CASCADES AT PORT ARTHUR

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the written plan of care for 1 of 11 residents (Resident #5) reviewed for care needs.<BR/>CNA C did not use a second staff to provide care per Resident #5's identified care needs. <BR/>Resident #5 fell from her bed. <BR/>Resident #5 sustained multiple fractures and required surgical intervention. <BR/>This failure could place the residents at risk for not receiving required care and services. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated 01/16/23 indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She said checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and they utilized the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain and she was given pain medication. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. <BR/>During observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said was sent to the hospital. She said she had two broken legs and two broken knee caps. She said her pain before the fall but it was worse after she sustained the two broken legs and two broken knee caps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. <BR/>During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. <BR/>During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system. <BR/>During an interview on 04/12/23 at 1:38 a.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 11 residents (Resident #5) reviewed for accidents.<BR/>CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. <BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for falls resulting in injury, pain, and hospitalization. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's most current care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>During an observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>Record review of an incident report dated 01/16/23, completed by LVN A indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. LVN A did not indicate Resident #5 was a 2-person assist.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the [NAME]. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there was two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident.<BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. <BR/>During an interview on 04/12/23 at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the [NAME] and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. <BR/>During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not follow the [NAME] for care needs the resident could have serious injuries or die.<BR/>During record review and interview on 04/12/23 at 1:04 p.m., the DON said they believed all staff were re-trained to check the [NAME] for level of resident assistance required after Resident #5's fall. She said she and the ADON monitored the care plans and [NAME] weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. <BR/>During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS before the fall. She said Resident #5 was weak on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS before her fall. She said the information was in the [NAME] system. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility but forgot to sign. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>Record review of the facility's Falls-Clinical Protocol revised 03/2018 indicated: .2. In addition, the nurse shall assess and document/report the following: .h. Precipitating factors, details on how fall occurred; . Falls Prevention-Potential Interventions - Nursing Measures . proper positioning .<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated : The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.<BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>The Administrator and DON were notified of the Immediate Jeopardy on 04/12/23 at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/13/23 at 12:35 p.m. and reflected the following: <BR/>1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. <BR/>2* Corrective Action<BR/>Nursing administration will review care plans and [NAME]'s for all residents to ensure they match with the resident's level of assistance required. This process began 4/12/23 and will be complete by 10 AM on 4/13/23. All areas of concerns have been addressed and all care plans match all [NAME]'s for all residents. <BR/>All nursing staff will be in-service on where to find a resident's level of assistance in the [NAME]. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. <BR/>All nursing staff will be in-service on abuse and neglect. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the [NAME]/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. <BR/>All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM.<BR/>The [NAME] showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the [NAME]. <BR/>The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of 4/12/23 4:30 PM. <BR/>3* Identification of Others<BR/> The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by 4/13/23 of all facility residents' administrative nurses. Assessment will compare care plans to [NAME]. <BR/>The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. <BR/>A facility record audit of residents [NAME] and care plans will be completed by Director of Nursing/Designee by 4/13/2023 10 AM.<BR/>4* Plan to prevent from recurring <BR/>Intervention for Neglect: DON/designee to evaluate care plan and [NAME] for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on [NAME] and levels of assistance prior to working the first shift. This is to be completed during orientation. <BR/>Training Plan<BR/>Initial Trainings: Facility to Initiate Training by 4/12/2023 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working 4/12/2023, and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by 4/13/23 10AM via in person on telephone training.<BR/>All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM.<BR/>Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations.<BR/>5* Ongoing Monitoring<BR/>Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate [NAME] knowledge during rounds. <BR/>6* QAPI<BR/>In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed 4/12/23 by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. <BR/>On 04/13/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Observations, interviews, and record reviews were conducted on 04/13/23 from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns.<BR/>Staff were able to discuss the required level of staff assistance for ADLs.<BR/>Staff were able to demonstrate the use of the [NAME] system for resident care needs. <BR/>Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures.<BR/>[NAME] for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the [NAME].<BR/>Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the [NAME].<BR/>Nursing staff were in-serviced on where to find a resident's level of assistance in the [NAME]. The training was completed on 04/13/23. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>Staff were in-service on abuse and neglect. The training was completed on 04/13/23. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>The 5-question quiz of [NAME] knowledge given to all tested staff indicated all staff scored 100%.<BR/>The [NAME] showed that resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on 01/17/23. <BR/>The administrator was in-service on 04/12/23 by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter.<BR/>There were no additional allegations of neglect or abuse identified during the investigation.<BR/>During an interview on 04/13/23 at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. <BR/>During an interview on 04/13/23 at 2:50 p.m., The DON said the audit of all residents' care plans and [NAME] revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents.<BR/>A facility record audit dated 04/13/23 of residents' [NAME] and care plans revealed no issues or concerns. <BR/>Staffing was reviewed for the previous two weeks and for 01/16/23. There was no concerns noted.<BR/>Five residents indicated they were afraid during care or had complaints of their care.<BR/>The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on 04/12/23.<BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 8 residents (Resident #1) reviewed for medication administration.<BR/>The facility failed to ensure Resident #1 received 4 applications of antifungal shampoo.<BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications. <BR/>Findings included: <BR/>Record review of a face sheet dated 05/08/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses anxiety and chronic pain.<BR/>Record review of an MDS assessment dated [DATE] indicated Resident #1 had moderate impaired cognition. She required supervision for personal hygiene. She required physical help for bathing.<BR/>Record review of a care plan dated 01/25/23 (revised on 05/08/23) indicated Resident #1 had ADL self-care performance deficit related to confusion, impaired balance and pain. Interventions included: Bathing/Showering-Avoid scrubbing and pat dry sensitive skin. Wash hair with Ketoconazole Shampoo 2% (antifungal medication - treats fungal or yeast infections in skin) and apply to affected areas of skin prn.<BR/>Record review of physician order dated 05/01/23, created by LVN A indicated Received a call from MD B with new order Ketoconazole (antifungal) 2% shampoo once a day X 5 then . Order summary: Ketoconazole Shampoo 2% Apply to scalp (shampoo) topically every day shift every 5 day(s) for scalp X 5 days then prn.<BR/>Record review of MAR/TAR dated 05/23 indicated Ketoconazole Shampoo 2% Apply to scalp (shampoo) topically every day shift every 5 day(s) for scalp X 5 days then prn. Resident #1's hair was shampooed on 05/02/23 and 05/07/23. Resident #1's hair was not shampooed as ordered on 05/03/23, 05/04/23, 05/05/23, or 05/06/23. There was an X on 05/03/23, 05/04/23, 05/05/23, and 05/06/23 of the MAR/TAR. The next day Resident #1 was scheduled for her hair shampoo was 05/12/23.<BR/>Record review of a skin assessment dated [DATE], completed by the ADON indicated Resident #1 continued to have raised crusty areas on the top of her scalp and on the back of her right hand.<BR/>During an observation and interview on 05/08/23 at 10:15 a.m., Resident #1 shook her head no and touched her hair when asked if staff washed her hair. She shrugged her shoulders when asked when her hair was last washed. Observation of Resident #1's hair and visible scalp area did not show visible skin issues. Her hair appeared clean.<BR/>During an interview and record review on 05/08/23 at 1:25 p.m., LVN A said she made an error when she input MD B's order for Resident #1's antifungal shampoo in the electronic record. She said she received a call from the pharmacy for clarification of the order and the shampoo bottle had the correct orders on the label. Record review of the shampoo bottle label indicated to shampoo Resident #1's hair for 5 days then prn. LVN A said she forgot to make the corrections in the electronic record. <BR/>During an interview on 05/08/23 at 2:25 p.m., the DON said she and the ADON were responsible for reviewing all orders and the MAR. She said she was off and the ADON was to review the orders and MAR. The ADON said she should have reviewed Resident #1's physician orders and MAR but it was not done because she was working the floor. The DON said Resident #1's skin condition would take longer to heal if the medicated shampoo was not applied as ordered.<BR/>Record review of the facility policy for Medication Orders revised 11/14 indicated: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders . 6. Treatment Orders-When recording treatment orders, specify the treatment, frequency, and duration of the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors.<BR/>The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure.<BR/>An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at risk of not receiving their medications as ordered, illness, hospitalizations, exacerbation of their disease processes, and death. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of na&iuml;ve coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat).<BR/>Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants.<BR/>Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. An unidentified staff indicated the order needed clarification. There was no documentation on the Discharge Home Medication List of the medication clarification.<BR/>Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. <BR/>Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued.<BR/>Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered.<BR/>Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. <BR/>Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24.<BR/>Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). <BR/>Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation.<BR/>Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested.<BR/>Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg. related to atherosclerotic heart disease of native coronary with unspecified angina pectoris.<BR/>Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related coffee ground emesis (vomit). The DON and MD were notified. RP was at bedside.<BR/>Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs had become mottled and cool. She was diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24.<BR/>Record review of Resident #1's hospice records dated 05/23/24 indicated passed away on 05/23/24 of heart failure.<BR/>During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on [DATE]. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto.<BR/>During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness. She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on [DATE] due to vomiting.<BR/>During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. <BR/>During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. <BR/>During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. <BR/>During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA. She said NP A never wrote orders for the Eliquis or ASA or Xarelto. <BR/>During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism or a blood clot due to DVT. <BR/>During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes.<BR/>LVN C was no longer employed with the facility and was not available for an interview.<BR/>Record review of the facility's Medication Therapy policy dated 2001 (revised 2007) indicated<BR/>1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks.<BR/>2. <BR/>Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments.<BR/>3. <BR/>All medication orders will be supported by appropriate care processes and practices.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>The resident's clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident.<BR/>2. <BR/>All decisions related to medications shall include appropriate elements of the care process, such as: <BR/>a. <BR/>Adequately detailed assessment;<BR/>b. <BR/>Review of causes of symptoms;<BR/>c. <BR/>Consideration of the clinical relevance of symptoms and abnormal diagnostic test results;<BR/>d. <BR/>Principles of prescribing for the elderly; and<BR/>e. <BR/>Each resident's wishes, values, goals, condition, and prognosis.<BR/>Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m.<BR/>The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following:<BR/>Resident #1 was discharged to the hospital on 5/17 24 and no longer resides in the facility.<BR/>A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. <BR/>In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director - All other licensed staff will be in-serviced prior to working next shift. <BR/>Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm<BR/>Facilities Plan to ensure compliance quickly: <BR/>Facility interventions were implemented to remove immediate jeopardy: <BR/>A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. <BR/>Education was completed with the Administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. <BR/>In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON if unable to verify orders after 2 attempts. DON/ADON will then notify the medical director.<BR/>*Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings.<BR/>On 06/16/24, the surveyor confirmed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the HER. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. <BR/>Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. <BR/>Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly.<BR/>Record review of the resident census dated 06/16/24 indicated here were no new admissions to the facility.<BR/>Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m. and included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m. to 6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the practitioner and documented in the progress notes.<BR/>During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. <BR/>During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. <BR/>On 06/16/24 at 1:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in compartments and permitted only authorized personnel to have access to the prescribed medications for 2 of 18 residents (Resident #11 and Resident #21) reviewed for storage of medications. <BR/>Resident #11 who had moderate intellectual disabilities had her morning medications left at bedside to consume unsupervised by authorized personnel. <BR/>The facility failed to supervise and ensure Resident #21 consumed dispensed medications prescribed and dispensed as ordered. <BR/>This failure could place residents at risk for consuming unsafe medications and having access to unauthorized medication. <BR/>Findings included: <BR/>1. Record review of a care plan last revised 09/24/21 indicated Resident #11 required limited assistance with ADLs due to periods of confusion to ensure ADLs are completed safely. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #11 had intact cognitive skills for daily decision making and an active diagnosis of moderate intellectual disabilities and required supervision with all ADLs. <BR/>Record review of face sheet and physician ' s orders dated August 2022 indicated Resident #11 was a [AGE] year-old female admitted to the facility 08/16/19 with diagnosis of moderate intellectual disabilities. <BR/>Record review of medication administration record (MAR) dated August 2022 indicated on 08/08/22 at 9:00 AM, LVN B administered to Resident #11 the following medications: <BR/>Anastrozole 1 mg one tablet (a medication given for breast cancer) <BR/>Aspirin EC 81mg one tablet (for syncope/a condition caused by fall in blood pressure) <BR/>Atenolol 50mg on tablet (for high blood pressure) <BR/>Calcium-Vitamin D 600-200mg on tablet (for breast cancer) <BR/>Glipizide 5mg one tablet (for diabetes) <BR/>During an observation and interview on 08/08/22 at 10:10 am, Resident #11 was sitting on the edge of her bed. On her bedside table in front of her was a small, clear plastic cup usually used for medication administration. The cup contained 5 pills. Resident #11 said the pills were her morning medication and she just woke up and found them sitting there. She said she was about to take the medications. <BR/>During an interview on 08/08/22 at 10:15 AM, LVN B said she left Resident #11 ' s morning medications at her bedside because the resident always gets testy with her and argued with her about taking her medications. LVN B said she had been leaving the medications at Resident #11 ' s bedside so she could take them later. She said Resident #11 was the only resident she leaves medication with, and she watches all other residents swallow their medication before leaving the resident. LVN B said she was intimidated by Resident #11 because she yelled at her and would stand up and move towards her when she asked her to take the medications in front of her. LVN B said that best practice was to wait until the resident swallowed the medication before leaving the room, but she was not going to argue with Resident #11. LVN B said she had worked at the facility for 4 months and DON and ADON were her direct supervisors. She said both DON and ADON had watched her do medication pass when she began working at the facility. <BR/>During an interview on 08/10/22 at 10:05 AM, the DON said that LVN B had reported to her that surveyor had questioned her about leaving Resident #11 ' s medication at her bedside and not witnessing the resident take the medication. The DON said she expected facility nurses to witness the resident taking the medications and not leave them at the bedside. The DON said she had completed an in-service to all nurses working on 08/08/22 regarding nurses should wait until all medications are taken before leaving a resident ' s room. She said she had watched LVN B giving medications during her orientation, and she required no additional training at that time. She said LVN B had never reported to her that she felt intimidated by Resident #11, or the problem would have been addressed. DON said that the possible negative outcome of not watching a resident take their medication could be they might not receive the medications as ordered by their physician. <BR/>During an interview on 08/10/22 at 1:01 PM, the Administrator said he expected nurses to stay with residents until they had taken their medications. He said he was aware that medication had been left at Resident #11 ' s bedside and the DON conducted an in-service regarding nurses staying with residents until medications were taken. <BR/>2. Record review of face sheet and physician ' s orders dated August 2022 indicated Resident #21 was an [AGE] year-old female admitted to the facility 05/09/22 with diagnosis of dementia and GERD (gastroesophageal reflux disease). Orders included Sucralfate Suspension 1 GM/10ML - Give 10 ml by mouth before meals and at bedtime for gastric protection. (Used to treat acid from the stomach that flows up into the esophagus) <BR/>Record review of a care plan last revised 06/15/22 indicated Resident #21 required extensive assistance with ADLs due to impaired cognition to ensure ADLs are completed safely. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #21 lacked cognitive skills for daily decision making and had an active diagnosis of dementia and required extensive assistance with all ADLs. <BR/>During an observation on 08/08/22 at 10:00 a.m., a 30 ml plastic medicine cup with 10 ml of pink liquid was found on the overbed table beside Resident #21 ' s bed. Resident #21 was sleeping. <BR/>During an interview and record review at 10:05 a.m., LVN A said she had not noticed the medication cup in resident's room earlier. She said she had not prepared nor dispensed this medication to Resident #21 this morning. LVN A added she ' had been picking up medications left at bedside this morning from various resident rooms while performing her medication pass. When asked to elaborate by surveyor, she declined further details. Resident #21's EMR (electronic medical record) was reviewed with LVN A who determined contents of cup was sucralfate suspension and was dispensed on a previous shift. Resident #21 ' s Sucralfate Suspension 1 GM/10ML was not due again until before lunch and scheduled for 08/08/22 at 11:30 a.m. <BR/>During an interview on 08/10/22 at 12:15 p.m., the DON said her expectations were for staff to administer medications once prepared and should not be left at bedside for any reason. Any medication not ingested by residents should be discarded and staff should document it in the electronic record. <BR/>During an interview on 08/10/22 at 12:30 p.m., the administrator said staff should never leave medications unattended at resident bedside for any reason. If prepared medications are not taken, it should be discarded or returned to the cart. Medications left unattended have the potential for hazardous results including accidental ingestion by another resident. <BR/>An undated Medication Administration-General Guidelines policy provided by facility indicated the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B. Administration.18) The resident is always observed after administration to ensure that the dose was completely ingested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 residents reviewed for infection control. (Resident #226, #220 and #224)<BR/>Resident #226 was unvaccinated for Covid-19 admitted and was placed in a room with no special precautions.<BR/>Residents #220 and #224 were not fully vaccinated for Covid-19 and was admitted without special precautions.<BR/>This failure could place the residents, staff, and visitors at risk for the spread of infection.<BR/>Findings included:<BR/>1. The admission face sheet with print date of 08/10/2022 indicated Resident #226 indicated he admitted on [DATE] was [AGE] years old with diagnosis of heart disease.<BR/>Record review of physician orders for Resident #226 dated August 2022 indicated no evidence of orders for isolation precautions.<BR/>Record review of vaccine record on 08/08/2022 indicated Resident #226 was not vaccinated for Covid.<BR/>During an observation and interview on 08/08/2022 at 10:00 a.m., Resident #226 sitting in his room by himself and said he was here for therapy to get stronger. There was no sign on his door or isolation cart on the outside of his room to indicate any special precautions.<BR/>During an observation on 08/09/2022 at 1:15 p.m., Resident #226's room had no sign on the door to indicate isolation and no isolation cart near the door.<BR/>During an interview on 08/09/2022 at 1:30 p.m., DON and ADON/ICP said Resident #226 was in a warm isolation room and when they were informed of the Resident #226 not having a sign or isolation cart by his door on 08/08/2022 or 08/09/2022. DON and ADON/ICP said there was a sign on his door and maybe the sign fell off the door.<BR/>During an observation and interview on 08/09/2022 at 1:35 p.m. DON, ADON/ICP went to Resident #226's room, and both said there was not a sign warning of precautions/ or an isolation cart outside of the room. DON said she would find out if someone had removed the isolation cart and she said maybe he removed the sign. ADON/ICP said the door should have a sign to indicate special precautions. She said without the sign staff or visitors would not know what precautions were in place.<BR/>During an interview on 08/09/2022 at 1:45 p.m. LVN C said she was the charge nurse for Resident #226 and was responsible for his care and services. She said he was not on special precautions. LVN C said he was being closely monitored for signs and symptoms of Covid 19. She said no one had told her that he needed to be on isolation precautions. LVN C said she had been trained on Covid and the use of personal protective equipment.<BR/>During an observation on 08/09/2022 at 2:15 p.m., DON and ADON /ICP nurse placed sign on Resident #226 door to indicate special precautions to enter room and placed an isolation cart which contained personal protective equipment outside of the room.<BR/>During an observation on 08/09/2022 at 3:00 p.m. CNA (Certified Nurse Aide) D walked into Resident #226's room and walked over to the resident within 2 to 3 feet from Resident #226. CNA D asked Resident #226 if he wanted a shower, the CNA D did not have an isolation gown, gloves, or face shield on. CNA D was wearing a N-95 mask . CNA D came out into the hall and the CNA observed the sign on the door, and he said no one had told me and I didn't know. He said he had been trained in personal protective equipment and isolation precautions.<BR/>2. Record review of the admission face sheet with print date of 08/10/2022 for Resident #220 indicated she admitted on [DATE] was [AGE] years old with diagnoses of kidney failure.<BR/>Record review of Resident #220's vaccine report indicated she had received her Covid Vaccines on 04/09/2021 and 04/28/2021 and the clinical record dated 08/04/2022 to 08/10/2022 contained no indication of being boosted or of having Covid during the last 90 days.