FORTRESS NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to provide safe transport for Resident #1 on 05/27/25 which resulted in a fall and Nondisplaced fracture of the proximal fibular metaphysis of the left knee.<BR/>This failure could result in serious injury such as a left knee fracture and a reduced quality of life .<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 06/02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included a left proximal fibular fracture (a break in the fibula bone, located on the outside of the lower leg, near the knee, often caused by twisting or blunt force injuries to the leg or foot), dementia (deterioration of brain and memory loss), diabetes mellitus type 2, rheumatoid arthritis (auto-immune disorder affecting major joints) , major depressive disorder, hypertension, and anxiety . <BR/>Record review of Resident #1's care plan, revised 05/28/25, reflected,<BR/>Resident #1 had a skin tear to right shin and right knee, and sustained a left knee fracture (left proximal fibular metaphysis) related to fall with interventions of splint to left knee, and teach the purpose of and the procedure for performing isometric and flexion/extension exercises, and pain treatment as indicated by MD. The care plan further reflected Resident #1 was at risk for trauma that may have a negative impact, related to a van incident. Interventions included a Licensed Mental Health Provider, consult with family regarding her condition, identify situation/event/images that trigger recollections of the traumatic event and limit Resident #1's exposure to these as much as possible, monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, mental health provider, and physician. The care plan further reflected Resident #1 had a potential for uncontrolled pain due to fracture of her left knee. Interventions included administration of analgesia per physician orders, and give &frac12; hour before treatments or care, anticipate her need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE] , reflected a BIMS score of 04, which indicated a moderate to severe cognitive impairment. Resident #1 required extensive assistance for bed mobility, transfers, and toilet use. She required the assistance of two people for transfers between surfaces.<BR/>Record review of Resident #1's Physician Order Summary Report, dated 06/02/25, reflected a 20-inch Universal Basic Knee Splint for stabilization of left fibula fracture, and ensure splint is in right place, patient able to perform weight bearing as tolerated while her knee was immobilized. The Order Summary Report further reflected Tramadol 50mg 1 tablet by mouth three times a day for pain, and every 6 hours for moderate pain, Psychiatry to evaluate and treat, and skin tear to right and left knee - cleanse with normal saline and pat dry, apply Xeroform and cover with gauze island dressing every day shift every Monday, Wednesday, and Friday, and as needed.<BR/>Record review of Resident #1's incident report, dated 05/27/2025, at approximately 1:30 PM, reflected the following, Resident #1 was being transported to a doctor's appointment. Driver A braked for a red-light resident slid out of wheelchair scraping knees, received a skin tear and a cut toe. Incident happened right by doctor's office parking lot. Doctor's staff cleaned and bandaged cuts and scrapes. Assessment conducted on 05/27/25 at 5:50 PM reflected Resident #1 had bruising to bilateral upper extremities, skin tear left knee, left upper extremity, abrasion right knee, moisture skin damage sacrum, and irritation to great right toe. Resident #1 was sent to the hospital for X-rays. Driver A was suspended immediately, and van was out of service until all drivers had been re-in serviced and safety check was done on all van equipment. Facility notified the responsible party and the nurse practitioner. <BR/>Record review of hospital records with an admission date/time of 05/27/25 at 09:36 PM and discharge date /time of 05/28/25 at 03:23 AM reflected, Resident #1 was a [AGE] year-old female presenting to the ED for evaluation of a fall that occurred today at approximately 4:00 PM. Resident #1 reported she was riding in a transport van when Driver A forcefully pressed the brakes, launching Resident #1 out of her wheelchair. Resident #1 landed on the vehicle floor and suffered impact to both knees. Associated symptoms included bilateral knee pain and mild neck pain. Denied back pain, chest pain, cough, congestion, rhinorrhea (runny nose), or headaches. There were no other complaints at this time. <BR/>X-ray Right Knee 3 Views reflected:<BR/>1. <BR/>No acute osseous abnormality.<BR/>2. <BR/>Severe tricompartmental osteoarthritic changes.<BR/>X-ray Left Knee 3 Views reflected:<BR/>1. <BR/>Nondisplaced fracture of the proximal fibular metaphysis.<BR/>2. <BR/>Moderate tricompartmental osteoarthritic changes.<BR/>3. <BR/>Possible soft tissue wound anterior to the patella.<BR/>Narrative: This patient is a pleasant non-ambulatory [AGE] year-old female who was in a transport van today and was in her wheelchair and the transport driver stopped abruptly and the patient fell from her wheelchair. Patient reporting bilateral knee pain. Patient with report of lower cervical and upper thoracic discomfort. Imaging showing no acute abnormalities of the head neck chest abdomen or pelvis. Patient with notable proximal fibular fracture on the left. X-ray of the ankle found to be unremarkable. Patient placed in a knee immobilizer. Given referral to orthopedics. Patient discharged home. At time of discharge patient is pain-free.<BR/>Diagnosis: Closed left fibular fracture .<BR/>Interview on 06/01/25 at 3:25 PM with the DON, who stated she had not been able to get Driver A to answer the phone since 05/27/25, and Driver A had been a no call/no show for CNA duties since the day of the van incident. The DON stated the facility conducted re-training on transporting residents in the van, and anyone who was not re-trained was not driving. She stated in the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. The DON further stated Resident #1 stated Driver A had slammed on the brakes and she slid out of the wheelchair onto her knees.<BR/>Interview on 06/01/25 at 3:15 PM with Driver B revealed she worked in Housekeeping and was also a van driver. Driver B stated she had received training on 05/28/25 that included inspecting the vehicle inside and out every week, and to check acceptable or document if there are repairs needed on the form and submit to Administration and Corporate. <BR/>Telephone interview on 6/02/25 at 07:15 AM, Driver A stated she received 30 minutes of training from another van driver before she drove the van herself. Driver A stated she had worked for the facility for 4 months. She stated she thought Resident #1 had been up too long on the day of her appointment. Driver A stated Resident #1 had been to her therapy session that morning, and was up for lunch, and then went to her doctor appointment in the early afternoon. Driver A stated she thought Resident #1 became fatigued and started slipping out of her wheelchair . Driver A stated she had all of the straps and hooks on to secure the wheelchair in the van, and the seat belts were secured on the resident for resident safety. Driver A stated there were no witnesses riding in the van with her, other than Resident #1's RP who had met them at the doctor's appointment. Driver A stated the RP met them at the doctor's appointment and had entered the van to assisted in getting Resident #1 back up and into the wheelchair . <BR/>Interview on 06/02/25 at 2:14 PM with MAINT revealed on the interior of the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. MAINT demonstrated how the seatbelt would secure a resident in a wheelchair once the 4 straps and hooks secured the wheelchair in place. MAINT stated he was up to date on the transport van maintenance, and he had looked at the Vehicle Inspection Reports and the van was in good working condition. He stated he looked at the transport van seatbelts and wheelchair straps after the incident and saw no issues. <BR/>Interview on 06/02/25 at 4:42 PM with the RP, who stated Driver A had asked her to hold the wheelchair and then Driver A lifted Resident #1, and the RP pushed the wheelchair forward under Resident #1's bottom so Driver A could get her back in the wheelchair . The RP stated Resident #1was seeing the orthopedic surgeon on Wednesday, 06/04/25. The RP believed Resident #1 had not been strapped in the wheelchair since she went forward on her knees and hit her head on the backside of the driver's seat. The RP further stated Resident #1 told her when Driver A turned, she slammed on her brakes, and that was when she fell out of the wheelchair. <BR/>Interview on 06/02/25 at 5:04 PM with Resident #1 revealed she knew something had happened to her, but she was not able to recall all the events. She stated she was having pain in her left knee and pointed to the left knee with a brace on it. Resident #1 stated Driver A slammed on the brakes and she remembered sliding out of the wheelchair and landed on her knees, and she did not remember too much after that. Resident #1 stated she did not remember if there was a seat belt on her or not. Resident #1 stated she had an appointment with a doctor who would check on her knee tomorrow, and the RP would be going along. <BR/>Record review of a statement from Resident #1, dated 05/27/25, included in the facility investigation reflected, Resident #1 stated that she slid out of her wheelchair while in the back of the van. She stated that she hit the back of the driver seat, and her knees went under her. Resident #1 stated that Driver A then attempted to help her but was unsuccessful due to how she was positioned. Resident #1 then stated that when she stopped, Driver A asked her RP who met them there to assist her in helping her back into the wheelchair. Resident #1 stated to ADON , during this statement, that at the time she had no pain but that she felt a slight tingling and burn just a tad bit but stated that she was having no pain when asked to rate pain. Resident #1 stated that the nurse at the doctor assessed her knee and cleaned it up and applied bandages. Educated Resident #1 on pain assessments and assessed her knees as well. Resident #1 stated that it was not that bad. Informed resident that we will send for X-ray of knees, and she said OKAY.<BR/>Record review of In-service conducted on 05/27/25 for staff who transport or assist with transporting residents in the van on the following (with return demonstration): Staff members not in-serviced will not transport residents.<BR/>1. <BR/>How to safely load and unload residents in the van using the lift<BR/>2. <BR/>Properly securing a resident in the van:<BR/>Ambulatory resident - securing with seat belt.<BR/>Non-ambulatory resident - securing the wheelchair and the resident.<BR/>Record review of the Vehicle Inspection Report dated 05/28/25 reflected the following relevant items were checked for the interior of the vehicle:<BR/>Instruments, gages, horn, and warning lights working properly.<BR/>Floors, seats, doors, and steps all clean and free of debris/stains<BR/>Seat Belts clean and in good working condition<BR/>Wheelchair Tie-Downs inspected and working properly.<BR/>Summary of the report reflected the van and equipment in good working condition.<BR/>Record review of In-service, conducted on 05/27/25, reflected, Resident involved in a van incident such as slipping out of the chair, tipping back in the chair, or hitting head, the transported should immediately stop and call 911, notify the Administrator and/or the DON immediately if you are off the property. Do not move the resident. If you're on the property immediately go, get a nurse to assess the resident. <BR/>Record review of the Employee Auto Training Handbook - Vehicle Inspection Report, dated 05/28/25, reflected the vehicle interior (including the seatbelts clean and in good working condition), vehicle exterior, fluid levels, and emergency equipment were acceptable, and the van and equipment were in good working condition.<BR/>Record review of the undated Employee Auto Training Handbook reflected,<BR/>The Driver Training Handbook is a statement of company and expectations as it pertains to transport vehicles, procedures to ensure resident safety and to promote safe driving practices.<BR/>Employee safety responsibilities<BR/>1. <BR/>Observe all organization safety and health rules and apply the principles of accident prevention in your day-to-day duties.<BR/>2. <BR/>Report any job-related injury, illness, or property damage to your supervisor immediately.<BR/>3. <BR/>Report any hazardous conditions and unsafe acts to your supervisor promptly.<BR/>4. <BR/>Follow proper lifting procedures always.<BR/>5. <BR/>Whenever driving an organization vehicle or personally owned vehicle for organization business seat belts must be used.<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice, for 3 of 4 residents (Resident #1, Residents #2, and Resident # 3) reviewed for the use of oxygen cannula and nebulizer.<BR/>The facility failed to ensure:<BR/> -Resident #1 and Resident #2's nebulizer mask and tubing were in a bag. <BR/>- Resident #3's oxygen cannula was in a bag <BR/>This failure could place residents at risk for respiratory infections.<BR/>The findings included:<BR/>1. Record review of Resident #1's face sheet on 04/16/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were acute respiratory failure with hypoxia (low oxygen level), Dementia, Anxiety, Hypertension, Type 2 diabetes mellitus and Iron deficiency. <BR/>Record review on 04/16/25 of Resident #1's initial MDS assessment, dated 02/15/25 revealed a BIMS score of 12 indicating his cognition was moderately impaired. <BR/>Record review on 04/16/25 of Resident #1's care plan dated 04/08/25 reflected he had COPD (Difficulty to Breath), and the relevant intervention was administering bronchodilators (agents that dilates airways) and oxygen therapy as ordered by the physician. <BR/>Record review on 04/16/25 of Resident #1's physician's order reflected: <BR/>Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML. 3 milliliter inhales orally every 4 hours as needed for SOB or Wheezing via nebulizer.<BR/>2. Record review of Resident #2's face sheet on 04/16/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were COPD (Difficulty to Breath), Acute respiratory failure with hypoxia, Anxiety disorder, Heart failure, Presence of cardiac pacemaker and Hypertension.<BR/>Record review on 04/16/25 of Resident #2's quarterly MDS assessment, dated 04/07/25 revealed a BIMS score of 15 indicating his cognition was intact. <BR/>Record review on 04/16/25 of Resident #2's care plan dated 04/08/25 reflected he had COPD, and the relevant intervention was administering bronchodilators and oxygen therapy as ordered by the physician . <BR/>Record review on 04/16/25 of Resident #2's physician's order reflected: <BR/>Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for Wheezing/SOB.<BR/>3. Record review of Resident #3's face sheet on 04/16/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Hypertension, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Heart failure, and End stage renal disease.<BR/>Record review on 10/16/24 of Resident #3's quarterly MDS assessment, dated 03/27/25 revealed a BIMS score of 15 indicating her cognition was intact. <BR/>Record review on 04/16/25 of Resident #3's care plan dated 03/28/24 revealed there were no care plan for oxygen therapy.<BR/>Record review on 04/16/25 of Resident #3's physician's order on 04/26/25 reflected:. <BR/>1.Check O2 sat Q shift and PRN every shift.<BR/> 2.Oxygen 2-5L PRN for comfort/keep oxygen saturation &gt;92% as needed for SaO2 &lt; 92%.<BR/>Record review of Resident #3's April 2025 MAR on 04/16/25 at 11:30am revealed the O2 level was checked on every day in April,2025, every shift. The last check was on 04/16/25 in the day shift. <BR/>During an observation and interview on 04/16/25 at 10:50 a.m., Resident #1 was lying in his bed . He was using oxygen through a cannula. There was a nebulizer on the bed side table. The mask and tubing of the nebulizers were exposed to the environment as they were not stored in a protective bag. There was a male urinal bottle sitting next to the exposed nebulizer mask of Resident #1. He stated the staff administer medication via nebulizer occasionally. He stated he could not remember when had used it lately. Resident #1 stated he used the urinal bottle regularly as he was not able to get out of bed for toileting. He stated he used the bottle about 30 minutes ago. <BR/>During an observation and interview on 04/16/25 at 11:10 a.m., Resident #2 was lying in bed in his room. There was a nebulizer on his bedside table that was not secured in a protective bag. Resident #2 stated he had breathing difficulties and used inhalers and oxygen therapy regularly.<BR/>During an observation and interview on 04/16/25 at 11:25 a.m., Resident #3 was in her room lying in her bed. Her oxygen cannula and tubing were laying on the floor. She stated she was not able to get up from bed and the staff assisted her to administer oxygen via a canula occasionally on request. <BR/>During an observation and interview with DON on 04/16/25 at 11:35 a.m., it was revealed the nebulizers and oxygen canula were at the same places as the previous observations, exposed to the open air . The DON who observed the masks and canula stated they were supposed to be stored in protective bags whenever not in use. The DON stated all staff were supposed to be compliant with the facility policy for using the oxygen cannula and nebulizers. She stated she noted down this deficiency in infection control practices among the staff and stated they needed more in services and training on oxygen and nebulizer therapies, sooner than later. She stated bagging the masks and cannulas while not in use was necessary to minimize the risk of spreading respiratory diseases among the residents.<BR/>Record review of the facility's policy, titled Protocol for Oxygen administration revised on 03/21/2023 reflected: <BR/>change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.<BR/>Record review of facility's policy titled Infection Control policy and procedure manual 2019 updated in March,2024 reflected:<BR/>The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

**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 in the facility with reasonable accommodation of each resident's needs for Resident #23.<BR/>Resident #23 call light was in Resident #26 bed tangled together.<BR/>This deficient practice could affect residents who needed assistance with activities of daily living and could result in needs not being met.<BR/>The findings were include:<BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #23 was [AGE] years old, admitted on [DATE] with diagnoses including Alzheimer's Disease with late onset, Essential(primary)Hypertension, Primary Generalized(osteo)Arthritis, Muscle waiting and atrophy, not elsewhere classified,unspececified site,musmbolismcle weakness(unspecified)contact with and (suspected)exposure to other viral communicable diseases, personal history of other venous Thrombosis and embolism, major depressive disorder, single episode without psychotic features hypermedia unspecified, Anxiety disorder unspecified ,other reduced mobility, Dysphagia, Oropharyngeal phase, Unspecified abnormalities, Unspecified lack of coordination, unspecified mycosis, and Difficult in walking, not elsewhere classified, Iron Deficiency anemia secondary to blood loss,Constipation unspecified Vitamin Deficiency Unspecified, Dermatitis unspecified<BR/>A record review of a care plan dated 06/23/2022 indicated Resident #23 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed.<BR/>A record review of Resident #23 MDS dated [DATE] indicated Resident #23 was understood and usually understood others. Resident #23 was cognitively intact with a brief interview for mental status BIMS score of 15. Resident #23 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>An Observation 6/20/2022 at 9:32 AM revealed Resident # 23's call light was in the bed with Resident #26 tangled together.<BR/>In an interview on 6/20/2022 at 9:35 AM Resident #23 stated she could not recall the last time she saw her call light. She stated when she needed something, she just goes and finds someone to help her. She stated it was important for her to have a call light because if she got sick she would be able to get help.<BR/>An observation and interview 6/22/2022 at 12:14 PM, observed Resident # 23's call light was tangled with Resident #26's call light. Sometimes the residents take each other's call lights. It is the staff responsibility to make sure the call lights are in view for each resident. She stated it is important for the resident to have possession of their own call light to be able to use when needed. Without call light in reach assistance of being needed will would not be met.<BR/>An interview 6/23/2022 at 10:55 AM, the DON revealed it is was the staff's responsibility to make sure the resident's call light was in reach. The DON stated they do not have a call light Policy for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 (Resident #40) of 25 residents reviewed for care plans, in that: <BR/>1. The facility failed to ensure Resident #40's comprehensive care plan addressed a discharge plan.<BR/>This failure could place the residents at risk of not receiving care and services to meet their needs.<BR/>Findings included: <BR/>Record review of Resident #40's Face sheet, 10/22/2024, reflected she was a [AGE] year-old woman, who was admitted to facility on 9/28/24 with a diagnoses of clostridioides difficile (C.Diff [contagious bacteria]) acute osteomyelitis (serious bone infection), right ankle and foot, cellulitis (bacterial infection) right toe, type II diabetes (insulin resistance), major depressive disorder and generalized anxiety.<BR/>Record review of Resident #40's MDS 10/22/2024, indicated she had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognitive function. <BR/>In an observation and interview with Resident #40 on 10/22/2024 at 2:10 PM, resident was observed to be clean and appropriately groomed. She reported that she was doing okay and felt safe at the facility. The resident stated she is on antibiotics due to a bone infection. She stated she is scheduled to return home on November 2, 2024, and had no concerns.<BR/>Records review on of Resident #40's comprehensive care plan dated 9/28/2024, reflected the resident's diagnosis with a focus on interventions that were actively being completed to support residents' health.<BR/>Record review on 10/24/2024 at 9:00 AM, Resident #40's comprehensive care plan dated 9/28/2024 and later revised 10/14/2024, revealed there was no discharge plan.<BR/>Record review of the facility's Discharge Planning Process Policy and Comprehensive Care Planning Policy revealed facility policy stated a comprehensive care plan will be developed within 7 days after completion of the comprehensive assessment.<BR/>In an interview on 10/24/2024 at 2:10 PM, Minimum Data Set Nurse (MDS) stated a resident's discharge should be documented in their care plan. MDS stated there could be some potential negative effects when discharge information is missing, leading to possible negative outcomes.<BR/>In an interview on 10/24/2024 at 2:15 PM, Social Worker (SW) stated the discharge plan has not been part of the care plan in the past but believed it should be included. SW was questioned on how staff would be aware of a resident's discharge plan if a discharge was to occur, she stated she hoped they would review the progress notes, though she was unsure if they would. SW stated she has not been trained on the facility's policy and procedures for discharge.<BR/>In an interview on 10/24/2024 at 2:23 PM, Director of Nursing (DON) stated, the discharge plan is created at the new admission. When asked if the discharge plan was part of the care plan, she stated it probably should be included. She stated the SW initiates the assessment while the team is responsible for the care plan. She stated the admission meeting usually have the MDS, SW, Dietary, Rehab Director, and Activity Coordinator present. DON stated the interventions would be documented on a care plan along with the discharge information. DON stated there is a potential for a bad outcome with no information documented but they usually have a care plan meeting before discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for all residents in the facility. <BR/>1. The facility failed to provide activities as scheduled on October 5th- October 6th, October 12th- October 13th , and October 19th to October 20th.<BR/>These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. <BR/>Findings include:<BR/>Record review of the resident participation record for October 2024 no activities did not occur on the weekends. <BR/>Record review of the Activity Calendar the times for activities on the weekend was not documented on the activity calendar. The activity participation records for the month of October weekend activities were not provided for the residents on the following dates:<BR/> a. 5th: Activity of Choice<BR/> Outside Social<BR/> Hydration Station<BR/> b. 6th: Football Social<BR/> Word Puzzles<BR/> Dominoes<BR/> c. 12th: Good News Social<BR/> College Football Social<BR/> Crossword Puzzles<BR/> d. 13th: Football Social<BR/> Morning News<BR/> Activity of Choice<BR/> e. 19th Activity of Choice<BR/> Name that [NAME]<BR/> College Football Social<BR/> f. 20th Football Social<BR/> Music Memory<BR/> Word Find Pages<BR/>In a confidential Resident Group Meeting on 10/23/2024 at 10:00 AM, there were nine residents present for the meeting. All nine residents stated there was not any weekend activities during the month of October 2024. The residents in the group stated they did not understand the weekend activities on the activity calendar. All residents discussed some of them did not enjoy football, puzzles, or dominoes. The residents in the group were voiced their concerns about most of the residents in the facility was not able to come out of their room and was not able to do puzzles or dominoes. The group also stated there were not any times on the calendar and they did not know what time the activity began on weekends. One person stated it has football social in the morning and football does not come on television until the afternoons. The group stated some of the residents' watches football does not prefer to watch the same teams. The group was asked what was name that [NAME] and everyone in the group stated they had never heard of [NAME]. The group stated during the week there is activities and they liked the Activity Director, however, she could not be at the facility seven days a week. The group stated someone needed to work on weekends to only do activities. Five of the seven residents in the meeting stated the CNAs and nurses did not have time to do activities on the weekends they were busy giving care and we do not want them to do activities it would decrease time giving care. One resident stated she became sad and lonely on the weekends because there was not anything to do. Five of the seven residents in attendance stated they became bored. One of the seven residents stated he felt this was when there were more behaviors from the residents on the weekends. The residents in the group stated activities were discussed in group but it was for during the week and not on weekends. <BR/>In an interview on 10/22/2024 at 9:30 AM, CNA C stated she did work sometimes on the weekends. She stated no one had discussed doing activities with the residents on the weekends with her. CNA C stated the nurses and the CNAs did not have time on the weekends to do activities in the dining room with the residents. She stated they were very busy giving care to the residents. CNA C stated if the staff did activities the residents care would decline. <BR/>In an interview on 10/24/2024 at 10:15 AM, RN A stated the staff was very busy on the weekends providing ADL care to the residents. She stated she had not observed any activities occurring on the weekends especially during the month of October 2024. RN A stated it would be very helpful if volunteers came in on weekends and did activities with the residents or hire a part time assistant to work weekends. She stated there was an activity assistant and she was no longer there as of few weeks ago. RN A stated there were activities during the week but not on weekends. She stated if residents did not receive activities there was a possibility a resident may become depressed, bored, have a decline in their cognition and/ or isolate themselves in their rooms. <BR/>In an interview on 10/24/2024 at 10:30 AM, the Administrator stated his expectations of the activity department was to follow the facility policies and CMS regulations. When asked if there was a possibility a resident may become bored or sad if they did not have activities on the weekends, the Administrator did not respond to the question. When asked about the participation records and if he expected the activities be documented when an activity occurred in the facility or outside the facility, the Administrator did not respond. The Administrator did not respond when asked who was responsible to ensure the Activity Director was providing activities for the residents on weekends. <BR/>In an interview on 10/24/2024 at 10:43 AM, the Corporate Regional Director stated activities were to be provided seven days per week. She stated a participation record was to be kept on all residents attending activity programs. She stated if a resident was not receiving activities on the weekends there was a possibility a resident may become bored and may affect the resident's quality of life. <BR/>In an interview on 10/24/24 11:10 AM, the Activity Director stated she was not aware of the CMS Federal guidelines for the activity department. She stated she read the activity policy few years ago, however, did not recall what the policy stated about weekend activities or participation records. She stated it was very difficult to find volunteers to come to the facility on weekends. She stated she did have dominoes, puzzle books, cards, etc. available in the dining area for the residents to do on the weekends. The Activity Director stated not all residents was physically able to do puzzles, dominoes or play cards. She stated if a resident was not able to do these type of activities they would not have anything to do on the weekends. She stated she had an assistant and was no longer working at the facility approximately 3 weeks ago. The Activity Director stated she had been an activity director at the facility at least 3 years. Activity Director stated she did not ask the residents about weekend activities. Activity Director stated there was a possibility a resident may become bored, depressed , lonely if they did not have any activities on the weekends. She stated the facility had a new Administrator approximately 3 weeks. She stated since he had been at the facility she did not have the opportunity to discuss her concerns in the activity department and the weekend activities was one of her concerns. She stated it was her responsibility to ensure all residents received activities they enjoyed and met their individual preference. She stated if an activity occurs she was to document it on the participation records. The Activity Director stated she made copies of the monthly calendar and documented each resident on a separate calendar. She stated she highlighted the activity the resident attended on their personal calendar she kept in a binder. The Activity Director stated she did not document participation records anywhere but on the calendar in the binder she gave to the surveyor, and this had been her participation record system for three years. Activity Director stated she did not document participation records in the computer. She stated residents not receiving activities on weekends the resident may have a decline in their mood, cognition, and overall life. The Activity Director stated she did not recall over the past year of doing any in services with the nursing department about doing activities on the weekends. She stated if there were not any times on the calendar the residents would not know what time to attend the activity. The Activity Director stated it would be difficult for some residents to go outside and socialize and she did not provide an alternative activity for the residents unable to go outside. She stated activity of choice was when the residents did what they wanted to do in their rooms. The Activity Director agreed this was not a group activity and she understands how this may be confusing to the residents. <BR/>In an interview on 10/24/2024 at 11:45 AM, Resident # 5 stated she had someone to visit on the weekends but sometimes she wanted to do an activity to socialize with other people. She stated sometimes it seemed lonely at the facility because there were no activities and nothing for the residents to do. Resident #5 stated they had activities during the week but did not have any on weekends this month. Resident #5 stated she did not want to discuss any-more about activities. <BR/>In an interview on 10/24/2024 at 12:15 PM, Resident #16 stated she did become sad sometimes on the weekends and lonely but did not have these feelings during the week. She stated there were activities during the week but on the weekends during this month there was not any activities and sometimes she became bored and tired of watching television. Resident #16 stated she did not like to play dominoes or wanted to do puzzles. She stated she did not recall the activity director asking her what she would prefer to do on weekends. <BR/>Record review of the Activity Director Personnel Record she had been an Activity Director for 25 years at this facility and she did have her current Activity Certification. <BR/>Record review of the Facilities Policy on Activity Programming, dated 2011, reflected The Activity director and staff will provide for ongoing Activity programs. <BR/>Practice Guidelines:<BR/>1. Recreation programs are based on the interest and needs of the residents expressed through the Activity assessment. <BR/>2. Resident's or families expressed needs and interests are included in the development of programs. Input from residents may be done on an individual basis or may be discussed at Resident Council/ Group.