. She stated the facility has washed the private curtains and were in the process of hanging them in the rooms. In an interview on 3/6/25 at 12:55 PM, KL stated that sometimes clean linens were not available until the second shift, which started at 2:00 PM. They were always short on linens since last fall. It was not like that when KL first began working at the facility. KL reported that a complaint was made to management before, but KL felt being treated differently after reporting. KL did not report things much anymore afterwards because of fear of retaliation for reporting issues. KL ran out of briefs on the unit this morning but got some from another hall. KL stated normally we have briefs. KL stated that without necessary tools KL could not provide resident care fairly or not at all. In an interview on 3/6/25 at 3:00 PM, the Laundry Tech stated the washers were down one or two months ago and that was when he started taking the laundry to the washateria down the street. He stated his process was separating the linens from the towels and personal items were always bagged separately. He stated isolation bags would come in red or yellow bags and usually the nursing staff would hand deliver, so he knew whether to wash them or throw them away. He stated he would always wash contaminated isolation laundry last. There were 2 standard size washing machines in operation. He stated he washed the laundry the same way when using the machines at the washateria. He stated the transport driver would help him with transporting the laundry to washateria. He stated he never brought contaminated/isolation laundry to the washateria because he did not know how well they would be cleaned. He stated he did not know whether the nurses threw them away or not. In an interview on 3/7/25 at 11:49 AM, the Administrator stated that a shipment was received yesterday (03/06/2025) so that should have solved the problem of residents without any sheets or shortage of bed sheets. There should not be anyone without sheets today. Some CNAs are taking them to their hall and then another hall does not have enough until the next batch was washed. She stated that the facility was working on the distribution of linens. The laundry starts around 4:30 AM so that there are sheets available for each hall when the shift changes at 6am. She stated she was Not sure how the shortage happened but suspected that since the trash barrels and dirty linen barrels were the same color, someone may have been throwing out the sheets by mistake. She stated, the color of the barrels will be changed to prevent that from happening. The Administrator was asked the question if the company was experiencing financial problems that would prevent purchasing linens needed for the facility. She stated she was not aware of any problems and that the facility was very conscious of waste and did not want unnecessary purchases to be made. She stated that she did not think resident beds without bed sheets would affect the psychosocial well-being of the resident because the residents who were aware enough to understand that, know that it was us and not them. It was not their fault we were in short supply so they should not feel bad about themselves. When asked if there was a dignity issue, she stated nobody should be on a bare mattress and that the facility was working on the problem. She stated it was not a system failure with the linen process. She stated it was a hoarding thing because we were short for a long time and now the CNAs are worried, they will not have enough so they grab all they can. We have also found residents with extra linens in their room. When asked if the failure to provide services was neglect, she stated the facility had not failed to provide them, they are here, they are being moved by staff. Until we get an abundance, then they will stop doing it. It is a process of unlearning. She stated that neglect comes with intent and neglect was a willful act to not provide something. She stated Abuse and Neglect trainings for all new hires was part of the orientation and as coordinator, I make sure everyone was trained. We also do education multiple times a year. In an Interview on 3/7/25 at 2:17 PM, NP #2 stated the only health issue from not having sheets on the bed that she could think of was the skin rubbing on bare mattress could cause skin breakdown. For psychosocial affect, it would depend on if the resident had a preexisting mental health issue such as a phobia or an obsession with neatness. It may not affect some residents at all. It would be very individualized. In an interview on 3/7/25 at 2:24 PM, the DON said there was no health risk that she could think of regarding resident's not having linens on their beds. As far as dignity, some people prefer to have a sheet on them so that would bother them. She said she thought it only impacted how they thought about the facility staff, not how they think about themselves. The DON said she would be mad at the person that wasn't taking care of me if she was in the residents' situation. In an Interview on 3/7/25 at 2:35 PM, LVN A said I've seen residents without sheets on the bed sometimes. We wait for them to come around with fresh ones and then the bed gets made. I can't think of any health risks. Residents might get mad at us, but I have not seen anyone get upset with themselves. In an interview on 3/9/25 at 7:06 PM, TQ stated that it sucks that they don't have the supplies. TQ stated there were no gloves, no sheets, no briefs, no wipes, and no staff. TQ stated there were no gloves and cannot clean poop without them. TQ stated they need sheets, wipes, gloves, briefs, and staff. TQ stated they would scavenger hunt at night for these items. In the last couple of days, they have had supplies they need, and this was the first night they were fully staffed. Interview on 3/9/25 at 7:30 PM with Resident #8's RP, stated there had been times she visited, and they did not have sheets on the bed and the staff would go to look for sheets. Sometimes they found one and sometimes they said it was drying and could not put one on the bed. The RP stated Resident #8 had been wet during the evening of 3/9/25. She was going to try to move him because they need a system. Interview on 3/9/25 at 7:40 PM, RM stated most times they had problems with gloves, and they did not have the supplies. RM had to come to work bringing own supply of gloves to make sure gloves were available when needed. RM stated last week the CNA's complained about linen, wipes, and diapers. The CNA's tried to do what they could do. RM stated once they do not have the material to work with it affects the residents. The residents went without sheets. Some of the residents complained of being cold. They did not have enough things to cover them. Interview on 3/9/25 at 7:45 PM the Social Services stated she did not know what happened in the building. She stated all she knew was that the washer went out and the Administrator was taking the laundry aide to the laundromat/washeteria to wash the sheets. She stated she did not know what happened with the sheets. Record review of Facility provided invoice dated 02/04/25 revealed, the facility ordered linens and towels. Record review of Facility provided invoice dated 02/07/25 revealed, the facility ordered washing machine parts. Record review of the facility's undated policy on Abuse and Neglect - Clinical Protocol read in part: Definitions:2. Neglect as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Record Review of the facility's undated policy Quality of Life- Homelike Environment reflected the following: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management shall maximize, the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident #1) received adequate supervision and that the resident environment remained as free of accident hazards as is possible, in that: The facility failed to ensure Resident #1 was served coffee at a safe temperature which resulted in a burn to her left hand. The facility failed to ensure a temperature log was kept to document temperatures of coffee prior to distribution and service to residents. An immediate jeopardy of past non-compliance was identified on 11/13/2024 at 1:30PM. The IJ template was provided to the facility Administrator on 11/13/2024 at 2:50PM. The Immediate Jeopardy was determined to have existed from 10/20/24 to 10/22/2024 due to the facility's implemented actions that corrected the non-compliance prior to survey entry. This failure injured Resident #1 and placed other resident at risk of injury, burns, pain, anxiety, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with dementia (decline in mental ability), schizoaffective disorder (chronic mental illness involving delusions and hallucinations), muscle wasting atrophy (muscle mass decrease), and spastic hemiplegia (type of cerebral palsy causing muscle tightness and paralysis) affecting left dominant side. Record review of Resident #1's MDS assessment, dated 09/11/2024, reflected the resident had a BIMS score of 11 indicating moderate cognitive impairment. It also reflected the resident's ability to ambulate by manual wheelchair and her need for supervision or touching assistance for eating. Record review of Resident #1's care plan, dated 07/09/2022, revealed the resident had an ADL self-care performance deficit and needed set-up help and supervision while eating. Record review of Resident #1's nurses note, dated 10/20/2024, reflected, .Resident came to the nurses station complaining of a burn. She reported that she had went to the kitchen for coffee and received a hot cup with no lid. Nurse observed reddened skin on the Left hand and wrist. Tylenol was given along with an ice pack to the hand. Resident seemed a bit anxious after the incident. Vitals assessed and found to be WNL and are as follows: BP:130/69 HR: 76 . Record review of the facility's investigation report, form 3613A, dated 10/28/2024, reflected the perpetrator, [NAME] A, was alleged to have given Resident #1 a cup of coffee without a lid on it which resulted in Resident #1 spilling it on her left hand and causing redness. It also reflected in the investigation summary that the resident had a history of removing the lid from drinks and spilling it on herself. There was conflicting reports given by Resident #1 and [NAME] A as to whether there was a lid on the coffee or not prior to serving. Record review of Rresident #1's wound assessment, dated 10/25/2024, revealed Resident #1 acquired a burn wound of the left hand full thickness measured at 6 x 2 x 0.1 cm with open ulceration area of 8.2cm out of 12 cm total surface area, light serious exudate, 70 % granulation tissue and 30% intact normal colored skin. The Wound Physician noted there was, . no indication of pain associated with this condition . and the wound had . improved evidenced by decreased surface area . The treatment plan included silver sulfadiazine once daily for 27 days and gauze roll once daily for 30 days. Record review of Resident #1's care plan, dated 10/21/2024, reflected resident had burn to left hand from spilled hot coffee measuring 6 cm x 7.5 cm x 0.1 cm and the goal was to have resident's skin concern heal without complications over the next 90 days with interventions, including treatments, pain, medication, and monitoring for skin breakdown. Interview and observation of Resident #1, on 10/29/2024 at 3:25PM, revealed the resident was lying in bed with bandages wrapped around her left hand. The resident stated she had the bandages because she was burned by hot coffee, but was no longer in pain at that time. In a phone interview with [NAME] A on 10/30/2024 at 2:49 PM, he stated Resident #1 often came to the kitchen to request for coffee and he gave it to her every time she asked. He stated she was the only resident to do so. He stated he was taught to give coffee to residents with a lid on the coffee mug. He stated he never checked coffee temperatures prior to serving the coffee. He stated on 10/20/2024, Resident #1 requested for coffee beyond their breakfast time, so he made a fresh batch of coffee for her, poured in the cup and put a lid on it prior to handing it to her. He said at that moment, Resident #1 wanted to drink her coffee right then and there. He observed her remove the lid immediately, and a result, she spilled some of the coffee on herself. He stated he did not see the risk of serving her coffee then because the cup had a lid on it. He stated he did not know the resident burned herself until after he was told by the nurse shortly after the incident. [NAME] A stated the Dietary Manager did not train him on the specifics of temping and serving coffee until after the incident. In a phone interview with the Dietary Manger, on 10/30/2024 at 3:10 PM, he stated all of his staff, excluding [NAME] A who was recently hired back onto the team, were aware of Resident #1's behaviors of asking for coffee throughout the day, including beating on the kitchen door to request for coffee. He said, prior to [NAME] A being hired, he verbally trained his staff to not give her coffee unless a nurse was present with her at the time of the request due to how disruptive it was to their meal service process and because of Resident #1's habit of immediately pouring the coffee from the facility cup to her personal steel cup. He stated he never did an in-service related to temping coffee because they never had an incident before that would necessitate it. The Dietary Manager said he did not see a risk because they thought the way they were distributing coffee was okay. He also said that they had lids in inventory. He stated that temperatures come out of the brewer around 145 degrees and they distributed the coffee when temped around 130 degrees. In an interview with the Regional Nurse Consultant on 10/31/2024 at 1:00 PM, she stated the kitchen staff should have kept a log of the temperature of the coffee prior to serving it because after the incident, there was no way to verify just how hot that coffee was to have caused Resident #1 to burn herself with it. In an interview with the Administrator on 11/01/2024 at 11:07 AM, she stated after looking into the incident, she believed the kitchen staff skipped steps, such as temping or cooling off the coffee prior to serving. The mistake resulted in Resident #1 getting burned, She pulled all the information on the case, talked with the dietitian, and helped setup and an in-service for all the staff. Record review of the facility's policy on Safety of Hot Liquids, dated 2018, reflected, . 1. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. 2. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. 3. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquids Safety Evaluations and update plan of care as applicable. 4. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: 1. Maintaining a hot liquids serving temperature of not more than 140 degrees Fahrenheit; 2. Serving hot beverages in a cup with a lid; 3. Encouraging residents to sit at a table while drinking or eating hot liquids; 4. Providing protective lap covering or clothing to protect skin from accidental spills; and 5. Staff supervision or assistance with hot beverages . Corrective Actions: Record review of the facility's in-service, titled Serving Hot Liquids, dated 10/22/2024, reflected training to all dietary staff detailing hot liquids were to be served between 135 degrees and 140 degrees and were to be served to residents only by clinical staff and not directly from the kitchen. It also reflected, . If a resident comes to the kitchen asking for coffee, they need to be redirected back to the appropriate nursing station for assistance . Coffee will be randomly tested for temperature before being given to staff. Record review of coffee temperature log, date ranging from 10/21/2024 - 10/30/2024, revealed the coffee temperature was being recorded daily once brewed and at meal service time, the coffee temperature was documented at 140 degrees each day. In an interview with Dietary Aide A, Dietary Aide B, and [NAME] on 10/30/2024 at 9:22 AM, they all stated that they were trained on hot liquids safety and knew not to hand coffee directly to residents without a nurse present. They also unanimously stated they were to document the temperature of the coffee once brewed and hand over the coffee to nursing staff once cooled down to 140 degrees prior to serving. In a phone interview with [NAME] A, on 10/30/2024 at 2:49 PM, he stated he was trained to no longer give resident's coffee, and to make sure nursing staff was present to distribute coffee to residents. He also stated the coffee temperature needed to be cooled down to 140 degrees and documented on the log before sending it out for the residents. In a phone interview with the Dietary Manager, on 10/30/2024 at 3:05PM, he stated following Resident #1's incident, he trained kitchen staff to ensure the temperature of the coffee out of the urn and prior to service were being documented. He stated the coffee should be temped at 130-140 degrees prior to allowing nursing staff to serve to residents. Observation and interview with Dietary Aide C, on 10/31/2024 at 7:10 AM, revealed coffee was brewed and temped at 157 degrees. Dietary Aide C documented the temperatures on the log. She reported that she was trained on hot liquids safety and knew she had to wait until the coffee temperature reached 140 degrees prior to serving. Observation on 10/31/2024 at 8:00 AM revealed Dietary Aide C temped the coffee at 140 degrees and reported to the present nursing staff that coffee was ready to be served. In an interview with Dietary Aide D, on 11/13/2024 at 9:56 AM, she stated she typically brewed and temped the coffee at around 160-180 degrees, transferred the coffee to the urn and waited for temperature to cool down to 140 degrees before putting out for meal service. She stated, preceding distribution of coffee, she made sure to confirm the temperature of the coffee with a nurse as a witness. Interview with [NAME] C on 11/13/2024 at 10:00AM, he stated he was trained on managing hot liquids following Resident #1's incident. She stated coffee was brewed between 160-180? and had to be cooled down to 140 degrees prior to meal service by the nursing staff. Observations of the kitchen on 11/13/2024 at 10:04 AM, revealed an unidentified resident came to the entrance of the kitchen requesting coffee and [NAME] C turned her away stating that she had to bring a nurse with her in order to receive coffee. Record review of in- service, titled Hot Liquids Safety, dated 10/21/2024, reflected training was provided to all nurses and nurse aides pertaining to distribution of hot coffee. The training detailed that staff were no longer allowed to reheat coffee for residents upon request. In an interview with CNA A, on 10/31/2024 at 1:29 PM, she stated she was trained on safety precautions for serving hot liquids and knew to set the coffee on the table in her room rather than passing it directly into her hands to prevent any spills and burns. In an interview CNA B, on 10/31/2024 at 1:50 PM, he stated he was trained on serving coffee and knew to make sure coffee was cool enough for residents to drink. He stated all residents were to be handed their coffee by nursing staff and they were not allowed to get coffee by themselves or from dietary staff. In a phone interview with the DON on 11/01/2024 at 11:54 AM, she stated she could confirm if there were rules in place for nursing staff to serve coffee but the distribution of coffee from the urns to the residents were typically always done by nursing staff . She stated staff have since been trained to ensure burn incidents did not happen again. In an interview with LVN A, on 11/13/24 at 2:05 PM, she stated she typically observed all mealtimes on her shift, and she had been trained to ensure that all residents were served by nursing staff only and the coffee was not too hot to them. In an interview with CNA C on 11/13/24 at 2:15 PM she stated she typically served residents coffee on the halls and was trained on hot liquid safety. She stated she ensured residents were served coffee from the urn using a cup with a lid. An immediate jeopardy of past non-compliance was identified on 11/13/2024 at 1:30PM. The IJ template was provided to the facility Administrator on 11/13/2024 at 2:50PM. The Immediate Jeopardy was determined to have existed from 10/20/24 to 10/22/2024 due to the facility's implemented actions that corrected the non-compliance prior to survey entry.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for 1 (Resident #1) of 3 residents reviewed for notification of changes. -The facility failed to notify the primary doctor (MD B) of Resident #1's pressure ulcers that were observed 10/6/23 to11/16/23 resulting in Stage. An Immediate Jeopardy (IJ) was identified on 12/7/2023. The IJ template was provided to the facility on [DATE] at 4:03 pm. While the IJ was removed on 12/8/2023 at 3:45 pm, the facility remained out of compliance at a severity of actual harm that is not IJ with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delayed treatment, deteriorating pressure ulcers, infections, and hospitalization . Findings include: Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with acute respiratory failure, type 2 diabetes (body does not produce insulin or resists it), nontraumatic intracerebral hemorrhage (bleeding to part of the brain), aphasia (unable to talk), anemia (low iron), epilepsy (seizures), anoxic brain injury (brain injury due to lack of oxygen), gastrostomy (tube into stomach for nutrition), and dependence on a ventilator (machine breathes for you). Record review of Resident# 1's entrance MDS, dated [DATE], revealed a blank BIMS score because it was unable to be performed due to the resident's cognition. The MDS also revealed the resident had impairment on both sides of his upper and lower extremities and was dependent with all activities. Resident #1 was always incontinent of bowel and bladder. The MDS revealed the resident was at risk of developing pressure ulcers/injuries but had no unhealed pressure ulcers/injuries at that time. It also indicated the resident had no venous/arterial ulcers, or any other wounds or skin problems. The MDS did not reveal a turning/re-positioning program, nutrition/hydration intervention, application of dressings, or pressure ulcer/injury care were being used. Record review of Resident #1's care plan, dated 10/3/23, revealed a Focus: Resident has an open wound to the sacrum and is at risk for infections. 11/8/23: 6cm x 5cm x 2cm, 11/15/23: 8cm x 7cm x 3cm- post debridement. Resident has an open wound to left ischium (hip area) and is at risk for infections. 11/8/23: 12cm x 4cm x 0cm, 11/15/23: 11cm x 6cm x 0cm- post debridement. Resident has a DTI to right heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Resident has a DTI to left heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Goal: Area will show signs of healing or heal without complications through/by next review date. Interventions: Follow up with MD as appropriate and scheduled. Keep dressing clean, dry, and intact. Observe dressing every shift and replace as needed for soiling, strike through drainage/bleeding. Provide treatment as ordered. Observe wound when changing dressing for S/S of healing or complications (odor, increased drainage etc.) or wound shows no improvement in 2 weeks notify MD of findings. Refer to wound care nurse as indicated. Focus: Resident #1 is bedfast most/all of the time and is at risk for skin break down. Goal: Resident #1 will have no increase in skin break down over the next 90 days. Interventions: Assess skin weekly for skin break down. Keep sheets clean and wrinkle free. Turn and re-position during rounds/PRN. Use positioning devices to prevent skin break down. Focus: Resident #1 is at risk for skin break down and injury AEB immobility and incontinence. Goal: Resident #1's skin will remain clean/dry, intact without evidence of break down over the next 90 days. Interventions: Assess skin on a weekly basis and PRN-report any break down to MD/RP. Assist with re-positioning as needed using padding between pressure areas. Check for incontinence during rounds and PRN-change promptly. Provide pressure reducing and positioning devices on resident's bed/wheelchair as indicated. Focus: Resident #1 is incontinent of (bladder/bowel) and is at risk for skin break down and pressure wound formation. Goal: Resident #1 will remain clean, dry, odor free and dignity will be maintained over the next 90 days. Interventions: Check for incontinent episode during rounds, change promptly and apply a protective skin barrier. Observe for s/sx of skin break down-report to nurse. Re-assess for possible toileting program-quarterly and PRN. Focus: Resident #1 is at risk for decline in ADL functions and injury r/t ICH, decreased mobility, anoxic brain damage. Goal: Resident #1 will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Interventions: Bed Mobility-Provide total assistance with 1-2 persons assistance. Dressing-Provide total assistance with 1-2 persons assistance. Personal hygiene/grooming-Provide total assistance with 1-2 persons assistance. Toileting-Provide total assistance with 1-2 persons assistance. Transfers- Provide total assistance with 1-2 persons assistance. Record review of Resident #1's previous hospital records dated 9/24/23, revealed a progress note from MD A which said, there was no rash or skin change. Record review of Resident #1's medical record revealed a Braden Scale for Predicting Pressure Sore Risk, dated 10/3/23 which indicated the resident was at moderate risk of developing pressure sores. Record review of Resident #1's Weekly Skin Monitoring dated 10/3/23, revealed an assessment from LVN A which indicated the resident had a small excoriation (scratch) on his left buttock. Record review of Resident #1's Weekly Skin Monitoring dated 10/6/23, revealed an assessment from the Wound Care Nurse which indicated the resident had a closed, dry area on sacrum (portion of spine between lower back and tailbone), a dry sore to the left buttocks, a dry sore to the left, rear, shoulder, a dry sore to the left knee, and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 10/13/23, revealed an assessment from LVN B which indicated there were no skin issues on the resident. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/18/23, revealed an assessment from the Wound Care Nurse saying the resident had a Stage II (only involves upper most layer of skin, shallow), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/20/23, revealed an assessment from the Wound Care Nurse which indicated the resident had redness to his sacrum (portion of spine between lower back and tailbone), redness to ischium (curved bone forming the base of pelvis) but it did not say which side, and bilateral (both) heel DTIs. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/25/23, revealed an assessment from the Wound Care Nurse saying the resident had a Stage III (extends through skin into deeper into tissue and fat), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/27/23, revealed an assessment from the Wound Care Nurse which indicated the resident had redness and shearing (tearing) to his sacrum (portion of spine between lower back and tailbone), redness to the left ischium (curved bone forming the base of pelvis), and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 11/3/23, revealed an assessment from the Wound Care Nurse which indicated the resident had a pressure wound to his sacrum (portion of spine between lower back and tailbone), shearing (tearing) to his left buttock, and bilateral (both) heel DTIs. Record review of Resident #1's medical record on 12/7/23 revealed no SBAR or Change in Condition documentation until 11/16/23. Record review revealed a Change in Condition Evaluation dated 11/16/23 and revealed there was a change in condition regarding a skin wound or ulcer that started on 11/16/23. It said Skin Evaluation-Describe Skin Changes: Wound. Describe the Wound: Any wound that will not stop bleeding OR that exposes subcutaneous tissue. Site: Sacrum- Exposed subcutaneous tissue. MD B was notified at 4:00 pm on 11/16/23. Record review of Resident #1's Physician Orders revealed there were no wound care orders until 11/16/23 by MD B: -Follow MD parameters as ordered. Notify MD for all changes in condition. Ordered 10/2/23. -PERFORM HEAD TO TOE ASSESSMENT. ASSESS ALL AREAS OF SKIN. Ordered on 10/2/23. -Skin assessment is to be done weekly, every day shift, every Mon for skin integrity support. Ordered 10/2/23. -Apply skin prep to both heels, every day shift. Ordered on 11/16/23. -Clean wound to left ischial (curved bone forming the base of pelvis) with NS, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23. -Clean wound to sacrum (portion of spine between lower back and tailbone) with NS, pat dry, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23. -Off load heels while in bed, every shift. Ordered 11/16/23. -Meropenem Intravenous Solution Reconstituted 1gm, Use 1gm intravenously every 8 hours for wound infection and severe leukocytosis for 14 days. Ordered 11/16/23. -Vancomycin HCl Intravenous Solution 1000mg/10ml, Use 1gm intravenously every 12hrs for wound infection and severe leukocytosis for 14 days. Ordered 11/16/23. -Zinc Oral Tablet, Give 50mg via G-tube one time a day to promote wound healing. Ordered 11/16/23. Record review of Resident #1's medical records revealed a Transfer Form filled out by RN A, dated 11/22/23, which indicated the resident was being transferred to the hospital for abnormal labs/wound infection. It also said the resident had started IV antibiotics (Vancomycin and Meropenem) on 11/17/23 for a possible wound infection and had no MDROs. The transfer form revealed the resident had an unstageable pressure ulcer to his sacrum (portion of spine between lower back and tailbone) and right buttocks, and DTIs to both heels. Interview with a family member on 12/1/23 at 9:58 am she revealed when Resident #1 first came to the facility, he had no wounds. Interview and observation with the hospital RN on 12/1/23 at 12:38 pm, Resident #1 was observed in ICU laying on his back on a bariatric air mattress. He had heel protecting boots on, had a foley (catheter into bladder to drain urine), PEG (tube into stomach for nutrition) tube running, and IV with antibiotics running, and was on a ventilator (machine breathes for you). She revealed Resident #1 had just returned from a debridement surgery for his wounds. She stated the resident came in with wounds to his sacrum (portion of spine between lower back and tailbone), both buttocks, both heels, and both ankles. She also said the resident had been running fever every night and was on contact isolation for Pseudomonas, Klebsiella, ESBL, VRE, and Staph Enterococcus (resistant bacteria). She said he had osteomyelitis (bone infection) to his sacrum (portion of spine between lower back and tailbone). Interview with LVN C on 12/5/23 at 10:25 am she revealed she informed the Wound Care Doctor verbally about pressure ulcers when he came to the facility weekly. She said nothing was documented that she spoke to the doctor. Interview with RN B on 12/5/23 at 10:30 am she revealed she would assess the residents with wound care orders to see if they had any other skin issues, and if they did, she would report it to the staff nurse. The staff nurse would notify the doctor. RN B said she had no communication with the doctor. Interview with LVN B on 12/5/23 at 11:12 am, she revealed she performed wound care over the weekend and saw two wounds she thought were worsening but did not remember which residents they were. She said she informed the DON and he said he would notify the doctor. She said she had no communication with the doctor. Interview on 12/7/23 at 12:05 pm with MD B, he said staff would update him verbally on wounds while he was in the facility, but he was unsure when Resident #1's wounds first started. He said there was not any documentation that he or his NP were notified. Record review of the facility's policy and procedure on Skin Assessment Monitoring Guidelines (revised 10/2021) read in part: Policy: All residents will be assessed upon admission, quarterly and with a significant change in condition to identify risk factors that may lead to impaired skin integrity .If a skin concern is noted, do not assume that the nursing team is aware. Validate that there is a treatment or monitoring order, that physician and resident/representative are aware and care plan reflects area of concern. If it is determined to be a new area note on 24-hour report, add to Alert Charting. Notify resident/representative and Director of Nursing/designee, note new treatment/monitoring orders, revise care plan as indicated. The Director of Nursing (DON)/designee will monitor Weekly Skin Monitoring UDAs in [EMR] to validate completion and follow up to any new skin areas identified. The Skin Committee will meet weekly and as needed to review Weekly Wound/Skin Report and make recommendations as deemed appropriate. Record review of the facility's policy and procedure on Wound Monitoring Guidelines (no revision date) read in part: Policy: It is the goal of the facility to maintain skin integrity. A resident who has developed or is admitted with a wound .will receive necessary treatment and services to promote healing, prevent infection and prevent new wounds from developing .Procedure: The licensed nurse will perform the following procedures for this classification of wounds identified on Admission, during Weekly Skin Monitoring Assessments or any other daily care: 1. Notify the physician for orders to treat each wound identified, including type. Wounds will be treated per established protocol unless otherwise specified by the physician. Transcribe orders onto Treatment Administration Record (TAR). Validate wound type/identification, goals and interventions are addressed on the resident's Care plan. Notify resident/resident representative regarding change in condition if applicable .6. All wounds .will be assessed on a weekly basis using the Weekly Wound Observation Tool (One Wound per UDA) in [EMR]. The Director of Nursing/designee will be responsible to validate that documentation is accurate and performed in a timely manner. 7. The Director of Nursing/designee will be responsible for completing and maintaining the Wound Log. Special Note: It is recommended that if a wound is initially classified as pressure injury/ulcer, however, the wound presents as vascular/arterial wound that prompt notification of physician with clarification orders related to type and classification of wound are obtained .Wound classification should be consistent throughout the resident medical record, including Weekly Skin Head to Toe UDAs, Wound Clinic notes, Physician Orders, Progress Notes and Care Plan. Consistency of documentation should be validated in Weekly Skin and Weight Meeting. On 12/7/2023 at 4:03pm the Administrator and DON were notified that an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 4:03pm. The Plan of removal was accepted on 12/8/2023 at 12:47pm. The plan of removal reflected the following: The facility needs to notify the Primary Care MD of any change in status to residents so treatment can start without delay. R[Resident] #1 was discharged from the facility on 11/22/2023. 1). Action: Chief Nursing Officer updated and re-educated facility Administrator and Director of Nursing on the Policy and Procedure for a). Change in a Resident's Condition or Status and b). Charting and Documentation on 12/07/2023. Mode of Education was a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 12/07/2023. Comprehension was assessed by the Chief Nursing Officer via the teach-back method on 12/07/2023. Start Date: 12/07/2023 Completion Date: 12/07/2023 Responsible: Chief Nursing Officer 2). Action: The Director of Nursing re-educated facility Licensed Nurses (RNs/LVNs) on duty of the facility Policy and Procedure for a). Change in a Resident's Condition or Status and b). Charting and Documentation on 12/07/2023. Staff not on duty during the training period will receive 1:1 training before starting their next shift from the Director of Nursing, or Assistant Director of Nursing or the facility Administrator. c) Nurses educated on notifying/consulting the physician for change of condition and wound or skin changes. Mode of Education was /will be a memo in the form of a copy of the Policy and Procedure and occurred in a face-to-face meeting on 12/07/2023 and ongoing until all Licensed Nurses (RNs/LVNS) have been re-educated. Education is to be added as part of the orientation for ongoing training of new hires, agency, and PRN staff through a combination of employee training, employee monitoring, and reporting processes. The teach-back method will be used to assess comprehension on 12/07/2023 and will be ongoing until all Licensed Nurses (RNs/LVNS) have been re-educated. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing 3). Action: The Director of Nursing educated Licensed Nurses (RNs/LVNs) specific education for reporting wound or skin changes of condition; nurses were/will be educated to report any exposed subcutaneous tissue; presence of or increased drainage; presence of or increase in odor; signs of infection, i.e. increased redness (erythema), swelling (induration), fever, increased size, or undermining AND any wound not responding to treatment upon weekly evaluation. The Director of Nursing educated Nurses on notifying/consulting the physician for change of condition and wound or skin changes. The director of Nursing will ensure that off-cycle Wound Observation Tool is completed within 24 hours upon discovery or a new wound and changes in current wounds and weekly thereafter. The Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Weekend Supervisor or Designee will do the same Saturday and Sunday. Compliance checks will be completed weekly by the Administrator by checking wound report to Wound Observation Tools completed in [EMR]. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing and Administrator 4). Action: The Director of Nursing and Assistant Director of Nursing have completed an audit of the development of new wounds or worsening wounds have been completed for the past 30 days, Wound Observation Tools have been completed and Interact Changes of Condition/SBAR Communication form have been completed in [EMR] for residents with Pressure Ulcers/injuries; both tools indicate MD notification. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing and Administrator 5). Action: The Director of Nursing and Administrator will review the 24-hour Report daily Monday through Friday in morning stand-up for potential and actual changes in resident's condition or status to ensure appropriate assessment, notification, and documentation. The facility will ensure the RNs/LVNs have complete Wound Observation Report and notified the MD upon a Resident Change of Condition or Status by ensuring the Interact SBAR Communication form is completed in [EMR]. The Administrator and Director of Nursing will provide additional education as deemed necessary to maintain ongoing compliance. Weekend Supervisor or Designee will do the same Saturday and Sunday. Compliance checks will be completed as part of monthly QAPI. Start Date: 12/07/2023 Completion Date: 12/08/2023 Responsible: The Director of Nursing and Administrator On 12/8/23 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed: Record review and interview on 12/8/23 at 9:12am revealed all facility residents were assessed by either the DON, ADON, or the CNO. Per the CNO they used the CNA Shower Sheet because it was the only form, they had with a body on it to mark an area. She also said if the CNA had marked something, the ADON, DON, or CNO still went back and double checked the skin. Out of all 65 facility's residents, 17 residents had redness or some kind of skin issues documented. After speaking with the CNO about some of the residents she went back and re-assessed them. Some of the residents did not have redness or scratches on them. There were 7 residents who had PUs. 1 of the resident's left the facility and the other one got better. Review of the resident's charts in [EMR] revealed the skin issues were documented. Interview on 12/8/23 at 11:27 am, LVN E revealed she had in-services on change in conditions and who to report them to. She said if there was a change in condition she would report it to the MD, and her supervisor. Then she would document it under the Change of Condition form in [EMR]. Interview on 12/8/23 at 11:33 am LVN F revealed she had training on change in condition and notifying the MD of a change in condition. She said if there was a change in condition, she would notify the MD and document it on the change of condition document in [EMR]. Interview on 12/8/23 at 11:49 am LVN G said she had in-services on change of condition. She said if there was a change in condition she would report it to the DON, the family, and the MD. She would report the change in [EMR] on the progress note. Record review on 12/8/23 at 12:56 pm revealed an in-service was given on 12/7/23 regarding Weekly Skin Monitoring to RNs and LVNs. 12 facility staff members signed the attendance sheet. The in-service was about skin assessment monitoring guidelines, wound monitoring guidelines, pressure injury management guidelines (with pictures), the Braden Scale, wound care insider (with pictures), skin monitoring: comprehensive CNA shower review, clinically unavoidable skin breakdown, and examples in [EMR]. In an interview with the DON on 12/8/23 at 1:00 pm he revealed they were putting red binders at every nurse's station that held information about examples of change in condition, who to notify, and SBAR sheets to use. Record review on 12/8/23 at 1:07 pm revealed an in-service was given on 12/7/23 regarding Change in Resident's Condition with 12 staff members signature in attendance. Record review also revealed in-services performed on 12/8/23 regarding Change in Resident Condition or Status and Charting Documentation for RNs and LVNs. 5 staff members signed for attendance. Interview on 12/8/23 at 3:07 pm, LVN E revealed the facility provided more in-services on wound care, wound measuring, and change of conditions and who to report to. Interview on 12/8/23 at 3:10 pm LVN F revealed there was another in-service on wound care, what to report to the MD regarding wounds, and what was considered a change in condition. Interview on 12/8/23 at 3:15 pm LVN G said there was another in-service about wounds, measuring wounds, and what was a change in condition. Record review on 12/8/23 at 3:18 pm revealed the Weekly Wound Observation Tool and the Interact Change in Condition, were completed for the 7 residents with wounds. Record review on 12/8/23 at 3:27 pm revealed the 24hr report for the morning, for Halls A & B on 12/8/23 was completed. The 24hr report included new admissions/discharges, residents with risk management cases (falls/chest pain), residents on antibiotics/new antibiotics ordered, residents with radiology/labs ordered, and residents who dad appointments/referrals. A copy of the 24hr report was kept for records. An Immediate Jeopardy (IJ) was identified on 12/7/2023. The IJ template was provided to the facility on [DATE] at 4:03pm. While the IJ was removed on 12/8/2023 at 3:45pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 7 residents reviewed for pressure ulcers. -The facility failed to turn/re-position Resident #1 and Resident #2 every 2 hours who were completely dependent and bed bound to prevent Pressure Ulcer development. -The facility failed to perform accurate skin assessments for Resident #1 (10/13/23 to 10/27/23) and Resident #2 (11/7/23 to 12/4/23) for Pressure Ulcers. -The facility failed to treat Resident #1's facility acquired pressure ulcers for over a month after being identified by Wound Care Nurse on 10/6/23 (sacrum, knee, buttocks, bilateral heels) . -The facility failed to identify Residents #2's risk for Presure Ulcers related to incontinence of bowl/bladder and bedbound, treat, and prevent further damage of Resident #2's Stage II (shallow, affected upper layer of skin) facility aquired pressure ulcer. -The facility failed to identify Resident #3's facility acquired MASD (moisture associated skin damage) who was incontinent of bowl/bladder and bedbound. An Immediate Jeopardy (IJ) was identified on 12/6/2023. The IJ template was provided to the facility on [DATE] at 3:22pm. While the IJ was removed on 12/8/2023 at 12:45pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, and could cause pain, infection, hospitalization , or death. Findings include: Resident #1 Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with acute respiratory failure, type 2 diabetes (body does not produce enough insulin or is resistant to it), nontraumatic intracerebral hemorrhage (bleeding into the brain), aphasia (unable to talk), anemia (low iron), epilepsy (seizures), anoxic brain injury (brain injury due to lack of oxygen), gastrostomy (tube in stomach for nutrition), and dependence on a ventilator (machine that breathes for you). Record review of Resident# 1's entrance MDS, dated [DATE], revealed a blank BIMS score because it was unable to be performed due to the resident's cognition. The MDS also revealed the resident had impairment on both sides of his upper and lower extremities and was dependent with all activities. Resident #1 was always incontinent of bowel and bladder. The MDS revealed the resident was at risk of developing pressure ulcers/injuries but had no unhealed pressure ulcers/injuries at that time. It also indicated the resident had no venous/arterial ulcers, or any other wounds or skin problems. The MDS did not reveal a turning/re-positioning program, nutrition/hydration intervention, application of dressings, or pressure ulcer/injury care were being used. Record review of Resident #1's care plan, dated 10/3/23, revealed a Focus: Resident has an open wound to the sacrum and is at risk for infections. 11/8/23: 6cm x 5cm x 2cm, 11/15/23: 8cm x 7cm x 3cm- post debridement. Resident has an open wound to left ischium (hip area) and is at risk for infections. 11/8/23: 12cm x 4cm x 0cm, 11/15/23: 11cm x 6cm x 0cm- post debridement. Resident has a DTI to right heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Resident has a DTI to left heel. 11/8/23: 4cm x 6cm x 0cm, 11/15/23: 4cm x 6cm x 0cm. Goal: Area will show signs of healing or heal without complications through/by next review date. Interventions: Follow up with MD as appropriate and scheduled. Keep dressing clean, dry, and intact. Observe dressing every shift and replace as needed for soiling, strike through drainage/bleeding. Provide treatment as ordered. Observe wound when changing dressing for S/S of healing or complications (odor, increased drainage etc.) or wound shows no improvement in 2 weeks notify MD of findings. Refer to wound care nurse as indicated. Focus: Resident #1 is bedfast most/all of the time and is at risk for skin break down. Goal: Resident #1 will have no increase in skin break down over the next 90 days. Interventions: Assess skin weekly for skin break down. Keep sheets clean and wrinkle free. Turn and re-position during rounds/PRN. Use positioning devices to prevent skin break down. Focus: Resident #1 is at risk for skin break down and injury AEB immobility and incontinence. Goal: Resident #1's skin will remain clean/dry, intact without evidence of break down over the next 90 days. Interventions: Assess skin on a weekly basis and PRN-report any break down to MD/RP. Assist with re-positioning as needed using padding between pressure areas. Check for incontinence during rounds and PRN-change promptly. Provide pressure reducing and positioning devices on resident's bed/wheelchair as indicated. Focus: Resident #1 is incontinent of (bladder/bowel) and is at risk for skin break down and pressure wound formation. Goal: Resident #1 will remain clean, dry, odor free and dignity will be maintained over the next 90 days. Interventions: Check for incontinent episode during rounds, change promptly and apply a protective skin barrier. Observe for s/sx of skin break down-report to nurse. Re-assess for possible toileting program-quarterly and PRN. Focus: Resident #1 is at risk for decline in ADL functions and injury r/t ICH, decreased mobility, anoxic brain damage. Goal: Resident #1 will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Interventions: Bed Mobility-Provide total assistance with 1-2 persons assistance. Dressing-Provide total assistance with 1-2 persons assistance. Personal hygiene/grooming-Provide total assistance with 1-2 persons assistance. Toileting-Provide total assistance with 1-2 persons assistance. Transfers- Provide total assistance with 1-2 persons assistance. Record review of Resident #1's previous hospital records dated 9/24/23, revealed a progress note from MD A which said, there was no rash or skin change. Record review of Resident #1's medical record revealed a Braden Scale for Predicting Pressure Sore Risk, dated 10/3/23 which indicated the resident was at moderate risk of developing pressure sores. Record review of Resident #1's Weekly Skin Monitoring dated 10/3/23 at 6:04 am, revealed an assessment from LVN A which indicated the resident had a small excoriation (scratch) on his left buttock. Record review of Resident #1's Weekly Skin Monitoring dated 10/6/23 at 4:12 pm, revealed an assessment from the Wound Care Nurse which indicated the resident had a closed, dry area on sacrum (portion of spine between lower back and tailbone), a dry sore to the left buttocks, a dry sore to the left, rear, shoulder, a dry sore to the left knee, and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 10/13/23 4:39am, revealed an assessment from LVN B which indicated there were no skin issues on the resident. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/18/23 at 6:11pm, revealed an assessment from the Wound Care Nurse saying the resident had a Stage II (shallow, affects upper most layer of skin), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/20/23 at 10:24 am, revealed an assessment from the Wound Care Nurse which indicated the resident had redness to his sacrum (portion of spine between lower back and tailbone), redness to ischium (curved bone forming the base of pelvis) but it did not say which side, and bilateral (both) heel DTIs. Record review of Resident #1's Wound-Weekly Observation Tool dated 10/25/23 at 6:10 pm, revealed an assessment from the Wound Care Nurse saying the resident had a Stage III (extends through skin into deeper tissue and fat), acquired sacrum (portion of spine between lower back and tailbone) pressure ulcer, which measured 3.5cm x 3cm x 1cm. Record review of Resident #1's Weekly Skin Monitoring dated 10/27/23 2:19 pm, revealed an assessment from the Wound Care Nurse which indicated the resident had redness and shearing (tearing) to his sacrum (portion of spine between lower back and tailbone), redness to the left ischium (curved bone forming the base of pelvis), and bilateral (both) heel DTIs. Record review of Resident #1's Weekly Skin Monitoring dated 11/3/23 at 12:04pm, revealed an assessment from the Wound Care Nurse which indicated the resident had a pressure wound to his sacrum (portion of spine between lower back and tailbone), shearing (tearing) to his left buttock, and bilateral (both) heel DTIs. Record review of Resident #1's Visit Report dated 11/1/23, from the Wound Care Doctor revealed Wound #1 was a Stage III ( (extends through skin into deeper tissue and fat) pressure ulcer to the sacrum (portion of spine between lower back and tailbone), acquired 10/2/23, and measured 5cm x 5cm x 0cm. Wound #2 was a pressure ulcer to the left heel, acquired 10/2/23, measured 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #3 was a pressure ulcer to the right heel, acquired 10/2/23, measured 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. According to the Visit Report, the Wound Care Doctor performed a surgical debridement on the same day to Wound #1, and subcutaneous (fatty tissue) slough (dead tissue) was removed. Record review of Resident #1's Wound-Weekly Observation Tool dated 11/1/23, revealed an assessment from the Wound Care Nurse saying the resident had a left and right heel DTI that he was admitted with, and measured 4cm x 6cm x 0cm, and there was a Stage II (only upper most layer of skin, and does not extend into fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis) from admission, that measured 12cm x 4cm x 0cm. She also recorded a sacrum (portion of spine between lower back and tailbone) Stage III (extends through skin into deeper tissue and fat) pressure ulcer that she indicated he was admitted with, and measured 5cm x 5cm x 0cm. Record review of Resident #1's Visit Report dated 11/8/23, from the Wound Care Doctor revealed Wound #1 was a deteriorating Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer to the sacrum (portion of spine between lower back and tailbone) and measured of 6cm x 5cm x 2cm. Wound #1 had exposed ligament (tissue connects bone to bone), with exposed ligament necrosis (dead tissue connects bone to bone) and exposed adipose necrosis (dead fat tissue). Wound #2, the pressure ulcer of the left heel, had no change and measured 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #3, the pressure ulcer to the right heel, had no change and measurements 4cm x 6cm x 0cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. The Visit Report revealed there was a new wound. Wound #4 was a Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis), acquired on 10/2/23, and measured 12cm x 4cm x 0cm. According to the Visit Report, the Wound Care Doctor performed a surgical debridement on the same day to Wound #1, and ligament (tissue connects bone to bone) and subcutaneous (fatty tissue) slough (dead tissue) were removed. The Wound Care Doctor also performed a surgical debridement of Wound #4, and subcutaneous (fatty tissue) slough (dead tissue) was removed. Record review of Resident #1's Wound-Weekly Observation Tool dated 11/8/23, revealed an assessment from the Wound Care Nurse saying the resident had a left and right heel DTI that was unchanged, and measured 4cm x 6cm x 0cm. She said there was now a Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis), that measured 12cm x 4cm x 0cm. There was also record of the sacrum (portion of spine between lower back and tailbone) worsening to a Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer, and measured 6cm x 5cm x 2cm. Record review of Resident #1's Visit Report dated 11/15/23, from the Wound Care Doctor revealed Wound #1 was a deteriorating Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer to the sacrum (portion of spine between lower back and tailbone), and measured 8 cm x 7 cm x 3 cm. Wound #1 had exposed ligament (tissue connects bone to bone), with exposed ligament necrosis (dead tissue connects bone to bone) and exposed adipose necrosis (dead fat tissue). Wound #2, the pressure ulcer of the left heel, had no change and measured 4 cm x 6 cm x 0 cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #3, the pressure ulcer to the right heel, had no change and measured of 4 cm x 6 cm x 0 cm, and was a deep tissue injury with non-blanchable deep red, maroon or purple discoloration. Wound #4, the Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis) had no change, except it had signs of infection with infectious drainage and measured of 11 cm x 6 cm x 0 cm. According to the Visit Report, the Wound Care Doctor performed a surgical debridement on the same day to Wound #1, where ligament (tissue connects bone to bone) and subcutaneous (fatty tissue) slough (dead tissue) were removed. The Wound Care Doctor also performed a surgical debridement of Wound #4 where subcutaneous (fatty tissue) slough (dead tissue) was removed. Record review of Resident #1's Wound-Weekly Observation Tool dated 11/15/23, revealed an assessment from the Wound Care Nurse saying the resident had a left and right heel DTI that was unchanged, and measured 4 cm x 6 cm x 0 cm. She said there was a worsening Stage III (extends through skin into deeper tissue and fat) pressure ulcer to the left ischial (curved bone forming the base of pelvis), that measured 11 cm x 6 cm x 0 cm. There was also record of the sacrum (portion of spine between lower back and tailbone) Stage IV (deep, extends into muscle, tendon, or bone) pressure ulcer worsening, and measured 8 cm x 7 cm x 3 cm. Record review of Resident #1's Change in Condition dated 11/16/23, revealed an unknown nurse indicated the resident had a change in condition due to a skin wound or ulcer. The nurse indicated the resident had a sacrum (portion of spine between lower back and tailbone) wound with exposed subcutaneous tissue and had abnormal CBC results. The WBC was 21,000 (normal < 11), which indicated an infection. Record review of Resident #1's Weekly Skin Monitoring dated 11/17/23, revealed an assessment from the Wound Care Nurse which indicated the resident had a Stage IV (deep, extends into muscle, tendon, or bone) pressure wound to his sacrum (portion of spine between lower back and tailbone), a Stage III (extends through skin into deeper tissue and fat) pressure wound to his left buttock, and bilateral (both) heel DTIs. Record review of Resident #1's Physician's Orders as of 11/20/23, revealed the following orders from the MD B: -Apply skin prep to both heels, every day shift. Ordered 11/16/23, to start 11/17/23. -Clean wound to left ischial (curved bone forming the base of pelvis) with NS, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23, to start 11/17/23. -Clean wound to sacrum (portion of spine between lower back and tailbone) with NS, pat dry, apply Alginate (type of wound dressing), cover with dry dressing, every day shift. Ordered 11/16/23, to start 11/17/23. -Off load heels while in bed, every shift. Ordered 11/16/23, to start 11/17/23. -Perform head to toe assessment. Assess all areas of skin. Ordered on 10/2/23. Record review of Resident #1's Physician Orders revealed there were no wound care orders prior to 11/16/23. Record review also revealed there were no orders for turning/re-positioning. Record review of Resident #1's November 2023 MAR revealed: -Clean wound to left ischial [curved bone forming the base of pelvis] with NS,apply Alginate (wound dressing), cover with dry dressing, one time a day. On 11/9/23-11/16/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. -Apply zinc (type of barrier cream) to shearing on left buttocks, one time [NAME]. On 11/4/23-11/8/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. -Clean wound to sacrum [portion of spine between lower back and tailbone] with NS, pat dry, apply Alginate (wound dressing), cover with dry dressing, one time a day. On 11/4/23-11/16/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. -Off load heels while in bed, one time a day. On 11/11/23-11/16/23 there was a 9 documented, which according to the MAR legend meant Other/See Nurse Notes. Record review of the nurse's notes revealed no documentation of the treatment. Record review of Resident #1's medical records revealed a Transfer Form filled out by RN A, dated 11/22/23, which indicated the resident was being transferred to the hospital for abnormal labs/wound infection. It also said the resident had started IV antibiotics (Vancomycin and Meropenem) on 11/17/23 for a possible wound infection and had no MDROs. The transfer form revealed the resident had an unstageable pressure ulcer to his sacrum (portion of spine between lower back and tailbone) and right buttocks, and DTIs to both heels. Interview with a family member on 12/1/23 at 9:5am she revealed when Resident #1 first came to the facility, he had no wounds. She stated staff wound never turn him or change him often enough, and she would try to get staff to turn him and change him every time she went to the facility. She said staff would argue with her that they had just turned him or changed him when she knew they had not because she would sit there all day. Interview and observation with the hospital RN on 12/1/23 at 12:3pm, Resident #1 was observed in ICU laying on his back on a bariatric air mattress. He had pressure relieving boots on, a foley (catheter into bladder for urine drainage), PEG (tube into stomach for nutrition) tube running, and IV with antibiotics running, and was on a ventilator (machine that breathes for you). She revealed Resident #1 had just returned from a debridement (removal of dead skin/tissue) surgery for his wounds. She stated the resident came in with wounds to his sacrum (portion of spine between lower back and tailbone), both buttocks, both heels, and both ankles. She also said the resident had been running fever every night and was on contact isolation for Pseudomonas, Klebsiella, ESBL, VRE, and Staph Enterococcus (different resistant strains of bacteria). She said he had osteomyelitis (bone infection) to his sacrum (portion of spine between lower back and tailbone). Record review of Resident #1's Emergency Department Note dated 11/22/23 from ER MD, revealed the resident was sent to the ER from the facility for an elevated WBC and low Hgb of 6.5. The progress note revealed the resident had a large decubitus ulcer, was started on broad-spectrum antibiotics, and was found to be anemic (low Hgb) with a Hgb of 4.1 (normal is > 12). The resident's lactic acid (an indicator of systemic infection) was 2.8 (normal is < 2) and his procalcitonin (an indicator of systemic infection) was 0.42 (normal is < 0.1). His WBC (indicator of infection) was 26.5 (normal is < 11). The admitting diagnoses were acute sepsis (systemic infection), leukocytosis (high WBC), acute anemia (low Hgb), and decubitus ulcer (pressure ulcer) of sacral region (portion of spine between lower back and tailbone) and he was admitted to ICU. Record review of Resident #1's Surgery Progress Note dated 11/25/23 from the Surgical MD, revealed he had sepsis (systemic infection), necrotic (dead tissue) decubitus wounds (pressure wounds) and protein-calorie malnutrition (not consuming enough proteins and calories to meet nutritional needs). The Progress Note revealed on 11/24/23 Resident #1 had debridement (surgical removal) involving bone and it was sent to pathology for review. The Progress Note said the resident was going to need a diverting colostomy (opening in the abdomen to the outside where the stool goes, to divert from the trauma and avoid contamination) and additional debridement (surgical removal). The plan and treatment: local wound care, antibiotics per ID, optimize nutrition, keep foley catheter (tube into bladder for constant drainage of urine) for wound care management, rectal tube (tube into rectum for constant drainage of feces), and surgery for colostomy (opening to outside of abdomen for stool to drain into) and additional debridement (surgical removal). According to the note the sacral (portion of spine between lower back and tailbone) wound was 11 cm x 8.5 cm 3.5 cm and the left ischial (curved bone forming the base of pelvis) wound was 11 cm x 10 cm x 7 cm. Record review of Resident #1's Surgery Progress Note dated 11/30/23 from Surgical MD, revealed on 11/27/23 the resident had a laparoscopic colostomy (minimally invasive surgery to divert stool from colon to exterior collection bag outside of abdomen) and debridement (surgical removal). The note also said the bone removed previously, came back from pathology revealing acute osteomyelitis (bone infection) of the left ischium (curved bone forming the base of pelvis), and the wounds were growing MDR organisms. He was also having low-grade fevers and still had leukocytosis (high WBC). Per Surgical MD, Resident #1 would need additional debridement (surgical removal) of the decubitus wounds. The sacral (portion of spine between lower back and tailbone) wound measured 11cm x 8cm x 4cm with scattered areas of necrosis (dead tissue) and the left ischial (curved bone forming the base of pelvis) wound measured 13cm x 13cm x 6cm with necrosis (dead tissue) along the bone and tendon (tissue that connects bone to bone). Record review of Resident #1's ICU Progress Notes dated 12/1/23 from ICU MD, revealed: -11/23/23: Consulted ID for sacral (portion of spine between lower back and tailbone) wound. The wound appeared to be the source of infection. Consulted surgery for possible debridement (surgical removal). -11/24/23: Resident had surgery for debridement (surgical removal) to sacral(portion of spine between lower back and tailbone) wound. Podiatry (foot doctor) was consulted for heel eschars (dead tissue). -11/25/23: Surgery planned for Monday (11/27/23). Needs a diverting colostomy (opening in the abdomen to the outside where the stool goes, to divert from the trauma and avoid contamination) and further debridement (surgical removal). -11/26/23: Surgery tomorrow (11/27/23). -11/27/23: Plan for ostomy (allows bodily waste to pass through a surgically created stoma on the abdomen)/debridement (surgical removal) today per surgery. -11/30/23: Plan for repeat debridement (surgical removal) tomorrow. Record review of Resident #1's lab results dated 11/30/23, revealed: -Left Ischium Bone: Klebsiella Pneumoniae-MDRO and Enterococcus Faecium, VRE-MDRO (Multi-Drug Resistant Bacteria) -Sacral Tissue: Enterococcus Faecium, VRE-MDRO and Staphylococcus, Not S. Aureus (Multi-Drug Resistant Bacteria) Interview with the Administrator on 12/5/23 at 10:10 am, she revealed the former Wound Care Nurse was let go 11/27/23. She said the ADON and DON performed wound care on 11/28/23 and 11/29/23. Then she said, RN B performed wound care the rest of the week, except on Saturday 12/2/23. The Administrator said on 12/2/23, LVN B performed wound care, then RN B would take back over again. The Administrator said the new Wound Care Nurse was starting on 12/7/23. Interview with LVN C on 12/5/23 at 10:25 am she revealed she informed the Wound Care Doctor verbally about pressure ulcers when he came to the facility, weekly. She said nothing was documented that she spoke to the doctor. She also said she monitored the wound status by looking at the wounds, but there were not orders to monitor every shift, so she would do it whenever she remembered to. LVN C said to prevent pressure ulcers, residents needed to be turned every 2 hours. Interview on 12/5/23 at 10:30 am with RN B she revealed she only worked PRN and had only been the Wound Care Nurse for the past 3-4 days. She said she did not monitor the wound progress by measuring or anything, she only followed the MD orders. She could observe for oozing/foul odor and see that the wound looked worse, but she had only been performing wound care for 3-4 days. She said she would see the residents who were on the wound list that was given to her, and she would assess them to see if they had any other skin issues. She said if the resident had any other skin issues, she would report it to the nurse and the nurse would notify the MD. She had no communication with the MD. Interview with the Wound Care Nurse on 12/5/23 at 10:34 am she said she quit at the facility on 11/27/23 because there were too many residents with wounds, and she did not have enough help. She said there were not enough CNAs, so residents were not being turned and mostly on Hall A the wounds were worsening. She revealed that she would have a resident with redness on Friday and then she would be off for the weekend and when she came back on Monday, there would be an open wound because the resident was not turned all weekend. She said she would tell the Administrator about the wounds worsening and about needing more help, but she never received any. The Wound Care Nurse said she remembered Resident #1 and that he did not have any wounds when he came to the facility, and that his wounds did worsen. Interview with the Wound Care Doctor on 12/5/23 at 11:02 am he said he compared the measurements of the wound from the previous week to the measurement of the current week to see if the wound was worsening. He said he did not see Resident #1 until 11/1/23, which was a month after he was admitted , and he did not know what happened between when he was admitted until when he saw him. Interview with LVN B on 12/5/23 at 11:12 am she said she was the PRN Wound Care Nurse who had only performed wound care once for the facility and it was on 12/1/23. She said she had an in-service on wound care, but that was all. She said she saw 2 residents who she thought had worsening wounds and she reported them to the DON, but she could not remember which residents they were. She said the DON told her he would take care of it and notify the Wound Care Doctor. She also said she had no communication with the Wound Care Doctor because she was only PRN. Interview with the Administrator and DON on 12/5/23 at 3:20 pm they revealed they had done a PIP at the end of November 2023 regarding skin assessments. The DON said the skin assessments the nurses were performing/documenting were not matching the Wound Care Doctor's skin assessments. The DON said the Wound Care Nurse was not assessing the residents like she was supposed to and then the staff nurses would assess the residents, so there would be different assessments with different findings on the same resident. The DON said the Wound Care Nurse was responsible for performing the admission assessment, any new wound, and then all the current wound assessments. He said if the staff nurse found a new wound, they were to tell the Wound Care Nurse and then she performed an assessment on the resident and then managed the resident. The Administrator said the Wound Care Nurse was not keeping up with the assessments on all the residents. The Administrator did not think the Wound Care Nurse was too overwhelmed with wounds or lack of help. The DON said he performed a skin sweep on 11/27/23 after they found out not all the assessments were being performed. Resident #2 Record review of Resident #2's undated face sheet, revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses of chronic respiratory failure (not being getting enough oxygen), traumatic brain injury, traumatic subarachnoid hemorrhage (bleeding to part of the brain), moderate protein-calorie malnutrition, dependence on respirator (a machine to breathe for him), tracheostomy (a tube in his throat), and gastrostomy (a tube in his stomach for nutrition). Record review of Resident #2's entrance MDS, dated [DATE], revealed a blank BIMS score because it was unable to be performed due to the resident's cognition. According to the MDS, the resident had impairment on both sides of his upper and lower extremities and was dependent with all activities. The resident was always incontinent of bladder and bowel. The MDS revealed the resident was at risk of developing pressure ulcers/injuries but had 0 unhealed pressure ulcers/injuries. He also had 0 venous/arterial ulcers or any other wounds and skin problems. According to the MDS the resident was not receiving pressure ulcer/injury care, turning/re-positioning program, or application of any dressings. Record review of Resident #2's care plan, dated 11/15/23, revealed Focus: The resident has potential/actual impairment to skin: abrasion. Initiated 12/5/23. There were no goals or interventions listed. There was not anything care planned for potential skin break down, incontinence, or that he was bedbound. Record review of Resident #2's Receiving Nurse's Note dated 11/7/23 from unknown nurse, revealed A 32yrs old male, arrived the facility .skin intact . Record review of Resident #2's initial Weekly Skin Monitoring dated 11/7/23 from the Wound Care Nurse, revealed the resident had redness to both buttocks. Record review of Resident #2's Progress Note dated 11/9/23 from MD B, revealed for skin: no rash or lesions. Record review of Resident #2's Braden Scale for Predicting Pressure Ulcer Risk dated 11/14/23 by LVN D, revealed the resident was at a very high risk of developing pressure ulcers. Record review of Resident #2's Skilled Nursing Notes dated 11/11/23, 11/12/23, 11/14/23, 11/18/23, 11/19/23, 11/20/23, 11/22/23, 11/23/23, 11/26/23, 11/27/23, 12/1/23, and 12/5/23 from unknown nurse, revealed skin concern noted; redness to buttocks. Record review of Resident #2's Weekly Skin Monitoring dated 11/21/23 from the Wound Care Nurse, revealed the resident had redness to both buttocks. Record review of Resident #2's Weekly Skin Monitoring dated 11/27/23 from the ADON, revealed the resident had no skin issues documented. Record review of the MDS Resident Matrix, printed 12/1/23, revealed Resident #2 had no pressure ulcers listed. Record review of Resident #2's Weekly Skin Monitoring dated 12/2/23 from LVN B, revealed the resident had no skin issues documented. Record review of Resident #2's Weekly Skin Monitoring dated 12/4/23 from the ADON, revealed the resident had no skin issues documented. Record review of Resident #2's Weekly Skin Monitoring dated 12/5/23 from the DON, revealed the resident had sacrum excoriation. Record review of Resident #2's Wound Weekly Observation Tool dated 12/6/23, revealed bilateral buttocks, acquired pressure ulcers, which measured 3cm x 6cm x 0.1cm. Record review of Resident #1's Physician Orders as of 12/8/23, from MD B revealed: -Apply Zinc to redness on buttocks daily, every day shift. Ordered 11/20/23. -Apply Zinc Oxide Cream and Leave Open to Air Every Shift and PRN every 12 hours as needed. Ordered 12/7/23. -Apply Zinc Oxide Cream and Leave