<BR/>Record review of physician orders for Resident #220 dated August 2022 indicated no evidence of orders for isolation precautions.<BR/>During an interview on 08/10/2022 at 10:00 a.m., DON and ADON/ICP nurse said then Resident #220 should had been admitted placed in an isolation room with precautions.<BR/>3. Record review of the admission face sheet with print date of 08/10/2022 for Resident #224 indicated she admitted on [DATE] and was [AGE] years old with diagnoses of respiratory failure.<BR/>Record review clinical record for Resident #224's vaccine report indicated she had received her 03/08/2021 [NAME] Covid vaccine and the contained no indication of being boosted or of having Covid during the last 90 days. The clinical record dated 08/05/2022 to 08/10/2022 contained no evidence of her being placed in isolation precautions.<BR/>Record review of physician orders for Resident #224 dated August 2022 indicated no evidence of orders for isolation precautions.<BR/>During an interview on 08/10/2022 at 10:00 a.m., DON and ADON said this Resident #224 was not boosted and should had been placed in isolation. They said if the residents were not placed in isolation precautions and if they developed Covid it could spread to other residents and staff.<BR/>During an interview on 08/10/2022 at 1:00 p.m. DON and ADON/ICP said they follow the CDC guidance and said both are responsible to make sure the staff follow the CDC guidance with training and monitoring the staff to ensure newly admitted residents, who are not fully vaccinated and who require special infection control precautions are placed in isolation.<BR/>The COVID-19 Response for Nursing Facilities dated 6/27/22 was obtained from the Internet on 08/10/2022 indicated CDC guidance indicated .New admissions, readmissions, and residents who have spent one or more nights away from the nursing facility are all considered residents with unknown COVID-19 status. All residents with unknown COVID-19 status must be quarantined per CDC guidance for long-term care facilities .<BR/>Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes | CDC was obtained from the Internet on 08/10/2022 indicated Residents with confirmed SARS-CoV-2 infection who have not met criteria to discontinue Transmission-Based Precautions should be placed in the designated COVID-19 care unit, regardless of vaccination status.In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse and neglect for 2 of 11 residents (Resident #5 and #4) reviewed for abuse and neglect. <BR/>1. CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. <BR/>An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>2. Resident #4 sustained a laceration to his left eyebrow and had blood in his mouth. Resident #4 indicated he fought with an unidentified staff. He was sent to the ER and received sutures. The facility identified the staff as CNA K. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of face sheet dated [DATE], indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's current care plan initiated [DATE] and revised on [DATE] indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of Kardex (electronic care needs) printed on [DATE] indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated [DATE], completed by LVN A indicated CNA C was providing incontinent care for Resident #5. CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of progress note dated [DATE] completed by LVN A, indicated CNA C was changing Resident #5 and she rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated [DATE] indicated Resident #5 sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur (thigh bone) metadiaphysis (the diaphysis (shaft or primary ossification centre), metaphysis (where the bone flares), right knee-minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella a flat, inverted triangular bone, situated on the front of the knee-joint proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla the space below the shoulder through which vessels and nerves enter and leave the upper arm; a person's armpit hematoma (A pool of clotted blood that forms in an organ, tissue, or body space). Her diagnoses included diffuse osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes) and osteopenia (a condition that begins as you lose bone mass and your bones get weaker). <BR/>Record review of hospital Discharge summary dated [DATE] indicated the fractures of Resident #5's left and right thigh bones were both repaired surgically.<BR/>During an interview on [DATE] at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on [DATE] after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries.<BR/>During an interview on [DATE] at 2:47 p.m., LVN A said on [DATE] at 10:00 a.m. she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said at the time of the incident, Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital at 12:00 p.m. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on [DATE] at 3:00 p.m. the DON said Resident #5's fall was reported to the Administrator on [DATE]. She said the Administrator said it was not reportable because it was a witnessed fall and not abuse. She said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there were two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff were required to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. She said the nurses were expected to monitor the aides to ensure care was provided per the care plans.<BR/>During an interview on [DATE] at 3:26 p.m., CNA C said on [DATE] at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 laid down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the Kardex indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the Kardex the day after the fall. She said the DON said it was not her fault because the Kardex was not updated. <BR/>During an interview on [DATE] at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the Kardex was not updated. She said the Kardex was populated by the care plan. She said Resident #5's care plan was in place from [DATE] and the Kardex was not changed.<BR/>During an interview on [DATE] at 3:45 p.m., the Administrator said Resident #5's fall off the bed on [DATE] was not reported because it was a witnessed fall. He said he did not suspect abuse or neglect. He said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware the DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the Kardex. He said CNA C was terminated on [DATE] for not calling and not showing for shifts. <BR/>During an observation and interview on [DATE] at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said she had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>During an interview on [DATE] at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the Kardex and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. He said the same situation could happen again if the facility did not recognize abuse or neglect. <BR/>During an interview on [DATE] at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the Kardex for a resident's level of care. She said she received retraining on [DATE] after the incident on the Kardex system and bed mobility prior to [DATE] and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the Kardex and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the Kardex. She said if staff did not follow the Kardex for care needs the resident could have serious injuries or die.<BR/>During an interview and record review on [DATE] at 1:04 p.m., the DON said they believed all staff were trained on [DATE] and [DATE] to check the Kardex for level of resident assistance required. She said she and the ADON monitored the care plans and Kardex weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. <BR/>During an interview on [DATE] at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the Kardex. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side before the fall on [DATE]. She said Resident #5 was not able to use her legs. She said resident care information was in the Kardex system. She said she was retrained on the Kardex system and bed mobility after the incident. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the Kardex system and bed mobility but forgot to sign. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 2:45 p.m., the RNC said she received an anonymous call from a blocked number. She said she was told of Resident #5's fall. She said she looked at Resident #5's clinical record and the hospital record. She said she called the CNO who told her the incident was reportable. She said she called the Administrator and told him the incident was reportable. She said the Administrator wanted the COO to review the incident. She said the COO agreed the incident was reportable as an allegation of neglect.<BR/>During an interview on [DATE] at 2:50 p.m., the DON said the incident of Resident #5's fall and injuries on [DATE] was neglect and reportable.<BR/>During an interview on [DATE] at 2:50 p.m. the ADON said incident of Resident #5's fall and injuries on [DATE] was neglect and reportable.<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated: The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.<BR/>Record review of the facility Resident Rights policy revised 02/21 indicated Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and implementation 1. Federal Law state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation; .<BR/>The Administrator and the DON as notified of the Immediate Jeopardy on [DATE] at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 12:35 p.m. and reflected the following: <BR/>1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. <BR/>2* Corrective Action<BR/>Nursing administration will review care plans and Kardex's for all residents to ensure they match with the resident's level of assistance required. This process began [DATE] and will be complete by 10 AM on [DATE]. All areas of concerns have been addressed and all care plans match all Kardex's for all residents. <BR/>All nursing staff will be in-service on where to find a resident's level of assistance in the Kardex. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. <BR/>All nursing staff will be in-service on abuse and neglect. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the Kardex/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. <BR/>All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM.<BR/>The Kardex showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the Kardex. <BR/>The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of [DATE] 4:30 PM. <BR/>3* Identification of Others<BR/>The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by [DATE] of all facility residents' administrative nurses. Assessment will compare care plans to Kardex. <BR/>The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. <BR/>A facility record audit of residents Kardex and care plans will be completed by Director of Nursing/Designee by [DATE] 10 AM.<BR/>4* Plan to prevent from recurring <BR/>Intervention for Neglect: DON/designee to evaluate care plan and Kardex for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on Kardex and levels of assistance prior to working the first shift. This is to be completed during orientation. <BR/>Training Plan<BR/>Initial Trainings: Facility to Initiate Training by [DATE] 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working [DATE], and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by [DATE] 10AM via in person on telephone training.<BR/>All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM.<BR/>Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations.<BR/>5* Ongoing Monitoring<BR/>Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate Kardex knowledge during rounds. <BR/>6* QAPI<BR/>In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed [DATE] by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate.<BR/>On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Observations, interviews, and record reviews were conducted on [DATE] from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the Kardex system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns.<BR/>Staff were able to discuss the required level of staff assistance for ADLs.<BR/>Staff were able to demonstrate the use of the Kardex system for resident care needs. <BR/>Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures.<BR/>Kardex for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the Kardex.<BR/>Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the Kardex.<BR/>Review of staff training indicated nursing staff were in-serviced on where to find a resident's level of assistance in the Kardex. The training was completed on [DATE]. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>Staff were in-service on abuse and neglect. The training was completed on [DATE]. <BR/>The 5-question quiz of Kardex knowledge given to all tested staff indicated all staff scored 100%.<BR/>The Kardex showed that Resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on [DATE]. <BR/>The administrator was in-service on [DATE] by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter.<BR/>There were no additional allegations of neglect or abuse identified during the investigation.<BR/>During an interview on [DATE] at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. <BR/>During an interview on [DATE] at 2:50 p.m., The DON said the audit of all residents' care plans and Kardex revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents.<BR/>A facility record audit dated [DATE] of residents' Kardex and care plans revealed no issues or concerns. <BR/>Staffing was reviewed for the previous two weeks and for [DATE]. There was no concerns noted.<BR/>Five residents said they were not afraid during care or had complaints of their care.<BR/>The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on [DATE].<BR/>An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>On [DATE] at 3:12 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>2. Record review of face sheet dated [DATE] indicated Resident #4 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included vascular dementia, diabetes, cognitive communication deficit, muscle weakness, muscle wasting and atrophy, and need for assistance with personal care.<BR/>Record review of MDS dated [DATE] indicated Resident #4 was usually able to express ideas and wants and able to understand others, had severe cognitive impairment, and required extensive assist of 1 persons for bed mobility and toilet use, 2+ person for transfers and personal hygiene. He was incontinent of bladder and bowel. There were no noted behaviors.<BR/>Record review of Resident #4's care plan indicated no care plans developed for aggression or behaviors.<BR/>Record review of incident report dated [DATE] and completed by LVN J indicated CNA K came to the nurse station and reported the resident had blood on his forehead. LVN J observed Resident #4 lying in bed with an open wound over his left eye with dried blood around the wound. When Resident #4 was asked what happened, Resident #4 said he said he had a fight with a nurse. Resident #4 was transported to the hospital.<BR/>Record review of Resident #4's hospital record dated [DATE] indicated Resident #4 said someone punched him.here for a fall according to (facility). Someone put Resident #4 back to bed, but no one knows who. Something happened last night that went unreported per EMS. 2 cm wound sutured with 4 sutures . Clinical impression: assault, facial laceration .SW was called to the ER to assist Resident #4 with possible NH abuse. Apparently the EMS staff advised LVN L that I (Resident #4) kicked a nurse and she hit me' . Communicating with Resident #4 is very difficult due to him being hard of hearing. The SW found Resident #4 to be awake and alert, just slow to respond. (In fact, he told the SW to please slow down. I might be old, but if I take my time I can get it all out. Resident #4 stated, I kicked my nurse and she hit me. I guess I made her mad. Resident #4 stated he was embarrassed that he kicked a woman and was remorseful for the event even occurring.<BR/>Record review of the facility investigation dated [DATE] indicated LVN J said CNA K came to the nurse station on [DATE] 15 minutes prior to the end of shift and reported Resident #4 had blood on his forehead. CNA K left the facility the immediately after she reported the blood on Resident #4. LVN O (day shift nurse) assisted with assessment. Resident #4 was lying in bed neatly tucked in bed. LVN O stated it looked staged how neatly Resident #4 was tucked in. Resident #4 sustained a laceration to his left eye and hematoma. There appeared to be blood in his mouth. There was a large amount of fresh blood on the privacy curtain adjacent to Resident #4's bed. When asked what happened, Resident #4 said he got in a fight with the nurse. Resident #4 was sent to the hospital for evaluation and assessment. CNA K was the only aide to provide care for Resident #4 on the night shift. The Administrator received a call from the SW at the hospital who reported Resident #4's injuries seemed suspicious to the hospital staff and Resident #4 told the EMS staff he got in a fight with the nurse. SW N interviewed Resident #4 and asked what happened. Resident #4 said he got in a fight with a nurse and said he had kicked the nurse as she hurt him when she moved him and she did not like that he kicked her. Resident #4 was not able to give a name or description. He received sutures above his eye and returned to the facility the same day. The night nurse and all CNAs were suspended. It was noted Resident #4 refers to all staff as nurse and did not differentiate between aides and nurses. The administrator observed a large amount of blood on the privacy curtain. It was bright red and appeared fresh. CNA K was the only staff identified to provide care for Resident #4 on [DATE]. CNA K returned to the facility to give her statement. She appeared nervous and fidgeted during the interview. She had black bandages on the middle and ring finger of her right hand. The ADON noted scratches on the fingers. CNA K indicated she was right-handed. CNA K refused to remove the bandages. CNA K said she did not know what happened to Resident #4. CNA K changed her statement to reporting the incident to the nurse early in the shift and then changed it back to the end of her shift. She denied Resident #4 had a fall or if there was an argument or a scuffle. <BR/>Progress note dated [DATE] indicated Resident #4 expired after testing positive for Covid-19 on [DATE] (unrelated to the abuse).<BR/>The investigator attempted to call CNA K on [DATE] at 12:27 p.m. The person who answered the phone said no when the investigator asked to speak to CNA K and disconnected the call. The investigator left a text message at 12:31 p.m. for CNA K at the same number and received no response.<BR/>Record review of CNA K's statement (undated) indicated she checked on Resident #4 and noticed dried up blood on his face and reported to the charge nurse. She checked on him a second time with CNA N, there was still blood on Resident #4 but she assumed LVN J had reported it.<BR/>Record review of LVN O's statement dated [DATE] indicated she arrived at the facility on [DATE] at approximately 5:45 a.m. She started rounds and observed Resident #4 lying in bed with blood and hematoma noted above his left eye. Blood was also noted in Resident #4's mouth with no visual laceration noted to his mouth. Resident #4 was sent to the ER for evaluation and treatment.<BR/>Record review of CNA M's statement

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards of practice for 1 of 19 residents reviewed for respiratory care and services. (Resident #9)<BR/>The facility did not provide Resident #9's oxygen with a clean filter. The filter was covered with a thick layer of white powdery substance.<BR/>This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life. <BR/>Findings included:<BR/>Record review of a face sheet dated 09/11/23 indicated Resident #9 was a [AGE] year-old female readmitted on [DATE] with diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves resulting in nerve damage disrupts communication between the brain and the body) and heart failure (a chronic condition in which the heart does not pump blood as well as it should).<BR/>Record review of the physician orders dated 09/11/23 indicated Resident #9 had diagnoses including multiple sclerosis and heart failure. The orders indicated Resident #9 was prescribed oxygen at 2 liters per minute per nasal cannula (a device that delivers extra oxygen through a tube into a person's nose) every shift for hypoxia with a start date of 12/23/22.<BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 3 indicating severely impaired cognition and received oxygen during last 14 days. Resident #9 had diagnoses of multiple sclerosis and heart failure.<BR/>Record review of the care plan revised 04/06/23 indicate Resident #9 had an altered respiratory status and breathing difficulty and received oxygen as ordered.<BR/>Record review of a MAR dated 09/12/23 indicated Resident #9 received oxygen at 2 liters per minute per nasal cannula every shift for hypoxia from 09/01/23 to 09/12/23. <BR/>During an observation and interview on 09/11/23 at 1:00 p.m., Resident #9 was lying in bed wearing oxygen at 2 liters per nasal cannula with a filter on the oxygen concentrator covered with a thick layer of white powdery substance. Resident #9 said she wears her oxygen when she was in bed. <BR/>During an observation on 09/12/23 at 2:48 p.m., Resident #9 was lying in bed wearing oxygen at 2 liters per nasal cannula with a filter on the oxygen concentrator covered with a thick layer of white powdery substance. <BR/>During an observation and interview on 09/12/23 at 2:49 p.m., LVN E said Resident #9 was her patient this week, she checked Resident #9's oxygen concentrator's filter and said it was dirty and should have been cleaned. She said she did not see it and did not think to clean it. LVN E said she had been here a month and 1/2 and never cleaned that filter and had not been in-serviced on cleaning filters and concentrators. LVN E said she was unsure of a backup to check the filters. LVN E said the risk was contamination to the resident by a dirty filter.<BR/>During an interview on 09/12/23 at 3:00 p.m., the DON and ADON said the night shift nurse was responsible for changing the oxygen tubing and cleaning the oxygen concentrator filters and the day shift nurse was to double check and clean the oxygen concentrator filters. They said Resident #9's concentrator filter was just overlooked. They said the staff were in-serviced recently on cleaning the oxygen concentrator filters and changing the oxygen tubing weekly. They said Resident # 9's filter should have been changed and not left dirty. The DON said the risk was a resident not getting the proper amount of oxygen prescribed.<BR/>During an interview on 09/13/23 at 2:55 p.m., the ADM said his expectation was oxygen concentrator filters be washed weekly with the oxygen tubing change. He said the nurses and CNAs were responsible for cleaning the oxygen concentrator filters and were in-serviced on it. The Administrator said the risk of a dirty filter was the oxygen concentrator may not work as efficiently as it should.<BR/>Record review of an Employee In-service Record dated 09/13/23 indicated the filter on the back of the concentrators must be cleaned weekly with the night shift responsible and all shifts monitoring with LVN E's signature on it.<BR/>Record review of a policy revised November 2011, titled, Departmental (Respiratory Therapy) - Prevention of Infection indicated, .9. Wash filters from oxygen concentrator every seven days with soap and water. Rinse and squeeze dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 3 of 9 residents reviewed for accurate medical records. (Residents #15, #55, and #61) <BR/>The facility did not ensure staff documented on the MARs medications were administered to Residents #15, #55, and #61.<BR/>This failure could place residents at risk of not receiving care and services to meet their needs. <BR/>Findings included: <BR/>1. Record review of October 2024 physician orders for Resident #15 indicated she was a [AGE] year-old female admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease ((COPD) a lung disease that blocks airflow making it difficult to breathe), gastro-esophageal reflux disease ((GERD) stomach contents leak backward from the stomach into the esophagus (food pipe)), hyperlipidemia (abnormally high levels of fats (lipids) in the blood), hypertension (a condition in which the force of the blood against the artery walls is too high), anxiety (persistent and excessive worry that interferes with daily activities), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and urinary tract infection ((UTI) an infection in the kidneys, ureters, bladder, or urethra).<BR/>Record review of the current MDS dated [DATE] indicated Resident #15 had moderately impaired cognition; she required substantial/maximum assistance for toileting hygiene; she was always incontinent of bladder; she had active diagnoses including hypertension, hyperlipidemia, depression, anxiety, and COPD; and she received antidepressant and antianxiety.<BR/>Record review of the current care plan revised 08/27/24 for Resident #15 indicated the following:<BR/>* she had impaired cognitive function/dementia or impaired thought processes with interventions including administer medications as ordered;<BR/>* she had coronary artery disease related to myocardial infarction with interventions including give medications for hypertension and give medications to control cholesterol level as ordered by the physician;<BR/>* she had has hypertension with interventions including give anti-hypertensive medications as ordered;<BR/>* she had an alteration in neurological (dizziness) related to vertigo and<BR/>lack of coordination with medication of antiemetic with interventions including give medications as ordered;<BR/>* she had COPD/Emphysema related to history of smoking with interventions including give aerosol or bronchodilators as ordered;<BR/>* she had GERD and acid reflux related to hyperacidity with interventions including give medications as ordered; and <BR/>* she had nausea and vomiting related to GERD and the use/side effects of medications with interventions including administer antiemetics as ordered.<BR/>Further review of the October 2024 physician orders for Resident #15 indicated she had the following orders:<BR/>* dated 10/03/24 for Nitrofurantoin (antibiotic) 100 mg give 1 capsule by mouth two times a day for UTI for 7 days;<BR/>* dated 09/07/24 for Cefpodoxime Proxetil (antibiotic) 100 mg give 1 tablet by mouth two times a day for UTI for 14 Days;<BR/>* dated 08/27/24 for Remeron (antidepressant) 15 mg (Mirtazapine) give 15<BR/>mg by mouth at bedtime for depression/appetite; <BR/>* dated 02/22/24 for Atorvastatin (to treat hyperlipidemia) 20 mg give 1 tablet by<BR/>mouth at bedtime for hyperlipidemia;<BR/>* dated 02/23/24 for Pantoprazole (to treat GERD) Delayed Release 40<BR/>mg give 1 tablet by mouth one time a day for GERD;<BR/>* dated 05/28/24 for Famotidine (to treat GERD) 20 mg give 1 tablet by mouth two times a day for acid reflux; <BR/>* dated 02/22/24 for Fluticasone Propionate (to treat nasal congestion) Nasal Suspension 50 mcg/act 1 spray in each nostril two times a day for congestion;<BR/>* dated 02/22/24 for Meclizine (antiemetic to treat nausea) 25 mg give 1 tablet by mouth two times a day for nausea; <BR/>* dated 02/22/24 for Metoprolol Tartrate (antihypertensive) 25 mg give 1 tablet by mouth two times a day for hypertension; <BR/>* dated 04/09/24 for buspirone (antianxiety)10 mg give 1 tablet by<BR/>mouth three times a day for anxiety; <BR/>* dated 02/22/24 for Ipratropium-Albuterol (asthma/COPD therapy) Solution 0.5-2.5 mg/3ml 1 vial inhale orally via nebulizer four times a day related to chronic obstructive pulmonary disease.