Every finding on record at Alden Park Strathmoor

Based on interview and record review, the facility failed to clarify resident admission orders for 1 of 5 residents (R5) reviewed for medications in the sample of 8.The findings include:R5's Hospital Discharge Packet, dated 12/13/25, shows a discharge order Ceftriaxone 2 grams, intravenously every 24 hours ending 1/2/26.R5's Medication Administration Record (MAR) for December 2025 shows an order for Ceftriaxone 2 gram, intravenously every 24 hours was not started on 12/13/25. On 3/4/26 at 1:30 PM, V2 (Director of Nursing) said R5 came back from the hospital on [DATE] on hospice. V2 said R5 did not have intravenous access that he was aware of. V2 said R5 was not receiving intravenous antibiotics. V2 reviewed R5's hospital Discharge Packet and said in one area the antibiotics were discontinued but did see where the intravenous antibiotics were listed under discharge orders. V2 said the admitting nurse should have called and clarified the orders.The facility's Physician Orders for Medications or Treatments Policy, dated 6/2022, shows, Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis must be verified with the attending physician.

Based on interview and record review, the facility failed to notify a resident's physician and Registered Dietician regarding a significant weight loss. This failure resulted in R2 experiencing a 28.6lb weight loss within a 2 week period with no nutritional interventions for 5 days. This applies to 1 of 3 residents reviewed for nutrition in the sample of 6.The findings include:R2's electronic face sheet, printed on 1/21/26, showed R2 was admitted to the facility on [DATE], and has diagnoses including but not limited to encephalopathy, acute respiratory failure with hypoxia, emphysema, and epilepsy.R2's facility assessment, dated 12/25/25, showed R2 has severe cognitive impairment and requires enteral tube feeding.R2's mini nutritional assessment performed by V9 (Registered Dietician), dated 12/19/25, showed R2 is malnourished.R2's weight log showed the following weights, 12/24/25 121.4lbs, 1/2/26, 96.9lbs, 1/7/26 94lbs, 1/15/26 92.8lbs., reflecting a significant weight loss of 20% within a 2 week period.R2's nursing progress notes, dated 1/7/26, showed, Nurse called power of attorney (POA) and updated on weight loss and plans to increase his tube feeding volume and rate. POA was under the impression he was on a continuous feed. Nurse let her know that he is on a total volume and once that is reached he is done with feeding until the restart in the evening. POA understood and was ok with that . R2's tube feeding assessment performed by V9 (Registered Dietician/RD), dated 1/21/26, showed, 1/15 92.8, BMI 13, IBW (ideal body weight) 170 +/- 5%. Weight loss noted and discussed in IDT (Interdisciplinary Team) weight meeting. Tube feeding formula switched to Glucerna 1.5 to provide additional calories. Weight stability/gradual weight gain desired. Caloric needs estimated to encourage weight goals . On 1/21/26 at 12:41PM, V2 (Director of Nursing) stated, Our documentation system triggers when there is a significant weight gain/loss. We do weight meetings on Thursdays every week and we talk about everyone that has triggered. Our Dietician, Food Service Director, nursing, and unit manager sit in on the meeting. It should be in the progress notes that there was a weight issue, and it was addressed. If there is a continuous weight loss sometimes, we will do weekly weights, but it's whatever the Dietician recommends or the physician recommends. Tube feedings are the same, there is no standard we do for them. We do whatever the recommendation is. (R2) is a pretty sick resident, he has some wounds and has had significant weight loss. We have addressed his significant weight loss in one of our meetings and we have been trying to get family to sign him onto hospice. The day the weights are noted to be significant is when we (management) should be notified so we can notify the Nurse Practitioner and Dietician and get recommendations. At 2:04PM, V2 stated, (R2) has had some weight fluctuations. He had a new colostomy and now the size has reduced to its normal size. No, I don't think that is the reason for his significant weight change. When there is a weight change the staff are supposed to be notifying the Dietician and physician right away, not days later. We need to act quickly for our residents who are vulnerable to additional weight loss to prevent any further deterioration of their condition. A resident on tube feeding is very high risk for weight fluctuations and should be monitored closely for weight changes.On 1/21/26 at 2:31PM, V9, RD, stated, We sometimes have people that have fluid related weight loss but (R2) did not have any excess fluid on him. Once a week, I pull the weight and vitals exception report, and we address all of the weight issues in our weight meeting. If a resident has a quarterly or annual assessment, sometimes it will get put in one big note for the notes from the weight meetings, otherwise it should be documented as its own progress note. I was not notified of (R2's) weight loss until I pulled the weight report on 1/7/26 prior to our 1/8 weight meeting. I don't always get notified for a significant weight loss, sometimes I just see it on the report when I pull it. It would be preferable for me to be notified of a weight change, but I also understand when it does not happen because they are busy. I have (R2's) caloric needs calculated as of his weight right now to help encourage weight gain. If he continues to tolerate the formula and the rate he's been getting, I can hopefully increase it and help him gain at least some of the weight back. The sooner we start interventions, the better our chances are to get the residents to gain weight back. I do not think that any of (R2's) weights have been inaccurate up to this point in his stay at the facility.The facility's policy titled, Nutrition Care Significant Weight Loss, dated 1/18, showed, Residents with a significant weight loss will be assessed by the Licensed Dietician .to reduce the risk of malnutrition .2. A significant weight loss is 5% in one month, 7 1/2% in 3 months and 10% in 6 months .

Based on interview and record review, the facility failed to ensure the correct type of insulin was administered to a resident. This applies to 1 of 3 residents (R1) reviewed for insulin administration in the sample of 3. This past non-compliance occurred from 12/5/2025 -12/9/2025. The findings include: The Facility Medication Correction Form, dated 12/5/25, states, Wrong insulin given, Novolog given instead of Lantus. Insulin in wrong bag. Novolog in Lantus bag (looked at?) label on bag but didn't see pen wrong place.On 1/20/26 at 11:00AM, V6 (LPN-Licensed Practical Nurse) stated, I was doing her insulin, her 8:00PM Lantus (Long-acting Insulin) dose supposed to be 40 units. The bag said Lantus and after I gave the insulin, I noticed the pen was the wrong color- I gave Novolog (Fast acting insulin) instead. The Lantus pen is gray. I got (V2- Director of Nursing) right away- he was working the floor on another wing, and we sent (R1) to the hospital. (V2) took over my cart and did a training with me. We notified the Nurse Practitioner. I checked the bag and it said Lantus, but it was the wrong pen in the bag.On 1/20/26 at 11:20 AM, V2 stated, It was on 12/5 at the HS (Bedtime) medication pass. I was working the back of the E wing, and the nurse (on the D wing) gave (R1) Novolog instead of Lantus. She (V6) came and got me right away and I went and we assessed (R1) and we did her blood sugar again. We called the Nurse Practitioner and the Power of Attorney, and we sent the patient to the ER. The medication pass was still ongoing, so I took over her cart, and I did a competency with her then and another one the next day. I did one 12/5, 12/6 and 12/7. I also did an in-service with all the nurses. Both insulins were in the same bag, and she took out the wrong one. Each one should be in its own bag. (R1) came back from the hospital with no new orders and she had no side effects from the error.R1's Progress Notes, dated 12/5/25 at 9:39 PM, stated, Resident sent out to (Local Hospital) for evaluation and treatment related to blood glucose. Nurse notified Power of Attorney, regarding resident transfer.Resident returned from (Local Hospital) at or around 04:05AM. No new orders noted. Vitals 97.3, 81, 121/73, 18 95% and BS (Blood Sugar) 137. Resident awake in her room engaging in ADLs.R1's Medication Administration Record shows she has orders for Lantus 40 units at bedtime and Novolog per Sliding Scale (depending on her blood sugar) three times a day with meals. R1's Hospital After Visit Summary shows R1's Point of Care Glucose was checked 9 times while in the emergency room, however, there are no results listed. R1's Diagnosis is listed as Insulin Overdose, accidental or unintentional, Hypoglycemia. R1 was monitored, provided education related to the signs and symptoms of hypoglycemia, and sent back to the facility with no further orders. The facility policy entitled Medication Pass Guidelines, dated 4/2019, states, Check the MDP (Multi-Dose Pen): Check the pharmacy label against the eMAR (Electronic Medication Administration Record); Compare the medication name and strength on the manufacturer label vs the pharmacy label. Prior to the survey date of 1/20/26, the facility had taken the following actions to correct the noncompliance:Corrective actions were immediately implemented, including competency retraining for the involved nurse (V6) on 12/5, 12/6 and 12/7.Facility wide in-service education on medication administration and insulin safety on 12/5, 12/6 and 12/8Revisions to medication storage practices- checked all medication carts to ensure all insulins were stored in the correct bags. Separated the types of insulin in the carts.Implementation of quality assurance audits to prevent reoccurrence starting on 12/9/25 and done at least 3x a week by clinical managers. QA meeting scheduled for the end of January 2026.