Based on observations, interviews, and records reviewed, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that it is not possible for 1 (CR #24) of 17 residents reviewed for weight loss. The facility failed to ensure CR #24 did not have unplanned weight loss of 14.68 percent in 30 days. A 3-month significant wight loss was unavailable due to the facility's failure to weigh resident upon admission. The facility failed to have CR #24 consult the Speech Language Pathologist (SLP) for diet texture upgrade to mechanical soft. The facility failed to ensure CR #24 was weighed weekly for 4 weeks to re-establish his baseline weight. These failures could place residents at risk of not maintaining their nutritional needs. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The findings included: CR #24 Record review of CR #24's face sheet revealed a [AGE] year-old male with an original admitted date of [DATE] and re-entry date of [DATE]. Diagnoses included dysphagia (difficult in swallowing food or liquid) following unspecified [CONDITION(S)] disease (affects the blood flow to the brain), non-Alzheimer's dementia, history of malignant neoplasm of larynx (cancer of voice box), and gastro-[CONDITION(S)] reflux disease without esophagitis (repeated back flow of stomach acid). Record review of CR #24's admission MDS dated [DATE] revealed the resident's BIMS score was left blank. The resident required limited assistance with one person assist for mobility, locomotion on and off unit, and eating. The resident required extensive assistance with 1 person assist for dressing and transfers. The resident was totally dependent with 1 person assist for toileting. Section D0500. Mood: E. Poor appetite or overeating was left blank. Section I5600. Nutritional noted Malnutrition (protein or calorie) or at risk for malnutrition. Section K0300.Weight Loss noted no or unknown weight loss. Section K0510. Nutritional Approaches: C. noted Mechanically altered diet - required change in texture of food or liquids. Record review of CR #24's Care Plan revised on [DATE], read in part . Focus: Has nutritional problem or potential nutritional problem. Goal: Will comply with recommended diet for weight reduction daily through review date. Interventions: Monitor/document/report as needed any signs/symptoms of dysphagia . including refusing to eat, appears concerned during meals. House Shakes as ordered. Provide, serve diet as ordered. Monitor intake and record each meal. Staff to assist with feeding. Registered Dietician evaluate and make diet change recommendations as needed. Weigh at same time of day and record: The resident is weighed at same time using same scale . Record review of CR #24's Care Plan revised on [DATE], read in part . Focus: The resident has an ADL self-care performance need. Goal: The resident will maintain current level of function in ADLs through the review date. Interventions: Eating: The resident is independent for eating . Record review of dietician's consulting notes dated [DATE] read in part ., recommended he be weighed weekly, for four weeks, so a weight baseline could be reestablished . Record review of order summary report dated [DATE] read in part . pureed texture, regular/thin liquids consistency, house shakes three times a day; yogurt with meals fortified meal plan . Record review of CR #24's weight logs titled Weight Summary Report dated [DATE] read in part . [DATE]: 116 lbs., [DATE]: 115 lbs., and [DATE]: 107.6 lbs. Observation on [DATE] at 10:57 a.m. revealed CR #24 was sitting in his wheelchair in the day room, in the secure unit. A head-to-toe visual assessment revealed he had a stoma (opening on the abdomen), was thin (cheek bones were noticeable on his face), and his skin looked pale. Observation and interview on [DATE] at 10:34 a.m. revealed the ADON weighing CR #24 on a flat weight scale. The ADON went to CR #24's room and got the wheelchair. She took the wheelchair to the flat scale and weighed the empty wheelchair. She recorded the weight of the empty wheelchair. She went to CR #24's room and transferred him to his wheelchair. She propelled him to the flat scale and weighed him. She noted the resident's weight with him in the wheelchair and she subtracted the weight of the empty wheelchair to arrive at resident's last weight which was recorded at 91.8 lbs. During an interview on [DATE] at 12:46 p.m. CEO/Owner said he had been part owner of the facility for about ,d+[DATE] months. He said he believed the DON notified him about the broken weight scale at the facility. He said he could not recall the date but believed it was right away. He said if the facility needed a piece of equipment to be replaced, the Administrator and/or the DON would notify him. He said once notified, he would move forward with the purchase, especially when it affected patient care. He said he instructed the DON and the Administrator to locate a scale to rent. He said a vendor to rent from could not be located. He said he could not recall what vendors had been contacted. He said the weight scale was purchased on [DATE]. During an interview on [DATE] at 1:43 p.m. with the RA, she said she had been at the facility for about [AGE] years. She said on or about [DATE] CR #24 had a healthy appetite, was very active, but his health had declined when she returned to work on [DATE]. She said CR #24 only drank his mighty protein shakes. She said she reported it to RN A. She said she got him a mighty shake with all his meals. She said she helped him drink his shakes. She said he would drink them with assistance. She said he had not been eating. She said she would get him ice cream to help him with his caloric intake. She said she reported the resident's change in condition to LVN F. During a telephone interview on [DATE] at 2:21 p.m. with CR #24's family member, he said he had concerns with CR #24's eating and weight loss, but the facility had not communicated to him that he had not been eating. Resident's family member said he found out about resident not eating when he visited the facility and told them he was concerned about resident's respiratory care. CR #24's family member visited the facility about 3 weeks ago. Resident's family member said they were not notified about any changes to the resident's diet. The resident's family member said the resident did not have an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Family member said he was sent to the emergency room last month; family member said the ER doctor, from the same hospital, instructed him to ask the hospital about the resident's dehydration. Record review of CR #24's laboratory work from the emergency room noted he had a high blood urea nitrogen level of 39 milligrams per deciliter, a high Creatinine level of 1.45 milligrams per deciliter, and a normal [MEDICATION(S)] level of 3.8 grams per deciliter. During a telephone interview on [DATE] at 2:48 p.m. with the facility's RDC, she said she arrived at the facility on [DATE]. She said she visited the facility ,d+[DATE] times per month, and she had completed a comprehensive assessment on CR #24 on [DATE]. She said she recommended liquid protein be added to his diet due to CR #24's rapid weight loss. She said she had a colleague, RCD #1, who saw CR #24 on [DATE]. She said RDC #1 recommended CR #24 be weighed weekly, for four weeks, so a weight baseline could be reestablished. RCD said she was not aware that the RDC said she was not told about the broken scale until [DATE] when she was leaving the facility. Interview on [DATE] at 4:15 p.m. with the Maintenance Director he said he had worked at the facility for about a month. He said he did not know if the new scale had been calibrated because it was recently delivered; he could not remember the date. The Maintenance Director said he forgot and said he had calibrated the scale. He said he used two different methods to calibrate the scale. He said he first weighed himself and the scale gave him an accurate reading, and then he took a notebook binder full of papers, weighed it, removed some papers, reweighed the binder, placed the papers back into the binder, and reweighed the binder one last time. The Maintenance Director said the weight of the binder did not change, so he knew the scale worked properly. He said he believed the scale was dropped off at the front door of the facility on Friday, [DATE], and he assembled it the following Monday, [DATE]. He said the scale needed to be calibrated every 3 months and/or every month. The Maintenance Director said a brand-new scale must be calibrated before it is used. He said he did not recall any of the staff members asking him if the scale had been calibrated prior to use. He said he did not document when he calibrated the scale. The Maintenance Director said as far as he knew, no one contacted an outside company to calibrate the scale. He said he had not received training on how to calibrate the scale from the facility. He said he just knew how it was done from prior work experience. During a telephone interview on [DATE] at 6:05 p.m. with the Speech and Language Pathologist, she said she was familiar with CR #24. She said CR #24 was eating double portions at the time of admission. She said CR #24's physical endurance started to go down because of the disease process. She said she had not conducted a swallow test. She said she did not recall receiving the recommendation from RDC #1 requesting a swallow test for CR #24. She said CR #24 was on a puree diet. She said CR #24 liked the pureed meals. She said going from pureed to mechanical soft diet would require a swallow test. She said CR #24 had a recent stay at the hospital where a swallow test should have been performed. She said she had not done any swallow test for CR #24 in the past three months. She said she went to visit CR #24 on same day to conduct a swallow test. She said CR #24 refused the shake. She said the puree diet physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 10:38 a.m. with RN A. She said she had been at the facility for about ,d+[DATE] months. She said her responsibilities included conducting assessments, monitoring residents, and talking to their doctors. She said CR #24 was sent to the hospital in the morning because he became unresponsive. She said she started CPR, one of the facility's residents' aides called 911. She said EMS arrived and changed positions with the first responder. She said CR #24 was transported to the hospital. She said she was the nurse who fed CR #24 in the morning. She said he ate grits, a little bit of oatmeal, and drank some of his milkshake. She said she left after CR #24 finished eating. During an interview on [DATE] at 10:38 a.m. with the Registered Nurse A said CR #24 became unresponsive approximately 45 minutes to an hour after he finished eating breakfast. She said Cardiopulmonary Resuscitation (CPR) was preformed, 911 and called, and emergency medical services took over upon their arrival at the facility. She said resident was transported to the hospital. The Charge Nurse said she fed the resident this morning, but he did not eat much (,d+[DATE] spoonsful of grits, oatmeal, and all his milkshake). She said when she the unit he was responsive and sitting up in his wheelchair. During a telephone interview on [DATE] at 11:12 a.m. with CR #24's Nurse Practitioner he said he received the terminal cancer diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the cancer diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He said the resident was admitted to the facility with weight concerns and were providing shakes to him. The Nurse Practitioner asked Surveyor what the point of the investigation was and said the resident ate when he wanted. The Nurse Practitioner did not want to answer any more questions and ended the interview. During an interview on [DATE] at 1:41 p.m., Administrator #2 said she had been working at the facility for about 1 month. She said she discovered that the flat weight scale was not working on [DATE]. Administrator #2 said she was told by corporate maintenance on [DATE], during their morning meeting, the scale was broken and a new one would be purchased within that day by regional maintenance. She said she requested an update from corporate office on the scale via text on [DATE] and was told it would be delivered between [DATE] and [DATE]. She said between [DATE] and [DATE], corporate never provided her with an update on the purchase of the new scale. Administrator #2 said her expectation was to have one purchased and delivered sooner. She said she was still learning and did not know how larger items were purchased but called two scale vendors the following week and was told they did not rent scales. She said the risk posed to residents when there was not a functioning scale in the facility. She said it could have the potential to affect residents' quality of care. She said residents could decline, they could have excessive weight loss, and/or weight gain, and weight variations indicative of other health issues. Administrator #2 said the risk posed to residents that required to be weighed weekly created a lack of care for their required nutritional needs. She said the delivery of the flat weight scale was scheduled to arrive on [DATE]. She said her expectation was that the scale needed to be setup and operational the day it was received. She said maintenance was responsible for completing the task but does not work onsite on the weekends. She said she followed up with maintenance on Monday, and it was setup and operational. She said she was not aware the scale was being used without having been calibrated until yesterday. She said when a recommendation for a diet change was made for a resident by a registered dietician, her expectation was for the order to be implemented within 24 to 72 hours. She said she was not aware if the facility had a policy for addressing specific timeframes for following through on dietician recommendations. Record review of the facility's policy related to weight loss, titled Weight Assessment and Intervention not dated read in part .Policy Statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment 1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Admissions and monthly weights will be recorded in each unit's Weight Record chart or notebook and the individual's medical record. Weekly weeks will be tracked separately. Analysis 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; d. Whether and to what extent weight stabilization or improvement can be anticipated. Interventions 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary team effort and will include the Physician, nursing staff, the Dietician, the Consultant Pharmacy, and the resident or resident's legal surrogate. Interventions 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: b. Nutrition and hydration needs of the resident . The Administrator was notified on [DATE] at 7:10 p.m. that an IJ was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on [DATE] at 5:24 p.m. and included: Plan of Removal The facility (Dietary Manager and DON) conducted order and tray card audits on [DATE] to ensure resident supplements are accurate and available as ordered. All nutrition recommendation orders from the last dietician visit on [DATE] were reviewed by the DON, dietary manager, and physician/NP on [DATE] to ensure implementation. Upon review on [DATE], there have been no new admissions to the facility. On the [DATE], the physician signed an Unavoidable Weight Loss form. On [DATE], the diet, supplement, meal intake, and weight variance of CR #24 was reviewed by nursing management due to the triggered weight loss. Education was presented by the DON on [DATE] to nursing management on Change of Condition notification. There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] CNAs document through the Point of Care system the percentage intake of each resident. The documentation is reviewed at each clinical meeting Clinical meetings are Monday through Friday, excluding major holidays. This is effective as of [DATE]. CNAs/nursing staff report intake changes to the charge nurse and/or nursing supervisor. Then the resident is assessed by a licensed nurse and appropriate interventions are implemented. Nursing staff was educated on focused meal assessment and appropriate interventions on [DATE] by the DON an regional nurse. CNAs were trained to verbally report residents who have a decline in percentage of intake. The nursing staff was educated on reporting meal intake was completed on [DATE] by the DON and regional nurse. Any meal with poor intake is reported to the charge nurse/nurse supervisor. Two or more meals in less than 24 hours are identified by clinical alerts on the Point of Care dashboard and/or verbal report from nursing staff prompt a notification to the RD by the nursing management team. The notification to RD education was completed by the Regional nurse with the nursing management team on [DATE]. The RD reviews intakes during the assessment of the residents. Each Kardex in the Point of Care system identifies residents that require assistance with meal intake and hydration. The Kardex is updated during the clinical meetings and reviewed by the nurse management team. Kardex updates are made during the clinical meetings. As of [DATE], the Kardex is current and has been reviewed by the DON and ADON. On [DATE], the facility manually calibrated a new scale and assessed Resident #1 to begin to establish an accurate baseline weight. Resident #1 had a weight of 93.6 pounds. The physician was notified on [DATE]. The resident is not presently in the facility, discharged to the hospital. The new floor scale arrived for the facility on [DATE] and was manually calibrated by the maintenance department on [DATE]. Hoyer lift scales were verified by an outside vendor for accuracy on [DATE]. A training on the use of the Hoyer lift scales was initiated on [DATE] by the maintenance department for nursing management and with the designated staff assigned with weighing the residents. Additional training was provided by the maintenance director for use of the platform scale on [DATE]. Any suspicion of inaccuracy must be immediately reported to maintenance (via maintenance log), DON, or Administrator. Record review of CR #24's electronic Weight Summary, noted the following: [DATE]: Resident was not weighed upon admission. [DATE], at 3:04 p.m.: 116.0 pounds [DATE], at 4:35 p.m.: 115.0 pounds [DATE], at 10:26 a.m.: 107.6 pounds Record review of RDC #1's Nutrition Recommendation Form, dated [DATE], noted Speech Language Pathologist consult for diet texture upgrade to regular. Record Review of CR #24's Care Plan Conference meeting notes, dated [DATE], noted resident's family members and facility staff were in attendance. No nutritional and or weight concerns noted. Noted under Consults Needed section was none. Record review of RDC #2's Progress Notes for CR #24, dated [DATE], noted resident had a 7.2% weight change in the past 30 days and there were no recent labs to review. RDC #2 noted the new scale was being used, possibly needed to be calibrated, and plan was placed to weigh resident weekly for the next four weeks to reestablish baseline weight. Record review of CR #24's emergency room report, dated [DATE], noted resident was admitted , on [DATE] at 8:38 p.m., for vomiting. Further review noted, resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Per family member, resident vomited yesterday ([DATE]) and today ([DATE]) at the facility. Noted on the report, under Assessment and Plan read in part, Per nutrition: suspect malnutrition, pureed menu, small frequent meals, continue boost plus. Record review of CR #24's electronic RDC #1 notes, dated [DATE], noted resident lost a significant amount of weight since returning from hospital and being admitted (-8% x 60 days). RDC #1 noted resident's intake was okay and was mostly at ,d+[DATE]%. RDC #1 requested liquid protein with a goal of weight remaining stable. RDC #1 recommended 30 ml (milliliter) of Protein liquid daily. Goal included maintaining a stable weight at 107 pounds (lbs.) and/or weight gain of 160 lbs. x 30 days. Goal also included an intake of meals/snacks/supplements by mouth improving to greater than (>) 75% x 30 days. Record review of CR #24's electronic Orders noted, Protein Liquid was ordered on [DATE] and started on [DATE], due to unspecified protein-calorie malnutrition. (The protein supplement order was placed 7 days and started 8 days after the RDC #2's recommended request on [DATE].) All 54 residents have the potential to be affected, all residents will be weighed weekly for 4 weeks to reestablish baseline weights beginning [DATE], with the first weekly weights being completed on [DATE]. Weekly weights will be monitored by DON/designee for weight variance greater than equal to 3% and/or 3 pounds beginning [DATE]. Any weekly weights greater than the parameter will receive physician and dietician notification in order to mitigate any patient decline beginning [DATE] (week 3). Three residents were identified with weight loss. The RPs, physicians, and dietician were notified on [DATE]. The recommendation by the Physician was to continue with the current plan of care until the nest scheduled visit. On [DATE], the facility completed a manual calibration in-service by maintenance department for the current scale with the nursing management and designees. A floor scale and two Hoyer scales are available for resident assessments. As of [DATE], the scale is installed, calibrated, and operational. Baseline weights are being established on all residents in the facility. The first week of weights was completed on [DATE] by nursing management and an additional nursing designee. The scale was calibrated prior to being used to record resident weights. All residents are potentially at risk, the dietician and medical director have been notified on [DATE] for additional recommendations regarding weight loss concerns for the residents, as well as identifying the ideal weights for the residents. The pharmacy consultant has been contacted on [DATE] to conduct a medication review for proper dosage corresponding to accurate weight. The facility (IDT team) will discuss weights during the morning meeting, weekly during the risk assessment meetings, monthly during QAPI, and as needed. The findings will be documented on QA forms and verified by the Administrator beginning [DATE]. By [DATE], all residents will have a new initial weight established. On [DATE], all supplement orders were audited for accuracy with dietary and nursing. The orders were accurate. The DON and Administrator made necessary notifications to the Medical Director, Pharmacy consultant, and dietician. The RP of Resident #1 was contacted (no answer, voice message left) to discuss care intentions. There was an emergency QAPI meeting held on [DATE] at 3:12 pm via zoom with the Medical Director, DON, Administrator, DOR, Dietary Manager, Unit Manager, and corporate maintenance to discuss the preliminary findings, in-services, and interventions. The policies and procedures reviewed by QAPI committee in emergency meeting on [DATE] include Change of condition; procedures for weighing residents; abuse and neglect; when to notify DON, Administrator, family and/or physician; and clinical meeting responsibilities The DON, Administrator, and regional nurse were responsible for preparing the QA tracking tools. The training occurred on [DATE] with the facility staff and will be ongoing to capture staff on leave/absent and as part of new hire orientation. The DON and ADON were responsible for the training. A training will be placed in staffing sign in book on [DATE] as a reference and for any agency staff to be available prior to a shift. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from [DATE] through [DATE]. Monitoring of the POR included: Observations and interview on [DATE] at 10:15 a.m. revealed the facility had one platform scale and two Hoyer lift scales installed and operational. The Restorative Aide checked the platform scale for accuracy using hand weights and the scale displayed the same weight as the hand weights. CNAs were observed documenting meal intakes and checked meal assistance needs. RA verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 10:30 a.m. with CNA L. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 10:45 a.m. with CNA P. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 11:00 a.m. with LVN D. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 11:00 a.m. with LVN F. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 2 p.m. with LVN G. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 2:15 p.m. with DON. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 2:35 p.m. with ADON A. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 2:45 p.m. with Dietary Manager. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 3:00 p.m. with Regional Maintenance Director. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. During an interview on [DATE] at 3:00 p.m. with QA Lead Corporate Nurse. She verbalized adequate understanding of the training regarding documentation of meal intake, reporting changes in meal intake, focused meal assessments, proper interventions, proper use of Hoyer and platform scales, identifying and reporting scale inaccuracies, weight monitoring, and change in condition. Interview on [DATE] at 10:18 a.m., the DON said if a resident ate less than 50% for 2 or more meals, the facility would offer a supplement, identify food preference, and notify the nurse, who would assess the resident. She said the nurse would notify the DON, MD, and RD. She said the scales could not be manually calibrated but could be checked for accuracy by putting a weight on it. She said the scales would be calibrated at least quarterly. The DON said the weights would be monitored weekly for 4 weeks to establish a baseline and any weekly weight that has a 3-to-5-pound discrepancy would be reported to the RD for intervention; if it was a huge loss, the MD would also be notified. Record review of the facility's in-service training related to a resident's change in condition dated [DATE] confirmed that DON, ADON A, LVN F, LVN D, LVN G, CNA L, CNA P, RA, Dietary Manager, Regional Maintenance Director, and the QA Lead Corporate Nurse were all in attendance. The topic included training on how to report residents who were showing a decline in food intake. Record review of the facility's in-service training related to procedures for weighing residents dated [DATE] confirmed that DON, ADON A, LVN F, LVN D, LVN G, CNA L, CNA P, RA, Dietary Manager, Regional Maintenance Director, and the QA Lead Corporate Nurse were all in attendance. The topic included training on how to weigh residents using the facility's scale. Record review of the facility's in-service training related to procedures for abuse and neglect dated [DATE] confirmed that DON, ADON A, LVN F, LVN D, LVN G, CNA L, CNA P, RA, Dietary Manager, Regional Maintenance Director, and the QA Lead Corporate Nurse were all in attendance. The topic included training on when to notify DON, Administrator, family and/or physician; and clinical meetin[TRUNCATED]