<BR/>3. Activity programs are be designed ( this is exactly how the policy is written) on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory) of the residents. <BR/>4. Programs will be geared to maintain functional ADLs, provide social interaction and, at the same time, protect residents from environmental over stimulation.<BR/>5. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or 'physician ordered' bed rest. <BR/>6. Programming includes large groups, small groups, individual and independent opportunities. <BR/>7. Programs may take place in mornings, afternoons and/or evenings that span throughout the entire week.<BR/>8. Programs use various areas available in and out of the health care center.<BR/>9. The resident population is cognitive assessed routinely to determine the number of functional level programs needed.<BR/>10. The opportunity is provided for regular community outings/ trips.<BR/>Programs are developed to include community resources and involvement within, as well as outside the health care center.<BR/>Record review of the Facility Policy on Activity Participation Records, dated 2019, reflected The Activity Department will maintain accurate records of group and individual program participation for each resident.<BR/>1. Resident attendance in programs is recorded on a daily basis to reflect resident attendance and will be used as a source of information for recording the resident's progress or lack of progress in the progress note. <BR/>2. Each resident has separate participation record of group activities and/or individual attendance and participation.<BR/>3. Active, passive, and refused is noted on the participation records.<BR/>4. Individual programs (one on ones) not the response to intervention by either a checklist or a narrative for each program or visit<BR/>5. Participation records stored in health care center per state regulation, but no fewer than five years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 4 (Resident#55, #54, #56, and#268) of 6 residents reviewed for narcotic pharmacy services.<BR/>1.CMA (F) administered narcotics and did not document in the narcotic book after administering to the residents. <BR/>This failure placed residents at risk for inadequate therapeutic outcomes, ineffective disease management and a decline in health.<BR/>The findings included:<BR/>Review of Resident #55's face sheet, dated 10/23/2024 revealed an [AGE] year-old male admitted to the facility with an initial admission date of 03/13/2023 and a admission date of 05/19/2024 with the following diagnosis: Gerstmann-Straussler-Scheinker Syndrome (GSS) is an extremely rare, always fatal (due to it being caused by prions) neurodegenerative disease that affects patients from 20 to 60 years in age, Adjustment disorder with depressed mood, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder (Unspecified), nontraumatic intracerebral hemorrhage in hemisphere (cortical), cerebral amyloid angiopathy (CAA) happens when amyloid (abnormal) proteins build up in blood vessels in your brain. The proteins damage your blood vessels and cause bleeding inside your brain. The condition is the most common cause of cognitive decline in people aged 60 and older, other abnormalities of gait and mobility, primary open-angle glaucoma a progressive eye disease that damages the optic nerve and causes vision loss., bilateral, indeterminate stage, unspecified dementia (Dementia is the loss of cognitive functioning that interferes with daily life and activities).<BR/>Review of Resident # 55's Quarterly MDS dated [DATE] reflected a BIMS score of 02. Which indicates severe cognitive impairment.<BR/>Review of Resident #55's Physician order revealed PHENobarbital Oral tablet 32.4 MG give one tablet by mouth two times a day related to other epilepsy. <BR/>Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered PHENobarbital Oral tablet 32.4 MG to Resident #55 at 08:00 AM and the medication at had not been documented in the narcotic book after being administered. <BR/>Review of Resident #54's face sheet, dated 10/23/2024 revealed an [AGE] year-old female admitted to the facility with an initial admission date of 03/10/2023 and a admission date of 01/25/2024 with the following diagnosis: Chronic respiratory failure with hypoxia, mild cognitive impairment of uncertain or unknown etiology, noninfective gastroenteritis (is inflammation of the stomach and intestines, often caused by viruses, bacteria or chemicals) and colitis (Unspecified), major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, morbid (severe) obesity due to excess calories, hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides), other sleep apnea, essential (primary) hypertension, fibromyalgia (is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), other malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify).<BR/>Review of Resident # 54's Quarterly MDS dated [DATE] reflected a BIMS score of 05. Which indicates severe cognitive impairment.<BR/>Review of Resident #54's Physician order revealed an order for Lyrica Capsule 150MG (Pregabalin) give one capsule by mouth two times a day for nerve pain.<BR/>Review of Resident #56's face sheet, dated 10/23/2024 revealed an [AGE] year-old female admitted to the facility with an initial admission date of 04/14/2023 and a admission date of 09/12/2024 with the following diagnosis: Chronic Diastolic (Congestive) heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), Dysuria (is pain or discomfort when urinating), Atherosclerotic heart disease(Atherosclerosis is a hardening of your arteries from plaque building up gradually inside them) of native coronary artery without angina pectoris (Angina is chest pain or discomfort that happens when your heart isn't receiving enough oxygen-rich blood), major depressive disorder (single episode, moderate), Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent severe without psychotic features, Dysphagia (difficulty swallowing), oropharyngeal phase, Other lack of coordination, Cognitive communication deficit, Pain (Unspecified), Unspecified protein caloire malnutrition, hyperlipemia (medical term for abnormally high levels of fats (lipids) in the blood), Essential (primary) hypertension (common condition that can damage your arteries and lead to serious complications), Cerebrovascular disease (term for conditions that affect blood flow to or within the brain), Muscle weakness (generalized), chest pain (unspecified), personal history of transient ischemic attack (brief stroke-like attack wherein symptoms resolve within 24 hours) and cerebral infarction (stroke is a life-threatening condition that happens when part of your brain doesn't have enough blood flow) without residual deficits. <BR/>Review of Resident # 56's Quarterly MDS dated [DATE] reflected a BIMS score of 06. Which indicates severe cognitive impairment.<BR/>Review of Resident #56's Physician order revealed an order for APAP/Codeine TAB 300-30MG give one tablet three times daily. <BR/>Review of Resident #268's face sheet, dated 10/23/2024 revealed an [AGE] year-old male admitted to the facility with an initial admission date of 10/17/2024 with the following diagnosis: Hypertensive heart disease with heart failure, Type 2 diabetes mellitus without complications, mixed Hyperlipemia (abnormally high levels of fats in the blood), Depression (Unspecified), Anxiety disorder (Unspecified), Occlusion and stenosis of right middle cerebral artery, Hemiplegia (form of paralysis that affects one side of the body) and hemiparesis (is weakness or paralysis on one side of the body caused by stroke) following cerebral infarction affecting left non-dominant side, Gastro-esophageal reflux disease (a digestive disorder that causes heartburn and acid indigestion) without esophagitis (inflammation of the esophagus), sacroiliitis (inflammation of the sacroiliac joint), radiculopathy (can cause pain, numbness and tingling along a pinched nerve in your back), lumbar region. <BR/>Review of Resident # 268's Quarterly MDS dated [DATE] reflected a BIMS score that was not given because the MDS was still in process and had not been completed during the survey visit.<BR/>Review of Resident #268's Physician order revealed Lyrica oral capsule 75MG (Pregabalin) give one capsule by mouth two times a day for nerve pain. <BR/>Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered Lyrica Capsule 150MG (Pregabalin) at 8:00 AM to Resident #54 and the medication had not documented in the narcotic book after being administered. <BR/>Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered one tablet of APAP/Codeine TAB 300-30MG to Resident #56 and the medication had not been documented in the narcotic book after being administered. <BR/>Observation on 10/22/2024 at 11:37 AM, revealed CMA (F) administered Lyrica oral capsule 75MG (Pregabalin) to Resident #268 and the medication had not been documented in the narcotic book after being administered. <BR/>During an interview on 10/22/2024 at 11:42 AM, CMA (F) stated that she did not log the narcotics in the book after administering them because she forgot today. CMA (F) voiced this could lead to a med error and acknowledged it could harm the resident. CMA (F) verbalized that another CMA or Nurse can come along after her and think the resident did not get the medication and administer it again to the resident. CMA (F) said she can't recall the last time she was in-serviced on documenting narcotics or medications after they are administered but she feels like they get in-services a lot. <BR/>During an interview on 10/23/2024 at 11:22 AM, the DON stated that adverse effect of the act of CMA (F) could be the resident receiving too much medication because staff would not know that the resident already received their narcotic medication. This would lead to a med error voiced the DON. DON voiced her expectations are for staff to document in the narcotic count sheet in the narcotic book and acknowledge the medication has been given in the electronic medical record. When the correct steps are completed a progress note is populated in the electronic medical record and staff are to document resident response to the medication at the time of administration. Also, DON stated that an in-service would be performed for narcotic administration. <BR/>Review of facility policy titled Medication Administration Procedures Pharmacy Policy & Procedure Manual 2003, Policy Statement reflected After the resident has been identified, administered the medication and immediately chart doses administered on the medication administration record. It is recommended that mediations be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration. Initials are to be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater for when the facility had a medication error rate of 6.25% based on 2 of 32 opportunities, which involved 2 of 5 residents (Resident #18 and Resident #26) and 2 of 2 MA's(MA C and MA L) observed during medication administration. <BR/>A) Resident #18 had a physician order for Amiodarone HCL 100 mg (for abnormal heart rhythm) to be given once daily. MA L failed to administer the medication. <BR/>B) Resident #26 had a physician order for Minoxidil (for hypertension) 5 mg one time daily. MA C administered 2.5mg. <BR/>These deficient practices could place residents at risk of not receiving therapeutic dosage of medications.<BR/>Findings Include: <BR/>A.) Review of Resident #18's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), Cerebral infarction due to embolism of cerebral artery (a brain lesion in which a cluster of brain cells die when they don't get enough blood) and Dementia (loss of cognitive functioning).<BR/>Review of Resident #18's Annual MDS dated [DATE] reflected Resident #18 had a BIMS score of 6indicating severe cognitive impairment. Resident #18 was coded to require limited assist with ADL's. Resident #18 was coded to have Atrial Fibrillation, Heart Failure, and hypertension.<BR/>Review of Resident #18's Comprehensive Care Plan dated 12/13/2019 and revised on 03/12/2021 reflected a focus area for Resident #18's alteration in cardiovascular status .Atrial Fibrillation. Interventions included administer medications as per orders. <BR/>Review of Resident #18's Consolidated Physician Orders dated 06/21/2022 reflected an order for Amiodarone HCL tablet 100 mg one by mouth one time a day for abnormal heart rhythm. <BR/>Observation on 06/21/2022 at 8:15 AM revealed MA L preparing Resident #18's medication for administration. The medications included the following:<BR/>-Carvedilol 12.5mg one tab, <BR/>-Eliquis 5mg one tab, and <BR/>-Lasix 20 mg one tab. <BR/>MA L did not administer Resident #18's Amiodarone. <BR/>In an Interview on 06/21/2022 at 10:00 AM, MA L stated she did not give Resident #18 the Amiodarone because Resident #18 was out of the medication and she had to order it. When MA L was asked if the medication would be at the facility during the AM period, she stated no that the medication would not be at the facility unit late in the evening. <BR/>In an interview on 06/21/2022 at 10:15 AM, LVN F stated MA L had not reported to her she was not able to give Resident #18 her Amiodarone or that Resident #18 was out of the medication. LVN A stated the medication was in the emergency kit and if she had told her she was not able to give the medication because the resident was out, she would have gotten MA L the medication from the emergency kit. <BR/>In an interview on 06/21/2022 at 10:33 AM, MA L stated she did not know the medication Amiodarone was in the emergency kit and stated she did not report to the nurse that she did not give Resident #18 all her medication. <BR/>B.) Review of Resident #26's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Myocardial infarction (heart attack), Cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood) Heart failure, and Hypertension (high blood pressure).<BR/>Review of Resident #26's Quarterly MDS dated [DATE] reflected Resident #26 had a BIMS score of 14 indicating resident was cognitively intact. Resident #26 was coded to require limited assist with ADL's. Resident #26 was coded to have coronary artery disease, hypertension and heart failure.<BR/>Review of Resident #26's Comprehensive Care Plan dated 12/13/2019 and revised 05/10/2022 reflected a focus area for Resident #26's has alteration in cardiac status: diagnoses include hypertension. Interventions included give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness . <BR/>Review of Resident #26's Consolidated Physician Orders dated 06/21/2022 reflected an order for Minoxidil give 5mg by mouth once time daily for hypertension. <BR/>Observation on 06/21/2022 at 8:50 AM, revealed MA C preparing Resident #26's medication for administration. MA C placed one 2.5 Mg tab of Minoxidil in the medication cup and administered it to the resident.<BR/>In an interview on 06/21/2022 at 10:05 AM, MA C stated she only gave Resident #26 one tablet of Minoxidil equal 2.5 mg. MA C stated Resident #26's Minoxidil order was 5mg and the resident should have gotten two tablets. <BR/>In an interview on 06/21/2022 at 11:15 AM, the DON stated she expected her staff to administer the appropriate medication and the appropriate dose to the residents. She stated the facility will do medication error reports and start in-serving staff on medication administration. <BR/>Review of the facility's Medication Administration Procedures dated 2003 and revised on 10/25/2017 reflected .The five rights of medication should always be adhered to<BR/>1. Right drug<BR/>2. Right dose<BR/>3. Right resident<BR/>4. Right time<BR/>5. Right route .<BR/>Review of the facility's policy, Ordering Medications dated 2003 reflected Reorder medication three to four days in advance of need to assure an adequate supply is on hand .

Based on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate <BR/>-The medication cart for the 400 halls had four unidentified loose pills.<BR/>-The facility failed to ensure expired medications were removed from the medication carts and medication room. <BR/>These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication.<BR/>The findings were:<BR/>Observation of medication cart for the 400 halls on 10/22/2024 at 2:00 pm revealed one green round pill imprinted with the number 40 on it and three white oval pills with the letter F on one side and the number 91 on the other side in the top-left drawer. RN B was not able to identify the four loose pills.<BR/>Observation on 10/23/2024 at 11:17 AM revealed the facility hall 400 Medication cart with an Advair Diskus Inhalation Aerosol Powder Breath Activated 250mg/50mcg with the expiration date of 05/23.<BR/>Interview with RN B on 10/22/2024 at 2:10 pm voiced that all four loose pills would be destroyed because she doesn't know who they belong to. The pills were immediately placed in the biohazard bin attached to the nurse cart. RN B voiced she thinks the pills may have gotten to the bottom of the cart and outside the pill packet because sometimes the packets are punctured and that would cause the pills to fall out. RN B verbalized that sometimes she has seen pills on the bottom of the cart. RN B voiced the facility can't really do anything to prevent it from happening. <BR/>Interview with DON on 10/23/2024 at 11:22 am verbalized loose pills don't need to be on the bottom of the carts. DON voiced if a nurse doesn't find a pill after they notice it missing and can't locate it in the cart, it would eventually lead to an issue. When asked what kind of issue. DON voiced someone could grab it accidentally and give it to another resident. She emphasized that a resident would not be able to get into a cart, that issue would be more of a concern for another employee, giving a pill to another resident. DON verbalized that she thinks the pills that been in there for a long time tend to get loose adhesives on the backings of the pill packets and that is why the pills fell out. DON voiced sometimes it could be a manufacturing issue or they have received the pill packets from pharmacy with loose adhesives in the past and they have sent them back to send sealed packets back to them. DON voiced audits on carts are done weekly and weekly audits are done for medication rooms too. More thorough audits are conducted monthly. DON verbalized that if a nurse found loose pills on the bottom of their carts she would expect them to dispose of it in the bio-hazard or they can come to her office so they can dispose of the pills using the drug buster. <BR/>Observation on 10/22/2024 at 1:58 PM revealed the facility medication room with a bottle of Aspirin with an expired date of 09/24 and a bottle of Daily Vitamin formula and Iron with an expired date of 08/24.<BR/>In an interview on 10/23/2024 at 11:19 AM with CMA (K), when asked if the resident that the expired inhaler is still a resident in the facility. CMA(K) acknowledged yes, resident still lives here and still uses the inhaler. CMA (K) verbalized she checks her cart for expired medications periodically. There is not a time period for checking the dates, staff just need to remember to check the dates. When CMA (K) was asked what some potential adverse effects could happen to the resident if they are given an expired inhaler. CMA (K) voiced the medication will not work properly. CMA (K) could not remember the last time she received an in service on checking carts for expired medications.<BR/>In an interview on 10/24/2024 at 01:43 PM, DON verbalized that the medication room is audited weekly, and all medications should be discarded if expired. The DON verbalized she is responsible for the audits and pharmacy and staff do them too. DON verbalized she would not expect her staff to administer an expired inhaler to a resident. The potential adverse effects if a resident received an expired inhaler would be the resident would not get the maximum benefit of the medication if it is expired. It could lead to respiratory depression or other complications. The DON voiced that the CMAs are supposed to be checking their carts for expired medications on a regular basis and she does spot checks for expired medications. <BR/>Review of the facility's Policy Medication Administration Procedures Policy does not specify when staff should check for expired dates. The policy does not specify or include anything related to ensuring residents do not get expired medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #s 23 and #26) of 6 residents reviewed for ADLs.<BR/>The facility did not provide Resident #23 with personal care services on 6/20/2022 and 6/22/2022. Resident # 23 had facial hair on chin and fingernails were long and dirty. The resident was not provided personal care services with showers on 6/20/2022 and 6/22/2022.<BR/>The facility did not provide Resident #26 with personal care services on 06/20/2022 and 6/22/2022. Resident #26 fingernails were long and dirty. <BR/>These failures could place 6 residents who were dependent on staff for personal care services at risk for embarrassment, infections, and discomfort.<BR/>Findings included: <BR/>Resident #23 <BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #23 was [AGE] years old, admitted on [DATE] with diagnoses including Alzheimer's Disease with late onset, Essential (primary) Hypertension, Primary Generalized (osteo) Arthritis and atrophy.<BR/>A Record review of a care plan dated 06/23/2022 indicated Resident #23 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed.<BR/>Record review of a care plan dated 6/23/2022 indicated Resident #23 Interventions included staff to check nail length, trim, and clean on bath day as necessary.<BR/>Record review of an MDS dated [DATE] indicated Resident #23 was understood and usually understood others. Resident #23 was cognitively intact with a brief interview for mental status scoreBIMS of 15. Resident #23 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an interview on 6/20/2022 at 9:32AM, Resident #23 stated she wanted her nails trimmed shorter and her hair shaved from under the chin. Resident #23 stated what could be done about it as it has always been like that. She stated hair was not supposed to be on her face and she feel embarrassed about it and want something done about the facial hair on the chin. it .<BR/>During an interview on 6/20/2022 at 12:258PM, CNA A said she was the shower aide for the facility. The residents received showers Monday, Wednesday, and Fridays. She stated she had been in serviced and know the She stated she know the shower protocol and was to follow the service plan of each resident. CNA A stated the nails and hair under the chin were not addressed for the resident at shower. CNA A could not give an exact reason to why the service was missed but stated it could affect the resident emotionally on appearance if grooming is was neglected.<BR/>During an observation on 6/22/2022 at 1:10PM, Resident #23's nails were dirty, nails, long, and had hair under chin. <BR/>Resident #26<BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #26 was [AGE] years old, admitted on [DATE] with diagnoses including St Elevation(Stemi)Myocardialincluding Myocardial infraction of unspecified site Dependence On Renal Dialysis , Dysphagia following cerebral infraction, cognitive communication deficit, Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, anemia, heart failure, unspecified, altered mental status and Gastic Ulcer, <BR/>A Record review of a care plan dated 06/23/2022 indicated Resident #26 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed. <BR/>An Record review of a MDS dated [DATE] indicated Resident #26 was understood and usually understood others. Resident #23 26 was cognitively intact with a brief interview for mental status scoreBIMS of 14. Resident #26 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an observation and interview on 6/20/2022 at 9:59AM, Resident #26's nails appeared long and dirty. She stated she liked her nails short and not long she could not recall the last time someone has cut her nails. She stated with her nails being long she may scratch herself and cause injury.<BR/>During and observation 6/20.2022 AT 9:59AM the resident's nails appeared long and dirty.<BR/>During an interview on 06/212022 at 12:14 p.m, CNA B said she was the shower aide for the facility. The residents received showers on Monday, Wednesday, and Fridays. She stated she knew the shower protocol and was to follow the resident's care plan. She stated she is inserviced on showers. She stated Resident #23 was showered on 6/20/2022 and the nails were simply missed during shower. CNA B knew the importance of stated nail care for the residents was to avoid injuries.<BR/>During an interview on 6/22/2022 at 1:10PM, the DON states stated the shower aides are to follow the care plan to address personal hygiene needs of each resident and it is important for the resident's hygiene.<BR/>Review of facility's Dressing and Personal Grooming Policy dated 2003 indicated the purpose of this procedure were to assist the resident as necessary with dressing and undressing to promote cleanliness.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #s 23 and #26) of 6 residents reviewed for ADLs.<BR/>The facility did not provide Resident #23 with personal care services on 6/20/2022 and 6/22/2022. Resident # 23 had facial hair on chin and fingernails were long and dirty. The resident was not provided personal care services with showers on 6/20/2022 and 6/22/2022.<BR/>The facility did not provide Resident #26 with personal care services on 06/20/2022 and 6/22/2022. Resident #26 fingernails were long and dirty. <BR/>These failures could place 6 residents who were dependent on staff for personal care services at risk for embarrassment, infections, and discomfort.<BR/>Findings included: <BR/>Resident #23 <BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #23 was [AGE] years old, admitted on [DATE] with diagnoses including Alzheimer's Disease with late onset, Essential (primary) Hypertension, Primary Generalized (osteo) Arthritis and atrophy.<BR/>A Record review of a care plan dated 06/23/2022 indicated Resident #23 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed.<BR/>Record review of a care plan dated 6/23/2022 indicated Resident #23 Interventions included staff to check nail length, trim, and clean on bath day as necessary.<BR/>Record review of an MDS dated [DATE] indicated Resident #23 was understood and usually understood others. Resident #23 was cognitively intact with a brief interview for mental status scoreBIMS of 15. Resident #23 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an interview on 6/20/2022 at 9:32AM, Resident #23 stated she wanted her nails trimmed shorter and her hair shaved from under the chin. Resident #23 stated what could be done about it as it has always been like that. She stated hair was not supposed to be on her face and she feel embarrassed about it and want something done about the facial hair on the chin. it .<BR/>During an interview on 6/20/2022 at 12:258PM, CNA A said she was the shower aide for the facility. The residents received showers Monday, Wednesday, and Fridays. She stated she had been in serviced and know the She stated she know the shower protocol and was to follow the service plan of each resident. CNA A stated the nails and hair under the chin were not addressed for the resident at shower. CNA A could not give an exact reason to why the service was missed but stated it could affect the resident emotionally on appearance if grooming is was neglected.<BR/>During an observation on 6/22/2022 at 1:10PM, Resident #23's nails were dirty, nails, long, and had hair under chin. <BR/>Resident #26<BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #26 was [AGE] years old, admitted on [DATE] with diagnoses including St Elevation(Stemi)Myocardialincluding Myocardial infraction of unspecified site Dependence On Renal Dialysis , Dysphagia following cerebral infraction, cognitive communication deficit, Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, anemia, heart failure, unspecified, altered mental status and Gastic Ulcer, <BR/>A Record review of a care plan dated 06/23/2022 indicated Resident #26 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed. <BR/>An Record review of a MDS dated [DATE] indicated Resident #26 was understood and usually understood others. Resident #23 26 was cognitively intact with a brief interview for mental status scoreBIMS of 14. Resident #26 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an observation and interview on 6/20/2022 at 9:59AM, Resident #26's nails appeared long and dirty. She stated she liked her nails short and not long she could not recall the last time someone has cut her nails. She stated with her nails being long she may scratch herself and cause injury.<BR/>During and observation 6/20.2022 AT 9:59AM the resident's nails appeared long and dirty.<BR/>During an interview on 06/212022 at 12:14 p.m, CNA B said she was the shower aide for the facility. The residents received showers on Monday, Wednesday, and Fridays. She stated she knew the shower protocol and was to follow the resident's care plan. She stated she is inserviced on showers. She stated Resident #23 was showered on 6/20/2022 and the nails were simply missed during shower. CNA B knew the importance of stated nail care for the residents was to avoid injuries.<BR/>During an interview on 6/22/2022 at 1:10PM, the DON states stated the shower aides are to follow the care plan to address personal hygiene needs of each resident and it is important for the resident's hygiene.<BR/>Review of facility's Dressing and Personal Grooming Policy dated 2003 indicated the purpose of this procedure were to assist the resident as necessary with dressing and undressing to promote cleanliness.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #15) reviewed for notification of changes in that:<BR/>The facility failed to fully notify Resident #15's primary care physician of all of Resident #15's status including ongoing elevated blood pressures and increased edema. <BR/>These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This deficient practice could place residents at risk of not having their primary care physician notified of changes, resulting in a delay in medical intervention and decline in health.<BR/>Findings included:<BR/>Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. <BR/>Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. <BR/>Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. <BR/>In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. <BR/>In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with his brother and sister, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his sister called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. <BR/>Review of Resident #15 EMR for Physician Progress Notes dated 03/22/2022 - 06/21/2022 revealed a physician progress noted completed by PHYS ASST on 03/29/2022. There were no other physician progress notes in Resident #15's EMR.<BR/>Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed:<BR/>03/24/2022 - 310.6 pounds on the wheelchair scale<BR/>04/01/2022 - 314.6 pounds (scale unknown)<BR/>05/10/2022 - 314.8 pounds (scale unknown)<BR/>06/16/2022 - 356.7 pounds (scale unknown)<BR/>In an interview on 06/21/2022 at 4:00 PM, the DON said PHYS K was notified of Resident #15's weight gain but was not sure if he was notified regarding Resident #15's elevated blood pressures. <BR/>In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had issues with intermittent high blood pressures and edema since May 2022. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. When asked where the documentation of the notification of the high blood pressures and edema to PHYS K was, she said she was not sure she documented it and then confirmed it was not in the EMR. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time (05/31/2022) and received a verbal order for antibiotics for the pneumonia. She stated she did not report increased edema and elevated blood pressures to PHYS K at that time. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increased weight from May to June 2022. <BR/>In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain because diet non-compliance. He stated he was told Resident #15 had increased swelling on his right arm and leg, but the facility attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures. He did not remember being contacted about increased edema overall. <BR/>Review of Resident #15 Blood Pressures 05/25/2022-06/22/2022 out of range in the EMR or greater than 145/90:<BR/>05/25/2022 - 9:26 AM - 176/84 mmHg<BR/>05/25/2022 - 8:38 PM - 157/99 mmHg<BR/>05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings documented for this day.**<BR/>05/28/2022 - 10:04 AM - 164/79 mmHG<BR/>05/28/2022 - 7:50 PM - 157/70 mmHG<BR/>05/29/2022 - 6:28 PM - 167/94 mmHG<BR/>05/30/2022 - 10:12 AM - 178/90 mmHG<BR/>05/30/2022 - 8:41 PM - 155/80 mmHG<BR/>05/31/2022 - 10:29 AM - 165/100 mmHG<BR/>05/31/2022 - 7:57 PM - 151/99 mmHG<BR/>06/01/2022 - 10:05 AM - 166/99 mmHG<BR/>06/01/2022 - 7:43 PM - 170/83 mmHG<BR/>06/02/2022 - 4:47 AM - 153/100 mmHG<BR/>06/02/2022 - 9:51 AM - 159/95 mmHG<BR/>06/02/2022 - 7:02 PM - 150/98 mmHG<BR/>06/03/2022 - 2:32 AM - 155/80 mmHG<BR/>06/03/2022 - 10:38 AM - 164/86 mmHG<BR/>06/04/2022 - 10:28 AM - 166/82 mmHG<BR/>06/04/2022 - 8:44 PM - 176/84 mmHG<BR/>06/05/2022 - 1:09 AM - 163/96 mmHG<BR/>06/05/2022 - 10:33 AM - 175/97 mmHG<BR/>06/05/2022 - 5:43 PM - 186/94 mmHG<BR/>06/05/2022 - 6:02 PM - 190/100 mmHG<BR/>06/06/2022 - 9:45 AM - 158/78 mmHG<BR/>06/06/2022 - 7:44 PM - 176/73 mmHG<BR/>06/07/2022 - 2:09 AM - 174/80 mmHG<BR/>06/08/2022 - 1:25 AM - 174/88 mmHG<BR/>06/08/2022 - 11:28 AM - 179/91 mmHG<BR/>06/08/2022 - 8:22 PM - 183/84 mmHG<BR/>06/09/2022 - 2:02 AM - 149/80 mmHG<BR/>06/09/2022 - 1:38 PM - 189/100 mmHG<BR/>06/09/2022 - 6:50 PM - 167/87 mmHG<BR/>06/10/2022 - 9:45 AM - 169/84 mmHG<BR/>06/10/2022 - 7:11 PM - 186/53 mmHG<BR/>06/11/2022 - 6:29 AM - 156/76 mmHG<BR/>06/11/2022 - 10:23 AM - 193/91 mmHG<BR/>06/11/2022 - 7:45 PM - 145/76 mmHG<BR/>06/12/2022 - 8:57 AM - 160/100 mmHG<BR/>06/13/2022 - 7:38 PM - 153/96 mmHG<BR/>06/14/2022 - 10:30 AM - 154/68 mmHG<BR/>06/14/2022 - 6:50 PM - 150/74 mmHG<BR/>06/15/2022 - 9:44 AM - 181/89 mmHG<BR/>06/15/2022 - 6:49 PM - 190/94 mmHG<BR/>06/16/2022 - 9:49 AM - 163/71 mmHG<BR/>06/16/2022 - 6:51 PM - 189/85 mmHG<BR/>06/17/2022 - 10:21 AM - 160/81 mmHG<BR/>06/18/2022 - 10:08 AM - 175/91 mmHG<BR/>06/18/2022 - 6:20 PM - 165/86 mmHG<BR/>06/19/2022 - 10:09 AM - 155/86 mmHG<BR/>06/19/2022 - 7:36 PM - 152/88 mmHG<BR/>06/22/2022 - 10:21 AM - 160/101 mmHG<BR/>Review of Resident #15 Nursing Progress Notes dated 05/25/2022 - 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. <BR/>Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor.<BR/>Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 <BR/>At 0108 V/S Temp 96.3, Pulse 85, 02 99% N/C <BR/>At 0135 Pulse 87, 02 97% <BR/>At 0210 V/S Temp 96.4, Pulse 84, Resp 22, 02 97% with O2 via nasal cannula<BR/>At 0255 V/S Temp 96.3, Pulse 82, Resp 24, 02 99% with O2 via nasal cannula<BR/>At O320 V/S Temp 96.2, Pulse 81, Resp 22, 02 96% with O2 via nasal cannula<BR/>At 0455 V/S Temp 96.3, Pulse 78, 02 99% with O2 via nasal cannula<BR/>At 0545 V/S Temp 97.5, Pulse 82, 02 97% with O2 via nasal cannula, BP 155/100 <BR/> [FAMILY MEMBER] called this morning about the change in condition and the treatment initiated. Would like update from of us.<BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified.<BR/>There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. <BR/>Review of Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. <BR/>The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. <BR/>The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following:<BR/>Problem: Notify of Changes<BR/>All residents have the potential to be affected by this deficient practice.<BR/>Interventions:<BR/>o <BR/>Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased edema, elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022.<BR/>o <BR/>The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for intermittent elevated blood pressure was entered into PCC. This was completed in PCC on 6/22/22.<BR/>o <BR/>The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing.<BR/>o <BR/>All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse.<BR/>o <BR/>Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased edema and significant weight gain.<BR/>o <BR/>Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings.<BR/>o <BR/>Assessing for increased edema and/or swelling.<BR/>o <BR/>Signs and symptoms of hyperglycemia and notification of Physician.<BR/>o <BR/>The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely.<BR/>o <BR/>The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. <BR/>o <BR/>The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased edema, and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including edema. This will be monitored by DON/ADON weekly, ongoing.<BR/>o <BR/>The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. <BR/>Monitoring: <BR/>o <BR/>Monitoring of this plan began on 6/22/2022 and will continue weekly x 4.<BR/>o <BR/>The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks.<BR/>o <BR/>The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened edema is communicated to the physician/NP and follow up as needed.<BR/>o <BR/>The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. <BR/>The Survey team monitored the plan of removal as follows: <BR/>Monitoring done from 06/23/2022 - 06/25/2022. <BR/>Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of Lasix on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. <BR/>In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. <BR/>Review of Resident #15 Physician Orders dated 06/22/2022 revealed Resident #15's blood pressure medications were changed and will be monitored by PHYS ASST weekly for effectiveness. <BR/>In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. <BR/>In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. <BR/>Review of facility Inservice education completed as part of Plan of Removal:<BR/>06/22/2022 Reporting Change in Condition to include high BP, increased edema and significant weight gain. All nurses completed the education. <BR/>06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated.<BR/>06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. <BR/>06/22/2022 Signs and Symptoms of Hyperglycemia and physician notification. All nurses completed the education. <BR/>06/22/2022 Edema Causes and signs. All nurses completed the education. <BR/>While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and 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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #15) of five residents reviewed for quality of care. <BR/>-The facility failed to provide treatment and care to Resident #15 who had a 41.9-pound weight gain with a diagnosis of chronic kidney disease who reported increased swelling in his limbs and had not been examined by a physician or physician assistant since 03/29/2022 following his admission to the facility on [DATE]. <BR/>-The facility failed to notify Resident #15's physician when he experienced high blood pressures up to 190/110 and increased edema. <BR/>-The facility failed to have parameters in place for notification to physician for nursing staff regarding high blood pressure and failed to have standing orders for treatment of intermittent high blood pressure. <BR/>-The facility failed to ensure they had the proper size blood pressure cuff to ensure accurate blood pressure readings in Resident #15 following a high result from a wrist cuff. <BR/>-The facility failed to properly address Resident #15's health complications from 05/30/2022 to 06/20/2022 and subsequently retaliated against Resident #15 by having him sign a Negotiated Risk Agreement effectively blaming him for his health problems related to his non-compliance with his diet. <BR/>These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures placed residents at risk for heart failure, kidney disease, increased disease complications, hospitalization, and death. <BR/>Findings included:<BR/>Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. <BR/>Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Resident #15 was not noted to have gained or lost weight in the last month or six months. <BR/>Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. <BR/>Review of Resident #15 Physician Orders dated 04/06/2022 revealed Resident #15 to be ordered Regular Consistency/Texture, low concentrated sweets diet with larger portions. <BR/>Review of Resident #15 Physician Order dated 03/22/2022 revealed Resident #15 to be ordered the following blood pressure medications and instructions:<BR/>-Carvedilol 25 MG - Give 1 tablet by mouth times per day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse.<BR/>-Hydrochlorothiazide Capsule 12.5 MG - Give one capsule by mouth one time a day as related to high blood pressure.<BR/>-Lisinopril Tablet 20 MG - Give one table by mouth one time a day as related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse.<BR/>-Nifedipine ER Tablet 60 MG - Give one table by mouth one time a day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse.<BR/>There were no high blood pressure parameters defined in the physician orders for Resident #15. <BR/>Review of Resident #15 EMR for Physician Progress Notes dated 03/22/2022 through 06/21/2022 revealed a physician progress noted completed by PHYS ASST on 03/29/2022. There were no other physician progress notes in Resident #15's EMR.Review of Physician Progress note dated 03/29/2022 written by PHYS ASST revealed Resident #15 was admitted to the facility after a tornado damaged his previous facility. Resident #15 noted to have prior diagnoses of stroke with right sided hemiplegia (partial paralysis), Type 2 Diabetes Mellitus, high blood pressure and chronic kidney disease. His weight was noted at 310.6 pounds and he was noted to have mild peripheral edema and right lower extremity edema. There was no note that the right upper extremity had edema. <BR/>In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes into the EMR for all residents. She stated Resident #15's EMR should be current with no missing physician progress notes. She stated she would double check that there were no pending notes that needed to be uploaded. She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. <BR/>Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed:<BR/>03/24/2022 - 310.6 pounds on the wheelchair scale<BR/>04/01/2022 - 314.6 pounds (scale unknown)<BR/>05/10/2022 - 314.8 pounds (scale unknown)<BR/>06/16/2022 - 356.7 pounds (scale unknown)<BR/>Review of Resident #15 Nursing Progress note dated 06/16/2022 at 10:27 AM, written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified.<BR/>In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. <BR/>In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with family members, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. <BR/>In an interview on 06/23/2022 at 2:45 PM, RP T stated she was the family member of Resident #15 and was on the phone with him when he was short of breath, coughing and having chest pain at the end of May (2022). She said Resident #15 said he had fluid on and did not feel good and felt like he could not breathe. She said she called to the nurse's station because no one was answering his call light. The nurse said she would go check on Resident #15. She said she was back on the phone with Resident #15 when the nurse checked on him and heard Resident #15 tell her the same symptoms. She said Resident #15 asked to see a doctor or go to the hospital and the nurse responded that if if he wanted to go to the hospital he would have to call 911 himself. She said the nurse then left the room. She said it was shift change and she called back to speak with new nurse, and she checked on Resident #15 and found his oxygen levels to be low and started him on oxygen. She said she was grateful the nurse did something for the resident and the other nurse refused to help. She said she could not remember that nurse's name. She said she checked on Resident #15 the next day and was told he had pneumonia. She said they called yesterday and told her Resident #15 had a large weight gain in one month and said it was because of large meals and too many snacks from the vending machine. She said they told her the PHYS ASST started him on fluid pills. She said she asked, if the weight gain was from snacks why would fluid pills help? and they had no answer. <BR/>In an interview on 06/21/2022 at 04:25 PM, CMA G stated she weighed Resident #15 on 06/16/2022 using the wheelchair scale in the therapy room. She stated she did not re-weigh him to confirm the weight. She stated she gave the ADON the weights for the residents and she manually entered them into the EMR. She stated she did not realize there was a significant difference in the previous weight because she did not have his record in front of her when weighing him and the other residents. She stated he did tell her about the increase swelling his right arm, but she thought that was his baseline due to his stroke that affected his right arm. <BR/>An observation 06/21/2022 at 4:28 PM, Resident #15 was weighed using the mechanical lift scale. His weight was 353.0 pounds, an increase of 38.2 pounds since 05/10/2022.<BR/>In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant sees all of their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She stated she was not sure of when he rounded on Resident #15 since admission. When asked for physician progress notes for Resident #15 (because there was only one uploaded into Resident #15's EMR), she stated she would check with their medical records assistant for additional physician progress notes. She stated Resident #15 was seen by the physician assistant when he was first admitted . She stated she was aware of the large weight gain in Resident #15 from May to June, but he was non-compliant with his diet and ate snacks from the vending machines, larger portions at meals and his family brought food from the outside in large portions. She stated his diet was the cause of the weight gain and the dietitian was notified to conduct an assessment. <BR/> In an interview on 06/21/2022 at 4:00 PM, the DON stated the weight for Resident #15 may have been an error because his weight in April and May were done using the mechanical lift scale and the weight on 06/16/2022 was done using the wheelchair scale. She said she would have him re-weighed using the mechanical lift scale. She said Resident #15 was non-compliant with his diet and ate all meals with larger portions and snacks from the vending machine all day. She said she had not spoken to him regarding the edema in his arm and leg. She said the swelling was normal for him on his right side because he had a stroke on his right side that caused paralysis and affected blood flow which resulted in the swelling. She said the swelling was normal for him and there had not been a change that she knew of in his right arm and leg from baseline. She said Resident #15 was seen by PHYS K's nurse practitioner via tele-health. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. <BR/>In an interview on 06/21/2022 at 4:35 PM, the DON stated Resident #15 decided to switch to the medical director as his physician and the PHYS ASST would see him the next morning to assess and evaluate the weight gain. <BR/>In a follow-up interview on 06/23/2022 at 2:16 PM, Resident #15 said the DON made him sign a document that he would not eat so much. He said he told them he had fluid on his body, and they told him that maybe if you did not eat so many snacks you wouldn't have so much fluid. He said he did not understand why they kept blaming snacks for his swelling when the PHYS ASST told him the swelling was due to fluid related to him either having congestive heart failure or decreased kidney function. He said he did not understand why they did not want to help him see a doctor when he first began complaining about the fluid when he was short of breath and told him he would have to call 911 himself. <BR/>Review of Resident #15 Negotiated Risk Agreement signed 06/22/2022 at 3:20 PM by Resident #15 and the facility. The summary of Resident's Current Health and Potential Risk were 36 pound weight gain in one month, edema, hypertensive crisis, diabetic crisis, repeated stroke death. The resident's desire or preference was noted as to eat, drink and smoke cigarettes as he desires without diet restrictions - resident eats double portions, seconds, and take away trays from kitchen as well as outside foods and vending machine. The final agreement with Resident #15 was he agreed to to try eating only double portions but not seconds or take away trays. Agrees to try to smoke less. Agrees to try to stay away from junk foods. <BR/>In an interview on 06/23/2022 at 2:03 PM, RNC A stated they had Resident #15 sign the NRA because he was not following his diet and subsequently gained 36 pounds. She said they asked him to limit his portions to stop the weight gain. When asked if the weight could be due to edema from complications of his health conditions, she responded the resident needed to control his portions to reduce his weight gain. When asked if his diagnosis of chronic kidney disease, and a possible decline in kidney function could have caused fluid retention and edema, she replied she was not aware of Resident #15 having chronic kidney disease as it was not on his diagnosis list in the EMR. When asked why it was not on his diagnosis list in the EMR when it was on his physician progress notes and history and physical, she did not know. <BR/>In an interview on 06/23/2022 at 2:10 PM, the ADMIN stated she wanted the doctor to stop the larger portions for Resident #15 because he was eating too much and that caused the weight gain. She said he ate two snacks at activities and would have two ice creams at ice cream socials which likely caused the weight gain. When asked if she thought he was eating greater than 14,000 calories per day consistently to be able to gain that much weight so fast, she said she did not know and was not a doctor, nurse or dietitian. <BR/>In an interview on 06/23/2022 at 1:36 PM, the RD stated she was notified of Resident #15's weight gain and planned to complete an assessment when she returned to the facility next week. She stated the ADON said he gained 40 pounds. She asked the ADON if Resident #15 had fluid on legs and arms and the ADON said he ate a lot at meals, ate snacks from the vending machine, and had food brought in from the outside that caused the weight gain. She said she saw Resident #15 was on a mild diuretic. She said had she known about the edema she would have recommended they re-weigh Resident #15 and assess for edema. She said the doctor would have been consulted for further orders regarding edema and the need for a stronger diuretic. She said she did not know why Resident #15 was not assessed for edema and his doctor notified of his weight gain and edema. She said it was not likely that Resident #15 gained 40 pounds in a month and all of it be related to excess calories causing increased fat stores. She said it was more likely he had fluid on and needed a diuretic. She stated she was not aware that Resident #15 had chronic kidney as it was not on his list of diagnoses and did not know why it was not on his diagnoses list. <BR/>Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor.<BR/>In an interview on 06/24/2022 at 3:14 PM, LVN J stated in late May she was called by Resident #15's responsible party and they reported Resident #15 was having respiratory problems. She said she assessed Resident #15 and found him to be breathing heavy and his oxygen levels were low. She said started oxygen on him and paged the on-call doctor. She said she received orders for Resident #14 for nebulizer treatments and with the oxygen and nebulizer treatment his symptoms improved. She said he required oxygen for several days all day and then only at night. She said she was not sure if any physician or anyone followed up on his symptoms or resolution of pneumonia. She said Resident #15 did report increased swelling or edema but was not sure if anyone was addressing it with his attending physician. She stated she was unaware of Resident #15 having a large weight gain from May to June. She said that would likely fit with his elevated blood pressures, respiratory issues and edema. <BR/>Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start doxycycline 100 MG BID (twice per day) for seven days. <BR/>Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 <BR/>At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C <BR/>At 0135 [1:35 AM]Pulse 87, 02 97% <BR/>At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C <BR/>At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, <BR/>At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C <BR/>At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C <BR/>At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. <BR/>[family member] called this morning about the change in condition and the treatment initiated. Would like update from of us.<BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN D revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. <BR/>In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered . He did not remember being contacted about increased edema overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the edema, weight gain and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having chronic kidney disease. He stated he had not physically examined Resident #15 since he was admitted to the facility. <BR/>Review of Resident #15 Physician Progress note dated 06/21/2022 revealed the MED DIR wrote a progress note after Resident #15 caught him in the hallway. The note referred to labs drawn 10 days prior to the date of the note. There wereno labs drawn in the previous 10 days for Resident #15. It noted Resident #15 to have edema on his right arm and right leg likely due to lack of movement as Resident #15 was partially paralyzed due to a stroke two years prior. This is a stable, chronic issue. Resident #15's high blood pressure was noted as stable, continue present prescriptions and monitor. <BR/>In an interview on 06/23/2022 at 3:10 PM, RNC B was asked to provide a copy of the labs MED DIR referred to in his note on 06/21/2022. RNC B stated those labs did not exist as Resident #15 had not had labs since 03/25/2022. He said he did not know what MED DIR was referring to in his note. When asked why MED DIR wrote the progress note and did not address the 36 pound weight gain, he did not know. <BR/>In an interview on 06/23/2022 at 3:21 PM, MED DIR stated he saw Resident #15 briefly on 06/21/2022 because Resident #15 had a question regarding the swelling in his right arm and leg. He said the swelling was likely due to Resident #15 not being able to move his right arm and leg because of a stroke that caused partial paralysis. When asked if the swelling in Resident #15's arm and leg accounted for a 36 pound weight gain in one month, he responded that is the same resident that has the swollen arm and leg? I thought they were two different residents. He said the 36 pound weight was fluid retention related to an underlying health condition either decreased kidney function or congestive heart failure. He said Resident #15 needed to be seen by a cardiologist to rule out congestive heart failure. He said 10 pounds of the weight gain may be due to excessive calories, but not 36 pounds. He said the respiratory distress Resident #15 experienced at the end of May was possibly related diastolic heart failure and Resident #15 should have been evaluated by a physician. He stated an echocardiogram was needed to look at Resident #15's heart. He stated he and his physician assistant would be following Resident #15 moving forward and refer him to a cardiologist. <BR/>In an interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food. She said she was not aware that when Resident #15 first complained of respiratory distress in May that he was told he would have to call 911 himself. She said a physician should have examined and assessed Resident #15 sooner. When asked why the facility had Resident #15 sign the negotiated risk agreement within an hour of the IJ being called, she said yeah she could see now that the timing could have been better and could be seen as punitive towards Resident #15. When asked why they did not have him sign it when they saw him eating all the snacks, she said she did not realize until the weight gain and the complications that they were a problem. When asked why another non-compliant resident with CHF who was sent out to the hospital for high fluid gains was not asked to sign an NRA, she said she did not know, and they should probably have her sign an NRA as well. She said she knew the facility had the extra-large cuffs in the past and was not sure when or how they went missing. She said they had one in the crash cart and should have used it until the new cuff was bought to take Resident #15's blood pressure. She stated she did not know why Resident #15 did not have upper parameters for his blood pressure except it was chaotic when they evacuated the sister facility that was damaged by a tornado and some areas were dropped. She said they have since added parameters and PRN medications for high blood pressures for Resident #15. She said the nurses should have been documenting for blood pressures &gt; 160/110 an intervention or a re-check. She said they likely re-took the blood pressure with a manual cuff and it wasn't as high, or they administered his morning medications and re-checked his blood pressure, and it was normal. She said they should have been documenting any out of parameter blood pressure and noted the intervention. <BR/>In an interview on 06/24/2022 at 4:15 PM, the ADMIN stated she was not a nurse and did not know much about Resident #15's disease process, edema and weight gains. She said they attributed to high meal and snack intake. She said they signed the NRA with him so he would know his daily choices have an effect on his health. She said she was not aware of him experiencing swelling and fluid gains. She said she was not aware of his CKD diagnosis and was not sure how that affected his weight gain. She said she did not think the NRA was punitive, it was done to educate the resident. She said they had not previously had him sign it because RNC A recommended after the IJ was called. She said a physician should have seen Resident #15 following the respiratory issues and excessive weight gain. She said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. <BR/>In an observation and interview on 06/22/2022 at 10:19 AM, the PHYS ASST completed a physical exam and assessment of Resident #15. Resident #15 stated to the PHYS ASST he had not seen a PHYS K since admitted to the facility. The PHYS ASST said she saw the swelling in Resident #15's right arm and right leg. Resident #15 stated he felt like he had swelling in his abdomen. He reported the shortness of breath in late May of 2022 to the PHYS ASST and she stated she ordered the chest x-ray which showed pneumonia. She stated she was not told Resident #15 was also complaining of having fluid on and swelling. Resident #15 reported to the PHYS ASST he needed oxygen at night and in the past at his previous facility he did not need oxygen routinely. He said he has not been able to wear a shoe on his right foot because of the swelling in at least 2 months. He stated he had a family history of having fluid on their heart and lungs. The PHYS ASST asked Resident #15 was on fluid pills in the past, and he said yes at his previous facility but not since being admitted here. He said he was told his kidneys were not working all the way, but they were just going to watch it. She said she would have lab work done to check his kidneys and start him on a fluid pill. Resident #15 did not know why they stopped the fluid pills. The PHYS ASST stat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse.<BR/>The facility failed to ensure Resident #1 was in a safe environment when LVN A recorded instances of pouring water onto her face, verbally taunting her, and striking her with her knee and sitting on her arm. <BR/>An immediate jeopardy existed from 03/05/24 - 03/06/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.<BR/>This failure could affect residents by placing them at risk for abuse that could cause diminished quality of life and increased psychosocial harm as well as physical harm.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted to the facility 07/18/19 with diagnoses including: depression, history of stroke (bleeding in the brain), dementia, and kidney disease requiring dialysis (removal of blood by a machine to clean toxins then replacing cleaned blood).<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had moderate difficulty with her hearing. It further revealed she usually understood others and usually could be understood. The review also revealed Resident #1 had impaired vision that required corrective lenses. Resident #1's BIMS score was an 8, which correlated with moderately impaired cognition. Further review revealed that Resident #1 did not exhibit physical or verbal behavioral symptoms directed towards others nor behavioral symptoms not directed towards others. <BR/>Review of Resident #1's latest care plan, dated 12/22/23, revealed Resident #1 was at risk for pressure related injury due to impaired mobility with intervention of administering medications as ordered and repositioning Resident #1 at least every 2 hours. Further review revealed Resident #1 was at risk for fluid deficit (dehydration) due to medications, dialysis and variable intake; the intervention for this concern was administer medication, encourage Resident #1 to drink fluids of choice, ensure fluids were within reach, and notify the nurse if Resident #1 refused to drink fluids. Further review revealed Resident #1 was at risk for discomfort/pain due to impaired mobility and recent hospitalization that led to dialysis; the intervention for Resident #1's potential discomfort/pain was anticipate her need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain intervention, and review for compliance. Further review revealed Resident #1 had a focus of being non-compliant with medication due to anxiety and interventions were to notify family and physician and notify supervisor.<BR/>Review of the facility's self-report dated 03/06/24 revealed that LVN A used her cell phone camera to record herself verbally and physically abusing Resident #1. There was a total of 5 videos, with 2 being repeats, that were sent by LVN A to an undisclosed employee who then sent the videos to the corporate office of the facility.<BR/>Review of the videos, sent to Corporate 03/05/24, revealed LVN A poured water on Resident #1 who was lying in bed. LVN A was heard taunting Resident #1 when Resident #1 became upset about the water poured on her face. Resident #1 swung her left arm out at LVN A each time LVN A approached her bed. LVN A was seen kneeing Resident #1, who was lying on a scoop mattress, and telling Resident #1 that she was going to take these pills. Resident #1 was heard calling LVN A a Black Bitch as she swung her arm at LVN A when LVN A approached Resident #1's bed. LVN A was heard asking Resident #1 if she is gay and throughout the video LVN A was laughing and taunting Resident #1. The next video revealed LVN A continued to taunt Resident #1 and she sat on Resident #1 while commenting that she was sitting on her. LVN A was seen sitting on Resident #1's left hip area, getting up and motioning to sit again as Resident #1 swung her arm at LVN A. LVN A was then seen grabbing Resident #1's blanket and trying to take it from Resident #1 while laughing and telling Resident #1 she was going to take these pills. The next video showed LVN A tugging at Resident #1's blanket and telling her that she would take the blanket if Resident #1 did not take these pills. Resident #1 stated to LVN A that it was her blanket and called LVN A a bitch. Resident #1 struck out with her right arm toward LVN A and LVN A responded by pouring more water on Resident #1's face, which was turned away from LVN A. Resident #1 called LVN A a bitch and LVN A laughed and held the water above Resident #1's head while Resident #1 lifted her right arm above her face to protect from further water being poured. LVN A slowly pretends to pour the water on Resident #1 while Resident #1's arm was over her face for protection but then withdrew the cup of water and laughed, then slowly moved closer to again threaten to pour water on Resident #1's face, held the cup for a few seconds and then poured the water when Resident #1 had lowered her arm. LVN A stated she was going to pour the water and Resident #1 said go ahead and pour it on me. LVN A poured a small amount on Resident #1 who then stated pour it all on me as she wiped the water away. LVN A was laughing and facing the camera. In the next clip, LVN A was kneeing Resident #1 3 times with Resident #1 swinging her left arm toward LVN A after the first kneeing incident. LVN A then grabbed Resident #1's left arm by the wrist and told her to open her mouth while grabbing Resident #1's mouth, and then poking her several times in the breast/chest area while calling Resident #1's name. LVN A then sat down on Resident #1's left arm and part of her abdomen while holding a cup of medication to Resident #1's mouth and looking back at the camera. LVN A then pulled on Resident #1's chin and Resident #1 opened her mouth and LVN A tilted the cup, so the medication ended up in Resident #1's mouth. LVN A then laughed and said ha ha gotcha; LVN A then grabbed the phone/camera. In all 5 video clips Resident #1 was wearing the same clothing and LVN A was wearing the same clothing in all 5 clips.<BR/>During an interview on 03/13/24 at 11:00 am with the ADM she stated that LVN A sent the videos to an unknown employee who then sent the videos to the corporate office on 03/05/24; the corporate office immediately contacted the ADM, around 03/05/24 at 3:30 pm, and ADM began suspension and termination paperwork. LVN A was not at work at the time, so ADM stated she contacted LVN A to come to the building to sign the suspension paperwork and that she would be terminated for abuse. Corporate office reported LVN A to the board of nursing and included the video files. ADM contacted the family, the police department , the ombudsman and reported to SA . In addition, she notified the MD. The ADM, with support staff from the Corporate Office, began in-servicing all employees on Abuse/Neglect/Exploitation, use of photography/social media, and HIPAA privacy laws. All in-servicing was started 03/05/24 and completed 03/06/24. In addition, skin sweeps of all residents were started 03/05/24 and completed 03/06/24. Resident #1 was assessed by nursing immediately and Social Work met with the resident and continued meeting with her through 03/13/24 (exit ). Resident #1 was followed by Psychiatry, so a call for an immediate visit was made and a psychologist visited with Resident #1 on 03/11/24 (first available time). The psychologist had seen Resident #1 in the past and stated that she had not declined in her baseline from the last time he had seen her several months before and this visit. All residents were given safe resident surveys with no other issues identified. Staff were all given surveys related to LVN A and whether any staff had observed abusive behavior, but no witnessed or other issues were identified. An Ad Hoc QAPI was held with ADM, DON, and MD on 03/05/24. The dialysis clinic that Resident #1 visited 3 times per week were notified to be on alert. In addition, the facility notified every facility in a 60-mile radius that LVN A was terminated and not eligible for re-hire. ADM stated that the police detective informed the ADM that Resident #1's RP would have to press charges for LVN A to be charged with any criminal act. The ADM also stated that the facility would continue asking 5 alert and oriented residents about any abuse or neglect concerns and if the residents feel safe; these questions would be asked for the next 5 weeks (if no concerns are voiced in the future questioning).