Based on observation, interview, and record review, the facility failed to ensure narcotic medication was safely stored and failed to ensure medications were administered for 2 of 4 (R1, R3) residents reviewed for medication storage and administration in the sample of 4.The findings include:1. The facility's undated and unsigned incident summary documents on 11/7/25, nursing staff on the behavioral care unit reported narcotic medications assigned to 2 residents were missing. A facility-wide search was immediately initiated. During the interview process, it was determined the medication cart had been left unlocked while the assigned nurse was within visible distance. This lapse in medication security allowed R1 to open the cart, remove several narcotic medications, and take them into his room with the intention of hiding them. On 11/22/25 at 1:00 PM, V8, Registered Nurse (RN), said he was working on the behavioral unit on 11/7/25, when he discovered missing narcotic medications in his medication cart. V8 said towards the end of his shift, he was verifying the count in his cart when he found 2 cards of Xanax (controlled medication) missing. He said the Director of Nursing was immediately notified. He said after searching the unit, the medication cards were found in R1s room. He does not know how R1 would have gotten the medications out of his cart. V8 said he had his keys throughout the shift, and the cart was within view. R1s face sheet documents he was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and disorganized schizophrenia. The 10/29/25 quarterly resident assessment and care screening documents he is cognitively intact. R1s 8/31/23 care plan notes he displays socially inappropriate behaviors due to his poor impulse control and psychosis such as taking things that do not belong to him or disregarding rules that interfere with his immediate desires.On 11/22/25, R1 said he was compliant with taking his medications from the nurse. He denied taking any medication cards from the medication cart.On 11/22/25 at 10:20 AM, V4, Licensed Practical Nurse (LPN), said R1 wanders the unit and takes medications. The nurse must stay with him to ensure he takes them. She said the nurse is the only person with the keys to the medication cart. It must be locked when stepping away. She was not sure what had happened, but somehow R1 ended up with medication cards in his room. She said there was a meeting about not leaving keys on the medication cart.On 11/22/25 at 12:00 PM, V3, Corporate Nurse, said V8 was assigned to the behavioral unit for 2nd shift. Towards the end of the shift, 2 narcotic medication cards were missing, and it was reported to V9, Director of Nursing. After the cart was re-checked, a search was conducted. V3 said V8 reported to him the medication cart had been locked. V3 said he determined the medication cart was located at the nurse's station and V8 was there with another resident. R1 came around the cart and opened the drawer. V3 could not say is the drawer was locked for sure, but R1 had 2 cards of Xanax. V3 said the medication cards were intact and R1 had not removed any of the pills. On 11/22/25, the behavioral unit medication cart was observed to be locked when unattended, and V4 was the only nurse working on the unit. She unlocked the cart when passing medications and locked the cart when stepping into resident rooms.2. R3 admission record shows an admit date of 6/3/25, with multiple diagnoses including aphasia (difficulty speaking) following a cerebral infarct (stoke), vascular dementia, and major depressive disorder. The 9/8/25 quarterly resident assessment and care screening documents her to have moderate cognitive impairment. The undated care plan showed she is resistive to care. She will also refuse/resist medications at times; including spitting medications out after administration despite education/encouragement and incentivized programming from staff.R3s nursing progress notes of 10/8/25 at 10:13 PM, show the counselor found in her room several pills that had been hidden by resident. DON aware and demanded 15-minute checks, and for the nurse to be aware of that behavior and assure the resident is taking her pills properly.On 11/22/25 at 12:00 PM, V3, V1 Administrator, and V7, Assistant Director of Nursing, said they were unaware of the incident. V3 said nurses should be staying with residents while administering medications and make sure they are not cheeking the pills.On 11/22/25 at 12:30 PM, V10, Behavioral Health Director, said, We found the pills in her room where she had spat the pills back into a cup following one of her medication administrations. I do not recall the number of pills, but it appeared to have been from 1 med pass. She was on daily room checks because she tends to hoard things. I gave the pills to the nurse to verify if they were hers. That is one of her behaviors, refusing her medications. On 11/22/25 at 1:00 PM, V8 said the [NAME] did find the medications and it looked like they were wet and had been spit out. He did not know how long she had those and was not able to identify the pills. He said when giving medications, the nurses are supposed to make sure the resident takes the pills and have them open their mouth to make sure they are taken. R3 is pretty compliant with doing the mouth check if you just ask her. V8 said R3 has a history of cheeking and pocketing her medication.On 11/22/25, R3 said she was not going to take her medications. R3 was alert but confused and had difficulty expressing her thoughts. Her room was located on the behavioral unit. On 11/22/25 at 10:20 AM, V4 said the nurse should stay with a resident to make sure they take their medications. On 11/22/2025 at 10:18 AM, R2 said he receives his medications daily when scheduled but did indicate two weeks ago, an African American agency nurse had come into his room on the evening shift and set a med cup that contained pills and a cup of water on my bedside table. R2 then indicated that this nurse said here's your meds then went back to her med cart that was outside of his doorway. R2 added that the nurse was standing in the doorway with her back turned away from him. R2 said he picked up the med cup and self-administered the medications with the water left by the nurse.On 11/22/2025 at 10:42 AM, R4 said a few weeks ago, a nurse on the evening shift left pills in a med cup on her bedside table then left the room and did not return. R4 said she does not recall taking the medications on that day.The facility's 2/2019 policy for Medication pass guidelines documents 11. Administering medications; Watch the resident swallow all medications. Do NOT leave any meds with the resident to take later. Do mouth checks, if necessary, to ensure meds were swallowed.The facility's 4/2019 policy for medication pass guidelines documents 3. Locking carts/keys: Carry your keys with you at all times. Never leave keys unattended in carts or out of the nurse's control, Do not leave cart(s) unlocked when unattended, lock cart when not in direct view. Schedule II controlled substances MUST be kept double locked.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer treatments were performed as ordered for 1 of 1 resident (R1) reviewed for pressure ulcers in the sample of 3. The findings include: R1's face sheet, printed on 8/1/25, showed diagnoses including but not limited to paraplegia, pressure ulcer of the sacral region stage 4 (lower area of the spine), third degree burns to the left and right lower legs, clostridium difficile (bacterial infection of the colon), neuropathic bladder, and chronic embolism/thrombosis of deep veins of right lower extremity. R1's facility assessment, dated 7/23/25, showed total staff dependence for toileting hygiene, dressing lower body, rolling, and transfers. The same assessment showed R1 is always incontinent of bowel. R1's weekly wound assessment, dated 8/1/25, showed a stage 4 sacral pressure ulcer measuring 4.7 x 4 x 0.5 centimeters (length x width x depth). The assessment showed a right, lower extremity burn measuring 6.9 x 1.9 x 1.1 (length x width x depth). The assessment showed the left, lower extremity burn was resolved as of 8/1/25. On 8/1/25 at 9:10 AM, R1 was seated in bed in her room. R1 was alert, oriented, and talkative. R1 stated she has a pressure ulcer on her back side and burns on her lower legs. R1 said the burns on both of her lower legs were from a heating blanket she was using at home (prior to facility admission). R1 said, The staff are not changing the dressings on any of the wounds like they should be doing. They should be changed on a daily basis and that is not happening. R1's sacral area was observed with a Certified Nurse Aide (V3) assisting her to turn. R1's sacral area had a dressing on it which was not dated or initialed. R1's left and right calves were observed and had dressings on them. Again, neither area was dated or initialed.R1's July 2025 physician orders showed an order, start dated 7/26/25, for wound care to the sacrum to be done on a daily basis. R1's July 2025 medication admission record showed wound care was not performed on 7/28 and 7/30. On 8/1/25 at 9:35 AM, V3 (Certified Nurse Aide) stated, (R1's) mental cognition is good. She is totally with it.On 8/1/25 at 11:05 AM, V2 (Wound Care Nurse) stated, (R1) is alert and oriented times four. She has to keep her wounds clean to avoid infection. She has orders for wound care on a daily basis. It is important to treat wounds as ordered. It is a basic nursing thing. Not treating wounds as ordered can cause them to worsen and slow healing.On 8/1/25 at 1:26 PM, V1 (Director of Nurses) stated wound care should be documented as soon as it is performed. No documentation means either the nurse forgot to document, or it was not done. There is the potential for wounds to heal slower or get infected when care is not given as ordered. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations policy, dated 3/2/21, states: 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. 24. Document the dressing change on the TAR or EHR (treatment administration record or electronic health record).

Based on observation, interview, and record review, the facility failed to ensure burn wound treatment orders were performed as ordered for 1 of 1 resident (R1) reviewed for non-pressure wounds in the sample of 3. The findings include: R1's face sheet, printed on 8/1/25, showed diagnoses including but not limited to paraplegia, pressure ulcer of the sacral region stage 4 (lower area of the spine), third degree burns to the left and right lower legs, clostridium difficile (bacterial infection of the colon), neuropathic bladder, and chronic embolism/thrombosis of deep veins of right lower extremity. R1's facility assessment, dated 7/23/25, showed total staff dependence for toileting hygiene, dressing lower body, rolling, and transfers. The same assessment showed R1 is always incontinent of bowel. R1's weekly wound assessment, dated 8/1/25, showed a stage 4 sacral pressure ulcer measuring 4.7 x 4 x 0.5 centimeters (length x width x depth). The assessment showed a right, lower extremity burn measuring 6.9 x 1.9 x 1.1 (length x width x depth). The assessment showed the left, lower extremity burn was resolved as of 8/1/25. On 8/1/25 at 9:10 AM, R1 was seated in bed in her room. R1 was alert, oriented, and talkative. R1 stated she has a pressure ulcer on her back side and burns on her lower legs. R1 said the burns on both of her lower legs were from a heating blanket she was using at home (prior to facility admission). R1 said, The staff are not changing the dressings on any of the wounds like they should be doing. They should be changed on a daily basis and that is not happening. R1's sacral area was observed with a Certified Nurse Aide (V3) assisting her to turn. R1's sacral area had a dressing on it, which was not dated or initialed. R1's left and right calves were observed and had dressings on them. Again, neither area was dated or initialed.R1's July 2025 physician orders showed an order, start dated 7/26/25, for wound care to the right and left lower extremities to be done on a daily basis. R1's July 2025 treatment administration record showed wound care was not performed on either extremity for 7/28 or 7/30/25. On 8/1/25 at 9:35 AM, V3 (Certified Nurse Aide) stated, (R1's) mental cognition is good. She is totally with it.On 8/1/25 at 11:05 AM, V2 (Wound Care Nurse) stated, (R1) is alert and oriented times four. She has to keep her wounds clean to avoid infection. She has orders for wound care on a daily basis. It is important to treat wounds as ordered. It is a basic nursing thing. Not treating wounds as ordered can cause them to worsen and slow healing.On 8/1/25 at 1:26 PM, V1 (Director of Nurses) stated, Wound care should be documented as soon as it is performed. No documentation means either the nurse forgot to document, or it was not done. There is the potential for wounds to heal slower or get infected when care is not given as ordered. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations policy, dated 3/2/21, states: 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. 24. Document the dressing change on the TAR or EHR (treatment administration record or electronic health record).

Based on interview and record review, the facility failed to treat a resident in a dignified manner by not ensuring an incontinent resident was changed for 1 of 1 resident (R1) reviewed for dignity in the sample of 3. The findings include: R1's face sheet, printed on 8/1/25, showed diagnoses including but not limited to paraplegia, pressure ulcer of the sacral region stage 4 (lower area of the spine), third degree burns to the left and right lower legs, clostridium difficile (bacterial infection of the colon), neuropathic bladder, and chronic embolism/thrombosis of deep veins of right lower extremity. R1's facility assessment, dated 7/23/25, showed total staff dependence for toileting hygiene, dressing lower body, rolling, and transfers. The same assessment showed R1 is always incontinent of bowel. On 8/1/25 at 9:10 AM, R1 was seated in bed in her room. R1 was alert, oriented, and talkative. R1 stated she is a paraplegic and needs help from staff with brief changes. R1 said she had terrible diarrhea a few nights ago and needed her brief changed multiple times in one evening. R1 said around 9:45 PM, she put on her call light and was told by the CNA (Certified Nursing Assistant) her shift was ending and the next aide on duty would come in to change her. R1 said no staff checked on her or changed her until around 6:15 AM the next morning. R1 said V2 (Wound Care Nurse) was the person who finally came into her room that morning and got her cleaned up. On 8/1/25 at 9:35 AM, V3 (Certified Nurse Aide) stated, (R1's) mental cognition is good. She is totally with it. (R1) is paralyzed from the waist down and needs to be checked for incontinence several times each shift. (R1) cannot feel if she is wet or soiled. On 8/1/25 at 11:05 AM, V2 (Wound Care Nurse) stated R1 is alert and oriented times four. V2 said she did see R1 that morning, and she did have stool in her brief. V2 said R1 was complaining that it had been a long wait to be changed, but did not recall the exact length of time. V2 said R1 had diarrhea overnight and a smell was present in the room. V2 said the sheets had stool on them and looked like they needed to be changed. V2 said, It is important to keep residents clean. Stool can cause infection and is gross to lay in. Staff should be checking residents at least every two hours, especially those that are bed bound and need help turning. On 8/1/25 at 1:26 PM, V1 (Director of Nurses) stated staff do overnight bed checks for safety and incontinence every two hours. V1 said R1 does need bed checks during the night. Residents should be changed immediately to stop wound infections and to stop skin break down. It is a dignity thing too. No one wants to be laying in a dirty brief.The facility's Routine Resident Checks policy, dated 9/2020, states: 1. To ensure the safety and well being of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel.