Based on observation, interview, and record review the facility failed to maintain infection control procedures that provided a safe, sanitary, and comfortable environment, to help prevent the development and transmission of disease and infection for 2 of 9 residents ( Resident #5 and #6) reviewed for infection control. The facility failed to screen staff and visitors prior to entering the facility. The facility failed to ensure staff who worked in the Covid19 positive hall wore appropriate PPE before entering covid19 positive hall. The facility designated hall for COVID19 positive residents did not have donning and doffing area for PPE . The facility failed to ensure used PPE containers did not over flow from being full. The facility failed to ensure used PPE was disposed of appropriately in the covid19 hall. An Immediate Jeopardy (IJ) was identified on 07/06/20. While the IJ was lowered on 07/13/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern as the facility continued to monitor effectiveness of their plan of removal. These failures placed all facility residents, staff, and visitors at risk of infection or outbreak due to COVID-19. Findings include: Record review of CDC.gov website read in part, screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Fever is either measured temperature >100.0F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs). Clinical judgement should be used to guide testing of individuals in such situations. Observation and interview on 07/04/2020 at 3.40pm revealed surveyor entered the facility using the main entrance. There were screening supplies with a questionnaire available on a table set up upon entrance. Surveyor after several minutes, saw a charge nurse exiting the facility carrying food. Surveyor asked RN #6 if there was anyone available to screen visitors. RN #6 at this time said she could check the surveyor's temperature . RN#6 after checking surveyor's temperature, told surveyor what it was and instructed surveyor to compete the questionnaire on her own. RN #6 then left the building without reviewing information surveyor provided on the screening/questionnaire log. Few minutes later , RN #6 re-entered the facility with same PPE she had on and returned to hall C and D. RN#6 said hall C was a covid free while hall D was quarantine hall for PUI ( Person under investigation) . Further observation on 7/4/2020 at 3:42pm of facility's main entrance near receptionist desk/area revealed a full and over flowing waste container which had used PPE (gowns and gloves) falling out of it. Observation and interview on 7/4/2020 at 3:43pm, revealed Housekeeping Aide #1 cleaning the floor in hall C. She said she was the only house on duty today and was making her way to other facility halls. She said she was responsible for removing full trash containers including the full container at the main entrance. She said eh had way for two days in leave and returned today to many changes. She said she was told not to go to the covid hall, but she was going to clean Hall D. When asked if there were any precautions he was to take for hall D, Housekeeping Aide #1 said no. Observation of hall D on 7/4/2020 at 3:45pm revealed Resident #6 and Resident #5 were the only two residents on quarantine . Both residents were in rooms D2 and D3 respectively. Rooms had no PPE set up and had no waste containers for used PPE. Residents were not interviewable . Observation and interview following above observation revealed CNA#2 who was signed to hall C and D entered room D2 a quarantine room . She talked to the Resident #5, then exited the room without removing her PPE . Interview at this time, CNA#2 said she did not remove her PPE because her understanding was Resident #5 was being monitored but was not positive. Interview on 7/4/2020 at 3:48pm, RN #6 said there was one housekeeping staff on duty cleaning the halls. She said the housekeeper will remove the full trash containers and replace them. RN #6 said she went to the covid hall briefly and returned. She said she should have changed her PPE when she returned. RN#6 said she was the nurse for hall C and D. Hall D had two PUIs who were running low grade temperatures and were being monitored for covid symptoms. She said there should be PPE donning and doffing areas set up for the quarantine hall. She said visitors were supposed to ring the bell at the main entrance and staff would open the door and screen the person .She said she did not know who left door open. RN#6 said staff should change PPE between hall C and D. Observation on 7/4/2020 at 3:50pm, surveyor exited the main building and entered the facility's designated covid19 positive hall which had 15 positive residents. There were 3 aides, one medication aide , one LVN and one RN working on the hall. Surveyor was not screened upon entrance the unit. Surveyor was not asked any screening questions by any staff present. Further observation on 7/4/2020 at 3:55pm revealed the entrance to the covid hall and exit door opens to a street. The entire hall was designated a hot zone. There was no designated cold zone- an area free of contamination where staff can don and doff PPE and there were no designated biohazard waste containers for contaminated PPE to reflect staff were doffing used PPE prior to exiting contaminated area. A few PPE were found in the staff break room down the hall, no other designated area was provided for donning and doffing PPE. Observation on 7/4/2020 at 3:58pm revealed MA#1 removed his gowns in the hall and placed gown in a container by the door which exits to a smoking area/patio. Interview following above observation , MA #1 said he was not aware of any designated place to dispose used gowns. He said staff placed all used PPE in any trash container available either in the resident's rooms or the container by the exit to the patio. Observation on 7/4/2020 at 4:10pm revealed CNA#1 removed used his gown while standing in on the hallway. He held the PPE while in his hand and then walked toward the exit door where he discarded the PPE in a container. Interviewed immediately following observation, CNA #1 said he was from a staffing agency. When asked if he received any training on how things are done on the covid hall said he just watched and followed other staff . He said he wasn't aware used PPE should be disposed of separately. Interview 7/4/2020 at 4:05pm, RN#2 said staff who worked in the covid positive hall were all covid19 negative . RN#2 said upon arrival through the side entrance which opened to a street, staff go into the hall and walk past 7 rooms that were occupied by positives residents with doors open before getting to a staff designated break room where they have gowns to don and then screen themselves. RN#2 when asked where used gowns were removed said they put them in any waste containers either in the residents' room or the trash containers by the patio exit. When asked where surveyor should remove used PPE to exit the hall, RN#2 said the surveyor will have to keep PPE on and exit and remove the used PPE outside. RN#2 further said she understood that removing the gown in the hot zone placed the staff at risk of exposure to covid19. She said they were not provided designed containers for the waste in the covid hall. Interview 7/4/2020 at 4:20pm, RN#2 said staff screened themselves and completed the questionnaires in the break room. When asked what PPE they should have on prior to entering the hall, RN #2 said staff designated to work in the covid19 positive hall usually go home with an N95 mask which they would have on when returning for their next shift. They go to the break room at the end of the hall to obtain a gown and face shield. RN#2 said she did not remember to screen the surveyor. She did not the who was responsible to screen visitors since visitors and other facility staff were not allowed into the covid hall. She said she was also concerned that staff who worked in the covid hall entered the hall without full PPE. She said the set up allowed them to enter the hall and walk pass positive resident rooms before getting to the staff break room where they can get gowns. She said she shared the same concerns with DON because she believed staff were being exposed to contamination. RN#2 said the set up was wrong because PPE should be readily available before entering the hall or upon entrance and that an area for doffing PPE should also be available . At this time, RN#2 said staff were doffing on anywhere on in the hall. Record review of covid19 hall screening log dated 7/4/2020 revealed at an unknown time and 1:35pm, two staff members who entered the non covid19 hall did not complete the screening questionnaires. There were only names, times of entrance, and temperatures documented. The rest of the questionnaire were left blank. Record review of covid19 hall screening log dated 7/4/2020 revealed at 6:08am and 6:30am,two staff members who entered the covid19 hall did not complete the screening questionnaires. There were only entrance times and temperatures documented. Interview on 7/4/2020 at 4:50pm, RN #2 after reviewing the screening log for the covid19 positive hall identified one of the blank entries was from the Medication aide on duty . Interview on 7/4/2020 at 5:02pm, MA#1 said he was supposed to complete the screening log but did not. MA#1 had no reason when asked why he didn't complete the screening. He further said he knew he should have. Interview on 07/04/2020 at 5:10pm, RN #2 confirmed the facility had 20 covid19 positive residents . 5 positive residents were in the hospital. There were 15 currently in the facility and census was 36. Observation on 7/6/2020 at 1:35pm, surveyor entered the facility and observed a hospice nurse enter at the same time. Hospice nurse entered the facility's main entrance, checked her temperature by herself, completed the questionnaire and entered resident care unit - hall C and D. There was no staff around at the time and the completed questionnaire were not reviewed. Interview on 7/6/2020 at 1:45pm, the facility Administrator and DON were informed of infection control concerns observed on 7/4/2020. The DON said the practices were wrong and were not the proper procedures for screening of both staff and visitors. The DON said she started work at the facility last week Thursday 6/25/2020 and was trying to set up new systems. The DON said the staff should not screen themselves and should wear full PPE before entering the Covid19 positive hall. The DON said the all visitors to the facility should be screened by staff at the main entrance and that completed questionnaires should be reviewed by the screening staff before the visit is allowed to enter . when asked who responsible for screening visitor, the DON said the staff were supposed to answer the door and screen the person. The DON was shown the picture of the over flowing trash container, she said it was acceptable. DON said the housekeeping staff should be making round and removing and replacing trash container before they become full. The DON said Resident # 5 and Resident #6 were in the PUI unit (Hall D) on 7/4/2020, were sent hospital 7/5/2020 where they tested covid positive. She said the RN#6 was the charge nurse for hall C and D but hall D was quarantine hall. The administrator said the facility were following the recommendations from special infection control assessment team (SICA) and changed the covid hall set up as recommended. Record review of the facility's policy on infection control manual and interim policy for suspected or confirmed coronavirus not dated revealed this facility will minimize exposures to respiratory pathogen, promptly identify residents or healthcare personnel with signs or symptoms of covid-19 and implement intervention based upon federal and state/local recommendation ( to include admission , visitation , standard and transmission based precautions , hand hygiene universal source control, PPE resident replacement and more) to prevent and /or mitigate the spread of covid-19. Further review of policy revealed the facility will implement screening as outlined by CDC. Record review of the nursing facility COVID-19 Response read in part A nursing facility must have a COVID-19 response plan that includes the following; (c) A nursing facility must screen all residents, staff and people who come to the facility in accordance with the following criteria of this subchapter: (1) Fever defined as a temperature of 100.4 Fahrenheit and above, or signs or symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; (2) Signs or symptoms of COVID-19 including, but not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; (3) Additional signs and symptoms as outlined by the CDC: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html; (4) Contact in the last 14 days, unless to provide or receive critical assistance, with someone who has a confirmed [DIAGNOSES REDACTED]. For updated information on affected countries visit: https://www.cdc.gov/coronavirus/2019-ncov/[MEDICATION NAME]/map-and-travel-notices.html. (d) A nursing facility must screen according to the following timeframes: (1) each resident at least three times a day, occurring at least once each shift; and (2) each employee or contractor before entering the facility at the start of their shift. (e) A nursing facility must cohort residents based on the residents' COVID-19 status. (f) A resident with unknown COVID-19 status must be quarantined and monitored for fever and symptoms of COVID-19 per CDC guidance. (g) A COVID-19 positive resident must be isolated until they meet CDC guidelines for the discontinuation of transmission-based precautions. i) All NF staff must wear a facemask while in the facility. Staff who are caring for COVID-19 positive residents and those caring for residents with unknown COVID-19 status must wear an N95 mask, gown, gloves, and goggles or a face shield. All facemasks and N95 masks must be in good functional condition as described in the COVID-19 Response for Nursing Facilities, and worn appropriately, completely covering the nose and mouth, at all times. The facility Administrator and DON were notified on 7/06/20 at 1:50pm pm that immediate jeopardy was identified due to the above failures. A copy of the IJ template was provided at this time and a plan of removal was requested. The final plan of removal was accepted on 07/09/20 at 11:47 am after several revisions were made. IJ plan of removal includes: The current policy was reviewed and updated to reflect the following: All staff and visitors will enter the facility through either the front entrance (non-COVID care staff) or the designated COVID entrance (COVID care staff) located in the rehab section of the facility beginning 7/6/20. Prior to entering, all will be screened by trained personnel, including a temperature check and questionnaire that includes all current COVID 19 symptoms beginning 7/6/20. During times when a screener is not present, the doors will remain locked, preventing entrance until screening has been completed. Locked doors will be equipped with doorbells, to alert staff of screening need. All staff will receive training regarding screening expectations by the Administrator or designee, to be completed by: 7/10/20. Director of Business Development or designee will check thermometers daily and log that they are functional; as well ensuring that COVID questionnaires are available in binders at the facility entrance and COVID unit entrance Facilities Plan to Ensure Continued Compliance: The screening document will be audited daily by the Administrator or designee to ensure screening is completed and documented The RN working each shift will ensure that screening tool has been completed and initial indicating review Results of the daily audit will be reported to the QAPI Committee monthly until the committee determines continued compliance is sustained for 3 months, or by the discretion of the QAPI committee. The COVID 19 designated unit has been moved, as of 7/6/20, per the request from the HHSC representative to incorporate the A and B hallways into one COVID unit or hot zone. A separate entrance at the end of the rehab hallway will be utilized by staff assigned to the COVID unit for entering and exiting. A cold zone has been designated for donning of appropriate PPE. Fire doors will separate the cold zone from the warm zone where a doffing station will be located with the appropriate biohazard waste container will be placed, emptied, and disposed of when full. Staff will bring biohazard waste container to receptacle bin in the B- hall utility, when this is full, maintenance will discard to biohazard waste. We will provide an in-service, so the staff understands how they will need to discard biohazard material and will have an audit to ensure staff complies. The hot zone is where the COVID positive residents will reside. A plastic doorway will be placed between the A hallway and the kitchen. A second plastic doorway will be placed front entrance hallway and entrance into the B hallway. A unit was deep cleaned prior to moving the COVID positive residents on 7/6/20. B unit will be deep cleaned by 7/8/20, prior to resident use. The C and D hallways will house non-COVID positive residents . All residents and staff will be retested on [DATE] and 7/8/20. All staff providing care on the COVID designated unit will be provided training before starting their shift on use of donning/doffing stations and appropriate disposal of PPE utilizing biohazard boxes. Facility Plan to Ensure Compliance: The current policy for care, cohorting. and staffing of the COVID positive unit was updated and training will be provided by Pathway Health Consultant or designee and completed by: 7/13/20 All staff will be provided education and have competency verification on: ¢ Transmission-based precautions (COVID-19) ¢ Donning/doffing/disposal of appropriate PPE ¢ Room and equipment cleaning and disinfecting ¢ A competency tool will be developed a utilized for validation of PPE use/donning/doffing/ and proper disposal Weekly audits will include (10) on day shift (3) on evening shift, and (2) on night shift on the COVID unit to ensure continued competency related to appropriate PPE use/donning/doffing/ and disposal Audit results will be reported to the QAPI committee monthly until continued compliance is sustained for 3 months, or by the discretion of the QAPI committee. Surveyor monitoring Record review of the facility's plan of removal binder on 7/9/20 revealed in-services that included designed of hall A for COVID positive residents, biohazard waste containers, PPE usage, signs/symptoms of COVID and staff and visitor screening and designated donning and doffing areas in the covid19 positive halls. Observation and interview on 7/9/2020 at 7:00pm revealed screening was set up at the facility's main entrance. There was a staff present to screen visitors and staff. Screener #1 said received training on how to screen everyone. She expressed understanding of what to do when anyone answered yes, she said the everyone must complete the questionnaire with temperate checks before they can enter the facility . Further observation revealed adequate PPE available , waste containers for used PPE and signs identifying hall designations with PPE requirement. Observations and interview on 7/9/20 at 7:15pm revealed a new entrance was created for hall A. A designated screening was set up upon entrance of hall A with a staff present ( Screener #2) . Surveyor was screened upon entrance with appropriate screening questions on the questionnaire presented to surveyor by the screener. Surveyor was asked to wait until a nurse can review questionnaire entries . Further observation and interview revealed PPE were available at the screening set up area and were provided to staff and visitors before allowed to enter the covid hall. There were N95 masks, gowns gloves and face shield on the PPE designed drawer. The Screener #2 said she received training on how to screen people and to notify the nurse if any one answered yes to any of the screening questions. She said she would have the person wait outside while she contacted the nurse for further directions. Observation and interview on 7/9/2020 between 7:45 pm and 8:40pm, two LVNs, two RN and two CNAs on the night shift were interviewed on the trainings provided to them on PPE usage, they had adequate understanding of the trainings and in-services received , when to change PPE and what PPE are needed to covid halls and quarantine halls. All were on hall A and they had full PPE on . Further observation of Hall A revealed waste containers were available and not full. Record review of the facility's plan of removal binder for all staff on 7/10/2020 revealed training log with employees' names and signatures, competency checks for donning and doffing PPEs, screening , standard precautions and transmission-based precautions from 7/7/20 to 7/9/2020. Interview on 7/10/2020 at 8:00pm , CNA #1 said he was from a staffing agency, he said he received training two days ago and again today when he arrived to work on the new set up . He said he was provided PPE . He said he knows the appropriate place to remove used PPE and was shown how not to contaminate himself while working on the covid positive hall. Observation and interview on 7/10/2020 between 4:17pm to 5:20pm on the facility's non covid halls C and D revealed appropriate screenings at the two facility entrances. PPE were seen at the screening set up area. Staff wore appropriate PPE. Two CNAs, one medication aide and one LVN were interviewed on recent trainings. They had appropriate understanding of PPE usage and were observed doffing and donning PPE appropriately at the designated places. Interview on 7/11/2020 at 5:25pm, RN#1 said she was from the management company that was recently awarded receivership of the facility. She said the facility currently had no management as the DON walked out after IJ was called and the administrator was out sick. She further said the facility did not have MDS staff, social worker or an ADON. She said she has been the point of contact for the facility and will continue until she hires some management staff for the facility. Observations on 7/11/20 between 8:30pm and 9:20pm revealed nursing staff in both covid hall and non covid hall were donning/doffing PPE properly. Observation and interview on 7/12/2020 between 11am and 2:00pm revealed no concerns with staff wearing PPE and screening of staff and visitors. Three CNAs, two LVNs, one RN and one Medication aide were interviewed had adequate understanding of trainings on donning and doffing PPEs, screening , standard precautions and transmission-based precautions. Record review of the non covid19 and covid hall screening logs from 7/7/ to 7/13/2020 revealed staff were been screened appropriately. Interview on 7/13/2020 at 5:00pm RN#5 said she was responsible for training staff. She said she was part of the management company. She said staff training included returned demonstration over donning/doffing with all staff. She said she has been making frequent rounds and observing staff to identify and correct inaccurate practices on PPE usage and cross contamination. On 7/13/2020 at 5:15pm, RN #1 was informed IJ was lowered however, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread as the facility continued to monitor effectiveness of their plan of removal.

Based on interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of eight residents (CR #1) reviewed for quality of care, in that; CR#1 did not have a baseline care plan developed for her low and high blood pressure . CR #1's identified low blood pressure values were not communicated to the DON. CR #1's physician was not consulted for her series of low blood pressure . CR#1's low blood pressure was not monitored when she was identified to have low blood pressure. CR#1's low blood pressure medication did not have a parameter for administration and when to hold medication. CR#1's condition was not adequately assessed for intervention as she deteriorated for 8 hours . 911 initiated resuscitation which was not successful. CR#1 was pronounced dead on arrival at the hospital ER. An immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was continuing to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one closed record who died . Findings include: 1/TX 423 CR#1 Record review of CR#1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. CR#1's admitting [DIAGNOSES REDACTED]. Record review of CR#1's hospital discharge summary dated [DATE] revealed CR#1 had a past medical history of [REDACTED]. CR#1 complained of malaise and lethargy. CR#1 also had past medical history of [REDACTED]. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed staff assessment of cognition for daily decision making was marked 3 indicating moderately impaired cognition . The MDS further revealed the resident's nutritional approach was feeding tube . Record review of CR#1's nursing notes dated [DATE] revealed CR#1 was transferred to the hospital ER where she was pronounced dead on arrival . Record review of CR#1's baseline care plan dated [DATE] revealed baseline care plan did not address the resident's [DIAGNOSES REDACTED]. Record review of CR#1's physician order [REDACTED]. Hold if SBP is greater than 140 ( Please check the blood pressure). Order had no parameters for when to hold the medication and when to contact the physician . Record review of CR#1's physician order [REDACTED]. Order had no parameters for administration , when to hold medication and when to contact the physician . Record review of CR#1's (MONTH) MAR indicated [REDACTED] [DATE]-,[DATE], ,[DATE], and ,[DATE] . ,[DATE]//19 - ,[DATE], ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE], and ,[DATE]. [DATE] - ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE] and ,[DATE] [DATE] - ,[DATE], ,[DATE] and ,[DATE]. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Further review revealed the medication was discontinued on [DATE] and restarted on [DATE] with no medication dose missed. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Medication was recorded as administered on [DATE] at 8:00am with a blood pressure of ,[DATE] and pulse of 125. Record review of CR#1's blood pressure log revealed on [DATE] at 05:03am, RN #2 documented a blood pressure of ,[DATE]. Record review of CR#1's progress notes revealed no documentation of intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's progress notes dated [DATE] at 11:10pm written by RN #1 revealed RN #1 had a hard time getting CR#1's blood pressure , CR#1's eyes were closed and no move was noted, warm to touch, RN #1 pinched CR#1's skin and it took a long time for the skin to go back to normal, NP was notified and order given was to bolus the resident with free water of 300ml and elevate CR#1's feet and recheck blood pressure in a hour. RN #1 gave CR#1 free water and elevated resident's feet. Blood pressure was rechecked and recorded, NP was notified and told new reading, and orders were given to increase CR#1's flush via pump to 30ml per hour and to give 100ml of free water every 6 hours, discontinue [MEDICATION NAME] 2.5 given 2 tablets via peg tube, make sure CR#1's blood pressure is taken . Record review of CR#1's blood pressure log revealed on [DATE] at 1:23 am, RN #2 documented a blood pressure of ,[DATE] . Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Record review of CR#1's progress notes revealed no documentation of any other intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's blood pressure log revealed on [DATE] at 06:17am , RN #2 documented a blood pressure blood pressure was ,[DATE]. Record review of CR#1's progress notes revealed no documentation of any intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's blood pressure log revealed on [DATE] at 8:01am, RN #1 documented a blood pressure of ,[DATE]. Record review of CR#1's progress notes dated [DATE] at 11:00am written by RN #1( morning nurse ) revealed CR#1 was in bed resting with her eyes closed, moving noted and blood pressure was unable to be taken on first attempt and was taken again with reading of blood pressure ,[DATE] pulse of 89 and gave CR#1 [MEDICATION NAME] and elevated her legs, called NP to report the condition of CR#1. NP stated she would be coming in the facility in about 2 hours, but in the meantime could we get a STAT chest X-ray and a CBC STAT. RN #1 cleaned CR#1's mouth and kept checking on the resident. Returned about 40 minutes later and checked CR#1's blood pressure and could not get a reading, tried several times, but could feel pulse was weak, as RN #1 was about to call NP again, the NP walked into the CR#1's room and ordered RN #1 to call EMS ambulance and send CR#1 to the hospital. RN #1 called two EMS ambulance services and wait time was too long. RN #1 returned to check on CR#1 and called NP to see the change on CR#1. Both RN #1 and NP went back to the room and RN #1 called 911 on her phone while in CR#1's room, pulse could be found but was weak and thread. Paramedics came and could find a pulse, about 30secs later paramedics started CPR as they transported CR#1 to the hospital. At about 10:58am, the nurse from the hospital emergency room called and stated that CR#1 had expired at 10:54am and wanted a phone number to the family member, RN #1 provided the number and 2 mins later the case manager called with more questions that RN #1 answered. The RP was notified, and NP was notified of the death of CR#1 at the hospital. Record review of CR#1's records revealed no documentation the resident's blood pressure values were rechecked by RN#1 as stated above after the reading of ,[DATE] was obtained and while RN#1 waited for NP to arrive to the facility. Interview on [DATE] at 12:55pm, CR#1's Family member stated the family was not notified CR#1 had a low blood pressure and was not notified CR#1 was sent out to the hospital. The Family member stated they received a call from the hospital on [DATE] approximately 10:30am informing them the resident had expired and they did not know CR#1 was sent out to hospital by facility. Interview on [DATE] at 1:19pm, the NP stated she received a call from RN #1 on [DATE] around 8 or 9 pm and gave order to elevate CR#1's legs and give extra water and to check blood pressure again and call back in a hour. NP stated she received a call back about an hour later and the resident blood pressure was stable. NP stated she did not receive any other calls after that time nor did she receive any calls around 1am about CR#1's blood pressure being ,[DATE]. Record review of CR#1's records revealed no documentation of a follow up blood pressure value as stated by the NP above. Interview on [DATE] at 1:35pm, RN #1 stated she arrived at facility at 6:30am on [DATE], did her rounds and saw CR#1 didn't look well and asked night nurse ( RN #2) how CR#1 had been. RN #1 said RN #2 reported CR#1 blood pressure was low but gave her medication ([MEDICATION NAME]) and blood pressure was okay. RN #1 stated she checked CR#1's blood pressure and it was low 72/over something, so she gave [MEDICATION NAME] and called the Np and told Np the resident's blood pressure was low and the resident did not look well. The NP stated she would be there within 1 or 2 hours. RN #1 stated she also gave water because CR#1 might have been dehydrated which was why blood pressure could have been low. RN #1 stated she continued checking on CR#1 to see if she was still breathing. RN#1 was asked who she checked on the resident and she said she was just peeking through the door to see if the resident was still breathing. RN #1 said CR#1 seemed to be getting worse, so she called NP and NP was walking into the resident's room. RN #1 stated NP arrived around 9am and told her to go ahead and call EMS. RN #1 stated she called 2 EMS companies, but both were going to take too long so she called 911 and 911 arrived between 5 to 7 minutes after call. RN#1 said 911 checked the resident's pulse and during the transfer to the stretcher , they lost pulse and immediately started CPR. Record review of CR#1's records revealed no documentation of CR#1's blood pressure monitoring after RN#1documented the value of ,[DATE]. There was no evidence or documentation indicating RN#1 assessed the resident again while waiting for the NP's arrival. Interview on [DATE] at 2:15pm, the ADON stated she did call the family, but everything happened so fast by the time CR#1 left the facility to go to the hospital , the hospital had already notified the family. Interview on [DATE] at 3:40pm, the DON stated she was not notified of CR#1's blood pressure being ,[DATE] at 1:23am in the morning of [DATE] and the NP or Physician should have been notified of low blood pressure . Interview on [DATE] at 10:03am, RN #2 stated she did not see the need to notify the physician or NP because CR#1's blood pressure was always low around midnight and she has the low blood pressure medication [MEDICATION NAME] every 8hrs. RN #2 said did not check blood pressure again after giving [MEDICATION NAME] at 12 midnight, because she had another dose scheduled at 8am. Interview on [DATE] at 4:15pm, the NP stated nurses should notify Physician and/or NP when systolic blood pressure was less than 90 and diastolic blood pressure was less than 60. NP said the nurses should know when blood pressure was low or high they should call the Physician or NP. Attempt was made to interview CR#1's Physician on [DATE] at 4:25pm. A massage was left, and call was not returned. In an interview on [DATE] at 4:46pm, the DON stated residents on blood pressure medications have parameters set by their physicians that should be followed. The DON stated CR#1 was on [MEDICATION NAME] for low blood pressure and RN#2 gave [MEDICATION NAME] on [DATE] at 12 midnight as the intervention for the low blood pressure values she obtained when she checked the resident's blood pressure . The DON stated RN#2 did not document the administration until 1:23am but medication was given at 12 midnight. The DON said RN#2 gave [MEDICATION NAME] as CR#1's intervention for low blood pressure and did not need to notify physician or NP about the low blood pressure since the resident was known to have that [DIAGNOSES REDACTED]. The DON stated CR#1 had no set or ordered parameters for her low blood pressure medication and the facility had no policy on when to notify physician or Np of low blood pressure obtained. Interview on [DATE] at 10:45am, the hospital risk manager stated there was no blood pressure or vitals taken for CR#1 at time of arrival at hospital ER by HFD and CPR was in progress upon arrival at 10:41am. CR#1 was intubated at facility prior to arrival. CR#1 Glucose was 60 and approximately 10 rounds of [MEDICATION NAME] was given in attempt to resuscitate and revive the resident's glucose, 48 multiple rounds of CPR, CR#1's time of death 10:54am. Interview on [DATE] at 10:27am, CNA#1 stated on [DATE] at 6am , she did her rounds and CR#1 was sleeping. CNA #1 stated she had been working with CR#1 since she was admitted into facility and CR#1 could not talk but did smile when talked to. CNA #1 stated around 9 or so she noticed CR#1 did not look good and when she was talking to CR#1 she did not smile or nothing as normal, so she knew she was not well. CNA #1 stated she notified RN#1 and RN#1 and Np walked into the resident's room and RN#1 called 911. Record review of facility's policy titled Change in a Resident's Condition or Status (date unknown) read in part: our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status . the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition . unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when: .a decision has been made to discharge the resident from the facility; and/or it is necessary to transfer the resident to a hospital/treatment center . The Administrator was notified of Immediate Jeopardy (IJ) on [DATE] at 9:25am due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 11:29p.m. after several revisions were made. Plan of Removal of / Immediate Jeopardy All residents have the potential to be affected by the deficiency Revision of the (IDT) Interdisciplinary Team - Admission and Discharge Protocol: Review all new patients and discharges and change of conditions upon occurrences. Director of Nursing/Assistant Director of Nursing/Therapy/Administrator/MDS Coordinator. The facility incorporates a holistic approach on caring for our patients. Upon each new patient they are accompanied with an admission packet that includes their History & Physical (H&P), Medication Administration Record [REDACTED]. At daily stand-up and/or stand-down the (IDT) Interdisciplinary Team reviews and discuss new patient's admission diagnosis, medical condition and any residents with significant changes in their medical conditions including discharges. The Point Click Care (PCC) includes corrective actions and follow-up. As a mitigation strategy, each month the team will receive In-service on these procedures and practices. Changes as follows: All facility physicians were called, and vital parameters obtained when to call physician; parameters binder is located at each nurses' station. Director of Nursing/Assistant Director of Nursing .Completed [DATE]. Parameters placed when to call MD for every blood pressure medication; Telephone orders directing nurses to refer to MD parameter log, nurses in-serviced on location and protocol. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. A binder was placed on all nursing stations where the list for MDs preferred parameters on when to call physicians are for reference; nurses in-serviced on binder location. Director of Nursing/Assistant Director of Nursing Completed [DATE]. New Protocol and collaboration re-established with Physician /Nurse Practitioner- on: Calling 911/Change of Condition/When to Notify Doctor/Using Nursing Judgement. - Nurse Practitioner .Completed [DATE] Director of Nursing (DON) has been educated in best practice, assessment and standards of care by the Chief Nursing Officer and Medical Director. Completed [DATE] Implemented Walking Rounds for verbal report from nurses for Incidents/Change of Conditions/Abnormal labs and vital signs and new Doctor orders, etc., Director of Nursing/Assistant Director of Nursing/Administrator/Director of Social Services. Completed [DATE] Review of policy and procedure titled, Change in Resident Condition and Doctor Notification Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Implement a new 24-hour tracking report and review daily .Director of Nursing/Assistant Director of Nursing. Completed [DATE]. NEW protocol implemented to call Director of Nursing with any change of condition and/or abnormalities in vitals and discharges . Director of Nursing. Completed [DATE] Implemented a new system for DON or designee to print out vital signs report daily to monitor compliance Director of Nursing/Assistant Director of Nursing. Completed [DATE] Facility-wide audit on all residents have been conducted to make sure any changes in condition had been addressed Director of Nursing/Assistant Director of Nursing/Designee. Completed [DATE]. Staff In-Services conducted related to notification of physician of abnormal vital signs especially blood pressure changes even if results are improving and change of condition. Medical Director and Director of Nursing. Completed [DATE]. In-Service staff; Topic: Assessment, Notification vs. Emergency 911. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Re-In-Service staff on the use of SBAR and Stop and Watch tools. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Competencies on [DEVICE]s/Diabetes Mellitus/[MEDICAL CONDITION]/Foley/Oxygen use, etc. Director of Nursing/Assistant Director of Nursing/Designee. Completed [DATE] Implement vital signs competency with Nurses'/C.M.A.s/C.N.As. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Re-education on Hypertension/[MEDICAL CONDITION] and parameters - given to Nurses & Certified Medication Aide (C.M.A). Director of Nursing/Assistant Director of Nursing. Completed [DATE] Re-educated & Disciplined RN#1 and RN#2 . Director of Nursing/Assistant Director of Nursing. Completed [DATE]. All discharges to hospital will be discussed in Stand-up meetings. Director of Nursing/Assistant Director of Nursing/Administrator. Completed [DATE]. Administrator will monitor and ensure that all residents with change of condition will be reviewed daily via the use of the 24-hour report, communication and/or discussion during the morning stand-up and/or stand-down meetings. Administrator/QAPI team .Completed [DATE]. Review of policies and procedures titled, Care Plans. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. All admissions from the last 48 hours will be audited and their [DIAGNOSES REDACTED]. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Significant information about residents' care will be added to the baseline care plan summary; ex. resident has a historical history outlined in medical records or interview has frequent UTIs; so, staff can be pro-active in preventing and be conscious to watch for early S/S. Director of Nursing. Completed [DATE]. Majority of staff have been in-serviced on hypertension/[MEDICAL CONDITION] and vitals; the remaining staff members will be completed by [DATE]; prior to assuming patient care responsibilities. This plan has been initiated [DATE] and completed [DATE]. Monitoring: Monitoring the plan to remove of the Immediate Jeopardy was conducted as follows: Interview on [DATE] at 1:26pm, the Administrator stated she was not aware of CR#1's low blood pressure and to her understanding the IJ was called because CR#1's condition was not timely relayed to the Physician or NP. The Administrator stated the facility DON and ADON are monitoring 24-hour report, communicating to nursing staff any immediate change of conditions, and notifying physicians of any resident on blood pressure medication to ensure all residents have parameters set. The Administrator stated RN#2 received a written warning and has been in-serviced on physician's parameters. Interview on [DATE] at 1:36pm , the DON said she thought the IJ was called because of failure starting at top with nursing management. There was no monitoring follow-up after intervention was implemented, registered nurses are taught in school what a normal blood pressure is and what is not normal and when to notify the MD. The DON stated RN#2 failed to report CR#1's blood pressure of ,[DATE] to physician , did not document she took blood pressure after medication was administered and did not report follow-up blood pressure . The DON stated all staff are being trained on change in condition and how to identify a change in condition, when to notify the MD, when to call 911, and acting promptly. The DON stated the facility is initiating a new 24hour report, training staff on stop and watch, SBAR and a 24hour report will be written. The DON stated a Physician's binder with all vital signs parameters and when to notify the physician is at each nursing station with physician's contact information. The DON stated staff will be trained on blood pressure ([MEDICAL CONDITION]/hypertension) parameters and competencies and in-serviced on change of condition. Record review of facility's training and in-service log revealed facility staff received training on identifying change of condition, acting promptly, notifying MD, calling 911 and when to call 911, SBAR, stop and watch, and facility communication 24-hour report form. Training was provided by the ADON . Record review of facility's training and in-service log revealed facility staff received training on when to notify the Director of Nursing, nursing judgement, using best judgement if situation warrants sending resident to hospital, then making the suggestion to the MD/NP, if unable to reach MD/NP, call the DON, notify the medical director, if unable to reach anyone call 911 if situation warrants, if orders by MD are not appropriate speak up, and notification verses emergency 911. These training were provided by the DON. Record review of facility's training and in-service log revealed facility staff received training by NP on when to call MD and NP and change of condition and what to look for and vital signs and parameters given. Record review of facility's log revealed identified residents with the [DIAGNOSES REDACTED]. Record review of facility's training and in-service log revealed facility staff received training provided by DON and Medical Director on MD notification, change of condition, labs & lab tracking, communication, teamwork, and MD parameters books. Record review of facility's training and in-service log revealed facility staff received training from the DON on communicating continuously with MD and NP until a resolution was received, the resident being sent out and if the resident was stable, reporting even if condition is improving and document. Record review of facility's training and in-service log revealed facility staff received training from the DON on abnormal vitals, calling MD/NP and DON for abnormal vital signs, check MD parameters in MD notification book, ensure MD/NP was notified , document vital signs and notification of new orders. Record review of facility's training and in-service log revealed facility staff received training by DON on [MEDICAL CONDITION]/hypertension. Record review of parameters binder revealed all physicians with patients at the facility had a tab with their name and the vitals and requirements of when to notify the physician or on-call designee and the contact information for the physician and designee. Record review of in-service log revealed nursing staff education provided by Medical Director with DON on best practice, assessment and standards of care. Record review of vital signs summary report for all residents dated [DATE] revealed no abnormal values of vital signs were identified. Record review of facility wide audit for resident with change of condition revealed no resident had a change of condition identified and resident on blood pressure medications were verified to have parameters. Record review of care plan policy (date unknown) revealed a care plan was based on a resident's comprehensive assessment and is developed by a care plan/interdisciplinary team . The resident and family or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Record review of disciplinary action form revealed RN#1 and RN#2 received disciplinary action signed by DON and employee. Interview on [DATE] at 10:23, the ADON stated in-services were provided to address manual blood pressure, correct way to use the thermometer and how to take vitals, what to report to the nurse , re-demonstrated on management staff, thermometer temp of 95.2 and asked if normal or abnormal, change in condition, medical director in-serviced change in condition, patient not normal self (usually walking then not walking, able to pick up cup and now unable to pick up cup) Hypo and hypertensive was covered, when to call 911, NP in-service on change condition, when to call 911, using nursing judgement and if patient has a decline, then call 911, nurse can call 911 and then notify MD letting them know patient needed to go without waiting on order from MD or NP. All full-time staff have been trained just waiting to train PRN staff as they become available. Interview on [DATE] at 10:42am, RN#3 stated staff in-service was provided on change in condition and when to report abnormal vitals to the MD. Interview on [DATE] at 11:19am , Medication-Aide#1 stated staff education was provided on blood pressure parameters. Medication-Aide #1 identified change in condition and said the nurse should be promptly notified of any change . Interview on [DATE] at 11:30am, CNA#13 stated she received in-service on abnormal vital signs and should notify the nurse right away. CNA#13 further said if she noticed anything different on a resident, she would immediately notify the nurse. Interview on [DATE] at 11:43am, Medication-Aide #2 stated change in condition should be reported to the nurse immediately and documented on 24-hour report. Medication-Aide #2 said MD Parameters were located in a binder at nursing station. Interview on [DATE] at 11:50am, CNA #2 said she received in-service on blood pressure parameters and identified where the parameter binder/vital signs was located at nursing station . She said the change in condition should be immediately reported to nurse. Interview on [DATE] at 12:00pm CNA#3 stated in-serviced blood pressure parameters and identified where the parameter binder vital signs was located at nursing. She said if any change was noticed on a resident, it would be immediately communicated to the nurse. Interview on [DATE] at 12:07pm, LVN#1 stated she was in-serviced on checking vitals and if abnormal , notify doctor, if she received a report from CMA/CNA on a change in condition, she should go recheck vitals and report to doctor. If vitals are abnormal, she would notify MD . She further said the resident's baseline vital signs should be known to staff caring for the resident so that change would be identified. She said she would notify DON, document in progress notes and also in 24hr report can document and have it put in 24hr report. She said the parameters binder for MD requirements was located at nursing station. Interview on [DATE] at 12:16pm LVN#2 said she had training on change in condition , blood Pressure parameters, when to notify MD and DON . Inform responsible party and when to call 911. Interview on [DATE] at 12:03pm and at 12:26pm , CNA#4 and CNA#5 said they received training on change in condition and notifying the charge nurse of anything identified during resident care. Interview on [DATE] at 12:03pm CNA#5 stated she was in-serviced on vital signs that are reportable to nurse as well as a change in condition in a resident . She further said she would notify nurse to assess resident before providing any kind of care. Interview on [DATE] at 12:39pm , Restorative Aide stated he was in-serviced on abnormal vitals . Anything over 120 or under 80 will be reported to the nurse. Restorative Aide said the parameter binder of MD requirements of vital signs to be report was located at nursing station. Interview on [DATE] at 12:49pm, the Housekeeping Supervisor stated he was in-serviced on change in condition of a resident and to notify the charge nurse immediately. Interview on [DATE] at 1:53pm, with the Administrator, DON, ADON, Director of Social Services, and MDS Coordinator , they all agreed that all department heads made arounds on all nursing stations and reviewed the 24hour report of incidents, change of condition, behaviors of complaints . Based on information received, they would go to the room of the identified resident and re-assess. Any residents sent out via ambulance to hospital will be discussed in morning meetings, vital sign summaries will also be pulled and reviewed in morning meetings to determine abnormal vitals. Interview on [DATE] at 2:33pm and at 2:41pm , CNA #6 and CNA #7 said they were trained on what could be considered a change in the residents' condition and to call the nurse immediately. They also said if a change was identified during care, they would stop care and take of the resident first. Interview on 0