<BR/>During an observation and interview on 10/14/24 at 10:03 a.m. Resident #15 was in bed with the bed in low position and had an air mattress. She was clean, neat, and had no odors. She was not able to answer questions appropriately. <BR/>Record review of the September 2024 MAR for Resident #15 indicated the following:<BR/>* on 09/08 and 09/22, did not have documentation she received the 05:00 a.m. dose of Pantoprazole Sodium Delayed Release 40 mg.<BR/>* on 09/07, did not have documentation she received the 05:00 p.m. dose of:<BR/>Famotidine 20 mg;<BR/>Fluticasone Propionate Nasal Suspension 50 mcg/act;<BR/>Meclizine HCl 25 mg;<BR/>Metoprolol Tartrate 25 mg;<BR/>buspirone HCl 10 mg; and <BR/>Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml.<BR/>* on 09/07, 09/17, 09/18, and 09/22, did not have documentation she received the 08:00 p.m. dose of Atorvastatin 20 mg.<BR/>* on 09/07, 09/17, 09/18, and 09/22, did not have documentation she received the 09:00 p.m. dose of:<BR/>Remeron 15 mg;<BR/>Cefpodoxime Proxetil 100 mg; and<BR/>Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml.<BR/>All of the entries were left blank. <BR/>Record review of the October 2024 MAR for Resident #15 indicated the following:<BR/>* on 10/09, did not have documentation she received the 05:00 a.m. dose of Pantoprazole Sodium Delayed Release 40 mg.<BR/>* on 10/07, 10/08, and 10/11, did not have documentation she received the 08:00 p.m. dose of Atorvastatin Calcium 20 mg.<BR/>* on 10/07 and 10/08, did not have documentation she received the 09:00 p.m. dose of Nitrofurantoin Macrocrystal Oral Capsule 100 mg;<BR/>* on 10/07, 10/08, and 10/11, did not have documentation she received the 09:00 p.m. dose of Remeron 15 mg; and <BR/>* on 10/04, 10/07, 10/08, and 10/11, did not have documentation she received the 09:00 p.m. dose of Ipratropium-Albuterol Solution 0.5-2.5 mg/3ml.<BR/>All of the entries were left blank.<BR/>2. Record review of a face sheet dated 10/16/24 indicated Resident #55 was an [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (loss of cognitive functioning), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and hypertensive heart disease without heart failure (caused by chronically high blood pressure).<BR/>Record review of the current MDS dated [DATE] indicated Resident #55 had severely impaired cognition; he was dependent on staff for toileting hygiene; he was always incontinent of bladder; he had active diagnoses including hyperlipidemia, Alzheimer's disease, and dementia; and he received medications of antipsychotic and antidepressant.<BR/>Record review of the current care plan for Resident #55 indicated he had a care plan: <BR/>* revised on 04/29/24, he had hyperlipidemia with interventions including administer meds as ordered;<BR/>* initiated on 10/14/24, he had a current acute infection and is on antibiotics: (UTI) with interventions including treatment(s) as ordered by MD/NP;<BR/>* initiated on 07/22/24, he had a behavior problem such as making sexual comments at staff while self-pleasuring and placed on antidepressant with interventions including administer medications as ordered;<BR/>* initiated on 01/29/24, he was physically aggressive touching staff inappropriately and hitting staff related to dementia with interventions including administer medications as ordered.<BR/>Record review of the October 2024 physician orders for Resident #55 indicated he had the following orders:<BR/>* dated 10/10/24 for Ciprofloxacin (antibiotic) 500 mg give 500 mg by<BR/>mouth two times a day for UTI for 10 days;<BR/>* dated 04/04/23 for Atorvastatin (to treat hyperlipidemia) calcium 20 mg give 1 tablet by mouth at bedtime related to hypertensive heart disease without heart failure;<BR/>* dated 04/20/24 for Mirtazapine (antidepressant) 30 mg give 1 tablet by mouth at<BR/>bedtime related to dementia; and<BR/>* dated 04/25/24 for Seroquel (antipsychotic) 25 mg (Quetiapine Fumarate) give 25 mg by mouth two times a day for agitation/sundowning.<BR/>During an observation and interview on 10/14/24 at 10:01a.m. Resident #55 was in the bed. He was clean, neat, and had no odors. He was not able to answer questions appropriately.<BR/>Record review of the September 2024 MAR for Resident #55 indicated the following:<BR/>* on 09/17, 09/18, and 09/22, did not have documentation he received the 08:00 p.m. dose of Atorvastatin Calcium 20 mg; and <BR/>* on 09/17, 09/18, and 09/22, did not have documentation he received the 09:00 p.m. dose of:<BR/>Remeron 15 mg;<BR/>Seroquel Oral Tablet 25 mg.<BR/>All of the entries were left blank.<BR/>Record review of the October 2024 MAR for Resident #55 indicated the following:<BR/>* on 10/07, 10/08, and 10/11, did not have documentation he received the 08:00 p.m. dose of Atorvastatin Calcium 20 mg;<BR/>* on 10/07, 10/08, and 10/11, did not have documentation he received the 09:00 p.m. dose of:<BR/>Mirtazapine 15 mg;<BR/>Seroquel Oral Tablet 25 mg; and <BR/>* on 10/11, did not have documentation he received the 09:00 p.m. dose of Ciprofloxacin 500 mg.<BR/>All of the entries were left blank. <BR/>3. Record review of the face sheet dated 10/16/24 indicated Resident #61 was an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (loss of cognitive functioning), major depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act), hypertension (a condition in which the force of the blood against the artery walls is too high), and tremors (involuntary movements of the body).<BR/>Record review of the current MDS dated [DATE] indicated Resident #61 had severely impaired cognition and he had active diagnoses including hypertension, Alzheimer's disease, dementia, and depression. <BR/>Record review of the current care plan revised on 10/01/24 for Resident #61 indicated: <BR/>* he had hypertension with interventions including give anti-hypertensive medications as ordered;<BR/>* he had tremors and received anticonvulsant medication with interventions including give medications as ordered by the physician;<BR/>* he had constipation related to decreased mobility with interventions including administer medications as ordered; <BR/>* he had impaired cognitive function and impaired thought process related to Alzheimer's disease with interventions including administer medications as ordered; and<BR/>* he had depression and received an anticonvulsant with interventions including administer medication as ordered by physician.<BR/>Record review of the October 2024 physician orders for Resident #61 indicated he had the following orders:<BR/>* dated 12/01/22 for Donepezil (to treat Alzheimer's disease) 10 mg give 10 mg by mouth at bedtime for Alzheimer;<BR/>* dated 09/04/24 for Metoprolol Succinate (antihypertensive) Extended Release 25 mg give 1 tablet by mouth at bedtime for hypertension; <BR/>* dated 11/07/22 for Docusate Sodium (stool softener) 100 mg give 1 capsule by mouth two times a day related to constipation;<BR/>* dated 10/11/23 for Depakote (anticonvulsant) Delayed Release 125 mg (Divalproex Sodium) give 125 mg by mouth three times a day for depression; and <BR/>* dated 10/10/23 for Primidone (anticonvulsant) 50 mg give 50 mg by mouth three times a day for tremors.<BR/>During an observation on 10/14/24 at 10:14 a.m. Resident #61 was in bed. He was clean, neat, and had no odors. He was calm and had no indication of agitation. <BR/>Record review of the September 2024 MAR for Resident #61 indicated the following:<BR/>* on 09/28, did not have documentation he received the 01:00 p.m. dose of:<BR/>Depakote Delayed Release 125 mg;<BR/>Primidone 50 mg; and <BR/>* on 09/17, 09/18, and 09/22, did not have documentation he received the 09:00 p.m. dose of:<BR/>Donepezil 10 mg<BR/>Metoprolol Succinate Extended Release 25 mg<BR/>All of the entries were left blank. <BR/>Record review of the October 2024 MAR for Resident #61 indicated the following:<BR/>* on 10/07, 10/08, and 10/11, did not have documentation he received the 09:00 p.m. dose of:<BR/>Donepezil 10 mg; and<BR/>Metoprolol Succinate Extended Release 25 mg.<BR/>All of the entries were left blank.<BR/>During an interview on 10/16/24 at 12:30 p.m., the DON said she expected the nurses to document when they gave medications at the time they give the medications. She said missed documentation of medications could make it appear the resident did not receive their medications and could cause double dosing. <BR/>During an interview on 10/16/24 at 12:45 p.m., the DON said she contacted the nurses for the night shift on the days of the missing medication documentation. She said RN C told her the hall was split between her and another nurse. She said RN C told her she gave her medications. <BR/>During a phone interview on 10/16/24 at 12:55 p.m., RN C said had Residents #15, # 55, and #61 on the evenings of the missed medications. She said she may have forgotten to document that the medications were given but she did give them. She said missed documentation of medications could make it appear the resident did not receive their medications and could cause double dosing. <BR/>Record review of a Charting and Documentation policy revised July 2017 indicated Policy Interpretation and Implementation: 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 8 residents (Resident #1) reviewed for medication administration.<BR/>The facility failed to ensure Resident #1 received 4 applications of antifungal shampoo.<BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications. <BR/>Findings included: <BR/>Record review of a face sheet dated 05/08/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses anxiety and chronic pain.<BR/>Record review of an MDS assessment dated [DATE] indicated Resident #1 had moderate impaired cognition. She required supervision for personal hygiene. She required physical help for bathing.<BR/>Record review of a care plan dated 01/25/23 (revised on 05/08/23) indicated Resident #1 had ADL self-care performance deficit related to confusion, impaired balance and pain. Interventions included: Bathing/Showering-Avoid scrubbing and pat dry sensitive skin. Wash hair with Ketoconazole Shampoo 2% (antifungal medication - treats fungal or yeast infections in skin) and apply to affected areas of skin prn.<BR/>Record review of physician order dated 05/01/23, created by LVN A indicated Received a call from MD B with new order Ketoconazole (antifungal) 2% shampoo once a day X 5 then . Order summary: Ketoconazole Shampoo 2% Apply to scalp (shampoo) topically every day shift every 5 day(s) for scalp X 5 days then prn.<BR/>Record review of MAR/TAR dated 05/23 indicated Ketoconazole Shampoo 2% Apply to scalp (shampoo) topically every day shift every 5 day(s) for scalp X 5 days then prn. Resident #1's hair was shampooed on 05/02/23 and 05/07/23. Resident #1's hair was not shampooed as ordered on 05/03/23, 05/04/23, 05/05/23, or 05/06/23. There was an X on 05/03/23, 05/04/23, 05/05/23, and 05/06/23 of the MAR/TAR. The next day Resident #1 was scheduled for her hair shampoo was 05/12/23.<BR/>Record review of a skin assessment dated [DATE], completed by the ADON indicated Resident #1 continued to have raised crusty areas on the top of her scalp and on the back of her right hand.<BR/>During an observation and interview on 05/08/23 at 10:15 a.m., Resident #1 shook her head no and touched her hair when asked if staff washed her hair. She shrugged her shoulders when asked when her hair was last washed. Observation of Resident #1's hair and visible scalp area did not show visible skin issues. Her hair appeared clean.<BR/>During an interview and record review on 05/08/23 at 1:25 p.m., LVN A said she made an error when she input MD B's order for Resident #1's antifungal shampoo in the electronic record. She said she received a call from the pharmacy for clarification of the order and the shampoo bottle had the correct orders on the label. Record review of the shampoo bottle label indicated to shampoo Resident #1's hair for 5 days then prn. LVN A said she forgot to make the corrections in the electronic record. <BR/>During an interview on 05/08/23 at 2:25 p.m., the DON said she and the ADON were responsible for reviewing all orders and the MAR. She said she was off and the ADON was to review the orders and MAR. The ADON said she should have reviewed Resident #1's physician orders and MAR but it was not done because she was working the floor. The DON said Resident #1's skin condition would take longer to heal if the medicated shampoo was not applied as ordered.<BR/>Record review of the facility policy for Medication Orders revised 11/14 indicated: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders . 6. Treatment Orders-When recording treatment orders, specify the treatment, frequency, and duration of the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors.<BR/>The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure.<BR/>An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at risk of not receiving their medications as ordered, illness, hospitalizations, exacerbation of their disease processes, and death. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of na&iuml;ve coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat).<BR/>Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants.<BR/>Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. An unidentified staff indicated the order needed clarification. There was no documentation on the Discharge Home Medication List of the medication clarification.<BR/>Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. <BR/>Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued.<BR/>Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered.<BR/>Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. <BR/>Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24.<BR/>Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). <BR/>Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation.<BR/>Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested.<BR/>Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg. related to atherosclerotic heart disease of native coronary with unspecified angina pectoris.<BR/>Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related coffee ground emesis (vomit). The DON and MD were notified. RP was at bedside.<BR/>Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs had become mottled and cool. She was diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24.<BR/>Record review of Resident #1's hospice records dated 05/23/24 indicated passed away on 05/23/24 of heart failure.<BR/>During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on [DATE]. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto.<BR/>During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness. She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on [DATE] due to vomiting.<BR/>During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. <BR/>During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. <BR/>During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. <BR/>During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA. She said NP A never wrote orders for the Eliquis or ASA or Xarelto. <BR/>During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism or a blood clot due to DVT. <BR/>During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes.<BR/>LVN C was no longer employed with the facility and was not available for an interview.<BR/>Record review of the facility's Medication Therapy policy dated 2001 (revised 2007) indicated<BR/>1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks.<BR/>2. <BR/>Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments.<BR/>3. <BR/>All medication orders will be supported by appropriate care processes and practices.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>The resident's clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident.<BR/>2. <BR/>All decisions related to medications shall include appropriate elements of the care process, such as: <BR/>a. <BR/>Adequately detailed assessment;<BR/>b. <BR/>Review of causes of symptoms;<BR/>c. <BR/>Consideration of the clinical relevance of symptoms and abnormal diagnostic test results;<BR/>d. <BR/>Principles of prescribing for the elderly; and<BR/>e. <BR/>Each resident's wishes, values, goals, condition, and prognosis.<BR/>Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m.<BR/>The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following:<BR/>Resident #1 was discharged to the hospital on 5/17 24 and no longer resides in the facility.<BR/>A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. <BR/>In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director - All other licensed staff will be in-serviced prior to working next shift. <BR/>Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm<BR/>Facilities Plan to ensure compliance quickly: <BR/>Facility interventions were implemented to remove immediate jeopardy: <BR/>A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. <BR/>Education was completed with the Administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. <BR/>In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON if unable to verify orders after 2 attempts. DON/ADON will then notify the medical director.<BR/>*Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings.<BR/>On 06/16/24, the surveyor confirmed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the HER. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. <BR/>Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. <BR/>Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly.<BR/>Record review of the resident census dated 06/16/24 indicated here were no new admissions to the facility.<BR/>Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m. and included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m. to 6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the practitioner and documented in the progress notes.<BR/>During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. <BR/>During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. <BR/>On 06/16/24 at 1:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure recommendations from PASARR evaluation were incorporated for 1 of 7 residents reviewed for coordination of PASRR services. (Resident #38)<BR/>Facility failed to provide specialized services for PASRR positive residents as agreed to during Resident #38's IDT meeting or provide information the services were no longer needed by the required timeframe.<BR/>This failure could place the residents with intellectual and developmental disabilities at risk of not receiving specialized services that would enhance their highest level of functioning.<BR/>Findings included:<BR/>Record review of a face sheet printed on 09/30/23 indicated Resident #38 was a [AGE] year-old male who admitted on [DATE]. His diagnoses included spastic quadriplegic cerebral palsy, epilepsy, abnormal posture, fusion of lumbar region of spine, and schizoaffective disorder bipolar type.<BR/>Record review of a PASRR Level 1 Screening dated 02/07/23 indicated Resident #38 had intellectual disability and developmental disability.<BR/>Record review of a PASRR Evaluation dated 02/10/23 indicated Resident #38 did meet criteria for ID/DD. <BR/>Record review of Resident #38's MDS dated [DATE] indicated he currently was considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition with intellectual disability and other related condition marked and he had a BIMS score of 15 out of 15 indicating he was cognitively intact.<BR/>Record review of Resident #38's care plan initiated 03/06/23 indicated the facility Interdisciplinary Team (IDT) has determined that the resident PASRR positive due to diagnoses of Cerebral Palsy and Intellectual Disability. Interventions included coordinate services with representative from the LMHA-Spindletop MHMR.<BR/>Surveyor requested IDT meeting dated 02/16/23 and PSCP dated 02/22/23 from the MDS Nurse but was not provided. <BR/>Record review of an email dated 06/26/23 at 04:46 p.m. from the PASRR Unit- Program Specialist<BR/>IDD Services indicated:<BR/>* the email was sent to the MDS Nurse and the ADM. <BR/>* This email is to summarize our phone conversation regarding your facility's non-compliance with the requirements outlined in the Texas Administrative Code, Chapter 19, Subchapter BB, section &sect;19.2704(i)(7)(A), which states your facility must initiate nursing facility specialized services within 20 business days after the date that the services are agreed to in the IDT meeting for the resident we spoke about.<BR/>As discussed on the phone, you will need to submit a NFSS request form for PASRR Specialized Services for DME for orthotic device and Special Needs car seat by 6/30/23 <BR/>* A complaint against your facility will be submitted to the Health and Human Services Commission Regulatory Division and a complaint investigation will be conducted because of one of the following:<BR/>o If the IDD PASRR Unit does not receive the NFSS request for specialized services in the LTC Portal by the specified due date(s) documented in this email.<BR/>o If a NFSS request is denied and the Nursing Facility did NOT complete a follow up request to ensure services were approved for the resident.<BR/>o The facility did not request a Service Planning Team (SPT) meeting with the resident's LIDDA by the noted due date to document changes, remove/update the services from the resident's comprehensive care plan in the portal on the PCSP form. (This would need to be completed if the individual's Medicaid is not active, if the PASRR specialized services are no longer needed or the resident is refusing services) <BR/>Record review of Resident #38's PCSP form Quarterly IDT/SPT Meeting dated 07/25/23 indicated in section A2900 Durable Medical Equipment: B) Orthotic device was coded (discontinued) and E) Special needs car seat or travel restraint was coded 4 (discontinued). Section A3200 Nursing Facility comments: New PSCP submitted due to new PL1 with added MI. Orthotic device and Special needs car seat discontinued due to family and resident stated no longer needed at this time. Also, unable to find DME provider that accepts PASRR Medicaid or that supplies specialized car seats. <BR/>Record review of Resident #38's care plan revised on 07/24/23 indicated his specialized services were PT/OT/ST. <BR/>During an interview 09/12/23 at 03:27 p.m. the MDS Nurse said she was responsible for following up with the PASRR services. She said it was important to follow up with the recommended services to help the resident. She said she did not submit the NFSS form because she was not able to locate a vendor for the items that were needed. She said once she submitted the form then she would 30 days to obtain the items needed. She said she tried contacting other facilities to find a vendor and could not find one. She said because of the difficulty they were having to find a vendor to provide the services Resident #38 was needing the resident's RP decided they did not take him out of the facility enough for them to have to have the car seat. She said she did not realize she had to have everything done by 06/30/23. She said she was not able to locate an email from the PASRR Unit Coordinator.<BR/>During an interview on 09/12/23 at 03:39 p.m. the Corporate MDS Nurse said she did not realize they were to submit the NFSS form into the portal when they could not find a vendor to provide a specialized service.<BR/>During an interview on 09/13/23 at 08:45 a.m., the ADM said he was not aware facility failed to provide specialized services for PASRR positive residents as agreed to during Resident #38's IDT meeting. He said had not received an email from the PASRR. <BR/>During an interview on 09/13/23 at 08:45 a.m., the MDS nurse said when she spoke with the PASRR Unit IDD Program Specialist on the phone she told her there were two ways to address the DME with one being to submit the NFSS form and try to obtain the items or to have an IDT meeting to cancel the need for them. She said they had several meetings prior to the IDT meeting she provided the surveyor dated 07/25/23 and would provide copies.<BR/>During the exit interview on 09/13/23 at 05:40 p.m. the facility ADM and DON was asked if they had any further information regarding the findings of the survey and they said they did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 19 residents reviewed for ADL care. (Resident #61)<BR/>The facility did not ensure Resident #61's fingernails were trimmed.<BR/>This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Record review of the physician orders dated September 2023 indicated Resident #61, re-admitted on [DATE], was [AGE] years old with diagnoses of metabolic encephalopathy (alteration in consciousness due to brain dysfunction), lack of coordination and cognitive communication deficit. <BR/>Record review of the MDS assessment dated [DATE] indicated Resident #61 had a BIMs score of 99 (score indicated resident was unable to complete the interview for mental status). The resident required total assistance of 2 persons for personal hygiene and had impairment to one side of the upper extremities. <BR/>Record review of a care plan updated 5/18/23 indicated Resident #61 had a self-care performance deficit related to confusion, limited mobility and limited range of motion. The intervention for personal hygiene indicated the resident required total assistance of two staff for personal hygiene and oral care. <BR/>During the following observations Resident #61's nails to her bilateral hands were approximately 1/2 past the tips of her fingers with jagged edges noted. The resident was not able to be interviewed:<BR/>*on 09/11/23 at 11:25 a.m.,<BR/>*on 09/12/23 at 12:58 a.m., <BR/>*on 09/13/23 at 9:05 a.m., and <BR/>*on 09/14/23 at 9:14 a.m.<BR/>During an observation on 09/11/23 at 11:25 a.m., CNA C entered the room and pulled the covers back to reveal Resident #61 had 1/2 long fingernails to both hands. The fingers to the right hand were contracted inward to the palm of the hand. There were no open areas to palm of the right hand. The CNA did not acknowledge the resident's nails were long. She said the resident was taken care of by CNA B and she only assisted the resident when she helped CNA B with care. <BR/>During observation and interview on 09/13/23 at 9:05 a.m., LVN A entered the room and pulled the covers off of Resident #61 to reveal the resident's right hand contracted with fingernails approximately 1/2 past the tips of each finger. There were no open areas to the palm of the right hand. The fingernails to the left hand were also approximately &frac12; past the tips of each finger. The LVN said the resident's nails did need to be trimmed. She said the CNAs were responsible for ensuring the nails were trimmed. LVN A then told CNA B to get the clippers and trim Resident #61's fingernails. CNA B said she could not find the clippers. LVN A said the clippers were in central supply. LVN A said she should be monitoring the resident's ADL care needs when she did her initial daily rounds. She said she did not notice the resident's nails needed to be trimmed. The LVN said the possible negative outcome could be that the nails would cut into the resident's skin. <BR/>During an interview on 09/13/23 at 9:08 a.m., CNA B said Resident #61's nails needed to be trimmed, but she could not find the nail clippers. She said she did not notice the resident's fingernails were long. She said it was her responsibility to check the resident's nails and clip them when needed. She said the possible negative outcome could be the fingernails would dig into the resident's skin and possibly cause infection. <BR/>During an interview on 09/13/23 at 9:14 a.m., the DON said Resident #61's nails were too long and needed to be trimmed. She said the aide should be making sure all resident's nails were trimmed. She said the resident's nails could cut into the skin and cause infection. She said her expectations were for the residents' nails to be kept trimmed. <BR/>During an interview on 09/13/23 at 11:34 a.m., the ADM said residents' nails should be trimmed routinely and as needed. He said his expectations were for the residents' fingernails to be trimmed routinely. <BR/>Record review of an Activities of Daily Living (ADLs), Supporting policy revised March 2018, indicated: . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards of practice for 1 of 19 residents reviewed for respiratory care and services. (Resident #9)<BR/>The facility did not provide Resident #9's oxygen with a clean filter. The filter was covered with a thick layer of white powdery substance.<BR/>This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life. <BR/>Findings included:<BR/>Record review of a face sheet dated 09/11/23 indicated Resident #9 was a [AGE] year-old female readmitted on [DATE] with diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves resulting in nerve damage disrupts communication between the brain and the body) and heart failure (a chronic condition in which the heart does not pump blood as well as it should).<BR/>Record review of the physician orders dated 09/11/23 indicated Resident #9 had diagnoses including multiple sclerosis and heart failure. The orders indicated Resident #9 was prescribed oxygen at 2 liters per minute per nasal cannula (a device that delivers extra oxygen through a tube into a person's nose) every shift for hypoxia with a start date of 12/23/22.<BR/>Record review of an annual MDS assessment dated [DATE] indicated Resident #9 had a BIMS score of 3 indicating severely impaired cognition and received oxygen during last 14 days. Resident #9 had diagnoses of multiple sclerosis and heart failure.<BR/>Record review of the care plan revised 04/06/23 indicate Resident #9 had an altered respiratory status and breathing difficulty and received oxygen as ordered.<BR/>Record review of a MAR dated 09/12/23 indicated Resident #9 received oxygen at 2 liters per minute per nasal cannula every shift for hypoxia from 09/01/23 to 09/12/23. <BR/>During an observation and interview on 09/11/23 at 1:00 p.m., Resident #9 was lying in bed wearing oxygen at 2 liters per nasal cannula with a filter on the oxygen concentrator covered with a thick layer of white powdery substance. Resident #9 said she wears her oxygen when she was in bed. <BR/>During an observation on 09/12/23 at 2:48 p.m., Resident #9 was lying in bed wearing oxygen at 2 liters per nasal cannula with a filter on the oxygen concentrator covered with a thick layer of white powdery substance. <BR/>During an observation and interview on 09/12/23 at 2:49 p.m., LVN E said Resident #9 was her patient this week, she checked Resident #9's oxygen concentrator's filter and said it was dirty and should have been cleaned. She said she did not see it and did not think to clean it. LVN E said she had been here a month and 1/2 and never cleaned that filter and had not been in-serviced on cleaning filters and concentrators. LVN E said she was unsure of a backup to check the filters. LVN E said the risk was contamination to the resident by a dirty filter.<BR/>During an interview on 09/12/23 at 3:00 p.m., the DON and ADON said the night shift nurse was responsible for changing the oxygen tubing and cleaning the oxygen concentrator filters and the day shift nurse was to double check and clean the oxygen concentrator filters. They said Resident #9's concentrator filter was just overlooked. They said the staff were in-serviced recently on cleaning the oxygen concentrator filters and changing the oxygen tubing weekly. They said Resident # 9's filter should have been changed and not left dirty. The DON said the risk was a resident not getting the proper amount of oxygen prescribed.<BR/>During an interview on 09/13/23 at 2:55 p.m., the ADM said his expectation was oxygen concentrator filters be washed weekly with the oxygen tubing change. He said the nurses and CNAs were responsible for cleaning the oxygen concentrator filters and were in-serviced on it. The Administrator said the risk of a dirty filter was the oxygen concentrator may not work as efficiently as it should.<BR/>Record review of an Employee In-service Record dated 09/13/23 indicated the filter on the back of the concentrators must be cleaned weekly with the night shift responsible and all shifts monitoring with LVN E's signature on it.<BR/>Record review of a policy revised November 2011, titled, Departmental (Respiratory Therapy) - Prevention of Infection indicated, .9. Wash filters from oxygen concentrator every seven days with soap and water. Rinse and squeeze dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); for 1 of 4 residents reviewed for notification. (Resident #1) <BR/>The facility failed to consult with Resident #1's physician, when Resident #1's HIV (a virus that attacks the human immune system) medication Triumeq (a medication used to treat HIV; discontinuation or interruption of antiretroviral therapy (ART) may result in viral rebound, immune decompensation, and/or clinical progression) was not available for administration in August 2023 for 11 doses and September 2023 for 3 doses. <BR/>An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. While the IJ was removed on 10/03/23 at 5:40 p.m., the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of a pattern due the facility's nned to evaluate the effectiveness of the corrective systems. <BR/>This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and could cause, or likely continue to cause, harm, impairment, or death.<BR/>Findings included : <BR/>Record review of physician's orders dated 10/02/23 indicated Resident #1 was an [AGE] year-old female re-admitted to the facility on [DATE]. Her diagnoses included HIV, diabetes (a disease in which the body's ability to produce or respond to the insulin hormone is impaired resulting in abnormal metabolism) and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). The orders indicated the resident was to receive Triumeq (antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body) 600-50-300 mg one tablet every day for antiviral. <BR/>Record review of the quarterly MDS dated [DATE] indicated Resident #1 was usually able to make herself understood, usually understood others, had moderately impaired cognitive skills and required supervision and set up for transfers and ambulation. She utilized a walker for mobility and had no impairment to upper and lower extremities. <BR/>Record review of the care plan dated 08/21/23 indicated Resident #1 was at risk for infections related to HIV. The goal indicated the resident would not display any complications related to immunodeficiency. Interventions included to administer medications as ordered and monitor/document and report signs and symptoms. <BR/>Record review of the August 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows:<BR/>*on 08/04/23 the date was coded a 6 and indicated the resident was in the hospital documented by the DON,<BR/>*on the following dates there was a code 9 on the date indicating other see progress note:<BR/>08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/10:23 documented by agency staff, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A,08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A. <BR/>*on 08/22/23, the date was coded a 6 and indicated the resident was in the hospital. <BR/>Record review of the September 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows:<BR/>*on 09/23/23 the date was coded a 1 and indicated the resident was absent from home without meds<BR/>*on 9/24/23 the date was coded a 3 and indicated the resident was absent from home with meds<BR/>*on 09/25/23, 9/26/23 documented by LVN E the date was coded a 9 and on 9/28/23 the date was coded a 9 documented by LVN B and indicated other see progress note <BR/>Record review of the nurses' progress notes for Resident #1 indicated the following:<BR/>*on 08/04/23 the resident was at the hospital. Resident #1 returned from hospital with a new antibiotic for pneumonia, <BR/>*on 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A, 08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A the Triumeq was on order, <BR/>*on 08/10/23 signed by LVN D, the documentation for Triumeq did not indicate the medication was not administered, <BR/>*on 08/22/23, the documentation indicated the resident was in the hospital. <BR/>*on 09/01/23, documentation indicated the resident was readmitted from the LTAC hospital. <BR/>*on 09/22/23 to 09/24/23, the resident was out of the facility with family<BR/>*on 09/25/23 documented by LVN E, 09/26/23 documented by LVN E and 09/28/23 documented by LVN B, the documentation indicated the medication was not available. <BR/>There was no documentation on the nurses' progress notes to indicate the physician was notified the Triumeq medication was not available or not administered. <BR/>Record review of a LTAC hospital Interdisciplinary Notes for Resident #1 dated 08/23/23 indicated, History of Present Illness: The patient is an [AGE] year-old female who resides at a nursing home, who presented to the emergency room on [DATE] and was found to have urinary tract infection and pneumonia. She was prescribed Lovenox (a medication used to thin the blood) and Rocephin (an antibiotic to treat infection) and sent back to the nursing home, where she continued to have functional decline. The patient has had increased weakness and falls since her emergency room visit. The patient was transferred to LTAC on 08/21/2023 for continuation of antibiotic medical management of above symptoms and strengthening. The patient is currently not able to participate in activities of daily living and mobility as she was prior to her emergency room visit. A consult was performed by Physical Medicine and Rehabilitation physician, who determined the patient was suffering from exacerbation of her Parkinson's disease. The patient wants to come to acute inpatient rehabilitation for aggressive physical and occupational therapy. medication. An order dated 8/24/23 indicated Resident #1's Triumeq medication was ordered for administration. The order indicated the resident could use own home supply. There was no documentation to indicate the resident did not have the Triumeq available upon admission to the LTAC. <BR/>During interview on 09/30 23 at 8:45 a.m., the DON said Resident #1 had gone out to the hospital on 08/0423 and returned the same day a diagnosis of pneumonia. She said when the resident returned, she was placed on skilled services. The Triumeq medication was a high-cost medication and was not covered on the insurance once the resident became skilled. She said as soon as the facility received the request for approval by the administrator, the approval was signed, faxed back and the resident received the medication. She said she was unaware the resident missed any doses of the Triumeq. <BR/>During an observation, interview and record review on 09/30/23 at 12:51 a.m., LVN A said she was the nurse who worked Hall 300, where Resident #1 resided. During a record review of Resident #1's August 2023 MAR with LVN A, she said Resident #1 was out of her Triumeq medication on 08/08/23, 08/09/23, 08/12/23, 08/13/23, 08/14/23 08/15/23, 08/18/23, 08/19/23, 08/20/23 and 08/21/23 where she documented the code 9. She said the resident had gone to the hospital on 8/4/23 but returned the same day and was diagnosed with pneumonia. She said the resident was weak because of the diagnoses of pneumonia and did continue to get weaker and was sent out to the LTAC for rehabilitation services on 08/22/23. She said it was her responsibility to administer the medications on Hall 300. She said she should have notified the DON and the physician when the Triumeq medication was not available. She said she did not know why she did not notify them, but she did not. She said she remembered Resident #1 was out of the Triumeq but did not remember notifying the pharmacy it was out. Observation of the bottle of Resident #1's Triumeq 30 count in the medication cart indicated the bottle was &frac34; full of medication. The bottle was dated 9/28/23. LVN A said it had been refilled on 9/28/23 and only a few pills had been administered out of the bottle. She said she should have notified the pharmacy when there were approximately 10 tablets left. LVN A said the possible negative outcome of not notifying the physician would be the resident's condition could worsen and the physician would not know the resident had missed her medication. <BR/>During an interview on 9/30 23 at 1:20 p.m., the DON said she was unaware Resident #1 did not have the Triumeq medication for 11 days during August 2023. She said the Triumeq was to treat her diagnosis of HIV. She said she and the physician should have been notified the medication was not available. She said she and the physician required notification, so interventions could be put in place to have the medication available for administration to the resident. She denied the resident could suffer increased symptoms by not having the medication available and said the medication was to keep the resident's HIV undetectable. <BR/>During an interview on 09/30/23 at 1:52 p.m., LVN B said she started orientation on Hall 300 on 09/27/23 last week. She said Resident #1's Triumeq was not available on Wednesday 09/27/23 and Thursday 9/28/23. She said she was in training and did medication pass with LVN C. She said she watched LVN C pass medications on Wednesday 09/27/23 and passed the medications herself on Thursday 09/28/23. She said LVN C told her the Triumeq was a medication that required approval from the administrator and it was not available. LVN B said if a medication was not available the physician should be notified. She said she did not notify the physician the medication was not available because she was in training and LVN B had faxed the pharmacy. She said the medication was for Resident #1's HIV. She said the possible negative outcome of not notifying the physician could be the physician would not be aware the resident did not receive the medication and the resident's HIV symptoms could exacerbate. <BR/>During a confidential interview on 9/30/23 at 2:04 p.m., an individual said the facility did not have Resident #1's Triumeq medication available when the resident went out on pass 9/22/23 to 09/24/23. The individual said the ADON was notified the resident did not have her medication. <BR/>During an interview on 09/30/23 at 2:22 p.m., the ADON said she was unaware Resident #1 did not have the Triumeq medication with her when she went out on pass 09/22/23 to 09/24/23. She denied staff had informed her the resident's medication was not available. She said Resident #1 should not miss a dose of the Triumeq medication and she was unaware that she did. She said staff should have called the pharmacy if the medication was not available. She said herself, the DON and the physician should be notified. <BR/>During an interview on 09/30/23 at 2:34 p.m., an attempt was made to call LVN D, who documented a code 9 on the August 2023 MAR on 08/10/23, with no answer and the mailbox was full; unable to leave message for call back. <BR/>During an interview on 09/30/23 at 2:48 p.m., the DON said she was unaware Resident #1 had not received the Triumeq until 09/28/23, when the administrator approved the medication for the pharmacy to refill it and he sent the approval to her, and she ordered the medication stat. She denied knowing the resident also did not have the medication in August 2023. She said she was unaware and did not notify the physician. <BR/>During an interview and record review on 09/30/23 at 3:12 p.m., LVN C said she worked two days last week on Hall 300, Wednesday 09/27/23 and Thursday 9/28/23, training LVN B. She said Resident #1's medication Triumeq was not available for administration either day. She said she did mark the MAR on 09/27/23 with a check which indicated she had administered the Triumeq, but she did not administer the medication because it was not available. She said she ordered the medication on 9/21/23 and there were pills left in the bottle but when she came back on 9/27/23 there were none left. During an interview and record review of a pharmacy Long Term Care Reorder Form dated 09/21/23, LVN C said she ordered the Triumeq on 09/21/23 and faxed it to the pharmacy and did not receive the fax back until the next day and noticed it said the Triumeq did not have an active order. The pharmacy Long Term Care Reorder form dated 09/21/23 had the Triumeq order request circled and had a label indicating No active order. Please send new order. She said she faxed an order for the Triumeq back to the pharmacy on 9/22/23 and was off the next few days. LVN C then provided an order dated 09/22/23 that indicated the Triumeq was ordered. Written across the bottom of the order was Please Refill. She said when she returned to work on 09/27/23 the resident was out of the Triumeq medication, so she called the pharmacy and asked them why it was not in the facility. She said the pharmacy told her it was a high-cost medication and was not covered and they had faxed over a high- cost medication approval request to the administrator but did not receive an approval and the medication could not be refilled until it was approved. She said she did not remember if she reported what the pharmacy said. She said she did not notify Resident #1's physician that the resident did not have the medication available for administration. She said the physician should have been notified. She said the physician would not have known the resident was out of her medication and could not intervene to make sure she received it. <BR/>During an interview on 09/30/23 at 3:45 p.m., LVN E, who worked Hall 300 on 9/25/23 and 9/26/23, said Resident #1's Triumeq medication was not available for administration. She said she did not usually work Hall 300 and was filling in, so she assumed someone had already ordered the medication and notified the physician. She said she did not notify the physician the medication was not available to administer. She said she told the ADON and the ADON told her to call the LTAC and make sure they did not have it. She said she knew LVN C had reordered the medication, but the pharmacy sent back the refill request saying it was a high-cost medication and had to be approved before it could be filled. <BR/>During an interview on 09/30/23 at 3:48 p.m., the ADON said the facility had sent Resident #1's Triumeq medication with her to the LTAC hospital on [DATE] because the hospital called and said they could not provide the medication. She said when the resident returned on 09/01/23, the facility had to go pick the medication up from the LTAC because the hospital did not send it back with her . She said she was unaware the resident did not have the Triumeq medication for 11 days in August 2023 or the last week of September 2023. She said no one notified her on 09/25/23 or 09/26/23 that Resident #1 did not have the Triumeq medication available for administration. <BR/>During an interview on 09/30/23 at 4:01 p.m., Pharmacist F said he pulled all of Resident #1's transactions off of the computer and the pharmacy had refilled Resident #1's Triumeq and had a signed receipt for 6/29/23 and 8/19/23, but did not find a signed receipt for July 2023. He said they had also sent 30 Triumeq tablets to the nursing facility on 09/28/23 . He said he had a note the pharmacy had communicated with the facility on 09/22/23 that the medication was a high dollar medication and could not be refilled without approval, but the Administrator , DON and ADON were out of the facility. He said the pharmacy then refaxed and emailed the information again on 9/25/23, 09/26/23, 09/27/23, and 09/28/23. He said the administrator signed the approval and returned it on 9/28/23 and it was refilled. Pharmacist F was asked why the facility would have possibly not had the Triumeq medication available in August 2023 and he said there was a refill request for the Triumeq from the facility on 07/05/23 but the medication had already been filled on 6/29/23 and it was too soon. He said there were no other communications found between the pharmacy and the facility regarding Resident #1's Triumeq medication requesting a refill for July 2023 and he did not have a signed receipt for July 2023. <BR/>During an interview on 10/02/23 at 10:09 a.m., the Administrator said he did not receive an approval request from the pharmacy until 09/28/23 and he immediately sent it back that day with his approval to be filled stat and Resident #1 received the medication the same day. He said he checked his emails daily and did not receive an approval request from the pharmacy until 09/28/23. He said on 09/28/23 he explained to the family member of Resident #1 the Triumeq was not covered because the resident was on skilled services, and it required his approval. He said he was not aware the resident did not receive her medication in August 2023 or the last week of September 2023. He said the resident should receive her medication as ordered. He said he notified his medical director, and the medical director told him there would be no negative outcome of missing the Triumeq medication. <BR/>During an interview and record review on 10/02/23 at 10:10 a.m., the DON provided a document, which she said was the July 2023 receipt for Resident #1's Triumeq. The top of the document had the words on order and Triumeq tablet cut in half indicating the page had been snipped. A pharmacy notes column indicated dispensed 7/26 updated to insurance-BA, 7/25 emailed facility-RR, 7/19 High $ emailed. There was no signature on the document. The DON said she did not have a signed receipt for the Triumeq for July 2023. <BR/>During an interview on 10/02/23 at 11:15 a.m., the NP said she nor Resident #1's physician was notified the resident did not receive the doses of Triumeq in August 2023 and September 2023. She said the resident had to have the Triumeq medication or it would exacerbate her HIV if she did not receive it. She said it was herself that would need to be notified and she did not receive a call and the records did not indicate the facility called the office to report the resident had missed the Triumeq doses. She said the facility had her personal cell phone number to call her. She said the records indicated the office was notified on 08/21/23 of lab work for Resident #1 and the office was notified when the resident fell, but there were no notifications about the resident missing her Triumeq doses. The NP said her notes indicated a family member called and wanted her to go to hospital on 8/21/23 and a family member called the office on 09/28/23 to report the resident did not receive her Triumeq medication last week from 9/22/23 to 9/28/23. She said her nurse called the ADON on 09/28/23 and spoke with her about Resident #1 not receiving the medication. <BR/>During an interview on 10/02/23 at 11:20 a.m., the ADON said no one from Resident #1's physician's office notified her that the resident's Triumeq medication was not available, and she was not aware of it. <BR/>During an interview on 10/02/23 at 1:02 p.m., the DON said she realized the emails from the pharmacy, requesting approval for Resident #1's medications on 09/25/23, 09/26/23, 09/27/23 and 09/28/23, were going to the other box and not the in box of her emails. She said she had just looked and the emails from the pharmacy were in the other box, and she had not checked the other box for incoming emails. <BR/>During an interview on 10/03/23 at 3:08 p.m., the MD said the ADM had called him either Saturday 9/30/23 or Sunday 10/01/23 and notified him Resident #1 did not receive her Triumeq medication. He said he had not previously been notified. He said it was his understanding that Resident #1 only missed 3 days of the Triumeq medication and that would not be a problem, but he did not understand the resident missed multiple doses in August 2023. He said approximately 15 doses could potentially cause a problem for the resident. <BR/>Record review of https://www.drugs.com/triumeq.html, last updated June 9, 2022, accessed on 10/03/23 indicated: Triumeq contains a combination of abacavir, dolutegravir, and lamivudine. Abacavir, dolutegravir, and lamivudine are antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body. Triumeq is used to treat human immunodeficiency virus (HIV), the virus that can cause acquired immunodeficiency syndrome (AIDS). Take Triumeq exactly as prescribed by your doctor. Use all HIV medications as directed and read all medication guides you receive. Do not change your dose or stop using a medicine without your doctor's advice. Every person with HIV should remain under the care of a doctor. Usual Adult Dose for HIV Infection: 1 tablet orally once a day. Use: For the treatment of HIV-1 infection. Get your prescription refilled before you run out of medicine completely. If you miss several doses, you may have a dangerous or even fatal allergic reaction once you start taking this medication again.<BR/>Record review of an Adverse Consequences and Medication Errors policy revised April 2014 indicated . Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate.<BR/>Record review of an Adverse Consequences and Medication Errors policy revised April 2014 indicated . Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate.<BR/>An Immediate Jeopardy (IJ) situation was identified on 10/02/23. The IJ template was provided to the Administrator on 10/02/23 at 4:30 p.m and the POR was requested. <BR/>The facility's POR dated 10/02/23 and accepted on 10/03/23 at 3:00 p.m. indicated: <BR/>[Resident #1] medication was ordered and received by the facility on 9/28/2023. Primary care physician notified of the identified missed doses of medication on 10/2/23. The Medical Director also notified. There were not consequences associated or directly correlated with missed doses of the resident's medication. A viral load test has been ordered STAT for the resident. <BR/>A facility audit to be completed by the Director of Nursing/Designee by 10/2/2023 of all residents with missed doses of medication in the past 7 days to assure that the medication was not held due to unavailability. For any medication identified as not given due to not available, the MD will be notified, and pharmacy will be contacted if the medication continues to not be available in the facility. If trends established, then we will QAPI the trend and in-service staff on root cause to prevent in the future. No other issues have been identified. <BR/>In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. All other licensed staff will be in-serviced prior to working the next shift. The regional nurse consultant in serviced the DON and Administrator on checking all email folders for notifications of high-cost medications or refills from the pharmacy. <BR/>Ad Hoc QAPI meeting completed with IDT and Medical Director on 10/2/2023.<BR/>Facilities Plan to ensure compliance quickly:<BR/>Facility interventions were implemented to remove immediate jeopardy: <BR/>Audit to be completed 10/2/23 by DON/Designee to identify any residents that did not receive medications due to availability, pharmacy was contacted, and MD notified. This audit included the med cart, med room and MARS. There were no other residents identified that missed doses due to medication unavailability. We did identify new admits on the weekend were at a risk due to pharmacy hours of operation and ordering cut off time at 6PM. These orders will be sent to the local pharmacy and then delivered to the facility. <BR/>Education was completed with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed medication administrations on 9/30/23. This includes checking all eFax's, and fax machines at the nurse's station. <BR/>In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. Staff will be responsible for contacting the MD/PCP for any missed doses. The DON and or designee will follow up in the morning clinical meeting to ensure compliance. LVN A has been given disciplinary action and trained one on one by the DON. <BR/>This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. <BR/>*Education to be completed with all nursing staff working by 10/3/2023 at 2 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training.