Based on observation, interview, and record review, the facility failed to ensure dietary aides handled dishware in a manner to prevent cross-contamination. This failure has the potential to affect all 156 residents in the facility, The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form, dated 5/12/25, showed a resident census of 156. On 5/12/25 at 9:05 AM, V16, Dietary Aide, placed a rack of dirty cups into the facility's dishwasher. After placing the cups into the dishwasher, V16 immediately walked over to a rack of clean pots, and began placing the pots on a kitchen shelf. V16 did not wash her hands after loading the dirty cups into the dishwasher. V16 wore no gloves. On 5/12/25 at 9:15 AM, V15, Dietary Aide, placed dirty breakfast dishes on a shelf by a kitchen sink. At 9:16 AM, V15 walked over to a rack of clean food trays, and placed the trays on a kitchen cart. V15 did not wash his hands after handling the dirty breakfast dishes. V15 wore no gloves. On 5/13/25 at 12:07 PM, V17, Certified Dietary Manager (CDM), stated, Staff should not be touching clean dishes after touching anything dirty to avoid cross-contamination. Staff should wash their hands when they are dirty and prior to touching clean dishes. The facility's Cross Contamination policy, dated 8/2018, showed, The Food & Nutrition Services staff will employ measures to prevent cross contamination . to reduce the risk of food borne illness . Practice good hand hygiene, hand washing, and glove use .

Based on interview and record review, the facility failed to screen residents for and offer the influenza vaccine to residents during influenza season; failed to screen residents for and offer the pneumococcal vaccine to residents upon admission; and failed to administer the pneumococcal vaccine to a resident who consented to receive the vaccine. These failures apply to 5 of 5 residents (R84, R137, R144, R145, R360) reviewed for influenza and pneumococcal vaccines in the sample of 31. The findings include: 1. R84's admission record showed R84 was admitted to the facility on [DATE]. R84's consent for the pneumococcal vaccine, dated 9/3/24, showed R84 consented to receive a pneumococcal vaccine. On 5/13/25 at 11:47 AM, V8, Infection Preventionist, stated R84 had never received a pneumococcal vaccine in the facility. 2. R137's admission record showed R137 was admitted to the facility on [DATE]. R137's immunization record, dated 5/13/25, showed no documentation R137 was ever screened for or educated on the influenza or pneumococcal vaccines. The record showed no documentation R137 ever received either vaccine. 3. R144's admission record showed R144 was admitted to the facility on [DATE]. R144's immunization record, dated 5/13/25, showed no documentation R144 was ever screened for or educated on the influenza or pneumococcal vaccines. The record showed no documentation R144 ever received either vaccine. 4. R145's admission record showed R145 was admitted to the facility on [DATE]. R145's immunization record, dated 5/13/25, showed no documentation R145 was ever screened for or educated on the influenza or pneumococcal vaccines. The record showed no documentation R145 ever received either vaccine. 5. R360's admission record showed R360 was admitted to the facility on [DATE]. R360's immunization record, dated 5/13/25, showed no documentation R360 was ever screened for or educated on the influenza or pneumococcal vaccines. The record showed no documentation R360 ever received either vaccine. On 5/13/25 at 11:47 AM, V8, Infection Preventionist, stated the facility had no documentation to support R137, R144, R145, and R360 had ever been screened for, educated on, or offered the influenza or pneumococcal vaccines while in the facility. V8 stated all residents should be screened for and offered the influenza vaccine from October-March annually. V8 stated all residents should be screened for and offered the pneumococcal vaccine upon admission to the facility by nursing staff. The facility's Influenza Vaccination policy, dated 12/14/2023, showed, The facility follows recommendations of the Center of Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) for influenza vaccinations to be offered October 1 through March 31 annually unless the immunization is medically contraindicated; the resident is already immunized; or after the provision of education on risks and benefits is reviewed with the resident/and or responsible party or chooses to refuse . All new admissions will be offered the influenza vaccine during October 1st through March 31st unless ordered otherwise or has already received the influenza vaccine . The facility's Pneumococcal Vaccination policy dated 12/2023 showed, It is the policy of this facility that residents will be offered immunization against pneumococcal disease in accordance with The Advisory Committee on Immunization Practices (ACIP) recommendations .

Based on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves in a manner to prevent cross contamination for one of 31 residents (R94) reviewed for infection control in the sample of 31. The findings include: R94's Admission Record, dated 5/13/25, shows he was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, narcolepsy, anemia, adult failure to thrive, dementia, and history of falling. R94's Care Plan, initiated 10/1/21, shows R94 experiences bladder incontinence and is incontinent of bowel. On 5/12/25 at 10:42 AM, V22, Certified Nursing Assistant (CNA), transferred R94 onto the toilet. R94 urinated and had a large bowel movement in the toilet. R94 used toilet paper to wipe the stool from R94's buttocks multiple times. V22 then pulled up R94's clean incontinence brief and R94's clean pants. R94 then flushed the toilet and pushed R94's wheelchair in front of the sink. V22 did not perform hand hygiene, nor did she wash her hands. On 5/13/25 at 10:27 AM, V14, Corporate Registered Nurse, said, Staff should change their gloves when they are dirty. Gloves should be changed prior to touching anything clean. The facility's Hand Hygiene Policy, dated October 2024, shows, It is the policy of the facility that hand hygiene is to be performed to reduce the potential spread of pathogens. There are two methods for hand hygiene: Alcohol based hand sanitizer (ABHS) is the preferred method of use in most clinical situation. ABHS should be used: When caring for a resident, when moving from a soiled body site to a clean body site of the same resident.

Based on observation, interview, and record review, the facility failed to ensure a resident who was contact isolation was allowed to leave her own room. This applies to 1 of 31 residents (R143) reviewed for resident rights in the sample of 31. The findings include: R143's face sheet shows she is a [AGE] year old female, with diagnoses including type 2 diabetes, fibromyalgia, generalized anxiety, chronic pain, restless leg syndrome, major depression, and urinary tract infection (UTI). R143's Urinalysis Culture Report, dated 4/29/25, shows Klebsiella pneumonia (MDRO). R143's Physician Order Sheets shows orders on 5/1/25 for Isolation: Contact Precautions: E Coli Urine. On 5/12/25 at 9:42 AM, R143 said last week she was placed on isolation for seven days for a urinary tract infection. At first, the staff said she could leave the room as long as she washed her hands. Then they changed their mind and said she had to stay in her room with the door closed, the last four to five days of her isolation. When she asked the staff why she couldn't leave they responded, It's (Facility) policy. She spoke to several staff including V4 (Assistant Administrator) and V8 (previous Director of Nursing-DON). R143 said, They did this so they could exert their power over me. It was rude, barbaric, and controlling. R143 said she is independent with cares, ambulates and toilets herself. She was compliant with hand washing, but they did not let me leave my room. R143 said she carries a small bottle of hand sanitizer with her and they told her no, she could not leave the room. On 5/13/25 at 7:49 AM, V7 (Unit Manager) said R143 was on contact isolation and could not leave her room. If they are on contact or droplet precautions residents remain in their room until the isolation time is discontinued. (R143) was upset she could not leave her room. On 5/13/25 at 9:03 AM, V6, Registered Nurse (RN), said, (R143) is very independent, and she is alert and oriented. She was moved to a private room and placed on isolation for Klebsiella (MDRO-multi drug resistant organism). (R143) was upset she could not leave her room, she does not like to be alone. Residents who are on contact isolation should remain in their room until isolation is completed, and practice hand hygiene when leaving the room. On 5/13/25 at 11:02 AM, V4 (Assistant Administrator) said R143 was on isolation, and she was told R143 could not leave her room. (R143) was asking why she couldn't leave her room, and the nurse on A wing said she has to stay in room. She notified V8 (previous Director of Nursing-DON) about R143's isolation concern. On 5/13/25 at 12:43 PM, V8 (previous Director of Nursing-DON) said, (R143) was on contact isolation and was not allowed to leave her room. She was educated on hand hygiene and educated to stay in her room. (R143) was independent, she could toilet herself, she could wash her hands and use appropriate infection control measures. We really wanted to make sure the organism was contained, and told (R143) she needed to remain in her room. On 5/13/25 at 10:25 AM, V14 (Corporate RN) said, If a resident is on contact isolation for an UTI, they can leave their room if they perform hand hygiene on their own, and as long as they are not touching other residents or residents food.

Based on observation, interview, and record review, the facility failed to set a resident's tube feeding pump to the Dietitian's recommended infusion setting for 1 of 4 residents (R30) reviewed for tube feedings in the sample of 31. The findings include: R30's Face Sheet, printed on 5/12/25, indicated R1 had a gastrostomy (tube feeding). On 5/12/25 at 11:00 AM, R30 was in bed connected to her tube feeding. The tube feeding pump showed an infusion rate of 55 milliliters (ml) per hour. The pump indicated the total volume to be infused was 1100 ml. On 5/13/25 at 8:28 AM, R30 was in bed, connected to her tube feeding. The tube feeding pump showed an infusion rate of 55 ml per hour. The pump indicated the total volume to be infused was 1100 ml. R30's Order Summary Report, dated 5/12/25, showed two orders for R30's tube feeding. One order was for a rate of 55 ml per hour, with a total volume of 1100 ml. The second order was for a rate of 60 ml per hour, with a total volume of 1200 ml. Both orders had a start date of 5/6/25. R30's Medication Administration Record for May 2025 showed, on 5/6/25 - 5/11/25, R30's tube feeding pump was infusing at 55 ml per hour, with a total infused volume of 1100 ml, and at 60 ml per hour with a total infused volume of 1200 ml. R30's Progress Notes, dated 5/12/25, 5/11/25, 5/10/25, 5/9/25, and 5/8/25, showed the tube feeding was infusing at a rate of 55 ml per hour, with a total volume of 1100 ml. On 5/13/25 at 8:28 AM, V12 (Registered Nurse) looked at R30's tube feeding orders and said, That's not right. V12 confirmed there were two tube feeding orders, and she would need to contact the Dietitian for clarification. V12 added there should only be one order. R30's Nutrition note, dated 5/1/25 entered by V13 (Dietitian), showed R30's previous weight loss was related to fluid and current weight loss was undesirable. The recommendation was to increase the tube feeding rate to 60 ml per hour, with a total infusion rate of 1200 ml, to increase caloric intake and promote weight stability. On 5/13/25 at 10:17 AM, V13 said R30 had weight loss that was fluid related, and on 5/1/25 she recommended to increasing R30's tube feeding rate to 60 ml per hour, with a total volume of 1200 ml to maintain R30's weight. V13 confirmed R30's tube feeding rate should be at 60 ml per hour, with a total volume 1200 ml. R30's Care Plan, with an initiated date of 2/6/25, showed R30 required tube feeding. Listed under interventions was to administer tube feeding as ordered. The facility's Enteral Nutritional Feeding, dated 9/2020, showed to verify orders for feeding.