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition and when there's a need to alter treatment significantly for one of eight residents (CR #1) reviewed for notification of changes, in that: CR #1's physician was not consulted when she was identified to have series of low blood pressure values resulting in CR#1's condition worsening due to no interventions for her low blood pressure for 8 hours . 911 initiated resuscitation which was not successful. CR#1 was pronounced dead on arrival at the hospital ER. CR#1's Responsible Party was not notified of her changes in condition and was not notified when she was transferred to the ER where she was pronounced dead on arrival. An immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was continuing to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one closed record who died . Findings include: 1/TX 423 CR#1 Record review of CR#1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. CR#1's admitting [DIAGNOSES REDACTED]. Record review of CR#1's hospital discharge summary dated [DATE] revealed CR#1 had a past medical history of [REDACTED]. CR#1 complained of malaise and lethargy. CR#1 also had past medical history of [REDACTED]. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed staff assessment of cognition for daily decision making was marked 3 indicating moderately impaired cognition . The MDS further revealed the resident's nutritional approach was feeding tube . Record review of CR#1's nursing notes dated [DATE] revealed CR#1 was transferred to the hospital ER where she was pronounced dead on arrival . Record review of CR#1's baseline care plan dated [DATE] revealed baseline care plan did not address the resident's [DIAGNOSES REDACTED]. Record review of CR#1's physician order [REDACTED]. Hold if SBP is greater than 140 ( Please check the blood pressure). Order had no parameters for when to hold the medication and when to contact the physician . Record review of CR#1's physician order [REDACTED]. Order had no parameters for administration , when to hold medication and when to contact the physician . Record review of CR#1's (MONTH) MAR indicated [REDACTED] [DATE]-,[DATE], ,[DATE], and ,[DATE] . ,[DATE]//19 - ,[DATE], ,[DATE] and ,[DATE]. [DATE] - ,[DATE], ,[DATE] and ,[DATE]. [DATE] - ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE] and ,[DATE]. [DATE] - ,[DATE], ,[DATE] and ,[DATE] [DATE] - ,[DATE], ,[DATE] and ,[DATE]. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Further review revealed the medication was discontinued on [DATE] and restarted on [DATE] with no medication dose missed. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Medication was recorded as administered on [DATE] at 8:00am with a blood pressure of ,[DATE] and pulse of 125. Record review of CR#1's blood pressure log revealed on [DATE] at 05:03am, RN #2 documented a blood pressure of ,[DATE]. Record review of CR#1's progress notes revealed no documentation of intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's progress notes dated [DATE] at 11:10pm written by RN #1 revealed RN #1 had a hard time getting CR#1's blood pressure , CR#1's eyes were closed and no move was noted, warm to touch, RN #1 pinched CR#1's skin and it took a long time for the skin to go back to normal, NP was notified and order given was to bolus the resident with free water of 300ml and elevate CR#1's feet and recheck blood pressure in a hour. RN #1 gave CR#1 free water and elevated resident's feet. Blood pressure was rechecked and recorded, NP was notified and told new reading, and orders were given to increase CR#1's flush via pump to 30ml per hour and to give 100ml of free water every 6 hours, discontinue [MEDICATION NAME] 2.5 given 2 tablets via peg tube, make sure CR#1's blood pressure is taken . Record review of CR#1's blood pressure log revealed on [DATE] at 1:23 am, RN #2 documented a blood pressure of ,[DATE]. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Record review of CR#1's progress notes revealed no documentation of any other intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's blood pressure log revealed on [DATE] at 06:17am , RN #2 documented a blood pressure blood pressure was ,[DATE]. Record review of CR#1's progress notes revealed no documentation of any intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's blood pressure log revealed on [DATE] at 8:01am, RN #1 documented a blood pressure of ,[DATE]. Record review of CR#1's progress notes dated [DATE] at 11:00am written by RN #1( morning nurse ) revealed CR#1 was in bed resting with her eyes closed, moving noted and blood pressure was unable to be taken on first attempt and was taken again with reading of blood pressure ,[DATE] pulse of 89 and gave CR#1 [MEDICATION NAME] and elevated her legs, called NP to report the condition of CR#1. NP stated she would be coming in the facility in about 2 hours, but in the meantime could we get a STAT chest X-ray and a CBC STAT. RN #1 cleaned CR#1's mouth and kept checking on the resident. Returned about 40 minutes later and checked CR#1's blood pressure and could not get a reading, tried several times, but could feel pulse was weak, as RN #1 was about to call NP again, the NP walked into the CR#1's room and ordered RN #1 to call EMS ambulance and send CR#1 to the hospital. RN #1 called two EMS ambulance services and wait time was too long. RN #1 returned to check on CR#1 and called NP to see the change on CR#1. Both RN #1 and NP went back to the room and RN #1 called 911 on her phone while in CR#1's room, pulse could be found but was weak and thread. Paramedics came and could find a pulse, about 30secs later paramedics started CPR as they transported CR#1 to the hospital. At about 10:58am, the nurse from the hospital emergency room called and stated that CR#1 had expired at 10:54am and wanted a phone number to the family member, RN #1 provided the number and 2 mins later the case manager called with more questions that RN #1 answered. The RP was notified, and NP was notified of the death of CR#1 at the hospital. Record review of CR#1's records revealed no documentation the resident's blood pressure values were rechecked by RN#1 as stated above after the reading of ,[DATE] was obtained and while RN#1 waited for NP to arrive to the facility. Interview on [DATE] at 12:55pm, CR#1's Family member stated the family was not notified CR#1 had a low blood pressure and was not notified CR#1 was sent out to the hospital. The Family member stated they received a call from the hospital on [DATE] approximately 10:30am informing them the resident had expired and they did not know CR#1 was sent out to hospital by facility. Interview on [DATE] at 12:55pm, CR#1's Family member stated the family was not notified CR#1 was weak or lethargic or had a low blood pressure and was not notified CR#1 was sent out to the hospital. The Family member stated they received a call from the hospital on [DATE] approximately 10:30am informing them the resident had expired and they did not know CR#1 was sent out to hospital by facility. Interview on [DATE] at 1:19pm the NP stated she received a call from RN #1 on [DATE] around 8 or 9 pm and gave order to elevate CR#1's legs and give extra water and to check blood pressure again and call back in a hour. NP stated she received a call back about an hour later and the resident blood pressure was stable. NP stated she did not receive any other calls after that time nor did she receive any calls around 1am about CR#1's blood pressure being ,[DATE]. NP stated RN #1 was supposed to call CR#1's family. Interview on [DATE] at 1:35pm, RN #1 stated she arrived at facility at 6:30am , did her rounds and saw CR#1 didn't look well and asked night nurse ( RN #2) how CR#1 had been. RN #1 said RN #2 reported CR#1 blood pressure was low but gave her medication ([MEDICATION NAME]) and blood pressure was okay. RN #1 stated she checked CR#1's blood pressure and it was low 72/over something, so she gave [MEDICATION NAME] and called the Np. The NP stated she would be there within 1 or 2 hours. RN #1 stated she also gave water because CR#1 might have been dehydrated which was why blood pressure could have been low. RN #1 stated she continued checking on CR#1 to see if she was still breathing and CR#1 seem to be getting worse so she called NP and NP was walking into the resident's room. RN #1 stated NP arrived around 9am and told her to go ahead and call EMS. RN #1 stated she called 2 EMS companies, but both were going to take too long so she called 911 and 911 arrived between 5 to 7 minutes after call. RN#1 said 911 checked the resident's pulse and during the transfer to the stretcher , they lost pulse and immediately started CPR. RN #1 stated she did not call the family after CR#1 went out with the ambulance, she had two other patients she had to attend to immediately and it just slipped her mind. Record review of CR#1's records revealed no documentation of CR#1's blood pressure monitoring between 1:23am and 6:17am on [DATE]. Interview on [DATE] at 2:15pm, the ADON stated she did call the family, but everything happened so fast by the time CR#1 left the facility to go to the hospital , the hospital had already notified the family. Interview on [DATE] at 2:23pm, the RP stated she did get a call from the facility and it was after the hospital had notified them of CR#1's death and the facility did not notify her CR#1 needed to go out to the hospital or that the resident had a change earlier that morning . Interview on [DATE] at 3:40pm, the DON stated she was not notified of CR#1's blood pressure being ,[DATE] at 1:23am in the morning of [DATE] and the NP or Physician should have been notified of low blood pressure . Interview on [DATE] at 10:03am, RN #2 stated she did not see the need to notify the physician or NP because CR#1's blood pressure was always low around midnight and she has the low blood pressure medication [MEDICATION NAME] every 8hrs. RN #2 did not check blood pressure again after giving [MEDICATION NAME] at 12 midnight, because she had another dose scheduled at 8am. Interview on [DATE] at 4:15pm, the NP stated nurses should notify Physician and/or NP when systolic blood pressure was less than 90 and diastolic blood pressure was less than 60. NP said the nurses should know when blood pressure was low or high they should call the Physician or NP. Interview on [DATE] at 10:45am, the hospital risk manager stated there was no blood pressure or vitals taken for CR#1 at time of arrival at hospital ER by HFD and CPR was in progress upon arrival at 10:41am. CR#1 was intubated at facility prior to arrival. CR#1 Glucose was 60 and approximately 10 rounds of [MEDICATION NAME] was given in attempt to resuscitate and revive the resident's glucose, 48 multiple rounds of CPR, CR#1's time of death 10:54am. Record review of facility's policy titled Change in a Resident's Condition or Status (date unknown) read in part: our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status . the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition . unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when: .a decision has been made to discharge the resident from the facility; and/or it is necessary to transfer the resident to a hospital/treatment center . The Administrator was notified of Immediate Jeopardy (IJ) on [DATE] at 9:25am due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 11:29p.m. after several revisions were made. Plan of Removal of Immediate Jeopardy All residents have the potential to be affected by the deficiency Revision of the (IDT) Interdisciplinary Team - Admission and Discharge Protocol: Review all new patients and discharges and change of conditions upon occurrences. Director of Nursing/Assistant Director of Nursing/Therapy/Administrator/MDS Coordinator. The facility incorporates a holistic approach on caring for our patients. Upon each new patient they are accompanied with an admission packet that includes their History & Physical (H&P), Medication Administration Record [REDACTED]. At daily stand-up and/or stand-down the (IDT) Interdisciplinary Team reviews and discuss new patient's admission diagnosis, medical condition and any residents with significant changes in their medical conditions including discharges. The Point Click Care (PCC) includes corrective actions and follow-up. As a mitigation strategy, each month the team will receive In-service on these procedures and practices. Changes as follows: All facility physicians were called, and vital parameters obtained when to call physician; parameters binder is located at each nurses' station. Director of Nursing/Assistant Director of Nursing .Completed [DATE]. Parameters placed when to call MD for every blood pressure medication; Telephone orders directing nurses to refer to MD parameter log, nurses in-serviced on location and protocol. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. A binder was placed on all nursing stations where the list for MDs preferred parameters on when to call physicians are for reference; nurses in-serviced on binder location. Director of Nursing/Assistant Director of Nursing Completed [DATE]. New Protocol and collaboration re-established with Physician /Nurse Practitioner- on: Calling 911/Change of Condition/When to Notify Doctor/Using Nursing Judgement. - Nurse Practitioner .Completed [DATE] Director of Nursing (DON) has been educated in best practice, assessment and standards of care by the Chief Nursing Officer and Medical Director. Completed [DATE] Implemented Walking Rounds for verbal report from nurses for Incidents/Change of Conditions/Abnormal labs and vital signs and new Doctor orders, etc., Director of Nursing/Assistant Director of Nursing/Administrator/Director of Social Services. Completed [DATE] Review of policy and procedure titled, Change in Resident Condition and Doctor Notification Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Implement a new 24-hour tracking report and review daily .Director of Nursing/Assistant Director of Nursing. Completed [DATE]. NEW protocol implemented to call Director of Nursing with any change of condition and/or abnormalities in vitals and discharges . Director of Nursing. Completed [DATE] Implemented a new system for DON or designee to print out vital signs report daily to monitor compliance Director of Nursing/Assistant Director of Nursing. Completed [DATE] Facility-wide audit on all residents have been conducted to make sure any changes in condition had been addressed Director of Nursing/Assistant Director of Nursing/Designee. Completed [DATE]. Staff In-Services conducted related to notification of physician of abnormal vital signs especially blood pressure changes even if results are improving and change of condition. Medical Director and Director of Nursing. Completed [DATE]. In-Service staff; Topic: Assessment, Notification vs. Emergency 911. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Re-In-Service staff on the use of SBAR and Stop and Watch tools. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Competencies on [DEVICE]s/Diabetes Mellitus/[MEDICAL CONDITION]/Foley/Oxygen use, etc. Director of Nursing/Assistant Director of Nursing/Designee. Completed [DATE] Implement vital signs competency with Nurses'/C.M.A.s/C.N.As. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Re-education on Hypertension/[MEDICAL CONDITION] and parameters - given to Nurses & Certified Medication Aide (C.M.A). Director of Nursing/Assistant Director of Nursing. Completed [DATE] Re-educated & Disciplined RN#1 and RN#2 . Director of Nursing/Assistant Director of Nursing. Completed [DATE]. All discharges to hospital will be discussed in Stand-up meetings. Director of Nursing/Assistant Director of Nursing/Administrator. Completed [DATE]. Administrator will monitor and ensure that all residents with change of condition will be reviewed daily via the use of the 24-hour report, communication and/or discussion during the morning stand-up and/or stand-down meetings. Administrator/QAPI team .Completed [DATE]. Review of policies and procedures titled, Care Plans. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. All admissions from the last 48 hours will be audited and their [DIAGNOSES REDACTED]. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Significant information about residents' care will be added to the baseline care plan summary; ex. resident has a historical history outlined in medical records or interview has frequent UTIs; so, staff can be pro-active in preventing and be conscious to watch for early S/S. Director of Nursing. Completed [DATE]. Majority of staff have been in-serviced on hypertension/[MEDICAL CONDITION] and vitals; the remaining staff members will be completed by [DATE]; prior to assuming patient care responsibilities. This plan has been initiated [DATE] and completed [DATE]. Monitoring: Monitoring the plan to remove of the immediate jeopardy/immediate threat was conducted as follows: Interview on [DATE] at 1:26pm, the Administrator stated she was not aware of CR#1's low blood pressure and to her understanding the IJ was called because CR#1's condition was not timely relayed to the Physician or NP. The Administrator stated the facility DON and ADON are monitoring 24-hour report, communicating to nursing staff any immediate change of conditions, and notifying physicians of any resident on blood pressure medication to ensure all residents have parameters set. The Administrator stated RN#2 received a written warning and has been in-serviced on physician's parameters. Interview on [DATE] at 1:36pm , the DON said she thought the IJ was called because of failure starting at top with nursing management. There was no monitoring follow-up after intervention was implemented, registered nurses are taught in school what a normal blood pressure is and what is not normal and when to notify the MD. The DON stated RN#2 failed to report CR#1's blood pressure of ,[DATE] to physician , did not document she took blood pressure after medication was administered and did not report follow-up blood pressure . The DON stated all staff are being trained on change in condition and how to identify a change in condition, when to notify the MD, when to call 911, and acting promptly. The DON stated the facility is initiating a new 24hour report, training staff on stop and watch, SBAR and a 24hour report will be written. The DON stated a Physician's binder with all vital signs parameters and when to notify the physician is at each nursing station with physician's contact information. The DON stated staff will be trained on blood pressure ([MEDICAL CONDITION]/hypertension) parameters and competencies and in-serviced on change of condition. Record review of facility's training and in-service log revealed facility staff received training on identifying change of condition, acting promptly, notifying MD, calling 911 and when to call 911, SBAR, stop and watch, and facility communication 24-hour report form. Training was provided by the ADON . Record review of facility's training and in-service log revealed facility staff received training on when to notify the Director of Nursing, nursing judgement, using best judgement if situation warrants sending resident to hospital, then making the suggestion to the MD/NP, if unable to reach MD/NP, call the DON, notify the medical director, if unable to reach anyone call 911 if situation warrants, if orders by MD are not appropriate speak up, and notification verses emergency 911. These training were provided by the DON. Record review of facility's training and in-service log revealed facility staff received training by NP on when to call MD and NP and change of condition and what to look for and vital signs and parameters given. Record review of facility's log revealed identified residents with the [DIAGNOSES REDACTED]. Record review of facility's training and in-service log revealed facility staff received training provided by DON and Medical Director on MD notification, change of condition, labs & lab tracking, communication, teamwork, and MD parameters books. Record review of facility's training and in-service log revealed facility staff received training from the DON on communicating continuously with MD and NP until a resolution was received, the resident being sent out and if the resident was stable, reporting even if condition is improving and document. Record review of facility's training and in-service log revealed facility staff received training from the DON on abnormal vitals, calling MD/NP and DON for abnormal vital signs, check MD parameters in MD notification book, ensure MD/NP was notified , document vital signs and notification of new orders. Record review of facility's training and in-service log revealed facility staff received training by DON on [MEDICAL CONDITION]/hypertension. Record review of parameters binder revealed all physicians with patients at the facility had a tab with their name and the vitals and requirements of when to notify the physician or on-call designee and the contact information for the physician and designee. Record review of in-service log revealed nursing staff education provided by Medical Director with DON on best practice, assessment and standards of care. Interview on [DATE] at 1:53pm, with the Administrator, DON, ADON, Director of Social Services, and MDS Coordinator , they all agreed that all department heads made arounds on all nursing stations and reviewed the 24hour report of incidents, change of condition, behaviors of complaints . Based on information received, they would go to the room of the identified resident and re-assess. Any residents sent out via ambulance to hospital will be discussed in morning meetings, vital sign summaries will also be pulled and reviewed in morning meetings to determine abnormal vitals. Record review of vital signs summary report for all residents dated [DATE] revealed no abnormal values of vital signs were identified. Record review of facility wide audit for resident with change of condition revealed no resident had a change of condition identified and resident on blood pressure medications were verified to have parameters. Record review of care plan policy (date unknown) revealed a care plan was based on a resident's comprehensive assessment and is developed by a care plan/interdisciplinary team . The resident and family or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Record review of disciplinary action form revealed RN#1 and RN#2 received disciplinary action signed by DON and employee. Interview on [DATE] at 10:23, the ADON stated in-services were provided to address manual blood pressure, correct way to use the thermometer and how to take vitals, what to report to notes, re-demonstrated on management staff, thermometer temp of 95.2 and asked if normal or abnormal, change in condition, medical director in-serviced change in condition, patient not normal self (usually walking then not walking, able to pick up cup and now unable to pick up cup) Hypo and hypertensive was covered, when to call 911, NP in-service on change condition, when to call 911, using nursing judgement and if patient has a decline, then call 911, nurse can call 911 and then notify MD letting them know patient needed to go without waiting on order from MD or NP. All full-time staff have been trained just waiting to train PRN staff as they become available. Interview on [DATE] at 10:42am, RN#3 stated staff in-service was provided on change in condition and when to report abnormal vitals to the MD. Interview on [DATE] at 11:19am , Medication-Aide#1 stated staff education was provided on blood pressure parameters. Medication-Aide #1 identified change in condition and said the nurse should be promptly notified of any change . Interview on [DATE] at 11:30am, CNA#13 stated she received in-service on abnormal vital signs and should notify the nurse right away. CNA#13 further said if she noticed anything different on a resident, she would immediately notify the nurse. Interview on [DATE] at 11:43am, Medication-Aide #2 stated change in condition should be reported to the nurse immediately and documented on 24-hour report. Medication-Aide #2 said MD Parameters were located in a binder at nursing station. Interview on [DATE] at 11:50am, CNA #2 said she received in-service on blood pressure parameters and identified where the parameter binder/vital signs was located at nursing station . She said the change in condition should be immediately reported to nurse. Interview on [DATE] at 12:00pm CNA#3 stated in-serviced blood pressure parameters and identified where the parameter binder vital signs was located at nursing. She said if any change was noticed on a resident, it would be immediately communicated to the nurse. Interview on [DATE] at 12:07pm, LVN#1 stated she was in-serviced on checking vitals and if abnormal , notify doctor, if she received a report from CMA/CNA on a change in condition, she should go recheck vitals and report to doctor. If vitals are abnormal, she would notify MD . She further said the resident's baseline vital signs should be known to staff caring for the resident so that change would be identified. She said she would notify DON, document in progress notes and also in 24hr report can document and have it put in 24hr report. She said the parameters binder for MD requirements was located at nursing station. Interview on [DATE] at 12:16pm LVN#2 said she had training on change in condition , blood Pressure parameters, when to notify MD and DON . Inform responsible party and when to call 911. Interview on [DATE] at 12:03pm and at 12:26pm , CNA#4 and CNA#5 said they received training on change in condition and notifying the charge nurse of anything identified during resident care. Interview on [DATE] at 12:03pm CNA#5 stated she was in-serviced on vital signs that are reportable to nurse as well as a change in condition in a resident . She further said she would notify nurse to assess resident before providing any kind of care. Interview on [DATE] at 12:39pm , Restorative Aide stated he was in-serviced on abnormal vitals . Anything over 120 or under 80 will be reported to the nurse. Restorative Aide said the parameter binder of MD requirements of vital signs to be report was located at nursing station. Interview on [DATE] at 12:49pm, the Housekeeping Supervisor stated he was in-serviced on change in condition of a resident and to notify the charge nurse immediately. Interview on [DATE] at 2:33pm and at 2:41pm , CNA #6 and CNA #7 said they were trained on what could be considered a change in the residents' condition and to call the nurse immediately. They also said if a change was identified during care, they would stop care and take of the resident first. Interview on [DATE] at 2:41pm, CNA# 7 stated she was in-serviced on blood pressure parameters and she would notify nurse if blood pressure was not normal, there was change in condition, if she noticed bruising while changing a resident , if a resident was not eating, and new behaviors. Interview on [DATE] at 2:51pm, LVN#3 stated she was in-serviced on parameters binder located at nursing station with all of facility doctors' parameter requirements in there and also to notify family , DON and the MD of any change in condition based on the resident. Interview on [DATE] at 3:05pm, CNA#8 stated if blood pressure values were either high or low, he should notify the MD. Interview on [DATE] at 3:20pm, RN#1 stated she was in-serviced on available parameters binder for notifying MD requirements at nursing station for systolic blood pressure less than 90 and heart rate below 60 and check for parameters for certain medication, high blood pressure 150 systolic and heart rate of above 100 notify MD, DON, nursing judgement can be used to determine when to call 911 or send patient to hospital based on judgement. She also said she was trained to notify RP also if anything mentioned above changes. Interview on [DATE] at 3:30pm, CNA#9 stated she was in-serviced on blood pressure parameters and change in condition and parameters binder

Based on interview and record review, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED].#1) reviewed for nursing services, in that; CR#1's physician was not consulted when she was identified to have series of low blood pressure. RN#1 did not assess, identify and monitor a significant change in CR#1's blood pressure and heart rate . CR#1 did not receive the emergent care she required until assessed by NP two hours later . DON did not identify that RN#2 should have consulted with CR#1's physician timely for intervention when her blood pressure was identified as low. DON did not ensure the nursing staff were trained and had adequate skills to assess , monitor and intervene when a resident's blood pressure declined, and the resident require emergent care. DON did not ensure facility residents on high blood pressure and low blood pressure medications had a parameter for administration and when to hold medication. CR#1's received no interventions for her low blood pressure for 8 hours . 911 initiated resuscitation which was not successful. CR#1 was pronounced dead on arrival at the hospital ER. An immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was continuing to train staff and monitor the effectiveness of the Plan of Removal. These failures affected one closed record who died . Findings include: 1/TX 423 CR#1 Record review of CR#1's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. CR#1's admitting [DIAGNOSES REDACTED]. Record review of CR#1's hospital discharge summary dated [DATE] revealed CR#1 had a past medical history of [REDACTED]. CR#1 complained of malaise and lethargy. CR#1 also had past medical history of [REDACTED]. Record review of CR #1's 5-day MDS assessment dated [DATE] revealed staff assessment of cognition for daily decision making was marked 3 indicating moderately impaired cognition . The MDS further revealed the resident's nutritional approach was feeding tube . Record review of CR#1's nursing notes dated [DATE] revealed CR#1 was transferred to the hospital ER where she was pronounced dead on arrival . Record review of CR#1's baseline care plan dated [DATE] revealed baseline care plan did not address the resident's [DIAGNOSES REDACTED]. Record review of CR#1's physician order [REDACTED]. Hold if SBP is greater than 140 ( Please check the blood pressure). Order had no parameters for when to hold the medication and when to contact the physician . Record review of CR#1's physician order [REDACTED]. Order had no parameters for administration , when to hold medication and when to contact the physician . Record review of CR#1's (MONTH) MAR indicated [REDACTED] [DATE]-,[DATE], ,[DATE], and ,[DATE] . ,[DATE]//19 - ,[DATE], ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE], and ,[DATE]. [DATE] - ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE], and ,[DATE]. [DATE] - ,[DATE], ,[DATE] and ,[DATE] [DATE] - ,[DATE], ,[DATE] and ,[DATE]. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Further review revealed the medication was discontinued on [DATE] and restarted on [DATE] with no medication dose missed. Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Medication was recorded as administered on [DATE] at 8:00am with a blood pressure of ,[DATE] and pulse of 125. Record review of CR#1's blood pressure log revealed on [DATE] at 05:03am, RN #2 documented a blood pressure of ,[DATE]. Record review of CR#1's progress notes revealed no documentation of intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's progress notes dated [DATE] at 11:10pm written by RN #1 revealed RN #1 had a hard time getting CR#1's blood pressure , CR#1's eyes were closed and no move was noted, warm to touch, RN #1 pinched CR#1's skin and it took a long time for the skin to go back to normal, NP was notified and order given was to bolus the resident with free water of 300ml and elevate CR#1's feet and recheck blood pressure in a hour. RN #1 gave CR#1 free water and elevated resident's feet. Blood pressure was rechecked and recorded, NP was notified and told new reading, and orders were given to increase CR#1's flush via pump to 30ml per hour and to give 100ml of free water every 6 hours, discontinue [MEDICATION NAME] 2.5 given 2 tablets via peg tube, make sure CR#1's blood pressure is taken . Record review of CR#1's blood pressure log revealed on [DATE] at 1:23 am, RN #2 documented a blood pressure of ,[DATE] . Record review of CR#1's (MONTH) 2019 MAR indicated [REDACTED]. Record review of CR#1's progress notes revealed no documentation of any other intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's blood pressure log revealed on [DATE] at 06:17am , RN #2 documented a blood pressure blood pressure was ,[DATE]. Record review of CR#1's progress notes revealed no documentation of any intervention following above blood pressure value and there was no documentation indicating CR#1's physician or NP were notified. Record review of CR#1's blood pressure log revealed on [DATE] at 8:01am, RN #1 documented a blood pressure of ,[DATE]. Record review of CR#1's progress notes dated [DATE] at 11:00am written by RN #1( morning nurse ) revealed CR#1 was in bed resting with her eyes closed, moving noted and blood pressure was unable to be taken on first attempt and was taken again with reading of blood pressure ,[DATE] pulse of 89 and gave CR#1 [MEDICATION NAME] and elevated her legs, called NP to report the condition of CR#1. NP stated she would be coming in the facility in about 2 hours, but in the meantime could we get a STAT chest X-ray and a CBC STAT. RN #1 cleaned CR#1's mouth and kept checking on the resident. Returned about 40 minutes later and checked CR#1's blood pressure and could not get a reading, tried several times, but could feel pulse was weak, as RN #1 was about to call NP again, the NP walked into the CR#1's room and ordered RN #1 to call EMS ambulance and send CR#1 to the hospital. RN #1 called two EMS ambulance services and wait time was too long. RN #1 returned to check on CR#1 and called NP to see the change on CR#1. Both RN #1 and NP went back to the room and RN #1 called 911 on her phone while in CR#1's room, pulse could be found but was weak and thread. Paramedics came and could find a pulse, about 30secs later paramedics started CPR as they transported CR#1 to the hospital. At about 10:58am, the nurse from the hospital emergency room called and stated that CR#1 had expired at 10:54am and wanted a phone number to the family member, RN #1 provided the number and 2 mins later the case manager called with more questions that RN #1 answered. The RP was notified, and NP was notified of the death of CR#1 at the hospital. Record review of CR#1's records revealed no documentation the resident's blood pressure values were rechecked by RN#1 as stated above after the reading of ,[DATE] was obtained and while RN#1 waited for NP to arrive to the facility. Interview on [DATE] at 12:55pm, CR#1's Family member stated the family was not notified CR#1 had a low blood pressure and was not notified CR#1 was sent out to the hospital. The Family member stated they received a call from the hospital on [DATE] approximately 10:30am informing them the resident had expired and they did not know CR#1 was sent out to hospital by facility. Interview on [DATE] at 1:19pm, the NP stated she received a call from RN #1 on [DATE] around 8 or 9 pm and gave order to elevate CR#1's legs and give extra water and to check blood pressure again and call back in a hour. NP stated she received a call back about an hour later and the resident blood pressure was stable. NP stated she did not receive any other calls after that time nor did she receive any calls around 1am about CR#1's blood pressure being ,[DATE]. Record review of CR#1's records revealed no documentation of a follow up blood pressure value as stated by the NP above. In an interview on [DATE] at 1:21pm NP stated she received a call from RN #1 the morning of [DATE] and informed RN #1 she would be at the facility shortly. The NP stated RN #1 called 2 ambulance services and both were going to be too long, so she told RN #1 to call 911. Np stated RN #1 was able to get a pulse of 80 something, and when the paramedics arrived they confirmed pulse of 80 at the time. NP stated EMS started CPR about 2mins later because they lost CR#1's pulse and the paramedics took her out immediately. NP stated not sure of cause of low pulse or how CR#1 declined so fast. NP stated CR#1's bp was stabilized the night before. Np stated when she arrived at facility she told RN #1 to call EMS because she didn't want to take chance and CR#1's bp was staying low. NP stated CR#1 wasn't looking that good and CR#1 wasn't speaking as she normally did. NP stated CR#1 was not lethargic until NP came back in room after RN #1 had call the 2 ambulance services. Interview on [DATE] at 1:35pm, RN #1 stated she arrived at facility at 6:30am on [DATE], did her rounds and saw CR#1 didn't look well and asked night nurse ( RN #2) how CR#1 had been. RN #1 said RN #2 reported CR#1 blood pressure was low but gave her medication ([MEDICATION NAME]) and blood pressure was okay. RN #1 stated she checked CR#1's blood pressure and it was low 72/over something, so she gave [MEDICATION NAME] and called the Np and told Np the resident's blood pressure was low and the resident did not look well. The NP stated she would be there within 1 or 2 hours. RN #1 stated she also gave water because CR#1 might have been dehydrated which was why blood pressure could have been low. RN #1 stated she continued checking on CR#1 to see if she was still breathing. RN#1 was asked who she checked on the resident and she said she was just peeking through the door to see if the resident was still breathing. RN #1 said CR#1 seemed to be getting worse, so she called NP and NP was walking into the resident's room. RN #1 stated NP arrived around 9am and told her to go ahead and call EMS. RN #1 stated she called 2 EMS companies, but both were going to take too long so she called 911 and 911 arrived between 5 to 7 minutes after call. RN#1 said 911 checked the resident's pulse and during the transfer to the stretcher , they lost pulse and immediately started CPR. RN#1 was asked if she could have done anything differently, she said should have called 911 instead of waiting for the NP to arrive. Record review of CR#1's records revealed no documentation of CR#1's blood pressure monitoring after RN#1documented the value of ,[DATE]. There was no evidence or documentation indicating RN#1 assessed the resident again while waiting for the NP's arrival. Interview on [DATE] at 2:15pm, the ADON stated she did call the family, but everything happened so fast by the time CR#1 left the facility to go to the hospital , the hospital had already notified the family. ADON said staff should call the resident physician as soon as possible when a change is identified. Interview on [DATE] at 3:40pm, the DON stated she was not notified of CR#1's blood pressure being ,[DATE] at 1:23am in the morning of [DATE] and the NP or Physician should have been notified of low blood pressure . The DON said the facility had no policy on blood pressure parameters or when a physician or on-call designee should be notified. Interview on [DATE] at 10:03am, RN #2 stated she did not see the need to notify the physician or NP because CR#1's blood pressure was always low around midnight and she has the low blood pressure medication [MEDICATION NAME] every 8hrs. RN #2 said did not check blood pressure again after giving [MEDICATION NAME] at 12 midnight, because she had another dose scheduled at 8am. Interview on [DATE] at 4:15pm, the NP stated nurses should notify Physician and/or NP when systolic blood pressure was less than 90 and diastolic blood pressure was less than 60. NP said the nurses should know when blood pressure was low or high they should call the Physician or NP. Attempt was made to interview CR#1's Physician on [DATE] at 4:25pm. A massage was left, and call was not returned. In an interview on [DATE] at 4:46pm, the DON stated residents on blood pressure medications have parameters set by their physicians that should be followed. The DON stated CR#1 was on [MEDICATION NAME] for low blood pressure and RN#2 gave [MEDICATION NAME] on [DATE] at 12 midnight as the intervention for the low blood pressure values she obtained when she checked the resident's blood pressure . The DON stated RN#2 did not document the administration until 1:23am but medication was given at 12 midnight. The DON said RN#2 gave [MEDICATION NAME] as CR#1's intervention for low blood pressure and did not need to notify physician or NP about the low blood pressure since the resident was known to have that [DIAGNOSES REDACTED]. The DON stated CR#1 had no set or ordered parameters for her low blood pressure medication and the facility had no policy on when to notify physician or Np of low blood pressure obtained. Interview on [DATE] at 10:45am, the hospital risk manager stated there was no blood pressure or vitals taken for CR#1 at time of arrival at hospital ER by HFD and CPR was in progress upon arrival at 10:41am. CR#1 was intubated at facility prior to arrival. CR#1 Glucose was 60 and approximately 10 rounds of [MEDICATION NAME] was given in attempt to resuscitate and revive the resident's glucose, 48 multiple rounds of CPR, CR#1's time of death 10:54am. Interview on [DATE] at 10:27am, CNA#1 stated on [DATE] at 6am , she did her rounds and CR#1 was sleeping. CNA #1 stated she had been working with CR#1 since she was admitted into facility and CR#1 could not talk but did smile when talked to. CNA #1 stated around 9 or so she noticed CR#1 did not look good and when she was talking to CR#1 she did not smile or nothing as normal, so she knew she was not well. CNA #1 stated she notified RN#1 and RN#1 and Np walked into the resident's room and RN#1 called 911. Record review of RN#1's employee file revealed she was hired [DATE]. Further review revealed basic training that included abuse and neglect. There was no record of any recent training or skills / competency checks. Record review of RN#2's employee file revealed she was hired [DATE]. Further review revealed basic training that included abuse and neglect. There was no record of any recent training or skills /competency checks. Record review of facility's policy titled Change in a Resident's Condition or Status (date unknown) read in part: our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status . the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a significant change in the resident's physical/emotional/mental condition . unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's family or representative when: .a decision has been made to discharge the resident from the facility; and/or it is necessary to transfer the resident to a hospital/treatment center . The Administrator was notified of Immediate Jeopardy (IJ) on [DATE] at 9:25am due to the above failures. A Plan of removal was requested. The final plan of removal was accepted on [DATE] at 11:29p.m. after several revisions were made. Plan of Removal of / Immediate Jeopardy All residents have the potential to be affected by the deficiency Revision of the (IDT) Interdisciplinary Team - Admission and Discharge Protocol: Review all new patients and discharges and change of conditions upon occurrences. Director of Nursing/Assistant Director of Nursing/Therapy/Administrator/MDS Coordinator. The facility incorporates a holistic approach on caring for our patients. Upon each new patient they are accompanied with an admission packet that includes their History & Physical (H&P), Medication Administration Record [REDACTED]. At daily stand-up and/or stand-down the (IDT) Interdisciplinary Team reviews and discuss new patient's admission diagnosis, medical condition and any residents with significant changes in their medical conditions including discharges. The Point Click Care (PCC) includes corrective actions and follow-up. As a mitigation strategy, each month the team will receive In-service on these procedures and practices. Changes as follows: All facility physicians were called, and vital parameters obtained when to call physician; parameters binder is located at each nurses' station. Director of Nursing/Assistant Director of Nursing .Completed [DATE]. Parameters placed when to call MD for every blood pressure medication; Telephone orders directing nurses to refer to MD parameter log, nurses in-serviced on location and protocol. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. A binder was placed on all nursing stations where the list for MDs preferred parameters on when to call physicians are for reference; nurses in-serviced on binder location. Director of Nursing/Assistant Director of Nursing Completed [DATE]. New Protocol and collaboration re-established with Physician /Nurse Practitioner- on: Calling 911/Change of Condition/When to Notify Doctor/Using Nursing Judgement. - Nurse Practitioner .Completed [DATE] Director of Nursing (DON) has been educated in best practice, assessment and standards of care by the Chief Nursing Officer and Medical Director. Completed [DATE] Implemented Walking Rounds for verbal report from nurses for Incidents/Change of Conditions/Abnormal labs and vital signs and new Doctor orders, etc., Director of Nursing/Assistant Director of Nursing/Administrator/Director of Social Services. Completed [DATE] Review of policy and procedure titled, Change in Resident Condition and Doctor Notification Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Implement a new 24-hour tracking report and review daily .Director of Nursing/Assistant Director of Nursing. Completed [DATE]. NEW protocol implemented to call Director of Nursing with any change of condition and/or abnormalities in vitals and discharges . Director of Nursing. Completed [DATE] Implemented a new system for DON or designee to print out vital signs report daily to monitor compliance Director of Nursing/Assistant Director of Nursing. Completed [DATE] Facility-wide audit on all residents have been conducted to make sure any changes in condition had been addressed Director of Nursing/Assistant Director of Nursing/Designee. Completed [DATE]. Staff In-Services conducted related to notification of physician of abnormal vital signs especially blood pressure changes even if results are improving and change of condition. Medical Director and Director of Nursing. Completed [DATE]. In-Service staff; Topic: Assessment, Notification vs. Emergency 911. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Re-In-Service staff on the use of SBAR and Stop and Watch tools. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Competencies on [DEVICE]s/Diabetes Mellitus/[MEDICAL CONDITION]/Foley/Oxygen use, etc. Director of Nursing/Assistant Director of Nursing/Designee. Completed [DATE] Implement vital signs competency with Nurses'/C.M.A.s/C.N.As. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Re-education on Hypertension/[MEDICAL CONDITION] and parameters - given to Nurses & Certified Medication Aide (C.M.A). Director of Nursing/Assistant Director of Nursing. Completed [DATE] Re-educated & Disciplined RN#1 and RN#2 . Director of Nursing/Assistant Director of Nursing. Completed [DATE]. All discharges to hospital will be discussed in Stand-up meetings. Director of Nursing/Assistant Director of Nursing/Administrator. Completed [DATE]. Administrator will monitor and ensure that all residents with change of condition will be reviewed daily via the use of the 24-hour report, communication and/or discussion during the morning stand-up and/or stand-down meetings. Administrator/QAPI team .Completed [DATE]. Review of policies and procedures titled, Care Plans. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. All admissions from the last 48 hours will be audited and their [DIAGNOSES REDACTED]. Director of Nursing/Assistant Director of Nursing. Completed [DATE]. Significant information about residents' care will be added to the baseline care plan summary; ex. resident has a historical history outlined in medical records or interview has frequent UTIs; so, staff can be pro-active in preventing and be conscious to watch for early S/S. Director of Nursing. Completed [DATE]. Majority of staff have been in-serviced on hypertension/[MEDICAL CONDITION] and vitals; the remaining staff members will be completed by [DATE]; prior to assuming patient care responsibilities. This plan has been initiated [DATE] and completed [DATE]. Monitoring: Monitoring the plan to remove of the Immediate Jeopardy was conducted as follows: Interview on [DATE] at 1:26pm, the Administrator stated she was not aware of CR#1's low blood pressure and to her understanding the IJ was called because CR#1's condition was not timely relayed to the Physician or NP. The Administrator stated the facility DON and ADON are monitoring 24-hour report, communicating to nursing staff any immediate change of conditions, and notifying physicians of any resident on blood pressure medication to ensure all residents have parameters set. The Administrator stated RN#2 received a written warning and has been in-serviced on physician's parameters. Interview on [DATE] at 1:36pm , the DON said she thought the IJ was called because of failure starting at top with nursing management. There was no monitoring follow-up after intervention was implemented, registered nurses are taught in school what a normal blood pressure is and what is not normal and when to notify the MD. The DON stated RN#2 failed to report CR#1's blood pressure of ,[DATE] to physician , did not document she took blood pressure after medication was administered and did not report follow-up blood pressure . The DON stated all staff are being trained on change in condition and how to identify a change in condition, when to notify the MD, when to call 911, and acting promptly. The DON stated the facility is initiating a new 24hour report, training staff on stop and watch, SBAR and a 24hour report will be written. The DON stated a Physician's binder with all vital signs parameters and when to notify the physician is at each nursing station with physician's contact information. The DON stated staff will be trained on blood pressure ([MEDICAL CONDITION]/hypertension) parameters and competencies and in-serviced on change of condition. Record review of facility's training and in-service log revealed facility staff received training on identifying change of condition, acting promptly, notifying MD, calling 911 and when to call 911, SBAR, stop and watch, and facility communication 24-hour report form. Training was provided by the ADON . Record review of facility's training and in-service log revealed facility staff received training on when to notify the Director of Nursing, nursing judgement, using best judgement if situation warrants sending resident to hospital, then making the suggestion to the MD/NP, if unable to reach MD/NP, call the DON, notify the medical director, if unable to reach anyone call 911 if situation warrants, if orders by MD are not appropriate speak up, and notification verses emergency 911. These training were provided by the DON. Record review of facility's training and in-service log revealed facility staff received training by NP on when to call MD and NP and change of condition and what to look for and vital signs and parameters given. Record review of facility's log revealed identified residents with the [DIAGNOSES REDACTED]. Record review of facility's training and in-service log revealed facility staff received training provided by DON and Medical Director on MD notification, change of condition, labs & lab tracking, communication, teamwork, and MD parameters books. Record review of facility's training and in-service log revealed facility staff received training from the DON on communicating continuously with MD and NP until a resolution was received, the resident being sent out and if the resident was stable, reporting even if condition is improving and document. Record review of facility's training and in-service log revealed facility staff received training from the DON on abnormal vitals, calling MD/NP and DON for abnormal vital signs, check MD parameters in MD notification book, ensure MD/NP was notified , document vital signs and notification of new orders. Record review of facility's training and in-service log revealed facility staff received training by DON on [MEDICAL CONDITION]/hypertension. Record review of parameters binder revealed all physicians with patients at the facility had a tab with their name and the vitals and requirements of when to notify the physician or on-call designee and the contact information for the physician and designee. Record review of in-service log revealed nursing staff education provided by Medical Director with DON on best practice, assessment and standards of care. Record review of vital signs summary report for all residents dated [DATE] revealed no abnormal values of vital signs were identified. Record review of facility wide audit for resident with change of condition revealed no resident had a change of condition identified and resident on blood pressure medications were verified to have parameters. Record review of care plan policy (date unknown) revealed a care plan was based on a resident's comprehensive assessment and is developed by a care plan/interdisciplinary team . The resident and family or legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Record review of disciplinary action form revealed RN#1 and RN#2 received disciplinary action signed by DON and employee. Interview on [DATE] at 10:23, the ADON stated in-services were provided to address manual blood pressure, correct way to use the thermometer and how to take vitals, what to report to the nurse , re-demonstrated on management staff, thermometer temp of 95.2 and asked if normal or abnormal, change in condition, medical director in-serviced change in condition, patient not normal self (usually walking then not walking, able to pick up cup and now unable to pick up cup) Hypo and hypertensive was covered, when to call 911, NP in-service on change condition, when to call 911, using nursing judgement and if patient has a decline, then call 911, nurse can call 911 and then notify MD letting them know patient needed to go without waiting on order from MD or NP. All full-time staff have been trained just waiting to train PRN staff as they become available. Interview on [DATE] at 10:42am, RN#3 stated staff in-service was provided on change in condition and when to report abnormal vitals to the MD. Interview on [DATE] at 11:05am, ADON said the facility did not test the skills and competencies of licensed nurses regarding blood pressure monitoring and when to notify a resident physician for a change in condition. She said licensed nursing staff were evaluated in procedural techniques like wound care /dressing change , urinary catheter care and glucometer use. Interview on [DATE] at 11:19am , Medication-Aide#1 stated staff education was provided on blood pressure parameters. Medication-Aide #1 identified change in condition and said the nurse should be promptly notified of any change . Interview on [DATE] at 11:30am, CNA#13 stated she received in-service on abnormal vital signs and should notify the nurse right away. CNA#13 further said if she noticed anything different on a resident, she would immediately notify the nurse. Interview on [DATE] at 11:43am, Medication-Aide #2 stated change in condition should be reported to the nurse immediately and documented on 24-hour report. Medication-Aide #2 said MD Parameters were located in a binder at nursing station. Interview on [DATE] at 11:50am, CNA #2 said she received in-service on blood pressure parameters and identified where the parameter binder/vital signs was located at nursing station . She said the change in condition should be immediately reported to nurse. Interview on [DATE] at 12:00pm CNA#3 stated in-serviced blood pressure parameters and identified where the parameter binder vital signs was located at nursing. She said if any change was noticed on a resident, it would be immedi

Based on observation, interview and record review, the facility failed to ensure that one Licensed Vocational Nurse (LVN #9) demonstrated competency in skills and techniques necessary to care for resident who need [MEDICAL CONDITION] suctioning for 1 of sixteen residents (Resident #256) reviewed for [MEDICAL CONDITION] suctioning, in that; LVN #9 did not use Normal Saline (NS) when suctioning Resident #256 through a tracheotomy and did not have NS available at bed side to clear secretions in suctioning catheter prior to re- suctioning Resident #256's [MEDICAL CONDITION]. LVN #9 did not ensure she had Normal Saline required for [MEDICAL CONDITION] suctioning of Resident #256 before beginning the procedure . Resident #256 became anxious and continued to use hand gestures to indicate air way obstruction. Her 's oxygen saturation dropped to 76% while her heart rate rose to 117 while LVN#9 repeatedly suctioned the resident inappropriately until another nurse intervened. LVN#9 left Resident #256's room during suctioning in search of Normal saline after another nurse requested it . LVN#9 returned 10 minutes later with normal saline. These failures affected one resident who continued to complain of shortness of breath from unclear tracheotomy tubing placing her at increased risk of complications from obstructed airway. Findings included: Record review of Resident #256's face sheet dated 11/21/18, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] . Her [DIAGNOSES REDACTED]. Record review of Resident# 256's Physician orders dated 11/21/18 indicated the following orders: Oxygen via Tracheotomy at 3-5 l/min every shift for Tracheotomy. Trach care daily and PRN (as needed) every shift. May suction as needed for Secretions for tracheotomy care. Trach size - 4 Brand of Tracheotomy Lock non-disposable. Record review of Resident #256's Nurse Admission Assessment form dated 11/21/18, revealed the resident was alert, oriented to person, situation and her short-term memory was intact. She had clear speech, she had no difficulty understanding others and others had no difficulty understanding her. Resident #256 needed extensive assistance of one staff for all activities of daily living (ADLs). Her respiratory rate was 11-24 per minute, unlabored and she reported sputum production, she used oxygen at a rate of 3-5 liters per minute, she had a tracheotomy and had orders for breathing treatment. Record review of Resident #256's baseline care plan dated 11/21/18 and revised on 11/28/18 revealed the resident used oxygen therapy routinely or as needed, at risk for ineffective gas exchange related to acute [MEDICAL CONDITION] with a tracheotomy in place, oxygen @ (at) 4 L (liter) automatic tubing compression (ATC) with humidification. The goals included no signs or symptoms of [MEDICAL CONDITION] through the next review date of 2/20/18. Interventions included: administer oxygen per physician orders, suction as needed, monitor for signs and symptoms of respiratory distress and report to the physician as needed. Monitor for signs and symptoms of distress which include accessory respiratory muscle use and decreased oxygen saturation (O 2 sats). Record review of Resident #256's baseline care plan dated 11/21/18 and revised on 11/28/18, revealed the resident had a tracheotomy in place related to breathing mechanics, cancer and surgery. The tracheotomy had a Shirley #4 disposable cannula scuffles tracheotomy tube in place. The goal indicated no abnormal drainage [MEDICAL CONDITION](tracheotomy), site through 2/20/18. Interventions included give humidified oxygen as prescribed, monitor document, restlessness, agitation, respiratory rate, depth and quality, suction as necessary and document every shift. Record review of Resident #256's Admission Minimum Data Set (MDS) assessment, dated 11/28/18, revealed Resident #256's speech was unclear, she was sometimes understood, she understands others and was severely impaired with cognition for daily decision making. Resident #256 needed extensive assistance of two staff for all activities of daily living (ADLs) and she ambulated with extensive assistance of two staff only once or twice during the review period. The MDS indicated the resident had shortness of breath (dyspnea) as follows: shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring), shortness of breath or trouble breathing when lying flat. The MDS indicated Resident #256 received oxygen therapy, suctioning and tracheotomy care. Observation on 11/27/18 at 9:35 a.m., revealed Resident #256 was sitting in the middle of her bed, the head of the bed was elevated at 45 degrees and she was dressed in a hospital gown. Resident #256 signaled with a hand wave while pointing at her tracheotomy site. Two surveyors standing in the hallway. entered Resident #256's room. When asked if she needed to be suctioned she nodded yes. LVN #9 was notified right away. Observation at 9:36 a.m., revealed LVN #9 came into the resident's room, briefly assessed her oxygen levels and stated she would be back with a tracheotomy (trach) care kit and the surveyor stayed at the resident's bedside. Observation and interview on 11/27/18 at 9:46 a.m., revealed LVN #9 returned to Resident #256's room with no tracheotomy kit. The LVN took a sterile suction catheter tubing from the resident's bedside drawer, turned the suction machine on, she put on clean gloves, opened the suction catheter, attached it to the suction machine and suctioned the resident via tracheotomy without using or putting normal saline into the suction catheter before suctioning the resident. The LVN suctioned a larger amount of yellow thick secretions from the tracheotomy and asked the resident if she was ok. The resident indicated she needed to be suctioned some more. The tubing was observed filled with a large amount of thick yellow secretions. Without using Normal Saline (NS) to clear the suction catheter tubing of the of thick yellow secretions, the LVN proceeded to re-insert the suction catheter tubing into the Resident #256 tracheotomy and proceeded to suction the resident again .The suction catheter was unable to maintain suction to remove additional secretions through the [MEDICAL CONDITION]. The LVN then checked Resident #256's oxygen levels and stated, the pulse oximeter (pulse ox) was not registering oxygen levels. She asked the resident if she needed more suctioning and the resident nodded her head for yes. The resident continued to indicate she needed more suctioning and appeared to be out of breath. The surveyor went to the hallway and asked for assistance. Observation on 11/27/18 at 9:47 a.m., RN #6 arrived at Resident # 256's bedside. At 9:51 a.m., RN#6 measured Resident # 256's oxygen levels to be 76 % with oxygen at 4 liters via tracheotomy and her pulse was 115. The RN removed the used soiled suction catheter tubing from the suction machine and replaced it with a sterile one then asked for Normal Saline (NS). There was no NS at the bedside and the LVN #9 left the room and returned with a 500 ml plastic bottle of NS. The RN used the NS to loosen and clear Resident #256's secretions via tracheotomy, prior to suctioning. A medium amount of thick yellow secretions was observed when the RN #6 suctioned the resident the third time. RN#6 cleared the tubing with NS and suctioned the fourth time with no more secretion obtained. Resident #256 indicated she was okay after the RN suctioned the resident. Interview on 11/28/18 11:00 a.m., RN #6 stated he was in the hallway and someone told him they needed assistance in Resident #256's room. RN #6 stated LVN #9 seemed anxious, the surveyor was also in the room, LVN #9 did some suctioning with no return, the pulse oximeter was not registering (O2 saturations) and there was no Normal Saline at the bedside. RN #6 stated, If the secretions are very thick, you may need to apply some NS into the tracheotomy to loosen the secretion then suction. There was no NS at Resident #256's bedside. You need NS specifically after suctioning you need to clear the tubing of secretion before re-using the tubing. The RN further stated, If secretions are thick, inject NS into [MEDICAL CONDITION] loosen secretions then suction. RN #6 stated in the facility there should be NS vials (15 ml) for single use or 500 ML bottles for multiple use, they are kept in the medication storage room and he expected nursing staff to have NS on hand whenever they go to suction a resident. RN #6 stated, Initially when I did her pulse oximeter to obtained Oxygen saturation levels , her oxygen saturation level was low, it was 75% on Oxygen. I suction her with new tubing and her sats went up to 99% . There was no NS at the bedside for clearing the tubing of secretions before re-using and that was when I asked LVN #9 to go get some NS. She then went out to get the NS. The RN stated, There should always be NS available when suctioning a tracheotomy. When the resident said she could not breath, you have to believe her and suction her. A patient's facial expression was one way to do an assessment but not definitive, check pulse ox, listen to lungs and take the resident's word just as doing a pain assessment. Interview on 11/27/18 at 11:42 a.m., LVN #9 stated, there was no NS at Resident #256's bedside. The LVN stated she went to her cart, she went to the oxygen room and the supplies room and found no NS. The LVN stated she returned to the bedside 10 minutes later and had found no NS for suctioning the resident. Then she suctioned the resident without NS. The LVN stated, I am PRN (work as needed) and I don't know the dynamics, I was not aware there was no NS at the bedside and no NS in the medication cart. The LVN stated after the RN asked, she went to the wound care nurse and returned with NS to use for suctioning Resident #256. Interview on 11/29/18 at 1:57p.m., the ADON stated, You need to have NS available to suction a tracheotomy. You can go in and suction one time, then use NS to clear the secretions out of the tubing before you go back in to suction a second time. You have to clear the tubing when suctioning. NS should have been somewhere easily accessible in the medication cart or medication storage room, but it was not available for the nurse to access, it was lock up in an office. The LVN should not have been all over the building looking for NS. Interview on 11/29/18 at 1:24 p.m., the Respiratory Therapy (RT) Director stated Resident #256'[MEDICAL CONDITION] and make was a size 4 Shirley. The Respiratory Therapy (RT) Director stated the process of suctioning Resident #256 included to turn the suction machine on, check her oxygen saturations, she (Resident #256) was alert and oriented, she was able to tell us when she needs to be suctioned, suction her when she says she needs to be suctioned. The RT Director stated Resident #256 had a productive cough, you need NS to rinse the Younker catheter (in-between suctioning). The RT Director further stated, if secretions are thick, then add NS [MEDICAL CONDITION] break down secretions before suctioning. then rinse catheter with NS before suctioning again. NS should be available for suctioning. Interview on 11/29/18 at 5:45p.m., the ADON stated we just [MEDICAL CONDITION] in-service, LVN #9 did not get the in-service because she worked PRN (when needed). We do not have a competency policy. We provide competency in-service in specialized areas once a year and as needed. Record review LVN#9's employee file revealed no records of tracheotomy suctioning and care in-services . Record review of the facility Policy titled Suctioning the Lower Airway (endotracheal or tracheotomy Tube) dated (MONTH) 2010, and Tracheotomy suctioning according to the stands of care Inservice dated 11/13/18, revealed the following: Review Physician orders or facility protocol for suctioning. Put on gloves as needed. Assess the resident's vital signs, breath sounds, respiratory effort, and general appearance. Position patient upright position with the patient's/resident's head in neutral alignment. Attach resident to a pulse oximeter. Assess resident's ability to cough. Remove and discard gloves. Remove the lid from the sterile solution (normal saline) and place it upside down on a clean surface. Open the package containing the disposable sterile container. using sterile technique, open the suction catheter kit and put on gloves. Using your non-dominant hand pour a small amount of sterile solution/normal saline into the sterile container. Using your non-dominant hand attach the catheter to the tubing. Turn the suction control valve to the ON position and set the suction pressure to the lowest possible vacuum pressure needed to effectively clear secretions. Using your dominant hand, lubricate the outside of the catheter by dipping it into sterile solution. With the sterile tip in the sterile solution /normal saline, occlude the suction control valve with the thumb of your non-dominant hand; suction a small amount of solution through the catheter. Ask the patient to take two deep breaths if able. Insert the suction catheter into the tracheotomy tube; don't apply suction while inserting. Withdraw the catheter while applying intermittent suction and rotating the catheter between your fingertips. Dip the free end of the suction catheter into the sterile solution/normal saline and apply suction until the catheter is clear of secretions. Assess the patient's response to suctioning Hyper -oxygenate the patient for at least one minute after suctioning. Allow patient to rest. Repeat suctioning if clinically indicated.