<BR/>Record review of Resident #1's EHR assessments tab revealed a Weekly Skin Assessment was performed on 03/05/24 at 4:09 pm and revealed no bruising or skin tears, but noted bilateral non-pressure wounds to the heals which were not marked as new.<BR/>Record review of the resident safe surveys revealed no other residents documented concerns about safety, nor did the residents feel abused and nor had they witnessed abuse at the facility.<BR/>Record review of staff surveys revealed that no staff member documented witnessing abuse or neglect of any resident by LVN A nor by any other staff member. In addition, all staff were able to identify the ADM as the abuse coordinator to contact immediately should staff have any concerns about abuse or neglect.<BR/>Record review of Resident #1's March 2024 Progress Notes revealed a progress note authored by the Social Worker (SW) on 03/05/24 at 6:02 pm and revealed the SW documented trying to interview Resident #1 about the abuse she endured from LVN A, but Resident #1 did not answer about abuse and asked for her breakfast. The SW documented that Resident #1 did not display signs of fear, distress or behavioral agitation. The next progress note authored by the SW on 03/06/24 at 12:24 revealed she contacted Resident #1's psychiatric provider who stated they would arrange for counseling services to contact the SW to setup an appointment. The SW authored a note on 03/06/24 at 5:01 pm that the counseling services contacted the SW, and a therapist would call the SW to discuss telehealth and in-person options.<BR/>During an interview and observation on 03/13/24 at 3:00 pm with Resident #1 revealed her room was dark and she said to go away. Resident #1 appeared to be resting comfortably in bed; no concerns were visible. Police officer exited room moments before. <BR/>During an interview with Police Detective on 03/13/24 at 3:10 pm he stated that he was gathering evidence still, as he had just attempted to interview Resident #1 but was unsuccessful. He further stated he still needed to interview Resident #1's RP and LVN A. He provided his contact information and stated he would provide an update and report when he was able.<BR/>During an interview on 03/19/24 at 9:10 am with LVN A she stated that nobody liked Resident #1 because Resident #1 was physically abusive, used bad language and refused care. She stated that sometime in January of 2024, LVN A had a cup of water to give Resident #1 and Resident #1 swung her hand and caused a little bit of water to spill on Resident #1. She said Resident #1 would respond to requests from LVN A by calling her a bitch and Resident #1 said fuck you. She stated she was supposed to go to work on 03/06/24, and she picked up her paycheck on 03/05/24 and everything was fine but was contacted by the ADM on 03/05/24 around 5 or 6 pm and the ADM told her she was suspended pending an investigation. She said the ADM was not allowed to tell her the allegations. LVN A stated on 03/06/24 she was called and asked to come to the facility and was notified she would be terminated. She denied any further incidents of water being spilled on Resident #1, she denied raising her voice to Resident #1, putting her hands on Resident #1, or any other incidents that would be viewed as abusive. LVN A did state that she had documented when Resident #1 had aggressive behavior toward LVN A.<BR/>Record review of Resident #1's January 2024 progress notes revealed that LVN A documented a behavior note on 01/30/24 at 7:22 am that further revealed that Resident #1 refused her medication and used foul language and told LVN A to leave her room. LVN A then offered Resident #1 her medication in the shower room and Resident #1 pulled LVN A's hair and knocked the medication cup out of LVN A's hand. LVN A then documented notifying Resident #1's RP of the encounter.<BR/>Record review of Resident #1's February 2024 progress notes revealed that LVN A documented on 02/03/24 at 2:51 pm that she had contacted Resident #1's RP about a behavior incident earlier that morning (no description or note found specifying the incident) and that a new order for in-patient psychiatric services was placed and RP would be updated when new information was available. Further review revealed a progress note on 02/09/24 at 8:13 am authored by LVN A that stated LVN A called the Mental health and mental rehabilitation crisis hotline to report that Resident #1 was using explicit language and displaying inappropriate behavior (not described) towards LVN A and another staff; LVN A was waiting for a return phone call. Review of a note dated 02/09/24 at 11:22 am by LVN A that revealed the return call from the crisis hotline personnel recommended LVN A speak with RP and MD to obtain inpatient psychiatric services for Resident #1; LVN A spoke to the ADM who recommended LVN A speak to the SW.<BR/>During an interview on 03/13/24 at 3:13 pm with LVN B, she stated the facility constantly trained on abuse and abuse prevention. She said, it starts your first day of work on the computer before you can work with residents. She stated at least once a month, but usually more, abuse was covered. LVN B stated the most recent abuse in-service was within the last week, she thought last Tuesday or Wednesday (03/05/24 or 03/06/24). She stated if she was concerned about abuse, she would have reported it to the abuse coordinator, the ADM and she felt the ADM would take it seriously.<BR/>During an interview on 03/13/24 at 3:20 pm with LVN C, she stated that they were in-serviced at least every month on abuse and the most recent was within the last few days. If she suspected abuse, she would protect the resident and notify the abuse coordinator, the ADM. She stated the ADM was new, but seemed good, she said staff were told there was an incident of abuse and to watch Resident #1 for any signs of change from her baseline. LVN C said Resident #1 seemed to be having more good days this week than the last few weeks.<BR/>During an interview on 03/13/24 at 3:26 pm with CNA D, she said she was trained on abuse at least every other month, but most recently last week. She said if she had witnessed abuse, she would have stopped it and notified the charge nurse immediately, then the DON, and the ADM who was the abuse coordinator. She gave the types of abuse and examples.<BR/>During an interview on 03/13/24 at 3:37 pm with HK E she said abuse was mentioned in trainings and meetings at least 3 - 4 times a month, and the latest was within the last week. She stated Resident #1 had good and bad days, but Resident #1 had never been physical with her. She said sometimes Resident #1 would yell at her, but when HK E responded calmly to Resident #1 and told her what she was doing and kept talking to her that Resident #1 would calm down. She stated that usually staff stepped out and gave Resident #1 a moment to calm down and tried again later.<BR/>Record review of in-services revealed all staff in-serviced on Abuse/neglect/exploitation, photography, social media usage, and HIPAA privacy laws which started on 03/05/24 and completed 03/06/24.<BR/>Record review revealed an attendance sheet for an Ad Hoc QAPI meeting on 03/05/24 which included the ADM, the DON, and the MD.<BR/>Record review of HR folder revealed termination paperwork that stated that LVN A was hired 11/17/23 and was suspended by the ADM on 03/05/24 with the ADM's stated intent to move straight to termination due to a substantiated allegation that LVN A abused a resident; the ADM also requested that LVN A be added to a list of people not to be rehired due to the abuse. Further review revealed a form titled Personnel Action Form and was marked Termination with LVN A's name and employee identification number. LVN A's final termination date was marked as 03/06/24, and her last day worked according to the form was 03/04/24. Further review of LVN A's HR folder revealed she was last in-serviced on Abuse/neglect/exploitation on the computer on 01/02/24. Further review revealed the facility documented all required background checks for LVN A, which included verification of her nursing license, criminal background check, check with the employee misconduct registry, and the state and federal office of the inspector general exclusion lists.<BR/>Record review of March 2024 nursing schedule revealed LVN A was not scheduled after 03/05/24.<BR/>Record review of facility's policy titled Abuse/Neglect dated 03/29/18 revealed abuse included . willful infliction of injury, intimidation, or punishment .verbal abuse included language that was disparaging or derogatory . Mental abuse included harassment, threats of punishment .physical abuse included . pinching, kicking, and hitting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to provide safe transport for Resident #1 on 05/27/25 which resulted in a fall and Nondisplaced fracture of the proximal fibular metaphysis of the left knee.<BR/>This failure could result in serious injury such as a left knee fracture and a reduced quality of life .<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 06/02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included a left proximal fibular fracture (a break in the fibula bone, located on the outside of the lower leg, near the knee, often caused by twisting or blunt force injuries to the leg or foot), dementia (deterioration of brain and memory loss), diabetes mellitus type 2, rheumatoid arthritis (auto-immune disorder affecting major joints) , major depressive disorder, hypertension, and anxiety . <BR/>Record review of Resident #1's care plan, revised 05/28/25, reflected,<BR/>Resident #1 had a skin tear to right shin and right knee, and sustained a left knee fracture (left proximal fibular metaphysis) related to fall with interventions of splint to left knee, and teach the purpose of and the procedure for performing isometric and flexion/extension exercises, and pain treatment as indicated by MD. The care plan further reflected Resident #1 was at risk for trauma that may have a negative impact, related to a van incident. Interventions included a Licensed Mental Health Provider, consult with family regarding her condition, identify situation/event/images that trigger recollections of the traumatic event and limit Resident #1's exposure to these as much as possible, monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, mental health provider, and physician. The care plan further reflected Resident #1 had a potential for uncontrolled pain due to fracture of her left knee. Interventions included administration of analgesia per physician orders, and give &frac12; hour before treatments or care, anticipate her need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE] , reflected a BIMS score of 04, which indicated a moderate to severe cognitive impairment. Resident #1 required extensive assistance for bed mobility, transfers, and toilet use. She required the assistance of two people for transfers between surfaces.<BR/>Record review of Resident #1's Physician Order Summary Report, dated 06/02/25, reflected a 20-inch Universal Basic Knee Splint for stabilization of left fibula fracture, and ensure splint is in right place, patient able to perform weight bearing as tolerated while her knee was immobilized. The Order Summary Report further reflected Tramadol 50mg 1 tablet by mouth three times a day for pain, and every 6 hours for moderate pain, Psychiatry to evaluate and treat, and skin tear to right and left knee - cleanse with normal saline and pat dry, apply Xeroform and cover with gauze island dressing every day shift every Monday, Wednesday, and Friday, and as needed.<BR/>Record review of Resident #1's incident report, dated 05/27/2025, at approximately 1:30 PM, reflected the following, Resident #1 was being transported to a doctor's appointment. Driver A braked for a red-light resident slid out of wheelchair scraping knees, received a skin tear and a cut toe. Incident happened right by doctor's office parking lot. Doctor's staff cleaned and bandaged cuts and scrapes. Assessment conducted on 05/27/25 at 5:50 PM reflected Resident #1 had bruising to bilateral upper extremities, skin tear left knee, left upper extremity, abrasion right knee, moisture skin damage sacrum, and irritation to great right toe. Resident #1 was sent to the hospital for X-rays. Driver A was suspended immediately, and van was out of service until all drivers had been re-in serviced and safety check was done on all van equipment. Facility notified the responsible party and the nurse practitioner. <BR/>Record review of hospital records with an admission date/time of 05/27/25 at 09:36 PM and discharge date /time of 05/28/25 at 03:23 AM reflected, Resident #1 was a [AGE] year-old female presenting to the ED for evaluation of a fall that occurred today at approximately 4:00 PM. Resident #1 reported she was riding in a transport van when Driver A forcefully pressed the brakes, launching Resident #1 out of her wheelchair. Resident #1 landed on the vehicle floor and suffered impact to both knees. Associated symptoms included bilateral knee pain and mild neck pain. Denied back pain, chest pain, cough, congestion, rhinorrhea (runny nose), or headaches. There were no other complaints at this time. <BR/>X-ray Right Knee 3 Views reflected:<BR/>1. <BR/>No acute osseous abnormality.<BR/>2. <BR/>Severe tricompartmental osteoarthritic changes.<BR/>X-ray Left Knee 3 Views reflected:<BR/>1. <BR/>Nondisplaced fracture of the proximal fibular metaphysis.<BR/>2. <BR/>Moderate tricompartmental osteoarthritic changes.<BR/>3. <BR/>Possible soft tissue wound anterior to the patella.<BR/>Narrative: This patient is a pleasant non-ambulatory [AGE] year-old female who was in a transport van today and was in her wheelchair and the transport driver stopped abruptly and the patient fell from her wheelchair. Patient reporting bilateral knee pain. Patient with report of lower cervical and upper thoracic discomfort. Imaging showing no acute abnormalities of the head neck chest abdomen or pelvis. Patient with notable proximal fibular fracture on the left. X-ray of the ankle found to be unremarkable. Patient placed in a knee immobilizer. Given referral to orthopedics. Patient discharged home. At time of discharge patient is pain-free.<BR/>Diagnosis: Closed left fibular fracture .<BR/>Interview on 06/01/25 at 3:25 PM with the DON, who stated she had not been able to get Driver A to answer the phone since 05/27/25, and Driver A had been a no call/no show for CNA duties since the day of the van incident. The DON stated the facility conducted re-training on transporting residents in the van, and anyone who was not re-trained was not driving. She stated in the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. The DON further stated Resident #1 stated Driver A had slammed on the brakes and she slid out of the wheelchair onto her knees.<BR/>Interview on 06/01/25 at 3:15 PM with Driver B revealed she worked in Housekeeping and was also a van driver. Driver B stated she had received training on 05/28/25 that included inspecting the vehicle inside and out every week, and to check acceptable or document if there are repairs needed on the form and submit to Administration and Corporate. <BR/>Telephone interview on 6/02/25 at 07:15 AM, Driver A stated she received 30 minutes of training from another van driver before she drove the van herself. Driver A stated she had worked for the facility for 4 months. She stated she thought Resident #1 had been up too long on the day of her appointment. Driver A stated Resident #1 had been to her therapy session that morning, and was up for lunch, and then went to her doctor appointment in the early afternoon. Driver A stated she thought Resident #1 became fatigued and started slipping out of her wheelchair . Driver A stated she had all of the straps and hooks on to secure the wheelchair in the van, and the seat belts were secured on the resident for resident safety. Driver A stated there were no witnesses riding in the van with her, other than Resident #1's RP who had met them at the doctor's appointment. Driver A stated the RP met them at the doctor's appointment and had entered the van to assisted in getting Resident #1 back up and into the wheelchair . <BR/>Interview on 06/02/25 at 2:14 PM with MAINT revealed on the interior of the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. MAINT demonstrated how the seatbelt would secure a resident in a wheelchair once the 4 straps and hooks secured the wheelchair in place. MAINT stated he was up to date on the transport van maintenance, and he had looked at the Vehicle Inspection Reports and the van was in good working condition. He stated he looked at the transport van seatbelts and wheelchair straps after the incident and saw no issues. <BR/>Interview on 06/02/25 at 4:42 PM with the RP, who stated Driver A had asked her to hold the wheelchair and then Driver A lifted Resident #1, and the RP pushed the wheelchair forward under Resident #1's bottom so Driver A could get her back in the wheelchair . The RP stated Resident #1was seeing the orthopedic surgeon on Wednesday, 06/04/25. The RP believed Resident #1 had not been strapped in the wheelchair since she went forward on her knees and hit her head on the backside of the driver's seat. The RP further stated Resident #1 told her when Driver A turned, she slammed on her brakes, and that was when she fell out of the wheelchair. <BR/>Interview on 06/02/25 at 5:04 PM with Resident #1 revealed she knew something had happened to her, but she was not able to recall all the events. She stated she was having pain in her left knee and pointed to the left knee with a brace on it. Resident #1 stated Driver A slammed on the brakes and she remembered sliding out of the wheelchair and landed on her knees, and she did not remember too much after that. Resident #1 stated she did not remember if there was a seat belt on her or not. Resident #1 stated she had an appointment with a doctor who would check on her knee tomorrow, and the RP would be going along. <BR/>Record review of a statement from Resident #1, dated 05/27/25, included in the facility investigation reflected, Resident #1 stated that she slid out of her wheelchair while in the back of the van. She stated that she hit the back of the driver seat, and her knees went under her. Resident #1 stated that Driver A then attempted to help her but was unsuccessful due to how she was positioned. Resident #1 then stated that when she stopped, Driver A asked her RP who met them there to assist her in helping her back into the wheelchair. Resident #1 stated to ADON , during this statement, that at the time she had no pain but that she felt a slight tingling and burn just a tad bit but stated that she was having no pain when asked to rate pain. Resident #1 stated that the nurse at the doctor assessed her knee and cleaned it up and applied bandages. Educated Resident #1 on pain assessments and assessed her knees as well. Resident #1 stated that it was not that bad. Informed resident that we will send for X-ray of knees, and she said OKAY.<BR/>Record review of In-service conducted on 05/27/25 for staff who transport or assist with transporting residents in the van on the following (with return demonstration): Staff members not in-serviced will not transport residents.<BR/>1. <BR/>How to safely load and unload residents in the van using the lift<BR/>2. <BR/>Properly securing a resident in the van:<BR/>Ambulatory resident - securing with seat belt.<BR/>Non-ambulatory resident - securing the wheelchair and the resident.<BR/>Record review of the Vehicle Inspection Report dated 05/28/25 reflected the following relevant items were checked for the interior of the vehicle:<BR/>Instruments, gages, horn, and warning lights working properly.<BR/>Floors, seats, doors, and steps all clean and free of debris/stains<BR/>Seat Belts clean and in good working condition<BR/>Wheelchair Tie-Downs inspected and working properly.<BR/>Summary of the report reflected the van and equipment in good working condition.<BR/>Record review of In-service, conducted on 05/27/25, reflected, Resident involved in a van incident such as slipping out of the chair, tipping back in the chair, or hitting head, the transported should immediately stop and call 911, notify the Administrator and/or the DON immediately if you are off the property. Do not move the resident. If you're on the property immediately go, get a nurse to assess the resident. <BR/>Record review of the Employee Auto Training Handbook - Vehicle Inspection Report, dated 05/28/25, reflected the vehicle interior (including the seatbelts clean and in good working condition), vehicle exterior, fluid levels, and emergency equipment were acceptable, and the van and equipment were in good working condition.<BR/>Record review of the undated Employee Auto Training Handbook reflected,<BR/>The Driver Training Handbook is a statement of company and expectations as it pertains to transport vehicles, procedures to ensure resident safety and to promote safe driving practices.<BR/>Employee safety responsibilities<BR/>1. <BR/>Observe all organization safety and health rules and apply the principles of accident prevention in your day-to-day duties.<BR/>2. <BR/>Report any job-related injury, illness, or property damage to your supervisor immediately.<BR/>3. <BR/>Report any hazardous conditions and unsafe acts to your supervisor promptly.<BR/>4. <BR/>Follow proper lifting procedures always.<BR/>5. <BR/>Whenever driving an organization vehicle or personally owned vehicle for organization business seat belts must be used.<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to provide safe transport for Resident #1 on 05/27/25 which resulted in a fall and Nondisplaced fracture of the proximal fibular metaphysis of the left knee.<BR/>This failure could result in serious injury such as a left knee fracture and a reduced quality of life .<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 06/02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included a left proximal fibular fracture (a break in the fibula bone, located on the outside of the lower leg, near the knee, often caused by twisting or blunt force injuries to the leg or foot), dementia (deterioration of brain and memory loss), diabetes mellitus type 2, rheumatoid arthritis (auto-immune disorder affecting major joints) , major depressive disorder, hypertension, and anxiety . <BR/>Record review of Resident #1's care plan, revised 05/28/25, reflected,<BR/>Resident #1 had a skin tear to right shin and right knee, and sustained a left knee fracture (left proximal fibular metaphysis) related to fall with interventions of splint to left knee, and teach the purpose of and the procedure for performing isometric and flexion/extension exercises, and pain treatment as indicated by MD. The care plan further reflected Resident #1 was at risk for trauma that may have a negative impact, related to a van incident. Interventions included a Licensed Mental Health Provider, consult with family regarding her condition, identify situation/event/images that trigger recollections of the traumatic event and limit Resident #1's exposure to these as much as possible, monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, mental health provider, and physician. The care plan further reflected Resident #1 had a potential for uncontrolled pain due to fracture of her left knee. Interventions included administration of analgesia per physician orders, and give &frac12; hour before treatments or care, anticipate her need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE] , reflected a BIMS score of 04, which indicated a moderate to severe cognitive impairment. Resident #1 required extensive assistance for bed mobility, transfers, and toilet use. She required the assistance of two people for transfers between surfaces.<BR/>Record review of Resident #1's Physician Order Summary Report, dated 06/02/25, reflected a 20-inch Universal Basic Knee Splint for stabilization of left fibula fracture, and ensure splint is in right place, patient able to perform weight bearing as tolerated while her knee was immobilized. The Order Summary Report further reflected Tramadol 50mg 1 tablet by mouth three times a day for pain, and every 6 hours for moderate pain, Psychiatry to evaluate and treat, and skin tear to right and left knee - cleanse with normal saline and pat dry, apply Xeroform and cover with gauze island dressing every day shift every Monday, Wednesday, and Friday, and as needed.<BR/>Record review of Resident #1's incident report, dated 05/27/2025, at approximately 1:30 PM, reflected the following, Resident #1 was being transported to a doctor's appointment. Driver A braked for a red-light resident slid out of wheelchair scraping knees, received a skin tear and a cut toe. Incident happened right by doctor's office parking lot. Doctor's staff cleaned and bandaged cuts and scrapes. Assessment conducted on 05/27/25 at 5:50 PM reflected Resident #1 had bruising to bilateral upper extremities, skin tear left knee, left upper extremity, abrasion right knee, moisture skin damage sacrum, and irritation to great right toe. Resident #1 was sent to the hospital for X-rays. Driver A was suspended immediately, and van was out of service until all drivers had been re-in serviced and safety check was done on all van equipment. Facility notified the responsible party and the nurse practitioner. <BR/>Record review of hospital records with an admission date/time of 05/27/25 at 09:36 PM and discharge date /time of 05/28/25 at 03:23 AM reflected, Resident #1 was a [AGE] year-old female presenting to the ED for evaluation of a fall that occurred today at approximately 4:00 PM. Resident #1 reported she was riding in a transport van when Driver A forcefully pressed the brakes, launching Resident #1 out of her wheelchair. Resident #1 landed on the vehicle floor and suffered impact to both knees. Associated symptoms included bilateral knee pain and mild neck pain. Denied back pain, chest pain, cough, congestion, rhinorrhea (runny nose), or headaches. There were no other complaints at this time. <BR/>X-ray Right Knee 3 Views reflected:<BR/>1. <BR/>No acute osseous abnormality.<BR/>2. <BR/>Severe tricompartmental osteoarthritic changes.<BR/>X-ray Left Knee 3 Views reflected:<BR/>1. <BR/>Nondisplaced fracture of the proximal fibular metaphysis.<BR/>2. <BR/>Moderate tricompartmental osteoarthritic changes.<BR/>3. <BR/>Possible soft tissue wound anterior to the patella.<BR/>Narrative: This patient is a pleasant non-ambulatory [AGE] year-old female who was in a transport van today and was in her wheelchair and the transport driver stopped abruptly and the patient fell from her wheelchair. Patient reporting bilateral knee pain. Patient with report of lower cervical and upper thoracic discomfort. Imaging showing no acute abnormalities of the head neck chest abdomen or pelvis. Patient with notable proximal fibular fracture on the left. X-ray of the ankle found to be unremarkable. Patient placed in a knee immobilizer. Given referral to orthopedics. Patient discharged home. At time of discharge patient is pain-free.<BR/>Diagnosis: Closed left fibular fracture .<BR/>Interview on 06/01/25 at 3:25 PM with the DON, who stated she had not been able to get Driver A to answer the phone since 05/27/25, and Driver A had been a no call/no show for CNA duties since the day of the van incident. The DON stated the facility conducted re-training on transporting residents in the van, and anyone who was not re-trained was not driving. She stated in the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. The DON further stated Resident #1 stated Driver A had slammed on the brakes and she slid out of the wheelchair onto her knees.<BR/>Interview on 06/01/25 at 3:15 PM with Driver B revealed she worked in Housekeeping and was also a van driver. Driver B stated she had received training on 05/28/25 that included inspecting the vehicle inside and out every week, and to check acceptable or document if there are repairs needed on the form and submit to Administration and Corporate. <BR/>Telephone interview on 6/02/25 at 07:15 AM, Driver A stated she received 30 minutes of training from another van driver before she drove the van herself. Driver A stated she had worked for the facility for 4 months. She stated she thought Resident #1 had been up too long on the day of her appointment. Driver A stated Resident #1 had been to her therapy session that morning, and was up for lunch, and then went to her doctor appointment in the early afternoon. Driver A stated she thought Resident #1 became fatigued and started slipping out of her wheelchair . Driver A stated she had all of the straps and hooks on to secure the wheelchair in the van, and the seat belts were secured on the resident for resident safety. Driver A stated there were no witnesses riding in the van with her, other than Resident #1's RP who had met them at the doctor's appointment. Driver A stated the RP met them at the doctor's appointment and had entered the van to assisted in getting Resident #1 back up and into the wheelchair . <BR/>Interview on 06/02/25 at 2:14 PM with MAINT revealed on the interior of the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. MAINT demonstrated how the seatbelt would secure a resident in a wheelchair once the 4 straps and hooks secured the wheelchair in place. MAINT stated he was up to date on the transport van maintenance, and he had looked at the Vehicle Inspection Reports and the van was in good working condition. He stated he looked at the transport van seatbelts and wheelchair straps after the incident and saw no issues. <BR/>Interview on 06/02/25 at 4:42 PM with the RP, who stated Driver A had asked her to hold the wheelchair and then Driver A lifted Resident #1, and the RP pushed the wheelchair forward under Resident #1's bottom so Driver A could get her back in the wheelchair . The RP stated Resident #1was seeing the orthopedic surgeon on Wednesday, 06/04/25. The RP believed Resident #1 had not been strapped in the wheelchair since she went forward on her knees and hit her head on the backside of the driver's seat. The RP further stated Resident #1 told her when Driver A turned, she slammed on her brakes, and that was when she fell out of the wheelchair. <BR/>Interview on 06/02/25 at 5:04 PM with Resident #1 revealed she knew something had happened to her, but she was not able to recall all the events. She stated she was having pain in her left knee and pointed to the left knee with a brace on it. Resident #1 stated Driver A slammed on the brakes and she remembered sliding out of the wheelchair and landed on her knees, and she did not remember too much after that. Resident #1 stated she did not remember if there was a seat belt on her or not. Resident #1 stated she had an appointment with a doctor who would check on her knee tomorrow, and the RP would be going along. <BR/>Record review of a statement from Resident #1, dated 05/27/25, included in the facility investigation reflected, Resident #1 stated that she slid out of her wheelchair while in the back of the van. She stated that she hit the back of the driver seat, and her knees went under her. Resident #1 stated that Driver A then attempted to help her but was unsuccessful due to how she was positioned. Resident #1 then stated that when she stopped, Driver A asked her RP who met them there to assist her in helping her back into the wheelchair. Resident #1 stated to ADON , during this statement, that at the time she had no pain but that she felt a slight tingling and burn just a tad bit but stated that she was having no pain when asked to rate pain. Resident #1 stated that the nurse at the doctor assessed her knee and cleaned it up and applied bandages. Educated Resident #1 on pain assessments and assessed her knees as well. Resident #1 stated that it was not that bad. Informed resident that we will send for X-ray of knees, and she said OKAY.<BR/>Record review of In-service conducted on 05/27/25 for staff who transport or assist with transporting residents in the van on the following (with return demonstration): Staff members not in-serviced will not transport residents.<BR/>1. <BR/>How to safely load and unload residents in the van using the lift<BR/>2. <BR/>Properly securing a resident in the van:<BR/>Ambulatory resident - securing with seat belt.<BR/>Non-ambulatory resident - securing the wheelchair and the resident.<BR/>Record review of the Vehicle Inspection Report dated 05/28/25 reflected the following relevant items were checked for the interior of the vehicle:<BR/>Instruments, gages, horn, and warning lights working properly.<BR/>Floors, seats, doors, and steps all clean and free of debris/stains<BR/>Seat Belts clean and in good working condition<BR/>Wheelchair Tie-Downs inspected and working properly.<BR/>Summary of the report reflected the van and equipment in good working condition.<BR/>Record review of In-service, conducted on 05/27/25, reflected, Resident involved in a van incident such as slipping out of the chair, tipping back in the chair, or hitting head, the transported should immediately stop and call 911, notify the Administrator and/or the DON immediately if you are off the property. Do not move the resident. If you're on the property immediately go, get a nurse to assess the resident. <BR/>Record review of the Employee Auto Training Handbook - Vehicle Inspection Report, dated 05/28/25, reflected the vehicle interior (including the seatbelts clean and in good working condition), vehicle exterior, fluid levels, and emergency equipment were acceptable, and the van and equipment were in good working condition.<BR/>Record review of the undated Employee Auto Training Handbook reflected,<BR/>The Driver Training Handbook is a statement of company and expectations as it pertains to transport vehicles, procedures to ensure resident safety and to promote safe driving practices.<BR/>Employee safety responsibilities<BR/>1. <BR/>Observe all organization safety and health rules and apply the principles of accident prevention in your day-to-day duties.<BR/>2. <BR/>Report any job-related injury, illness, or property damage to your supervisor immediately.<BR/>3. <BR/>Report any hazardous conditions and unsafe acts to your supervisor promptly.<BR/>4. <BR/>Follow proper lifting procedures always.