Based on interview and record review, the facility failed to screen residents for, educate them on, or offer the COVID-19 vaccine/booster to residents upon admission to the facility for 3 of 5 residents (R137, R144, R145) reviewed for the COVID-19 vaccination in the sample of 31. The findings include: 1. R137's admission record showed R137 was admitted to the facility on [DATE]. R137's immunization record, dated 5/13/25, showed no documentation R137 was ever screened for, educated on, or offered the COVID-19 vaccine/booster. The record showed no documentation R137 ever received the vaccine. 2. R144's admission record showed R144 was admitted to the facility on [DATE]. R144's immunization record, dated 5/13/25, showed no documentation R144 was ever screened for, educated on, or offered the COVID-19 vaccine/booster. The record showed no documentation R144 ever received the vaccine. 3. R145's admission record showed R145 was admitted to the facility on [DATE]. R145's immunization record, dated 5/13/25, showed no documentation R145 was ever screened for, educated on, or offered the COVID-19 vaccine/booster. The record showed no documentation R145 ever received the vaccine. On 5/13/25 at 11:47 AM, V8, Infection Preventionist, stated the facility had no documentation to support R137, R144, and R145 had ever been screened for, educated on, or offered the COVID-19 vaccine/booster while in the facility. V8 stated all residents should be screened for and offered the COVID-19 vaccine upon admission to the facility by nursing staff. The facility's COVID-19 Vaccinations policy, dated 2/2025, showed, When recommended vaccines are available, the facility will ensure COVID-19 vaccines are readily accessible to both residents and staff . The residents medical record includes documentation that indicates, at a minimum the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine: and b. Each dose of COVID-19 vaccine administered to the resident; or c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal .

Based on observation, interview, and record review, the facility failed to ensure a resident's safety and prevent a resident from being burned by the heater (radiator) in her room. This failure resulted in R2 sustaining a deep partial-thickness burn to her right foot when she fell against the radiator mounted on the wall in her room. The facility failed to monitor temperatures of hot beverages prior to serving to residents. This failure resulted in R3 sustaining full thickness burns to her right thigh, left thigh, and buttock after spilling tea on her lap. These failures have the potential to affect all 160 residents in the facility. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/17/25 when R2 burnt her foot on the radiator in her room; sustaining a deep partial thickness burn to her right foot. The Immediate Jeopardy was identified on 2/13/25. V1 Administrator was notified of the Immediate Jeopardy on 2/13/25. This surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 2/13/25 and the deficient practice was corrected on 2/12/25 however noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The Facility Data Sheet, dated 2/11/25, showed a resident census of 160. On 2/11/25, V1, Administrator, stated every resident room in the facility had a wall mounted radiator. 1. R2's Post Occurrence Documentation note, dated 1/17/25 at 8:04 PM, showed R2 was found, by staff, on the floor of her room with her right leg stuck under the heater. The note showed R2 was found to have a burn to her dorsal area (top) of her foot. R2's Nurses Note, dated 1/17/25 at 8:33 PM, showed facility staff were notified of abnormal lab results on R2. R2 was sent to a local hospital for an evaluation due to her abnormal labs. R2's hospital records, dated 1/17/25-1/27/25, showed R2 was subsequently hospitalized with diagnoses of a high blood potassium level, Influenza A, urinary tract infection (UTI), and a second-degree burn to her right foot. The records showed R2's right foot burn required wound debridement during her hospitalization . R2 was discharged from the hospital on 1/27/25 and was readmitted to the facility. R2's readmission medical provider/nurse practitioner note, dated 2/3/25, showed R2 was seen today for readmission. She was recently hospitalized due to shortness of breath, cough, and a fall out of bed. She was admitted for sepsis due to UTI as well as bacterial . She was found to have a deep partial-thickness contact burn of the right dorsum of the foot and underwent bedside debridement . R2's wound note, dated 1/31/25, showed R2 was assessed by the facility's wound physician upon her readmission to the facility. The note showed, Report new wound to right foot. Burnt her foot via radiator . The note showed R2's burn covered the top (dorsal area) of her right foot and the first two toes of her right foot. The note showed R2's burn measured 9 cm (centimeters) x 5.5 cm x 0.1 cm. On 2/11/25 at 11:25 AM, R2 was in bed with her right foot propped up on a pillow. A large gauze dressing was noted around R2's right foot and ankle. When R2 was asked what happened to her foot, R2 stated, I got burned. I fell and my foot got stuck under the heater. My bed used to be over by the wall with the heater. I stuck in between there (between her bed and wall/radiator) when I fell . I couldn't get up. My foot was burning. On 2/11/25 at 9:52 AM, V14, Registered Nurse (RN), stated, That night (1/17/25), (R2) had a fall. I heard her calling for help. I found her on the floor of her room, stuck between the bed and the radiator on the wall. Her right foot had gotten stuck in the radiator. When I pulled her foot out from under the radiator, the top of her foot was bright red . On 2/11/25 at 1:55 PM, V12, Wound Physician, stated he was currently treating R2 for a second degree burn to her right foot caused by the radiator in her room. On 2/11/25 at 11:30 AM, V9, Maintenance Director, stated the facility currently did not have a process in place to monitor the temperatures heat produced by the wall radiators and/or the temperature of the radiator covers. V9 stated wall radiators were located in every resident room in the facility. V9 stated, We don't check the temperatures of the radiators. We can't control the wall radiators. They just kick in when the forced air heating system of the facility has trouble maintaining room temperatures. When it's colder outside and the forced air system has trouble keeping the temperatures up, the wall radiators will work longer and harder to help keep the room temperatures where they need to be. V9 also stated the facility did not monitor the outdoor daily temperatures. On 2/11/25, V1, Administrator, stated the facility did not have a policy or process on monitoring the temperatures of the wall mounted radiators. 2. A facility incident report, dated 1/23/25, showed R3 sustained burns to her right thigh, left thigh, and buttock area after spilling hot tea in her lap on 1/19/25. R3's wound note, dated 1/24/25, showed R3 was evaluated by V12 Wound Physician for burns to her bilateral thighs and buttocks caused by scalding of hot water. R3's right thigh burn measured 3.5 cm x 1.8 cm x 0.1 cm. R3's left thigh burn measured 6.0 cm x 4.0 cm x 0.1 cm. The note showed no measurements for R3's burn to her buttocks but showed the skin to R3's buttocks appeared red. On 2/11/25 at 2:34 PM, R3 was seated in bed. R3 stated on 1/19/25, the aide had just gotten a cup of hot water for my tea. I eat in my room. She put the cup on my table. I went to pick up the cup. My hand started shaking and spilled the whole cup all over my lap. It was hot. Not sure how hot it was but it burnt my legs. On 2/11/25 at 1:23 PM, V10, Dietary Manager ,stated it is the policy of the facility that no hot beverages leave the kitchen until the temperature of the beverage is at 120 degrees Fahrenheit (F) or below. V10 stated, We would get hot water for tea either by boiling tap water on the stove or getting it out of the coffee machine. We pour the hot water and/or coffee into separate insulated carafes and wait for the temperatures to drop before taking the carafes to the floor or dining room. The dietary aides are responsible for monitoring the beverage temperatures before beverages leave the kitchen. Once the temperatures are ok, the activity aides come down and get the drinks to pass out to residents while they are waiting for the food to come. On the day of the incident, I believe it was a Sunday, the activity aide ran out of hot water for tea. My understanding is that she came down and refilled the carafe with hot water by herself. I am not sure where she got the hot water from, but she did not check the temp of the water before she poured it for a resident . On 2/11/25 at 1:43 PM, V11, Activity Aide, stated on 1/19/25, I was serving coffee, cocoa, and tea to the residents before dinner. I ran out of the coffee and hot water I had in the containers I had gotten from the aides in the kitchen. I quick ran down to kitchen to refill my containers. I got the hot water for the tea out of the pot that was on the stove. The stove wasn't on, but the pot of hot water on the stove was steaming. I poured some of the hot water into my container and went back up to the floor. I have no idea what the temp of the water was. (R3) asked for a cup of hot water for her tea. I poured her a cup and put the cup on her table. We didn't put lids on the cups at that time. I was just walking out of her room when I heard her start yelling. She spilled her tea on her lap. On 2/11/25 at 1:55 PM, V12, Wound Physician, stated R3 had full thickness burns to her thighs from being scalded by water. The facility's AT RISK Hot Food and Beverage Temperature Service policy, dated 12/2024, showed, Food will be served at a temperature that is safe and palatable . Hot beverages to include coffee, tea, hot chocolate, hot water, cappuccino will be served at an ideal temperature of 120 degrees . The Immediate Jeopardy that began on 1/17/24 was removed 2/13/25, when the facility took the following actions to remove the immediacy: On 01/21/2025, education listed below was reinforced by the Administrator and Director of Nursing, with all staff that were working and those that were scheduled to work upcoming shifts thereafter. Education will continue to be conducted prior to the start of the next shift for each nursing, housekeeping, and dietary staff member and on an ongoing basis until all employees scheduled to work have been educated and demonstrate understanding of the education through pop quizzes and/or return demonstration of competency. Education will focus primarily on maintenance, nursing, dietary, and housekeeping staff with the potential to be impacted by non-compliance and not limited to staff involved in the actual incident. 1. All residents' heaters were reviewed for conditions that may make them unsafe. All resident beds were visually inspected to ensure they were not touching or within a close distance of the heaters. 2. All staff were educated on room safety checks and notifications to appropriate parties/vendors of equipment malfunction. Completed 01/21/2025 and ongoing for all incoming staff not on duty this day. 3. The [NAME] President of Facilities Environmental Services and Life Safety was called in on 01/21/2025 to verify that all resident's heaters are in good repair and functioning properly. 4. All staff were educated on updated hot beverage and temperature policy. Completed 1/23/2025 and ongoing for all incoming staff not on duty this day. 5. Coded door knobs were replaced on both kitchen doors to ensure only kitchen staff are to enter and exit from the kitchen, and have access to kitchen equipment and supplies. 6. A crowd control belt was added at the kitchen entrance at the elevator to remind any staff other than Dietary to ask for dietary's assistance. 7. Resident Council Meeting held on 2/12/25 to educate residents on the updated hot beverage policy 8. Resident Council Meeting held on 2/12/2025 to educate residents on room safety and keeping themselves away from thermal surfaces. 9. On 01/21/2025, the facility Administrator and IDT (interdisciplinary team) reviewed related policies and procedures. The following policies were reviewed: Incident/Accidents; Fall Management; Dietary Food and Beverage temperatures 10. The Administrator initiated a QA (Quality Assurance) audit tool for environmental safety checks to ensure that environmental hazards are resolved. Heaters in residents' rooms and common areas shall be maintained in a manner to prevent residents from prolonged contact with thermal surfaces. Weekly temperature checks of the radiator's thermal surface will be conducted with an Infrared Thermometer and placed on a log. Random room audits will be conducted 1 time per week for the duration of the heating season, and then on an as needed basis to ensure residents are safely placed away from the radiators. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Initiated 2/12/2025 and ongoing for QA monitoring. 11. The Administrator initiated a QA audit tool for hot beverage serving and temperature taking, to ensure that dietary staff are preparing hot liquids and taking temps of liquids as per the policy and ensure that hot beverages are served at the appropriate temperature. All resident wings will be reviewed 2 times a week for 30 days, then 1 time a week for 30 days, and then on an as needed basis until ongoing compliance is achieved The results of the QA audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. Initiated 1/23/2025 and ongoing for QA monitoring. 12. An emergency QA meeting was held by the Administrator with the Interdisciplinary Care Team and Medical Director on 01/21/2025 and 2/12/25 to review the removal plan. The QA committee shall meet monthly thereafter and review the results of the QA audits. Changes to the policy and procedure shall be made as indicated by the QA results. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator. Completed 02/12/2025 and ongoing for QA monitoring.