Based on observation, interview, and record review, the facility failed to ensure tracheotomy (trach) care was provided with care consistent with professional standards of practice for one of 16 residents (Resident #256) reviewed for [MEDICAL CONDITION] care and tracheal suctioning, in that; LVN #9 did not use Normal Saline (NS) when suctioning Resident #256 through a tracheotomy and did not have NS available at bed side to clear secretions in suctioning catheter prior to re- suctioning Resident #256's [MEDICAL CONDITION]. LVN #9 did not ensure she had Normal Saline required for [MEDICAL CONDITION] suctioning of Resident #256 before beginning the procedure . Resident #256 became anxious and continued to use hand gestures to indicate air way obstruction. Her 's oxygen saturation dropped to 76% while her heart rate rose to 117 while LVN#9 repeatedly suctioned the resident inappropriately until another nurse intervened. LVN#9 left Resident #256's room during suctioning in search of Normal saline after another nurse requested it . LVN#9 returned 10 minutes later with normal saline. These failures affected one resident who continued to complain of shortness of breath from unclear tracheotomy tubing placing her at increased risk of complications from obstructed airway. Findings included: Record review of Resident #256's face sheet dated 11/21/18, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] . Her [DIAGNOSES REDACTED]. Record review of Resident# 256's Physician orders dated 11/21/18 indicated the following orders: Oxygen via Tracheotomy at 3-5 l/min every shift for Tracheotomy. Trach care daily and PRN (as needed) every shift. May suction as needed for Secretions for tracheotomy care. Trach size - 4 Brand of Tracheotomy Lock non-disposable. Record review of Resident #256's Nurse Admission Assessment form dated 11/21/18, revealed the resident was alert, oriented to person, situation and her short-term memory was intact. She had clear speech, she had no difficulty understanding others and others had no difficulty understanding her. Resident #256 needed extensive assistance of one staff for all activities of daily living (ADLs). Her respiratory rate was 11-24 per minute, unlabored and she reported sputum production, she used oxygen at a rate of 3-5 liters per minute, she had a tracheotomy and had orders for breathing treatment. Record review of Resident #256's baseline care plan dated 11/21/18 and revised on 11/28/18 revealed the resident used oxygen therapy routinely or as needed, at risk for ineffective gas exchange related to acute [MEDICAL CONDITION] with a tracheotomy in place, oxygen @ (at) 4 L (liter) automatic tubing compression (ATC) with humidification. The goals included no signs or symptoms of [MEDICAL CONDITION] through the next review date of 2/20/18. Interventions included: administer oxygen per physician orders, suction as needed, monitor for signs and symptoms of respiratory distress and report to the physician as needed. Monitor for signs and symptoms of distress which include accessory respiratory muscle use and decreased oxygen saturation (O 2 sats). Record review of Resident #256's baseline care plan dated 11/21/18 and revised on 11/28/18, revealed the resident had a tracheotomy in place related to breathing mechanics, cancer and surgery. The tracheotomy had a Shirley #4 disposable cannula scuffles tracheotomy tube in place. The goal indicated no abnormal drainage [MEDICAL CONDITION](tracheotomy), site through 2/20/18. Interventions included give humidified oxygen as prescribed, monitor document, restlessness, agitation, respiratory rate, depth and quality, suction as necessary and document every shift. Record review of Resident #256's Admission Minimum Data Set (MDS) assessment, dated 11/28/18, revealed Resident #256's speech was unclear, she was sometimes understood, she understands others and was severely impaired with cognition for daily decision making. Resident #256 needed extensive assistance of two staff for all activities of daily living (ADLs) and she ambulated with extensive assistance of two staff only once or twice during the review period. The MDS indicated the resident had shortness of breath (dyspnea) as follows: shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring), shortness of breath or trouble breathing when lying flat. The MDS indicated Resident #256 received oxygen therapy, suctioning and tracheotomy care. Observation on 11/27/18 at 9:35 a.m., revealed Resident #256 was sitting in the middle of her bed, the head of the bed was elevated at 45 degrees and she was dressed in a hospital gown. Resident #256 signaled with a hand wave while pointing at her tracheotomy site. Two surveyors standing in the hallway. entered Resident #256's room. When asked if she needed to be suctioned she nodded yes. LVN #9 was notified right away. Observation at 9:36 a.m., revealed LVN #9 came into the resident's room, briefly assessed her oxygen levels and stated she would be back with a tracheotomy (trach) care kit and the surveyor stayed at the resident's bedside. Observation and interview on 11/27/18 at 9:46 a.m., revealed LVN #9 returned to Resident #256's room with no tracheotomy kit. The LVN took a sterile suction catheter tubing from the resident's bedside drawer, turned the suction machine on, she put on clean gloves, opened the suction catheter, attached it to the suction machine and suctioned the resident via tracheotomy without using or putting normal saline into the suction catheter before suctioning the resident. The LVN suctioned a larger amount of yellow thick secretions from the tracheotomy and asked the resident if she was ok. The resident indicated she needed to be suctioned some more. The tubing was observed filled with a large amount of thick yellow secretions. Without using Normal Saline (NS) to clear the suction catheter tubing of the of thick yellow secretions, the LVN proceeded to re-insert the suction catheter tubing into the Resident #256 tracheotomy and proceeded to suction the resident again .The suction catheter was unable to maintain suction to remove additional secretions through the [MEDICAL CONDITION]. The LVN then checked Resident #256's oxygen levels and stated, the pulse oximeter (pulse ox) was not registering oxygen levels. She asked the resident if she needed more suctioning and the resident nodded her head for yes. The resident continued to indicate she needed more suctioning and appeared to be out of breath. The surveyor went to the hallway and asked for assistance. Observation on 11/27/18 at 9:47 a.m., RN #6 arrived at Resident # 256's bedside. At 9:51 a.m., RN#6 measured Resident # 256's oxygen levels to be 76 % with oxygen at 4 liters via tracheotomy and her pulse was 115. The RN removed the used soiled suction catheter tubing from the suction machine and replaced it with a sterile one then asked for Normal Saline (NS). There was no NS at the bedside and the LVN #9 left the room and returned with a 500 ml plastic bottle of NS. The RN used the NS to loosen and clear Resident #256's secretions via tracheotomy, prior to suctioning. A medium amount of thick yellow secretions was observed when the RN #6 suctioned the resident the third time. RN#6 cleared the tubing with NS and suctioned the fourth time with no more secretion obtained. Resident #256 indicated she was okay after the RN suctioned the resident. Interview on 11/28/18 11:00 a.m., RN #6 stated he was in the hallway and someone told him they needed assistance in Resident #256's room. RN #6 stated LVN #9 seemed anxious, the surveyor was also in the room, LVN #9 did some suctioning with no return, the pulse oximeter was not registering (O2 saturations) and there was no Normal Saline at the bedside. RN #6 stated, If the secretions are very thick, you may need to apply some NS into the tracheotomy to loosen the secretion then suction. There was no NS at Resident #256's bedside. You need NS specifically after suctioning you need to clear the tubing of secretion before re-using the tubing. The RN further stated, If secretions are thick, inject NS into [MEDICAL CONDITION] loosen secretions then suction. RN #6 stated in the facility there should be NS vials (15 ml) for single use or 500 ML bottles for multiple use, they are kept in the medication storage room and he expected nursing staff to have NS on hand whenever they go to suction a resident. RN #6 stated, Initially when I did her pulse oximeter to obtained Oxygen saturation levels , her oxygen saturation level was low, it was 75% on Oxygen. I suction her with new tubing and her sats went up to 99% . There was no NS at the bedside for clearing the tubing of secretions before re-using and that was when I asked LVN #9 to go get some NS. She then went out to get the NS. The RN stated, There should always be NS available when suctioning a tracheotomy. When the resident said she could not breath, you have to believe her and suction her. A patient's facial expression was one way to do an assessment but not definitive, check pulse ox, listen to lungs and take the resident's word just as doing a pain assessment. Interview on 11/27/18 at 11:42 a.m., LVN #9 stated, there was no NS at Resident #256's bedside. The LVN stated she went to her cart, she went to the oxygen room and the supplies room and found no NS. The LVN stated she returned to the bedside 10 minutes later and had found no NS for suctioning the resident. Then she suctioned the resident without NS. The LVN stated, I am PRN (work as needed) and I don't know the dynamics, I was not aware there was no NS at the bedside and no NS in the medication cart. The LVN stated after the RN asked, she went to the wound care nurse and returned with NS to use for suctioning Resident #256. Interview on 11/29/18 at 1:57p.m., the ADON stated, You need to have NS available to suction a tracheotomy. You can go in and suction one time, then use NS to clear the secretions out of the tubing before you go back in to suction a second time. You have to clear the tubing when suctioning. NS should have been somewhere easily accessible in the medication cart or medication storage room, but it was not available for the nurse to access, it was lock up in an office. The LVN should not have been all over the building looking for NS. Interview on 11/29/18 at 1:24 p.m., the Respiratory Therapy (RT) Director stated Resident #256'[MEDICAL CONDITION] and make was a size 4 Shirley. The Respiratory Therapy (RT) Director stated the process of suctioning Resident #256 included to turn the suction machine on, check her oxygen saturations, she (Resident #256) was alert and oriented, she was able to tell us when she needs to be suctioned, suction her when she says she needs to be suctioned. The RT Director stated Resident #256 had a productive cough, you need NS to rinse the Younker catheter (in-between suctioning). The RT Director further stated, if secretions are thick, then add NS [MEDICAL CONDITION] break down secretions before suctioning. then rinse catheter with NS before suctioning again. NS should be available for suctioning. Interview on 11/29/18 at 5:45p.m., the ADON stated we just [MEDICAL CONDITION] in-service, LVN #9 did not get the in-service because she worked PRN (when needed). We do not have a competency policy. We provide competency in-service in specialized areas once a year and as needed. Record review LVN#9's employee file revealed no records of tracheotomy suctioning and care in-services . Record review of the facility Policy titled Suctioning the Lower Airway (endotracheal or tracheotomy Tube) dated (MONTH) 2010, and Tracheotomy suctioning according to the stands of care Inservice dated 11/13/18, revealed the following: Review Physician orders or facility protocol for suctioning. Put on gloves as needed. Assess the resident's vital signs, breath sounds, respiratory effort, and general appearance. Position patient upright position with the patient's/resident's head in neutral alignment. Attach resident to a pulse oximeter. Assess resident's ability to cough. Remove and discard gloves. Remove the lid from the sterile solution (normal saline) and place it upside down on a clean surface. Open the package containing the disposable sterile container. using sterile technique, open the suction catheter kit and put on gloves. Using your non-dominant hand pour a small amount of sterile solution/normal saline into the sterile container. Using your non-dominant hand attach the catheter to the tubing. Turn the suction control valve to the ON position and set the suction pressure to the lowest possible vacuum pressure needed to effectively clear secretions. Using your dominant hand, lubricate the outside of the catheter by dipping it into sterile solution. With the sterile tip in the sterile solution /normal saline, occlude the suction control valve with the thumb of your non-dominant hand; suction a small amount of solution through the catheter. Ask the patient to take two deep breaths if able. Insert the suction catheter into the tracheotomy tube; don't apply suction while inserting. Withdraw the catheter while applying intermittent suction and rotating the catheter between your fingertips. Dip the free end of the suction catheter into the sterile solution/normal saline and apply suction until the catheter is clear of secretions. Assess the patient's response to suctioning Hyper -oxygenate the patient for at least one minute after suctioning. Allow patient to rest. Repeat suctioning if clinically indicated.

Based on observation, interview, and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for five of eleven residents (Resident #1, #2, #3, #4 and #5) reviewed for administration. The Administrator failed to: Implement the facility Neglect policy Supervise and monitor the maintenance department and repairs to ensure the facility had effective cooling system for halls B, C and D since (MONTH) 5th, (YEAR). Ensure staff were trained on how to operate newly acquired portable AC units used in the resident's rooms. Ensure the facility was maintained at a consistent and comfortable temperature for residents' safety and comfort. Supervise and monitor the DON to ensure nursing staff were trained to properly assess, monitor and hydrate the residents. The DON failed to Ensure staff were trained to monitor and ensure residents in three affected halls were hydrated Ensure staff provided comfortable temperature for residents' safety and comfort. An Immediate Jeopardy (IJ) was identified on 06/29/18. While the IJ was lowered on 07/02/18, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern due to the facility's need to monitor implementation of the Plan of Removal (POR). These failures affected five residents and had the potential to affect 55 other residents in halls C, D and B, placing them at risk of not having needs met which could result in injury or harm. Findings Included: Resident # 1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 4 indicating severely impaired cognition. The resident required extensive assistance of one person with bed mobility, transfer and toilet use. Resident #2 Record review of Resident #2''s s face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed the resident was moderately impaired for daily decision making cognitive skills. Observation of hall C and interview on 06/28/18 at 12:15pm revealed room [ROOM NUMBER] belonging to resident #1 and #2 had temperature of 81 degrees Fahrenheit. There was a portable AC unit in the room which did not have a required heat exhaust pipe that would remove emitted heat from room. The room felt like a heater was on. Temperature reading on the portable AC unit was 80 and temperature of 138 degrees Fahrenheit was measured around the heat exhaust duct of the Portable AC unit via air gun digital thermometer by two surveyors. Further observation reveled Resident #2 was in bed with privacy curtain pulled to a close. Resident #2 stated she was hot. Resident #2 further stated her family member also brought her a small table fan to help cool her. A small table fan was noted standing on the right side of the resident and was on. Resident #1 has a fan facing her position in bed. In an attempted interview with Resident#1 following above observation, the resident did not answer questions about of her room temperature. When asked if room was comfortable for her, Resident stated yes. Interview on 6/28/18 at 12:40mp, the facility Maintenance Assistant was asked why the room felt like a heater was on and where the hot air was coming from in the above room. He said it must be from the portable AC unit in room [ROOM NUMBER]. When asked why the portable Ac unit did not have an heat exhaust pipe taking heat outside the room, he said he did not know why whoever set it up did not properly connect the pipe as it should. He further said the heat in the room was coming from the AC unit which defeats the purpose of having the AC in the room. He said he will connect the AC unit properly. The facility Maintenance Assistant said he did not know how long the unit was left in the room [ROOM NUMBER] but said the facility's cooling system have been having problems for a month. The facility Maintenance Assistant said the facility purchased portable AC units and installed window AC units to help cool the room and hallways in affected hall. The facility Maintenance Assistant was asked what training was provided for maintenance staff prior to operating the portable AC unit, he said staff should just follow the manufactures' instruction that came with equipment. Interview on 06/28/18 at 12:47pm, the facility Administrator said the facility had purchased portable AC units for use in the resident's rooms. She said she was not sure how the AC units worked but stated she believed the units come with instruction. When asked how she ensured the facility staff were trained on how to operate the new devices, the Administrator said the maintenance staff installed the units. The Administrator was asked who was responsible for overseeing the maintenance department and she said it as herself. Hall observations Observation on 06/28/18 from 1:44pm to 2:00pm, revealed 9 residents rooms in hall C, 6 rooms in hall D and three residents room sin hall B had newly installed Window AC units in which were either off, set on energy savings and were not cooling rooms. AC vents were not blowing out cool air in the rooms. No staff was seen passing fluids to residents on halls C and D. Residents water pitches did not have fresh ice and cold water in these rooms. Interview on 6/28/18 at 1:10pm, CNA#2 who was the assigned aide in hall C said staff passed ice three times a day or once a shift. When asked the last time he passed out ice/water for his 6am - 2pm shift, CNA#2 said he passed out ice and water to the residents before Lunch (12noon). CNA#2 said he was not aware of any measures he was required to do since the AC in the resident's rooms were not working well. He said some residents' rooms in hall C were hot due to the AC not working well. Observation on 06/28/18 revealed the following temperatures in degrees Fahrenheit in the residents' rooms. HALL C: Room C2- 79 with fan on at 2:20pm Room C4 -79 at 2:22pm, and Room C4- 80 at 2:22pm. HALL D; Room D4-79 at 2:30pm, Room D7- 80 at 2:33pm, Room D8-79 at 3:19pm and Room D11-79 at 2:35pm. Observation on 06/28/18 at 2:18pm revealed a portable AC unit at the beginning of hall D which was on and recorded temperature of 80 degrees Fahrenheit. The area where the unit was felt like a heater was on. Further observation revealed the portable AC unit required an exhaust pipe to take heat out but did not have one. Resident #5 Record review of Resident #5's face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's admission MDS dated [DATE] revealed a BIMS score of 11, indicating moderately impaired cognition. Observation and interview on 06/28/18 at 2:38pm, Resident #5 who was in bed under covers in D-7 stated her room was very hot and uncomfortable. Resident #5's face was flushed, and her cheeks were red. Resident #5 asked if she could have a fan to cool her down. Resident #5's room temperatures was 80 degrees Fahrenheit. Observation on 6/28/18 at 3:22 pm revealed room temperature in room C4 was 80-degree Fahrenheit. Resident #1 and #2 were in their beds. Interview on 06/28/18 at 3:38pm, the facility Administrator said they did not know what the problem with the AC system was. The Administrator said only Hall C 's AC system was identified by an AC company as not functioning in its full capacity. When asked why hall B and D had newly installed AC unit in the resident's room, the Administrator said they bought more than needed and decided to install them in the resident's room. When asked why the hallway were hot and had industrial size fan blowing, the Administrator said it was to cool the hallways. The Administrator was asked what the facility was doing to find out the problem and fix it, she said they had an outside AC company that will be coming out to check their AC system for hall C only on Monday 7/2/18. The Administrator was asked why nothing has been done since this issue had been going on for more than a month now, but she said the facility had addressed the problem by buying additional AC units and fans. Interview on 06/28/18 at 4:00pm, Maintenance Director said he started working at the facility about three weeks ago. He said he worked on the AC unit serving hall D two weeks ago and it stated working better. Interview on 06/28/18 at 4:03pm, ADON when asked why there was as industrial size fan in hall B, she stated the facility 's AC system is just not cooling well. When asked for how long now, she said for some time now. Interview on 06/28/18 at 4:18pm, the facility Administrator was asked for evidence to show that facility AC's system had been check by AC professionals and their recommendations. The Administrator said she will send these documents, but none was provided despite repeated inquires since 06/05/2018. Resident #3 Record review of Resident #3's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility 11/14/2017. His [DIAGNOSES REDACTED]. [MEDICAL CONDITION], hyperlipemia, [MEDICAL CONDITIONS], sensorineural hearing loss, hypertension, and [MEDICAL CONDITIONS]. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further review of the MDS revealed the resident required extensive assistance of one person with bed mobility, transfer, toilet use and bathing. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility 09/01/2017. His [DIAGNOSES REDACTED]. Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 11 indicating moderately impaired cognition. Further review of the MDS revealed the resident required extensive assistance of one person with bed mobility, toilet use personal hygiene, bathing and limited assistance on one staff for transfers. Observation on 7/1/18 at 6:00pm revealed Resident#3 and #4 in their respective beds in room C-7. Room felt hot and temperature measured was 81 degrees Fahrenheit. The window AC I the room was turned off. When AC unit was turned on, the AC unit registered temperature of 83 degrees Fahrenheit. Window blind was up with the sun direction shining into the room. Window AC unit in the room was off. Further observation revealed Resident #3 had a white long sleeve shirt on and in bed while Resident #4 had short sleeve t-shirt on. Resident #4 's face was red and flushed. Resident #3 was closer to the window with the sun on his bed. Observation of the residents' water pitchers revealed small water in pitchers but had no ice. Interview following above observations, Resident #4 said it was too hot and uncomfortable in the room. Resident #4 was asked why his AC unit was off, but he said he did not know why. The resident asked to turn on AC and requested for some cold water. Resident #3 said it hot in the room. When asked why they did not call for help to have the AC unit turned on, both residents said the staff do not answer call lights. Residents were asked the last time the they were provided cold water, they said it had been a while. Interview on 07/1/18 at 6:10pm, CNA#1 said she was not aware the residents' AC was off. She said the residents probably got cold and turned it off. She said Resident #4 ambulated with his wheel chair and could turn off AC. CNA#1 was asked when she made the last rounds and provided ice water to the residents, she stated she just did it. When asked how often she made rounds, she said every two hours. CNA#1 said she was aware of the AC problem in hall C. Interview with Regional Maintenance director on 7/3/18 at 12:38 PM, he stated there was an issue with the air conditioning unit in (MONTH) (YEAR), and it was taken care of, but he could not remember off the top of his head, what the problem was, and that he had it written down in his book, but the book was in his car, which was at the mechanic shop. Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 4/1/18- Hall A: replaced filter. 4/2/18-Hall B: replaced filter. 4/3/18-Hall C: replaced filter. 4/4/18-Hall D: replaced filter. 4/13/18-Hall C: replaced blows motor. 4/27/18: cleaned AC coil 4/30/18: changed filters Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 5/1/18: replaced AC belt 5/20/18-Hall B: fix leak AC drain line. 5/8/18-Hall B: Changed filter. 5/11/18 -sealed AC vent in hall C Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 6/11/18- D4, D2 and D3: cleaned coils 6/12/18- D4, D5 and D6: cleaned coils 6/13/18- D7, D8 and D9: cleaned coils 6/14/18 -D10, D11 and D12: cleaned coils 6/16/18 - B4: cleaned coils 6/17/18 - B6: cleaned coils 6/18/18 - B8: Cleaned coils 6/20/18 - Hall C and A: cleaned condensing coils 6/21/18 - HR and Rehab Office: cleaned condensing coils 6/22/18 - Roof top: cleaned coils for B hall. 6/28/18 - HR Office: cleaned condensing coils 7/1/18 - Hall C: cleaned AC coils 7/2/18 - Hall A: cleaned AC coils Record review of a facility provided proposal from an outside AC company dated 6/11/18 revealed the company will provide and install 2.5-ton Trane system for hallway. Interview on 6/29/18 at 4:28pm, the facility's Regional Maintenance Director said the temperatures in residents' rooms for halls B, C and D were checked frequently throughout the day. Observation of the facility hall C was made on 06/29/18 at 4:48pm, revealed Room D7 -had temperature of 79 degree and Room C4-75. Room felt like the heater was on. Interview following above observation, the Administrator said maintenance staff had just worked on the portable AC unit in room C4. She said the heat exhaust pipe was kicked out by Resident # 2 while she was attempting to get in and out of her room. She explained the facility maintenance assistant had just worked to reconnect it. Interview on 06/29/18 at 5:06pm, the facility's Regional Maintenance Director said the AC company will install a new AC unit for hall C on Monday 7/02/18 to supplement the existing system. When asked how this will impact Halls B and D, the facility's Regional Maintenance Director said their plan was to first install this unit for hall C and see how far it goes. According to the national weather services, Houston area were advised of a heat index of 108 on 06/29/18 from the afternoon until early evening. Record review of facility's policy on abuse and neglect dated (MONTH) (YEAR) revealed the facility will do all within is control to prohibit neglect for all residents. The policy further defined Neglect as failure to provide good and services necessary to avoid physical, harm, mental anguish or mental illness. Record review of facility policy on homelike environment not dated revealed residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belonging to the extent possible. The Administrator was notified of the Immediate Jeopardy on 06/29/18 at 4:20 PM due to the above failures. A Plan of removal was requested. After several revisions, the Plan of Removal was accepted on 07/02/2018 at 7:34 PM The Plan of Removal reflected: Review of policy and procedure titled, Inspection of Heat/Air Conditioning System by the Administrator/ Maintenance Director. A tool was created to record temperature in the facility. Temperatures in every room are to be recorded every 2 hours during the day by Maintenance Director and every 4 hours after sundown. Concerns will be reported to the QAPI team immediately. Any temperatures reading over 76 are to be reported to the Administrator, maintenance director and director of nursing immediately. Residents in C4 were relocated to the A wing. A Window AC Unit was installed in D7. Window Tint was installed on glass doors in the hallways, monitored by the Administrator / Maintenance Director. Completed 7/1/18. Based on recommendations from the full HVAC Evaluation done on 6/30/18 coils in Halls A, B, and D were cleaned and the filters in these halls have been replaced. Administrator/ Maintenance Director to monitor and will be completed 7/2/18. 2.5-ton A/C was installed on Hall C. initiated 7/2/18. Administrator/ Maintenance Director to monitor and will be completed 7/3/18. Staff in-services were done related to reporting issues related to a/c and air concerns to Administrator and Maintenance Director, and during daily stand up meetings. Administrator/ Maintenance Director will monitor. This will be completed 6/29/18. In services done for proper use and control of window a/c units to all staff by the Administrator / Maintenance Director, initiated 6/29/18 and Completed 6/30/18. Portable A/C units have been removed from all areas by the Administrator /Maintenance Director/Leadership team, completed 6/29/18. QAPI team re-educated on signs of dehydration, QAPI team, along with leadership team is on a shift schedule to ensure follow through of hydration passes, vital sign checks by the Administrator /DON/QAPI, completed 6/29/18. All staff educated on where to locate extra fans, if necessary. Staff educated on notifying the Administrator, maintenance director, and director of nursing immediately if any resident is requesting a fan by Administrator/Maintenance Director, Completed 6/29/18 Non-verbal/Bed Bound residents were relocated to the A Wing. Staff was re-educated on signs and symptoms of dehydration. An extra aide placed here, to closely monitor. Monitored by DON/ADON/Administrator, completed 6/29/18. Staff in-services were done related to keeping residents cool and comfortable by the DON/ADON. Initiated 6/29/18 and completed 6/30/18. Observations on patients will be done every 30 minutes to high risk residents, and every hour on all other residents. Rounding will be documented on a recording tool implemented on 6/28/18. DON/ADON.Initiated 6/29/18 and completed 6/30/18. Residents educated on using their call light to allow educated staff to adjust their a/c units by DON/ADON/Administrator. Initiated 6/29/18 and completed 6/30/18 DON has re-educated staff on the importance of fluids, along with signs and symptoms of dehydration. Staff re-educated on what signs and symptoms to look for when entering room. DON/ADON/Administrator. Initiated 6/29/18 and completed 6/30/18. Staff will pass ice and water every two hours, and document on the hydration documentation tool implemented 6/28/18. DON/ADON to monitor and completed 6/29/18. Taking full VS including; BP, PR on all residents every 4 hours during the day and observe all high-risk residents every 30 minutes. Observe every other resident every hour. This will be documented on the Vital sign documentation tool. DON/ADON/SUPERVISOR to monitor. DON/ADON/Department heads. Initiated 6/29/18 and completed 6/30/18. Activities and nursing department have been re-educated on going to every patient and asking them if they would like to join activities going on in the main activity room (dining room). Activity Director to document in activity log. DON/ ADON/ administrator/activities director to monitor. Initiated 6/29/18 and completed 6/30/18. Activities director educated on the importance of having activities such as ice cream socials throughout the summer time. administrator/DON/ADON/activity director. Completed 6/30/18. This plan has been initiated 6/29/18 and will be completed 07/03/18. Monitoring Observations were conducted on all resident care units from 06/30/18 to 07/05/18 and all shift were monitored. Resident room temperatures were taken in Halls A, B C, and D which were averaging upper 60s in rooms and 54 degrees discharging through the AC vent. Observation and interview on 6/30/18 at 3:28pm revealed Resident #1 and #2 were moved to another room in hall A. Residents stated they were comfortable. Resident #2 said her new room felt much better. Interview on 6/30/18 at 3:33pm, the facility's Regional Maintenance Director said the AC company came out to the facility today and evaluated the entire AC system. He further said the report and recommendation will be sent to the facility on Monday 7/2/18. Record review of facility AC system evaluation report performed by an AC company not signed on 7/2/18 revealed the following; Hall A - average supply temperature in room :66 degrees Average temperature in hall 73 Recommend cleaning existing coils and replacing filters for more efficient operation Temperatures in hall A seem to be better than other hails. Hall B- average supply temperature in room :68 degrees Average temperature in hall 73.5 Recommend cleaning existing coils and replacing filters for more efficient operation Temperatures in hall A seem to be better than other hails. Hall C- average supply temperature in room :69 degrees Average temperature in hall 73. Existing HVAC unit (3 split system 4-ton, 4-ton, 3 ton) would normally cool the rooms but hallway is not ducted (no supplies) thus creates an overall supply problem to cool the hall Solution; Monday we are installing an additional 2.5-ton system to cover the hallway area. This will supply cool air to the hallway and thus reduce the stress on the units supplying the rooms in Hall C. Hall D- average supply temperature in room:67.2 degrees Average temperature in hall 73.5 Recommend cleaning existing coils and on condenser and AHUs and replacing filters for more efficient operation 25 staff members (two RNS, 11 CNAs, 8LVNs, 2MAs, and two maintenance staff) interviewed were representative of various facility shifts from 7/2/18 to 7/5/18. Staff were able to verbalize the facility plan to remove IJ regarding removal of all portable AC units from resident rooms, monitoring signs of dehydration and making hydration rounds. Observation of the facility halls B, C and D involving various facility shifts from 7/2/18 to 7/5/18 revealed the residents' rooms were cooler with no complaints from the residents. Interview on 7/2/18 at 8:45pm, the facility Administrator said the facility has installed new AC unit in Hall C and coils and filters are cleaned and replaced in hall B, C and D. She further said the facility continues to monitor residents' room, taking vital signs for vulnerable and cognitively impaired residents. Record review of facility temperature logs, staff training logs, resident monitoring logs, cognitively impaired resident's vital signs logs, residents' rooms temperature logs and hydration logs from 7/2/18 to 7/5/18 revealed no concerns. Interview on 7/3/18 at 11:49 AM, the facility Administrator stated the air conditioning company were in the facility installing a new unit that would cool the facility. She further stated she did not know the details or the ins and outs of what was being installed, she only knew it was being worked on. Observation on 7/4/18 at from 9:38pm to 10:20pm, revealed residents' rooms and hallways were much cooler and average temperature for Halls B, C and D was 70.5 degrees. Interview on 7/4/18 between 9:38pm and 10:15pm revealed 5 afternoon shift staff and 5-night shift staff verbalized understanding of what to do and who to contact should any resident need a fan, 30 minutes to one-hour vital signs checks, monitor AC units in rooms and offering fluid. Record review of the facility monitoring folder on 7/5/18 revealed evidence that staff monitored residents every 30 minutes to one hour, checking vital signs, assessment for signs of dehydration, monitoring AC units in the residents' room and offering fluids. Observation on 7/5/18 between 5:30pm to 6:00pm revealed average temperatures measured in residents' rooms in Halls A, B C and D were between 71 to 73 degrees Fahrenheit. No sign of discomfort was observed on residents. Interview on 7/5/18 between 6:00pm to 6:30pm revealed no residents' complaint regarding AC in resident's rooms. Interview on 7/5/18 at 6:35pm, the facility Administrator when asked what she thought lead to the immediate jeopardy, said she did not know how to answer the question but believed the facility did everything they could to protect the residents. She said she had only been in the frailty for about 3 weeks. She further said the Portal AC in room C4 had only been in the room that day prior to surveyors walked in. The Administrator said no one was harmed but agreed there were potential for harm. On 07/02/18 at 8:45p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern due to the facility's need to monitor implementation of the Plan of Removal (POR). The facility was continuing to monitor their new cooling system. According to the facility census dated 06/05/18, the facility census was 75.