<BR/> On 10/03/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>During observation on 09/30/23 at 12:51 p.m., Resident #1's Triumeq medication was dated 09/28/23 and available in the Hall 300 nurses' medication cart. <BR/>During interviews on 10/03/23 from 3:18 p.m. to 3:28 p.m., Resident #1's NP and the MD said they were notified of Resident #1's missed doses of Triumeq. <BR/>Record review of the audit tool completed by the DON indicated residents were identified that did not have their medications available. The medications were unavailable for 9 residents and the physicians were notified on 09/30/23, 10/02/23 and 10/03/23. No new orders were implemented.<BR/>Record review of signed in-services to LVNs indicated the LVNs were trained on documenting missed doses of medications, who to notify, and notification of the physician with posttests taken and dated 10/02/23 and 10/03/23. <BR/>Record review of in-services dated 09/30/23 to 10/03/23 indicated the LVNs were trained on supervision to prevent missed medication administration. <BR/>Record review of the Regional Nurse Consultant's in-service to the DON and ADM dated 10/03/23 indicated the DON and ADM were trained to check all email folders for notifications of high cost medications or refills from the pharmacy. <BR/>Record review of a counseling note dated 10/03/23 indicated LVN A was counseled on documentation, notification, and medications not being available. <BR/>During an interview on 10/03/23 at 3:53 p.m., the DON was able to verbalize how to check emails for pharmacy notifications. <BR/>During interviews on 10/03/23 from 4:20 p.m. to 5:20 p.m., three day shift LVNs, 3 evening shift LVNs and 2 night shift LVNs were able to verbalize the appropriate interventions to put in place to ensure the medications were available, refilled timely, weekend admits received their medications, the physician and DON were notified timely if medications were not available for administration and when to notify the pharmacy. <BR/>On 10/03/23 at 5:40 p.m., the Administrator was informed the IJ was removed; however; the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors.<BR/>The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure.<BR/>An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures could place residents at risk of not receiving their medications as ordered, illness, hospitalizations, exacerbation of their disease processes, and death. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of na&iuml;ve coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat).<BR/>Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants.<BR/>Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. An unidentified staff indicated the order needed clarification. There was no documentation on the Discharge Home Medication List of the medication clarification.<BR/>Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. <BR/>Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued.<BR/>Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered.<BR/>Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. <BR/>Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24.<BR/>Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). <BR/>Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation.<BR/>Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested.<BR/>Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg. related to atherosclerotic heart disease of native coronary with unspecified angina pectoris.<BR/>Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related coffee ground emesis (vomit). The DON and MD were notified. RP was at bedside.<BR/>Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs had become mottled and cool. She was diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24.<BR/>Record review of Resident #1's hospice records dated 05/23/24 indicated passed away on 05/23/24 of heart failure.<BR/>During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on [DATE]. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto.<BR/>During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness. She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on [DATE] due to vomiting.<BR/>During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. <BR/>During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. <BR/>During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. <BR/>During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA. She said NP A never wrote orders for the Eliquis or ASA or Xarelto. <BR/>During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism or a blood clot due to DVT. <BR/>During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes.<BR/>LVN C was no longer employed with the facility and was not available for an interview.<BR/>Record review of the facility's Medication Therapy policy dated 2001 (revised 2007) indicated<BR/>1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks.<BR/>2. <BR/>Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments.<BR/>3. <BR/>All medication orders will be supported by appropriate care processes and practices.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>The resident's clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident.<BR/>2. <BR/>All decisions related to medications shall include appropriate elements of the care process, such as: <BR/>a. <BR/>Adequately detailed assessment;<BR/>b. <BR/>Review of causes of symptoms;<BR/>c. <BR/>Consideration of the clinical relevance of symptoms and abnormal diagnostic test results;<BR/>d. <BR/>Principles of prescribing for the elderly; and<BR/>e. <BR/>Each resident's wishes, values, goals, condition, and prognosis.<BR/>Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m.<BR/>The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following:<BR/>Resident #1 was discharged to the hospital on 5/17 24 and no longer resides in the facility.<BR/>A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. <BR/>In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director - All other licensed staff will be in-serviced prior to working next shift. <BR/>Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm<BR/>Facilities Plan to ensure compliance quickly: <BR/>Facility interventions were implemented to remove immediate jeopardy: <BR/>A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. <BR/>Education was completed with the Administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. <BR/>In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON if unable to verify orders after 2 attempts. DON/ADON will then notify the medical director.<BR/>*Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings.<BR/>On 06/16/24, the surveyor confirmed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the HER. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. <BR/>Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. <BR/>Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly.<BR/>Record review of the resident census dated 06/16/24 indicated here were no new admissions to the facility.<BR/>Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m. and included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m. to 6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the practitioner and documented in the progress notes.<BR/>During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. <BR/>During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. <BR/>On 06/16/24 at 1:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the written plan of care for 1 of 11 residents (Resident #5) reviewed for care needs.<BR/>CNA C did not use a second staff to provide care per Resident #5's identified care needs. <BR/>Resident #5 fell from her bed. <BR/>Resident #5 sustained multiple fractures and required surgical intervention. <BR/>This failure could place the residents at risk for not receiving required care and services. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated 01/16/23 indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She said checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and they utilized the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain and she was given pain medication. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. <BR/>During observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said was sent to the hospital. She said she had two broken legs and two broken knee caps. She said her pain before the fall but it was worse after she sustained the two broken legs and two broken knee caps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. <BR/>During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. <BR/>During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system. <BR/>During an interview on 04/12/23 at 1:38 a.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers receive treatment and care in accordance with the comprehensive assessments, professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #2) reviewed for wound treatment. <BR/>The facility failed to ensure Resident #2 received wound care as ordered.<BR/>This failure could place residents at risk for inconsistent care resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization.<BR/>Findings included:<BR/>Record review off Resident #2's face sheet dated 08/02/23 indicated he was a [AGE] year old male, re-admitted on [DATE] (initial admission on [DATE]) and his diagnoses included functional quadriplegia (complete immobility due to severe physical disability or frailty), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), local infection of the skin and subcutaneous tissue, pressure ulcer of other site stage 4, pressure ulcer of left hip unstageable, pressure ulcer of other site stage 3, pressure ulcer of right hip unstageable, pressure ulcer of right heel stage 1, and pressure induced deep tissue damage of left heel.<BR/>Record review of an MDS assessment dated [DATE] indicated Resident #2 was able to make himself understood and to understand others, he had a BIMS score of 12 (no cognitive impairment). He had one stage 1 pressure injury, two stage 3 pressure injuries, two stage 4 pressure injuries, and one unstageable pressure injury that were present upon admission.<BR/>Record review of care plan dated 07/06/23 Resident #2 had multiple pressure injuries. Interventions included implement wound care protocol.<BR/>Record review of physician orders dated 08/02/23 indicated the following:<BR/>HEEL: APPLY SKIN PREP AND LEAVE OPEN TO<BR/>AIR DAILY every day shift for PREVENTING SKIN<BR/>BREAKDOWN/PROMOTE WOUND HEALING<BR/>**OFFLOAD HEELS WITH PILLOWS<BR/>Phone Active 07/07/2023 07/08/2023<BR/>LEFT HIP (LATERAL): CLEANSE WITH NORMAL<BR/>SALINE, PAT DRY WITH GAUZE, PACK WITH<BR/>GAUZE SATURATED WITH NORMAL SALINE AND<BR/>COVER WITH SILICONE BORDERED FOAM DRSG<BR/>EVERY M/W/F + PRN as needed for PROMOTE<BR/>WOUND HEALING<BR/>Phone Active 07/07/2023 07/07/2023<BR/>LEFT HIP (LATERAL): CLEANSE WITH NORMAL<BR/>SALINE, PAT DRY WITH GAUZE, PACK WITH<BR/>GAUZE SATURATED WITH NORMAL SALINE AND<BR/>COVER WITH SILICONE BORDERED FOAM DRSG<BR/>EVERY M/W/F + PRN every day shift every Mon,<BR/>Wed, Fri for PROMOTE WOUND HEALING<BR/>Phone Active 07/07/2023 07/10/2023<BR/>LEFT KNEE (LATERAL): CLEANSE WITH<BR/>NS/WOUND CLEANSER, PAT DRY WITH GAUZE,<BR/>APPLY CALCIUM ALGINATE TO WOUND, AND<BR/>COVER WITH SILICONE BORDERED FOAM DRSG<BR/>EVERY M/W/F + PRN as needed for PROMOTE<BR/>WOUND HEALING<BR/>Phone Active 07/07/2023 07/07/2023<BR/>LEFT KNEE (LATERAL): CLEANSE WITH<BR/>NS/WOUND CLEANSER, PAT DRY WITH GAUZE,<BR/>APPLY CALCIUM ALGINATE TO WOUND, AND<BR/>COVER WITH SILICONE BORDERED FOAM DRSG<BR/>EVERY M/W/F + PRN every day shift every Mon,<BR/>Wed, Fri<BR/>Phone Active 07/07/2023 07/10/2023<BR/>LEFT SCAPULA: CLEANSE WITH NORMAL<BR/>SALINE, PAT DRY WITH GAUZE, PACK WITH<BR/>GAUZE SATURATED WITH NORMAL SALINE, AND<BR/>COVER WITH SILICONE BORDERED FOAM DRSG<BR/>EVERY M/W/F + PRN as needed for PROMOTE<BR/>WOUND HEALING<BR/>Phone Active 07/07/2023 07/07/2023<BR/>LEFT SCAPULA: CLEANSE WITH NORMAL<BR/>SALINE, PAT DRY WITH GAUZE, PACK WITH<BR/>GAUZE SATURATED WITH NORMAL SALINE, AND<BR/>COVER WITH SILICONE BORDERED FOAM DRSG<BR/>EVERY M/W/F + PRN every day shift every Mon,<BR/>Wed, Fri for PROMOTE WOUND HEALING<BR/>Phone Active 07/07/2023 07/10/2023.<BR/>Record review of TAR dated July 2023 indicated Resident #2 did not receive wound care on 07/27/23 (date of re-admit), 07/28/23, 07/29/23, 07/30/23, and 07/31/23. Staff did not e-sign the TAR to indicate the wound care was completed.<BR/>Record review of TAR dated August 2023 indicated Resident #2 did not receive wound care on 08/01/23. Staff did not e-sign the TAR to indicate the wound care was completed.<BR/>Record review of progress notes in Resident #2's clinical records from 07/27/23 through 08/01/23 indicated there was no documentation of wound care completion.<BR/>Record review of the Resident #2's skin assessment dated [DATE], completed by (unknown staff) indicated the following:<BR/>Stage 4 Left scapula (shoulder blade) 8 cm X 6 cm x .5 cm<BR/>Unstageable Left lateral hip 4 cm X 3.5 cm x 1.2 cm<BR/>Stage 3 Left lateral knee 2 cm x 1.5 cm x .3 cm<BR/>Stage 3 sacrum (large, triangular bone at the base of the spine) 2 cm x .08 cm x .2 cm<BR/>Unstageable Right lateral hip 4 cm x 3.4 cm x .8 cm<BR/>There were no heel wounds noted.<BR/>During an interview on 08/02/23 at 1:11 p.m., Resident #2's family member said he (Resident #2) received wound care that day because the surveyors were in the facility. She said there was no wound care for the previous 5 days. Resident #2 said he had not received wound care since being re-admitted to the facility. Resident #2 said he was not repositioned and had only refused to be repositioned maybe twice.<BR/>During an interview and record review on 08/02/23 at 1:28 p.m., LVN F said she had not completed Resident #2's wound care on 07/28/23 because she understood it was done by the TX nurse when she was in the facility. She said the TX nurse completed the wound care. She said she did not completed Resident #2's wound care on 07/27/23, 07/28/23, 07/31/23 or 08/01/23. Record review of the electronic record for Resident #2 indicated on the dashboard in bold red letters when the TX nurse was working on the floor and on weekends all nurses were responsible for checking the TAR tab and completing wound care TX daily. She said the electronic dashboard indicated she was responsible for performing the wound care when the TX nurse was working the hall. She said she had not noticed the large bold red note until now. LVN F stated not receiving wound care could cause the resident to get infection or wounds to worsen. She said she did not remember being trained and did not know she was supposed to do the wound care; she thought the wound care nurse was performing the wound care. She said she was not reminded to do the wound care.<BR/>During an interview on 08/02/23 at 1:17 p.m., TX LVN E said she completed all treatments except on weekends or if she was working as a hall nurse. She said she had to work the hall on Thursday 07/27/23, Friday ;7/28/23, Monday 07/31/23, and Tuesday 08/01/23 and did not do the treatments for the facility on those days except for the hall she was working on. She said she started as the TX nurse on 02/23/23. She said there was an in-service the nurses signed about 1 or 2 months ago instructing them they were responsible for wound care when the TX nurse was working the hall. TX LVN E said the nurses would come on shift and initial the schedule and her name would be assigned a hall and not listed as working as TX nurse. She said she had reminded the nurses they would have to do the TX if she was working a hall. She said LVN F completed Resident #2's wound care today, 08/02/23. TX LVN E said the wound care NP comes to the facility weekly on Thursdays and had not assessed Resident #2 yet (since re-admit). <BR/>An observation on 08/02/23 at 2:00 p.m. of Resident #2's wounds (with TX LVN E present) indicated the following:<BR/>Right hip dressing dated 08/02/23- 2 cm x 1.5 cm x .5 cm deep, slough yellowish to wound bed<BR/>Sacrum dressing dated 08/02/23-1 cm x 2.7 cm x .5 cm, slough to wound bed, deepest point is approximately .25 cm wide,<BR/>Left lateral knee dressing dated 08/02/23-.8 cm x .9 cm x .4 cm deep,<BR/>Left hip dressing dated 08/08/23-3 cm x 2.2 cm x. 6 cm deep,<BR/>Left scapula dressing dated 08/02/23-4.4 cm x 6.5 cm x .4 cm ,<BR/>DTI left heel-2 cm x1 .7 cm,<BR/>New-left lateral ankle .6 X .5 cm, and <BR/>Right heel-3.5 x 2 cm.<BR/>During an interview on 08/02/23 at 3:19 p.m., TX LVN E said she completed Resident #2's wound care on 07/27/23, when the resident returned from the hospital. When asked how she could have done the wound care with the dressing dated 06/22/23, she said she looked at the wound on 07/27/23 and replaced the old dressing over the wound until she could clarify the order with the physician. She said the physician ordered clean wound with wound cleaner, apply skin prep and leave open to air. She said she forgot and never went back and changed it after she received the order. She said the negative outcome of not changing the dressings as ordered was increased risk of infection and wound deterioration.<BR/>During an interview on 08/03/23 at 10:42 a.m., the DON said Resident #2's treatments were not completed on his knee, hips, sacrum, or scapula on Monday, Wednesday, and Friday as ordered. She said his heels were not treated for 5 days after admission. She said the negative outcome could be risk of wound deterioration and infection. She said it was the facility's expectations all wound care be completed as ordered.<BR/>LVN G was called on 08/03/23 at 10:45 a.m. and did not respond. <BR/>Record review of a screen shot of the electronic record dated 06/02/23 (provided by the facility on 08/02/23) indicated When wound care nurse is working as a floor nurse: (and on weekends) All nurses are responsible for checking the TAR tab and completing wound care treatments daily.<BR/>Record review of staff in-service dated 05/16/23 and 07/06/23 indicated LVN F was trained to complete wound care per orders and to check the TAR tab every shift when the TX nurse was working the hall or out of the facility. LVN F's signature was on the training. <BR/>Record review of staff in-service dated 07/06/23 indicated LVN G was trained to completed wound care per orders and to check the TAR tab every shift when the TX nurse was working the hall or out of the facility. LVN G's signature was on the training. <BR/>Record review of the facility's Pressure Ulcer/Skin Breakdown policy dated 2001 (revised April 2018) indicated . The physician will order pertinent wound treatments .<BR/>Record review of the facility's Repositioning policy dated 2001 (revised May 2013) indicated . Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 8 residents (Resident #1) reviewed for medication administration.<BR/>The facility failed to ensure Resident #1 received 4 applications of antifungal shampoo.<BR/>This failure could place residents at risk of not receiving the therapeutic benefits of their medications. <BR/>Findings included: <BR/>Record review of a face sheet dated 05/08/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses anxiety and chronic pain.<BR/>Record review of an MDS assessment dated [DATE] indicated Resident #1 had moderate impaired cognition. She required supervision for personal hygiene. She required physical help for bathing.<BR/>Record review of a care plan dated 01/25/23 (revised on 05/08/23) indicated Resident #1 had ADL self-care performance deficit related to confusion, impaired balance and pain. Interventions included: Bathing/Showering-Avoid scrubbing and pat dry sensitive skin. Wash hair with Ketoconazole Shampoo 2% (antifungal medication - treats fungal or yeast infections in skin) and apply to affected areas of skin prn.<BR/>Record review of physician order dated 05/01/23, created by LVN A indicated Received a call from MD B with new order Ketoconazole (antifungal) 2% shampoo once a day X 5 then . Order summary: Ketoconazole Shampoo 2% Apply to scalp (shampoo) topically every day shift every 5 day(s) for scalp X 5 days then prn.<BR/>Record review of MAR/TAR dated 05/23 indicated Ketoconazole Shampoo 2% Apply to scalp (shampoo) topically every day shift every 5 day(s) for scalp X 5 days then prn. Resident #1's hair was shampooed on 05/02/23 and 05/07/23. Resident #1's hair was not shampooed as ordered on 05/03/23, 05/04/23, 05/05/23, or 05/06/23. There was an X on 05/03/23, 05/04/23, 05/05/23, and 05/06/23 of the MAR/TAR. The next day Resident #1 was scheduled for her hair shampoo was 05/12/23.<BR/>Record review of a skin assessment dated [DATE], completed by the ADON indicated Resident #1 continued to have raised crusty areas on the top of her scalp and on the back of her right hand.<BR/>During an observation and interview on 05/08/23 at 10:15 a.m., Resident #1 shook her head no and touched her hair when asked if staff washed her hair. She shrugged her shoulders when asked when her hair was last washed. Observation of Resident #1's hair and visible scalp area did not show visible skin issues. Her hair appeared clean.<BR/>During an interview and record review on 05/08/23 at 1:25 p.m., LVN A said she made an error when she input MD B's order for Resident #1's antifungal shampoo in the electronic record. She said she received a call from the pharmacy for clarification of the order and the shampoo bottle had the correct orders on the label. Record review of the shampoo bottle label indicated to shampoo Resident #1's hair for 5 days then prn. LVN A said she forgot to make the corrections in the electronic record. <BR/>During an interview on 05/08/23 at 2:25 p.m., the DON said she and the ADON were responsible for reviewing all orders and the MAR. She said she was off and the ADON was to review the orders and MAR. The ADON said she should have reviewed Resident #1's physician orders and MAR but it was not done because she was working the floor. The DON said Resident #1's skin condition would take longer to heal if the medicated shampoo was not applied as ordered.<BR/>Record review of the facility policy for Medication Orders revised 11/14 indicated: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders . 6. Treatment Orders-When recording treatment orders, specify the treatment, frequency, and duration of the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 11 (Resident #5) residents reviewed for abuse and neglect.<BR/>On 01/16/23, Resident #5 fell off the bed during incontinent care resulting in multiple fractures and required surgical intervention. CNA C did not use second staff to provide care for Resident #5. The facility did not report abuse and neglect until 01/28/23, 12 days later.<BR/>This failure could place residents at risk of emotional, physical, and mental abuse. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's current care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated 01/16/23, completed by LVN A indicated CNA C was providing incontinent care for Resident #5. CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and she rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur (thigh bone) metadiaphysis (the diaphysis (shaft or primary ossification center), metaphysis (where the bone flares), right knee-minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella a flat, inverted triangular bone, situated on the front of the knee-joint proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla the space below the shoulder through which vessels and nerves enter and leave the upper arm; a person's armpit hematoma (A pool of clotted blood that forms in an organ, tissue, or body space). Her diagnoses included diffuse osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes) and osteopenia (a condition that begins as you lose bone mass and your bones get weaker). <BR/>Record review of hospital Discharge summary dated [DATE] indicated the fractures of Resident #5's left and right thigh bones were both repaired surgically.<BR/>During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said on 01/16/23 at 10:00 a.m. she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said at the time of the incident, Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital at 12:00 p.m. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the [NAME]. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5's fall was reported to the Administrator on 01/16/23. She said the Administrator said it was not reportable because it was a witnessed fall and not abuse. She said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there were two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff were required to follow the resident plan of care and what was indicated in the [NAME]. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. She said the nurses were expected to monitor the aides to ensure care was provided per the care plans.<BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 laid down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said Resident #5's fall off the bed on 01/16/23 was not reported because it was a witnessed fall. He said he did not suspect abuse or neglect. He said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware the DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. He said CNA C was terminated on 01/24/23 for not calling and not showing for shifts. <BR/>During observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said was sent to the hospital. She said she had two broken legs and two broken knee caps. She said her pain before the fall but it was worse after she sustained the two broken legs and two broken knee caps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>During an interview on 04/12/23 at 10:56 a.m., the Administrator said he did not recognize the incident as abuse or neglect because it was a witnessed fall. He said the same situation could happen again of the facility did not recognize abuse or neglect. <BR/>During an interview on 04/12/23 at 1:04 p.m., the DON said the same situation of not reporting a reportable incident could occur if the facility staff did not recognize abuse or neglect. <BR/>During an interview on 04/13/23 at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. <BR/>During an interview on 04/13/23 at 2:45 p.m., the RNC said she received an anonymous call from a blocked number. She said she was told of Resident #5's fall. She said she looked at Resident #5's clinical record and the hospital record. She said she called the CNO who told her the incident was reportable. She said she called the Administrator and told him the incident was reportable. She said the Administrator wanted the COO to review the incident. She said the COO agreed the incident was reportable as an allegation of neglect.<BR/>During an interview on 04/13/23 at 2:50 p.m., the DON said the incident of Resident #5's fall and injuries on 01/16/23 was neglect and reportable.<BR/>During an interview on 04/13/23 at 2:50 p.m. the ADON said incident of Resident #5's fall and injuries on 01/16/23 was neglect and reportable.