Based on observation, interview, and record review, the facility failed to store medication in a manner to prevent diversion for 2 residents (R8, R9) in 5 med rooms reviewed for medication storage in the sample of 13. The findings include: On 6/5/24 at 10:15 AM, all five medication rooms were checked for medication storage compliance. V5, Registered Nurse (RN), unlocked the A wing medication room door. This surveyor opened the unlocked refrigerator. The refrigerator contained an unopened bottle of morphine sulfate liquid on the top shelf. The bottle label showed it was issued for R8. The C wing medication room was unlocked by V6, RN. This surveyor opened the unlocked refrigerator. The refrigerator contained two ABHR suppositories in a clear plastic baggie on a shelf. The label on the baggie showed it was issued for R9. At 10:20 AM, V6 was asked what ABHR stood for. V6 looked the information up on his phone and said it stood for Ativan, Benadryl, Haldol and Reglan. On 6/6/24 at 8:55 AM, V2, Director of Nursing (DON), said morphine and lorazepam should be stored under two locks. It's a controlled drug and could be misused or abused. R8's 5/30/24 hospice record showed a physician signed order for morphine concentrate 100 milligram (mg)/5 milliliter (ml) (20mg/ml) oral solution. Administer 0.25ml (5 mg) orally or sublingually every 1-2 hours as needed. For pain or dyspnea. R8's record showed she was a current facility resident. The facility's 9/2022 Medication Pass Guidelines showed Schedule II controlled substances must be kept double locked. It is a good practice to keep all controls under double lock. The Drug Enforcement Administration (DEA) website showed morphine was a Schedule II narcotic under the Controlled Substances Act. R9's 11/30/23 hospice orders showed a physician signed order for ABHR suppository (Ativan 0.5 mg; Benadryl 25 mg; Haldol 0.5 mg; Reglan 10 mg;), 1 suppository rectally, every four hours as needed for nausea or vomiting. R9's record showed he passed away in the facility on 4/5/24. A lorazepam (Ativan) controlled drug storage policy and recommendations was requested and not received. The National Institutes of Health (NIH) website showed lorazepam concentrate had a risk of abuse, misuse, and addiction. This drug was a Schedule IV medication with a potential for abuse and addiction and should be refrigerated. This site showed lorazepam was a federally controlled substance because it can be abused or lead to dependence. The facility's 9/2020 Medication Storage Policy showed after 30 days, if the patient has not returned to the facility, medications should be returned to the pharmacy.

Based on interview and record review, the facility failed to ensure a complete assessment was completed with R2's initial change in condition and immediately notify the physician of the change in condition. The facility failed to obtain physician orders for an increase in oxygen per nasal cannula. This failure resulted in R2 being transported to the local emergency department on 3/25/24, 4.5 hours after her intial change in condition. R2 was in respiratory distress and failure upon arrival to the emergency department. This applies to 1 of 4 residents (R2) reviewed for quality of care in the sample of 12. The findings include: The Face Sheet, dated 4/29/24, for R2 showed medical diagnoses including acute respiratory failure, pneumonia, neuromuscular dysfunction of bladder, muscle weakness, unspecified abnormalities of gait, cognitive communication deficit, chronic obstructive pulmonary disease, low back pain, cardiomegaly, gastroesophageal reflux disease, obstructive sleep apnea, transient ischemic attack, dependence on supplemental oxygen, edema, hypertension, nicotine dependence, osteoporosis, allergic rhinitis, muscle spasm, intervertebral disc displacement, spondylosis, neuralgia and neuritis, fibromyalgia, heart failure, disease of pancreas, solitary pulmonary nodule, opioid dependence, non-rheumatic aortic valve insufficiency, disorders of kidney and ureter, history of Covid 19, congestive heart failure, moderate protein calorie malnutrition, cervicalgia, and chronic pain syndrome. The Pulmonary Consult, dated 3/4/24 for R2 showed, (R2) seen today for in-house pulmonary consultation. Resting comfortable in bed and in no acute distress. (R2) denies any shortness of breath, chest pain, fever or chills, cough. Does report chronic oxygen use. Pulse 72 beats per minute; oxygen saturation 93% on 3 liters per nasal cannula; respiratory rate 18 breaths per minute. Lungs: diminished to auscultation bilaterally, no wheeze, crackles, or rhonchi. Nonlabored respirations. Plan: severe COPD (chronic obstructive pulmonary disease). On supplemental oxygen by nasal cannula. Albuterol, 2 puffs every 4 hours as needed. Breztri, 2 puffs twice daily. Plan/Recommendations: continue current management. Please call pulmonary for any changes to patient respiratory status. The Physician Orders, dated 3/1/24 for R2 showed, Oxygen per nasal cannula @ 2-4 liters per minute continuous every shift. The Care Plan, dated 3/14/24, for R2 showed R2 in on antibiotic Cefdinir and doxycycline related to pneumonia. Monitor/document/report to MD (medical doctor) signs/symptoms of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, and agitation, and altered sleep cycle. R2 is noted with potential for respiratory difficulty secondary to sleep apnea. Administer oxygen as ordered. Monitor for any changes in respiratory status and notify MD as needed. R2 is noted with potential for respiratory difficulty secondary to diagnosis of chronic obstructive pulmonary disease. Unable to lie flat due to shortness of breath. Administer oxygen per MD orders. Monitor for signs of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, somnolence. R2 requires oxygen therapy secondary to respiratory failure and chronic obstructive pulmonary disease. Adjust oxygen to maintain saturation within adequate parameters (no parameters given). Administer oxygen per MD orders. Monitor for changes in respiratory status. Report any acute changes to MD. Monitor for signs and symptoms of respiratory distress and report to MD as needed. Respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. The Nurse's Notes, dated 3/15/24 for R2 showed, at 12:55 AM, receiving oxygen at 3 liters per nasal cannula; head of bed elevated to prevent shortness of breath. At 6:34 AM resident was diagnosed with pneumonia on 3/14/24 by chest x-ray. Resident was started on levofloxacin 500 mg per day and received the first dose last night. Resident on 3 liters oxygen continuously by nasal cannula. Resident oxygen saturations monitored at 2:30 AM and (oxygen) saturation was 93% on 3 liters; upon next round at 4:00 AM resident saturation was 88% and resident was given breathing treatment. Resident's head was lowered to change her adult brief and resident's saturation dropped to 77%. Resident oxygen temporarily increased to 5 liters and oxygen saturation increased back up to 88%. There was not a complete assessment documented or notification to the doctor of a change in condition when R2's oxygen saturations started to drop, continued to stay lower than normal, and oxygen was increased to 5 liters. The Resident's Vitals Record for R2, dated 3/15/24, showed at 2:29 AM, her oxygen saturation was 93% (no liters of oxygen documented). At 6:05 AM, R2 was 88 % on 5 liters of oxygen per nasal cannula. At 8:34 AM, R2's oxygen saturation was 84% (no liters of oxygen documented). The Change in Condition Evaluation form completed and dated 3/15/24 at 8:32 AM (4.5 hours after her initial change in condion) showed, Respiratory evaluation - other respiratory changes. Specify other: pneumonia. The assessment did not include if there was shortness of breath present or lung sounds. The Transfer Form completed by V12, RN (Registered Nurse), and dated 3/15/24 at 8:38 AM for R2 showed R2 was sent to the hospital on 3/15/24 at 8:25 AM for respiratory arrest. Pulse 102, respirations 20, oxygen saturation 84% via nasal cannula. Devices/treatments: oxygen at 6 liters per minute by nasal cannula/mask. The Nurse's Note written by V12, RN, and dated 3/15/24 at 1:53 PM for R2 showed resident oxygen saturation dropped to the low 80's while on 6 liters of oxygen with a continuous pulse oximeter on. R2 was sent to the emergency room . The Emergency Department Provider Note, dated 3/15/24 for R2 showed, (R2) .presents with altered mental status. The patient currently resides at a nursing home. The paramedics state the patient was noted to be altered over the past two days. The patient was noted to be hypoxic on room air today. As such, she has been transferred to the ED (emergency department) for evaluation. On arrival to the ED, the patient was in severe respiratory distress, with altered mental status, and unable to provide a medical history. Physical exam: blood pressure 143/46; pulse 124; temperature 102.7 degrees Fahrenheit; respiratory rate 38. Pulmonary: tachypnea, accessory muscle usage and respiratory distress present. Decreased breath sounds present. Neurological: she is unresponsive. Medical decision-making: On arrival the patient was unresponsive, hypoxic and in respiratory failure. As such, the patient was emergently intubated. On 4/26/24 at 11:57 AM, V13, RN, stated shortly before R2 went to the hospital, her oxygen saturation dropped some, so he bumped her up while he tried to contact the doctor. V13 stated R2 was maintaining her oxygen saturation in range, his shift ended, and another nurse came in. V13 stated if R2's baseline oxygen stauration was in the mid 90's on 3-4 liters and she dropped to 88%, that would be a change in condition for the resident. V13 stated he would have called the doctor. V13 stated he normally documents he contacted the doctor or that the doctor was contacted. V13 stated R2 was alert and talking to him. On 4/26/24 at 11:37 AM, V12, RN, stated she received report at 6:00 AM on 3/15/24 from V13, RN, who told her R2 had been diagnosed with pneumonia and was maintaining her oxygen saturation. V12 stated V13 told her he bumped up R2's oxygen to maintain her oxygen saturation at 88%. V12 stated V13 said he had put a continuous pulse oximeter on R2 because she had been de-satting (oxygen saturation level was dropping). V12 stated R2 de-satted quickly later. V12 stated after she spoke to the doctor, she put R2 on 6 liters. V12 stated she was told by the physician to send R2 out. V12 stated they have to follow the phsycians orders for oxygen. V12 was not sure if having an oxygen saturation of 88%-92% for somone with chronic obstructive pulmonary disease was in the policy or not. V12 stated she did not remember if she wrote the order from the doctor to increase R2's oxygen to 6 liters or not. On 4/26/24 at 12:20 PM, V11, NP (Pulmonology Nurse Practitioner), stated R2's baseline oxygen saturation was 93% - 96% on 3 liters of oxygen. V11 stated R2 's oxygen saturation of 88% on 5 liters of oxygen would be a change in condition for her, and the provider should be updated. V11 stated if the nurse could not titrate the oxygen back down and go to R2's basline oxygen saturation, that should be relayed to the provider. If R2 needed more oxygen and was at 6 liters then R2 needed to be sent out; she was unstable. V11 stated if they knew R2 had severe chronic obstructive pulmonary disease, had pneumonia, and needed an increase in oxygen, then the provider should have been notified right away On 4/26/24 at 1:54 PM, V15, CNA (Certified Nursing Assistant), stated R2 was not her resident on the day she was sent out, but she helped the other CNA with her. R2 was breathing heavily, had her oxygen on, and a full oxygen tank next to her that was working. V15 stated they reported it to the nurse. On 4/26/24 at 1:59 PM, V16, CNA, stated R2 had continuous oxygen. R2's oxygen saturation was unstable and it started at night and was lower than it should have been. When (R2's) oxygen saturation monitor beeped, I got the nurse. (R2's) pulse oximetry was on the lower end before I came in. (R2) wasn't speaking; she mumbled, but it wasn't clear. (R2's) breathing did not sound right. (R2) sounded more congested, a heavier sound. V16 stated R2's oxygen was at 5 liters before the pulse oximeter machine started alarming The facility's Oxygen Titration policy (9/2020) showed, oxygen will be titrated to maintain oxygen saturation levels greater than or equal to 92% unless prescribed otherwise. The facility's Change of Condition (Resident) policy (9/2020) showed, attending physicians or physician on call/NP (nurse practitioner) and responsible party will be notified of all changes in condition. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received.