Based on observation, interview and record review, the facility failed to ensure the resident were free from neglect for five of eleven residents (Resident #1, #2, #3, #4 and #5) reviewed for neglect. The facility failed to have a functioning air conditioning system for halls B, C and D since (MONTH) 5th, (YEAR). The facility failed to ensure a Portable AC unit placed in Resident #1 and #2's room had its exhaust pipe connected to discharged heat outside the room. Temperature of 138 degrees Fahrenheit was measured around the heat exhaust duct of the Portable AC unit with Resident #1 and #2 in the room. The facility failed to ensure window AC unit placed in Resident #3 and Resident# 4's room was turned on. The temperature in the room on 7/1/18 was 81 degrees Fahrenheit with residents in bed. The facility failed to ensure Resident #5 's room temperature was comfortable for her. Room temperature was 80 degrees Fahrenheit on 06/28/18. The facility failed to ensue staff were trained on how to operate newly acquired portable AC units used in the resident's rooms. The Facility failed to ensure staff were trained to monitor and ensure residents in three affected halls were monitored and hydrated. An Immediate Jeopardy (IJ) was identified on 06/29/18. While the IJ was lowered on 07/02/18, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern due to the facility's need to monitor implementation of the Plan of Removal (POR). These failures affected five residents and had the potential to affect 55 other residents in halls C, D and B, placing them at risk of not having needs met which could result in injury or harm. Findings Included: Resident # 1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 4 indicating severely impaired cognition. The resident required extensive assistance of one person with bed mobility, transfer and toilet use. Resident #2 Record review of Resident #2''s s face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed the resident was moderately impaired for daily decision making cognitive skills. Observation of hall C and interview on 06/28/18 at 12:15pm revealed room [ROOM NUMBER] belonging to resident #1 and #2 had temperature of 81 degrees Fahrenheit. There was a portable AC unit in the room which did not have a required heat exhaust pipe that would remove emitted heat from room. The room felt like a heater was on. Temperature reading on the portable AC unit was 80 and temperature of 138 degrees Fahrenheit was measured around the heat exhaust duct of the Portable AC unit via air gun digital thermometer by two surveyors. Further observation reveled Resident #2 was in bed with privacy curtain pulled to a close. Resident #2 stated she was hot. Resident #2 further stated her family member also brought her a small table fan to help cool her. A small table fan was noted standing on the right side of the resident and was on. Resident #1 has a fan facing her position in bed. In an attempted interview with Resident#1 following above observation, the resident did not answer questions about of her room temperature. When asked if room was comfortable for her, Resident stated yes. Interview on 6/28/18 at 12:40mp, the facility Maintenance Assistant was asked why the room felt like a heater was on and where the hot air was coming from in the above room. He said it must be from the portable AC unit in room [ROOM NUMBER]. When asked why the portable Ac unit did not have an heat exhaust pipe taking heat outside the room, he said he did not know why whoever set it up did not properly connect the pipe as it should. He further said the heat in the room was coming from the AC unit which defeats the purpose of having the AC in the room. He said he will connect the AC unit properly. The facility Maintenance Assistant said he did not know how long the unit was left in the room [ROOM NUMBER] but said the facility's cooling system have been having problems for a month. The facility Maintenance Assistant said the facility purchased portable AC units and installed window AC units to help cool the room and hallways in affected hall. The facility Maintenance Assistant was asked what training was provided for maintenance staff prior to operating the portable AC unit, he said staff should just follow the manufactures' instruction that came with equipment. Interview on 06/28/18 at 12:47pm, the facility Administrator said the facility had purchased portable AC units for use in the resident's rooms. She said she was not sure how the AC units worked but stated she believed the units come with instruction. When asked how she ensured the facility staff were trained on how to operate the new devices, the Administrator said the maintenance staff installed the units. The Administrator was asked who was responsible for overseeing the maintenance department and she said it as herself. Hall observations Observation on 06/28/18 from 1:44pm to 2:00pm, revealed 9 residents rooms in hall C, 6 rooms in hall D and three residents room sin hall B had newly installed Window AC units in which were either off, set on energy savings and were not cooling rooms. AC vents were not blowing out cool air in the rooms. No staff was seen passing fluids to residents on halls C and D. Residents water pitches did not have fresh ice and cold water in these rooms. Interview on 6/28/18 at 1:10pm, CNA#2 who was the assigned aide in hall C said staff passed ice three times a day or once a shift. When asked the last time he passed out ice/water for his 6am - 2pm shift, CNA#2 said he passed out ice and water to the residents before Lunch (12noon). CNA#2 said he was not aware of any measures he was required to do since the AC in the resident's rooms were not working well. He said some residents' rooms in hall C were hot due to the AC not working well. Observation on 06/28/18 revealed the following temperatures in degrees Fahrenheit in the residents' rooms. HALL C: Room C2- 79 with fan on at 2:20pm Room C4 -79 at 2:22pm, and Room C4- 80 at 2:22pm. HALL D; Room D4-79 at 2:30pm, Room D7- 80 at 2:33pm, Room D8-79 at 3:19pm and Room D11-79 at 2:35pm. Observation on 06/28/18 at 2:18pm revealed a portable AC unit at the beginning of hall D which was on and recorded temperature of 80 degrees Fahrenheit. The area where the unit was felt like a heater was on. Further observation revealed the portable AC unit required an exhaust pipe to take heat out but did not have one. Resident #5 Record review of Resident #5's face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's admission MDS dated [DATE] revealed a BIMS score of 11, indicating moderately impaired cognition. Observation and interview on 06/28/18 at 2:38pm, Resident #5 who was in bed under covers in D-7 stated her room was very hot and uncomfortable. Resident #5's face was flushed, and her cheeks were red. Resident #5 asked if she could have a fan to cool her down. Resident #5's room temperatures was 80 degrees Fahrenheit. Observation on 6/28/18 at 3:22 pm revealed room temperature in room C4 was 80-degree Fahrenheit. Resident #1 and #2 were in their beds. Interview on 06/28/18 at 3:38pm, the facility Administrator said they did not know what the problem with the AC system was. The Administrator said only Hall C 's AC system was identified by an AC company as not functioning in its full capacity. When asked why hall B and D had newly installed AC unit in the resident's room, the Administrator said they bought more than needed and decided to install them in the resident's room. When asked why the hallway were hot and had industrial size fan blowing, the Administrator said it was to cool the hallways. The Administrator was asked what the facility was doing to find out the problem and fix it, she said they had an outside AC company that will be coming out to check their AC system for hall C only on Monday 7/2/18. The Administrator was asked why nothing has been done since this issue had been going on for more than a month now, but she said the facility had addressed the problem by buying additional AC units and fans. Interview on 06/28/18 at 4:00pm, Maintenance Director said he started working at the facility about three weeks ago. He said he worked on the AC unit serving hall D two weeks ago and it stated working better. Interview on 06/28/18 at 4:03pm, ADON when asked why there was as industrial size fan in hall B, she stated the facility 's AC system is just not cooling well. When asked for how long now, she said for some time now. Interview on 06/28/18 at 4:18pm, the facility Administrator was asked for evidence to show that facility AC's system had been check by AC professionals and their recommendations. The Administrator said she will send these documents, but none was provided despite repeated inquires since 06/05/2018. Resident #3 Record review of Resident #3's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility 11/14/2017. His [DIAGNOSES REDACTED]. [MEDICAL CONDITION], hyperlipemia, [MEDICAL CONDITIONS], sensorineural hearing loss, hypertension, and [MEDICAL CONDITIONS]. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further review of the MDS revealed the resident required extensive assistance of one person with bed mobility, transfer, toilet use and bathing. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility 09/01/2017. His [DIAGNOSES REDACTED]. Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 11 indicating moderately impaired cognition. Further review of the MDS revealed the resident required extensive assistance of one person with bed mobility, toilet use personal hygiene, bathing and limited assistance on one staff for transfers. Observation on 7/1/18 at 6:00pm revealed Resident#3 and #4 in their respective beds in room C-7. Room felt hot and temperature measured was 81 degrees Fahrenheit. The window AC I the room was turned off. When AC unit was turned on, the AC unit registered temperature of 83 degrees Fahrenheit. Window blind was up with the sun direction shining into the room. Window AC unit in the room was off. Further observation revealed Resident #3 had a white long sleeve shirt on and in bed while Resident #4 had short sleeve t-shirt on. Resident #4 's face was red and flushed. Resident #3 was closer to the window with the sun on his bed. Observation of the residents' water pitchers revealed small water in pitchers but had no ice. Interview following above observations, Resident #4 said it was too hot and uncomfortable in the room. Resident #4 was asked why his AC unit was off, but he said he did not know why. The resident asked to turn on AC and requested for some cold water. Resident #3 said it hot in the room. When asked why they did not call for help to have the AC unit turned on, both residents said the staff do not answer call lights. Residents were asked the last time the they were provided cold water, they said it had been a while. Interview on 07/1/18 at 6:10pm, CNA#1 said she was not aware the residents' AC was off. She said the residents probably got cold and turned it off. She said Resident #4 ambulated with his wheel chair and could turn off AC. CNA#1 was asked when she made the last rounds and provided ice water to the residents, she stated she just did it. When asked how often she made rounds, she said every two hours. CNA#1 said she was aware of the AC problem in hall C. Interview with Regional Maintenance director on 7/3/18 at 12:38 PM, he stated there was an issue with the air conditioning unit in (MONTH) (YEAR), and it was taken care of, but he could not remember off the top of his head, what the problem was, and that he had it written down in his book, but the book was in his car, which was at the mechanic shop. Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 4/1/18- Hall A: replaced filter. 4/2/18-Hall B: replaced filter. 4/3/18-Hall C: replaced filter. 4/4/18-Hall D: replaced filter. 4/13/18-Hall C: replaced blows motor. 4/27/18: cleaned AC coil 4/30/18: changed filters Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 5/1/18: replaced AC belt 5/20/18-Hall B: fix leak AC drain line. 5/8/18-Hall B: Changed filter. 5/11/18 -sealed AC vent in hall C Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 6/11/18- D4, D2 and D3: cleaned coils 6/12/18- D4, D5 and D6: cleaned coils 6/13/18- D7, D8 and D9: cleaned coils 6/14/18 -D10, D11 and D12: cleaned coils 6/16/18 - B4: cleaned coils 6/17/18 - B6: cleaned coils 6/18/18 - B8: Cleaned coils 6/20/18 - Hall C and A: cleaned condensing coils 6/21/18 - HR and Rehab Office: cleaned condensing coils 6/22/18 - Roof top: cleaned coils for B hall. 6/28/18 - HR Office: cleaned condensing coils 7/1/18 - Hall C: cleaned AC coils 7/2/18 - Hall A: cleaned AC coils Record review of a facility provided proposal from an outside AC company dated 6/11/18 revealed the company will provide and install 2.5-ton Trane system for hallway. Interview on 6/29/18 at 4:28pm, the facility's Regional Maintenance Director said the temperatures in residents' rooms for halls B, C and D were checked frequently throughout the day. Observation of the facility hall C was made on 06/29/18 at 4:48pm, revealed Room D7 -had temperature of 79 degree and Room C4-75. Room felt like the heater was on. Interview following above observation, the Administrator said maintenance staff had just worked on the portable AC unit in room C4. She said the heat exhaust pipe was kicked out by Resident # 2 while she was attempting to get in and out of her room. She explained the facility maintenance assistant had just worked to reconnect it. Interview on 06/29/18 at 5:06pm, the facility's Regional Maintenance Director said the AC company will install a new AC unit for hall C on Monday 7/02/18 to supplement the existing system. When asked how this will impact Halls B and D, the facility's Regional Maintenance Director said their plan was to first install this unit for hall C and see how far it goes. According to the national weather services, Houston area were advised of a heat index of 108 on 06/29/18 from the afternoon until early evening. Record review of facility's policy on abuse and neglect dated (MONTH) (YEAR) revealed the facility will do all within is control to prohibit neglect for all residents. The policy further defined Neglect as failure to provide good and services necessary to avoid physical, harm, mental anguish or mental illness. Record review of facility policy on homelike environment not dated revealed residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belonging to the extent possible. The Administrator was notified of the Immediate Jeopardy on 06/29/18 at 4:20 PM due to the above failures. A Plan of removal was requested. After several revisions, the Plan of Removal was accepted on 07/02/2018 at 7:34 PM The Plan of Removal reflected: Review of policy and procedure titled, Inspection of Heat/Air Conditioning System by the Administrator/ Maintenance Director. A tool was created to record temperature in the facility. Temperatures in every room are to be recorded every 2 hours during the day by Maintenance Director and every 4 hours after sundown. Concerns will be reported to the QAPI team immediately. Any temperatures reading over 76 are to be reported to the Administrator, maintenance director and director of nursing immediately. Residents in C4 were relocated to the A wing. A Window AC Unit was installed in D7. Window Tint was installed on glass doors in the hallways, monitored by the Administrator / Maintenance Director. Completed 7/1/18. Based on recommendations from the full HVAC Evaluation done on 6/30/18 coils in Halls A, B, and D were cleaned and the filters in these halls have been replaced. Administrator/ Maintenance Director to monitor and will be completed 7/2/18. 2.5-ton A/C was installed on Hall C. initiated 7/2/18. Administrator/ Maintenance Director to monitor and will be completed 7/3/18. Staff in-services were done related to reporting issues related to a/c and air concerns to Administrator and Maintenance Director, and during daily stand up meetings. Administrator/ Maintenance Director will monitor. This will be completed 6/29/18. In services done for proper use and control of window a/c units to all staff by the Administrator / Maintenance Director, initiated 6/29/18 and Completed 6/30/18. Portable A/C units have been removed from all areas by the Administrator /Maintenance Director/Leadership team, completed 6/29/18. QAPI team re-educated on signs of dehydration, QAPI team, along with leadership team is on a shift schedule to ensure follow through of hydration passes, vital sign checks by the Administrator /DON/QAPI, completed 6/29/18. All staff educated on where to locate extra fans, if necessary. Staff educated on notifying the Administrator, maintenance director, and director of nursing immediately if any resident is requesting a fan by Administrator/Maintenance Director, Completed 6/29/18 Non-verbal/Bed Bound residents were relocated to the A Wing. Staff was re-educated on signs and symptoms of dehydration. An extra aide placed here, to closely monitor. Monitored by DON/ADON/Administrator, completed 6/29/18. Staff in-services were done related to keeping residents cool and comfortable by the DON/ADON. Initiated 6/29/18 and completed 6/30/18. Observations on patients will be done every 30 minutes to high risk residents, and every hour on all other residents. Rounding will be documented on a recording tool implemented on 6/28/18. DON/ADON.Initiated 6/29/18 and completed 6/30/18. Residents educated on using their call light to allow educated staff to adjust their a/c units by DON/ADON/Administrator. Initiated 6/29/18 and completed 6/30/18 DON has re-educated staff on the importance of fluids, along with signs and symptoms of dehydration. Staff re-educated on what signs and symptoms to look for when entering room. DON/ADON/Administrator. Initiated 6/29/18 and completed 6/30/18. Staff will pass ice and water every two hours, and document on the hydration documentation tool implemented 6/28/18. DON/ADON to monitor and completed 6/29/18. Taking full VS including; BP, PR on all residents every 4 hours during the day and observe all high-risk residents every 30 minutes. Observe every other resident every hour. This will be documented on the Vital sign documentation tool. DON/ADON/SUPERVISOR to monitor. DON/ADON/Department heads. Initiated 6/29/18 and completed 6/30/18. Activities and nursing department have been re-educated on going to every patient and asking them if they would like to join activities going on in the main activity room (dining room). Activity Director to document in activity log. DON/ ADON/ administrator/activities director to monitor. Initiated 6/29/18 and completed 6/30/18. Activities director educated on the importance of having activities such as ice cream socials throughout the summer time. administrator/DON/ADON/activity director. Completed 6/30/18. This plan has been initiated 6/29/18 and will be completed 07/03/18. Monitoring Observations were conducted on all resident care units from 06/30/18 to 07/05/18 and all shift were monitored. Resident room temperatures were taken in Halls A, B C, and D which were averaging upper 60s in rooms and 54 degrees discharging through the AC vent. Observation and interview on 6/30/18 at 3:28pm revealed Resident #1 and #2 were moved to another room in hall A. Residents stated they were comfortable. Resident #2 said her new room felt much better. Interview on 6/30/18 at 3:33pm, the facility's Regional Maintenance Director said the AC company came out to the facility today and evaluated the entire AC system. He further said the report and recommendation will be sent to the facility on Monday 7/2/18. Record review of facility AC system evaluation report performed by an AC company not signed on 7/2/18 revealed the following; Hall A - average supply temperature in room :66 degrees Average temperature in hall 73 Recommend cleaning existing coils and replacing filters for more efficient operation Temperatures in hall A seem to be better than other hails. Hall B- average supply temperature in room :68 degrees Average temperature in hall 73.5 Recommend cleaning existing coils and replacing filters for more efficient operation Temperatures in hall A seem to be better than other hails. Hall C- average supply temperature in room :69 degrees Average temperature in hall 73. Existing HVAC unit (3 split system 4-ton, 4-ton, 3 ton) would normally cool the rooms but hallway is not ducted (no supplies) thus creates an overall supply problem to cool the hall Solution; Monday we are installing an additional 2.5-ton system to cover the hallway area. This will supply cool air to the hallway and thus reduce the stress on the units supplying the rooms in Hall C. Hall D- average supply temperature in room:67.2 degrees Average temperature in hall 73.5 Recommend cleaning existing coils and on condenser and AHUs and replacing filters for more efficient operation 25 staff members (two RNS, 11 CNAs, 8LVNs, 2MAs, and two maintenance staff) interviewed were representative of various facility shifts from 7/2/18 to 7/5/18. Staff were able to verbalize the facility plan to remove IJ regarding removal of all portable AC units from resident rooms, monitoring signs of dehydration and making hydration rounds. Observation of the facility halls B, C and D involving various facility shifts from 7/2/18 to 7/5/18 revealed the residents' rooms were cooler with no complaints from the residents. Interview on 7/2/18 at 8:45pm, the facility Administrator said the facility has installed new AC unit in Hall C and coils and filters are cleaned and replaced in hall B, C and D. She further said the facility continues to monitor residents' room, taking vital signs for vulnerable and cognitively impaired residents. Record review of facility temperature logs, staff training logs, resident monitoring logs, cognitively impaired resident's vital signs logs, residents' rooms temperature logs and hydration logs from 7/2/18 to 7/5/18 revealed no concerns. Interview on 7/3/18 at 11:49 AM, the facility Administrator stated the air conditioning company were in the facility installing a new unit that would cool the facility. She further stated she did not know the details or the ins and outs of what was being installed, she only knew it was being worked on. Observation on 7/4/18 at from 9:38pm to 10:20pm, revealed residents' rooms and hallways were much cooler and average temperature for Halls B, C and D was 70.5 degrees. Interview on 7/4/18 between 9:38pm and 10:15pm revealed 5 afternoon shift staff and 5-night shift staff verbalized understanding of what to do and who to contact should any resident need a fan, 30 minutes to one-hour vital signs checks, monitor AC units in rooms and offering fluid. Record review of the facility monitoring folder on 7/5/18 revealed evidence that staff monitored residents every 30 minutes to one hour, checking vital signs, assessment for signs of dehydration, monitoring AC units in the residents' room and offering fluids. Observation on 7/5/18 between 5:30pm to 6:00pm revealed average temperatures measured in residents' rooms in Halls A, B C and D were between 71 to 73 degrees Fahrenheit. No sign of discomfort was observed on residents. Interview on 7/5/18 between 6:00pm to 6:30pm revealed no residents' complaint regarding AC in resident's rooms. Interview on 7/5/18 at 6:35pm, the facility Administrator when asked what she thought lead to the immediate jeopardy, said she did not know how to answer the question but believed the facility did everything they could to protect the residents. She said she had only been in the facility for about 3 weeks. She further said the Portal AC in room C4 had only been in the room that day prior to surveyors walked in. The Administrator said no one was harmed but agreed there were potential for harm. On 07/02/18 at 8:45p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern due to the facility's need to monitor implementation of the Plan of Removal (POR). The facility was continuing to monitor their new cooling system. According to the facility census dated 06/05/18, the facility census was 75.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for five of 11 residents ( Resdent#1,#2,#3,#4 and #5), staff, and the public reviewed for a safe environment. The facility failed to have a functioning air conditioning system for halls B, C and D since (MONTH) 5th, (YEAR). The facility failed to ensure a Portable AC unit placed in Resident #1 and #2's room had its exhaust pipe connected to discharged heat outside the room. Temperature of 138 degrees Fahrenheit was measured around the heat exhaust duct of the Portable AC unit with Resident #1 and #2 in the room. The facility failed to ensure window AC unit placed in Resident #3 and Resident# 4's room was turned on. The temperature in the room on 7/1/18 was 81 degrees Fahrenheit with residents in bed. The facility failed to ensure Resident #5 's room temperature was comfortable for her. Room temperature was 80 degrees Fahrenheit on 06/28/18. The facility failed to ensue staff were trained on how to operate newly acquired portable AC units used in the resident's rooms. The Facility failed to ensure staff were trained to monitor and ensure residents in three affected halls were monitored and hydrated. An Immediate Jeopardy (IJ) was identified on 06/29/18. While the IJ was lowered on 07/02/18, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern due to the facility's need to monitor implementation of the Plan of Removal (POR). These failures affected five residents and had the potential to affect 55 other residents in halls C, D and B, placing them at risk of not having needs met which could result in injury or harm. Findings Included: Resident # 1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 4 indicating severely impaired cognition. The resident required extensive assistance of one person with bed mobility, transfer and toilet use. Resident #2 Record review of Resident #2''s s face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's MDS dated [DATE] revealed the resident was moderately impaired for daily decision making cognitive skills. Observation of hall C and interview on 06/28/18 at 12:15pm revealed room [ROOM NUMBER] belonging to resident #1 and #2 had temperature of 81 degrees Fahrenheit. There was a portable AC unit in the room which did not have a required heat exhaust pipe that would remove emitted heat from room. The room felt like a heater was on. Temperature reading on the portable AC unit was 80 and temperature of 138 degrees Fahrenheit was measured around the heat exhaust duct of the Portable AC unit via air gun digital thermometer by two surveyors. Further observation reveled Resident #2 was in bed with privacy curtain pulled to a close. Resident #2 stated she was hot. Resident #2 further stated her family member also brought her a small table fan to help cool her. A small table fan was noted standing on the right side of the resident and was on. Resident #1 has a fan facing her position in bed. In an attempted interview with Resident#1 following above observation, the resident did not answer questions about of her room temperature. When asked if room was comfortable for her, Resident stated yes. Interview on 6/28/18 at 12:40mp, the facility Maintenance Assistant was asked why the room felt like a heater was on and where the hot air was coming from in the above room. He said it must be from the portable AC unit in room [ROOM NUMBER]. When asked why the portable Ac unit did not have an heat exhaust pipe taking heat outside the room, he said he did not know why whoever set it up did not properly connect the pipe as it should. He further said the heat in the room was coming from the AC unit which defeats the purpose of having the AC in the room. He said he will connect the AC unit properly. The facility Maintenance Assistant said he did not know how long the unit was left in the room [ROOM NUMBER] but said the facility's cooling system have been having problems for a month. The facility Maintenance Assistant said the facility purchased portable AC units and installed window AC units to help cool the room and hallways in affected hall. The facility Maintenance Assistant was asked what training was provided for maintenance staff prior to operating the portable AC unit, he said staff should just follow the manufactures' instruction that came with equipment. Interview on 06/28/18 at 12:47pm, the facility Administrator said the facility had purchased portable AC units for use in the resident's rooms. She said she was not sure how the AC units worked but stated she believed the units come with instruction. When asked how she ensured the facility staff were trained on how to operate the new devices, the Administrator said the maintenance staff installed the units. The Administrator was asked who was responsible for overseeing the maintenance department and she said it as herself. Hall observations Observation on 06/28/18 from 1:44pm to 2:00pm, revealed 9 residents rooms in hall C, 6 rooms in hall D and three residents room sin hall B had newly installed Window AC units in which were either off, set on energy savings and were not cooling rooms. AC vents were not blowing out cool air in the rooms. No staff was seen passing fluids to residents on halls C and D. Residents water pitches did not have fresh ice and cold water in these rooms. Interview on 6/28/18 at 1:10pm, CNA#2 who was the assigned aide in hall C said staff passed ice three times a day or once a shift. When asked the last time he passed out ice/water for his 6am - 2pm shift, CNA#2 said he passed out ice and water to the residents before Lunch (12noon). CNA#2 said he was not aware of any measures he was required to do since the AC in the resident's rooms were not working well. He said some residents' rooms in hall C were hot due to the AC not working well. Observation on 06/28/18 revealed the following temperatures in degrees Fahrenheit in the residents' rooms. HALL C: Room C2- 79 with fan on at 2:20pm Room C4 -79 at 2:22pm, and Room C4- 80 at 2:22pm. HALL D; Room D4-79 at 2:30pm, Room D7- 80 at 2:33pm, Room D8-79 at 3:19pm and Room D11-79 at 2:35pm. Observation on 06/28/18 at 2:18pm revealed a portable AC unit at the beginning of hall D which was on and recorded temperature of 80 degrees Fahrenheit. The area where the unit was felt like a heater was on. Further observation revealed the portable AC unit required an exhaust pipe to take heat out but did not have one. Resident #5 Record review of Resident #5's face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's admission MDS dated [DATE] revealed a BIMS score of 11, indicating moderately impaired cognition. Observation and interview on 06/28/18 at 2:38pm, Resident #5 who was in bed under covers in D-7 stated her room was very hot and uncomfortable. Resident #5's face was flushed, and her cheeks were red. Resident #5 asked if she could have a fan to cool her down. Resident #5's room temperatures was 80 degrees Fahrenheit. Observation on 6/28/18 at 3:22 pm revealed room temperature in room C4 was 80-degree Fahrenheit. Resident #1 and #2 were in their beds. Interview on 06/28/18 at 3:38pm, the facility Administrator said they did not know what the problem with the AC system was. The Administrator said only Hall C 's AC system was identified by an AC company as not functioning in its full capacity. When asked why hall B and D had newly installed AC unit in the resident's room, the Administrator said they bought more than needed and decided to install them in the resident's room. When asked why the hallway were hot and had industrial size fan blowing, the Administrator said it was to cool the hallways. The Administrator was asked what the facility was doing to find out the problem and fix it, she said they had an outside AC company that will be coming out to check their AC system for hall C only on Monday 7/2/18. The Administrator was asked why nothing has been done since this issue had been going on for more than a month now, but she said the facility had addressed the problem by buying additional AC units and fans. Interview on 06/28/18 at 4:00pm, Maintenance Director said he started working at the facility about three weeks ago. He said he worked on the AC unit serving hall D two weeks ago and it stated working better. Interview on 06/28/18 at 4:03pm, ADON when asked why there was as industrial size fan in hall B, she stated the facility 's AC system is just not cooling well. When asked for how long now, she said for some time now. Interview on 06/28/18 at 4:18pm, the facility Administrator was asked for evidence to show that facility AC's system had been check by AC professionals and their recommendations. The Administrator said she will send these documents, but none was provided despite repeated inquires since 06/05/2018. Resident #3 Record review of Resident #3's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility 11/14/2017. His [DIAGNOSES REDACTED]. [MEDICAL CONDITION], hyperlipemia, [MEDICAL CONDITIONS], sensorineural hearing loss, hypertension, and [MEDICAL CONDITIONS]. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further review of the MDS revealed the resident required extensive assistance of one person with bed mobility, transfer, toilet use and bathing. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted to the facility 09/01/2017. His [DIAGNOSES REDACTED]. Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 11 indicating moderately impaired cognition. Further review of the MDS revealed the resident required extensive assistance of one person with bed mobility, toilet use personal hygiene, bathing and limited assistance on one staff for transfers. Observation on 7/1/18 at 6:00pm revealed Resident#3 and #4 in their respective beds in room C-7. Room felt hot and temperature measured was 81 degrees Fahrenheit. The window AC I the room was turned off. When AC unit was turned on, the AC unit registered temperature of 83 degrees Fahrenheit. Window blind was up with the sun direction shining into the room. Window AC unit in the room was off. Further observation revealed Resident #3 had a white long sleeve shirt on and in bed while Resident #4 had short sleeve t-shirt on. Resident #4 's face was red and flushed. Resident #3 was closer to the window with the sun on his bed. Observation of the residents' water pitchers revealed small water in pitchers but had no ice. Interview following above observations, Resident #4 said it was too hot and uncomfortable in the room. Resident #4 was asked why his AC unit was off, but he said he did not know why. The resident asked to turn on AC and requested for some cold water. Resident #3 said it hot in the room. When asked why they did not call for help to have the AC unit turned on, both residents said the staff do not answer call lights. Residents were asked the last time the they were provided cold water, they said it had been a while. Interview on 07/1/18 at 6:10pm, CNA#1 said she was not aware the residents' AC was off. She said the residents probably got cold and turned it off. She said Resident #4 ambulated with his wheel chair and could turn off AC. CNA#1 was asked when she made the last rounds and provided ice water to the residents, she stated she just did it. When asked how often she made rounds, she said every two hours. CNA#1 said she was aware of the AC problem in hall C. Interview with Regional Maintenance director on 7/3/18 at 12:38 PM, he stated there was an issue with the air conditioning unit in (MONTH) (YEAR), and it was taken care of, but he could not remember off the top of his head, what the problem was, and that he had it written down in his book, but the book was in his car, which was at the mechanic shop. Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 4/1/18- Hall A: replaced filter. 4/2/18-Hall B: replaced filter. 4/3/18-Hall C: replaced filter. 4/4/18-Hall D: replaced filter. 4/13/18-Hall C: replaced blows motor. 4/27/18: cleaned AC coil 4/30/18: changed filters Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 5/1/18: replaced AC belt 5/20/18-Hall B: fix leak AC drain line. 5/8/18-Hall B: Changed filter. 5/11/18 -sealed AC vent in hall C Record review of the facility's maintenance log dated (MONTH) (YEAR) revealed the following entries: 6/11/18- D4, D2 and D3: cleaned coils 6/12/18- D4, D5 and D6: cleaned coils 6/13/18- D7, D8 and D9: cleaned coils 6/14/18 -D10, D11 and D12: cleaned coils 6/16/18 - B4: cleaned coils 6/17/18 - B6: cleaned coils 6/18/18 - B8: Cleaned coils 6/20/18 - Hall C and A: cleaned condensing coils 6/21/18 - HR and Rehab Office: cleaned condensing coils 6/22/18 - Roof top: cleaned coils for B hall. 6/28/18 - HR Office: cleaned condensing coils 7/1/18 - Hall C: cleaned AC coils 7/2/18 - Hall A: cleaned AC coils Record review of a facility provided proposal from an outside AC company dated 6/11/18 revealed the company will provide and install 2.5-ton Trane system for hallway. Interview on 6/29/18 at 4:28pm, the facility's Regional Maintenance Director said the temperatures in residents' rooms for halls B, C and D were checked frequently throughout the day. Observation of the facility hall C was made on 06/29/18 at 4:48pm, revealed Room D7 -had temperature of 79 degree and Room C4-75. Room felt like the heater was on. Interview following above observation, the Administrator said maintenance staff had just worked on the portable AC unit in room C4. She said the heat exhaust pipe was kicked out by Resident # 2 while she was attempting to get in and out of her room. She explained the facility maintenance assistant had just worked to reconnect it. Interview on 06/29/18 at 5:06pm, the facility's Regional Maintenance Director said the AC company will install a new AC unit for hall C on Monday 7/02/18 to supplement the existing system. When asked how this will impact Halls B and D, the facility's Regional Maintenance Director said their plan was to first install this unit for hall C and see how far it goes. According to the national weather services, Houston area were advised of a heat index of 108 on 06/29/18 from the afternoon until early evening. Record review of facility's policy on abuse and neglect dated (MONTH) (YEAR) revealed the facility will do all within is control to prohibit neglect for all residents. The policy further defined Neglect as failure to provide good and services necessary to avoid physical, harm, mental anguish or mental illness. Record review of facility policy on homelike environment not dated revealed residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belonging to the extent possible. The Administrator was notified of the Immediate Jeopardy on 06/29/18 at 4:20 PM due to the above failures. A Plan of removal was requested. After several revisions, the Plan of Removal was accepted on 07/02/2018 at 7:34 PM The Plan of Removal reflected: Review of policy and procedure titled, Inspection of Heat/Air Conditioning System by the Administrator/ Maintenance Director. A tool was created to record temperature in the facility. Temperatures in every room are to be recorded every 2 hours during the day by Maintenance Director and every 4 hours after sundown. Concerns will be reported to the QAPI team immediately. Any temperatures reading over 76 are to be reported to the Administrator, maintenance director and director of nursing immediately. Residents in C4 were relocated to the A wing. A Window AC Unit was installed in D7. Window Tint was installed on glass doors in the hallways, monitored by the Administrator / Maintenance Director. Completed 7/1/18. Based on recommendations from the full HVAC Evaluation done on 6/30/18 coils in Halls A, B, and D were cleaned and the filters in these halls have been replaced. Administrator/ Maintenance Director to monitor and will be completed 7/2/18. 2.5-ton A/C was installed on Hall C. initiated 7/2/18. Administrator/ Maintenance Director to monitor and will be completed 7/3/18. Staff in-services were done related to reporting issues related to a/c and air concerns to Administrator and Maintenance Director, and during daily stand up meetings. Administrator/ Maintenance Director will monitor. This will be completed 6/29/18. In services done for proper use and control of window a/c units to all staff by the Administrator / Maintenance Director, initiated 6/29/18 and Completed 6/30/18. Portable A/C units have been removed from all areas by the Administrator /Maintenance Director/Leadership team, completed 6/29/18. QAPI team re-educated on signs of dehydration, QAPI team, along with leadership team is on a shift schedule to ensure follow through of hydration passes, vital sign checks by the Administrator /DON/QAPI, completed 6/29/18. All staff educated on where to locate extra fans, if necessary. Staff educated on notifying the Administrator, maintenance director, and director of nursing immediately if any resident is requesting a fan by Administrator/Maintenance Director, Completed 6/29/18 Non-verbal/Bed Bound residents were relocated to the A Wing. Staff was re-educated on signs and symptoms of dehydration. An extra aide placed here, to closely monitor. Monitored by DON/ADON/Administrator, completed 6/29/18. Staff in-services were done related to keeping residents cool and comfortable by the DON/ADON. Initiated 6/29/18 and completed 6/30/18. Observations on patients will be done every 30 minutes to high risk residents, and every hour on all other residents. Rounding will be documented on a recording tool implemented on 6/28/18. DON/ADON.Initiated 6/29/18 and completed 6/30/18. Residents educated on using their call light to allow educated staff to adjust their a/c units by DON/ADON/Administrator. Initiated 6/29/18 and completed 6/30/18 DON has re-educated staff on the importance of fluids, along with signs and symptoms of dehydration. Staff re-educated on what signs and symptoms to look for when entering room. DON/ADON/Administrator. Initiated 6/29/18 and completed 6/30/18. Staff will pass ice and water every two hours, and document on the hydration documentation tool implemented 6/28/18. DON/ADON to monitor and completed 6/29/18. Taking full VS including; BP, PR on all residents every 4 hours during the day and observe all high-risk residents every 30 minutes. Observe every other resident every hour. This will be documented on the Vital sign documentation tool. DON/ADON/SUPERVISOR to monitor. DON/ADON/Department heads. Initiated 6/29/18 and completed 6/30/18. Activities and nursing department have been re-educated on going to every patient and asking them if they would like to join activities going on in the main activity room (dining room). Activity Director to document in activity log. DON/ ADON/ administrator/activities director to monitor. Initiated 6/29/18 and completed 6/30/18. Activities director educated on the importance of having activities such as ice cream socials throughout the summer time. administrator/DON/ADON/activity director. Completed 6/30/18. This plan has been initiated 6/29/18 and will be completed 07/03/18. Monitoring Observations were conducted on all resident care units from 06/30/18 to 07/05/18 and all shift were monitored. Resident room temperatures were taken in Halls A, B C, and D which were averaging upper 60s in rooms and 54 degrees discharging through the AC vent. Observation and interview on 6/30/18 at 3:28pm revealed Resident #1 and #2 were moved to another room in hall A. Residents stated they were comfortable. Resident #2 said her new room felt much better. Interview on 6/30/18 at 3:33pm, the facility's Regional Maintenance Director said the AC company came out to the facility today and evaluated the entire AC system. He further said the report and recommendation will be sent to the facility on Monday 7/2/18. Record review of facility AC system evaluation report performed by an AC company not signed on 7/2/18 revealed the following; Hall A - average supply temperature in room :66 degrees Average temperature in hall 73 Recommend cleaning existing coils and replacing filters for more efficient operation Temperatures in hall A seem to be better than other hails. Hall B- average supply temperature in room :68 degrees Average temperature in hall 73.5 Recommend cleaning existing coils and replacing filters for more efficient operation Temperatures in hall A seem to be better than other hails. Hall C- average supply temperature in room :69 degrees Average temperature in hall 73. Existing HVAC unit (3 split system 4-ton, 4-ton, 3 ton) would normally cool the rooms but hallway is not ducted (no supplies) thus creates an overall supply problem to cool the hall Solution; Monday we are installing an additional 2.5-ton system to cover the hallway area. This will supply cool air to the hallway and thus reduce the stress on the units supplying the rooms in Hall C. Hall D- average supply temperature in room:67.2 degrees Average temperature in hall 73.5 Recommend cleaning existing coils and on condenser and AHUs and replacing filters for more efficient operation 25 staff members (two RNS, 11 CNAs, 8LVNs, 2MAs, and two maintenance staff) interviewed were representative of various facility shifts from 7/2/18 to 7/5/18. Staff were able to verbalize the facility plan to remove IJ regarding removal of all portable AC units from resident rooms, monitoring signs of dehydration and making hydration rounds. Observation of the facility halls B, C and D involving various facility shifts from 7/2/18 to 7/5/18 revealed the residents' rooms were cooler with no complaints from the residents. Interview on 7/2/18 at 8:45pm, the facility Administrator said the facility has installed new AC unit in Hall C and coils and filters are cleaned and replaced in hall B, C and D. She further said the facility continues to monitor residents' room, taking vital signs for vulnerable and cognitively impaired residents. Record review of facility temperature logs, staff training logs, resident monitoring logs, cognitively impaired resident's vital signs logs, residents' rooms temperature logs and hydration logs from 7/2/18 to 7/5/18 revealed no concerns. Interview on 7/3/18 at 11:49 AM, the facility Administrator stated the air conditioning company were in the facility installing a new unit that would cool the facility. She further stated she did not know the details or the ins and outs of what was being installed, she only knew it was being worked on. Observation on 7/4/18 at from 9:38pm to 10:20pm, revealed residents' rooms and hallways were much cooler and average temperature for Halls B, C and D was 70.5 degrees. Interview on 7/4/18 between 9:38pm and 10:15pm revealed 5 afternoon shift staff and 5-night shift staff verbalized understanding of what to do and who to contact should any resident need a fan, 30 minutes to one-hour vital signs checks, monitor AC units in rooms and offering fluid. Record review of the facility monitoring folder on 7/5/18 revealed evidence that staff monitored residents every 30 minutes to one hour, checking vital signs, assessment for signs of dehydration, monitoring AC units in the residents' room and offering fluids. Observation on 7/5/18 between 5:30pm to 6:00pm revealed average temperatures measured in residents' rooms in Halls A, B C and D were between 71 to 73 degrees Fahrenheit. No sign of discomfort was observed on residents. Interview on 7/5/18 between 6:00pm to 6:30pm revealed no residents' complaint regarding AC in resident's rooms. Interview on 7/5/18 at 6:35pm, the facility Administrator when asked what she thought lead to the immediate jeopardy, said she did not know how to answer the question but believed the facility did everything they could to protect the residents. She said she had only been in the frailty for about 3 weeks. She further said the Portal AC in room C4 had only been in the room that day prior to surveyors walked in. The Administrator said no one was harmed but agreed there were potential for harm. On 07/02/18 at 8:45p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern due to the facility's need to monitor implementation of the Plan of Removal (POR). The facility was continuing to monitor the new cooling system. According to the facility census dated 06/05/18, the facility census was 75.

Based on record review, and interviews, the administration failed to oversee the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical well-being of five of 52 residents (Residents #37, #39, #49, #38 and #35) reviewed for quality of care. The Administrator failed to oversee and assist with the development and implementation of effective policies and procedures on identifying code status and promptly consulting the physician with changes. The Administrator failed to supervise the DON on training and monitoring the nursing staff to assess code status and consult physicians concerning changes in residents' code status. The DON failed to ensure all staff were trained to monitor, assess, and consult physicians timely concerning changes in residents' code status. The DON failed to ensure clinical documentation regarding code status was accurate and available to staff in the event of an emergency situation. This failure resulted in the identification of an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy and a scope of widespread. This deficient practice affected five residents and placed 47 residents at risk for facility staff inaccurately identifying a code status in the event of an emergency which could lead to a resident being resuscitated or allowed to die without intervention against their wishes. Findings include: Interview with the DON on [DATE] at 9:15 a.m. she stated Resident #47 was Witness #1 on the DNR form for Resident #37. She said Witness #1 on the DNR form should be a competent person and sometimes another resident was used. When asked what the criteria was to identify a competent resident, the DON stated any resident who was alert and oriented to person, place, and situation was competent enough to sign as Witness #1. When asked if Resident #47 met these criteria the DON stated Resident #47's competency varied, depending upon the day. Interview with the ADON on [DATE] at 12:05 p.m. she stated Resident #37's code status was a Do Not Resuscitate (DNR). Interview with the DON on [DATE] at 12:15 p.m. she stated the facility's process for identifying a resident's code status was as follows: 1. Staff was to look in the front of the resident's medical record for a red or green colored flash sheet. A red flash sheet indicated the resident was a DNR and a green flash sheet indicated the resident was a full code. 2. Staff was to then look in the medical record for a code status indication on the facesheet. 3. Staff was to also look in the medical record for a physician's orders [REDACTED]. Interview on [DATE] at 1:20p.m., the ADON said Resident #39's out of hospital DNR form was awaiting physician signature. She explained the resident was considered a full code until the necessary and required authorization and signatures were received by the facility. The ADON agreed Resident #39 was full code and should not have the red flash sheet indicating he was a DNR in his chart. The ADON agreed staff verified the residents' code status from the chart in emergency and so it was necessary to have the right information about the code status in the charts. Interview on [DATE] at 2:10 P.M. the Administrator stated the facility had already started acting on the code status issues of the residents. He could not recall being advised of this issue prior to the survey. He stated he monitored the effectiveness of the DON through various ways, including monthly subcommittee and QA meetings. During the same interview he stated the company provided numerous resources for the Administrator and the DON to utilize to assist in training and monitoring staff. He stated the company had a Medical Director, Regional Director, Corporate Staff and Corporate Nursing staff to assist the facility. Interview on [DATE] at 2:25 P.M. the DON stated she was responsible for the residents' chart documentation reflecting a code status. The DON stated she had no knowledge of the code status issues in the residents' charts and there was no routine audit done on the residents' charts looking specifically for code status documentation. The DON further stated the nursing staff was trained during initial orientation on obtaining residents' code status upon admission. She said their training included taking report from the transferring entity and obtaining a verbal code status. She further stated if the code status was unknown at the time of admission, the resident was assumed to be a Full Code and a green code status flash sheet was placed in the front of the chart. She said no further training on obtaining code status was provided after this new hire orientation. She said some more training was needed and she had already started this training as well as a facility wide chart audit and would ensure it was completed by each nurse especially in the area of code status and notifying physicians. Resident #37 Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 9:25 a.m. revealed Resident #37 lying in bed with a fall mat on the floor next to the bed. Resident #37 had his eyes open but could not verbally communicate when questions were asked. Observation on [DATE] at 10:00 a.m. revealed Resident #37 lying in bed apparently watching television. Resident was still unable to verbally communicate when questions were asked. Observation on [DATE] at 9:30 a.m. revealed Resident #37 lying in bed with his eyes open. Resident #37 was able to repeat parts of questions asked to him and answer very direct questions with a yes/no response. Record review of Resident #37's MDS dated [DATE] and [DATE] revealed a BIMS scores of 00, meaning he was unable to complete the assessment and staff had to assess his mental status. The staff assessments revealed Resident #37's mental status was moderately impaired and the resident had poor decision making ability. Record review of the Care Plan dated [DATE] revealed Resident #37 had impaired communication as evidenced by his reduced ability to understand and be understood by others. Further review of the same Care Plan revealed Resident #37 had impaired daily decision making ability. Record review of Resident #37's medical record revealed a red colored DNR flash sheet and an Out of Hospital DNR form signed by all parties. The medical record also revealed a written physician's orders [REDACTED].#37's code status was DNR. Record review of Resident #37's [DATE], [DATE], and [DATE] electronic physician orders [REDACTED].#37 was a Full Code. Interview with LVN #12 on [DATE] at 12:00 p.m. she stated Resident #37's code status was a Full Code. Interview on [DATE] at 2:35 p.m. LVN #11 stated if a resident was unresponsive she would initiate CPR, notify the DON, the family, and the physician. She stated if the resident was a Full Code she would call for help, grab the crash cart, start CPR and have someone call 911. She stated if the resident's code status was unknown she would send a CNA to look at the chart or bring it to her. She said all new charts had a full code flash sheet in the front of the chart until it was changed and the DON usually did that. She stated they depended on the code status in the front of the chart to be correct. She further stated there were other ways to check but if it was an emergency they would rely on the notification at the very front of the chart for accuracy. She further stated if an ambulance was called they went to the chart to determine the code status as well as made a copy of the face sheet which also had the code status on it. Interview on [DATE] at 2:50 p.m. CNA #31 stated if a resident was unresponsive she would call for the nurse. When CNA #31 was asked how she would know a resident's code status she said she would ask the nurse. Resident #39 Record review of Resident #39's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #39's MDS dated [DATE] revealed she was severely impaired for cognition, required extensive assistance with ADLs and was incontinent of bowel and bladder. Further review of MDS revealed Resident #39 had range of motion limitation on both sides of her lower extremities. Record review of Resident #39's face sheet revealed no advance directives on file. Record review of Resident #39's physician order [REDACTED]. Record review of Resident #39's MAR/TAR dated [DATE] revealed no advance directives. Record review of Resident #39's chart revealed a red sheet with bold print that read DNR (do not resuscitate). Record review of Resident #39's out of hospital DNR dated [DATE] revealed no physician's signatures. Record review of 14 resident charts for halls A and B revealed there was one chart for Resident #49 that did not have a red or green code status flash sheet in the front of the chart. Continued review revealed there was one record for Resident #38 with a code status in the front of the chart but there was no order for the code status. Record review of 16 resident charts for Hall D revealed there was one chart (Resident #35) who did not have a red or green code status flash sheet in the front of the chart but had an order for [REDACTED].>Interview on [DATE] at 2:30 p.m. LVN #2 stated if a resident was found unresponsive she would call for help, check for code status, if Full Code she would initiate CPR, notify the DON, the family, and the physician and would have someone call 911. LVN #2 stated if a resident was a DNR status, she would notify the DON, the family, and the physician then make sure the resident was safe and comfortable. She stated if the Resident's code status was unknown she would send a CNA to bring her the chart. LVN #2 stated all new residents' charts had a full code flash sheet in the front of the chart until it was changed by the DON, when all forms were signed. LVN #2 stated other ways to check for code status included the Face Sheet and MARs but if it was an emergency they would rely on the Green/Full Code or Red/DNR flash sheet in the very front of the chart. Interview on [DATE] at 2:40 p.m. CNA #15 stated if a resident was unresponsive she would call for the nurse and make sure the resident was safe. When CNA #15 was asked how she would know a Resident's code status she said she would have to check the residents chart. CNA #15 stated she was trained by the facility to respond to an emergency and was CPR certified. Interview on [DATE] at 3:00 p.m. LVN #4 stated if there was an emergency and a resident was unresponsive she would check the chart for code status. She stated CPR would be started immediately for Full Code residents, she would then call for help, call 911, notify the DON, the family, and the physician. Residents who were a DNR code status would be made comfortable, then the DON, the family, and the physician would be notified. When questioned how the code status was checked in the chart, LVN #4 stated there was a code status sheet; Red indicated a DNR status and Green indicated a Full code status. LVN #4 stated the other ways to check for Code status included looking on the Face Sheet and MARs but in an emergency she would rely on the Green/Full Code or Red/DNR flash sheet in the very front of the chart. Record review of the facility's Do Not Resuscitate (DNR) Policy dated [DATE], revealed Each resident's medical record will be flagged in a standardized manner to identify the resident's code status as DNR or FULL CODE. Further review of the same policy revealed 8. Social Services and Nursing Designee are responsible for ensuring that each resident's code status is properly documented and displayed on the Resident's medical record. To signify a resident is not to be resuscitated, the Facility will prominently note the medical record by placing a red sticker or red flash sheet designating DNR on the inside cover of the file. To signify a resident is a FULL CODE and should be resuscitated, the Facility will prominently note the file by placing a green sticker or green flash sheet designating Full Code on the inside cover of the resident's medical record. Further review of the same policy also revealed 10. Nursing will be responsible for ensuring that all DNR orders are carried over each month on the Physician order [REDACTED]. The facility Administrator was notified on [DATE] at 2:08 p.m. that an IJ situation had been identified due to the facility's failure to have a clear system of identifying residents' code status in the event of an emergency. Plan of Removal of the IJ: 1. An audit of code status for all residents comparing facesheet code to physician orders [REDACTED]. 2. Chart of Resident #38 was reviewed to determine signature by physician - physician had signed Texas Out of Hospital DNR; code status order was corrected in the computer chart of Resident #39 was reviewed; copy of Texas Out of Hospital DNR is on the chart; original is pending MD signature; order remains Full Code pending MD signature; status will be updated upon receipt of signed Texas Out of Hospital DNR which is per policy. Signature by physician is expected [DATE]. 3. All facility staff will be reeducated on identification of code status of a resident; by checking the front of the chart, in absence of a red (DNR) sheet or a green (Full Code) flash sheet; review the Resident face sheet; and reviewing the order. Also, charge nurses will be reeducated to obtain a code status order from the resident's physician and notify the DON/designee. Staff on vacation will be reeducated on their first day of return to work. Completed [DATE] except 3 staff - 2 are on vacation and 1 is on FMLA; each will receive the education on the first day she returns to work. 4. Medical Director Dr. Aman Jafar notified of IJ [DATE]. The surveyors monitored the current Plan of Removal from [DATE] until [DATE] as follows: Interviews were conducted with LVN #5, LVN #7, and LVN #12 who stated they had received education demonstrating the three step process for identifying a resident's code status in the event of a medical emergency. All stated they felt comfortable with handling a medical emergency with the current process for identifying the code status. On [DATE] at 10:18 a.m. the facility Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of widespread due to the facility requiring more time to train all staff and monitor their Plan of Removal. The CMS 672 listed the census of 52 residents.

Based on observation, interview, and record review, the facility failed to provide residents the right to formulate an advance directive for five of 52 residents (Residents #37, #39, #49, #38 and #35) reviewed for advance directives. Resident #37's medical record had a red colored flash sheet at the front indicating he was a DNR; a face sheet with no code status; [DATE] physician's orders [REDACTED]. Resident #39's medical record had a red colored flash sheet at the front indicating she was a DNR, a face sheet with no code status, a physician's order [REDACTED]. Facility policy stated a resident was considered a full code until the necessary and required authorization and signatures were received by the facility even if the resident indicated they wished to be a DNR. Residents #49 and #35 had no red or green flash sheet at the front of the chart indicating code status. Resident #38 had a code status flash sheet at the front of the chart but had no physician's order [REDACTED]. This failure resulted in the identification of an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], 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 widespread. The facility continued to train its staff on identification of code status of a resident. This failure affected five residents and placed 47 residents at risk for facility staff inaccurately identifying a code status in the event of an emergency which could lead to a resident being resuscitated or allowed to die without intervention against their wishes. Findings include: Resident #37 Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 9:25 a.m. revealed Resident #37 lying in bed with a fall mat on the floor next to the bed. Resident #37 had his eyes open but could not verbally communicate when questions were asked. Observation on [DATE] at 10:00 a.m. revealed Resident #37 lying in bed apparently watching television. Resident was still unable to verbally communicate when questions were asked. Observation on [DATE] at 9:30 a.m. revealed Resident #37 lying in bed with his eyes open. Resident #37 was able to repeat parts of questions asked to him and answer very direct questions with a yes/no response. Record review of Resident #37's MDS dated [DATE] and [DATE] revealed a BIMS scores of 00, meaning he was unable to complete the assessment and staff had to assess his mental status. The staff assessments revealed that Resident #37's mental status was moderately impaired and the resident had poor decision making ability. Record review of the Care Plan dated [DATE] revealed Resident #37 had impaired communication as evidenced by his reduced ability to understand and be understood by others. Further review of the same Care Plan revealed Resident #37 had impaired daily decision making ability. Record review of Resident #33's face sheet revealed no advance directives on file. Record review of Resident #37's medical record revealed a red colored flash sheet identifying him as having a DNR code status and an Out of Hospital DNR form signed by all parties. The medical record also revealed a written physician's orders [REDACTED].#37's code status was DNR. Record review of Resident #37's [DATE], [DATE], and [DATE] electronic physician orders [REDACTED].#37 was a Full Code. Interview with the DON on [DATE] at 9:15 a.m. she stated Resident #47 was Witness #1 on the DNR form for Resident #37. She said Witness #1 on the DNR form should be a competent person and sometimes another resident was used. When asked what the criteria was used for a competent resident, the DON stated that any resident who was alert and oriented to person, place, and situation was competent enough to sign as Witness #1. When asked if Resident #47 met these criteria the DON stated that the Resident's competency varied, depending upon the day. Interview with LVN #12 on [DATE] at 12:00 p.m. revealed Resident #37's code status was a Full Code. Interview with the ADON on [DATE] at 12:05 p.m. revealed Resident #37's code status was a Do Not Resuscitate (DNR). Interview with the DON on [DATE] at 12:15 p.m. revealed the facility's process for identifying a resident's code status was as follows: 1. Staff was to look in the front of the Resident's medical record for a red or green colored flash sheet. A red flash sheet indicated a DNR status and a green flash sheet indicated a Full Code status. 2. Staff was to then look in the medical record for a code status indication on the facesheet. 3. Staff was to also look in the medical record for a physician's orders [REDACTED]. Interview on [DATE] at 2:35 p.m. LVN #11 stated if a resident was unresponsive she would initiate CPR, notify the DON, the family, and the physician. She stated if the resident was a Full Code she would call for help, grab the crash cart, start CPR and have someone call 911. She stated if the resident's code status was unknown she would send a CNA to look at the chart or bring it to her. She said all new charts had a full code green flash sheet in the front of the chart until it was changed and the DON usually did that. She stated they depended on the code status in the front of the chart to be correct. She further stated there were other ways to check but if it was an emergency they would rely on the notification at the very front of the chart for accuracy. She further stated if an ambulance was called they went to the chart to determine the code status as well as made a copy of the face sheet which also had the code status on it. Interview on [DATE] at 2:50 p.m. CNA #31 stated if a resident was unresponsive she would call for the nurse. When CNA #31 was asked how she would know a resident's code status she said she would ask the nurse. Resident # 39 Record review of Resident #39's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #39's MDS dated [DATE] revealed she was severely impaired for cognition, required extensive assistance with ADLs and was incontinent of bowel and bladder. Further review of this MDS revealed Resident #39 had range of motion limitation on both sides of her lower extremity. Record review of Resident #39's face sheet revealed no advance directives on file. Record review of Resident #39's physician order [REDACTED]. Record review of Resident #39's MAR/TAR dated [DATE] revealed no advance directives. Record review of Resident #39's chart revealed a red flash sheet with bold print that read DNR (do not resuscitate). Record review and interview on [DATE] at 1:20 P.M. revealed Resident #39's out of hospital DNR dated [DATE] had no physician's signatures. Interview with the ADON during this record review she stated they were awaiting the physician's signature. She explained the resident was considered a full code until the necessary and required authorization and signatures were received by the facility. The ADON agreed Resident #39 was a full code and should not have DNR in her chart. The ADON agreed staff verified a resident's code status from their chart in an emergency and so it was necessary to have the right information about the code status in the charts. Record review of 14 resident charts for halls A and B revealed there was one chart for Resident #49 that did not have a red or green code status flash sheet in the front of the chart. Continued review revealed there was one record for Resident #38 with a code status in the front of the chart but there was no order for the code status. Record review of 16 resident charts for Hall D revealed there was one chart (Resident #35) that did not have a red or green code status flash sheet in the front of the chart but had an order for [REDACTED].>Interview on [DATE] at 2:10 P.M. the Administrator stated the facility had already started acting on the code status issues of the residents. He could not recall being advised of this issue prior to the survey. During the above interview on [DATE] at 2:25 P.M. the DON stated she was responsible for the residents' chart documentation reflecting a code status. The DON stated she had no knowledge of the code status issues in the residents' charts and that there was no routine audit done on the residents' charts looking specifically for code status documentation. The DON further stated the nursing staff was trained during initial orientation on obtaining residents' code status upon admission. She said their training included taking report from the transferring entity and obtaining a verbal code status. She further stated if the code status was unknown at the time of admission, the resident was assumed to be a Full Code and a green code status flash sheet was placed in the front of the chart. She said no further training on obtaining code status was provided after this new hire orientation. She said some more training was needed and she had already started this training as well as a facility wide chart audit and would ensure it was completed by each nurse especially in the area of code status and notifying physicians. Interview on [DATE] at 2:30 p.m. LVN #2 stated if a resident was found unresponsive she would call for help, check for code status, if Full Code she would initiate CPR, notify the DON, the family, and the physician and would have someone call 911. LVN #2 stated if a resident was a DNR status, she would notify the DON, the family, and the physician then make sure the resident was safe and comfortable. She stated if the Resident's code status was unknown she would send a CNA to bring her the chart. LVN #2 stated all new residents' charts had a green full code flash sheet in the front of the chart until it was changed by the DON, when all forms were signed. LVN #2 stated other ways to check for code status included the Face Sheet and MARs but if it was an emergency they would rely on the Green/Full Code or Red/DNR flash sheet in the very front of the chart. Interview on [DATE] at 2:40 p.m. CNA #15 stated if a resident was unresponsive she would call for the nurse and make sure the resident was safe. When CNA #15 was asked how she would know a Resident's code status she said she would have to check the residents chart. CNA #15 stated she was trained by the facility to respond to an emergency and was CPR certified. Interview on [DATE] at 3:00 p.m. LVN #4 stated if there was an emergency and a resident was unresponsive she would check the chart for code status. She stated CPR would be started immediately for Full Code residents, she would then call for help, call 911, notify the DON, the family, and the physician. Residents who were a DNR code status would be made comfortable, then the DON, the family, and the physician would be notified. When questioned how the code status was checked in the chart, LVN #4 stated there was a code status flash sheet; Red indicated a DNR status and Green indicated a Full code status. LVN #4 stated the other ways to check for Code status included looking on the Face Sheet and MARs but in an emergency she would rely on the Green/Full Code or Red/DNR flash sheet in the very front of the chart. Record review of the facility's Do Not Resuscitate (DNR) Policy dated [DATE], revealed Each resident's medical record will be flagged in a standardized manner to identify the resident's code status as DNR or FULL CODE. Further review of the same policy revealed 8. Social Services and Nursing Designee are responsible for ensuring that each resident's code status is properly documented and displayed on the Resident's medical record. To signify a resident is not to be resuscitated, the Facility will prominently note the medical record by placing a red sticker or red flash sheet designating DNR on the inside cover of the file. To signify a resident is a FULL CODE and should be resuscitated, the Facility will prominently note the file by placing a green sticker or green flash sheet designating Full Code on the inside cover of the resident's medical record. Further review of the same policy also revealed 10. Nursing will be responsible for ensuring that all DNR orders are carried over each month on the Physician order [REDACTED]. The facility Administrator was notified on [DATE] at 2:08 p.m. that an IJ situation had been identified due to the facility's failure to have a clear system of identifying residents' code status in the event of an emergency. Plan of Removal of the IJ: 1. An audit of code status for all residents comparing facesheet code to physician orders [REDACTED]. 2. Chart of resident #37 was reviewed to determine signature by physician - physician had signed Texas Out of Hospital DNR; code status order was corrected in the computer. Chart of Resident #39 was reviewed; copy of Texas Out of Hospital DNR is on the chart; original is pending MD signature; order remains Full Code pending MD signature; status will be updated upon receipt of signed Texas Out of Hospital DNR which is per policy. Signature by physician is expected [DATE]. 3. All facility staff will be reeducated on identification of code status of a resident; by checking the front of the chart, in absence of a red (DNR) flash sheet or a green (Full Code) flash sheet; review the Resident face sheet; and reviewing the order. Also, charge nurses will be reeducated to obtain a code status order from the resident's physician and notify the DON/designee. Staff on vacation will be reeducated on their first day of return to work. Completed [DATE] except 3 staff - 2 are on vacation and 1 is on FMLA; each will receive the education on the first day she returns to work. 4. Medical Director was notified of IJ [DATE]. The surveyors monitored the current Plan of Removal from [DATE] until [DATE] as follows: Record reviews were conducted of Residents #37, #39, #49, #38 and #35 charts and all code statuses on face sheets, MARs/TARs and physicians were compared and found to be updated and correct. Record reviews were conducted and confirmed all staff, with the exception of three staff who were on leave, had been in-serviced on identifying the code status of a resident. Interviews were conducted on [DATE], [DATE] and [DATE] with LVN #5, LVN #7, and LVN #12 who stated they had received education demonstrating the 3 step process for identifying a resident's code status in the event of a medical emergency. All stated they felt comfortable with handling a medical emergency with the current process for identifying the code status. On [DATE] at 10:18 a.m. the facility Administrator and DON were informed the IJ was removed. However, 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 widespread due to the facility requiring more time to train all staff and monitor their Plan of Removal. The CMS 672 listed the census of 52 residents.