<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy revised 11/15 indicated : The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Time Period for Reporting 1. Serious Bodily Injury - 2-hour Limit: If the events that caused the reasonable suspicion result in serious bodily injury to a resident, the covered individual (owner, operator, employee, manager, agent, or contractor) shall report the suspicion immediately to State Survey Agencies and Law Enforcement, but no later than 2 hours after forming the suspicion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for 1 of 11 residents (Resident #5) reviewed for investigation of incidents. <BR/>The facility's investigation did not include interviews or statements from staff members (LVN A and CNA B ) who worked on the same day and shift with CNA C. The facility's investigation did not include a review of Resident #5's care needs (2-person assist). CNA C did not ensure a second staff assisted during incontinent care for Resident #5. Resident #5 fell off the bed during incontinent care resulting in multiple fractures and required surgical intervention.<BR/>This failure could place the residents at risk for further abuse, neglect, exploitation and mistreatment. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated 01/16/23 indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. The incident report did not include LVN A or CNA B's witness statements or a review of care needs.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>Record review of the facility's investigation for Resident #5 dated 02/03/23 indicated the incident category as neglect. The incident occurred on 01/16/23 at 10:00 a.m. The incident was reported on 01/28/23 at 10:58 a.m. Resident #5 was interviewable. She did not have a history of falls. CNA C was listed as a witness. The regional nurse received an anonymous call that stated the facility was neglectful in taking care of Resident #5 after her fall. The facility reported only due to family complaint. CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. The fall was witnessed during care. Staff acted quickly and correctly and Resident was sent out for further evaluation per Resident #5's physician. Hospital x-rays revealed multiple fractures due to severe osteoporosis. There was no neglect in the facility's response or care of the resident. <BR/>Record review of the facility's investigation dated 02/03/23 indicated there were no statements from LVN A or CNA C available for review. <BR/>During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries. He said he was not able to locate any statements related to the investigation.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said on 01/16/23 at 10:00 a.m. she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She said checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and they utilized the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain and she was given pain medication. LVN A said Resident #5's daughter was coming up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5's fall was reported to the Administrator on 01/16/23. She said the Administrator said it was not reportable and was not investigated initially because it was a witnessed fall and not abuse. She said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there was two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed.<BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. <BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said Resident #5's fall off the bed on 01/16/23 was not reported because it was a witnessed fall. He said he did not suspect abuse or neglect. He said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. He said he was not able to locate statements or interviews for the investigation.<BR/>During observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said was sent to the hospital. She said she had two broken legs and two broken knee caps. She said her pain before the fall but it was worse after she sustained the two broken legs and two broken knee caps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy revised 11/15 indicated : . Abuse-Allegation and Reporting .2. The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property. Definitions of Abuse 1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the written plan of care for 1 of 11 residents (Resident #5) reviewed for care needs.<BR/>CNA C did not use a second staff to provide care per Resident #5's identified care needs. <BR/>Resident #5 fell from her bed. <BR/>Resident #5 sustained multiple fractures and required surgical intervention. <BR/>This failure could place the residents at risk for not receiving required care and services. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated 01/16/23 indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She said checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and they utilized the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain and she was given pain medication. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. <BR/>During observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said was sent to the hospital. She said she had two broken legs and two broken knee caps. She said her pain before the fall but it was worse after she sustained the two broken legs and two broken knee caps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. <BR/>During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. <BR/>During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. <BR/>During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system. <BR/>During an interview on 04/12/23 at 1:38 a.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 11 residents (Resident #5) reviewed for accidents.<BR/>CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. <BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for falls resulting in injury, pain, and hospitalization. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's most current care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>During an observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>Record review of an incident report dated 01/16/23, completed by LVN A indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. LVN A did not indicate Resident #5 was a 2-person assist.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the [NAME]. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there was two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident.<BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. <BR/>During an interview on 04/12/23 at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the [NAME] and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. <BR/>During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not follow the [NAME] for care needs the resident could have serious injuries or die.<BR/>During record review and interview on 04/12/23 at 1:04 p.m., the DON said they believed all staff were re-trained to check the [NAME] for level of resident assistance required after Resident #5's fall. She said she and the ADON monitored the care plans and [NAME] weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. <BR/>During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS before the fall. She said Resident #5 was weak on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS before her fall. She said the information was in the [NAME] system. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility but forgot to sign. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>Record review of the facility's Falls-Clinical Protocol revised 03/2018 indicated: .2. In addition, the nurse shall assess and document/report the following: .h. Precipitating factors, details on how fall occurred; . Falls Prevention-Potential Interventions - Nursing Measures . proper positioning .<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated : The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.<BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>The Administrator and DON were notified of the Immediate Jeopardy on 04/12/23 at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/13/23 at 12:35 p.m. and reflected the following: <BR/>1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. <BR/>2* Corrective Action<BR/>Nursing administration will review care plans and [NAME]'s for all residents to ensure they match with the resident's level of assistance required. This process began 4/12/23 and will be complete by 10 AM on 4/13/23. All areas of concerns have been addressed and all care plans match all [NAME]'s for all residents. <BR/>All nursing staff will be in-service on where to find a resident's level of assistance in the [NAME]. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. <BR/>All nursing staff will be in-service on abuse and neglect. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the [NAME]/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. <BR/>All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM.<BR/>The [NAME] showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the [NAME]. <BR/>The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of 4/12/23 4:30 PM. <BR/>3* Identification of Others<BR/> The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by 4/13/23 of all facility residents' administrative nurses. Assessment will compare care plans to [NAME]. <BR/>The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. <BR/>A facility record audit of residents [NAME] and care plans will be completed by Director of Nursing/Designee by 4/13/2023 10 AM.<BR/>4* Plan to prevent from recurring <BR/>Intervention for Neglect: DON/designee to evaluate care plan and [NAME] for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on [NAME] and levels of assistance prior to working the first shift. This is to be completed during orientation. <BR/>Training Plan<BR/>Initial Trainings: Facility to Initiate Training by 4/12/2023 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working 4/12/2023, and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by 4/13/23 10AM via in person on telephone training.<BR/>All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM.<BR/>Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations.<BR/>5* Ongoing Monitoring<BR/>Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate [NAME] knowledge during rounds. <BR/>6* QAPI<BR/>In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed 4/12/23 by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. <BR/>On 04/13/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Observations, interviews, and record reviews were conducted on 04/13/23 from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns.<BR/>Staff were able to discuss the required level of staff assistance for ADLs.<BR/>Staff were able to demonstrate the use of the [NAME] system for resident care needs. <BR/>Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures.<BR/>[NAME] for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the [NAME].<BR/>Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the [NAME].<BR/>Nursing staff were in-serviced on where to find a resident's level of assistance in the [NAME]. The training was completed on 04/13/23. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>Staff were in-service on abuse and neglect. The training was completed on 04/13/23. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>The 5-question quiz of [NAME] knowledge given to all tested staff indicated all staff scored 100%.<BR/>The [NAME] showed that resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on 01/17/23. <BR/>The administrator was in-service on 04/12/23 by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter.<BR/>There were no additional allegations of neglect or abuse identified during the investigation.<BR/>During an interview on 04/13/23 at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. <BR/>During an interview on 04/13/23 at 2:50 p.m., The DON said the audit of all residents' care plans and [NAME] revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents.<BR/>A facility record audit dated 04/13/23 of residents' [NAME] and care plans revealed no issues or concerns. <BR/>Staffing was reviewed for the previous two weeks and for 01/16/23. There was no concerns noted.<BR/>Five residents indicated they were afraid during care or had complaints of their care.<BR/>The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on 04/12/23.<BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 24 residents reviewed for infection control. (Resident #226, #220 and #224)<BR/>Resident #226 was unvaccinated for Covid-19 admitted and was placed in a room with no special precautions.<BR/>Residents #220 and #224 were not fully vaccinated for Covid-19 and was admitted without special precautions.<BR/>This failure could place the residents, staff, and visitors at risk for the spread of infection.<BR/>Findings included:<BR/>1. The admission face sheet with print date of 08/10/2022 indicated Resident #226 indicated he admitted on [DATE] was [AGE] years old with diagnosis of heart disease.<BR/>Record review of physician orders for Resident #226 dated August 2022 indicated no evidence of orders for isolation precautions.<BR/>Record review of vaccine record on 08/08/2022 indicated Resident #226 was not vaccinated for Covid.<BR/>During an observation and interview on 08/08/2022 at 10:00 a.m., Resident #226 sitting in his room by himself and said he was here for therapy to get stronger. There was no sign on his door or isolation cart on the outside of his room to indicate any special precautions.<BR/>During an observation on 08/09/2022 at 1:15 p.m., Resident #226's room had no sign on the door to indicate isolation and no isolation cart near the door.<BR/>During an interview on 08/09/2022 at 1:30 p.m., DON and ADON/ICP said Resident #226 was in a warm isolation room and when they were informed of the Resident #226 not having a sign or isolation cart by his door on 08/08/2022 or 08/09/2022. DON and ADON/ICP said there was a sign on his door and maybe the sign fell off the door.<BR/>During an observation and interview on 08/09/2022 at 1:35 p.m. DON, ADON/ICP went to Resident #226's room, and both said there was not a sign warning of precautions/ or an isolation cart outside of the room. DON said she would find out if someone had removed the isolation cart and she said maybe he removed the sign. ADON/ICP said the door should have a sign to indicate special precautions. She said without the sign staff or visitors would not know what precautions were in place.<BR/>During an interview on 08/09/2022 at 1:45 p.m. LVN C said she was the charge nurse for Resident #226 and was responsible for his care and services. She said he was not on special precautions. LVN C said he was being closely monitored for signs and symptoms of Covid 19. She said no one had told her that he needed to be on isolation precautions. LVN C said she had been trained on Covid and the use of personal protective equipment.<BR/>During an observation on 08/09/2022 at 2:15 p.m., DON and ADON /ICP nurse placed sign on Resident #226 door to indicate special precautions to enter room and placed an isolation cart which contained personal protective equipment outside of the room.<BR/>During an observation on 08/09/2022 at 3:00 p.m. CNA (Certified Nurse Aide) D walked into Resident #226's room and walked over to the resident within 2 to 3 feet from Resident #226. CNA D asked Resident #226 if he wanted a shower, the CNA D did not have an isolation gown, gloves, or face shield on. CNA D was wearing a N-95 mask . CNA D came out into the hall and the CNA observed the sign on the door, and he said no one had told me and I didn't know. He said he had been trained in personal protective equipment and isolation precautions.<BR/>2. Record review of the admission face sheet with print date of 08/10/2022 for Resident #220 indicated she admitted on [DATE] was [AGE] years old with diagnoses of kidney failure.<BR/>Record review of Resident #220's vaccine report indicated she had received her Covid Vaccines on 04/09/2021 and 04/28/2021 and the clinical record dated 08/04/2022 to 08/10/2022 contained no indication of being boosted or of having Covid during the last 90 days.<BR/>Record review of physician orders for Resident #220 dated August 2022 indicated no evidence of orders for isolation precautions.<BR/>During an interview on 08/10/2022 at 10:00 a.m., DON and ADON/ICP nurse said then Resident #220 should had been admitted placed in an isolation room with precautions.<BR/>3. Record review of the admission face sheet with print date of 08/10/2022 for Resident #224 indicated she admitted on [DATE] and was [AGE] years old with diagnoses of respiratory failure.<BR/>Record review clinical record for Resident #224's vaccine report indicated she had received her 03/08/2021 [NAME] Covid vaccine and the contained no indication of being boosted or of having Covid during the last 90 days. The clinical record dated 08/05/2022 to 08/10/2022 contained no evidence of her being placed in isolation precautions.<BR/>Record review of physician orders for Resident #224 dated August 2022 indicated no evidence of orders for isolation precautions.<BR/>During an interview on 08/10/2022 at 10:00 a.m., DON and ADON said this Resident #224 was not boosted and should had been placed in isolation. They said if the residents were not placed in isolation precautions and if they developed Covid it could spread to other residents and staff.<BR/>During an interview on 08/10/2022 at 1:00 p.m. DON and ADON/ICP said they follow the CDC guidance and said both are responsible to make sure the staff follow the CDC guidance with training and monitoring the staff to ensure newly admitted residents, who are not fully vaccinated and who require special infection control precautions are placed in isolation.<BR/>The COVID-19 Response for Nursing Facilities dated 6/27/22 was obtained from the Internet on 08/10/2022 indicated CDC guidance indicated .New admissions, readmissions, and residents who have spent one or more nights away from the nursing facility are all considered residents with unknown COVID-19 status. All residents with unknown COVID-19 status must be quarantined per CDC guidance for long-term care facilities .<BR/>Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes | CDC was obtained from the Internet on 08/10/2022 indicated Residents with confirmed SARS-CoV-2 infection who have not met criteria to discontinue Transmission-Based Precautions should be placed in the designated COVID-19 care unit, regardless of vaccination status.In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered.

Based on interview and record review, the facility failed to ensure the residents promptly received mail for 2 of 6 residents reviewed for resident rights. (Residents # 10 and #23). <BR/>The facility did not implement a system for delivering mail on Saturdays; resulting in Residents #10 and #21 not receiving mail delivered on Saturdays until Monday. <BR/>This failure could place the residents at risk of a diminished quality of life.<BR/>Findings included:<BR/>During a group interview on 09/12/23 at 09:20 a.m., Residents # 10 and #23 said they did not receive their mail on Saturday. Resident #23 said her mail was received Monday through Friday, but she did not receive her mail on Saturday. Resident #10 said she received lots of mail and several times has had things come in on Saturday, it sits at the receptionist desk, and was not passed to the residents until Monday when the AD was at the facility. Residents #10 and #23 said they should not have to wait until Monday to get their mail. <BR/>During an interview on 09/13/23 at 02:20 p.m., the AD said she worked Monday-Friday. She said during the week she receives the mail, sorts it, and hands it out to the residents. <BR/>During an interview on 09/13/23 at 03:05 pm, the ADM said mail was delivered to the facility by the post office on Saturdays. He said mail was not being delivered to residents on the weekend at this time because they did not have a receptionist any longer. A policy was requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse and neglect for 2 of 11 residents (Resident #5 and #4) reviewed for abuse and neglect. <BR/>1. CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. <BR/>An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>2. Resident #4 sustained a laceration to his left eyebrow and had blood in his mouth. Resident #4 indicated he fought with an unidentified staff. He was sent to the ER and received sutures. The facility identified the staff as CNA K. <BR/>These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.<BR/>Findings included:<BR/>1. Record review of face sheet dated [DATE], indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's current care plan initiated [DATE] and revised on [DATE] indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of Kardex (electronic care needs) printed on [DATE] indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>Record review of an incident report dated [DATE], completed by LVN A indicated CNA C was providing incontinent care for Resident #5. CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of progress note dated [DATE] completed by LVN A, indicated CNA C was changing Resident #5 and she rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated [DATE] indicated Resident #5 sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur (thigh bone) metadiaphysis (the diaphysis (shaft or primary ossification centre), metaphysis (where the bone flares), right knee-minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella a flat, inverted triangular bone, situated on the front of the knee-joint proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla the space below the shoulder through which vessels and nerves enter and leave the upper arm; a person's armpit hematoma (A pool of clotted blood that forms in an organ, tissue, or body space). Her diagnoses included diffuse osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes) and osteopenia (a condition that begins as you lose bone mass and your bones get weaker). <BR/>Record review of hospital Discharge summary dated [DATE] indicated the fractures of Resident #5's left and right thigh bones were both repaired surgically.<BR/>During an interview on [DATE] at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on [DATE] after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries.<BR/>During an interview on [DATE] at 2:47 p.m., LVN A said on [DATE] at 10:00 a.m. she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said at the time of the incident, Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital at 12:00 p.m. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on [DATE] at 3:00 p.m. the DON said Resident #5's fall was reported to the Administrator on [DATE]. She said the Administrator said it was not reportable because it was a witnessed fall and not abuse. She said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there were two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff were required to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. She said the nurses were expected to monitor the aides to ensure care was provided per the care plans.<BR/>During an interview on [DATE] at 3:26 p.m., CNA C said on [DATE] at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 laid down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the Kardex indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the Kardex the day after the fall. She said the DON said it was not her fault because the Kardex was not updated. <BR/>During an interview on [DATE] at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the Kardex was not updated. She said the Kardex was populated by the care plan. She said Resident #5's care plan was in place from [DATE] and the Kardex was not changed.<BR/>During an interview on [DATE] at 3:45 p.m., the Administrator said Resident #5's fall off the bed on [DATE] was not reported because it was a witnessed fall. He said he did not suspect abuse or neglect. He said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware the DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the Kardex. He said CNA C was terminated on [DATE] for not calling and not showing for shifts. <BR/>During an observation and interview on [DATE] at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said she had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>During an interview on [DATE] at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the Kardex and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. He said the same situation could happen again if the facility did not recognize abuse or neglect. <BR/>During an interview on [DATE] at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the Kardex for a resident's level of care. She said she received retraining on [DATE] after the incident on the Kardex system and bed mobility prior to [DATE] and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the Kardex and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the Kardex. She said if staff did not follow the Kardex for care needs the resident could have serious injuries or die.<BR/>During an interview and record review on [DATE] at 1:04 p.m., the DON said they believed all staff were trained on [DATE] and [DATE] to check the Kardex for level of resident assistance required. She said she and the ADON monitored the care plans and Kardex weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. <BR/>During an interview on [DATE] at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the Kardex. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side before the fall on [DATE]. She said Resident #5 was not able to use her legs. She said resident care information was in the Kardex system. She said she was retrained on the Kardex system and bed mobility after the incident. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the Kardex system and bed mobility but forgot to sign. She said if staff did not follow the Kardex for care needs then residents could get seriously injured.<BR/>During an interview on [DATE] at 2:45 p.m., the RNC said she received an anonymous call from a blocked number. She said she was told of Resident #5's fall. She said she looked at Resident #5's clinical record and the hospital record. She said she called the CNO who told her the incident was reportable. She said she called the Administrator and told him the incident was reportable. She said the Administrator wanted the COO to review the incident. She said the COO agreed the incident was reportable as an allegation of neglect.<BR/>During an interview on [DATE] at 2:50 p.m., the DON said the incident of Resident #5's fall and injuries on [DATE] was neglect and reportable.<BR/>During an interview on [DATE] at 2:50 p.m. the ADON said incident of Resident #5's fall and injuries on [DATE] was neglect and reportable.<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated: The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.<BR/>Record review of the facility Resident Rights policy revised 02/21 indicated Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and implementation 1. Federal Law state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation; .<BR/>The Administrator and the DON as notified of the Immediate Jeopardy on [DATE] at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 12:35 p.m. and reflected the following: <BR/>1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. <BR/>2* Corrective Action<BR/>Nursing administration will review care plans and Kardex's for all residents to ensure they match with the resident's level of assistance required. This process began [DATE] and will be complete by 10 AM on [DATE]. All areas of concerns have been addressed and all care plans match all Kardex's for all residents. <BR/>All nursing staff will be in-service on where to find a resident's level of assistance in the Kardex. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. <BR/>All nursing staff will be in-service on abuse and neglect. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the Kardex/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. <BR/>All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM.<BR/>The Kardex showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the Kardex. <BR/>The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of [DATE] 4:30 PM. <BR/>3* Identification of Others<BR/>The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by [DATE] of all facility residents' administrative nurses. Assessment will compare care plans to Kardex. <BR/>The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. <BR/>A facility record audit of residents Kardex and care plans will be completed by Director of Nursing/Designee by [DATE] 10 AM.<BR/>4* Plan to prevent from recurring <BR/>Intervention for Neglect: DON/designee to evaluate care plan and Kardex for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on Kardex and levels of assistance prior to working the first shift. This is to be completed during orientation. <BR/>Training Plan<BR/>Initial Trainings: Facility to Initiate Training by [DATE] 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working [DATE], and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by [DATE] 10AM via in person on telephone training.<BR/>All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM.<BR/>Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations.<BR/>5* Ongoing Monitoring<BR/>Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate Kardex knowledge during rounds. <BR/>6* QAPI<BR/>In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed [DATE] by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate.<BR/>On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Observations, interviews, and record reviews were conducted on [DATE] from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the Kardex system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns.<BR/>Staff were able to discuss the required level of staff assistance for ADLs.<BR/>Staff were able to demonstrate the use of the Kardex system for resident care needs. <BR/>Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures.<BR/>Kardex for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the Kardex.<BR/>Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the Kardex.<BR/>Review of staff training indicated nursing staff were in-serviced on where to find a resident's level of assistance in the Kardex. The training was completed on [DATE]. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>Staff were in-service on abuse and neglect. The training was completed on [DATE]. <BR/>The 5-question quiz of Kardex knowledge given to all tested staff indicated all staff scored 100%.<BR/>The Kardex showed that Resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on [DATE]. <BR/>The administrator was in-service on [DATE] by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter.<BR/>There were no additional allegations of neglect or abuse identified during the investigation.<BR/>During an interview on [DATE] at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. <BR/>During an interview on [DATE] at 2:50 p.m., The DON said the audit of all residents' care plans and Kardex revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents.<BR/>A facility record audit dated [DATE] of residents' Kardex and care plans revealed no issues or concerns. <BR/>Staffing was reviewed for the previous two weeks and for [DATE]. There was no concerns noted.<BR/>Five residents said they were not afraid during care or had complaints of their care.<BR/>The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on [DATE].<BR/>An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>On [DATE] at 3:12 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>2. Record review of face sheet dated [DATE] indicated Resident #4 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included vascular dementia, diabetes, cognitive communication deficit, muscle weakness, muscle wasting and atrophy, and need for assistance with personal care.<BR/>Record review of MDS dated [DATE] indicated Resident #4 was usually able to express ideas and wants and able to understand others, had severe cognitive impairment, and required extensive assist of 1 persons for bed mobility and toilet use, 2+ person for transfers and personal hygiene. He was incontinent of bladder and bowel. There were no noted behaviors.<BR/>Record review of Resident #4's care plan indicated no care plans developed for aggression or behaviors.<BR/>Record review of incident report dated [DATE] and completed by LVN J indicated CNA K came to the nurse station and reported the resident had blood on his forehead. LVN J observed Resident #4 lying in bed with an open wound over his left eye with dried blood around the wound. When Resident #4 was asked what happened, Resident #4 said he said he had a fight with a nurse. Resident #4 was transported to the hospital.<BR/>Record review of Resident #4's hospital record dated [DATE] indicated Resident #4 said someone punched him.here for a fall according to (facility). Someone put Resident #4 back to bed, but no one knows who. Something happened last night that went unreported per EMS. 2 cm wound sutured with 4 sutures . Clinical impression: assault, facial laceration .SW was called to the ER to assist Resident #4 with possible NH abuse. Apparently the EMS staff advised LVN L that I (Resident #4) kicked a nurse and she hit me' . Communicating with Resident #4 is very difficult due to him being hard of hearing. The SW found Resident #4 to be awake and alert, just slow to respond. (In fact, he told the SW to please slow down. I might be old, but if I take my time I can get it all out. Resident #4 stated, I kicked my nurse and she hit me. I guess I made her mad. Resident #4 stated he was embarrassed that he kicked a woman and was remorseful for the event even occurring.<BR/>Record review of the facility investigation dated [DATE] indicated LVN J said CNA K came to the nurse station on [DATE] 15 minutes prior to the end of shift and reported Resident #4 had blood on his forehead. CNA K left the facility the immediately after she reported the blood on Resident #4. LVN O (day shift nurse) assisted with assessment. Resident #4 was lying in bed neatly tucked in bed. LVN O stated it looked staged how neatly Resident #4 was tucked in. Resident #4 sustained a laceration to his left eye and hematoma. There appeared to be blood in his mouth. There was a large amount of fresh blood on the privacy curtain adjacent to Resident #4's bed. When asked what happened, Resident #4 said he got in a fight with the nurse. Resident #4 was sent to the hospital for evaluation and assessment. CNA K was the only aide to provide care for Resident #4 on the night shift. The Administrator received a call from the SW at the hospital who reported Resident #4's injuries seemed suspicious to the hospital staff and Resident #4 told the EMS staff he got in a fight with the nurse. SW N interviewed Resident #4 and asked what happened. Resident #4 said he got in a fight with a nurse and said he had kicked the nurse as she hurt him when she moved him and she did not like that he kicked her. Resident #4 was not able to give a name or description. He received sutures above his eye and returned to the facility the same day. The night nurse and all CNAs were suspended. It was noted Resident #4 refers to all staff as nurse and did not differentiate between aides and nurses. The administrator observed a large amount of blood on the privacy curtain. It was bright red and appeared fresh. CNA K was the only staff identified to provide care for Resident #4 on [DATE]. CNA K returned to the facility to give her statement. She appeared nervous and fidgeted during the interview. She had black bandages on the middle and ring finger of her right hand. The ADON noted scratches on the fingers. CNA K indicated she was right-handed. CNA K refused to remove the bandages. CNA K said she did not know what happened to Resident #4. CNA K changed her statement to reporting the incident to the nurse early in the shift and then changed it back to the end of her shift. She denied Resident #4 had a fall or if there was an argument or a scuffle. <BR/>Progress note dated [DATE] indicated Resident #4 expired after testing positive for Covid-19 on [DATE] (unrelated to the abuse).<BR/>The investigator attempted to call CNA K on [DATE] at 12:27 p.m. The person who answered the phone said no when the investigator asked to speak to CNA K and disconnected the call. The investigator left a text message at 12:31 p.m. for CNA K at the same number and received no response.<BR/>Record review of CNA K's statement (undated) indicated she checked on Resident #4 and noticed dried up blood on his face and reported to the charge nurse. She checked on him a second time with CNA N, there was still blood on Resident #4 but she assumed LVN J had reported it.<BR/>Record review of LVN O's statement dated [DATE] indicated she arrived at the facility on [DATE] at approximately 5:45 a.m. She started rounds and observed Resident #4 lying in bed with blood and hematoma noted above his left eye. Blood was also noted in Resident #4's mouth with no visual laceration noted to his mouth. Resident #4 was sent to the ER for evaluation and treatment.<BR/>Record review of CNA M's statement

Based on observation, interview, and record review, the facility failed to have the most recent survey of the facility posted in a place readily available to resident's, family members, and/or legal representatives for 6 of 6 residents reviewed for survey results. (Residents #3, #10, #11, #23, #33, and #43)<BR/>The facility did not have the most recent survey results available. <BR/>This failure could place residents, family members, and legal representatives at risk of not being informed of survey results. <BR/>Findings included:<BR/>During a group interview on 09/12/23 at 09:20 a.m., Residents #3, #10, #11, #23, #33, and #43 said they did not know where to find the book with the survey results from HHSC visits. <BR/>During an observation of the posted sign at the receptionist desk on 09/13/23 at 2:30 p.m., the sign indicated the survey book could be found in a blue book behind the nursing station of the facility. The sign was in small lettering. <BR/>During an observation of the nursing station on 09/13/23 at 2:35 p.m., a blue book labeled Survey Results was found in the nursing station. <BR/>Record review of the blue book labeled Survey Results indicated the results of HHSC visits for 2018, 2019, 2020, and 2021. There were no results for HHSC visits for 2022 or 2023.<BR/>During an observation and interview on 09/13/23 at 2:50 p.m., the ADM said the survey book was located in the nursing station. After attempting to locate the survey book in the nursing station, the ADM said, I can't find it, I don't know where it went. He said anyone could go into the nursing station to obtain the book to look at the recent survey results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 11 residents (Resident #5) reviewed for accidents.<BR/>CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. <BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for falls resulting in injury, pain, and hospitalization. <BR/>Findings included:<BR/>Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away).<BR/>Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed).<BR/>Record review of Resident #5's most current care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene.<BR/>Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility.<BR/>During an observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. <BR/>Record review of an incident report dated 01/16/23, completed by LVN A indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. LVN A did not indicate Resident #5 was a 2-person assist.<BR/>Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m.<BR/>Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia.<BR/>Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically.<BR/>During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries.<BR/>During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the [NAME]. She said if staff did not use 2-person assist when required it could result in injury or death of a resident.<BR/>During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there was two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident.<BR/>During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. <BR/>During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed.<BR/>During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. <BR/>During an interview on 04/12/23 at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the [NAME] and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. <BR/>During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not follow the [NAME] for care needs the resident could have serious injuries or die.<BR/>During record review and interview on 04/12/23 at 1:04 p.m., the DON said they believed all staff were re-trained to check the [NAME] for level of resident assistance required after Resident #5's fall. She said she and the ADON monitored the care plans and [NAME] weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. <BR/>During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS before the fall. She said Resident #5 was weak on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS before her fall. She said the information was in the [NAME] system. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>During an interview on 04/12/23 at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility but forgot to sign. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured.<BR/>Record review of the facility's Falls-Clinical Protocol revised 03/2018 indicated: .2. In addition, the nurse shall assess and document/report the following: .h. Precipitating factors, details on how fall occurred; . Falls Prevention-Potential Interventions - Nursing Measures . proper positioning .<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated : The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.<BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>The Administrator and DON were notified of the Immediate Jeopardy on 04/12/23 at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/13/23 at 12:35 p.m. and reflected the following: <BR/>1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. <BR/>2* Corrective Action<BR/>Nursing administration will review care plans and [NAME]'s for all residents to ensure they match with the resident's level of assistance required. This process began 4/12/23 and will be complete by 10 AM on 4/13/23. All areas of concerns have been addressed and all care plans match all [NAME]'s for all residents. <BR/>All nursing staff will be in-service on where to find a resident's level of assistance in the [NAME]. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. <BR/>All nursing staff will be in-service on abuse and neglect. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the [NAME]/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. <BR/>All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM.<BR/>The [NAME] showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the [NAME]. <BR/>The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of 4/12/23 4:30 PM. <BR/>3* Identification of Others<BR/> The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by 4/13/23 of all facility residents' administrative nurses. Assessment will compare care plans to [NAME]. <BR/>The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. <BR/>A facility record audit of residents [NAME] and care plans will be completed by Director of Nursing/Designee by 4/13/2023 10 AM.<BR/>4* Plan to prevent from recurring <BR/>Intervention for Neglect: DON/designee to evaluate care plan and [NAME] for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on [NAME] and levels of assistance prior to working the first shift. This is to be completed during orientation. <BR/>Training Plan<BR/>Initial Trainings: Facility to Initiate Training by 4/12/2023 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working 4/12/2023, and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by 4/13/23 10AM via in person on telephone training.<BR/>All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. <BR/>A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM.<BR/>Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations.<BR/>5* Ongoing Monitoring<BR/>Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate [NAME] knowledge during rounds. <BR/>6* QAPI<BR/>In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed 4/12/23 by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. <BR/>On 04/13/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:<BR/>Observations, interviews, and record reviews were conducted on 04/13/23 from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns.<BR/>Staff were able to discuss the required level of staff assistance for ADLs.<BR/>Staff were able to demonstrate the use of the [NAME] system for resident care needs. <BR/>Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures.<BR/>[NAME] for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the [NAME].<BR/>Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the [NAME].<BR/>Nursing staff were in-serviced on where to find a resident's level of assistance in the [NAME]. The training was completed on 04/13/23. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>Staff were in-service on abuse and neglect. The training was completed on 04/13/23. <BR/>Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift.<BR/>The 5-question quiz of [NAME] knowledge given to all tested staff indicated all staff scored 100%.<BR/>The [NAME] showed that resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on 01/17/23. <BR/>The administrator was in-service on 04/12/23 by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter.<BR/>There were no additional allegations of neglect or abuse identified during the investigation.<BR/>During an interview on 04/13/23 at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. <BR/>During an interview on 04/13/23 at 2:50 p.m., The DON said the audit of all residents' care plans and [NAME] revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents.<BR/>A facility record audit dated 04/13/23 of residents' [NAME] and care plans revealed no issues or concerns. <BR/>Staffing was reviewed for the previous two weeks and for 01/16/23. There was no concerns noted.<BR/>Five residents indicated they were afraid during care or had complaints of their care.<BR/>The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on 04/12/23.<BR/>An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in compartments and permitted only authorized personnel to have access to the prescribed medications for 2 of 18 residents (Resident #11 and Resident #21) reviewed for storage of medications. <BR/>Resident #11 who had moderate intellectual disabilities had her morning medications left at bedside to consume unsupervised by authorized personnel. <BR/>The facility failed to supervise and ensure Resident #21 consumed dispensed medications prescribed and dispensed as ordered. <BR/>This failure could place residents at risk for consuming unsafe medications and having access to unauthorized medication. <BR/>Findings included: <BR/>1. Record review of a care plan last revised 09/24/21 indicated Resident #11 required limited assistance with ADLs due to periods of confusion to ensure ADLs are completed safely. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #11 had intact cognitive skills for daily decision making and an active diagnosis of moderate intellectual disabilities and required supervision with all ADLs. <BR/>Record review of face sheet and physician ' s orders dated August 2022 indicated Resident #11 was a [AGE] year-old female admitted to the facility 08/16/19 with diagnosis of moderate intellectual disabilities. <BR/>Record review of medication administration record (MAR) dated August 2022 indicated on 08/08/22 at 9:00 AM, LVN B administered to Resident #11 the following medications: <BR/>Anastrozole 1 mg one tablet (a medication given for breast cancer) <BR/>Aspirin EC 81mg one tablet (for syncope/a condition caused by fall in blood pressure) <BR/>Atenolol 50mg on tablet (for high blood pressure) <BR/>Calcium-Vitamin D 600-200mg on tablet (for breast cancer) <BR/>Glipizide 5mg one tablet (for diabetes) <BR/>During an observation and interview on 08/08/22 at 10:10 am, Resident #11 was sitting on the edge of her bed. On her bedside table in front of her was a small, clear plastic cup usually used for medication administration. The cup contained 5 pills. Resident #11 said the pills were her morning medication and she just woke up and found them sitting there. She said she was about to take the medications. <BR/>During an interview on 08/08/22 at 10:15 AM, LVN B said she left Resident #11 ' s morning medications at her bedside because the resident always gets testy with her and argued with her about taking her medications. LVN B said she had been leaving the medications at Resident #11 ' s bedside so she could take them later. She said Resident #11 was the only resident she leaves medication with, and she watches all other residents swallow their medication before leaving the resident. LVN B said she was intimidated by Resident #11 because she yelled at her and would stand up and move towards her when she asked her to take the medications in front of her. LVN B said that best practice was to wait until the resident swallowed the medication before leaving the room, but she was not going to argue with Resident #11. LVN B said she had worked at the facility for 4 months and DON and ADON were her direct supervisors. She said both DON and ADON had watched her do medication pass when she began working at the facility. <BR/>During an interview on 08/10/22 at 10:05 AM, the DON said that LVN B had reported to her that surveyor had questioned her about leaving Resident #11 ' s medication at her bedside and not witnessing the resident take the medication. The DON said she expected facility nurses to witness the resident taking the medications and not leave them at the bedside. The DON said she had completed an in-service to all nurses working on 08/08/22 regarding nurses should wait until all medications are taken before leaving a resident ' s room. She said she had watched LVN B giving medications during her orientation, and she required no additional training at that time. She said LVN B had never reported to her that she felt intimidated by Resident #11, or the problem would have been addressed. DON said that the possible negative outcome of not watching a resident take their medication could be they might not receive the medications as ordered by their physician. <BR/>During an interview on 08/10/22 at 1:01 PM, the Administrator said he expected nurses to stay with residents until they had taken their medications. He said he was aware that medication had been left at Resident #11 ' s bedside and the DON conducted an in-service regarding nurses staying with residents until medications were taken. <BR/>2. Record review of face sheet and physician ' s orders dated August 2022 indicated Resident #21 was an [AGE] year-old female admitted to the facility 05/09/22 with diagnosis of dementia and GERD (gastroesophageal reflux disease). Orders included Sucralfate Suspension 1 GM/10ML - Give 10 ml by mouth before meals and at bedtime for gastric protection. (Used to treat acid from the stomach that flows up into the esophagus) <BR/>Record review of a care plan last revised 06/15/22 indicated Resident #21 required extensive assistance with ADLs due to impaired cognition to ensure ADLs are completed safely. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #21 lacked cognitive skills for daily decision making and had an active diagnosis of dementia and required extensive assistance with all ADLs. <BR/>During an observation on 08/08/22 at 10:00 a.m., a 30 ml plastic medicine cup with 10 ml of pink liquid was found on the overbed table beside Resident #21 ' s bed. Resident #21 was sleeping. <BR/>During an interview and record review at 10:05 a.m., LVN A said she had not noticed the medication cup in resident's room earlier. She said she had not prepared nor dispensed this medication to Resident #21 this morning. LVN A added she ' had been picking up medications left at bedside this morning from various resident rooms while performing her medication pass. When asked to elaborate by surveyor, she declined further details. Resident #21's EMR (electronic medical record) was reviewed with LVN A who determined contents of cup was sucralfate suspension and was dispensed on a previous shift. Resident #21 ' s Sucralfate Suspension 1 GM/10ML was not due again until before lunch and scheduled for 08/08/22 at 11:30 a.m. <BR/>During an interview on 08/10/22 at 12:15 p.m., the DON said her expectations were for staff to administer medications once prepared and should not be left at bedside for any reason. Any medication not ingested by residents should be discarded and staff should document it in the electronic record. <BR/>During an interview on 08/10/22 at 12:30 p.m., the administrator said staff should never leave medications unattended at resident bedside for any reason. If prepared medications are not taken, it should be discarded or returned to the cart. Medications left unattended have the potential for hazardous results including accidental ingestion by another resident. <BR/>An undated Medication Administration-General Guidelines policy provided by facility indicated the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B. Administration.18) The resident is always observed after administration to ensure that the dose was completely ingested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 of 5 residents reviewed for PRN psychotropic medications. (Resident #22)<BR/>The facility did not have an order to extend a prn order beyond 14 days, have physician documentation for rationale, or have documentation to indicate the duration for the PRN order for Resident #22. <BR/>This failure could place residents at risk of decreased quality of life due to improper use of psychotropic medications.<BR/>Findings included:<BR/>Record review of the physician orders for September 2023 indicated Resident #22 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities). She had an order for alprazolam (antianxiety) 0.5mg twice daily prn anxiety with start date of 12/30/21. <BR/>Record review of the Pharmacy Consultant reviews indicated for Resident # 22's alprazolam 0.5mg twice daily prn anxiety indicated:<BR/>* on 02/22/23 Communication regarding psychoactive medication review to include alprazolam 0.5mg twice daily prn anxiety since 12/30/21 with Psych NP marking disagree and documented resident having hallucinations/delusions;<BR/>* on 03/28/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 04/27/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 05/18/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 06/15/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 07/21/23 Pharmacist wrote refused to rewrite 02/22/23; and <BR/>* on 08/24/23 Pharmacist wrote refused to rewrite 02/22/23.<BR/>Record review of Resident #22's MARs indicated:<BR/>* in March 2023 she received 7 doses of the prn alprazolam; <BR/>* in April 2023 she received 9 doses of the prn alprazolam;<BR/>* in May 2023 she received 5 doses of the prn alprazolam;<BR/>* in June 2023 she received 14 doses of the prn alprazolam;<BR/>* in July 2023 she received 14 doses of the prn alprazolam;<BR/>* in August 2023 she received 9 doses of the prn alprazolam; and <BR/>* in September 2023 she received 7 doses of the prn alprazolam. <BR/>During an interview on 09/13/23 at 10:41 a.m. the Psych NP said she and psych physician did not write a prn alprazolam order unless it was an emergency, and it would only be for a onetime dose. She said Resident # 22's prn alprazolam order from 12/2021 would have been from the PCP .