<BR/>5. <BR/>Whenever driving an organization vehicle or personally owned vehicle for organization business seat belts must be used.<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, and the facility failed to ensure the content of the notice included the effective date of transfer or discharge and the location to which the resident was transferred or discharged for one (Resident #1) of five residents reviewed for residents returning to the facility.<BR/>The facility failed to provide a 30-day discharge notice to Resident #1's RP and the ombudsman. <BR/>This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, a disruption of care, and being discharged without alternate placement. <BR/>Findings Include:<BR/>Review of Resident #1's undated face sheet reflected a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Type 2 diabetes(a chronic condition that affects the way the body processes blood sugar), convulsions(involuntary muscle contractions), anxiety disorder(feelings of fear), Alzheimer's(memory loss), dementia(loss of memory).<BR/>Review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS Summary score of 1 indicated severe cognitive impairment.<BR/>Review of Resident #1's care plan dated 01-17-2023 revealed Resident #1 had a behavioral problem related to hitting another resident with interventions-divert attention such as ambulating, soft speaking, initiated seeking another facility for further evaluation and treatment, intervention as necessary to protect the rights and safety of others approach/speak in a calm manner, divert attention, remove from the situation and take to alternate location as needed, minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention such as ambulating, soft speaking. Resident #1 had a behavioral problem related to hitting, screaming, and cussing staff with interventions-anticipate and meet the resident's needs, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from the situation, and take to alternate location as needed, minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention such as ambulating, and soft speaking. Resident #1 had an impaired cognitive function/dementia/Alzheimer's or impaired thought process and required medication for diagnosis of Alzheimer's with interventions administer medications as ordered, communicate with the resident/family/caregivers, regarding the resident's capabilities and needs, and use the residents preferred name. Resident #1 had an ADL self-care performance deficit with interventions bathing(supervise as needed), Bed Mobility(supervision as needed), walking(provide supervision as needed), personal hygiene/oral care(the resident requires extensive assistance 1 staff participation with personal hygiene and oral care. Dressing(The resident requires extensive assistance 1 staff participation to dress, and toilet use(The resident requires the extensive assistance of 1 staff). Resident #1 used anti-anxiety medications, adjustment issues, anxiety disorder with interventions to educate the resident/family, and caregivers about risks and side effects, give anti-anxiety mediations ordered by the physician, side effects (mania, hostility, rage, aggressive, impulsive behavior, and hallucinations, monitor/record occurrence for behavior symptoms(pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. There was no care plan for discharge planning related to the facility not being able to meet the needs of Resident #1 and issuance of a 30-day discharge notice.<BR/>Review of Resident # 1's progress notes dated 02-24-2023 at 3:07 PM entered by the SW revealed she had been in communication with the local behavioral hospital all day regarding the resident's transfer. Local behavioral hospital staff stated They have it figured out as far as financially. However, the bed that was to be used by the resident is still in use, therefore resident is not able to be transferred today. Local behavioral hospital staff hoped that tomorrow will be better and will keep SW updated. SW attempted to call the resident's s mother to inform her, but there was no answer, and SW left a voicemail. Progress notes dated 03-08-2023 at 3:41 PM entered by SW revealed SW had been attempting to find a behavioral hospital to refer the resident to for medical behavior management due to the resident's increased agitation and combativeness. Both local behavioral hospitals of Clearlake are willing to accept, but both require a mental health warrant. SW called the County Justice of the Peace and was informed to call the county clerk's office, then the county attorney's office, then the local police department. None of the parties mentioned were able to help. SW called MHMR crisis team supervisor for advice. SW was again told that if it is because of dementia, they cannot issue mental health warrant. The crisis team supervisor suggested that the resident be sent to the emergency department and possibly get a warrant issued there. SW has informed DON and Administrator regarding this and will continue to follow up. SW also spoke to the resident's mother and sister to inform them of recent behaviors and attempt to refer out. Progress notes dated 03-09-2023 at 4:13 PM entered by the SW revealed SW was asked by DON to call MHMR in order to get the resident screened in order to be transferred to a behavioral hospital. SW called MHMR staff, but he was out of the office and asked that SW called the MHMR crisis hotline and speak to them. SW did this and completed the screening on the phone. SW was disconnected at the end of the call and attempted to call back, SW will continue to follow up with this. Progress noted dated 03-13-2023 at 2:37 PM entered by SW revealed Resident has been accepted at the local behavioral hospital in [NAME] for behavior management. SW has been in contact with the resident's family, and they are informed. SW provided the name, address, and phone number of the facility. SW also explained possible expectations for the family. Resident will be transported by city ambulance with an estimated arrival of 4 PM pick-up time. Progress notes dated 04-07-2023 at 3:10 PM entered by the SW revealed the SW was informed by the Administrator that [NAME] contacted her and informed her that the resident would be discharged on Monday and family will be picking her up. Approximately ten minutes later, the resident's sister called and explained the same. The resident's sister was understandably upset and voiced her concerns. She states she is feeling overwhelmed, unsure, lost, and abandoned. She feels that the facility should take the resident back but understands when SW explained it has gone to corporate at this point. SW again explained that it is not that we do not want the resident back, we are just concerned for her safety. SW explained that she had been looking for a memory care unit with no luck but will continue to look until placement is found. SW asked the resident's sister if she would be open to afford private pay. The Resident's sister states the family cannot afford private, but she is open to placement in the San [NAME] area. SW has reached out to the local behavioral hospital in San [NAME] and sent a referral packet. SW will continue to follow up with this. The Resident's sister mentioned that she is upset because she feels the resident should not have to pay as Fortress has not done anything for her since she has been gone and is continue not to. After hanging up, SW was informed that the resident will be refunded and will be calling the resident's sister with details. SW called the Resident's sister and informed her of this, to which she was pleased.<BR/>During an interview on 04-14-2023 at 10:15 AM with Administrator stated she sent out a 30 day discharge 4-12-2023 by certified mail and email to the RP. The administrator had not received a reponse or a confimation of receipt. The administrator stated the resident is being discharged due to her saftey and other residents. The administrator stated she emailed the local ombudsman 4-5-2023 to advised they were unable to accept Resident #1 back at the facility for concern of safety of other residents due to Resident # 1's behavior.<BR/>During an interview on 04-14-2023 at 11:59 AM with RP stated she received a discharge by email (unable to recall the date received as she had health issues going on at the moment)and she have not signed it as she is waiting on her daughter to go over it with her. RP stated she is having health issues herself and she is in hope of finding a placement for her daughter. The SW have been in contact with her to help her with finding placement for her daughter.<BR/>During an interview on 04-14-2023 at 12:30 PM with a case worker with a local behavior hospital stated Resident #1 was admitted to the hospital on [DATE]. The Psych nurse and Nurse practitioner have deemed Resident# 1 stable to return to the nursing facility. Resident # 1's insurance will no longer cover her hospital stay because she is not showing any behaviors. Clinical Notes have been sent to the facility and normally a stay for patients is between seven to fourteen days. Resident # 1 is not showing aggressive behaviors and has been sleeping. Resident # 1 aggressive behavior medications have been managed and was scheduled for discharge on [DATE]. The hospital sent the nursing facility all documents pertaining to Resident #1's discharge from the hospital.<BR/>During an interview on 04/14/2023 at 12:45 PM with the Administrator and DON stated the facility needed to provide documentation from the Psych doctor and nurse practitioner that Resident #1 is able to safely discharge back to the facility.<BR/>During an interview on 04-14-2023 at 1:00 PM SW stated she had been in contact with Resident # 1's RP and sister regarding trying to find placement for the resident. The SW stated she had contacted two facilities and those two facilities had denied Resident # 1 due to behaviors. SW stated the behavior facility needs to show that the resident is deemed safe to return to the facility.<BR/>During an interview on 04-14-2023 at 3:00 PM with Administrator stated she had spoken with corporate, and they agreed they will not take the resident back due to her behaviors. The administrator understood the deficiency of not allowing the resident to return to the facility.<BR/>Review of the email From the ombudsman dated 4-5-2023 revealed the ombudsman recommending the facility provide a discharge notice since the facility is effectively discharging the resident by not allowing her to return. The discharge notice should have been sent to the ombudsman and the RP on 4-5-2023.<BR/>Review of facility discharge or transfer to another facility not dated stated the facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. A resident's declination of treatment does not constitute grounds for discharge unless the facility is unable to meet the needs of the resident or protect the health and safety of others. If applicable, the facility will demonstrate that the resident or, if applicable, the resident representative, received information regarding the risks of refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident's needs or protect the health and safety of others. Notifications of Discharges for facility-initiated transfer or discharge of a resident, the facility will notify the resident, and the resident representatives of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman.

**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 in the facility with reasonable accommodation of each resident's needs for Resident #23.<BR/>Resident #23 call light was in Resident #26 bed tangled together.<BR/>This deficient practice could affect residents who needed assistance with activities of daily living and could result in needs not being met.<BR/>The findings were include:<BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #23 was [AGE] years old, admitted on [DATE] with diagnoses including Alzheimer's Disease with late onset, Essential(primary)Hypertension, Primary Generalized(osteo)Arthritis, Muscle waiting and atrophy, not elsewhere classified,unspececified site,musmbolismcle weakness(unspecified)contact with and (suspected)exposure to other viral communicable diseases, personal history of other venous Thrombosis and embolism, major depressive disorder, single episode without psychotic features hypermedia unspecified, Anxiety disorder unspecified ,other reduced mobility, Dysphagia, Oropharyngeal phase, Unspecified abnormalities, Unspecified lack of coordination, unspecified mycosis, and Difficult in walking, not elsewhere classified, Iron Deficiency anemia secondary to blood loss,Constipation unspecified Vitamin Deficiency Unspecified, Dermatitis unspecified<BR/>A record review of a care plan dated 06/23/2022 indicated Resident #23 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed.<BR/>A record review of Resident #23 MDS dated [DATE] indicated Resident #23 was understood and usually understood others. Resident #23 was cognitively intact with a brief interview for mental status BIMS score of 15. Resident #23 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>An Observation 6/20/2022 at 9:32 AM revealed Resident # 23's call light was in the bed with Resident #26 tangled together.<BR/>In an interview on 6/20/2022 at 9:35 AM Resident #23 stated she could not recall the last time she saw her call light. She stated when she needed something, she just goes and finds someone to help her. She stated it was important for her to have a call light because if she got sick she would be able to get help.<BR/>An observation and interview 6/22/2022 at 12:14 PM, observed Resident # 23's call light was tangled with Resident #26's call light. Sometimes the residents take each other's call lights. It is the staff responsibility to make sure the call lights are in view for each resident. She stated it is important for the resident to have possession of their own call light to be able to use when needed. Without call light in reach assistance of being needed will would not be met.<BR/>An interview 6/23/2022 at 10:55 AM, the DON revealed it is was the staff's responsibility to make sure the resident's call light was in reach. The DON stated they do not have a call light Policy for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one 1resident, (Resident #23) of 6 residents reviewed for resident rights. <BR/>Residents #23 did not have lower part of body covered when wheeled from room to the shower area. <BR/>This failure could place affected resident #23 and could place the remaining residents living in the facility at risk for diminished quality of life and increase risk of embarrassment. <BR/>The findings include:<BR/>Record review of a A face sheet dated 6/23/2022 indicated Resident #23 was [AGE] years old, admitted on [DATE] with diagnoses including Alzheimer's Disease with late onset, Essential(primary)Hypertension, Primary Generalized(osteo)Arthritis, Muscle waiting and atrophy, not elsewhere classified,unspececified site,musmbolismcle weakness(unspecified)contact with and (suspected)exposure to other viral communicable diseases, personal history of other venous Thrombosis and embolism, major depressive disorder, single episode without psychotic features hypermedia unspecified, Anxiety disorder unspecified , and other reduced mobility, Dysphagia, Orophanogel phase, Unspecified abnormalities, Unspecified lack of coordination, unspecified mycosis, Difficult in walking, not elsewhere classified, Iron Deficiency anemia secondary to blood loss,Constiipation unspecified Vitamin Deficiency Unspecified, Dermatitis unspecified.<BR/>Record review of aAn MDS dated [DATE] indicated Resident #23 was understood and usually understood others. Resident #23 was cognitively intact with a brief interview for mental statusBIMS score of 15. Resident #23 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an observation on 6/22/2022 at 12:09PM, revealed Resident #23 was being wheeled from room to the shower by CNA B with the lower private area being exposed.<BR/>During an interview on 6/22/2022 at 12:30PM, revealed Resident #23 did not know that her private area was not covered when she was going to the shower area. Resident #23 stated she is was shame to know that someone had seen her not being dressed.<BR/>During an interview on 6/22/2022 at 12:20 PM, CNA A stated she did not look to see if Resident #23 was covered when she took her to shower. She stated Resident #23 normally wear a long dress and she didn't realize she only had a t shirt on. She stated it was her error for not looking. she She was told bystated CNA B to her when going in the shower area that Resident #23 lower part of body was not covered when taking the resident to the shower. She states stated it was very irresponsible and this could cause a resident to be depressed knowing they were exposed.<BR/>During an interview on 6/22/2022 at 12:50 PM, CNA B stated she was wheeling Resident#26 to shower when she noticed that Resident #23 lower part of body was uncovered. CNA B stated that when CNA Ashe backed resident Resident #26 in shower that's when she visually seen Resident#23 being uncovered. CNA B know the importance of covering a resident when taking them to shower. Thisstated that could cause a resident to be shameful knowing they were exposed.<BR/>During an interview on 6/23/2022 at 10:55AM, the DON stated it is was the CNAs responsibility to make sure a resident is was covered when taking them to the shower area . She stated it is important to protect and follow the rights of each resident to avoid embarrassment to the resident.<BR/>A record review on 6/23/2022 of the facility's statement of Resident Rights dateds 11/28/2016 states stated a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 (Resident #s 23 and #26) of 6 residents reviewed for ADLs.<BR/>The facility did not provide Resident #23 with personal care services on 6/20/2022 and 6/22/2022. Resident # 23 had facial hair on chin and fingernails were long and dirty. The resident was not provided personal care services with showers on 6/20/2022 and 6/22/2022.<BR/>The facility did not provide Resident #26 with personal care services on 06/20/2022 and 6/22/2022. Resident #26 fingernails were long and dirty. <BR/>These failures could place 6 residents who were dependent on staff for personal care services at risk for embarrassment, infections, and discomfort.<BR/>Findings included: <BR/>Resident #23 <BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #23 was [AGE] years old, admitted on [DATE] with diagnoses including Alzheimer's Disease with late onset, Essential (primary) Hypertension, Primary Generalized (osteo) Arthritis and atrophy.<BR/>A Record review of a care plan dated 06/23/2022 indicated Resident #23 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed.<BR/>Record review of a care plan dated 6/23/2022 indicated Resident #23 Interventions included staff to check nail length, trim, and clean on bath day as necessary.<BR/>Record review of an MDS dated [DATE] indicated Resident #23 was understood and usually understood others. Resident #23 was cognitively intact with a brief interview for mental status scoreBIMS of 15. Resident #23 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an interview on 6/20/2022 at 9:32AM, Resident #23 stated she wanted her nails trimmed shorter and her hair shaved from under the chin. Resident #23 stated what could be done about it as it has always been like that. She stated hair was not supposed to be on her face and she feel embarrassed about it and want something done about the facial hair on the chin. it .<BR/>During an interview on 6/20/2022 at 12:258PM, CNA A said she was the shower aide for the facility. The residents received showers Monday, Wednesday, and Fridays. She stated she had been in serviced and know the She stated she know the shower protocol and was to follow the service plan of each resident. CNA A stated the nails and hair under the chin were not addressed for the resident at shower. CNA A could not give an exact reason to why the service was missed but stated it could affect the resident emotionally on appearance if grooming is was neglected.<BR/>During an observation on 6/22/2022 at 1:10PM, Resident #23's nails were dirty, nails, long, and had hair under chin. <BR/>Resident #26<BR/>A Record review of a face sheet dated 6/23/2022 indicated Resident #26 was [AGE] years old, admitted on [DATE] with diagnoses including St Elevation(Stemi)Myocardialincluding Myocardial infraction of unspecified site Dependence On Renal Dialysis , Dysphagia following cerebral infraction, cognitive communication deficit, Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side, anemia, heart failure, unspecified, altered mental status and Gastic Ulcer, <BR/>A Record review of a care plan dated 06/23/2022 indicated Resident #26 had a self-care deficit and the interventions included to assist with personal hygiene as require: hair, shaving, oral care as needed. <BR/>An Record review of a MDS dated [DATE] indicated Resident #26 was understood and usually understood others. Resident #23 26 was cognitively intact with a brief interview for mental status scoreBIMS of 14. Resident #26 required extensive assist for mobility, toileting, personal hygiene, and bathing. <BR/>During an observation and interview on 6/20/2022 at 9:59AM, Resident #26's nails appeared long and dirty. She stated she liked her nails short and not long she could not recall the last time someone has cut her nails. She stated with her nails being long she may scratch herself and cause injury.<BR/>During and observation 6/20.2022 AT 9:59AM the resident's nails appeared long and dirty.<BR/>During an interview on 06/212022 at 12:14 p.m, CNA B said she was the shower aide for the facility. The residents received showers on Monday, Wednesday, and Fridays. She stated she knew the shower protocol and was to follow the resident's care plan. She stated she is inserviced on showers. She stated Resident #23 was showered on 6/20/2022 and the nails were simply missed during shower. CNA B knew the importance of stated nail care for the residents was to avoid injuries.<BR/>During an interview on 6/22/2022 at 1:10PM, the DON states stated the shower aides are to follow the care plan to address personal hygiene needs of each resident and it is important for the resident's hygiene.<BR/>Review of facility's Dressing and Personal Grooming Policy dated 2003 indicated the purpose of this procedure were to assist the resident as necessary with dressing and undressing to promote cleanliness.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #15) of five residents reviewed for quality of care. <BR/>-The facility failed to provide treatment and care to Resident #15 who had a 41.9-pound weight gain with a diagnosis of chronic kidney disease who reported increased swelling in his limbs and had not been examined by a physician or physician assistant since 03/29/2022 following his admission to the facility on [DATE]. <BR/>-The facility failed to notify Resident #15's physician when he experienced high blood pressures up to 190/110 and increased edema. <BR/>-The facility failed to have parameters in place for notification to physician for nursing staff regarding high blood pressure and failed to have standing orders for treatment of intermittent high blood pressure. <BR/>-The facility failed to ensure they had the proper size blood pressure cuff to ensure accurate blood pressure readings in Resident #15 following a high result from a wrist cuff. <BR/>-The facility failed to properly address Resident #15's health complications from 05/30/2022 to 06/20/2022 and subsequently retaliated against Resident #15 by having him sign a Negotiated Risk Agreement effectively blaming him for his health problems related to his non-compliance with his diet. <BR/>These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>These failures placed residents at risk for heart failure, kidney disease, increased disease complications, hospitalization, and death. <BR/>Findings included:<BR/>Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. <BR/>Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Resident #15 was not noted to have gained or lost weight in the last month or six months. <BR/>Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. <BR/>Review of Resident #15 Physician Orders dated 04/06/2022 revealed Resident #15 to be ordered Regular Consistency/Texture, low concentrated sweets diet with larger portions. <BR/>Review of Resident #15 Physician Order dated 03/22/2022 revealed Resident #15 to be ordered the following blood pressure medications and instructions:<BR/>-Carvedilol 25 MG - Give 1 tablet by mouth times per day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse.<BR/>-Hydrochlorothiazide Capsule 12.5 MG - Give one capsule by mouth one time a day as related to high blood pressure.<BR/>-Lisinopril Tablet 20 MG - Give one table by mouth one time a day as related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse.<BR/>-Nifedipine ER Tablet 60 MG - Give one table by mouth one time a day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse.<BR/>There were no high blood pressure parameters defined in the physician orders for Resident #15. <BR/>Review of Resident #15 EMR for Physician Progress Notes dated 03/22/2022 through 06/21/2022 revealed a physician progress noted completed by PHYS ASST on 03/29/2022. There were no other physician progress notes in Resident #15's EMR.Review of Physician Progress note dated 03/29/2022 written by PHYS ASST revealed Resident #15 was admitted to the facility after a tornado damaged his previous facility. Resident #15 noted to have prior diagnoses of stroke with right sided hemiplegia (partial paralysis), Type 2 Diabetes Mellitus, high blood pressure and chronic kidney disease. His weight was noted at 310.6 pounds and he was noted to have mild peripheral edema and right lower extremity edema. There was no note that the right upper extremity had edema. <BR/>In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes into the EMR for all residents. She stated Resident #15's EMR should be current with no missing physician progress notes. She stated she would double check that there were no pending notes that needed to be uploaded. She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. <BR/>Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed:<BR/>03/24/2022 - 310.6 pounds on the wheelchair scale<BR/>04/01/2022 - 314.6 pounds (scale unknown)<BR/>05/10/2022 - 314.8 pounds (scale unknown)<BR/>06/16/2022 - 356.7 pounds (scale unknown)<BR/>Review of Resident #15 Nursing Progress note dated 06/16/2022 at 10:27 AM, written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified.<BR/>In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. <BR/>In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with family members, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. <BR/>In an interview on 06/23/2022 at 2:45 PM, RP T stated she was the family member of Resident #15 and was on the phone with him when he was short of breath, coughing and having chest pain at the end of May (2022). She said Resident #15 said he had fluid on and did not feel good and felt like he could not breathe. She said she called to the nurse's station because no one was answering his call light. The nurse said she would go check on Resident #15. She said she was back on the phone with Resident #15 when the nurse checked on him and heard Resident #15 tell her the same symptoms. She said Resident #15 asked to see a doctor or go to the hospital and the nurse responded that if if he wanted to go to the hospital he would have to call 911 himself. She said the nurse then left the room. She said it was shift change and she called back to speak with new nurse, and she checked on Resident #15 and found his oxygen levels to be low and started him on oxygen. She said she was grateful the nurse did something for the resident and the other nurse refused to help. She said she could not remember that nurse's name. She said she checked on Resident #15 the next day and was told he had pneumonia. She said they called yesterday and told her Resident #15 had a large weight gain in one month and said it was because of large meals and too many snacks from the vending machine. She said they told her the PHYS ASST started him on fluid pills. She said she asked, if the weight gain was from snacks why would fluid pills help? and they had no answer. <BR/>In an interview on 06/21/2022 at 04:25 PM, CMA G stated she weighed Resident #15 on 06/16/2022 using the wheelchair scale in the therapy room. She stated she did not re-weigh him to confirm the weight. She stated she gave the ADON the weights for the residents and she manually entered them into the EMR. She stated she did not realize there was a significant difference in the previous weight because she did not have his record in front of her when weighing him and the other residents. She stated he did tell her about the increase swelling his right arm, but she thought that was his baseline due to his stroke that affected his right arm. <BR/>An observation 06/21/2022 at 4:28 PM, Resident #15 was weighed using the mechanical lift scale. His weight was 353.0 pounds, an increase of 38.2 pounds since 05/10/2022.<BR/>In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant sees all of their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She stated she was not sure of when he rounded on Resident #15 since admission. When asked for physician progress notes for Resident #15 (because there was only one uploaded into Resident #15's EMR), she stated she would check with their medical records assistant for additional physician progress notes. She stated Resident #15 was seen by the physician assistant when he was first admitted . She stated she was aware of the large weight gain in Resident #15 from May to June, but he was non-compliant with his diet and ate snacks from the vending machines, larger portions at meals and his family brought food from the outside in large portions. She stated his diet was the cause of the weight gain and the dietitian was notified to conduct an assessment. <BR/> In an interview on 06/21/2022 at 4:00 PM, the DON stated the weight for Resident #15 may have been an error because his weight in April and May were done using the mechanical lift scale and the weight on 06/16/2022 was done using the wheelchair scale. She said she would have him re-weighed using the mechanical lift scale. She said Resident #15 was non-compliant with his diet and ate all meals with larger portions and snacks from the vending machine all day. She said she had not spoken to him regarding the edema in his arm and leg. She said the swelling was normal for him on his right side because he had a stroke on his right side that caused paralysis and affected blood flow which resulted in the swelling. She said the swelling was normal for him and there had not been a change that she knew of in his right arm and leg from baseline. She said Resident #15 was seen by PHYS K's nurse practitioner via tele-health. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. <BR/>In an interview on 06/21/2022 at 4:35 PM, the DON stated Resident #15 decided to switch to the medical director as his physician and the PHYS ASST would see him the next morning to assess and evaluate the weight gain. <BR/>In a follow-up interview on 06/23/2022 at 2:16 PM, Resident #15 said the DON made him sign a document that he would not eat so much. He said he told them he had fluid on his body, and they told him that maybe if you did not eat so many snacks you wouldn't have so much fluid. He said he did not understand why they kept blaming snacks for his swelling when the PHYS ASST told him the swelling was due to fluid related to him either having congestive heart failure or decreased kidney function. He said he did not understand why they did not want to help him see a doctor when he first began complaining about the fluid when he was short of breath and told him he would have to call 911 himself. <BR/>Review of Resident #15 Negotiated Risk Agreement signed 06/22/2022 at 3:20 PM by Resident #15 and the facility. The summary of Resident's Current Health and Potential Risk were 36 pound weight gain in one month, edema, hypertensive crisis, diabetic crisis, repeated stroke death. The resident's desire or preference was noted as to eat, drink and smoke cigarettes as he desires without diet restrictions - resident eats double portions, seconds, and take away trays from kitchen as well as outside foods and vending machine. The final agreement with Resident #15 was he agreed to to try eating only double portions but not seconds or take away trays. Agrees to try to smoke less. Agrees to try to stay away from junk foods. <BR/>In an interview on 06/23/2022 at 2:03 PM, RNC A stated they had Resident #15 sign the NRA because he was not following his diet and subsequently gained 36 pounds. She said they asked him to limit his portions to stop the weight gain. When asked if the weight could be due to edema from complications of his health conditions, she responded the resident needed to control his portions to reduce his weight gain. When asked if his diagnosis of chronic kidney disease, and a possible decline in kidney function could have caused fluid retention and edema, she replied she was not aware of Resident #15 having chronic kidney disease as it was not on his diagnosis list in the EMR. When asked why it was not on his diagnosis list in the EMR when it was on his physician progress notes and history and physical, she did not know. <BR/>In an interview on 06/23/2022 at 2:10 PM, the ADMIN stated she wanted the doctor to stop the larger portions for Resident #15 because he was eating too much and that caused the weight gain. She said he ate two snacks at activities and would have two ice creams at ice cream socials which likely caused the weight gain. When asked if she thought he was eating greater than 14,000 calories per day consistently to be able to gain that much weight so fast, she said she did not know and was not a doctor, nurse or dietitian. <BR/>In an interview on 06/23/2022 at 1:36 PM, the RD stated she was notified of Resident #15's weight gain and planned to complete an assessment when she returned to the facility next week. She stated the ADON said he gained 40 pounds. She asked the ADON if Resident #15 had fluid on legs and arms and the ADON said he ate a lot at meals, ate snacks from the vending machine, and had food brought in from the outside that caused the weight gain. She said she saw Resident #15 was on a mild diuretic. She said had she known about the edema she would have recommended they re-weigh Resident #15 and assess for edema. She said the doctor would have been consulted for further orders regarding edema and the need for a stronger diuretic. She said she did not know why Resident #15 was not assessed for edema and his doctor notified of his weight gain and edema. She said it was not likely that Resident #15 gained 40 pounds in a month and all of it be related to excess calories causing increased fat stores. She said it was more likely he had fluid on and needed a diuretic. She stated she was not aware that Resident #15 had chronic kidney as it was not on his list of diagnoses and did not know why it was not on his diagnoses list. <BR/>Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor.<BR/>In an interview on 06/24/2022 at 3:14 PM, LVN J stated in late May she was called by Resident #15's responsible party and they reported Resident #15 was having respiratory problems. She said she assessed Resident #15 and found him to be breathing heavy and his oxygen levels were low. She said started oxygen on him and paged the on-call doctor. She said she received orders for Resident #14 for nebulizer treatments and with the oxygen and nebulizer treatment his symptoms improved. She said he required oxygen for several days all day and then only at night. She said she was not sure if any physician or anyone followed up on his symptoms or resolution of pneumonia. She said Resident #15 did report increased swelling or edema but was not sure if anyone was addressing it with his attending physician. She stated she was unaware of Resident #15 having a large weight gain from May to June. She said that would likely fit with his elevated blood pressures, respiratory issues and edema. <BR/>Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start doxycycline 100 MG BID (twice per day) for seven days. <BR/>Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 <BR/>At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C <BR/>At 0135 [1:35 AM]Pulse 87, 02 97% <BR/>At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C <BR/>At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, <BR/>At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C <BR/>At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C <BR/>At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. <BR/>[family member] called this morning about the change in condition and the treatment initiated. Would like update from of us.<BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN D revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. <BR/>In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered . He did not remember being contacted about increased edema overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the edema, weight gain and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having chronic kidney disease. He stated he had not physically examined Resident #15 since he was admitted to the facility. <BR/>Review of Resident #15 Physician Progress note dated 06/21/2022 revealed the MED DIR wrote a progress note after Resident #15 caught him in the hallway. The note referred to labs drawn 10 days prior to the date of the note. There wereno labs drawn in the previous 10 days for Resident #15. It noted Resident #15 to have edema on his right arm and right leg likely due to lack of movement as Resident #15 was partially paralyzed due to a stroke two years prior. This is a stable, chronic issue. Resident #15's high blood pressure was noted as stable, continue present prescriptions and monitor. <BR/>In an interview on 06/23/2022 at 3:10 PM, RNC B was asked to provide a copy of the labs MED DIR referred to in his note on 06/21/2022. RNC B stated those labs did not exist as Resident #15 had not had labs since 03/25/2022. He said he did not know what MED DIR was referring to in his note. When asked why MED DIR wrote the progress note and did not address the 36 pound weight gain, he did not know. <BR/>In an interview on 06/23/2022 at 3:21 PM, MED DIR stated he saw Resident #15 briefly on 06/21/2022 because Resident #15 had a question regarding the swelling in his right arm and leg. He said the swelling was likely due to Resident #15 not being able to move his right arm and leg because of a stroke that caused partial paralysis. When asked if the swelling in Resident #15's arm and leg accounted for a 36 pound weight gain in one month, he responded that is the same resident that has the swollen arm and leg? I thought they were two different residents. He said the 36 pound weight was fluid retention related to an underlying health condition either decreased kidney function or congestive heart failure. He said Resident #15 needed to be seen by a cardiologist to rule out congestive heart failure. He said 10 pounds of the weight gain may be due to excessive calories, but not 36 pounds. He said the respiratory distress Resident #15 experienced at the end of May was possibly related diastolic heart failure and Resident #15 should have been evaluated by a physician. He stated an echocardiogram was needed to look at Resident #15's heart. He stated he and his physician assistant would be following Resident #15 moving forward and refer him to a cardiologist. <BR/>In an interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food. She said she was not aware that when Resident #15 first complained of respiratory distress in May that he was told he would have to call 911 himself. She said a physician should have examined and assessed Resident #15 sooner. When asked why the facility had Resident #15 sign the negotiated risk agreement within an hour of the IJ being called, she said yeah she could see now that the timing could have been better and could be seen as punitive towards Resident #15. When asked why they did not have him sign it when they saw him eating all the snacks, she said she did not realize until the weight gain and the complications that they were a problem. When asked why another non-compliant resident with CHF who was sent out to the hospital for high fluid gains was not asked to sign an NRA, she said she did not know, and they should probably have her sign an NRA as well. She said she knew the facility had the extra-large cuffs in the past and was not sure when or how they went missing. She said they had one in the crash cart and should have used it until the new cuff was bought to take Resident #15's blood pressure. She stated she did not know why Resident #15 did not have upper parameters for his blood pressure except it was chaotic when they evacuated the sister facility that was damaged by a tornado and some areas were dropped. She said they have since added parameters and PRN medications for high blood pressures for Resident #15. She said the nurses should have been documenting for blood pressures &gt; 160/110 an intervention or a re-check. She said they likely re-took the blood pressure with a manual cuff and it wasn't as high, or they administered his morning medications and re-checked his blood pressure, and it was normal. She said they should have been documenting any out of parameter blood pressure and noted the intervention. <BR/>In an interview on 06/24/2022 at 4:15 PM, the ADMIN stated she was not a nurse and did not know much about Resident #15's disease process, edema and weight gains. She said they attributed to high meal and snack intake. She said they signed the NRA with him so he would know his daily choices have an effect on his health. She said she was not aware of him experiencing swelling and fluid gains. She said she was not aware of his CKD diagnosis and was not sure how that affected his weight gain. She said she did not think the NRA was punitive, it was done to educate the resident. She said they had not previously had him sign it because RNC A recommended after the IJ was called. She said a physician should have seen Resident #15 following the respiratory issues and excessive weight gain. She said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. <BR/>In an observation and interview on 06/22/2022 at 10:19 AM, the PHYS ASST completed a physical exam and assessment of Resident #15. Resident #15 stated to the PHYS ASST he had not seen a PHYS K since admitted to the facility. The PHYS ASST said she saw the swelling in Resident #15's right arm and right leg. Resident #15 stated he felt like he had swelling in his abdomen. He reported the shortness of breath in late May of 2022 to the PHYS ASST and she stated she ordered the chest x-ray which showed pneumonia. She stated she was not told Resident #15 was also complaining of having fluid on and swelling. Resident #15 reported to the PHYS ASST he needed oxygen at night and in the past at his previous facility he did not need oxygen routinely. He said he has not been able to wear a shoe on his right foot because of the swelling in at least 2 months. He stated he had a family history of having fluid on their heart and lungs. The PHYS ASST asked Resident #15 was on fluid pills in the past, and he said yes at his previous facility but not since being admitted here. He said he was told his kidneys were not working all the way, but they were just going to watch it. She said she would have lab work done to check his kidneys and start him on a fluid pill. Resident #15 did not know why they stopped the fluid pills. The PHYS ASST stat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #49) of three residents reviewed for pressure ulcers. <BR/>-The facility failed to ensure proper positioning to prevent pressure ulcer development in Resident #49 who was observed to have her knee leaning up against a wall.<BR/>-The facility failed to ensure Resident #49 wore her podus boots to prevent further development of pressure ulcers or further decline of her current pressure ulcers injuries while in bed.<BR/>-The facility failed to ensure Resident #49 had the wedge between her knees while in bed to prevent skin breakdown. <BR/>These failures could result in residents experiencing further skin breakdown, pressure ulcer development or decline and additional complications related to pressure ulcers. <BR/>Findings included:<BR/>Review of Resident #49 face sheet dated 06/24/2022 revealed Resident #49 was a [AGE] year old female admitted to the facility on [DATE] with a diagnosis of dementia with Lewy bodies (type of dementia characterized by changes in sleep, behavior, cognition, movement and regulation of automatic bodily functions).<BR/>Review of Resident #49 quarterly MDS assessment dated [DATE] revealed Resident #49 to have a BIMS score of 3 to indicated impaired cognition. Resident #49 required extensive assistance by at least two people for bed mobility. Resident #49 had one unstageable pressure injury upon admission and three deep tissue injuries present on admission. Treatments noted for Resident #49 included pressure relieving device for bed, nutrition intervention, pressure ulcer care, application of non-surgical dressings and application of ointments/medications. <BR/>Review of Resident #49 care plan dated 04/04/2022 revealed Resident #49 was admitted with an unstageable pressure ulcer on her sacrum, right hip and left medial knee with interventions including the use of an air mattress, following facility policies for treatment and prevention of skin breakdown and monitoring the wounds for healing weekly. The care plan noted Resident #49 had a deep tissue injury to her left heel , left lateral foot and right heel with interventions including podus boot to affected feet, nutrition interventions, monitoring for wound healing weekly and administer medications as ordered. Resident #49 had a self-care deficit for ADL's and required one person assistance for bed mobility. <BR/>Review of Resident #49 physician orders dated 05/11/2022 revealed Resident #49 to wear podus boots while in bed ordered for DTIs on both feet. <BR/>An observation on 06/21/22 at 3:04 PM revealed Resident #49 was in bed with right knee leaned against the wall. Resident #49 had a cushion between her legs noted to have an unstageable pressure ulcer to inside of left knee. Resident #49 noted with foot protectors in the chair across the room. Resident #49 noted with unstageable DTI to right heel and stage III DTI to outside left foot and Stage IV pressure ulcer noted to coccyx area . The wounds were clean without slough. Observation of right hip revealed a pressure ulcer 3cm x 2cm with slough there was no dressing on the wound. <BR/>In an interview on 06/21/2022 at 3:10 PM, LVN E, the treatment nurse stated the new pressure ulcer on Resident #49's left medial knee occurred over the weekend probably because they were not putting the cushion between her legs. LVN E stated Resident #49 should have the podus boots on at all times when in bed. She stated the areas appear on the resident overnight due to her declining health. LVN E stated she did Resident #49's treatment this morning and the area on Resident #49's hip was unstageable with a scab and the scab must have come off. She stated she would call the MD and update him and get a new order for the hip wound. She stated Resident #49's knee should not be up against the wall as it could develop a pressure ulcer there. <BR/>In an interview on 06/23/2022 at 12:10 PM, CNA L stated he re-positioned Resident #49 every two hours and made sure her wedge is was between her legs. He stated when Resident #49 was in bed she had to have the podus boots on to prevent further skin breakdown. He said Resident #49 was not able to change positions without assistance. He said he has not observed Resident #49 to move or re-position herself. He stated Resident #49's knee should not be leaned against the wall because it could cause a pressure ulcer. He stated he received training in the prevention of pressure ulcers. <BR/>In an interview on 06/23/2022 at 12:15 PM, the PHYS ASST stated Resident #49 had unavoidable pressure ulcers that were expected due to other health conditions. She stated it was necessary to continue best practices to prevent additional skin breakdown or worsening pressure ulcers. The PHYS ASST stated Resident #49 should have the wedge in place between her knees and the podus boots on when in bed. She stated Resident #49 required re-positioning every two hours and her knee should not be leaned against the wall as it could cause a pressure ulcer. <BR/>In an interview on 06/24/2022 at 4:00 PM, the DON stated Resident #49 should have had her podus boots on while in bed as ordered by the physician. She stated she was unaware of the new skin issue on her knee related to not having the wedge between her knees. She said the wedge should be used when Resident #49 was positioned on her side to prevent skin damage. She said Resident #49's knee should not have been leaned against the wall as it could have caused a pressure ulcer. She said they moved her away from the wall when she was positioned on her right side to ensure her knee was not against the wall. She said they did not have a policy for pressure ulcer prevention and treatment but followed professional guidelines. <BR/>Review of the facility's Turning a Resident in Bed Policy (undated) revealed the purpose was to provide comfort, prevent skin irritation and breakdown and to promote good body alignment. Instructions included placing a small pillow between his knees to prevent skin irritation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision.<BR/>The facility failed to provide safe transport for Resident #1 on 05/27/25 which resulted in a fall and Nondisplaced fracture of the proximal fibular metaphysis of the left knee.<BR/>This failure could result in serious injury such as a left knee fracture and a reduced quality of life .<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated 06/02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included a left proximal fibular fracture (a break in the fibula bone, located on the outside of the lower leg, near the knee, often caused by twisting or blunt force injuries to the leg or foot), dementia (deterioration of brain and memory loss), diabetes mellitus type 2, rheumatoid arthritis (auto-immune disorder affecting major joints) , major depressive disorder, hypertension, and anxiety . <BR/>Record review of Resident #1's care plan, revised 05/28/25, reflected,<BR/>Resident #1 had a skin tear to right shin and right knee, and sustained a left knee fracture (left proximal fibular metaphysis) related to fall with interventions of splint to left knee, and teach the purpose of and the procedure for performing isometric and flexion/extension exercises, and pain treatment as indicated by MD. The care plan further reflected Resident #1 was at risk for trauma that may have a negative impact, related to a van incident. Interventions included a Licensed Mental Health Provider, consult with family regarding her condition, identify situation/event/images that trigger recollections of the traumatic event and limit Resident #1's exposure to these as much as possible, monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, mental health provider, and physician. The care plan further reflected Resident #1 had a potential for uncontrolled pain due to fracture of her left knee. Interventions included administration of analgesia per physician orders, and give &frac12; hour before treatments or care, anticipate her need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.<BR/>Record review of Resident #1's Quarterly MDS, dated [DATE] , reflected a BIMS score of 04, which indicated a moderate to severe cognitive impairment. Resident #1 required extensive assistance for bed mobility, transfers, and toilet use. She required the assistance of two people for transfers between surfaces.<BR/>Record review of Resident #1's Physician Order Summary Report, dated 06/02/25, reflected a 20-inch Universal Basic Knee Splint for stabilization of left fibula fracture, and ensure splint is in right place, patient able to perform weight bearing as tolerated while her knee was immobilized. The Order Summary Report further reflected Tramadol 50mg 1 tablet by mouth three times a day for pain, and every 6 hours for moderate pain, Psychiatry to evaluate and treat, and skin tear to right and left knee - cleanse with normal saline and pat dry, apply Xeroform and cover with gauze island dressing every day shift every Monday, Wednesday, and Friday, and as needed.<BR/>Record review of Resident #1's incident report, dated 05/27/2025, at approximately 1:30 PM, reflected the following, Resident #1 was being transported to a doctor's appointment. Driver A braked for a red-light resident slid out of wheelchair scraping knees, received a skin tear and a cut toe. Incident happened right by doctor's office parking lot. Doctor's staff cleaned and bandaged cuts and scrapes. Assessment conducted on 05/27/25 at 5:50 PM reflected Resident #1 had bruising to bilateral upper extremities, skin tear left knee, left upper extremity, abrasion right knee, moisture skin damage sacrum, and irritation to great right toe. Resident #1 was sent to the hospital for X-rays. Driver A was suspended immediately, and van was out of service until all drivers had been re-in serviced and safety check was done on all van equipment. Facility notified the responsible party and the nurse practitioner. <BR/>Record review of hospital records with an admission date/time of 05/27/25 at 09:36 PM and discharge date /time of 05/28/25 at 03:23 AM reflected, Resident #1 was a [AGE] year-old female presenting to the ED for evaluation of a fall that occurred today at approximately 4:00 PM. Resident #1 reported she was riding in a transport van when Driver A forcefully pressed the brakes, launching Resident #1 out of her wheelchair. Resident #1 landed on the vehicle floor and suffered impact to both knees. Associated symptoms included bilateral knee pain and mild neck pain. Denied back pain, chest pain, cough, congestion, rhinorrhea (runny nose), or headaches. There were no other complaints at this time. <BR/>X-ray Right Knee 3 Views reflected:<BR/>1. <BR/>No acute osseous abnormality.<BR/>2. <BR/>Severe tricompartmental osteoarthritic changes.<BR/>X-ray Left Knee 3 Views reflected:<BR/>1. <BR/>Nondisplaced fracture of the proximal fibular metaphysis.<BR/>2. <BR/>Moderate tricompartmental osteoarthritic changes.<BR/>3. <BR/>Possible soft tissue wound anterior to the patella.<BR/>Narrative: This patient is a pleasant non-ambulatory [AGE] year-old female who was in a transport van today and was in her wheelchair and the transport driver stopped abruptly and the patient fell from her wheelchair. Patient reporting bilateral knee pain. Patient with report of lower cervical and upper thoracic discomfort. Imaging showing no acute abnormalities of the head neck chest abdomen or pelvis. Patient with notable proximal fibular fracture on the left. X-ray of the ankle found to be unremarkable. Patient placed in a knee immobilizer. Given referral to orthopedics. Patient discharged home. At time of discharge patient is pain-free.<BR/>Diagnosis: Closed left fibular fracture .<BR/>Interview on 06/01/25 at 3:25 PM with the DON, who stated she had not been able to get Driver A to answer the phone since 05/27/25, and Driver A had been a no call/no show for CNA duties since the day of the van incident. The DON stated the facility conducted re-training on transporting residents in the van, and anyone who was not re-trained was not driving. She stated in the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. The DON further stated Resident #1 stated Driver A had slammed on the brakes and she slid out of the wheelchair onto her knees.<BR/>Interview on 06/01/25 at 3:15 PM with Driver B revealed she worked in Housekeeping and was also a van driver. Driver B stated she had received training on 05/28/25 that included inspecting the vehicle inside and out every week, and to check acceptable or document if there are repairs needed on the form and submit to Administration and Corporate. <BR/>Telephone interview on 6/02/25 at 07:15 AM, Driver A stated she received 30 minutes of training from another van driver before she drove the van herself. Driver A stated she had worked for the facility for 4 months. She stated she thought Resident #1 had been up too long on the day of her appointment. Driver A stated Resident #1 had been to her therapy session that morning, and was up for lunch, and then went to her doctor appointment in the early afternoon. Driver A stated she thought Resident #1 became fatigued and started slipping out of her wheelchair . Driver A stated she had all of the straps and hooks on to secure the wheelchair in the van, and the seat belts were secured on the resident for resident safety. Driver A stated there were no witnesses riding in the van with her, other than Resident #1's RP who had met them at the doctor's appointment. Driver A stated the RP met them at the doctor's appointment and had entered the van to assisted in getting Resident #1 back up and into the wheelchair . <BR/>Interview on 06/02/25 at 2:14 PM with MAINT revealed on the interior of the van the 4 black straps with hooks were to secure the wheelchair in place, and the red seatbelts were to secure the resident in a wheelchair and were to go across the resident's chest and across the resident's lap. MAINT demonstrated how the seatbelt would secure a resident in a wheelchair once the 4 straps and hooks secured the wheelchair in place. MAINT stated he was up to date on the transport van maintenance, and he had looked at the Vehicle Inspection Reports and the van was in good working condition. He stated he looked at the transport van seatbelts and wheelchair straps after the incident and saw no issues. <BR/>Interview on 06/02/25 at 4:42 PM with the RP, who stated Driver A had asked her to hold the wheelchair and then Driver A lifted Resident #1, and the RP pushed the wheelchair forward under Resident #1's bottom so Driver A could get her back in the wheelchair . The RP stated Resident #1was seeing the orthopedic surgeon on Wednesday, 06/04/25. The RP believed Resident #1 had not been strapped in the wheelchair since she went forward on her knees and hit her head on the backside of the driver's seat. The RP further stated Resident #1 told her when Driver A turned, she slammed on her brakes, and that was when she fell out of the wheelchair. <BR/>Interview on 06/02/25 at 5:04 PM with Resident #1 revealed she knew something had happened to her, but she was not able to recall all the events. She stated she was having pain in her left knee and pointed to the left knee with a brace on it. Resident #1 stated Driver A slammed on the brakes and she remembered sliding out of the wheelchair and landed on her knees, and she did not remember too much after that. Resident #1 stated she did not remember if there was a seat belt on her or not. Resident #1 stated she had an appointment with a doctor who would check on her knee tomorrow, and the RP would be going along. <BR/>Record review of a statement from Resident #1, dated 05/27/25, included in the facility investigation reflected, Resident #1 stated that she slid out of her wheelchair while in the back of the van. She stated that she hit the back of the driver seat, and her knees went under her. Resident #1 stated that Driver A then attempted to help her but was unsuccessful due to how she was positioned. Resident #1 then stated that when she stopped, Driver A asked her RP who met them there to assist her in helping her back into the wheelchair. Resident #1 stated to ADON , during this statement, that at the time she had no pain but that she felt a slight tingling and burn just a tad bit but stated that she was having no pain when asked to rate pain. Resident #1 stated that the nurse at the doctor assessed her knee and cleaned it up and applied bandages. Educated Resident #1 on pain assessments and assessed her knees as well. Resident #1 stated that it was not that bad. Informed resident that we will send for X-ray of knees, and she said OKAY.<BR/>Record review of In-service conducted on 05/27/25 for staff who transport or assist with transporting residents in the van on the following (with return demonstration): Staff members not in-serviced will not transport residents.<BR/>1. <BR/>How to safely load and unload residents in the van using the lift<BR/>2. <BR/>Properly securing a resident in the van:<BR/>Ambulatory resident - securing with seat belt.<BR/>Non-ambulatory resident - securing the wheelchair and the resident.<BR/>Record review of the Vehicle Inspection Report dated 05/28/25 reflected the following relevant items were checked for the interior of the vehicle:<BR/>Instruments, gages, horn, and warning lights working properly.<BR/>Floors, seats, doors, and steps all clean and free of debris/stains<BR/>Seat Belts clean and in good working condition<BR/>Wheelchair Tie-Downs inspected and working properly.<BR/>Summary of the report reflected the van and equipment in good working condition.<BR/>Record review of In-service, conducted on 05/27/25, reflected, Resident involved in a van incident such as slipping out of the chair, tipping back in the chair, or hitting head, the transported should immediately stop and call 911, notify the Administrator and/or the DON immediately if you are off the property. Do not move the resident. If you're on the property immediately go, get a nurse to assess the resident. <BR/>Record review of the Employee Auto Training Handbook - Vehicle Inspection Report, dated 05/28/25, reflected the vehicle interior (including the seatbelts clean and in good working condition), vehicle exterior, fluid levels, and emergency equipment were acceptable, and the van and equipment were in good working condition.<BR/>Record review of the undated Employee Auto Training Handbook reflected,<BR/>The Driver Training Handbook is a statement of company and expectations as it pertains to transport vehicles, procedures to ensure resident safety and to promote safe driving practices.<BR/>Employee safety responsibilities<BR/>1. <BR/>Observe all organization safety and health rules and apply the principles of accident prevention in your day-to-day duties.<BR/>2. <BR/>Report any job-related injury, illness, or property damage to your supervisor immediately.<BR/>3. <BR/>Report any hazardous conditions and unsafe acts to your supervisor promptly.<BR/>4. <BR/>Follow proper lifting procedures always.<BR/>5. <BR/>Whenever driving an organization vehicle or personally owned vehicle for organization business seat belts must be used.<BR/>The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical care of each resident was supervised by a physician for one (Resident #15) of five residents reviewed for supervision of medical care by a physician.<BR/>The facility did not ensure Resident #15's physician examined and assessed Resident #15 upon a significant change in condition following Resident #15 having intermittent high blood pressures, shortness of breath, chest pain, and a 41.9-pound weight gain in 36 days. <BR/>These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This failure could affect residents who had a change in condition by not ensuring that residents' care was provided by a physician who was knowledgeable of their current health status changes.<BR/>Findings included:<BR/>Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. <BR/>Review of Resident #15 quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate he had intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. <BR/>Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. <BR/>Review of Resident #15 Physician or Non-Physician Provider (Nurse Practitioner or Physician Assistant) Visits dated from 03/22/2022 through 06/20/2022 revealed Resident #15 was seen these following dates:<BR/>-03/29/2022 by PHYS ASST upon admission<BR/>-05/05/2022 by nurse practitioner via tele-health <BR/>Review of Physician Progress note dated 03/29/2022 written by PHYS ASST revealed Resident #15 was admitted to the facility after a tornado damaged his previous facility. Resident #15 noted to have prior diagnoses of stroke with right sided hemiplegia (partial paralysis), Type 2 Diabetes Mellitus, high blood pressure and chronic kidney disease. His weight was noted at 310.6 pounds and he was noted to have mild peripheral edema and right lower extremity edema. There was no note that the right upper extremity had edema. <BR/>Review of Resident #15 Blood Pressures from 05/25/2022-06/22/2022, that were out of range in the EMR or greater than 145/90 were as follows :<BR/>-05/25/2022 - 9:26 AM - 176/84 mmHg<BR/>-05/25/2022 - 8:38 PM - 157/99 mmHg<BR/>-05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings document for this day.**<BR/>-05/28/2022 - 10:04 AM - 164/79 mmHG<BR/>-05/28/2022 - 7:50 PM - 157/70 mmHG<BR/>-05/29/2022 - 6:28 PM - 167/94 mmHG<BR/>-05/30/2022 - 10:12 AM - 178/90 mmHG<BR/>-05/30/2022 - 8:41 PM - 155/80 mmHG<BR/>-05/31/2022 - 10:29 AM - 165/100 mmHG<BR/>-05/31/2022 - 7:57 PM - 151/99 mmHG<BR/>-06/01/2022 - 10:05 AM - 166/99 mmHG<BR/>-06/01/2022 - 7:43 PM - 170/83 mmHG<BR/>-06/02/2022 - 4:47 AM - 153/100 mmHG<BR/>-06/02/2022 - 9:51 AM - 159/95 mmHG<BR/>-06/02/2022 - 7:02 PM - 150/98 mmHG<BR/>-06/03/2022 - 2:32 AM - 155/80 mmHG<BR/>-06/03/2022 - 10:38 AM - 164/86 mmHG<BR/>-06/04/2022 - 10:28 AM - 166/82 mmHG<BR/>-06/04/2022 - 8:44 PM - 176/84 mmHG<BR/>-06/05/2022 - 1:09 AM - 163/96 mmHG<BR/>-06/05/2022 - 10:33 AM - 175/97 mmHG<BR/>-06/05/2022 - 5:43 PM - 186/94 mmHG<BR/>-06/05/2022 - 6:02 PM - 190/100 mmHG<BR/>-06/06/2022 - 9:45 AM - 158/78 mmHG<BR/>-06/06/2022 - 7:44 PM - 176/73 mmHG<BR/>-06/07/2022 - 2:09 AM - 174/80 mmHG<BR/>-06/08/2022 - 1:25 AM - 174/88 mmHG<BR/>-06/08/2022 - 11:28 AM - 179/91 mmHG<BR/>-06/08/2022 - 8:22 PM - 183/84 mmHG<BR/>-06/09/2022 - 2:02 AM - 149/80 mmHG<BR/>-06/09/2022 - 1:38 PM - 189/100 mmHG<BR/>-06/09/2022 - 6:50 PM - 167/87 mmHG<BR/>-06/10/2022 - 9:45 AM - 169/84 mmHG<BR/>-06/10/2022 - 7:11 PM - 186/53 mmHG<BR/>-06/11/2022 - 6:29 AM - 156/76 mmHG<BR/>-06/11/2022 - 10:23 AM - 193/91 mmHG<BR/>-06/11/2022 - 7:45 PM - 145/76 mmHG<BR/>-06/12/2022 - 8:57 AM - 160/100 mmHG<BR/>-06/13/2022 - 7:38 PM - 153/96 mmHG<BR/>-06/14/2022 - 10:30 AM - 154/68 mmHG<BR/>-06/14/2022 - 6:50 PM - 150/74 mmHG<BR/>-06/15/2022 - 9:44 AM - 181/89 mmHG<BR/>-06/15/2022 - 6:49 PM - 190/94 mmHG<BR/>-06/16/2022 - 9:49 AM - 163/71 mmHG<BR/>-06/16/2022 - 6:51 PM - 189/85 mmHG<BR/>-06/17/2022 - 10:21 AM - 160/81 mmHG<BR/>-06/18/2022 - 10:08 AM - 175/91 mmHG<BR/>-06/18/2022 - 6:20 PM - 165/86 mmHG<BR/>-06/19/2022 - 10:09 AM - 155/86 mmHG<BR/>-06/19/2022 - 7:36 PM - 152/88 mmHG<BR/>-06/22/2022 - 10:21 AM - 160/101 mmHG<BR/>Review of Resident #15 Nursing Progress Notes dated 05/25/2022 to 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. <BR/>Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start doxycycline 100 MG BID (twice per day) for seven days.<BR/>Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325[11:35pm] , resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor.<BR/>Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 <BR/>At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C <BR/>At 0135 [1:35 AM]Pulse 87, 02 97% <BR/>At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C <BR/>At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, <BR/>At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C <BR/>At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C <BR/>At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. <BR/>[family member] called this morning about the change in condition and the treatment initiated. Would like update from of us.<BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN Drevealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified.<BR/>Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified.<BR/>There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. <BR/>In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg, in his neck and back of head. <BR/>In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his family member had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse , she told him he was fine and did nothing. He said he was on the phone with his family members, who told him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested to the nurses multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. <BR/>In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant saw all their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She was not sure of when the doctor rounded on Resident #15 since Resident #15 was admitted to the facility. When asked for physician progress notes for Resident #15, she stated she would check with their medical records assistant for additional physician progress notes. She stated Resident #15 was seen by the physician assistant when he was first admitted . <BR/>In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes into the EMR for all residents. She stated Resident #15's EMR should be current with no missing physician progress notes. She stated she would double check that there were no pending notes that needed to be uploaded. She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. <BR/>In an interview on 06/21/2022 at 4:00 PM, the DON said Resident #15 was seen by PHYS K's nurse practitioner via tele-health on 05/05/2022. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. <BR/>In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had been having issues with intermittent high blood pressures and edema. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. She stated the CMAs would notify the nurse of high blood pressure if it was over 145/90. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time and received a verbal order for antibiotics for the pneumonia. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increase weight from May to June 2022 . When asked where the documentation of the notification of the high blood pressures and edema to PHYS K was, she said she was not sure she documented it and then stated it was not in the EMR. <BR/>In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered. He did not remember being contacted about increased edema overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the edema, weight gain, and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having chronic kidney disease. He stated he had not physically examined Resident #15 since he was admitted to the facility. <BR/>In a follow-up interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or the PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food . She said a physician should have examined and assessed Resident #15 sooner. <BR/>In an interview on 06/24/2022 at 4:15 PM, the ADMIN said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. The ADMIN could not say why Resident #15 was not seen sooner by a doctor. <BR/>In an interview on 06/25/2022 at 11:30 AM, RNC B stated, it would have been ideal to have Resident #15 seen by a physician following his respiratory distress, elevated blood pressures and excessive weight gain. He said he was not sure why the facility did not follow the policy to have the medical director see Resident #15 when they facility was not receiving a response from the attending physician.<BR/>Facility did not have a policy for physician services or supervision of a resident by a physician. <BR/>Review of the facility's policy, Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. <BR/>The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. <BR/>The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following:<BR/>Problem: Physician Visits<BR/>All residents have the potential to be affected by this deficient practice.<BR/>Interventions:<BR/>o <BR/>Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased edema, elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022.<BR/>o <BR/>The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for intermittent elevated blood pressure was entered into PCC. This was completed in PCC on 6/22/22.<BR/>o <BR/>The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing.<BR/>o <BR/>All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse.<BR/>o <BR/>Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased edema and significant weight gain.<BR/>o <BR/>Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings.<BR/>o <BR/>Assessing for increased edema and/or swelling.<BR/>o <BR/>Signs and symptoms of hyperglycemia and notification of Physician.<BR/>o <BR/>The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely.<BR/>o <BR/>The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. <BR/>o <BR/>The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased edema, and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including edema. This will be monitored by DON/ADON weekly, ongoing.<BR/>o <BR/>The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. <BR/>Monitoring: <BR/>o <BR/>Monitoring of this plan began on 6/22/2022 and will continue weekly x 4.<BR/>o <BR/>The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks.<BR/>o <BR/>The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened edema is communicated to the physician/NP and follow up as needed.<BR/>o <BR/>The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. <BR/>The Survey team monitored the plan of removal as follows: <BR/>Monitoring done from 06/23/2022 - 06/25/2022. <BR/>Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of Lasix on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. <BR/>In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. <BR/>Review of Resident #15 Physician Orders dated 06/22/2022 revealed Resident #15's blood pressure medications were changed and will be monitored by PHYS ASST weekly for effectiveness. <BR/>In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. <BR/>In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. <BR/>Review of facility Inservice education completed as part of Plan of Removal:<BR/>06/22/2022 Reporting Change in Condition to include high BP, increased edema and significant weight gain. All nurses completed the education. <BR/>06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated.<BR/>06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. <BR/>06/22/2022 Signs and Symptoms of Hyperglycemia and physician notification. All nurses completed the education. <BR/>06/22/2022 Edema Causes and signs. All nurses completed the education. <BR/>While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and 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 that the medication error rate was not five percent or greater for when the facility had a medication error rate of 6.25% based on 2 of 32 opportunities, which involved 2 of 5 residents (Resident #18 and Resident #26) and 2 of 2 MA's(MA C and MA L) observed during medication administration. <BR/>A) Resident #18 had a physician order for Amiodarone HCL 100 mg (for abnormal heart rhythm) to be given once daily. MA L failed to administer the medication. <BR/>B) Resident #26 had a physician order for Minoxidil (for hypertension) 5 mg one time daily. MA C administered 2.5mg. <BR/>These deficient practices could place residents at risk of not receiving therapeutic dosage of medications.<BR/>Findings Include: <BR/>A.) Review of Resident #18's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Atrial Fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), Cerebral infarction due to embolism of cerebral artery (a brain lesion in which a cluster of brain cells die when they don't get enough blood) and Dementia (loss of cognitive functioning).<BR/>Review of Resident #18's Annual MDS dated [DATE] reflected Resident #18 had a BIMS score of 6indicating severe cognitive impairment. Resident #18 was coded to require limited assist with ADL's. Resident #18 was coded to have Atrial Fibrillation, Heart Failure, and hypertension.<BR/>Review of Resident #18's Comprehensive Care Plan dated 12/13/2019 and revised on 03/12/2021 reflected a focus area for Resident #18's alteration in cardiovascular status .Atrial Fibrillation. Interventions included administer medications as per orders. <BR/>Review of Resident #18's Consolidated Physician Orders dated 06/21/2022 reflected an order for Amiodarone HCL tablet 100 mg one by mouth one time a day for abnormal heart rhythm. <BR/>Observation on 06/21/2022 at 8:15 AM revealed MA L preparing Resident #18's medication for administration. The medications included the following:<BR/>-Carvedilol 12.5mg one tab, <BR/>-Eliquis 5mg one tab, and <BR/>-Lasix 20 mg one tab. <BR/>MA L did not administer Resident #18's Amiodarone. <BR/>In an Interview on 06/21/2022 at 10:00 AM, MA L stated she did not give Resident #18 the Amiodarone because Resident #18 was out of the medication and she had to order it. When MA L was asked if the medication would be at the facility during the AM period, she stated no that the medication would not be at the facility unit late in the evening. <BR/>In an interview on 06/21/2022 at 10:15 AM, LVN F stated MA L had not reported to her she was not able to give Resident #18 her Amiodarone or that Resident #18 was out of the medication. LVN A stated the medication was in the emergency kit and if she had told her she was not able to give the medication because the resident was out, she would have gotten MA L the medication from the emergency kit. <BR/>In an interview on 06/21/2022 at 10:33 AM, MA L stated she did not know the medication Amiodarone was in the emergency kit and stated she did not report to the nurse that she did not give Resident #18 all her medication. <BR/>B.) Review of Resident #26's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: Myocardial infarction (heart attack), Cerebral infarction (a brain lesion in which a cluster of brain cells die when they don't get enough blood) Heart failure, and Hypertension (high blood pressure).<BR/>Review of Resident #26's Quarterly MDS dated [DATE] reflected Resident #26 had a BIMS score of 14 indicating resident was cognitively intact. Resident #26 was coded to require limited assist with ADL's. Resident #26 was coded to have coronary artery disease, hypertension and heart failure.<BR/>Review of Resident #26's Comprehensive Care Plan dated 12/13/2019 and revised 05/10/2022 reflected a focus area for Resident #26's has alteration in cardiac status: diagnoses include hypertension. Interventions included give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness . <BR/>Review of Resident #26's Consolidated Physician Orders dated 06/21/2022 reflected an order for Minoxidil give 5mg by mouth once time daily for hypertension. <BR/>Observation on 06/21/2022 at 8:50 AM, revealed MA C preparing Resident #26's medication for administration. MA C placed one 2.5 Mg tab of Minoxidil in the medication cup and administered it to the resident.<BR/>In an interview on 06/21/2022 at 10:05 AM, MA C stated she only gave Resident #26 one tablet of Minoxidil equal 2.5 mg. MA C stated Resident #26's Minoxidil order was 5mg and the resident should have gotten two tablets. <BR/>In an interview on 06/21/2022 at 11:15 AM, the DON stated she expected her staff to administer the appropriate medication and the appropriate dose to the residents. She stated the facility will do medication error reports and start in-serving staff on medication administration. <BR/>Review of the facility's Medication Administration Procedures dated 2003 and revised on 10/25/2017 reflected .The five rights of medication should always be adhered to<BR/>1. Right drug<BR/>2. Right dose<BR/>3. Right resident<BR/>4. Right time<BR/>5. Right route .<BR/>Review of the facility's policy, Ordering Medications dated 2003 reflected Reorder medication three to four days in advance of need to assure an adequate supply is on hand .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain timely laboratory services to meet the needs of 2 (Resident #49 and Resident #53) of 10 residents reviewed for ordered laboratory services in that:<BR/>The facility failed to ensure Resident #49's and Resident #53's ordered C-Diff (germ that causes severe diarrhea and inflammation of the colon) culture laboratory order were completed per physician order in a timely manner. <BR/>This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, ensuring appropriate transmission based precautions were put into place to prevent infection in other residents, and ensuring treatment needs were identified and addressed.<BR/>Findings included:<BR/>Resident #49<BR/>Review of Resident #49 face sheet dated 06/24/2022 revealed Resident #49 was a [AGE] year old female admitted to the facility on [DATE] with a diagnoses of pneumonia, bipolar disorder, atrial fibrillation (condition in which the heart beats irregularly), Type 2 Diabetes Mellitus, high blood pressure, dementia with Lewy bodies (type of dementia characterized by changes in sleep, behavior, cognition, movement and regulation of automatic bodily functions) and glaucoma (nerve damage to the nerve connecting the nerve to the brain due to high eye pressure).<BR/>Review of Resident #49 quarterly MDS assessment dated [DATE] revealed Resident #49 had a BIMS score of 3 to indicated impaired cognition. Resident #49 required total assistance from one staff member for assistance with ADL's. <BR/>Review of Resident #49 care plan dated 04/04/2022 revealed Resident #49 had a potential fluid deficit related to dementia with an intervention to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow-up as indicated. <BR/>Review of Resident #49 physician orders revealed Resident #49 was ordered to have stool culture - rule out c-diff on 06/17/2022. <BR/>In an interview on 06/21/2022 at 5:40 PM, LVN D stated if a doctor wrote an order for a lab or stool culture, she would enter the order in the EMR, obtain the ordered sample and send it to the lab. She stated the ADON, or DON checked for the results and notified the doctor of the results. She said if there was a problem with the lab, she would notify the DON and the doctor for further instructions. She said she was not aware of any pending labs for Resident #49 and did not know Resident #49 had an order for C-Diff stool culture. She said she did not know who received the order from the physician for the stool culture. <BR/>In an interview on 06/23/2022 at 1:09 PM, LVN H stated she received the stool culture order for Resident #49 from the physician assistant due to Resident #49 having a foul smelling bowel movement. She stated she went to obtain the stool culture and Resident #49 did not have a bowel movement, but had foul smelling urine and discharge and from her urethra. She stated she obtained a urine sample and Resident #49 was later diagnosed with a UTI. She stated she should have called the physician assistant or doctor to have the C-Diff culture discontinued. She stated Resident #49 was not symptomatic at this time for C-diff. She stated had Resident #49 continued to have episodes of diarrhea on the date of the stool culture order, they would have initiated contact isolation precautions until the stool culture result was received. <BR/>Resident #53<BR/>Review of Resident #53 face sheet dated 06/24/2022 revealed Resident #53 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of MRSA infection of pressure ulcers which were present on admission, endocarditis, chronic kidney disease, malignant neoplasm of the prostate, Type 2 Diabetes Mellitus, high blood pressure, congestive heart failure and chronic non-pressure ulcers of the lower legs. <BR/>Review of Resident #53 admission MDS assessment dated [DATE] revealed Resident #53 had a BIMS score of 7 to indicate moderately impaired cognition . Resident#53 required extensive assistance from one staff member for completion of ADL's. <BR/>Review of Resident #53 care plan dated 05/25/2022 revealed Resident #53 has a pressure ulcer or potential for pressure ulcer development with the intervention to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow-up as indicated. <BR/>Review of Resident #53 physician orders dated 06/06/2022 revealed an order for stool culture - diarrhea - on antibiotics - rule out C-Diff. <BR/>In an interview on 06/20/2022 at 1:30 PM, the DON stated the lab results for Resident #49 and Resident #53's should be in their EMR, but possibly the medical records manager had not uploaded the results to their records. The DON stated the cultures were completed and the results should have been uploaded in the EMR. <BR/>In an interview on 06/21/2022 at 3:35 PM, the medical records ASST stated all medical records should be uploaded and, in the resident's, EMR record. She will check to see if there were any lab results for Resident #49 and Resident #53. She said the DON/ADON checked the lab results, notified the MD, and then gave the labs to her to add to the resident's EMR. She said they usually get results in 48 hours, unless a STAT lab, then after reviewed by MD, the results were in the EMR within 2 days. <BR/>In an interview on 06/21/2022 at 4:00 PM, the DON stated the C-diff labs were not resulted. Resident #49 had a problem with the collection, and she was trying to figure out what happened that the lab was unable to process the stool culture. Resident #53's stool culture had the wrong requisition and should have been repeated immediately. Resident #49 should have been repeated and they have since sent out new cultures for both residents today. <BR/>In an interview on 06/23/2022 at 12:15 PM, the PHYS ASST stated she ordered the stool cultures for Resident #49 and Resident #53. She stated Resident #49 had a foul-smelling bowel movement similar to what C-Diff had a history of smelling like, so she wanted to rule it out. She stated Resident #49 was not currently symptomatic for C-Diff, but had she continued to have symptoms of C-Diff and due to not having a lab result, she could have gone without treatment for C-Diff. She said ongoing C-diff could have caused dehydration and other bowel complications. She said she ordered the c-diff culture for Resident #53 because he had some loose bowel movements and since he was on strong antibiotics for MRSA infection, she wanted to rule out C-diff infection. She said Resident #53 was not currently symptomatic for C-diff. <BR/>In a follow-up interview on 06/24/2022 at 4:00 PM, the DON stated Resident #49 and Resident #53's stool cultures drawn on 06/21/2022 were negative for C-diff. She stated the process for labs was for the nurse to receive the order, enter the order into the EMR and obtain the sample. She stated she or the ADON would check for results and notify the MD for further orders. She stated if either resident had ongoing symptoms of C-Diff they would have put them in contact isolation. She stated Resident #49 did not have another bowel movement the day the culture was ordered and therefore the sample was not obtained. She said the nurse should have gotten the sample the next day or called the doctor to have the order discontinued. She stated the sample for Resident #53 had the wrong requisition and should have been corrected the next day. She stated they should have collected another sample with the correct requisition the next day. She stated there could have been complications in delaying treatment of C-Diff including dehydration and colon issues. She stated not placing a resident with C-Diff in contact isolation could have resulted in cross contamination to other residents. She said the facility did not have a specific policy for labs and followed professional guidelines regarding samples. <BR/>Review of the facility's Infection Control Policy Type and Duration of Precautions dated March 2018 revealed C. Difficile required contact isolation for the duration of the illness until resident was no longer symptomatic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse.<BR/>The facility failed to ensure Resident #1 was in a safe environment when LVN A recorded instances of pouring water onto her face, verbally taunting her, and striking her with her knee and sitting on her arm. <BR/>An immediate jeopardy existed from 03/05/24 - 03/06/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.<BR/>This failure could affect residents by placing them at risk for abuse that could cause diminished quality of life and increased psychosocial harm as well as physical harm.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted to the facility 07/18/19 with diagnoses including: depression, history of stroke (bleeding in the brain), dementia, and kidney disease requiring dialysis (removal of blood by a machine to clean toxins then replacing cleaned blood).<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had moderate difficulty with her hearing. It further revealed she usually understood others and usually could be understood. The review also revealed Resident #1 had impaired vision that required corrective lenses. Resident #1's BIMS score was an 8, which correlated with moderately impaired cognition. Further review revealed that Resident #1 did not exhibit physical or verbal behavioral symptoms directed towards others nor behavioral symptoms not directed towards others. <BR/>Review of Resident #1's latest care plan, dated 12/22/23, revealed Resident #1 was at risk for pressure related injury due to impaired mobility with intervention of administering medications as ordered and repositioning Resident #1 at least every 2 hours. Further review revealed Resident #1 was at risk for fluid deficit (dehydration) due to medications, dialysis and variable intake; the intervention for this concern was administer medication, encourage Resident #1 to drink fluids of choice, ensure fluids were within reach, and notify the nurse if Resident #1 refused to drink fluids. Further review revealed Resident #1 was at risk for discomfort/pain due to impaired mobility and recent hospitalization that led to dialysis; the intervention for Resident #1's potential discomfort/pain was anticipate her need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain intervention, and review for compliance. Further review revealed Resident #1 had a focus of being non-compliant with medication due to anxiety and interventions were to notify family and physician and notify supervisor.<BR/>Review of the facility's self-report dated 03/06/24 revealed that LVN A used her cell phone camera to record herself verbally and physically abusing Resident #1. There was a total of 5 videos, with 2 being repeats, that were sent by LVN A to an undisclosed employee who then sent the videos to the corporate office of the facility.<BR/>Review of the videos, sent to Corporate 03/05/24, revealed LVN A poured water on Resident #1 who was lying in bed. LVN A was heard taunting Resident #1 when Resident #1 became upset about the water poured on her face. Resident #1 swung her left arm out at LVN A each time LVN A approached her bed. LVN A was seen kneeing Resident #1, who was lying on a scoop mattress, and telling Resident #1 that she was going to take these pills. Resident #1 was heard calling LVN A a Black Bitch as she swung her arm at LVN A when LVN A approached Resident #1's bed. LVN A was heard asking Resident #1 if she is gay and throughout the video LVN A was laughing and taunting Resident #1. The next video revealed LVN A continued to taunt Resident #1 and she sat on Resident #1 while commenting that she was sitting on her. LVN A was seen sitting on Resident #1's left hip area, getting up and motioning to sit again as Resident #1 swung her arm at LVN A. LVN A was then seen grabbing Resident #1's blanket and trying to take it from Resident #1 while laughing and telling Resident #1 she was going to take these pills. The next video showed LVN A tugging at Resident #1's blanket and telling her that she would take the blanket if Resident #1 did not take these pills. Resident #1 stated to LVN A that it was her blanket and called LVN A a bitch. Resident #1 struck out with her right arm toward LVN A and LVN A responded by pouring more water on Resident #1's face, which was turned away from LVN A. Resident #1 called LVN A a bitch and LVN A laughed and held the water above Resident #1's head while Resident #1 lifted her right arm above her face to protect from further water being poured. LVN A slowly pretends to pour the water on Resident #1 while Resident #1's arm was over her face for protection but then withdrew the cup of water and laughed, then slowly moved closer to again threaten to pour water on Resident #1's face, held the cup for a few seconds and then poured the water when Resident #1 had lowered her arm. LVN A stated she was going to pour the water and Resident #1 said go ahead and pour it on me. LVN A poured a small amount on Resident #1 who then stated pour it all on me as she wiped the water away. LVN A was laughing and facing the camera. In the next clip, LVN A was kneeing Resident #1 3 times with Resident #1 swinging her left arm toward LVN A after the first kneeing incident. LVN A then grabbed Resident #1's left arm by the wrist and told her to open her mouth while grabbing Resident #1's mouth, and then poking her several times in the breast/chest area while calling Resident #1's name. LVN A then sat down on Resident #1's left arm and part of her abdomen while holding a cup of medication to Resident #1's mouth and looking back at the camera. LVN A then pulled on Resident #1's chin and Resident #1 opened her mouth and LVN A tilted the cup, so the medication ended up in Resident #1's mouth. LVN A then laughed and said ha ha gotcha; LVN A then grabbed the phone/camera. In all 5 video clips Resident #1 was wearing the same clothing and LVN A was wearing the same clothing in all 5 clips.<BR/>During an interview on 03/13/24 at 11:00 am with the ADM she stated that LVN A sent the videos to an unknown employee who then sent the videos to the corporate office on 03/05/24; the corporate office immediately contacted the ADM, around 03/05/24 at 3:30 pm, and ADM began suspension and termination paperwork. LVN A was not at work at the time, so ADM stated she contacted LVN A to come to the building to sign the suspension paperwork and that she would be terminated for abuse. Corporate office reported LVN A to the board of nursing and included the video files. ADM contacted the family, the police department , the ombudsman and reported to SA . In addition, she notified the MD. The ADM, with support staff from the Corporate Office, began in-servicing all employees on Abuse/Neglect/Exploitation, use of photography/social media, and HIPAA privacy laws. All in-servicing was started 03/05/24 and completed 03/06/24. In addition, skin sweeps of all residents were started 03/05/24 and completed 03/06/24. Resident #1 was assessed by nursing immediately and Social Work met with the resident and continued meeting with her through 03/13/24 (exit ). Resident #1 was followed by Psychiatry, so a call for an immediate visit was made and a psychologist visited with Resident #1 on 03/11/24 (first available time). The psychologist had seen Resident #1 in the past and stated that she had not declined in her baseline from the last time he had seen her several months before and this visit. All residents were given safe resident surveys with no other issues identified. Staff were all given surveys related to LVN A and whether any staff had observed abusive behavior, but no witnessed or other issues were identified. An Ad Hoc QAPI was held with ADM, DON, and MD on 03/05/24. The dialysis clinic that Resident #1 visited 3 times per week were notified to be on alert. In addition, the facility notified every facility in a 60-mile radius that LVN A was terminated and not eligible for re-hire. ADM stated that the police detective informed the ADM that Resident #1's RP would have to press charges for LVN A to be charged with any criminal act. The ADM also stated that the facility would continue asking 5 alert and oriented residents about any abuse or neglect concerns and if the residents feel safe; these questions would be asked for the next 5 weeks (if no concerns are voiced in the future questioning).<BR/>Record review of Resident #1's EHR assessments tab revealed a Weekly Skin Assessment was performed on 03/05/24 at 4:09 pm and revealed no bruising or skin tears, but noted bilateral non-pressure wounds to the heals which were not marked as new.<BR/>Record review of the resident safe surveys revealed no other residents documented concerns about safety, nor did the residents feel abused and nor had they witnessed abuse at the facility.<BR/>Record review of staff surveys revealed that no staff member documented witnessing abuse or neglect of any resident by LVN A nor by any other staff member. In addition, all staff were able to identify the ADM as the abuse coordinator to contact immediately should staff have any concerns about abuse or neglect.<BR/>Record review of Resident #1's March 2024 Progress Notes revealed a progress note authored by the Social Worker (SW) on 03/05/24 at 6:02 pm and revealed the SW documented trying to interview Resident #1 about the abuse she endured from LVN A, but Resident #1 did not answer about abuse and asked for her breakfast. The SW documented that Resident #1 did not display signs of fear, distress or behavioral agitation. The next progress note authored by the SW on 03/06/24 at 12:24 revealed she contacted Resident #1's psychiatric provider who stated they would arrange for counseling services to contact the SW to setup an appointment. The SW authored a note on 03/06/24 at 5:01 pm that the counseling services contacted the SW, and a therapist would call the SW to discuss telehealth and in-person options.<BR/>During an interview and observation on 03/13/24 at 3:00 pm with Resident #1 revealed her room was dark and she said to go away. Resident #1 appeared to be resting comfortably in bed; no concerns were visible. Police officer exited room moments before. <BR/>During an interview with Police Detective on 03/13/24 at 3:10 pm he stated that he was gathering evidence still, as he had just attempted to interview Resident #1 but was unsuccessful. He further stated he still needed to interview Resident #1's RP and LVN A. He provided his contact information and stated he would provide an update and report when he was able.<BR/>During an interview on 03/19/24 at 9:10 am with LVN A she stated that nobody liked Resident #1 because Resident #1 was physically abusive, used bad language and refused care. She stated that sometime in January of 2024, LVN A had a cup of water to give Resident #1 and Resident #1 swung her hand and caused a little bit of water to spill on Resident #1. She said Resident #1 would respond to requests from LVN A by calling her a bitch and Resident #1 said fuck you. She stated she was supposed to go to work on 03/06/24, and she picked up her paycheck on 03/05/24 and everything was fine but was contacted by the ADM on 03/05/24 around 5 or 6 pm and the ADM told her she was suspended pending an investigation. She said the ADM was not allowed to tell her the allegations. LVN A stated on 03/06/24 she was called and asked to come to the facility and was notified she would be terminated. She denied any further incidents of water being spilled on Resident #1, she denied raising her voice to Resident #1, putting her hands on Resident #1, or any other incidents that would be viewed as abusive. LVN A did state that she had documented when Resident #1 had aggressive behavior toward LVN A.<BR/>Record review of Resident #1's January 2024 progress notes revealed that LVN A documented a behavior note on 01/30/24 at 7:22 am that further revealed that Resident #1 refused her medication and used foul language and told LVN A to leave her room. LVN A then offered Resident #1 her medication in the shower room and Resident #1 pulled LVN A's hair and knocked the medication cup out of LVN A's hand. LVN A then documented notifying Resident #1's RP of the encounter.<BR/>Record review of Resident #1's February 2024 progress notes revealed that LVN A documented on 02/03/24 at 2:51 pm that she had contacted Resident #1's RP about a behavior incident earlier that morning (no description or note found specifying the incident) and that a new order for in-patient psychiatric services was placed and RP would be updated when new information was available. Further review revealed a progress note on 02/09/24 at 8:13 am authored by LVN A that stated LVN A called the Mental health and mental rehabilitation crisis hotline to report that Resident #1 was using explicit language and displaying inappropriate behavior (not described) towards LVN A and another staff; LVN A was waiting for a return phone call. Review of a note dated 02/09/24 at 11:22 am by LVN A that revealed the return call from the crisis hotline personnel recommended LVN A speak with RP and MD to obtain inpatient psychiatric services for Resident #1; LVN A spoke to the ADM who recommended LVN A speak to the SW.<BR/>During an interview on 03/13/24 at 3:13 pm with LVN B, she stated the facility constantly trained on abuse and abuse prevention. She said, it starts your first day of work on the computer before you can work with residents. She stated at least once a month, but usually more, abuse was covered. LVN B stated the most recent abuse in-service was within the last week, she thought last Tuesday or Wednesday (03/05/24 or 03/06/24). She stated if she was concerned about abuse, she would have reported it to the abuse coordinator, the ADM and she felt the ADM would take it seriously.<BR/>During an interview on 03/13/24 at 3:20 pm with LVN C, she stated that they were in-serviced at least every month on abuse and the most recent was within the last few days. If she suspected abuse, she would protect the resident and notify the abuse coordinator, the ADM. She stated the ADM was new, but seemed good, she said staff were told there was an incident of abuse and to watch Resident #1 for any signs of change from her baseline. LVN C said Resident #1 seemed to be having more good days this week than the last few weeks.<BR/>During an interview on 03/13/24 at 3:26 pm with CNA D, she said she was trained on abuse at least every other month, but most recently last week. She said if she had witnessed abuse, she would have stopped it and notified the charge nurse immediately, then the DON, and the ADM who was the abuse coordinator. She gave the types of abuse and examples.