Based on observation, interview and record review the facility failed to ensure that staff provided services that met professional standards of quality for 1 of 5 residents reviewed for having [MEDICAL CONDITION] activity. - Resident #19 experienced multiple [MEDICAL CONDITION] on [DATE] from 4:18 p.m. to 5:05 p.m. -LVN CC and LVN KKKK failed to recognize medical emergencies and changes in condition, assess and intervene in a timely manner when Resident #19 experienced multiple [MEDICAL CONDITION] on [DATE]. - The pulse oximeters used to check Resident #19 ' s oxygen levels were not working properly (equipment used to monitor oxygen saturation in the blood). Resident #19's oxygen saturation level reading was 85 % and LVN KKKK provided oxygen only after surveyor intervention. Resident #19 was transported to the hospital on [DATE] at 5:20 p.m. This failure resulted in an IJ. The Administrator, Executive Director and Regional Clinical Services Director were informed of the IJ on [DATE] at 6:45 p.m. While the IJ was removed on [DATE] at 2:15 p.m. the facility remained out of compliance at a scope of isolated, no actual harm with potential of more than minimal harm because the facility was still monitoring the effectiveness of the Plan of Removal. This failure affected one resident and could place the other 84 residents at risk of not receiving needed medical services. Findings include: I. PROFESSIONAL STANDARDS: A. The Texas Board of Nursing documented in their rules and regulations in the Texas Administrative Code (TAC), Title 22, Part II, Chapter 217, Subsection 217.11, effective [DATE], a Licensed Vocational Nurse shall - - (1)(D) Accurately and completely report and document (i) the client's status including signs and symptoms, (ii) nursing care rendered, and (v) client response... - (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; TAC 217.12 Unprofessional Conduct The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licenses... These behaviors include but are not limited to: (1) Unsafe Practice -- actions or conduct including, but not limited to: (4) Careless or repetitive conduct that may endanger a client's life, health, or safety. Actual injury to a client need not be established...." Findings include: Resident #19 Record review of Resident #19's Face Sheet revealed she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #19 BIMS score was 14 out of 15 which indicated that she was cognitively intact; was able to express ideas and wants, able to recall questions without cues required. Further review of the ADL assistance section revealed that Resident #19 required limited assistance for all transfers and needed one person physical assistance for personal hygiene. Record review of the Care Plan dated [DATE] and revised on [DATE] revealed Resident #19 was at risk for falls and at risk to hurt herself during [MEDICAL CONDITION] activity. Approaches included: To assess characteristics before, during and after [MEDICAL CONDITION], pad side rails, keep bed in lowest position. If [MEDICAL CONDITION] occurs, remove all restrictive clothing and objects of potential harm. Turn head to side to maintain patent airway. In an interview with LVN CC on [DATE] at 4:15 p.m., he said he was busy calling Resident #19's family because of a change in Resident #19's condition. Observation of Resident #19 on [DATE] at 4:18 p.m. revealed she was lying in bed, flat on her back, was non-responsive and was having facial [MEDICAL CONDITION]. Further observation of the room revealed there was no nurse at bedside, side rails were not padded and down and the bed was in the highest position. Observation at this time revealed that Rehabilitation Tech QQQ was just standing at the foot of the bed. Resident #19 was observed to have [MEDICAL CONDITION] activity every 2 to 3 minutes while there was no nursing staff present to provide assistance or intervention. On [DATE] at 4:25 p.m. the Nurse Surveyor went to the nurses' station to ask LVN CC to return to Resident #19's room and monitor her [MEDICAL CONDITION] activity. LVN CC said he was aware of the [MEDICAL CONDITION] activity and was calling Resident #19's doctor or NP. The Nurse Surveyor then asked if anybody had checked Resident #19's vital signs and LVN CC said he did but did not write it down. Further observation and interview on [DATE] at 4:28 p.m. revealed that LVN CC came in Resident #19's room and the resident was still having [MEDICAL CONDITION] activity. Without assessing Resident #19's condition LVN CC said, " I am still trying to get the Nurse Practitioner". LVN CC walked out of the room again without providing intervention, rolling the resident to the side, lowering the bed to the lower position, protecting her airway and went back to the nurses' station. Rehabilitation Tech QQQ was just standing at the foot of the bed. Resident #19 continued to have [MEDICAL CONDITION] activity. According to Lippincott, Williams & Wilkins (2009, pXXX,[DATE]) during a complex partial [MEDICAL CONDITION] consciousness becomes impaired, it begins as a simple partial [MEDICAL CONDITION] in which the conciousness is not impaired and evolves to an impairment of conciousness... symptoms include "motor symptoms (jerking of the thumb or the cheeks)...guidelines for [MEDICAL CONDITION] management revealed in part: "...stay with the patient during the [MEDICAL CONDITION], and be ready to intervene if complications such as airway obstruction develop. If necessary, have another staff member obtain the appropriate equipment...move hard or sharp objects out of the patients' way...continually assess the patient during the [MEDICAL CONDITION] the [MEDICAL CONDITION] is prolonged and the patient becomes hypoxemic, administer oxygen as ordered..." Observation on [DATE] at 4:41 p.m. revealed that LVN KKKK who was the facility Staff Developer, was walking down the hall. Nurse Surveyor called her attention to Resident #19's bedside who was still lying flat in a raised bed, with unpadded side rails and was having [MEDICAL CONDITION] activity. In an interview at this time LVN KKKK said " the staff was calling the Nurse Practitioner". LVN KKKK said that Resident #19 had similar episodes of [MEDICAL CONDITION] activities last month and a Nurse Practitioner (NP) who was in the building wrote an order for [REDACTED].#19 was still on that medication. LVN KKKK said Resident #19 was always alert and responsive to questions asked. LVN KKKK proceeded to touch Resident #19's hands and said " I am concerned for her hands being very cold". LVN KKKK did not complete a nursing assessment. LVN KKKK did not check vital signs, lay the resident on her side to maintain an open airway and prevent the person from inhaling any secretions or make changes to the position of the bed and walked out of the room. Rehabilitation Tech QQQ was just standing at the foot of the bed and Resident #19 was still having [MEDICAL CONDITION] activity. In an interview with Rehabilitation Tech QQQ on [DATE] at 4:47 p.m. regarding responding to an emergency situation, he said he was instructed to be in the room and watch the resident. Observation on [DATE] at 4:49 p.m. LVN KKKK came to Resident #19's room stated " she is still on [MEDICATION NAME] twice daily" and left the room again. In an interview with LVN CC on [DATE] at 4:50 p.m. regarding what action he would take in an a medical emergency, he said he would call the doctor and the resident family. Nurse surveyor asked LVN CC about Resident #19's oxygen saturation and oxygen administration. LVN CC went to the medication cart, got a pulse oximeter and put it on Resident #19's index finger for less than 3 seconds and said the oxygen saturation (O2 sat) was 97% . Nurse surveyor requested to see O2 sat again , LVN CC put the pulse oximeter on the index finger and it took one minute to get a reading of 85%. At 5:00 p.m. LVN CC said he was going to get another pulse oximeter and it did not work. At 5:05 p.m. LVN KKKK then brought in an oxygen tank( at the nurse surveyor request ) and administered 3 liters via nasal cannula. At this time LVN KKKK said she would have to place batteries in the pulse oximeters, LVN KKKK went to another hall and got a working pulse oximeter from another station that was working. According to Lippincottt, Williams & Wilkins (2009) guidelines for pulse oxymetry used revealed in part : " normal SpO2 levels for pulse oxymetry are 95% to 100% for adults ...lower levels may indicate hypoxemia that warrants intervention ...for those patients follow facility policy ...which may include increasing oxygen therapy. " Observation on [DATE] at 5:20 p.m. Resident #19 was transferred via ambulance to a local hospital. Record review of the Facility Policy on Emergency situations revised on [DATE], revealed in part, Procedures: - Qualified staff initiates the appropriate emergency procedures, i.e. oxygen, ....... - call 911 when the resident's/patient's condition is life threatening, unless the patient/resident is coding ,and staff has determined that the resident/patient is DNR. - Qualified staff attempts to stabilize and monitor the patient /resident until the advance medical team arrives. - Facility staff will promptly contact: . The attending physician or alternate: . The family/responsible party; . The Director of Nursing/Designee; - Document the occurrence in the medical record. The facility did not follow their policy and procedure and care plan as LVN CC and LVN KKKK failed to stabilize Resident #19 and failed to initiate emergency procedures. LVN KKKK did not complete a nursing assessment. LVN KKKK did not check vital signs, lay the resident on her side to maintain an open airway and prevent the resident from inhaling any secretions or make changes to the position of the bed and walked out of the room. Record review of the employee file for LVN CC revealed that he was hired on [DATE]. Further review revealed no orientation or training regarding changes in condition, emergency procedures or guidelines to address [MEDICAL CONDITION] activity located in the file. This failure resulted in an immediate Jeopardy (IJ). The Administrator, Executive Director and Regional Clinical Services Director were informed of the IJ on [DATE] at 6:45 p.m. The facility submitted several plan of removal that required corrections and a revision was accepted on [DATE]. The following plan of action to remove the IJ was submitted by the Administrator on [DATE] at 2:00 p.m. PLAN TO REMOVE IMMEDIATE JEOPARDY Immediate Response: ?Resident was sent to emergency room for evaluation - Hospital ?All residents were assessed to identify if there are any medical emergencies or changes in condition completed on [DATE]. No other residents were found to have medical emergency or change of condition. ?The nurse identified related to this deficient practice has been suspended pending investigation. The Facility will report said occurrence as per requirement to the appropriate agencies. ?Inspected all facility medical emergency equipment for proper functioning completed [DATE]. ?Re education started immediately for licensed nurses in regards to timely assessment and documentation of changes in condition and response to medical emergencies. Licensed nurses were presented with medical emergency scenarios and they were required to respond with actions to be taken which are listed in the policy and procedure. Procedure states: 1. Qualified staff initiates the appropriate emergency procedures, i.e. oxygen, suction, CPR with or without AED as appropriate, etc. In accordance with patient/resident advanced directives. 2. Call 911 when patients/residents condition is life threatening, unless the patient/resident is coding and staff has determined that patient/resident is a DNR. 3. Qualified staff attempts to stabilize and monitor the patient/resident until the advanced medical team arrives, if appropriate. 4. Facility staff will promptly contact: attending physician or alternate, the family/responsible party, DON/designee. 5. Document the occurrence in the medical record. 6. Send appropriate documentation with the patient / resident if he/she transferred to the hospital. " Scenarios were also given for equipment not functioning properly and response in medical emergencies such as chest pain, SOB, . Licensed nurses were reeducated on backup equipment locations (emergency carts on each station.) Reeducation completed [DATE] and completed on [DATE]. ? As a facility practice and as a systematic approach to ensure the staff at the facility has knowledge of, and understands, the emergency policy and procedure and how to respond to medical emergencies, the healthcare center will have mandatory training for our nursing orientation and at least annually. PRN and part time licensed nurses will not be permitted to work until reeducation has been completed. ?Re-education was started immediately for all Licensed nursing staff on [DATE] conducted by the Regional Clinical Services Director on: 1. Responding to a medical emergency 2. Policies and procedure for medical emergencies and responding with proper equipment; and timeliness of assessment *** Licensed staff will not be permitted to work until reeducation has been completed. *** Administrative Nurse/designee will validate proper functioning of equipment weekly. Director of Nursing will be notified of any concerns. Backup equipment blood pressure cuffs will be available in case of an emergency and located in the emergency carts on each station. During an interview on [DATE] at 6:48 p.m. with the Administrator she said the plan to remove the immediate jeopardy response was that the facility would assess all residents to ensure there were no other changes in condition , all medical emergency equipment would be inspected for proper functioning and all licensed staff would be re-educated in regards to timely assessment of changes in resident's condition and response to medical emergencies. In an interview with Regional Clinical Services Director ( RN) on [DATE] at 7:30 p.m. she said the interim DON was not in the building had gone home. Regional Clinical Services Director (RN) said the staff were trained to assess the residents, by checking their vital signs and document, instruct another nurse to call the doctor or 911, give oxygen and then call the family later. In an interview with the Interim DON [DATE] at 10:00 a.m. regarding medical emergencies, infection control, care of equipment, pharmacy drug regimen reviews she did not say anything and allowed the Regional Clinical Services Director (RCSD) to respond. The RCSD said the staff were trained to assess the residents, by checking their vital signs and document, instruct another nurse to call the doctor or 911, give oxygen and then call the family later. On [DATE] at 2:30 p.m. this Nurse Surveyor asked the Interim DON did she know what her duties were and she responded that she had not sat down with the Administrator or the Regional Clinical Services Director to discuss what she was suppose to do as an Interim DON. During an interview with the Regional Clinical Services Director at this time, she said the Interim DON had just been assigned to her position. She further stated that the DON had been on leave for approximately a month following surgery. Record review of the in service training conducted on 2012 revealed that the nursing staff had been in serviced on changes in condition and evaluation of Residents to include checking vital signs on [DATE]. LVN KKKK signed the attendance sheet. Further review revealed another in service that included changes in condition dated [DATE]. The in-service was given by LVN KKKK. No in-services were found on what to do during a [MEDICAL CONDITION]. The facility was monitored on [DATE] and [DATE] to verify that the staff was educated on the plan of action. Interviews on [DATE] - [DATE] on 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10 p.m. shift at various times with nursing staff stated the facility had provided training for responding to a medical emergency . Nursing staff was able to give specific examples of the procedures and how to respond in a medical emergency situation. Interview were also conducted with staff regarding recognition of changes of condition, nursing assessments to include complete resident assessments after incidents, [MEDICAL CONDITION] or other situations and knowledge of the location of medical emergency equipment. Observation/monitoring of the facility on [DATE] - [DATE] revealed the facility equipment (blood pressure machine and pulse oximeter) for emergencies was located on the nurses' medication carts and was functioning properly. While the IJ was removed on [DATE] at 2:15 pm the facility remained out of compliance at a scope of isolated, no actual harm with potential of more than minimal harm due need for continued training and monitoring of nursing staff on proper assessments in case of medical emergencies and changes of condition. The Facility's CMS 672 listed 85 residents.

c, Bladder Hypertonicity and Reflux. Record review of the quarterly MDS assessment dated [DATE] revealed that Resident #19 BIMS score was 14 out of 15 which indicated that she was cognitively intact; was able to express ideas and wants, able to recall questions without cues required. Further review of the ADL assistance section revealed that Resident #19 required limited assistance for all transfers and needed one person physical assistance for personal hygiene. Record review of the Care Plan dated [DATE] and revised on [DATE] revealed Resident #19 was at risk for falls and at risk to hurt herself during [MEDICAL CONDITION] activity. Approaches included: To assess characteristics before, during and after [MEDICAL CONDITION], pad side rails, keep bed in lowest position. If [MEDICAL CONDITION] occurs, remove all restrictive clothing and objects of potential harm. Turn head to side to maintain patent airway. In an interview with LVN CC on [DATE] at 4:15 p.m., he said he was busy calling Resident #19's family because of a change in Resident #19's condition. Observation of Resident #19 on [DATE] at 4:18 p.m. revealed she was lying in bed, flat on her back, was non-responsive and was having facial [MEDICAL CONDITION]. Further observation of the room revealed there was no nurse at bedside, side rails were not padded and down and the bed was in the highest position. Observation at this time revealed that Rehabilitation Tech QQQ was just standing at the foot of the bed. Resident #19 was observed to have [MEDICAL CONDITION] activity every 2 to 3 minutes while there was no nursing staff present to provide assistance or intervention. On [DATE] at 4:25 p.m. the Nurse Surveyor went to the nurses' station to ask LVN CC to return to Resident #19's room and monitor her [MEDICAL CONDITION] activity. LVN CC said he was aware of the [MEDICAL CONDITION] activity and was calling Resident #19's doctor or NP. The Nurse Surveyor then asked if anybody had checked Resident #19's vital signs and LVN CC said he did but did not write it down. Further observation and interview on [DATE] at 4:28 p.m. revealed that LVN CC came in Resident #19's room and the resident was still having [MEDICAL CONDITION] activity. Without assessing Resident #19's condition LVN CC said, " I am still trying to get the Nurse Practitioner". LVN CC walked out of the room again without providing intervention, rolling the resident to the side, lowering the bed to the lower position, protecting her airway and went back to the nurses' station. Rehabilitation Tech QQQ was just standing at the foot of the bed. Resident #19 continued to have [MEDICAL CONDITION] activity. According to Lippincott, Williams & Wilkins (2009, pXXX,[DATE]) during a complex partial [MEDICAL CONDITION] consciousness becomes impaired, it begins as a simple partial [MEDICAL CONDITION] in which the conciousness is not impaired and evolves to an impairment of conciousness... symptoms include "motor symptoms (jerking of the thumb or the cheeks)...guidelines for [MEDICAL CONDITION] management revealed in part: "...stay with the patient during the [MEDICAL CONDITION], and be ready to intervene if complications such as airway obstruction develop. If necessary, have another staff member obtain the appropriate equipment...move hard or sharp objects out of the patients' way...continually assess the patient during the [MEDICAL CONDITION] the [MEDICAL CONDITION] is prolonged and the patient becomes hypoxemic, administer oxygen as ordered..." Observation on [DATE] at 4:41 p.m. revealed that LVN KKKK who was the facility Staff Developer, was walking down the hall. Nurse Surveyor called her attention to Resident #19's bedside who was still lying flat in a raised bed, with unpadded side rails and was having [MEDICAL CONDITION] activity. In an interview at this time LVN KKKK said " the staff was calling the Nurse Practitioner". LVN KKKK said that Resident #19 had similar episodes of [MEDICAL CONDITION] activities last month and a Nurse Practitioner (NP) who was in the building wrote an order for [REDACTED].#19 was still on that medication. LVN KKKK said Resident #19 was always alert and responsive to questions asked. LVN KKKK proceeded to touch Resident #19's hands and said " I am concerned for her hands being very cold". LVN KKKK did not complete a nursing assessment. LVN KKKK did not check vital signs, lay the resident on her side to maintain an open airway and prevent the person from inhaling any secretions or make changes to the position of the bed and walked out of the room. Rehabilitation Tech QQQ was just standing at the foot of the bed and Resident #19 was still having [MEDICAL CONDITION] activity. In an interview with Rehabilitation Tech QQQ on [DATE] at 4:47 p.m. regarding responding to an emergency situation, he said he was instructed to be in the room and watch the resident. Observation on [DATE] at 4:49 p.m. LVN KKKK came to Resident #19's room stated " she is still on [MEDICATION NAME] twice daily" and left the room again. In an interview with LVN CC on [DATE] at 4:50 p.m. regarding what action he would take in an a medical emergency, he said he would call the doctor and the resident family. Nurse surveyor asked LVN CC about Resident #19's oxygen saturation and oxygen administration. LVN CC went to the medication cart, got a pulse oximeter and put it on Resident #19's index finger for less than 3 seconds and said the oxygen saturation (O2 sat) was 97% . Nurse surveyor requested to see O2 sat again , LVN CC put the pulse oximeter on the index finger and it took one minute to get a reading of 85%. At 5:00 p.m. LVN CC said he was going to get another pulse oximeter and it did not work. At 5:05 p.m. LVN KKKK then brought in an oxygen tank( at the nurse surveyor request ) and administered 3 liters via nasal cannula. At this time LVN KKKK said she would have to place batteries in the pulse oximeters, LVN KKKK went to another hall and got a working pulse oximeter from another station that was working. According to Lippincottt, Williams & Wilkins (2009) guidelines for pulse oxymetry used revealed in part : " normal SpO2 levels for pulse oxymetry are 95% to 100% for adults ...lower levels may indicate hypoxemia that warrants intervention ...for those patients follow facility policy ...which may include increasing oxygen therapy. " Observation on [DATE] at 5:20 p.m. Resident #19 was transferred via ambulance to a local hospital. Record review of the Facility Policy on Emergency situations revised on [DATE], revealed in part, Procedures: - Qualified staff initiates the appropriate emergency procedures, i.e. oxygen, ....... - call 911 when the resident's/patient's condition is life threatening, unless the patient/resident is coding ,and staff has determined that the resident/patient is DNR. - Qualified staff attempts to stabilize and monitor the patient /resident until the advance medical team arrives. - Facility staff will promptly contact: . The attending physician or alternate: . The family/responsible party; . The Director of Nursing/Designee; - Document the occurrence in the medical record. The facility did not follow their policy and procedure and care plan as LVN CC and LVN KKKK failed to stabilize Resident #19 and failed to initiate emergency procedures. LVN KKKK did not complete a nursing assessment. LVN KKKK did not check vital signs, lay the resident on her side to maintain an open airway and prevent the resident from inhaling any secretions or make changes to the position of the bed and walked out of the room. Record review of the employee file for LVN CC revealed that he was hired on [DATE]. Further review revealed no orientation or training regarding changes in condition, emergency procedures or guidelines to address [MEDICAL CONDITION] activity located in the file. This failure resulted in an immediate Jeopardy (IJ). The Administrator, Executive Director and Regional Clinical Services Director were informed of the IJ on [DATE] at 6:45 p.m. The facility submitted several plan of removal that required corrections and a revision was accepted on [DATE]. The following plan of action to remove the IJ was submitted by the Administrator on [DATE] at 2:00 p.m. PLAN TO REMOVE IMMEDIATE JEOPARDY Immediate Response: ?Resident was sent to emergency room for evaluation - Hospital ?All residents were assessed to identify if there are any medical emergencies or changes in condition completed on [DATE]. No other residents were found to have medical emergency or change of condition. ?The nurse identified related to this deficient practice has been suspended pending investigation. The Facility will report said occurrence as per requirement to the appropriate agencies. ?Inspected all facility medical emergency equipment for proper functioning completed [DATE]. ?Re education started immediately for licensed nurses in regards to timely assessment and documentation of changes in condition and response to medical emergencies. Licensed nurses were presented with medical emergency scenarios and they were required to respond with actions to be taken which are listed in the policy and procedure. Procedure states: 1. Qualified staff initiates the appropriate emergency procedures, i.e. oxygen, suction, CPR with or without AED as appropriate, etc. In accordance with patient/resident advanced directives. 2. Call 911 when patients/residents condition is life threatening, unless the patient/resident is coding and staff has determined that patient/resident is a DNR. 3. Qualified staff attempts to stabilize and monitor the patient/resident until the advanced medical team arrives, if appropriate. 4. Facility staff will promptly contact: attending physician or alternate, the family/responsible party, DON/designee. 5. Document the occurrence in the medical record. 6. Send appropriate documentation with the patient / resident if he/she transferred to the hospital. " Scenarios were also given for equipment not functioning properly and response in medical emergencies such as chest pain, SOB, . Licensed nurses were reeducated on backup equipment locations (emergency carts on each station.) Reeducation completed [DATE] and completed on [DATE]. ? As a facility practice and as a systematic approach to ensure the staff at the facility has knowledge of, and understands, the emergency policy and procedure and how to respond to medical emergencies, the healthcare center will have mandatory training for our nursing orientation and at least annually. PRN and part time licensed nurses will not be permitted to work until reeducation has been completed. ?Re-education was started immediately for all Licensed nursing staff on [DATE] conducted by the Regional Clinical Services Director on: 1. Responding to a medical emergency 2. Policies and procedure for medical emergencies and responding with proper equipment; and timeliness of assessment *** Licensed staff will not be permitted to work until reeducation has been completed. *** Administrative Nurse/designee will validate proper functioning of equipment weekly. Director of Nursing will be notified of any concerns. Backup equipment blood pressure cuffs will be available in case of an emergency and located in the emergency carts on each station. During an interview on [DATE] at 6:48 p.m. with the Administrator she said the plan to remove the immediate jeopardy response was that the facility would assess all residents to ensure there were no other changes in condition , all medical emergency equipment would be inspected for proper functioning and all licensed staff would be re-educated in regards to timely assessment of changes in resident's condition and response to medical emergencies. In an interview with Regional Clinical Services Director ( RN) on [DATE] at 7:30 p.m. she said the interim DON was not in the building had gone home. Regional Clinical Services Director (RN) said the staff were trained to assess the residents, by checking their vital signs and document, instruct another nurse to call the doctor or 911, give oxygen and then call the family later. In an interview with the Interim DON [DATE] at 10:00 a.m. regarding medical emergencies, infection control, care of equipment, pharmacy drug regimen reviews she did not say anything and allowed the Regional Clinical Services Director (RCSD) to respond. The RCSD said the staff were trained to assess the residents, by checking their vital signs and document, instruct another nurse to call the doctor or 911, give oxygen and then call the family later. On [DATE] at 2:30 p.m. this Nurse Surveyor asked the Interim DON did she know what her duties were and she responded that she had not sat down with the Administrator or the Regional Clinical Services Director to discuss what she was suppose to do as an Interim DON. During an interview with the Regional Clinical Services Director at this time, she said the Interim DON had just been assigned to her position. She further stated that the DON had been on leave for approximately a month following surgery. Record review of the in service training conducted on 2012 revealed that the nursing staff had been in serviced on changes in condition and evaluation of Residents to include checking vital signs on [DATE]. LVN KKKK signed the attendance sheet. Further review revealed another in service that included changes in condition dated [DATE]. The in-service was given by LVN KKKK. No in-services were found on what to do during a [MEDICAL CONDITION]. The facility was monitored on [DATE] and [DATE] to verify that the staff was educated on the plan of action. Interviews on [DATE] - [DATE] on 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10 p.m. shift at various times with nursing staff stated the facility had provided training for responding to a medical emergency . Nursing staff was able to give specific examples of the procedures and how to respond in a medical emergency situation. Interview were also conducted with staff regarding recognition of changes of condition, nursing assessments to include complete resident assessments after incidents, [MEDICAL CONDITION] or other situations and knowledge of the location of medical emergency equipment. Observation/monitoring of the facility on [DATE] - [DATE] revealed the facility equipment (blood pressure machine and pulse oximeter) for emergencies was located on the nurses' medication carts and was functioning properly. While the IJ was removed on [DATE] at 2:15 pm the facility remained out of compliance at a scope of isolated, no actual harm with potential of more than minimal harm due need for continued training and monitoring of nursing staff on proper assessments in case of medical emergencies and changes of condition. The Facility's CMS 672 listed 85 residents.

Based on record review and interview the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to: Related to Immediate Jeopardy: 1) Supervise the Interim DON to ensure the nursing staff was knowledgeable on recognizing/responding to medical emergencies, changes in residents condition and timely assessments. Resident #19 had a [MEDICAL CONDITION] on [DATE] and was not assessed in a timely manner. 2) Monitor the Interim DON to ensure that the nursing staff monitored the facility's equipment for functioning properly (Pulseoximeter for checking O2 saturation). Related to Non-Immediate Jeopardy: 3) Supervise the Interim DON to ensure that the facility had an adequate infection control program. 4) Monitor the Interim DON to ensure that their contracted pharmacist performed monthly or quarterly drug regimen reviews. The Interim DON failed to: Related to Immediate Jeopardy 1) Monitor and train the nursing staff to ensure they were knowlegable in responding to, recognizing medical emergencies, changes in resident conditions and perform timely assessment. 2) Supervise the nursing staff to ensure the nursing staff monitored the facility's equipment for proper functioning (Pulseoximeter for checking O2 saturation). Related to Non-Immediate Jeopardy: 3) Monitor and train the staff to ensure that the facility had an effective infection control program. 4) Monitor to ensure the facility's contracted pharmacy performed drug regimen reviews. This failure related to Resident #19 resulted in an IJ. The Administrator, Executive Director and Regional Clinical Services Director were informed of the IJ on [DATE] at 6:45 p.m. While the IJ was removed on [DATE] at 2:15 p.m. the facility remained out of compliance at a scope of isolated, no actual harm with potential of more than minimal harm due need for continued training and monitoring of nursing staff on proper assessments in case of medical emergencies and changes of condition. This failure could place all residents at risk of increased decline in medical conditions, increase risk of infections and overall decline in their well-being. Findings include: Medical Emergencies: Record review of the Face Sheet for Resident #19 revealed she was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. Observation of Resident #19's on [DATE] at 4:18 p.m. revealed she was lying in bed flat on her back, was non-responsive and was having facial [MEDICAL CONDITION]. Further observation of the room revealed there were no nurse at bedside, side rails were not padded and down and the bed was on the highest position. Observation at this time revealed that Rehabilitation Tech QQQ was just standing at the foot of the bed. Resident #19 was observed to have [MEDICAL CONDITION] activity every 2 to 3 minutes while there was no nurse present to provide assistance or intervention. On [DATE] at 4:25 p.m. the nurse surveyor went to the nurses ' station to ask LVN CC to return to Resident #19's room and monitor her [MEDICAL CONDITION] activities. LVN CC said he was aware of [MEDICAL CONDITION] activity and was calling Resident #19 ' s doctor or nurse practitioner ( NP). Nurse surveyor then asked if anybody had checked Resident #19's vital signs and LVN CC said he did but did not write it down. Further observation and interview on [DATE] at 4:28 pm revealed that LVN CC came in Resident #19's room and she was still having [MEDICAL CONDITION] activity. Without assessing Resident #19 ' s condition LVN CC said" I am still trying to get the Nurse Practitioner". LVN CC walked out of the room again and went back to the nurses' station, leaving the resident with Rehabilitation Tech QQQ who was just standing at the foot of the bed. Resident #19 continued to have [MEDICAL CONDITION] activity. Observation on [DATE] at 4:41 p.m. revealed that LVN KKKK who was the facility Staff Developer, was walking down the hall. The Nurse Surveyor called her attention to Resident #19's bedside who was still lying flat in a raised bed, with unpadded side rails and was having [MEDICAL CONDITION] activity. In an interview at this time LVN KKKK said " the staff was calling the Nurse Practitioner". LVN KKKK said that Resident #19 had similar episodes of [MEDICAL CONDITION] activity last month and a Nurse Practitioner who was in the building wrote an order for [REDACTED].#19 was still on that medication. LVN KKKK said Resident #19 was always alert and responsive to questions asked. LVN KKKK proceeded to touch Resident #19's hands and said " I am concern for her hands being very cold". LVN KKKK did not complete a nursing assessment, checked vital signs or made changed to the bed and walked out the room. Rehabilitation Tech QQQ was just standing at the foot of the bed and Resident #19 was still having [MEDICAL CONDITION] activities. In an interview with Rehabilitation Tech QQQ on [DATE] at 4:47 p.m. regarding responding to an emergency situation, he said he was instructed to be in room and watch the resident. At 4:49 p.m. LVN KKKK came to Resident #19's room stated " she is still on [MEDICATION NAME] twice daily" and left the room again. In an interview with LVN CC on [DATE] at 4:50 p.m. regarding what action he would take in an a medical emergency, he said he would call the doctor and resident family. Nurse surveyor asked LVN CC about Resident #19's oxygen saturation and oxygen administration. LVN CC then when to the medication cart, got a pulse oximeter and put it on Resident #19's index finger less than 3 seconds and said the oxygen saturation (O2 sat) was 97% . The Nurse surveyor requested to see O2 sat again , LVN CC put the pulse oximeter on Resident #19's index finger and it took one minute to get a reading of 85%. At 5:00 p.m. LVN CC said he was going to get another pulse oximeter because the pulse oximeter did not work properly. At 5:05 p.m. LVN KKKK brought in an oxygen tank( at the nurse surveyor request ) and administered 3 liters via nasal cannula. At this time LVN KKKK she said she would have to place batteries in the pulse oximeters. LVN KKKK went to another hall and got a pulse oximeter from that was functioning properly. At 5:20 p.m. Resident #19 was transferred via ambulance to a local hospital. Record review on [DATE] of the facility's " Nursing Policies and Procedures dated [DATE] revealed: Record review on [DATE] of the facility's " Nursing Policies and Procedures dated [DATE] revealed: Subject Emergency - 911 Procedures: 1. Qualified staff initiates the appropriate emergency procedures, ie., oxygen,... 2. Call 911 when the patient's/resident's condition is life threatening... 3. Qualified staff attempts to stabilize and monitor the patient/resident..." The Policy and Procedure only applied to residents with full codes and was not specific to change in conditions ie., [MEDICAL CONDITION] activity precautions. No other policy and procedure was presented before the conclusion of this survey. The facility did not follow their policy and procedure and care plan as LVN CC and LVN KKKK failed to stabilize Resident #19 and failed to initiate emergency procedures. LVN KKKK did not complete a nursing assessment. LVN KKKK did not check vital signs, lay the resident on her side to maintain an open airway and prevent the resident from inhaling any secretions or make changes to the position of the bed and walked out of the room. Facility's Equipment: During an interview with LVN CC about Resident #19's oxygen saturation and oxygen administration. LVN CC left the room and returned, went to the medication cart, got a pulse oximeter and returned to the room. He put the pulse oximeter on Resident #19's index finger less than 3 seconds. LVN CC said the oxygen saturation (O2 sat) was 97%. Observation [DATE]at 4:50 p.m. revealed the pulse oximeter (for Hall C&D) used to check Resident #19's oxygen concentration was not working properly (the equipment used to monitor oxygen saturation in the blood). The Nurse Surveyor requested to see O2 sat performed again. Further observation at this time revealed LVN CC to reluctantly put the pulse oximeter on and it took one minute to get a reading of 85%. At 5:00 p.m. LVN CC said he was going to get another pulse oximeter from Hall A & B and it did not work properly. Observation at 5:05 p.m. revealed LVN KKKK entered Resident #19's room with an oxygen tank( at the Nurse Surveyor request ) and administered oxygen via nasal cannula at 3 liters. At this time LVN KKKK said she would have to place batteries in the pulse oximeters. Record review of the in service training conducted on 2012 revealed that the nursing staff had been in serviced on changes in condition and evaluation of Residents to include checking vital signs on [DATE]. LVN KKKK signed the attendance sheet. Further review revealed another in service that included changes in condition dated [DATE]. The in-service was given by LVN KKKK. No in-services were found on what to do during a [MEDICAL CONDITION]. This failure resulted in an IJ. The Administrator, Executive Director and Regional Clinical Services Director were informed of the IJ on [DATE] at 6:45 p.m. The facility submitted several plans of removal that required corrections and a revision was accepted on [DATE]. The following plan of action to remove the IJ was submitted by the Administrator on [DATE] at 2:00 p.m. PLAN TO REMOVE IMMEDIATE JEOPARDY Immediate Response: ?Resident was sent to emergency room for evaluation - Hospital ?All residents were assessed to identify if there are any medical emergencies or changes in condition completed on [DATE]. No other residents were found to have medical emergency or change of condition. ?The nurse identified related to this deficient practice has been suspended pending investigation. The Facility will report said occurrence as per requirement to the appropriate agencies. ?Inspected all facility medical emergency equipment for proper functioning completed [DATE]. ?Re education started immediately for licensed nurses in regards to timely assessment and documentation of changes in condition and response to medical emergencies. Licensed nurses were presented with medical emergency scenarios and they were required to respond with actions to be taken which are listed in the policy and procedure. Procedure states: 1. Qualified staff initiates the appropriate emergency procedures, i.e. oxygen, suction, CPR with or without AED as appropriate, etc. In accordance with patient/resident advanced directives. 2. Call 911 when patients/residents condition is life threatening, unless the patient/resident is coding and staff has determined that patient/resident is a DNR. 3. Qualified staff attempts to stabilize and monitor the patient/resident until the advanced medical team arrives, if appropriate. 4. Facility staff will promptly contact: attending physician or alternate, the family/responsible party, DON/designee. 5. Document the occurrence in the medical record. 6. Send appropriate documentation with the patient / resident if he/she transferred to the hospital. " Scenarios were also given for equipment not functioning properly and response in medical emergencies such as chest pain, SOB, . Licensed nurses were reeducated on backup equipment locations (emergency carts on each station.) Reeducation completed [DATE] and completed on [DATE]. ?As a facility practice and as a systematic approach to ensure the staff at the facility has knowledge of, and understands, the emergency policy and procedure and how to respond to medical emergencies, the healthcare center will have mandatory training for our nursing orientation and at least annually. PRN and part time licensed nurses will not be permitted to work until reeducation has been completed. ?Reeducation was started immediately for all Licensed nursing staff on [DATE] conducted by the Regional Clinical Services Director on: 1. Responding to a medical emergency 2. Policies and procedure for medical emergencies and responding with proper equipment; and timeliness of assessment ***Licensed staff will not be permitted to work until reeducation has been completed. ***Administrative Nurse/designee will validate proper functioning of equipment weekly. Director of Nurses will be notified of any concerns. Backup equipment blood pressure cuffs will be available in case of an emergency and located in the emergency carts on each station. During an interview on [DATE] at 6:48 p.m. with the Administrator she said the plan to remove the immediate jeopardy response was that the facility would assess all residents to ensure there were no other changes in condition , all medical emergency equipment would be inspected for proper functioning and all licensed staff would be re-educated in regards to timely assessment of changes in resident's condition and response to medical emergencies. In an interview with Regional Clinical Services Director ( RN) on [DATE] at 7:30 p.m. she said the interim DON was not in the building had gone home. Regional Clinical Services Director (RN) said the staff were trained to assess the residents, by checking their vital signs and document, instruct another nurse to call the doctor or 911, give oxygen and then call the family later. In an interview with the Interim DON [DATE] at 10:00 a.m. regarding medical emergencies, infection control, care of equipment, pharmacy drug regimen reviews she did not say anything and allowed the Regional Clinical Services Director (RCSD) to respond. The RCSD said the staff were trained to assess the residents, by checking their vital signs and document, instruct another nurse to call the doctor or 911, give oxygen and then call the family later. Non- Immediate Jeopardy Medications: During record reviews of 10 residents, none of the records had documentation of a Medication Regimen Review( MRR) performed by a pharmacist. During an interview with the Interim DON on [DATE] at 10:30 a.m., when asked for the facility's consultant pharmacist drug regimen. The Interim DON picked up the drug book at the nurses' station and presented it to the nurse surveyor. When the nurse surveyor asked for the consultant pharmacist drug regimen, the Interim DON said she would ask the RCSD. During an interview with the RSCD on [DATE] at 2:00 p.m. and at 4:00 p.m. regarding consulting pharmacist drug regimen she said she was still looking for it. During an interview with the ADM and the ED on [DATE] at 7:30 p.m. they were asked for the facility's consulting pharmacist drug regimen, they said they could not find the book. The ADM said the former DON had the consulting pharmacist drug regimen book and she was off sick for over a month. During an interview with the ADM on [DATE], she presented a "Pharmacy and Consulting Services " contract dated [DATE] that had been signed by the prospective pharmacy consultant. . Infection Control Issues: During the survey with duration of 4 days several staff members to include the Interim DON, licensed nurses, certified nurses aides and housekeeping staff failed to follow adequate infection control procedures to include hand washing, contamination during wound care [MEDICAL CONDITION], not following precautions with residents on contact isolation, improper handling of linen, trash and housekeeping equipment. Tracking and trending infections: Record review of the facility's infection control log from [DATE] to [DATE] revealed no: tracking of organism , culture date, isolated date, reculture date and no resolve date for infections. In an interview with LVN KKKK on [DATE] at 10:15 a.m. regarding the facility infection control training she said for newly hired employees she took them around the building , then they watched a video. She then assigned the new hire to a preceptor and they use the skilled check list for any task they perform. LVN KKKK was asked about trachoestomy training, she said somebody came out, she could not remember when but most staff they hire had experience regarding hand washing. LVN KKKK said she did not have a system in place regarding tracking and trending organisms and she did not know to do that. During an interview with the Administrator on [DATE] at 3:15 p.m. she said the quality assessment and assurance committee meets monthly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. She also said Weekly Quality Care meetings are held to identify facility issues. She stated that the Policy and Procedures were being re-evaluated by the disciplinary team after the survey team reported issues to include the IJ situation. She provided a list of 17 residents diagnosed with [REDACTED]. In an interview with the Interim DON [DATE] at 10:00 a.m. regarding medical emergencies, infection control, care of equipment, pharmacy drug regimen reviews she did not say anything and allowed the Regional Clinical Services Director to respond to questions. On [DATE] at 2:30 p.m. this Nurse Surveyor asked the Interim DON did she know what her duties were and she responded that she had not sat down with the Administrator or the Regional Clinical Services Director to discuss what she was suppose to do as an Interim DON, while the facility DON was out on sick leave. During an interview with the Regional Clinical Services Director at this time, she said the Interim DON had just been assigned to her position. She further stated that the facility DON had been on leave for approximately a month. The facility's CMS 672 listed 85 residents. Refer to F-281, 309 and F-441 for additional evidence.