<BR/>During an interview on 09/13/23 at 02:04 p.m. the ADON said any prn psychotropic medication order should be renewed every 14 days unless the physician documents the need for it to be longer. Surveyor requested a policy regarding prn psychotropic medications. <BR/>A policy for prn psychotropic medications was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received services with reasonable accommodation of the resident's needs and preferences for 1 of 19 (Resident #278) residents reviewed for call light placement.<BR/>Resident #278, who required extensive assistance of 2 to transfer, did not have her call light in reach. <BR/>This failure could place the residents at risk for not receiving the appropriate care and services to maintain their highest practicable well-being. <BR/>Findings included:<BR/>Record review of physician orders dated September 2023 indicated Resident #278, readmitted [DATE], was [AGE] years old with diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it). <BR/>Record review of a significant change MDS assessment dated [DATE] indicated Resident #278 had severely impaired cognition and minimal difficulty hearing. The resident required extensive assistance of 2 persons to transfer. <BR/>A care plan updated 09/08/23 indicated Resident #278 had poor injury related to balance and confusion. Interventions did not include keeping call light within resident reach. <BR/>During an observation on 09/11/23 at 9:30 a.m., Resident #278 was in bed with the bed in the lowest position. Fall mats were on both side of bed. The call light was looped and sitting on top of a desk approximately 2 feet from resident's bed. The call light was not in reach of Resident #278.<BR/>During an interview on 09/11/23 at 9:35 a.m., LVN F said Resident #278 had declined in mobility since her hospitalization and readmission on [DATE]. She said the resident was able to use her call light and had been using it in previous days. She said the call light should be always kept within resident's reach. CNA C (who was also in the room) took the call light off of the desk and attached it to bed cover of the resident. She said staff were to keep resident call light within reach so they can call for help and for fall prevention. 27 <BR/>During an interview on 09/12/23 at 9:35 a.m., the DON said her expectations were for the staff to place call lights within resident reach. The ADON said the facility had done in-service training for nursing staff about keeping call lights with reach of residents and fall prevention. <BR/>During an interview on 09/13/23 at 10:20 a.m., the ADM said he expected call lights to be placed within resident reach. He said the facility had given numerous in-service trainings on placement of call lights. He said nursing staff were responsible for ensuring residents had call lights within reach and the DON was responsible for monitoring call light placement and nursing staff. He said possible negative outcome of not keeping call light within reach could be the resident is unable to call for assistance when needed. <BR/>A facility policy titled Strategies for Reducing the Risk of Falls dated March 2018 stated in part to keep call light within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the minimum healthcare information necessary to properly care for a resident for 1 of 4 residents reviewed for baseline care plan. (Resident #73)<BR/>The facility did not address Resident #73's PASRR in the baseline care plan. <BR/>This failure could place newly admitted residents at risk of not having their individual, medical, functional, and psychosocial needs identified, appropriately addressed, and could cause physical or psychosocial decline in health.<BR/>Findings included:<BR/>Record review of a face sheet printed 09/13/23 indicated Resident #73 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral palsy and mental disorder. <BR/>Record review of a PASRR Level 1 Screening for Resident #73 indicated it was dated 08/14/23.<BR/>Record review of a PASRR Evaluation (also known as a PASRR Level 2) for Resident #73 indicated it was dated 08/14/23.<BR/>Record review of a baseline care plan for Resident #73 indicated 1. Resident Information: 2. PASRR Levels initiated: a. Level 1, b. Level 2, c. None The box for c. None was marked. <BR/>During an interview on 09/13/23 at 02:50 p.m. the ADON said the charge nurses were to initiate the baseline care plan as part of the admission packet. She said the PASRR should have been marked for Level 1 and Level 2 for Resident #73. <BR/>During an interview on 09/13/23 at 03:10 p.m. the DON said she ultimately was responsible for ensuring the baseline care plans were filled out correctly. She said she expected the baseline care plans to be filled out correctly. Surveyor requested a policy at this time. <BR/>A policy for baseline care plans was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #71)<BR/>The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #71's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder).<BR/>This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.<BR/>Findings included:<BR/>Record review of a face sheet printed 09/13/23 indicated Resident #71 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behaviors) and depression (medical illness that negatively affects how you feel, the way you think, and how you act).<BR/>Record review of the September 2023 physician orders indicated Resident #71 was to receive Seroquel (antipsychotic used to treat schizophrenia) for depression with start date of 05/04/23 and Cymbalta (antidepressant used to treat depression) for depression with start date of 05/04/23. <BR/>Record review of Resident #71's care plan dated 05/23/23 indicated she used an antidepressant medication related to depression and she used an antipsychotic medication related to schizophrenia diagnosis. <BR/>Record review of an MDS dated [DATE] indicated Resident #71 had moderately impaired cognition with a BIMS score of 10 out of 15, she had no behaviors, she had active diagnoses of depression and schizophrenia, and she received an antipsychotic and an antidepressant for the 7 days prior to the assessment. <BR/>Record review of the September 2023 MAR indicated Resident #71 received Cymbalta daily for depression and Seroquel daily for depression. <BR/>During an observation and interview on 09/11/23 at 09:32 a.m. Resident #71 was In bed. She was clean, neat, and had no odors. She said she was doing okay. <BR/>During an interview on 09/13/23 at 03:10 p.m. the DON said an antipsychotic should be ordered for an appropriate diagnosis. She said Resident #71 had a diagnosis of schizophrenia so the Seroquel should be for the diagnosis of schizophrenia not depression. She said it was the nurse's responsibility to ensure the right diagnosis was with the right medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 of 5 residents reviewed for PRN psychotropic medications. (Resident #22)<BR/>The facility did not have an order to extend a prn order beyond 14 days, have physician documentation for rationale, or have documentation to indicate the duration for the PRN order for Resident #22. <BR/>This failure could place residents at risk of decreased quality of life due to improper use of psychotropic medications.<BR/>Findings included:<BR/>Record review of the physician orders for September 2023 indicated Resident #22 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities). She had an order for alprazolam (antianxiety) 0.5mg twice daily prn anxiety with start date of 12/30/21. <BR/>Record review of the Pharmacy Consultant reviews indicated for Resident # 22's alprazolam 0.5mg twice daily prn anxiety indicated:<BR/>* on 02/22/23 Communication regarding psychoactive medication review to include alprazolam 0.5mg twice daily prn anxiety since 12/30/21 with Psych NP marking disagree and documented resident having hallucinations/delusions;<BR/>* on 03/28/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 04/27/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 05/18/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 06/15/23 Pharmacist wrote refused to rewrite 02/22/23;<BR/>* on 07/21/23 Pharmacist wrote refused to rewrite 02/22/23; and <BR/>* on 08/24/23 Pharmacist wrote refused to rewrite 02/22/23.<BR/>Record review of Resident #22's MARs indicated:<BR/>* in March 2023 she received 7 doses of the prn alprazolam; <BR/>* in April 2023 she received 9 doses of the prn alprazolam;<BR/>* in May 2023 she received 5 doses of the prn alprazolam;<BR/>* in June 2023 she received 14 doses of the prn alprazolam;<BR/>* in July 2023 she received 14 doses of the prn alprazolam;<BR/>* in August 2023 she received 9 doses of the prn alprazolam; and <BR/>* in September 2023 she received 7 doses of the prn alprazolam. <BR/>During an interview on 09/13/23 at 10:41 a.m. the Psych NP said she and psych physician did not write a prn alprazolam order unless it was an emergency, and it would only be for a onetime dose. She said Resident # 22's prn alprazolam order from 12/2021 would have been from the PCP .<BR/>During an interview on 09/13/23 at 02:04 p.m. the ADON said any prn psychotropic medication order should be renewed every 14 days unless the physician documents the need for it to be longer. Surveyor requested a policy regarding prn psychotropic medications. <BR/>A policy for prn psychotropic medications was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in compartments and permitted only authorized personnel to have access to the prescribed medications for 2 of 18 residents (Resident #11 and Resident #21) reviewed for storage of medications. <BR/>Resident #11 who had moderate intellectual disabilities had her morning medications left at bedside to consume unsupervised by authorized personnel. <BR/>The facility failed to supervise and ensure Resident #21 consumed dispensed medications prescribed and dispensed as ordered. <BR/>This failure could place residents at risk for consuming unsafe medications and having access to unauthorized medication. <BR/>Findings included: <BR/>1. Record review of a care plan last revised 09/24/21 indicated Resident #11 required limited assistance with ADLs due to periods of confusion to ensure ADLs are completed safely. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #11 had intact cognitive skills for daily decision making and an active diagnosis of moderate intellectual disabilities and required supervision with all ADLs. <BR/>Record review of face sheet and physician ' s orders dated August 2022 indicated Resident #11 was a [AGE] year-old female admitted to the facility 08/16/19 with diagnosis of moderate intellectual disabilities. <BR/>Record review of medication administration record (MAR) dated August 2022 indicated on 08/08/22 at 9:00 AM, LVN B administered to Resident #11 the following medications: <BR/>Anastrozole 1 mg one tablet (a medication given for breast cancer) <BR/>Aspirin EC 81mg one tablet (for syncope/a condition caused by fall in blood pressure) <BR/>Atenolol 50mg on tablet (for high blood pressure) <BR/>Calcium-Vitamin D 600-200mg on tablet (for breast cancer) <BR/>Glipizide 5mg one tablet (for diabetes) <BR/>During an observation and interview on 08/08/22 at 10:10 am, Resident #11 was sitting on the edge of her bed. On her bedside table in front of her was a small, clear plastic cup usually used for medication administration. The cup contained 5 pills. Resident #11 said the pills were her morning medication and she just woke up and found them sitting there. She said she was about to take the medications. <BR/>During an interview on 08/08/22 at 10:15 AM, LVN B said she left Resident #11 ' s morning medications at her bedside because the resident always gets testy with her and argued with her about taking her medications. LVN B said she had been leaving the medications at Resident #11 ' s bedside so she could take them later. She said Resident #11 was the only resident she leaves medication with, and she watches all other residents swallow their medication before leaving the resident. LVN B said she was intimidated by Resident #11 because she yelled at her and would stand up and move towards her when she asked her to take the medications in front of her. LVN B said that best practice was to wait until the resident swallowed the medication before leaving the room, but she was not going to argue with Resident #11. LVN B said she had worked at the facility for 4 months and DON and ADON were her direct supervisors. She said both DON and ADON had watched her do medication pass when she began working at the facility. <BR/>During an interview on 08/10/22 at 10:05 AM, the DON said that LVN B had reported to her that surveyor had questioned her about leaving Resident #11 ' s medication at her bedside and not witnessing the resident take the medication. The DON said she expected facility nurses to witness the resident taking the medications and not leave them at the bedside. The DON said she had completed an in-service to all nurses working on 08/08/22 regarding nurses should wait until all medications are taken before leaving a resident ' s room. She said she had watched LVN B giving medications during her orientation, and she required no additional training at that time. She said LVN B had never reported to her that she felt intimidated by Resident #11, or the problem would have been addressed. DON said that the possible negative outcome of not watching a resident take their medication could be they might not receive the medications as ordered by their physician. <BR/>During an interview on 08/10/22 at 1:01 PM, the Administrator said he expected nurses to stay with residents until they had taken their medications. He said he was aware that medication had been left at Resident #11 ' s bedside and the DON conducted an in-service regarding nurses staying with residents until medications were taken. <BR/>2. Record review of face sheet and physician ' s orders dated August 2022 indicated Resident #21 was an [AGE] year-old female admitted to the facility 05/09/22 with diagnosis of dementia and GERD (gastroesophageal reflux disease). Orders included Sucralfate Suspension 1 GM/10ML - Give 10 ml by mouth before meals and at bedtime for gastric protection. (Used to treat acid from the stomach that flows up into the esophagus) <BR/>Record review of a care plan last revised 06/15/22 indicated Resident #21 required extensive assistance with ADLs due to impaired cognition to ensure ADLs are completed safely. <BR/>Record review of a quarterly MDS dated [DATE] indicated Resident #21 lacked cognitive skills for daily decision making and had an active diagnosis of dementia and required extensive assistance with all ADLs. <BR/>During an observation on 08/08/22 at 10:00 a.m., a 30 ml plastic medicine cup with 10 ml of pink liquid was found on the overbed table beside Resident #21 ' s bed. Resident #21 was sleeping. <BR/>During an interview and record review at 10:05 a.m., LVN A said she had not noticed the medication cup in resident's room earlier. She said she had not prepared nor dispensed this medication to Resident #21 this morning. LVN A added she ' had been picking up medications left at bedside this morning from various resident rooms while performing her medication pass. When asked to elaborate by surveyor, she declined further details. Resident #21's EMR (electronic medical record) was reviewed with LVN A who determined contents of cup was sucralfate suspension and was dispensed on a previous shift. Resident #21 ' s Sucralfate Suspension 1 GM/10ML was not due again until before lunch and scheduled for 08/08/22 at 11:30 a.m. <BR/>During an interview on 08/10/22 at 12:15 p.m., the DON said her expectations were for staff to administer medications once prepared and should not be left at bedside for any reason. Any medication not ingested by residents should be discarded and staff should document it in the electronic record. <BR/>During an interview on 08/10/22 at 12:30 p.m., the administrator said staff should never leave medications unattended at resident bedside for any reason. If prepared medications are not taken, it should be discarded or returned to the cart. Medications left unattended have the potential for hazardous results including accidental ingestion by another resident. <BR/>An undated Medication Administration-General Guidelines policy provided by facility indicated the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. B. Administration.18) The resident is always observed after administration to ensure that the dose was completely ingested.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 9 months reviewed (January 2023 through September 2023) and failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. <BR/>* The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, and September 2023.<BR/>* The facility did not have RN coverage for 8 consecutive hours in April 2023, May 2023, and August 2023.<BR/>* The DON served as a CN in May 2023, June 2023, and August 2023 with census of greater than 60 residents. <BR/>These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.<BR/>Findings included:<BR/>Record review of the CMS Payroll Based Journal report for the 2nd quarter of 2023 (January 1, 20232023, through March 31, 2023) indicated there were no RN hours for the following dates: 01/01/23, 01/28/23, 01/29/23; 02/18/23, 02/19/23, 02/26/23; 03/04/23, 03/05/23, and 03/26/23.<BR/>Record review of the April 2023 RN time sheets indicated:<BR/>* 1st (Sa)-RN H worked 7.68 hours<BR/>* 2nd (Su)-RN H worked 7.97 hours<BR/>* 8th (Sa)-No RN <BR/>* 9th (Su)-RN H worked 7.83 hours<BR/>* 15th (Sa)-No RN<BR/>* 16th (Su)-No RN<BR/>* 22nd (Sa)-No RN<BR/>* 23rd (Su)-No RN<BR/>* 29th (Sa)-No RN; and <BR/>* 30th (Su)-No RN<BR/>Record review of the April 2023 RN time sheets indicated:<BR/>* 1st (Sa)-RN H worked 7.68 hours<BR/>* 2nd (Su)-RN H worked 7.97 hours<BR/>* 8th (Sa)-No RN <BR/>* 9th (Su)-RN H worked 7.83 hours<BR/>* 15th (Sa)-No RN<BR/>* 16th (Su)-No RN<BR/>* 22nd (Sa)-No RN<BR/>* 23rd (Su)-No RN<BR/>* 29th (Sa)-No RN<BR/>* 30th (Su)-No RN<BR/>Record review of the May 2023 RN time sheets indicated:<BR/>* 6th (Sa)-RN H worked 7.73 hours<BR/>* 7th (Su)-No RN<BR/>* 21st (Su)-No RN<BR/>* 27th (Sa)-No RN<BR/>* 28th (Su)-No RN<BR/>Record review of the June 2023 RN time sheets indicated:<BR/>* 11th (Su)-No RN<BR/>* 24th (Sa)-No RN<BR/>* 25th (Su)-No RN<BR/>Record review of the July 2023 RN time sheets indicated:<BR/>* 1st (Sa)-No RN<BR/>* 2nd (Su)-No RN<BR/>* 8th (Sa)-No RN<BR/>* 9th (Su)-No RN<BR/>* 15th (Sa)-No RN<BR/>* 16th (Su)-No RN<BR/>* 22nd (Sa)-No RN<BR/>* 23rd (Su)-No RN<BR/>* 29th (Sa)-No RN<BR/>* 30th (Su)-No RN<BR/>Record review of the August 2023 RN time sheets indicated:<BR/>* 6th (Su)-No RN<BR/>* 12th (Sa)-No RN<BR/>* 13th (Su)-No RN<BR/>* 19th (Sa)-No RN<BR/>* 26th (Sa)-RN J worked 6.0 hours <BR/>* 27th (Su)-RN J worked 6.0 hours<BR/>Record review of the Daily Assignment Schedule sheets indicated the DON worked as a CN on:<BR/>* 05/20/23 6a-2p shift;<BR/>* 06/03/23 2p-10p shift;<BR/>* 06/07/23 2p-10p shift;<BR/>* 06/10/23 2p-10p shift;<BR/>* 06/14/23 2p-10p shift;<BR/>* 06/15/23 2p-10p shift;<BR/>* 08/04/23 6a-2p and 2p-10p shift; and <BR/>* 08/05/23 6a-2p shift.<BR/>Record review of a list of the census provided by facility on 09/13/23 indicated the following:<BR/>* 05/20/23 the census was 86;<BR/>* 06/03/23 the census was 82;<BR/>* 06/07/23 the census was 81;<BR/>* 06/10/23 the census was 84;<BR/>* 06/14/23 the census was 82;<BR/>* 06/15/23 the census was 82;<BR/>* 08/04/23 the census was 74; and<BR/>* 08/05/23 the census was 74.<BR/>During an interview on 09/13/23 at 11:33 a.m. the ADM said the DON could serve as a CN any time in a nursing facility. He said he did not like to use agency nurses because it cost too much and they always say they are just agency nurses. <BR/>During an interview on 09/13/23 at 11:50 a.m. the ADM said the DON could serve as a CN when the census was 60 or less or if there was an emergency. He said they did not have a nurse to work the floor at times so the DON worked it. <BR/>During an interview on 09/13/23 at 03:10 p.m. the DON said she could serve as a CN when the census was 60 or less. She said she had covered as floor nurse at times when they were short because they did not use agency nurses. She said they had been short on RNs so she covered a lot on the weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for 1 (Residents #1) of 5 residents reviewed for quality of life.<BR/>The facility failed to ensure Resident #1, who was on a pureed diet, was sitting upright during his meal.<BR/>This deficient practice could put residents at risk of choking and diminished quality of life.<BR/>Findings included:<BR/>Record review of face sheet dated 6/27/23 indicated Resident #1 was admitted [DATE], was [AGE] years old and had diagnoses including oropharyngeal phase dysphagia (a medical condition that causes a disruption or delay in swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).<BR/>Record review of an MDS dated [DATE] indicated Resident #1 had severe cognitive impairment, required extensive assistance of one person for bed mobility, and limited assistance with eating.<BR/>Record review of a care plan updated 6/27/23 indicated Resident #1 had a focus of diet restrictions due to dysphagia with interventions including to instruct resident to eat in an upright position .<BR/>During an observation on 6/26/2023 at 12:57 p.m., Resident #1's bed was in the lowest position and flat. The Resident's pureed lunch plate was on a chair next to the bed. Resident #1 was propped on his left elbow eating his lunch. He was not able to answer questions appropriately.<BR/>During an observation and interview on 6/26/23 at 1:02 p.m., LVN A said Resident #1 should have been positioned upright in his bed with the overbed table in front of him. CNA B walked in and said he did it; he said Resident #1 was a fall risk and thought it was safer to let him eat with the bed flat and lowered all the way down. He then raised the bed enough to get the over bed table in front of Resident #1 and positioned him upright so he could finish drinking his fluids.<BR/>During an interview on 6/26/23 at 1:45 p.m., the DON said all residents should be positioned upright during meals to prevent choking.<BR/>During an interview on 6/27/23 at 11:39 a.m., the SLP said Resident #1 should always be sitting upright, preferably at a 90-degree angle, when he was eating. She said he would pocket food (holding food in mouth without swallowing) and if lying down it could possibly block his airway. She said he was on a pureed diet, and she was not able to upgrade his diet due to the pocketing.<BR/>Record review of the facility's policy Preparing the Resident for a Meal, revised September 2010 indicated 7. Unless otherwise indicated, residents whose meals are served in bed should be properly positioned by using wedges and pillows to achieve a nearly upright position. (Note: Having the resident in the sitting position, with the head slightly forward, will lessen the possibility of choking.)

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 9 months reviewed (January 2023 through September 2023) and failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. <BR/>* The facility did not have RN coverage for Saturdays (SA) and Sundays (SU) in January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, and September 2023.<BR/>* The facility did not have RN coverage for 8 consecutive hours in April 2023, May 2023, and August 2023.<BR/>* The DON served as a CN in May 2023, June 2023, and August 2023 with census of greater than 60 residents. <BR/>These failures could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.<BR/>Findings included:<BR/>Record review of the CMS Payroll Based Journal report for the 2nd quarter of 2023 (January 1, 20232023, through March 31, 2023) indicated there were no RN hours for the following dates: 01/01/23, 01/28/23, 01/29/23; 02/18/23, 02/19/23, 02/26/23; 03/04/23, 03/05/23, and 03/26/23.<BR/>Record review of the April 2023 RN time sheets indicated:<BR/>* 1st (Sa)-RN H worked 7.68 hours<BR/>* 2nd (Su)-RN H worked 7.97 hours<BR/>* 8th (Sa)-No RN <BR/>* 9th (Su)-RN H worked 7.83 hours<BR/>* 15th (Sa)-No RN<BR/>* 16th (Su)-No RN<BR/>* 22nd (Sa)-No RN<BR/>* 23rd (Su)-No RN<BR/>* 29th (Sa)-No RN; and <BR/>* 30th (Su)-No RN<BR/>Record review of the April 2023 RN time sheets indicated:<BR/>* 1st (Sa)-RN H worked 7.68 hours<BR/>* 2nd (Su)-RN H worked 7.97 hours<BR/>* 8th (Sa)-No RN <BR/>* 9th (Su)-RN H worked 7.83 hours<BR/>* 15th (Sa)-No RN<BR/>* 16th (Su)-No RN<BR/>* 22nd (Sa)-No RN<BR/>* 23rd (Su)-No RN<BR/>* 29th (Sa)-No RN<BR/>* 30th (Su)-No RN<BR/>Record review of the May 2023 RN time sheets indicated:<BR/>* 6th (Sa)-RN H worked 7.73 hours<BR/>* 7th (Su)-No RN<BR/>* 21st (Su)-No RN<BR/>* 27th (Sa)-No RN<BR/>* 28th (Su)-No RN<BR/>Record review of the June 2023 RN time sheets indicated:<BR/>* 11th (Su)-No RN<BR/>* 24th (Sa)-No RN<BR/>* 25th (Su)-No RN<BR/>Record review of the July 2023 RN time sheets indicated:<BR/>* 1st (Sa)-No RN<BR/>* 2nd (Su)-No RN<BR/>* 8th (Sa)-No RN<BR/>* 9th (Su)-No RN<BR/>* 15th (Sa)-No RN<BR/>* 16th (Su)-No RN<BR/>* 22nd (Sa)-No RN<BR/>* 23rd (Su)-No RN<BR/>* 29th (Sa)-No RN<BR/>* 30th (Su)-No RN<BR/>Record review of the August 2023 RN time sheets indicated:<BR/>* 6th (Su)-No RN<BR/>* 12th (Sa)-No RN<BR/>* 13th (Su)-No RN<BR/>* 19th (Sa)-No RN<BR/>* 26th (Sa)-RN J worked 6.0 hours <BR/>* 27th (Su)-RN J worked 6.0 hours<BR/>Record review of the Daily Assignment Schedule sheets indicated the DON worked as a CN on:<BR/>* 05/20/23 6a-2p shift;<BR/>* 06/03/23 2p-10p shift;<BR/>* 06/07/23 2p-10p shift;<BR/>* 06/10/23 2p-10p shift;<BR/>* 06/14/23 2p-10p shift;<BR/>* 06/15/23 2p-10p shift;<BR/>* 08/04/23 6a-2p and 2p-10p shift; and <BR/>* 08/05/23 6a-2p shift.<BR/>Record review of a list of the census provided by facility on 09/13/23 indicated the following:<BR/>* 05/20/23 the census was 86;<BR/>* 06/03/23 the census was 82;<BR/>* 06/07/23 the census was 81;<BR/>* 06/10/23 the census was 84;<BR/>* 06/14/23 the census was 82;<BR/>* 06/15/23 the census was 82;<BR/>* 08/04/23 the census was 74; and<BR/>* 08/05/23 the census was 74.<BR/>During an interview on 09/13/23 at 11:33 a.m. the ADM said the DON could serve as a CN any time in a nursing facility. He said he did not like to use agency nurses because it cost too much and they always say they are just agency nurses. <BR/>During an interview on 09/13/23 at 11:50 a.m. the ADM said the DON could serve as a CN when the census was 60 or less or if there was an emergency. He said they did not have a nurse to work the floor at times so the DON worked it. <BR/>During an interview on 09/13/23 at 03:10 p.m. the DON said she could serve as a CN when the census was 60 or less. She said she had covered as floor nurse at times when they were short because they did not use agency nurses. She said they had been short on RNs so she covered a lot on the weekends.

Based on interview, and record review, the facility failed to ensure the posted daily staffing data was retained for 18 of 18 months reviewed for staffing postings.<BR/>The facility did not have 18 months of staffing postings data. <BR/>This failure could place residents, families, and visitors at risk of not having access to information regarding staffing data and facility census.<BR/>Findings included:<BR/>On 09/12/23 at 11:35 a.m. surveyor requested the posted daily staffing data fromthe HR staff for 05/20/23, 06/03/23, 06/07/23, 06/10/23, 06/14/23, 06/15/23, 08/04/23, and 08/05/23.<BR/>During an interview on 09/13/23 at 03:10 p.m., the DON said she did not have the daily staffing postings for the dates the surveyor requested. She said she thought the MR staff kept them but was told they did not. She said she would throw them away when they were pulled from the posted area instead of keeping them in a book or on the computer, so she did not have the postings for the last 18 months. Surveyor requested a policy at this time. <BR/>A policy for daily staffing postings was not provided prior to exit.