Based on observation, interview, and record review, the facility failed to provide assistance at meals or implement interventions for a resident with significant weight loss for 1 of 5 residents (R48) reviewed for nutrition in the sample of 31. This failure resulted in R48 having a 10.22% weight loss in one month. The findings include: R48's face sheet showed a [AGE] year old female with diagnosis of Alzheimer's Disease, cerebrovascular disease, dementia, osteoarthritis, and chronic kidney disease. A diagnosis of failure to thrive was added 3/14/24. R48's weights showed a 2/1/24 weight of 107.6 pounds, and a 3/4/24 weight of 96.6 pounds. R48's 3/16/24 nutrition note showed R48's weight of 96.6 pounds was a 5% weight change in one month. This note showed a failure to thrive diagnosis was added, and the weight loss was contributed to a recent illness. No new interventions were added or recommended. R48's care plan showed she was at risk for dehydration and weight loss due to variable intake, history of dementia, and history of dehydration. This plan of care showed to monitor and encourage fluid intake, offer substitutes as needed and provide assistance or cueing for meals as needed. R48's physician order sheet (POS) showed a a 5/20/20 order for fortified potatoes, a 5/21/20 order for fortified cereal, a 2/7/22 order for a nutritional supplement twice daily, and a 12/5/23 order for fortified pudding. R48's 2/16/24 Nutrition Quarterly Assessment showed she required supervision with meals. On 04/02/24 at 12:36 PM, R48 was in a wheelchair at a table in the dining room. R48's food was in front of her. Staff were present in the room assisting other residents. R48 was not assisted, cued to eat, or prompted by staff. At 12:45 PM, R48 repeatedly moved away from the dining table by self propelling and moving the wheelchair away from the table. Staff would push her wheelchair back into place at the table . No attempts to assist or encourage R48 to eat were done. At 12:56 PM, R18, who was seated to R48's right at the dining table, pulled R48's plate of food away from R48 and toward herself. R18 ate some of R48's food with her fingers. R48 showed indifference at her food being taken. At 12:58 PM, V4, Memory Care Director, moved R48 in her wheelchair back to the dining table without noticing there was no food plate in front of her. R48 continued to attempt to move away from the table. At 1:01 PM, V4 pushed R48 in her wheelchair from the dining room and down the hall to her room. On 04/03/24 at 08:44 AM, R48 was in a wheelchair at the dining table. Minimal food was gone from her plate. There was no staff assisting R48. There was no cueing, supervision, or prompting her to eat. On 4/4/24 at 9:15 AM, V14, Dietician, said she was familiar with R48, and R48 is to be supervised during meals. I would expect the staff to be watching the residents, assisting them as needed, and to intervene if another resident is removing food from her tray. Due to her diagnosis of dementia, some days she eats well on her own, and other days she just stares off and needs staff assistance to eat. It's variable. I expect the staff to ensure they are meeting her needs each day. Cueing is an important aspect of meal supervision. Her PO (oral) intake is variable between 50-100%. On 4/4/24 at 10:42 AM, V2, Director of Nursing (DON), said R48 was diagnosed with shingles on 2/12/24, and was isolated in her room. V2 said, That's the reason for her weight loss.

Based on observation, interview, and record review, the facility failed to maintain sanitization logs, and failed to ensure food was covered during transportation. This applies to all residents residing in the facility. The findings include: The CMS 671 form, dated 4/2/24, showed 155 residents residing in the facility. 1. On 4/2/24 at 9:53 AM, staff were observed using the facility dishwasher after the breakfast meal. V18 (Dietary Aide) stated, The dishwasher sanitizing temperature is tested with a heat strip before every use. It is tested before every meal to be sure it is running hot enough to clean the dishes correctly. The test results are documented on the log after each test. At 10:20 AM, V20 (Dietary Aide) tested random sanitizer buckets for the proper chemical levels. V20 said the buckets are tested three times each day, and the results are documented on the log. The March and April 2024 dishwasher and sanitation bucket logs were reviewed with V17 (Dietary Manager) present. The March dishwasher log was missing eight temperature test results. The March sanitation bucket log was missing 34 sanitation level test results. On 4/3/24 at 2:50 PM, V17 stated, It is important to test and document the results, so we know the dishes and surfaces are being sanitized correctly. Staff should be checking and documenting test results three times per day. Residents are at risk of food borne illness if dishes and surfaces are not clean. The facility's Mechanical Washing Sanitation Testing policy revision, dated 3/18, states: Before dishes are washed, the sanitation temperature or chemical sanitizer in the dish machine should be tested with the correct test strip . 2. On 4/2/24 at 11:31 AM, V19 (Dietary Aide) was observed transporting resident food carts from the basement kitchen to the first-floor kitchenette area. The carts came up from the basement via a common elevator used by staff and visitors. The dessert cakes on every cart were uncovered. On 4/3/24 at 11:39 AM, the resident lunch carts were observed in the first-floor kitchenette and C wing dining room. The chocolate puddings on every cart were uncovered. Dietary staff were observed exiting the elevator with additional lunch carts. All puddings were uncovered. At 2:48 PM, V17 (Dietary Manager) stated he was not sure why the desserts are not covered prior to leaving the kitchen. V17 said the foods are covered before being transported onto the resident units, but not on the way up to the kitchenette for plating. V17 said all food should be covered to prevent dust and other particles from falling on top of the food. V17 stated the desserts should have been covered prior to being transported upstairs. The facility's Transportation of Food policy revision dated 8/18 states: .Food will be transported in a covered container as quickly as possible.