Based on observation, interview and record review the facility failed to thoroughly assess one (Resident #1) of six sampled residents and administer pain medication in a timely manner when the resident experienced an increased amount of pain. - Resident #1 experienced an increased amount of physical pain when receiving care. Pain medication, as needed, had been ordered but not administered. This failure contributed to increased pain for Resident #1 and placed 30 other residents, on the pain management program, at risk for not receiving adequate assessments for identified needs and services. Findings include: Review of Resident #1's medical record reflected she was a sixty year old female originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] caused by many factors-such as unrelieved pressure, friction, humidity, ...) , chronic tracheitis (bacterial infection of the windpipe, and hypertension. Observation on 2/29/12 at 10:22 AM revealed Resident #1 had a [MEDICAL CONDITION] (an opening through the neck into the windpipe - tube is placed to provide an airway and to remove secretions from the lungs), a [DEVICE] (tube in the abdomen used for enteral nutrition), bilateral upper extremity contractures, bilateral lower extremity frog-leg contractures (restricted internal rotation and adduction of the hips resulting in the knees being flexed and the thigh drawn up to nearly a right angle and the feet and heels drawn up into the perineal area). Resident #1 was unable to speak, unable to point, unable to make her needs known, and unable to understand questions. Observation on 2/29/12 from 10:22 AM through 10:55 AM in Resident #1's room revealed that the resident was receiving care from Licensed Vocational Nurse (LVN) B and Certified Nurse Aide (CNA) A. Resident #1 was lying in bed with an expression of pain on her face, FACES score six. (Wong-Baker FACES Scale is a pain scale used for persons whose communication is impaired). Wong-Baker FACES scale: Zero (0) = no pain, 2 = Hurts a little bit, 4 = Hurts a little more, 6 = Hurts even more, 8 = Hurts a whole lot, 10 = Hurts worst. Resident #1 ' s head of bed was flat. Large bubbles were coming out of Resident #1 ' [MEDICAL CONDITION], bursting, and falling onto the 4 x 4 gauze. Resident #1 ' s neck was contracted toward the left side. LVN B placed the palm of his left hand against the left side of Resident #1 ' s face and pulled her head, toward the right, away from her left shoulder and wiped Resident #1's neck. Resident FACES scale went to 10. FACES scale was eight (8) after LVN B let go of Resident #1's face. CNA A got a wipe and again LVN B placed the palm of his left hand against the left side of Resident #1 ' s face and pulled her head away from her left shoulder. FACES scale was10. Throughout the care provided to Resident #1, her FACES scores fluctuated from 10 up to 6 then CNA A and MA C repositioned Resident #1 onto her back after incontinent care. Resident #1 ' s FACES score declined to four (4). At 10:48 AM, LVN B returned to the room, with [MEDICAL CONDITION] kit. Resident #1 ' s FACES score was two (2) prior to suctioning. LVN B provided [MEDICAL CONDITION] for Resident #1. LVN B inserted the suction tubing through [MEDICAL CONDITION] until Resident #1 gagged. Resident #1 ' s face became deep red, brows were furrowed, eyes were squinting shut, and mouth was downturned-FACES ten (10). LVN B suctioned as he removed the suction tubing from [MEDICAL CONDITION]. After suctioning, FACES 8. LVN B repeated the suctioning and again Resident #1 ' s FACES went to ten (10). LVN B stopped the suctioning and replaced 4 x 4 [MEDICAL CONDITION] under Resident #1 ' [MEDICAL CONDITION]. LVN B placed oxygen mask over Resident #1 ' s cannula. Resident received oxygen at 3 liters per minute (l/m). Resident FACES score decreased to four (4). Observation on 2/29/12 at 1:30 PM revealed Resident #1 was in bed. The head of the bed was elevated 45 degrees. Oxygen was running at 3 l/m. Glucerna was running at eighty (80) ml/hr. Resident #1 ' s eyes were closed. FACES zero (0). Observation on 2/29/12 at 4:00 PM revealed Resident #1 was in bed. The head of the bed was elevated 45 degrees. Oxygen was running at 3 l/m. Glucerna was running at eighty (80) ml/hr. Resident #1 ' s eyes were open. FACES zero (0). In an interview on 2/29/12 at 10:23 AM the surveyor asked LVN B if he thought Resident #1 was in pain. LVN B said, " She grimaces when you provide her care. She has pain, but when you stop providing care, her pain goes away. " The surveyor asked LVN B if Resident #1 had any as needed (PRN) pain medication. LVN B said, " Yes. But she got her scheduled [MEDICATION NAME] 5/325 this morning. The surveyor asked LVN B if he gave Resident #1 any PRN pain medication this morning and LVN B said, " No. " The surveyor asked LVN B if Resident #1 routinely receives any PRN pain medication prior to ADL care and LVN B said , " No. " During Resident #1 ' s ADL care, the surveyor asked LVN B if the secretions were causing Resident #1 any discomfort and LVN B shrugged his shoulders. The surveyor asked LVN B about Resident #1 ' s rash. LVN B said they had zinc to put on it. During an observation and interview on 2/29/12 at 10:24 AM, the surveyor asked CNA A, during Resident #1's ADL care, if she thought Resident #1 looked uncomfortable. CNA A stated, "She looks uncomfortable. She always looks like she ' s in pain when you provide her care but when you stop moving her around she returns to normal-she quits looking like she ' s in pain." During an observation and interview on 2/29/12 at 10:40 AM, the surveyor asked CNA A, during Resident # 1's ADL care, if she thought Resident #1 looked uncomfortable. CNA A stated, "She looks uncomfortable." During an interview on 2/29/12 at 10:42 AM, while incontinent care was being provided, MA C stated, "I come sometimes to help the CNA ' s reposition her when they have to do incontinent care, because of her contractures. " The surveyor asked MA C if Resident #1 looked like she was in pain during ADL care. MA C said, " she looks uncomfortable, like she ' s in pain. But she always looks like she ' s hurting when you do her care. " The surveyor asked MA C what she does if the resident is hurting when she ' s in their room. MA C said " I always ask residents if they are hurting, and if they are, I give them their as needed (PRN) pain med." The surveyor asked MA C if Resident #1 receives any pain medication before staff provides care. MA C said, " I don ' t know. " In an interview on 2/29/12 at 11:00 PM the surveyor asked LVN B to provide the MAR from the medication cart. LVN B pulled Resident #1 ' s record from the medication cart. There was no PRN pain medication record on Resident #1's MAR. In an interview on 2/29/12 at 12:24 PM the surveyor ask the Director of Nurses (DON) why Resident #1 ' s PRN pain medication order was not in the Medication Administration Record on the medication aid ' s medication cart. The DON said she did not know. The surveyor asked the DON how Resident #1 would be offered PRN pain medication if the order for it was not in the MAR, on the cart. The DON said the med aid or the nurse could always look in Resident #1 ' s chart for an order. DON said the order should be on the MAR and could not explain why it wasn ' t. The DON said, " They know she has PRN pain medication available. " The DON printed the order, for [MEDICATION NAME] 5/500 mg 1-2 tabs via [MEDICAL CONDITION] tube PRN for breakthrough pain every four hours (12:00AM, 04:00 AM, 08:00 AM 12:00 PM, 4:00 PM and 8:00 PM) from the computer. In an interview on 2/29/12 at 2:05 PM the surveyor ask the DON what the following order meant: FYI-may use PRN stock [MEDICATION NAME] for scheduled stock, as well, until the scheduled stock arrives. Continuous. The DON said, " I guess it means they can take [MEDICATION NAME] off the emergency cart for Resident #1 ' s use until her medication arrives. " Record review of Resident #1 ' s physician ' s telephone orders dated 2/15/12 reflected the following: FYI: may use PRN [MEDICATION NAME] supply for scheduled, as well, until scheduled supply of [MEDICATION NAME] is restocked. In an interview and observation on 2/29/12 at 2:10, LVN B and the surveyor pulled Resident #1 ' s pain medication from the medication cart. There were seventy-seven (77) tablets of [MEDICATION NAME] 5/500mg one to two (1-2) tabs by mouth (PO) every four (4) hours PRN. LVN B said, " These are used as her scheduled medications, not necessarily PRN medications In an interview on 2/29/12 at 11:13 AM Registered Nurse E said staff had received in-services on pain-identification, verbal and non-verbal assessment, and orders. RN E said, " We use a zero to ten pain scale for verbal residents. " The surveyor asked what scale was used for non-verbal residents. LVN E said zero to ten. The surveyor asked RN E to explain the non-verbal scale. LVN E said " grimacing " . In an interview on 2/29/12 at 11:30 AM the surveyor asked LVN D if CNA ' s were performing care and saw pain on a resident, what were her expectations of the CNA ' s? LVN D said, " I expect CNA ' s to finish incontinent care and then come report the resident ' s pain to me. Then I ' ll go assess the pain. In general, I expect the CNA ' s to finish their ADL care then come tell me if the resident is in pain. " In an interview on 2/29/12 at 12:24 PM the Director of Nurses (DON) said if a resident with [MEDICAL CONDITION] visible secretions and audible gurgling it would cause discomfort because the resident wouldn ' t be getting enough oxygen. The DON went on to further say she would expect a CNA to stop care and report to the nurse if the CNA saw a resident with pain. Then the DON would expect the nurse to do an assessment, give PRN pain medicine or call the doctor for orders for breakthrough pain. In an interview and observation on 2/29/12 at 2:15 PM, the Administrator asked the surveyor to accompany him and LVN B to Resident #1 ' s room. Upon arrival in the room, Resident had FACES four (4) - brows slightly furrowed and mouth slightly down-turned. The Administrator instructed LVN B to " fluff her pillow. " LVN B approached the bed on Resident #1 ' s right side and fluffed Resident #1 ' s pillow. FACES six (6). The Administrator said, " See, just fluffing her pillow causes her to grimace. " The surveyor said, " Do you think it has anything to do with her right forearm lying and pressing on the exposed rail of the bed? " LVN B picked up Resident #1 ' s upper torso and slightly moved Resident #1 to get her right forearm off of the bed rail. FACES six (6). The Administrator said, " Well? ' The surveyor said, " Do you think it has to do with Resident #1 ' s right hand being under her back? " LVN B pulled on Resident #1 ' s right wrist/forearm and repositioned Resident #1 ' s right arm. FACES 8. The surveyor asked LVN B what position Resident #1 ' s right arm and hand were normally in. LVN B said " by her right side. " After all repositioning, FACES two (2). The administrator said, What we ' re going to wind up doing is having to discharge her because we can ' t meet her needs, and that is not in her best interest. " Record review of Resident #1 ' s Medication Administration Record dated 2/1/ 2012 through 2/29/12 reflected Resident #1 had the following orders for pain: ? [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 milligrams (mg) one tablet per [DEVICE] every six hours (schedule 12:00 AM, 6:00AM, 12:00 PM , and 6:00 PM) ? [MEDICATION NAME] ([MEDICATION NAME]) 50 mg one tab per [DEVICE] four times a day (schedule 8:00 AM, 12:00 PM, 4:00 PM and 8:00PM) ? Check pain level every four hours and PRN (schedule 8:00 AM, 12:00 PM, 4:00 PM and 8:00PM Record review of Resident #1 ' s Consolidated Physicians orders dated 2/1/ 2012 through 2/29/12 reflected Resident #1 had the following orders for pain: ? [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 5/325 milligrams (mg) one tablet per [DEVICE] every six hours (schedule 12:00 AM, 6:00AM, 12:00 PM , and 6:00 PM) ? [MEDICATION NAME] ([MEDICATION NAME]) 50 mg one tab per [DEVICE] four times a day (schedule 8:00 AM, 12:00 PM, 4:00 PM and 8:00PM) ? [MEDICATION NAME] 5/500 mg 1-2 tabs via [MEDICAL CONDITION] tube PRN for breakthrough pain every four hours (12:00AM, 04:00 AM, 08:00 AM 12:00 PM, 4:00 PM and 8:00 PM) ? Check pain level every four hours and PRN (schedule 8:00 AM, 12:00 PM, 4:00 PM and 8:00PM Record review of Resident #1 ' s February 2012 Treatment Flowsheet for PRN pain medication administration reflected the following: the facility was unable to produce the administration record for February, 2012, prior to exit. Record review dated 2/8/12 through 3/9/12 of Resident #1 ' s General Flowsheet reflected the following: Evaluate resident for non-verbal indicators of pain every four hours. Identify resident specific indicators; grimacing, crying, other. There were no days from February 8 through February 29, 2012 that indicated Resident #1 had pain. Record review of Resident #1 ' s Pain flow sheet dated February 2012 was blank. In an interview 0n 2/29/12 at 12:24 PM the surveyor ask the DON why Resident #1 ' s Pain flow sheet was not filled out for February. The DON said it wouldn ' t be filled out unless the general flow sheet identified the resident had pain, and her general flowsheet has no indicator of pain. Resident #1 ' s medications flow sheet, to evaluate her pain, also has all zeros so the Pain flow sheet would not be filled out. The surveyor asked the DON, if the staff admit that Resident #1 has pain everytime they provide care, shouldn ' t the pain flow sheet be filled out since it has an area for site, location, precipiting factors, non medical interventions, medication, and pain rating score after the intervention? The DON said, I see what you mean. Record review of Resident #1 ' s Advanced Geriatrics Nurse Practioner note dated 2/14/12 reflected Resident #1 received an assessment with the following noted: Psychiatric-mildly agitated and responsive to painful stimuli. Record review of Resident #1's admission minimum data set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] reflected in the section for pain; - Should the staff assessment for pain be conducted?- this was blank - the section for pain also reflected no signs of pain were observed or documented. Record review of Resident #1's quarterly MDS dated [DATE] reflected the following: Resident #1 did not receive any PRN pain medications; there were no non-medication interventions for pain; staff assessment for pain be conducted was blank; indicators of pain or possible pain in the last five days was blank; frequency of pain in the past five days was blank.-Resident #1 had no speech. -Resident #1 never made herself understood. -Resident #1 never understood others. -Resident #1 cognitive skills were severly impaired. Review of Resident #1 ' s Care Plan dated 12/14/11 reflected Resident #1 had contractures, with a goal of: a. contractures will not increase, b. skin breakdown will not occur, c. increased pain will be relieved within an hour of intervention The approach to attain these goals was a. monitor for increased pain/stiffness-provide meds, assess for relief b. Reposition every two hours c. Keep contractured areas clean, dry, provide passive range of motion-do not force contractured areas d. Re-educate staff on care of contractures and repositioning Record review of Resident #1's Care Plan dated 12/14/11 reflected Resident #1 had pain/discomfort, with a goal of; Will maintain current ADLs and pain/discomfort will be relieved within one hour after intervention. The approach to attain these goals was; a. monitor for signs/symptoms increased pain/discomfort-provide meds, assess for relief b. provide pressure relieving and positioning devices c. assess and document pain d. educate CNA staff to stop care and notify nurse of facial grimacing or signs/symptoms of discomfort and resume care after nursing assessment of pain ..... Record review of Lexi-Comp Drug Information Handbook, for Nursing 8th Edition, 2007 reflected the following: [MEDICATION NAME] 5/325 has an onset of action in 10-20 minutes [MEDICATION NAME] 5/325 has a duration of action in 4-8 hours [MEDICATION NAME]/ [MEDICATION NAME] is the generic name for [MEDICATION NAME] [MEDICATION NAME] ([MEDICATION NAME]) 50 mg has an onset of action in 1 hour [MEDICATION NAME] ([MEDICATION NAME]) 50 mg has duration of action on 9 hours [MEDICATION NAME] ([MEDICATION NAME]) 50 mg has a time to peak of 2 hours Review of facilities Pain Management Policy and Procedures dated 7/2009 reflected the following: ? Qualified staff will implement the Facility Pain Management Program, including evaluation/re-evaluation for residents experiencing either acute or chronic pain. ? Document pain as the fifth vital sign ...as needed, guided by individual patient need ? Utilize the Wong Baker Faces Scale for those with cognitive impairment or non-conversive ? Consider a Pain Specialist consultation if pain management continues to be ineffective ? Documentation of pain should include Date/Time, Site location, Type, Current intensity, Precipitating/Aggravating Factor, Non-Med Intervention, Medication/Dose ? appropriate staff to receive on-going in-service education and competency testing in relation to pain management Record review of facility " What you need to know-Pain Management dated 11/2010 used in the facility in-service on pain reflected the following: -Definition of Pain- Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individuals ' pain memory, expectations and emotions. Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. -Procedures ...utilize the pain evaluation tool. Initiate the pain flow sheet ...Utilize the numeric rating scale (0-10) ... ... staff evaluation of pain or possible pain in cognitively impaired or non-verbal residents using non-verbal sounds, vocal complaints, facial expressions, protective body movements ... Record review of facility " What you need to know-Pain Management: a guide for CNA ' s dated 11/2010 used in the facility in-service on pain reflected the following: Observe residents carefully for signs of pain Report ...any signs of pain you have observed Monitor and continually reassess the resident ' s pain Anticipate activities that might cause the resident pain. If the resident has prn prescription for pain medication, suggest taking the medication prior to these activities. The Facility's PoC from 12/09/11 survey for F309 included "Nursing staff were re-educated on 12/15/11on policies and procedures for pain management, pain assessment and appropriate notification of nursing supervisor(s) ... DON or Designee will conduct routine checks for pain by randomly asking residents if they have been treated for [REDACTED]." The CMS 802 listed 31 residents on pain management programs.

Based on observation, record review and interview the facility failed to ensure residents received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. The facility failed to ensure staff secured indwelling catheter tubing to prevent movement and urethra traction for 3 of 5 sampled residents (#4, #3 and #2), 3 random residents (#19, #20, #21) with indwelling catheters and 1 resident (#22) with a suprapubic catheter. 1. Resident #4's indwelling catheter tubing was not secured to his body to prevent moving and urethral traction resulting in a penile shaft laceration from meatus to the scrotum. This injury was not identified, assessed or brought to the attention of the physician. Resident #4 was hospitalized and will require surgery to repair the damage. 2. Resident #3's indwelling catheter tubing was not secured to the body to prevent tension resulting in a penile laceration less than 1cm. 3. Resident #2's indwelling catheter tubing was not secured to the body to prevent tension and not changed according to physician's orders [REDACTED]. 4. Resident #19's indwelling catheter tubing was not secured to the body to prevent tension. 5. Resident #20's indwelling catheter tubing was not secured to the body to prevent tension. 6. Resident #22's suprapubic catheter tubing was not secured to prevent tension resulting in bleeding from insertion site. The failure to secure the catheter tubing from movement causing friction on the tissues resulting in a laceration of the urethra (tube which carries urine from the bladder thru the penis for excretion from the body ) and penile shaft effected 2 residents and placed 5 residents at risk for development of lacerations or worsening of laceration and infections which could result in hospitalization . Findings include: Resident # 4 Review of Resident #4's admission sheet revealed he was [AGE] year and admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation on 11/16/10 at 11:00 a.m. revealed Resident #4 lying in bed in a supine position. The indwelling catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observation on 11/16/10 at 1:00 p.m. revealed Resident #4 in bed in a left side lying position The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observations on 11/16/10 at 3:00 p.m. and 4: 00 p.m. revealed Resident #4 in bed in the right side lying position. The catheter collection bag was attached to the right bed frame. The catheter tubing was not secured to his body to prevent tension Observation on 11/17/10 at 7:30 a.m. revealed Resident #4 in bed in the left side lying position. The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observation on 11/17/10 at 9:00 a.m. revealed Resident #4 in bed in the left side lying position. A hospice nurse was performing a bed bath. The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. There was 400 cc of yellow colored urine in the bag. Observation on 11/17/10 at 10:30 a.m. and 12:00 p.m. revealed Resident #4 sitting in the reclining gerichair. The catheter collection bag was attached to left chair frame. The tubing was not secured to his body to prevent tension. Observation on 11/17/10 at 2: 00 p.m. revealed Resident #4 in bed in the left side lying position. The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observation on 11/17/10 at 3:00 p.m. revealed Resident #4 in bed in the left side lying position. The catheter collection bag was attached to left bed frame. The tubing was not secured to his body to prevent tension. Observations on 11/17/10 at 3:48 p.m. revealed CNA S providing perineal/catheter care to Resident #4. CNA S removed the soiled brief. Stool was present. The catheter tubing was not secured to his body to prevent tension. There was a small amount of blood and purulent discharge on the soiled brief. Resident #4 was hitting his head with his fist, moaning and grimacing while CNA S was removing the brief and providing incontinent and catheter care. The Surveyor observed a laceration from the penis head, penis glans to the scrotum. There was no anchor used to hold the catheter tubing in place. CNA S did not acknowledge the injury at 4:20 p.m. the catheter was not anchored. Review of Resident #4's weekly skin assessments dated 10/6/10, 10/13/10, 10/20/10, 11/3/10, 11/11/10 and 11/17/10 revealed no documentation of the penile laceration. No new skin problems were identified. Review of Resident #4's nurses' notes, physician's progress notes and physician's orders [REDACTED]. There was also no documentation that Resident #4's responsible party was notified. Review of the facility's skills verification checklist and competency needs identification for certified nurse aides dated 3/2006 revealed there was nothing documented on securing indwelling catheter tubing to the body to prevent tension. During an interview on 11/19/10 at 10:50 a.m., CNA L said he started working for the facility 2 months ago. He said he knew to secure residents' catheter collection bags in cloth bags so they would not drag on the floor. CNA L further said he did not have in-service training on catheters and securing the tubing to the body to prevent tension. CNA L said Resident #4's penile injury had been like that since he started working at the facility. During an interview on 11/19/10 at 10:58 a.m., CNA AL said she started working at the facility 8 months ago on the 6:00 a.m. to 2:00 p.m. shift. She said she knew to secure the collection bag to prevent it from dragging on the floor by placing it in the cloth bag. She said when transferring a resident with a catheter collection bag from a bed to a Geri Chair, she would place the bag in the cloth bag. During an interview on 11/19/10 at 11:03 a.m., CNA B said she started working the 6:00 a.m. to 2:00 p.m. shift. She knew to secure the collection bag by placing it in the clothe bag so it would not drag on the floor by resident's bedside. She said when she repositioned residents, she knew to empty the bag to prevent the bag from dragging. She said she has not taken care of Resident #4. During an interview on 11/ 19/10 at 11:06 a.m., RN H said she knew to secure the resident's catheter collection bag by placing it in the fabric bag so it would not drag on the floor. She said she had no training on securing catheter tubing to the body and had been a nurse for 3 years. She also said she was not aware of the laceration to Resident #4's penis. She said she had not provided any catheter care for him. During an interview on 11/19/10 at 11:10 a.m., unit manager LVN T said she knew to secure catheter tubing by taping it to resident's thigh and circle the tubing and clip it to the bedding. LVN T said no staff had reported any problem with any indwelling catheter to her except one time when Resident #4's catheter was not draining well. The catheter was changed and it worked well now. She did not remember how long ago it was. Observation on 11/19/10 at 11:20 a.m. revealed Resident #4 lying on his back (supine position), the catheter tubing was not secured to his body to prevent tension. The DON and LVN T observed the catheter tubing. LVN T opened Resident #4's brief; the tubing was kinked underneath his buttock; a small amount of bleeding and purulent discharge was noted on the brief. LVN T was asked to look at the under side of the penis. The DON and LVN T saw the laceration from the penile head to the scrotal sac. LVN T said "Oh my God, I have not seen a catheter like this and have not changed the catheter since Resident #4's admission". The DON said she had not seen Resident #4's indwelling catheter since his admission to the facility. The DON further said Resident #4 "came from a home with poor care to the facility, and I would love to research it". During an interview on 11/19/10 at 1:42 p.m., the Hospice Nurse ( RN O) said she had been a nurse for [AGE] years. She said she was called to the building yesterday, 11/18/10 at 5:10 p.m. She said she had never seen a laceration of a penile shaft "that bad". RN O said the hospice CNA provided services (including bed bath) to Resident #4 on 11/18/10 and did not mention seeing any laceration to the resident's penis. RN O said she performed Resident #4's head-to-toe comprehensive assessment on 10/29/10, 11/3/10, 11/8/10, 11/15/10 and 11/17/10 but did not look at his penis because the facility staff was supposed to do the assessments. Review of Resident #4's admission transfer note to the facility dated 3/23/10 from the hospital revealed he was admitted with an indwelling urinary catheter and multiple pressure ulcers. There was no documentation that Resident #4's was admitted with a lacerated penile shaft. Resident #3 Record review of Resident #3's admission sheet revealed he [AGE] year and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observations on 11/17/10 at 5:10 p.m. revealed LVN A and unit manager LVN MS providing perineal/catheter care to Resident #3. LVN A unhooked the catheter collection bag from the right side bed frame and placed it on Resident #3's bed. There was 800 cc of yellow-colored urine in the bag. The catheter tubing was not secured to the body to prevent tension. There was a laceration less than 1cm. While staff removed the soiled brief and performed incontinent and catheter care Resident #3 was moaning in pain. There was no catheter anchor used to hold the tubing in place and prevent movement. Resident #2 Review of Resident #2's admission sheet revealed she was [AGE] years old and was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 11/16/10 at 10:50 a.m. revealed Resident #2 sitting in a Geri-chair. She had an indwelling catheter. The urine collection bag was in a blue pouch attached to the side of the Geri-chair. The catheter tubing was not secured to the body to prevent tension. Observation further revealed there was a blue-colored clamp attached to the urine collection bag tubing that was not being used. Observation on 11/17/10 at 9:45 a.m. during incontinent and catheter care revealed Resident #2 was lying in a bed. The indwelling catheter tubing and urine collection bag in a blue pouch was attached to the side of the bed-frame but was not secured to the body to prevent tension. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed she was assessed as being incontinent of bowel, had an indwelling urinary catheter, was dependent on staff for activities of daily living including toileting, and had no current infection. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's treatment flow sheet dated 11/1/10-11/30/10 revealed it was without staff's initials indicating a change of the indwelling catheter on 7th and urine collection bag on 7th and 21st of November as prescribed by physician's orders [REDACTED]. indicating catheter care was performed on November 5th (1st shift), November 7th (3rd shift), November 11 th (2nd shift) and November 12 th (3rd shift). Review of the Hall B's 24 Hour Report Book revealed Resident #2's indwelling catheter was changed on November 18th on the night shift because it was leaking. Review of Resident #2's urine culture and sensitivity and urinalysis report dated 11/2/10 revealed the urine was cloudy in clarity, WBC 10-20, bacteria - many, and Isolated Providencia Stuartii 51,000 - 100,000 cfu/ml. Review of Resident #2's physician's orders [REDACTED]. Resident #19 Review of Resident #19's admission sheet revealed she was [AGE] years old and was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 11/18/10 at 3:15 p.m. revealed Resident #19 was lying in bed. An indwelling catheter and urine collection bag in a blue pouch was attached to the side of the Geri-chair. The catheter tubing was not secured to the body to prevent tension. Review of Resident #19's initial MDS assessment dated [DATE] revealed she was assessed as being continent of bowel, had an indwelling urinary catheter and had no current infection. Review of Resident #19's physician's orders [REDACTED]. Review of Resident #19's treatment flow sheet dated 11/1/10 - 11/30/10 revealed the indwelling catheter was changed on 11/5/10 because of leakage and indwelling catheter care was provided each shift. Resident #20 Review of Resident #20's admission sheet revealed she [AGE] years old and was readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 11/18/10 at 3:20 p.m. revealed Resident #20 was lying in bed. An indwelling catheter and urine collection bag in a blue pouch was attached to the side of the bed-frame. The catheter tubing was not secured to the body to prevent tension. Review of Resident #20's quarterly MDS assessment dated [DATE] revealed she was assessed as being occasionally incontinent of bowel, had an indwelling urinary catheter, had pneumonia in infection and was extensive to total dependent on one person assistance for activities of daily living. Review of Resident #20's urine culture and sensitivity and urinalysis report dated 10/5/10 revealed urine was cloudy in clarity, WBC clumps - few, bacteria - rare and Isolated [DIAGNOSES REDACTED] Pneumoniae 10,000 - 50,000 cfu/ml. Review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's treatment flow sheet dated 11/1/10 - 11/30/10 revealed the indwelling catheter and urine collection bag were changed on 11/7/10 and indwelling catheter care was provided each shift. During an interview on 11/18/10 at 10:55 a.m., Unit Manager/ LVN B stated if Resident # 2's treatment flowsheet was not initialed by staff to change indwelling catheter, urine collection bag and provide catheter care each shift then those treatments were not done. She also stated on her unit, LVN's performed catheter care and they did not secure Resident # 2's indwelling catheter tubing because she had problem of developing skin blisters. She also stated she did not know if Resident #19 and Resident #20's indwelling catheters were secured to their bodies or not. During an interview on 11/18/10 at 11:05 a.m., with CNA E stated "I do not know how to secure the Foley catheter and I have not been trained on catheter care since I started working in February. I am being honest". During an interview on 11/18/10 at 11:15 a.m., CNA G stated "DON has delegated me to check-off new CNAs for catheter care. I tell new CNAs to put the catheter tubing underneath the resident's legs but I do not know about securing the catheter. I just know there is a blue clamp attached to the urine collection bag which should be secured to the resident's bed-pad". Resident #22 Review of Resident #22's admission sheet revealed he was [AGE] years old and was admitted on [DATE]. His [DIAGNOSES REDACTED]. Observation on 11/18/10 at 10:00 a.m. revealed Resident #22 sitting in his wheel chair. The Surveyor requested to view the resident's catheter. He was transferred from his wheel chair to his bed. Observation revealed he had a supra pubic catheter that was not secured. There was blood, an offensive odor and no dressing on the site. During an interview at this time, Resident #22 was asked about staff securing the tubing of his catheter. He said he could sometimes feel the tension from the catheter tubing. Review of Resident #22's minimum data set assessment dated [DATE] revealed his cognitive skills for decision-making were assessed as modified independent and he had an indwelling catheter. Review of Resident #22's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #22's Urinary Continence Evaluation dated 10/18/10 revealed he was diagnosed as having a [MEDICAL CONDITION] bladder. Review of his care plan dated 11/18/10 resident at risk for urinary tract infection. Review of the facility's Catheter Nursing Policies and Procedures dated 3/2006 revealed the heading of Catheter Use and Insertion........"3. F. The catheter is secured to the patient's / resident's leg (or in special circumstances the abdomen) to prevent unnecessary trauma to the urethra and bladder neck". The facility resident census and condition CMS 672 form listed 7 residents with urinary catheters.

Based on observation, interview and record review the facility failed to ensure that residents who entered the facility with indwelling catheters received the appropriate treatment and services. The facility failed to ensure staff secured indwelling catheter tubing to prevent tension for 3 of 5 sampled residents (#4, #3 and #2), 3 random residents (#19, #20, #21) with indwelling catheters and 1 resident (#22) with a suprapubic catheter. 1. Resident #4's indwelling catheter tubing was not secured resulting in a penile shaft laceration from meatus to the scrotum. This injury was not identified, assessed or brought to the attention of the physician. Resident #4 was hospitalized and will require surgery to repair the damage. 2. Resident #3's indwelling catheter tubing was not secured to the body to prevent tension resulting in a penile laceration less than 1cm. 3. Resident #2's indwelling catheter tubing was not secured to the body to prevent tension and not changed according to physician's orders [REDACTED]. 4. Resident #19's indwelling catheter tubing was not secured to the body to prevent tension. 5. Resident #20's indwelling catheter tubing was not secured to the body to prevent tension. 6. Resident #22's suprapubic catheter tubing was not secured to prevent tension resulting in bleeding from insertion site. The failure effected 2 resident and placed 5 residents at risk for development of laceration or worsening of laceration and infections which could result in hospitalization . Findings include: Resident # 4 Review of Resident #4's admission sheet revealed he was [AGE] year and admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation on 11/16/10 at 11:00 a.m. revealed Resident #4 lying in bed in a supine position. The indwelling catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observation on 11/16/10 at 1:00 p.m. revealed Resident #4 in bed in a left side lying position The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observations on 11/16/10 at 3:00 p.m. and 4: 00 p.m. revealed Resident #4 in bed in the right side lying position. The catheter collection bag was attached to the right bed frame. The catheter tubing was not secured to his body to prevent tension Observation on 11/17/10 at 7:30 a.m. revealed Resident #4 in bed in the left side lying position. The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observation on 11/17/10 at 9:00 a.m. revealed Resident #4 in bed in the left side lying position. A hospice nurse was performing a bed bath. The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. There was 400 cc of yellow colored urine in the bag. Observation on 11/17/10 at 10:30 a.m. and 12:00 p.m. revealed Resident #4 sitting in the reclining gerichair. The catheter collection bag was attached to left chair frame. The tubing was not secured to his body to prevent tension. Observation on 11/17/10 at 2: 00 p.m. revealed Resident #4 in bed in the left side lying position. The catheter collection bag was attached to the left bed frame. The catheter tubing was not secured to his body to prevent tension. Observation on 11/17/10 at 3:00 p.m. revealed Resident #4 in bed in the left side lying position. The catheter collection bag was attached to left bed frame. The tubing was not secured to his body to prevent tension. Observations on 11/17/10 at 3:48 p.m. revealed CNA S providing perineal/catheter care to Resident #4. CNA S removed the soiled brief. Stool was present. The catheter tubing was not secured to his body to prevent tension. There was a small amount of blood and purulent discharge on the soiled brief. Resident #4 was hitting his head with his fist, moaning and grimacing while CNA S was removing the brief and providing incontinent and catheter care. The Surveyor observed a laceration from the penis head, penis glans to the scrotum. There was no anchor used to hold the catheter tubing in place. CNA S did not acknowledge the injury at 4:20 p.m. the catheter was not anchored. Review of Resident #4's weekly skin assessments dated 10/6/10, 10/13/10, 10/20/10, 11/3/10, 11/11/10 and 11/17/10 revealed no documentation of the penile laceration. No new skin problems were identified. Review of Resident #4's nurses' notes, physician's progress notes and physician's orders [REDACTED]. There was also no documentation that Resident #4's responsible party was notified. Review of the facility's skills verification checklist and competency needs identification for certified nurse aides dated 3/2006 revealed there was nothing documented on securing indwelling catheter tubing to the body to prevent tension. During an interview on 11/19/10 at 10:50 a.m., CNA L said he started working for the facility 2 months ago. He said he knew to secure residents' catheter collection bags in cloth bags so they would not drag on the floor. CNA L further said he did not have in-service training on catheters and securing the tubing to the body to prevent tension. CNA L said Resident #4's penile injury had been like that since he started working at the facility. During an interview on 11/19/10 at 10:58 a.m., CNA AL said she started working at the facility 8 months ago on the 6:00 a.m. to 2:00 p.m. shift. She said she knew to secure the collection bag to prevent it from dragging on the floor by placing it in the cloth bag. She said when transferring a resident with a catheter collection bag from a bed to a Geri Chair, she would place the bag in the cloth bag. During an interview on 11/19/10 at 11:03 a.m., CNA B said she started working the 6:00 a.m. to 2:00 p.m. shift. She knew to secure the collection bag by placing it in the clothe bag so it would not drag on the floor by resident's bedside. She said when she repositioned residents, she knew to empty the bag to prevent the bag from dragging. She said she has not taken care of Resident #4. During an interview on 11/ 19/10 at 11:06 a.m., RN H said she knew to secure the resident's catheter collection bag by placing it in the fabric bag so it would not drag on the floor. She said she had no training on securing catheter tubing to the body and had been a nurse for 3 years. She also said she was not aware of the laceration to Resident #4's penis. She said she had not provided any catheter care for him. During an interview on 11/19/10 at 11:10 a.m., unit manager LVN T said she knew to secure catheter tubing by taping it to resident's thigh and circle the tubing and clip it to the bedding. LVN T said no staff had reported any problem with any indwelling catheter to her except one time when Resident #4's catheter was not draining well. The catheter was changed and it worked well now. She did not remember how long ago it was. Observation on 11/19/10 at 11:20 a.m. revealed Resident #4 lying on his back (supine position), the catheter tubing was not secured to his body to prevent tension. The DON and LVN T observed the catheter tubing. LVN T opened Resident #4's brief; the tubing was kinked underneath his buttock; a small amount of bleeding and purulent discharge was noted on the brief. LVN T was asked to look at the under side of the penis. The DON and LVN T saw the laceration from the penile head to the scrotal sac. LVN T said "Oh my God, I have not seen a catheter like this and have not changed the catheter since Resident #4's admission". The DON said she had not seen Resident #4's indwelling catheter since his admission to the facility. The DON further said Resident #4 "came from a home with poor care to the facility, and I would love to research it". During an interview on 11/19/10 at 1:42 p.m., the Hospice Nurse ( RN O) said she had been a nurse for [AGE] years. She said she was called to the building yesterday, 11/18/10 at 5:10 p.m. She said she had never seen a laceration of a penile shaft "that bad". RN O said the hospice CNA provided services (including bed bath) to Resident #4 on 11/18/10 and did not mention seeing any laceration to the resident's penis. RN O said she performed Resident #4's head-to-toe comprehensive assessment on 10/29/10, 11/3/10, 11/8/10, 11/15/10 and 11/17/10 but did not look at his penis because the facility staff was supposed to do the assessments. Review of Resident #4's admission transfer note to the facility dated 3/23/10 from the hospital revealed he was admitted with an indwelling urinary catheter and multiple pressure ulcers. There was no documentation that Resident #4's was admitted with a lacerated penile shaft. Resident #3 Record review of Resident #3's admission sheet revealed he [AGE] year and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observations on 11/17/10 at 5:10 p.m. revealed LVN A and unit manager LVN MS providing perineal/catheter care to Resident #3. LVN A unhooked the catheter collection bag from the right side bed frame and placed it on Resident #3's bed. There was 800 cc of yellow-colored urine in the bag. The catheter tubing was not secured to the body to prevent tension. While staff removed the soiled brief and performed incontinent and catheter care Resident #3 was moaning in pain. There was no catheter anchor used to hold the catheter in place. Resident #2 Review of Resident #2's admission sheet revealed she was [AGE] years old and was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 11/16/10 at 10:50 a.m. revealed Resident #2 sitting in a Geri-chair. She had an indwelling catheter. The urine collection bag was in a blue pouch attached to the side of the Geri-chair. The catheter tubing was not secured to the body to prevent tension. Observation further revealed there was a blue-colored clamp attached to the urine collection bag tubing that was not being used. Observation on 11/17/10 at 9:45 a.m. during incontinent and catheter care revealed Resident #2 was lying in a bed. The indwelling catheter tubing and urine collection bag in a blue pouch was attached to the side of the bed-frame but was not secured to the body to prevent tension. Review of Resident #2's quarterly MDS assessment dated [DATE] revealed she was assessed as being incontinent of bowel, had an indwelling urinary catheter, was dependent on staff for activities of daily living including toileting, and had no current infection. Review of Resident #2's physician's orders [REDACTED]. Review of Resident #2's treatment flow sheet dated 11/1/10-11/30/10 revealed it was without staff's initials indicating a change of the indwelling catheter on 7th and urine collection bag on 7th and 21st of November as prescribed by physician's orders [REDACTED]. indicating catheter care was performed on November 5th (1st shift), November 7th (3rd shift), November 11 th (2nd shift) and November 12 th (3rd shift). Review of the Hall B's 24 Hour Report Book revealed Resident #2's indwelling catheter was changed on November 18th on the night shift because it was leaking. Review of Resident #2's urine culture and sensitivity and urinalysis report dated 11/2/10 revealed the urine was cloudy in clarity, WBC 10-20, bacteria - many, and Isolated Providencia Stuartii 51,000 - 100,000 cfu/ml. Review of Resident #2's physician's orders [REDACTED]. Resident #19 Review of Resident #19's admission sheet revealed she was [AGE] years old and was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 11/18/10 at 3:15 p.m. revealed Resident #19 was lying in bed. An indwelling catheter and urine collection bag in a blue pouch was attached to the side of the Geri-chair. The catheter tubing was not secured to the body to prevent tension. Review of Resident #19's initial MDS assessment dated [DATE] revealed she was assessed as being continent of bowel, had an indwelling urinary catheter and had no current infection. Review of Resident #19's physician's orders [REDACTED]. Review of Resident #19's treatment flow sheet dated 11/1/10 - 11/30/10 revealed the indwelling catheter was changed on 11/5/10 because of leakage and indwelling catheter care was provided each shift. Resident #20 Review of Resident #20's admission sheet revealed she [AGE] years old and was readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Observation on 11/18/10 at 3:20 p.m. revealed Resident #20 was lying in bed. An indwelling catheter and urine collection bag in a blue pouch was attached to the side of the bed-frame. The catheter tubing was not secured to the body to prevent tension. Review of Resident #20's quarterly MDS assessment dated [DATE] revealed she was assessed as being occasionally incontinent of bowel, had an indwelling urinary catheter, had pneumonia in infection and was extensive to total dependent on one person assistance for activities of daily living. Review of Resident #20's urine culture and sensitivity and urinalysis report dated 10/5/10 revealed urine was cloudy in clarity, WBC clumps - few, bacteria - rare and Isolated [DIAGNOSES REDACTED] Pneumoniae 10,000 - 50,000 cfu/ml. Review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's physician's orders [REDACTED]. Review of Resident #20's treatment flow sheet dated 11/1/10 - 11/30/10 revealed the indwelling catheter and urine collection bag were changed on 11/7/10 and indwelling catheter care was provided each shift. During an interview on 11/18/10 at 10:55 a.m., Unit Manager/ LVN B stated if Resident # 2's treatment flowsheet was not initialed by staff to change indwelling catheter, urine collection bag and provide catheter care each shift then those treatments were not done. She also stated on her unit, LVN's performed catheter care and they did not secure Resident # 2's indwelling catheter tubing because she had problem of developing skin blisters. She also stated she did not know if Resident #19 and Resident #20's indwelling catheters were secured to their bodies or not. During an interview on 11/18/10 at 11:05 a.m., with CNA E stated "I do not know how to secure the Foley catheter and I have not been trained on catheter care since I started working in February. I am being honest". During an interview on 11/18/10 at 11:15 a.m., CNA G stated "DON has delegated me to check-off new CNAs for catheter care. I tell new CNAs to put the catheter tubing underneath the resident's legs but I do not know about securing the catheter. I just know there is a blue clamp attached to the urine collection bag which should be secured to the resident's bed-pad". Resident #22 Review of Resident #22's admission sheet revealed he was [AGE] years old and was admitted on [DATE]. His [DIAGNOSES REDACTED]. Observation on 11/18/10 at 10:00 a.m. revealed Resident #22 sitting in his wheel chair. The Surveyor requested to view the resident's catheter. He was transferred from his wheel chair to his bed. Observation revealed he had a supra pubic catheter that was not secured. There was blood, an offensive odor and no dressing on the site. During an interview at this time, Resident #22 was asked about staff securing the tubing of his catheter. He said he could sometimes feel the tension from the catheter tubing. Review of Resident #22's minimum data set assessment dated [DATE] revealed his cognitive skills for decision-making were assessed as modified independent and he had an indwelling catheter. Review of Resident #22's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of Resident #22's Urinary Continence Evaluation dated 10/18/10 revealed he was assesed with a [DIAGNOSES REDACTED]. Review of his care plan dated 11/18/10 resident at risk for urinary tract infection. Review of the facility's Catheter Nursing Policies and Procedures dated 3/2006 revealed the heading of Catheter Use and Insertion........"3. F. The catheter is secured to the patient's / resident's leg (or in special circumstances the abdomen) to prevent unnecessary trauma to the urethra and bladder neck". The facility resident census and condition CMS 672 form listed 7 residents with urinary catheters.