<BR/>During an interview on 03/13/24 at 3:37 pm with HK E she said abuse was mentioned in trainings and meetings at least 3 - 4 times a month, and the latest was within the last week. She stated Resident #1 had good and bad days, but Resident #1 had never been physical with her. She said sometimes Resident #1 would yell at her, but when HK E responded calmly to Resident #1 and told her what she was doing and kept talking to her that Resident #1 would calm down. She stated that usually staff stepped out and gave Resident #1 a moment to calm down and tried again later.<BR/>Record review of in-services revealed all staff in-serviced on Abuse/neglect/exploitation, photography, social media usage, and HIPAA privacy laws which started on 03/05/24 and completed 03/06/24.<BR/>Record review revealed an attendance sheet for an Ad Hoc QAPI meeting on 03/05/24 which included the ADM, the DON, and the MD.<BR/>Record review of HR folder revealed termination paperwork that stated that LVN A was hired 11/17/23 and was suspended by the ADM on 03/05/24 with the ADM's stated intent to move straight to termination due to a substantiated allegation that LVN A abused a resident; the ADM also requested that LVN A be added to a list of people not to be rehired due to the abuse. Further review revealed a form titled Personnel Action Form and was marked Termination with LVN A's name and employee identification number. LVN A's final termination date was marked as 03/06/24, and her last day worked according to the form was 03/04/24. Further review of LVN A's HR folder revealed she was last in-serviced on Abuse/neglect/exploitation on the computer on 01/02/24. Further review revealed the facility documented all required background checks for LVN A, which included verification of her nursing license, criminal background check, check with the employee misconduct registry, and the state and federal office of the inspector general exclusion lists.<BR/>Record review of March 2024 nursing schedule revealed LVN A was not scheduled after 03/05/24.<BR/>Record review of facility's policy titled Abuse/Neglect dated 03/29/18 revealed abuse included . willful infliction of injury, intimidation, or punishment .verbal abuse included language that was disparaging or derogatory . Mental abuse included harassment, threats of punishment .physical abuse included . pinching, kicking, and hitting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #15) reviewed for notification of changes in that:<BR/>The facility failed to fully notify Resident #15's primary care physician of all of Resident #15's status including ongoing elevated blood pressures and increased edema. <BR/>These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.<BR/>This deficient practice could place residents at risk of not having their primary care physician notified of changes, resulting in a delay in medical intervention and decline in health.<BR/>Findings included:<BR/>Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. <BR/>Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. <BR/>Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. <BR/>In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. <BR/>In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with his brother and sister, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his sister called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. <BR/>Review of Resident #15 EMR for Physician Progress Notes dated 03/22/2022 - 06/21/2022 revealed a physician progress noted completed by PHYS ASST on 03/29/2022. There were no other physician progress notes in Resident #15's EMR.<BR/>Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed:<BR/>03/24/2022 - 310.6 pounds on the wheelchair scale<BR/>04/01/2022 - 314.6 pounds (scale unknown)<BR/>05/10/2022 - 314.8 pounds (scale unknown)<BR/>06/16/2022 - 356.7 pounds (scale unknown)<BR/>In an interview on 06/21/2022 at 4:00 PM, the DON said PHYS K was notified of Resident #15's weight gain but was not sure if he was notified regarding Resident #15's elevated blood pressures. <BR/>In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had issues with intermittent high blood pressures and edema since May 2022. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. When asked where the documentation of the notification of the high blood pressures and edema to PHYS K was, she said she was not sure she documented it and then confirmed it was not in the EMR. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time (05/31/2022) and received a verbal order for antibiotics for the pneumonia. She stated she did not report increased edema and elevated blood pressures to PHYS K at that time. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increased weight from May to June 2022. <BR/>In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain because diet non-compliance. He stated he was told Resident #15 had increased swelling on his right arm and leg, but the facility attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures. He did not remember being contacted about increased edema overall. <BR/>Review of Resident #15 Blood Pressures 05/25/2022-06/22/2022 out of range in the EMR or greater than 145/90:<BR/>05/25/2022 - 9:26 AM - 176/84 mmHg<BR/>05/25/2022 - 8:38 PM - 157/99 mmHg<BR/>05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings documented for this day.**<BR/>05/28/2022 - 10:04 AM - 164/79 mmHG<BR/>05/28/2022 - 7:50 PM - 157/70 mmHG<BR/>05/29/2022 - 6:28 PM - 167/94 mmHG<BR/>05/30/2022 - 10:12 AM - 178/90 mmHG<BR/>05/30/2022 - 8:41 PM - 155/80 mmHG<BR/>05/31/2022 - 10:29 AM - 165/100 mmHG<BR/>05/31/2022 - 7:57 PM - 151/99 mmHG<BR/>06/01/2022 - 10:05 AM - 166/99 mmHG<BR/>06/01/2022 - 7:43 PM - 170/83 mmHG<BR/>06/02/2022 - 4:47 AM - 153/100 mmHG<BR/>06/02/2022 - 9:51 AM - 159/95 mmHG<BR/>06/02/2022 - 7:02 PM - 150/98 mmHG<BR/>06/03/2022 - 2:32 AM - 155/80 mmHG<BR/>06/03/2022 - 10:38 AM - 164/86 mmHG<BR/>06/04/2022 - 10:28 AM - 166/82 mmHG<BR/>06/04/2022 - 8:44 PM - 176/84 mmHG<BR/>06/05/2022 - 1:09 AM - 163/96 mmHG<BR/>06/05/2022 - 10:33 AM - 175/97 mmHG<BR/>06/05/2022 - 5:43 PM - 186/94 mmHG<BR/>06/05/2022 - 6:02 PM - 190/100 mmHG<BR/>06/06/2022 - 9:45 AM - 158/78 mmHG<BR/>06/06/2022 - 7:44 PM - 176/73 mmHG<BR/>06/07/2022 - 2:09 AM - 174/80 mmHG<BR/>06/08/2022 - 1:25 AM - 174/88 mmHG<BR/>06/08/2022 - 11:28 AM - 179/91 mmHG<BR/>06/08/2022 - 8:22 PM - 183/84 mmHG<BR/>06/09/2022 - 2:02 AM - 149/80 mmHG<BR/>06/09/2022 - 1:38 PM - 189/100 mmHG<BR/>06/09/2022 - 6:50 PM - 167/87 mmHG<BR/>06/10/2022 - 9:45 AM - 169/84 mmHG<BR/>06/10/2022 - 7:11 PM - 186/53 mmHG<BR/>06/11/2022 - 6:29 AM - 156/76 mmHG<BR/>06/11/2022 - 10:23 AM - 193/91 mmHG<BR/>06/11/2022 - 7:45 PM - 145/76 mmHG<BR/>06/12/2022 - 8:57 AM - 160/100 mmHG<BR/>06/13/2022 - 7:38 PM - 153/96 mmHG<BR/>06/14/2022 - 10:30 AM - 154/68 mmHG<BR/>06/14/2022 - 6:50 PM - 150/74 mmHG<BR/>06/15/2022 - 9:44 AM - 181/89 mmHG<BR/>06/15/2022 - 6:49 PM - 190/94 mmHG<BR/>06/16/2022 - 9:49 AM - 163/71 mmHG<BR/>06/16/2022 - 6:51 PM - 189/85 mmHG<BR/>06/17/2022 - 10:21 AM - 160/81 mmHG<BR/>06/18/2022 - 10:08 AM - 175/91 mmHG<BR/>06/18/2022 - 6:20 PM - 165/86 mmHG<BR/>06/19/2022 - 10:09 AM - 155/86 mmHG<BR/>06/19/2022 - 7:36 PM - 152/88 mmHG<BR/>06/22/2022 - 10:21 AM - 160/101 mmHG<BR/>Review of Resident #15 Nursing Progress Notes dated 05/25/2022 - 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. <BR/>Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor.<BR/>Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 <BR/>At 0108 V/S Temp 96.3, Pulse 85, 02 99% N/C <BR/>At 0135 Pulse 87, 02 97% <BR/>At 0210 V/S Temp 96.4, Pulse 84, Resp 22, 02 97% with O2 via nasal cannula<BR/>At 0255 V/S Temp 96.3, Pulse 82, Resp 24, 02 99% with O2 via nasal cannula<BR/>At O320 V/S Temp 96.2, Pulse 81, Resp 22, 02 96% with O2 via nasal cannula<BR/>At 0455 V/S Temp 96.3, Pulse 78, 02 99% with O2 via nasal cannula<BR/>At 0545 V/S Temp 97.5, Pulse 82, 02 97% with O2 via nasal cannula, BP 155/100 <BR/> [FAMILY MEMBER] called this morning about the change in condition and the treatment initiated. Would like update from of us.<BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. <BR/>Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified.<BR/>There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. <BR/>Review of Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. <BR/>The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. <BR/>The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following:<BR/>Problem: Notify of Changes<BR/>All residents have the potential to be affected by this deficient practice.<BR/>Interventions:<BR/>o <BR/>Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased edema, elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022.<BR/>o <BR/>The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for intermittent elevated blood pressure was entered into PCC. This was completed in PCC on 6/22/22.<BR/>o <BR/>The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing.<BR/>o <BR/>All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse.<BR/>o <BR/>Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased edema and significant weight gain.<BR/>o <BR/>Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings.<BR/>o <BR/>Assessing for increased edema and/or swelling.<BR/>o <BR/>Signs and symptoms of hyperglycemia and notification of Physician.<BR/>o <BR/>The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely.<BR/>o <BR/>The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. <BR/>o <BR/>The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased edema, and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including edema. This will be monitored by DON/ADON weekly, ongoing.<BR/>o <BR/>The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. <BR/>Monitoring: <BR/>o <BR/>Monitoring of this plan began on 6/22/2022 and will continue weekly x 4.<BR/>o <BR/>The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks.<BR/>o <BR/>The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened edema is communicated to the physician/NP and follow up as needed.<BR/>o <BR/>The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. <BR/>The Survey team monitored the plan of removal as follows: <BR/>Monitoring done from 06/23/2022 - 06/25/2022. <BR/>Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of Lasix on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. <BR/>In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. <BR/>Review of Resident #15 Physician Orders dated 06/22/2022 revealed Resident #15's blood pressure medications were changed and will be monitored by PHYS ASST weekly for effectiveness. <BR/>In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. <BR/>In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. <BR/>Review of facility Inservice education completed as part of Plan of Removal:<BR/>06/22/2022 Reporting Change in Condition to include high BP, increased edema and significant weight gain. All nurses completed the education. <BR/>06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated.<BR/>06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. <BR/>06/22/2022 Signs and Symptoms of Hyperglycemia and physician notification. All nurses completed the education. <BR/>06/22/2022 Edema Causes and signs. All nurses completed the education. <BR/>While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and 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 that residents are free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse.<BR/>The facility failed to ensure Resident #1 was in a safe environment when LVN A recorded instances of pouring water onto her face, verbally taunting her, and striking her with her knee and sitting on her arm. <BR/>An immediate jeopardy existed from 03/05/24 - 03/06/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.<BR/>This failure could affect residents by placing them at risk for abuse that could cause diminished quality of life and increased psychosocial harm as well as physical harm.<BR/>Findings included:<BR/>Review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted to the facility 07/18/19 with diagnoses including: depression, history of stroke (bleeding in the brain), dementia, and kidney disease requiring dialysis (removal of blood by a machine to clean toxins then replacing cleaned blood).<BR/>Review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had moderate difficulty with her hearing. It further revealed she usually understood others and usually could be understood. The review also revealed Resident #1 had impaired vision that required corrective lenses. Resident #1's BIMS score was an 8, which correlated with moderately impaired cognition. Further review revealed that Resident #1 did not exhibit physical or verbal behavioral symptoms directed towards others nor behavioral symptoms not directed towards others. <BR/>Review of Resident #1's latest care plan, dated 12/22/23, revealed Resident #1 was at risk for pressure related injury due to impaired mobility with intervention of administering medications as ordered and repositioning Resident #1 at least every 2 hours. Further review revealed Resident #1 was at risk for fluid deficit (dehydration) due to medications, dialysis and variable intake; the intervention for this concern was administer medication, encourage Resident #1 to drink fluids of choice, ensure fluids were within reach, and notify the nurse if Resident #1 refused to drink fluids. Further review revealed Resident #1 was at risk for discomfort/pain due to impaired mobility and recent hospitalization that led to dialysis; the intervention for Resident #1's potential discomfort/pain was anticipate her need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain intervention, and review for compliance. Further review revealed Resident #1 had a focus of being non-compliant with medication due to anxiety and interventions were to notify family and physician and notify supervisor.<BR/>Review of the facility's self-report dated 03/06/24 revealed that LVN A used her cell phone camera to record herself verbally and physically abusing Resident #1. There was a total of 5 videos, with 2 being repeats, that were sent by LVN A to an undisclosed employee who then sent the videos to the corporate office of the facility.<BR/>Review of the videos, sent to Corporate 03/05/24, revealed LVN A poured water on Resident #1 who was lying in bed. LVN A was heard taunting Resident #1 when Resident #1 became upset about the water poured on her face. Resident #1 swung her left arm out at LVN A each time LVN A approached her bed. LVN A was seen kneeing Resident #1, who was lying on a scoop mattress, and telling Resident #1 that she was going to take these pills. Resident #1 was heard calling LVN A a Black Bitch as she swung her arm at LVN A when LVN A approached Resident #1's bed. LVN A was heard asking Resident #1 if she is gay and throughout the video LVN A was laughing and taunting Resident #1. The next video revealed LVN A continued to taunt Resident #1 and she sat on Resident #1 while commenting that she was sitting on her. LVN A was seen sitting on Resident #1's left hip area, getting up and motioning to sit again as Resident #1 swung her arm at LVN A. LVN A was then seen grabbing Resident #1's blanket and trying to take it from Resident #1 while laughing and telling Resident #1 she was going to take these pills. The next video showed LVN A tugging at Resident #1's blanket and telling her that she would take the blanket if Resident #1 did not take these pills. Resident #1 stated to LVN A that it was her blanket and called LVN A a bitch. Resident #1 struck out with her right arm toward LVN A and LVN A responded by pouring more water on Resident #1's face, which was turned away from LVN A. Resident #1 called LVN A a bitch and LVN A laughed and held the water above Resident #1's head while Resident #1 lifted her right arm above her face to protect from further water being poured. LVN A slowly pretends to pour the water on Resident #1 while Resident #1's arm was over her face for protection but then withdrew the cup of water and laughed, then slowly moved closer to again threaten to pour water on Resident #1's face, held the cup for a few seconds and then poured the water when Resident #1 had lowered her arm. LVN A stated she was going to pour the water and Resident #1 said go ahead and pour it on me. LVN A poured a small amount on Resident #1 who then stated pour it all on me as she wiped the water away. LVN A was laughing and facing the camera. In the next clip, LVN A was kneeing Resident #1 3 times with Resident #1 swinging her left arm toward LVN A after the first kneeing incident. LVN A then grabbed Resident #1's left arm by the wrist and told her to open her mouth while grabbing Resident #1's mouth, and then poking her several times in the breast/chest area while calling Resident #1's name. LVN A then sat down on Resident #1's left arm and part of her abdomen while holding a cup of medication to Resident #1's mouth and looking back at the camera. LVN A then pulled on Resident #1's chin and Resident #1 opened her mouth and LVN A tilted the cup, so the medication ended up in Resident #1's mouth. LVN A then laughed and said ha ha gotcha; LVN A then grabbed the phone/camera. In all 5 video clips Resident #1 was wearing the same clothing and LVN A was wearing the same clothing in all 5 clips.<BR/>During an interview on 03/13/24 at 11:00 am with the ADM she stated that LVN A sent the videos to an unknown employee who then sent the videos to the corporate office on 03/05/24; the corporate office immediately contacted the ADM, around 03/05/24 at 3:30 pm, and ADM began suspension and termination paperwork. LVN A was not at work at the time, so ADM stated she contacted LVN A to come to the building to sign the suspension paperwork and that she would be terminated for abuse. Corporate office reported LVN A to the board of nursing and included the video files. ADM contacted the family, the police department , the ombudsman and reported to SA . In addition, she notified the MD. The ADM, with support staff from the Corporate Office, began in-servicing all employees on Abuse/Neglect/Exploitation, use of photography/social media, and HIPAA privacy laws. All in-servicing was started 03/05/24 and completed 03/06/24. In addition, skin sweeps of all residents were started 03/05/24 and completed 03/06/24. Resident #1 was assessed by nursing immediately and Social Work met with the resident and continued meeting with her through 03/13/24 (exit ). Resident #1 was followed by Psychiatry, so a call for an immediate visit was made and a psychologist visited with Resident #1 on 03/11/24 (first available time). The psychologist had seen Resident #1 in the past and stated that she had not declined in her baseline from the last time he had seen her several months before and this visit. All residents were given safe resident surveys with no other issues identified. Staff were all given surveys related to LVN A and whether any staff had observed abusive behavior, but no witnessed or other issues were identified. An Ad Hoc QAPI was held with ADM, DON, and MD on 03/05/24. The dialysis clinic that Resident #1 visited 3 times per week were notified to be on alert. In addition, the facility notified every facility in a 60-mile radius that LVN A was terminated and not eligible for re-hire. ADM stated that the police detective informed the ADM that Resident #1's RP would have to press charges for LVN A to be charged with any criminal act. The ADM also stated that the facility would continue asking 5 alert and oriented residents about any abuse or neglect concerns and if the residents feel safe; these questions would be asked for the next 5 weeks (if no concerns are voiced in the future questioning).<BR/>Record review of Resident #1's EHR assessments tab revealed a Weekly Skin Assessment was performed on 03/05/24 at 4:09 pm and revealed no bruising or skin tears, but noted bilateral non-pressure wounds to the heals which were not marked as new.<BR/>Record review of the resident safe surveys revealed no other residents documented concerns about safety, nor did the residents feel abused and nor had they witnessed abuse at the facility.<BR/>Record review of staff surveys revealed that no staff member documented witnessing abuse or neglect of any resident by LVN A nor by any other staff member. In addition, all staff were able to identify the ADM as the abuse coordinator to contact immediately should staff have any concerns about abuse or neglect.<BR/>Record review of Resident #1's March 2024 Progress Notes revealed a progress note authored by the Social Worker (SW) on 03/05/24 at 6:02 pm and revealed the SW documented trying to interview Resident #1 about the abuse she endured from LVN A, but Resident #1 did not answer about abuse and asked for her breakfast. The SW documented that Resident #1 did not display signs of fear, distress or behavioral agitation. The next progress note authored by the SW on 03/06/24 at 12:24 revealed she contacted Resident #1's psychiatric provider who stated they would arrange for counseling services to contact the SW to setup an appointment. The SW authored a note on 03/06/24 at 5:01 pm that the counseling services contacted the SW, and a therapist would call the SW to discuss telehealth and in-person options.<BR/>During an interview and observation on 03/13/24 at 3:00 pm with Resident #1 revealed her room was dark and she said to go away. Resident #1 appeared to be resting comfortably in bed; no concerns were visible. Police officer exited room moments before. <BR/>During an interview with Police Detective on 03/13/24 at 3:10 pm he stated that he was gathering evidence still, as he had just attempted to interview Resident #1 but was unsuccessful. He further stated he still needed to interview Resident #1's RP and LVN A. He provided his contact information and stated he would provide an update and report when he was able.<BR/>During an interview on 03/19/24 at 9:10 am with LVN A she stated that nobody liked Resident #1 because Resident #1 was physically abusive, used bad language and refused care. She stated that sometime in January of 2024, LVN A had a cup of water to give Resident #1 and Resident #1 swung her hand and caused a little bit of water to spill on Resident #1. She said Resident #1 would respond to requests from LVN A by calling her a bitch and Resident #1 said fuck you. She stated she was supposed to go to work on 03/06/24, and she picked up her paycheck on 03/05/24 and everything was fine but was contacted by the ADM on 03/05/24 around 5 or 6 pm and the ADM told her she was suspended pending an investigation. She said the ADM was not allowed to tell her the allegations. LVN A stated on 03/06/24 she was called and asked to come to the facility and was notified she would be terminated. She denied any further incidents of water being spilled on Resident #1, she denied raising her voice to Resident #1, putting her hands on Resident #1, or any other incidents that would be viewed as abusive. LVN A did state that she had documented when Resident #1 had aggressive behavior toward LVN A.<BR/>Record review of Resident #1's January 2024 progress notes revealed that LVN A documented a behavior note on 01/30/24 at 7:22 am that further revealed that Resident #1 refused her medication and used foul language and told LVN A to leave her room. LVN A then offered Resident #1 her medication in the shower room and Resident #1 pulled LVN A's hair and knocked the medication cup out of LVN A's hand. LVN A then documented notifying Resident #1's RP of the encounter.<BR/>Record review of Resident #1's February 2024 progress notes revealed that LVN A documented on 02/03/24 at 2:51 pm that she had contacted Resident #1's RP about a behavior incident earlier that morning (no description or note found specifying the incident) and that a new order for in-patient psychiatric services was placed and RP would be updated when new information was available. Further review revealed a progress note on 02/09/24 at 8:13 am authored by LVN A that stated LVN A called the Mental health and mental rehabilitation crisis hotline to report that Resident #1 was using explicit language and displaying inappropriate behavior (not described) towards LVN A and another staff; LVN A was waiting for a return phone call. Review of a note dated 02/09/24 at 11:22 am by LVN A that revealed the return call from the crisis hotline personnel recommended LVN A speak with RP and MD to obtain inpatient psychiatric services for Resident #1; LVN A spoke to the ADM who recommended LVN A speak to the SW.<BR/>During an interview on 03/13/24 at 3:13 pm with LVN B, she stated the facility constantly trained on abuse and abuse prevention. She said, it starts your first day of work on the computer before you can work with residents. She stated at least once a month, but usually more, abuse was covered. LVN B stated the most recent abuse in-service was within the last week, she thought last Tuesday or Wednesday (03/05/24 or 03/06/24). She stated if she was concerned about abuse, she would have reported it to the abuse coordinator, the ADM and she felt the ADM would take it seriously.<BR/>During an interview on 03/13/24 at 3:20 pm with LVN C, she stated that they were in-serviced at least every month on abuse and the most recent was within the last few days. If she suspected abuse, she would protect the resident and notify the abuse coordinator, the ADM. She stated the ADM was new, but seemed good, she said staff were told there was an incident of abuse and to watch Resident #1 for any signs of change from her baseline. LVN C said Resident #1 seemed to be having more good days this week than the last few weeks.<BR/>During an interview on 03/13/24 at 3:26 pm with CNA D, she said she was trained on abuse at least every other month, but most recently last week. She said if she had witnessed abuse, she would have stopped it and notified the charge nurse immediately, then the DON, and the ADM who was the abuse coordinator. She gave the types of abuse and examples.<BR/>During an interview on 03/13/24 at 3:37 pm with HK E she said abuse was mentioned in trainings and meetings at least 3 - 4 times a month, and the latest was within the last week. She stated Resident #1 had good and bad days, but Resident #1 had never been physical with her. She said sometimes Resident #1 would yell at her, but when HK E responded calmly to Resident #1 and told her what she was doing and kept talking to her that Resident #1 would calm down. She stated that usually staff stepped out and gave Resident #1 a moment to calm down and tried again later.<BR/>Record review of in-services revealed all staff in-serviced on Abuse/neglect/exploitation, photography, social media usage, and HIPAA privacy laws which started on 03/05/24 and completed 03/06/24.<BR/>Record review revealed an attendance sheet for an Ad Hoc QAPI meeting on 03/05/24 which included the ADM, the DON, and the MD.<BR/>Record review of HR folder revealed termination paperwork that stated that LVN A was hired 11/17/23 and was suspended by the ADM on 03/05/24 with the ADM's stated intent to move straight to termination due to a substantiated allegation that LVN A abused a resident; the ADM also requested that LVN A be added to a list of people not to be rehired due to the abuse. Further review revealed a form titled Personnel Action Form and was marked Termination with LVN A's name and employee identification number. LVN A's final termination date was marked as 03/06/24, and her last day worked according to the form was 03/04/24. Further review of LVN A's HR folder revealed she was last in-serviced on Abuse/neglect/exploitation on the computer on 01/02/24. Further review revealed the facility documented all required background checks for LVN A, which included verification of her nursing license, criminal background check, check with the employee misconduct registry, and the state and federal office of the inspector general exclusion lists.<BR/>Record review of March 2024 nursing schedule revealed LVN A was not scheduled after 03/05/24.<BR/>Record review of facility's policy titled Abuse/Neglect dated 03/29/18 revealed abuse included . willful infliction of injury, intimidation, or punishment .verbal abuse included language that was disparaging or derogatory . Mental abuse included harassment, threats of punishment .physical abuse included . pinching, kicking, and hitting .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 waste receptacles reviewed for garbage disposal.<BR/>-Waste receptacle #1 had its top lid opened when no one was disposing of trash.<BR/>These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.<BR/>Findings include: <BR/>Observation and interview on 09/13/2023 at 11:25 AM with the Dietary Manager, revealed that one of the two waste receptacle's' lid was observed opened. The waste receptacle was located on facility property about 15 yards from the building. The closest entrance to the facility was through an external kitchen door. There was no fence surrounding the waste receptacles. There was trash inside the dumpster and no facility staff was disposing of trash at the time the lid was observed open. The Dietary Manager said the lid to the dumpster should be closed to avoid flies and pest getting into the dumpster which could then possibly get into the facility. She said the lid was open because the staff could not reach the lid to close it and that normally staff used a stick to reach the lid to close it. She said the risk to residents was they could get sick because of the flies and pest that could get inside the facility. The maintenance person went outside, and the Dietary Manager asked him if he could close it. The maintenance person walked towards the dumpster, found the stick, and closed the lid on the dumpster. She said the facility had a policy on food storage and refuse disposal. The Dietary Manager said the policy was the dumpster lid should always be closed unless someone was throwing away trash.<BR/>Interview on 09/14/2023 at 5 PM with the Administrator who said the outdoor trash receptacle applied to the dumpster.<BR/>Record review of the Dietary Services Policy & Procedure Manual 2012 dated 2012 reflected in part .Trash cans must be covered at all times, except during use <BR/>.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that:<BR/>-The facility stored unlabeled and unsealed foods in the refrigerator. <BR/>This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status<BR/>Findings include:<BR/>Observation and interview on 09/13/2023 at 11:25 AM with [NAME] A revealed containers labeled green tomatoes and ketchup in the refrigerator were opened and unsealed, open to the air. She said the green tomatoes and ketchup should be closed so that nothing like bugs or bacteria got inside. She closed and sealed the lids on the containers and said she would have to throw it away. A bag of what appeared to be coleslaw mix was observed with no label, in the refrigerator. [NAME] A identified the food as coleslaw mix and said the food in the fridge should be dated so staff knew if it was good or bad. She said she would throw away the coleslaw mix as well. She said the policy was that food in the refrigerator should be sealed and labeled. She said risk to residents if food was not sealed or labeled was they could get sick and or die. <BR/>Interview on 09/14/2023 at 1:51 PM with the Dietary Manager, she said she had worked at the facility since February 2023. She said as the dietary manager she managed the dietary department, new staffing, ordered all supplies, charted the dietary side of things, and cooked, and/or washed dishes when needed. She said if food was cooked and placed in the refrigerator, it should be sealed and dated. She said there were two dates on it, an open date, and the delivery date. She said canned fruit was dated from the date it was opened. She said food was dated to ensure food was not expired. She said the risk to residents if food was not labeled or sealed was it could make residents sick, or they could die.<BR/>Record review of the Dietary Services Policy & Procedure Manual 2012 dated 2012 reflected in part .Open packages of food are stored in closed containers with tight covers and dated as to when opened <BR/>Record review of U.S. Food and Drug Administration Food Code dated 2022 reflected in part . 3-305.11 (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .<BR/>.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that:<BR/>-The facility stored unlabeled and unsealed foods in the refrigerator. <BR/>This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status<BR/>Findings include:<BR/>Observation and interview on 09/13/2023 at 11:25 AM with [NAME] A revealed containers labeled green tomatoes and ketchup in the refrigerator were opened and unsealed, open to the air. She said the green tomatoes and ketchup should be closed so that nothing like bugs or bacteria got inside. She closed and sealed the lids on the containers and said she would have to throw it away. A bag of what appeared to be coleslaw mix was observed with no label, in the refrigerator. [NAME] A identified the food as coleslaw mix and said the food in the fridge should be dated so staff knew if it was good or bad. She said she would throw away the coleslaw mix as well. She said the policy was that food in the refrigerator should be sealed and labeled. She said risk to residents if food was not sealed or labeled was they could get sick and or die. <BR/>Interview on 09/14/2023 at 1:51 PM with the Dietary Manager, she said she had worked at the facility since February 2023. She said as the dietary manager she managed the dietary department, new staffing, ordered all supplies, charted the dietary side of things, and cooked, and/or washed dishes when needed. She said if food was cooked and placed in the refrigerator, it should be sealed and dated. She said there were two dates on it, an open date, and the delivery date. She said canned fruit was dated from the date it was opened. She said food was dated to ensure food was not expired. She said the risk to residents if food was not labeled or sealed was it could make residents sick, or they could die.<BR/>Record review of the Dietary Services Policy & Procedure Manual 2012 dated 2012 reflected in part .Open packages of food are stored in closed containers with tight covers and dated as to when opened <BR/>Record review of U.S. Food and Drug Administration Food Code dated 2022 reflected in part . 3-305.11 (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .<BR/>.