Based on observation, interview, and record review, the facility failed to ensure multi-dose vials were labeled when opened (R16, R13), failed to dispose of an expired medication (R56), and failed to double lock a controlled medication (R127) for four of four residents reviewed for medication storage in the sample of 31. The findings include: 1. R16's April 2024 order summary report showed an order start, dated 11/2/20, for fluphenazine decanoate (antipsychotic) to be administered intramuscularly at 37.5 milligrams every 21 days for schizophrenia. R13's April 2024 order summary report showed an order start, dated 6/7/17, for fluphenazine decanoate (antipsychotic) to be administered intramuscularly at 25 milligrams/milliliter every 28 days for schizophrenia and bipolar disorder. On 4/3/24 at 9:51 AM, R16 and R13's medications were in the B wing medication room. Both multi-dose vials were opened, and half of the medication had been dispensed. The vials were not dated with any open date or staff identification. 2. On 4/3/24 at 9:51 AM, the B wing medication room contained eight multi-dose vials of haloperidol (antipsychotic), which was labeled with R56's name. All eight vials were sealed and showed expiration dates of January 2024. R56's April 2024 order summary report was reviewed, and there was no order for the haloperidol. On 4/3/24 at 10:00 AM, V22 (Registered Nurse) stated she would guess the open multi-dose vials for R16 and R13 were only good for 30 days. V22 said after that it needs to be dumped. V22 said, The vials are undated and there is no way of knowing how long they are usable. They should have been dated so staff know when they are expired. V22 stated, The haloperidol is expired and needs to be discarded. It cannot be used after the expiration date. There is no need for it to be in the medication room. It should have been given to the Director of Nurses already. There is the potential to accidentally give it to the resident. It could cause a fatal mistake or not work as well. On 4/3/24 at 2:19 PM, V23 (Nurse Consultant Pharmacy) stated multi-dose vials need to be labeled with the open date, and are only good for so many days. V23 said the fluphenazine manufacturer determines how long the vials are usable after being open. V23 stated expired medication could become less potent and be less effective. V23 said there should not be expired medications in the medication room. There is the potential for nurses to give it to the resident by mistake, and it needs to be disposed of as soon as it is expired. At 3:05 PM, V23 verified the fluphenazine vials were usable for 28 days after being opened. V23 said there is no way of knowing when to disposed of the vials when the dates are missing. The facility's Storage/Labeling/Packing of Medication policy, dated 1/2022, states: 4. Medication requiring refrigeration are stored in a refrigerator located in a locked room accessible only to licensed staff. 5. Individual resident's medications are stored and labeled according to legal requirements, including requirements of acceptable manufacturing practices. 10. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. 35175 3 R127's face sheet showed a [AGE] year old female with diagnosis of dementia, severe protein calorie malnutrition, depression, Raynaud's syndrome, Systemic Lupus Erythematosus, functional quadriplegia, coronary artery dissection, heart failure and rheumatoid arthritis. On 04/03/24 at 08:51 AM, the medication storage task was done on the facility's memory care wing. This surveyor was assisted by V4, Memory Care Director. V4 was looking through keys to unlock the medication refrigerator in the medication room. This surveyor reached down and opened the unlocked door. Inside the refrigerator was an unopened bottle of lorazepam with R127's name on it. On 04/03/24 at 1:40 PM, V23, Nurse Consultant/ Pharmacy, said, Liquid lorazepam should be stored under 2 locks. It is considered controlled drug and has potential for abuse. V23 said she would check to see if there's a policy. The refrigerator should be locked for safety. That's not stored properly. A lorazepam controlled drug storage policy and recommendations was requested and not received. R127's physician order sheet (POS) showed a 3/27/24 order for lorazepam concentrate (liquid) to be given every four hours as needed. The National Institutes of Health (NIH) website showed lorazepam concentrate had a risk of abuse, misuse, and addiction. This drug was a Schedule IV medication with a potential for abuse and addiction and should be refrigerated. This site showed lorazepam was a federally controlled substance because it can be abused or lead to dependence.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer interventions were in place, residents were turned and repositioned, and residents at risk for pressure had prevention measures in place for 5 of 12 residents (R146, R2, R11, R36, R75) reviewed for pressure ulcers in the sample of 31. The findings include: 1.R146's Facesheet, dated 4/4/24, showed diagnoses to include, but not limited to: chronic respiratory failure, stroke with right sided weakness, disorder of the brain, acute necrotizing hemorrhagic encephalopathy, generalized edema, dysphagia, sacral pressure ulcer, neuromuscular dysfunction of the bladder, gastrostomy tube, and patent foramen ovale. R146's facility assessment, dated 1/20/24, showed he had severe cognitive impairment and was dependent on staff for all ADLs (Activities of Daily Living). R146's Care plan, iniated 3/14/24, showed, [R146] has an ADL functional performance deficit related to chronic respiratory failure, hemiplegia, HTN (hypertension), brain disorders, diabetes, dysphagia, edema, and muscle weakness . R146's Care Plan, initiated 3/14/24, showed, Actual alteration in skin integrity related to a stage 3 pressure injury on his sacrum, present on admission. Also has a healing tracheostomy . Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. R146's Physician Order Sheet, dated 4/4/24, showed, low air loss mattress. R146's Weight on 4/1/24 showed 176.9 pounds. R146's Wound Assessment, dated 3/29/24, showed R146 had a sacral wound measuring 8 cm x 3 cm x 0.3 cm with 60% granulations; 20% necrotic/brown eschar; and 20% epithelialization. The note showed to continue offloading (proper use of the air mattress and turning/repositioning) and providing pericare. On 4/2/24 at 10:43 AM, R146 was lying on an air mattress, with the head of his bed elevated. The air mattress control panel was attached to the foot of the bed. The number on the weight display showed 270 pounds. R146's air mattress model had a digital display that showed the weight in numbers. At 1:29 PM, R146 was observed lying on the air mattress. The weight display showed 270. On 4/3/24 at 10:43 AM, R146 was lying in bed and the tube feeding pump was alarming. The air mattress weight display now showed 180. On 4/4/24 at 8:40 AM, V11 (Licensed Practical Nurse - LPN), V10 (Unit Manager), V3 (Wound Care Nurse), and V13 (Certified Nursing Assistant - CNA) entered R146's room to provide wound care. V13 (CNA) assisted R146 with turning to the left side. V11 (LPN) used hand on hand to assist R146 in turning further on his side. V11 removed an old foam dressing to R146's sacral wound. R146's entire sacral area had redness, and there were two open areas noted, one at the top of the gluteal cleft and one just to the right of this area. V3 (Wound Care Nurse) said she rounds with the Wound Care Nurse Practitioner, and she had assessed this area as one pressure wound. V11 completed the R146's dressing change. R146 remained on the air mattress with the weight display at 180. The surveyor asked V3 (Wound Care Nurse) what the settings on the air mattress display meant. V3 replied, I'm not an expert on the beds, but [V10] received the training and she knows how they work. V10 (Unit Manager) stepped up and said the 180 was the weight setting. V10 said the resident's weight is obtained and the bed is set with the correct information. V10 said she would have to check R146's weight and left the room. V10 returned and said R146's weigh was 176. The surveyor asked V10 if there was any reason R146's weight would have been set at 270. V10 stared blankly and replied, No, it should not have been set at that. I have no idea how it would have been. V10 said the display panel on R146's model did not lock, someone could have changed it. V3 (Wound Care Nurse) said the air distribution and firmness of the bed would be based on the resident's weight. V3 said the bed would be more firm with a higher weight setting. V3 said it's important to ensure the air beds are set properly for wound healing and prevention of pressure wounds. V3 stated, I don't know who is responsible for ensuring the beds are set properly, but someone should be rounding daily to check that. 2. R2's Facesheet, dated 4/4/24, showed diagnoses to include, but no limited to: chronic respiratory failure, diabetes, dependence on ventilator, osteoarthritis, hypertension, gastrostomy tube, congestive heart failure, unspecified convulsions, disorder of adrenal gland, aphasia, schizophrenia, hydrocephalus, and stroke. R2's Physician Order sheet, dated 4/4/24, showed low air loss mattress. R2's Weight on 4/1/24 was 161.8 pounds. R2's Care Plan, initatied 2/28/20, showed, [R2] has an ADL self care performance deficit related to limited mobility, CVA (stroke), chronic respiratory failure, HTN (hypertension), GERD, gastrostomy, type 2 diabetes, and osteoarthritis . R2's Care Plan, initated 2/10/20, showed, [R2] has the potential for alteration in skin integrity secondary to incontinence, assist required with bed mobility, and presence of medical equipment which may cause pressure. Has chronic moisture in skin folds causing rashes. MASD (Moisture Associated Skin Disorder) from loos stools related to antibiotic use . Pressure reduction foam mattress or pressure redistribution support (low air or alternating) in bed . On 4/2/24 at 10:44 AM, V29 (Registered Nurse - RN) entered R2's room to administer medications. R2 was lying in an air bed. R2's elbows, wrists, knees, and hips were contracted. R2's arms were tucked tight against her chest, and her legs were pulled up toward her bottom. R2 was nonverbal and totally dependent on staff for care. R2 was receiving mechanical ventilation. V29 said R2 is contracted all over and is at risk for developing pressure ulcers. V29 said she is completely dependent on staff for all ADLs and doesn't communicate with the staff. R2's air mattress display had several green hash marks that displayed the weight setting. R2's showed that her bed was set at 340. At 1:19 PM, V30 (Respiratory Therapist - RT) entered R2's room to provide a nebulizer treatment. R2 was lying on her back, in the air bed. The weight setting remained at 340. On 4/4/24 at 8:32 AM, R2 was lying in her air bed. The setting had been changed to 180. On 4/4/24 at 8:16 AM, the surveyor took V10 into R2's room. V10 said R2's air mattress a different model than R146's. V10 said R2's model showed the green hashes lit up to the weight setting. V10 stated, Right now it's set at 180. The surveyor asked why it would be set at 340. V10 replied, It should not have been set at 340. I don't even know how that would happen. This display has a lock button on it. When the beds are delivered, I set them at the correct settings. I don't know how they would have been set incorrectly. This is ridiculous. On 4/4/24 at 8:28 AM, V3 (Wound Care Nurse) said she didn't know why R2 was on an air bed. At that time, V12 (CNA) walked by and replied, Because she's on a vent. All our vents are on an air mattress. V3 said she would review R2's care plan and past assessments because she wasn't familiar with R2. V3 said R2's care plan showed she is at risk for skin breakdown due to her diagnoses and dependence on staff for movement. 31615 3. R11's admission record shows she was admitted to the facility on [DATE]. Her care plan for potential alteration in skin integrity documents a history of stage 3 pressure injuries to her sacrum. The interventions include a pressure reduction foam mattress or redistribution support (low air or alternating air)in bed. The facility resident matrix shows R11 currently has a Stage 3 pressure injury. On 4/2/24, the air mattress on R11's bed was a Proactive 4000/5000XD and was set at 210 pounds. On 4/3/24 the bed was set at 240 pounds. The weights and vitals summary sheet shows on 4/1/24, R11 weighed 186 pounds. 4. On 4/2/24, R36 was observed at frequent intervals between the hours of 10:00 AM and 2:30 PM, and during those observations, she was found to be lying on her back in bed. She had no pillows for repositioning or heels elevated during the observations. On 4/2/24, the air mattress was a Proactive Protekt 6000 and set to a weight of 280 pounds. On 4/3/24, the bed setting was 180 pounds. The weights and vitals summary sheet shows on 4/3/24, R36 weighed 157 pounds. On 4/4/24 at 9:50 AM, V27, CNA, said R36 has to be repositioned by staff at least every 2 hours as she is unable to move on her own. She said R36 has a pressure wound on her buttocks, and she needs to be moved so it can heal. 5. R75's 3/29/24 skin evaluation for R75 documents she has a stage 3 pressure ulcer to her sacrum. The same document shows a plan of care of off loading her torso, lower extremity, and general body. On 4/2/24, R75 was observed at frequent intervals between the hours of 10:00 AM and 2:30 PM, and during those observations R75 was sitting up in the same position in her bed. She was not out of bed for the noon meal or activities. R75 appeared to be a petite, frail woman. She had an air mattress Proactive 4000/5000XD on her bed set at 180 pounds. On 4/3/24 the bed setting was at 150 pounds. The weight and vitals summary shows on 4/1/24, R75 weighed 91 pounds. On 4/4/24 at 9:00 AM, V28 RN (Registered Nurse) said R75 has to be turned every 2 hours to relieve the pressure to the sacrum. She has a dressing change daily to her wound already on that area. The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations Policy, dated 3/2/21, showed, Policy: 1. Identify residents at risk for developing pressure injuries. 2. Identify the presence of pressure injuries and/or other skin alterations. 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. The undated Air Mattress Operation Manual showed this mattress had individualized, customized settings. The manual showed, This product is designed to provide maximum comfort to patients. Make sure that you operate this product in a proper way optimizing its value . Weight/Pressure set up: Users can adjust air mattress to a desired firmness according to patient ' s weight or the suggestion from a health care professional .

Based on observation, interview, and record review, the facility failed to identify a significant weight loss and failed to ensure interventions were in place for a resident with significant weight loss. This failure resulted in R86 sustaining a 21.6 pound (16.41%) weight loss in one month. This applies to 2 of 2 residents (R86, and R117) reviewed for weight loss in the sample of 28. The findings include: 1. R86's Admission Record (Face Sheet) shows her diagnoses to include, metabolic encephalopathy, type 1 diabetes mellitus with ketoacidosis, chronic kidney disease, congestive heart failure, non-pressure chronic ulcers of bilateral ankles/feet, and peripheral vascular disease. R86's 3/15/23 POS (Physician Order Sheets) shows fortified cereal was ordered for every morning. There were no more intervention until 6/22/23. R86's Progress notes shows on 3/18/2023 at 7:00 PM, V19,RD (Registered Dietitian) wrote R86 triggered for significant weight loss of 5% in 30 days. R86's weight was 132 pounds at that time. V19's suggested an intervention of fortified cereal, and to continue to monitor R86's weight. The progress notes from 3/15/23 to present shows the Nurse Practitioner documented R86 is well nourished. R86's electronic medical record shows on 4/3/23, R86's weight was 131.6 pounds, and on 5/9/23, her weight was 110.0 pounds, for a weight loss of 21.6 pounds, or 16.41% in one month. R86's BMI (Body Mass Index) at that weight (110 pounds) is 20.1. R86's weight on 6/5/23 was 102.5 pounds, which makes her BMI 18.7. According to the CDC (Centers for Disease Control) web site, the BMI is calculated by an adults weight in kilograms by they're height in meters squared. A healthy BMI is between 18.5 and 24.9. R86's Care Plan shows she requires Nutritional Support, and the goal is for her to adhere to her therapeutic diet. There is no weight loss care plan. R86's 5/22/23 MDS (Minimum Data Set) shows she is cognitively intact. Section G shows R86 needs supervision for eating. R86's weights: 1/2/23 147 pounds; 2/8/23 132 pounds; 3/15/23 131.2 pounds; 4/3/23 131.6 pounds, 5/9/23 110 pounds; 6/5/23 102.5 pounds. The 5/21/23 Nutritional Quarterly/Reassessment Assessment shows R86's weight on 5/9/23 (110 pounds) and 4/3/23 (132 pounds). This same document shows significant weight loss. The interventions suggested were to continue to monitor food intake and weights. The Summery shows the current diet meets nutritional needs. V19's weight notes shows all the residents who triggered from April to May 2023, and R86's name is not printed on the notes, however, her name (R86's) is hand written on the notes with a down arrow. On 6/21/23 at 8:30 AM, R86 ate half of her breakfast and only a few bites of her super cereal. On 6/21/23 at 12:30 PM, R86 said, she was not hungry. R86 said, I don't always eat because I'm not hungry. I don't want to stuff myself and be uncomfortable. 6/22/23 12:30 PM, V19, RD (Registered Dietitian), said, The process is the CNA's (Certified Nursing Assistants) gets the weights on the residents monthly and put those weights into our electronic medical records, which automatically triggers a significant weight loss for a resident who lost a lot of weight. These weights go to V10, DM (Dietary Manager), and then we have a monthly meeting to discuss the residents with weight loss and possible interventions. For some reason, (R86) did not trigger for weight loss between April and May 2023. Her (R86's) weight loss is severe from April 2023 to May 2023, and she would have put in additional interventions if I had been aware. V19 said she doesn't see month to month weight comparisons on residents unless they trigger for weight loss, so she doesn't know how she could have known. V19 said she is not sure why R86 did not trigger. V19 said R86's weight loss could impact her health in a negative way. On 6/22/23 1:00 PM, V3, DON (Director of Nursing), said he looks at all the weights every month, and if he thinks the weight is wrong, he will re-weigh the resident. V3 said he did not re-weigh R86 in May 2023. V3 said he is not sure how he missed that. V3 said the system didn't flag R86 for weight loss, and he believes it was an error of the Dietitian for not clicking a certain box. V3 said, That is too much weight to loss in a month, and could be detrimental to R86's health. On 06/22/23 1:30 PM, V10, DM (Dietary Manager), said he goes over all the weights that triggered for weight lose with V19, RD, every month. V10 said he doesn't know why R86 did not trigger for weight loss. V10 admitted , That's a lot of weight to lose. V10 said he enters all the weights the CNA's take, so V19 can review them and make recommendations. V10 didn't notice the change because he depends on the electronic medical record to trigger weight loss for that resident. V10 said, That could impact her health in a negative way. (R86) had significant weight loss between April and May. 20042 2. R117's The Nutrition Quarterly/Reassessment/Assessment, dated 5/26/23, showed she is to have fortified potatoes twice a day, nutritional supplement shake twice a day and fortified pudding at lunch. The weight history included: 5/2/23-129 lbs (pounds); 4/3/23-130 lbs; 3/2/23-145 lbs, 2/10/23-146 lbs, 1/4/23-146 lbs, and 12/5/22-150 lbs. Significant weight change in past 6 months and past 3 months. Variable intake. Dining skills: supervision. Nutrition goals: maintain hydration, increase intake, and oral intake greater than 50%. R117's MDS (Minimum Data Set) Assessment, dated 5/29/23, showed moderately impaired cognition; supervision and set up needed for eating. R117's Dietary Care Plans, dated 6/5/23, showed, requires nutritional support related to dysphagia following cerebral infarction; has the potential for hypo/hyper glycemic reactions secondary to diagnosis of diabetes mellitus; (R117) has potential for altered cardiac function related to diagnoses of hypertension. R117 did not have a care plan in place for a significant weight loss. R117's Admission Record (Face Sheet), dated 6/22/23, showed medical diagnoses including right sided hemiplegia following cerebral infarction, aphasia, dysphagia, atrial fibrillation, type 2 diabetes mellitus, polyosteoarthritis, adjustment disorder with depressed mood, vascular dementia, and hypertension. R117's Physician Orders, dated 6/22/23, showed fortified pudding in the afternoon for a nutritional supplement On 6/21/23 at 12:27 PM, R117 was sitting in her wheelchair at the dining room table. R117 had a general diet that consisted of rice, mixed vegetables, cake, and chicken with mushrooms and a sauce. R117 had an unopened container of fortified chocolate pudding on the table near her plate. At 12:43 PM, R117 wheeled herself away from table after eating her chicken, some vegetables, and cake. R117's container of fortified pudding remained unopened and untouched on the table. Staff were not observed providing verbal cues to R117 during her meal; no one encouraged R117 to eat her fortified pudding. On 6/22/23 at 7:49 AM, V3, DON (Director of Nursing), stated, (R117) has had weight loss and we put interventions in place. (R117) goes to the dining room to eat, is monitored at meals, and receives supplements to help with her weight loss. The supplements are important because they are to help her gain weight. Staff are to assist with opening supplements and encourage the resident to eat the supplement. The facility's Nutrition Care Significant Weight Loss policy (1/2018) showed, Policy: Residents with significant weight loss will be assessed by the Licensed Dietician. Purpose: To reduce the risk of malnutrition. Procedure: Residents with significant weight loss will be discussed with members of the interdisciplinary team (IDT). A significant weight loss is 5% in one month, 7.5% in 3 months, and 10% in 6 months. The Licensed Dietician (LD) will evaluate the cause of the weight loss and recommend nutrition interventions to prevent further weight loss or enhanced weight gain. Interventions may include supplements, snacks, favorite foods, referral to other member of the health care team for evaluation, diet liberalization, etc. The LD will document findings and recommendations in the medical record. Recommendations will be discussed wit the resident, member(s) of the IDT, and forwarded to the physician via nursing services. Upon change in diet order (physician order) or other intervention the care plan will be updated. The facility's Nutrition Assessment policy (12/2017) showed, Policy: A nutrition assessment will be completed for each resident admitted into the building. Purpose: To reduce the risk of malnutrition. Care plans are developed to identify nutrition problems/strengths, goals, and approaches. The Nutrition Intervention & Monitoring policy (1/2018) showed, Policy: The Licensed Dietician (LD) will evaluate assessment data and develop nutrition interventions as appropriate. Purpose: To reduce the risk of altered nutrition. Procedure: Upon evaluation of the assessment data the LD will determine if a nutrition intervention recommendation is required. Interventions may be required for such things as significant changes in oral intake, weight, abnormal labs, increased nutrient needs, referral to other IDT (interdisciplinary team) member, and so forth. The LD will document the recommendation in the medical record and the dietician recommendation form. The LD will provide a copy of the Dietitian Recommendation form to the Director of Nursing or designee for a decision by the physician. After implementation of the intervention the nutrition status of the resident will be reviewed at a minimum of quarterly. When status is not improving the LD will offer alternative interventions or indicate why current interventions continue to be appropriate.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner, which resulted in a resident (R1) falling and subsequently fracturing her left hip which required surgical repair. This past noncompliance occurred from (MONTH) 17, 2020 to (MONTH) 18, 2020. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: R1's Care Plan, dated (MONTH) 19, 2019, showed R1 required the assistance of two staff members when being transferred due to her past medical history of [REDACTED]. R1's facility assessment, dated (MONTH) 10, 2019, showed R1 was cognitively intact and required extensive assistance of two staff members when transferred and toileted. R1's Fall Incident Report, dated (MONTH) 17, 2020 at 11:16 PM, showed R1 slid off the toilet as she was being transferred by V4, Certified Nursing Assistant (CNA). 911 was called and R1 sent to a local hospital due to her complaint of left hip pain. R1's hospital physician H & P (history and physical) notes, dated (MONTH) 18, 2020, showed R1 was attempting to go to the bathroom with the help of a CNA as she is wheelchair-bound. She says she fell over the toilet and fell on to her left hip. The notes also showed R1 was being admitted to the hospital for a fall at nursing home with subsequent left [MEDICAL CONDITION]. R1's hospital Operative Report, dated (MONTH) 18, 2020, showed R1 underwent surgical repair of her left [MEDICAL CONDITION]. On (MONTH) 25, 2020 at 8:30 AM, R1 was lying in bed as V6, CNA, was providing cares to R1. A large gauze bandage was noted to R1's left lateral hip area. R1 pointed to her left hip and stated, I broke my hip when I had a fall. (V4, CNA) transferred me to the toilet by herself and I didn't really make it all the way on the toilet and I fell off. She (V4) didn't use no gait belt when she tried to move me either. I fell on my left side. Now I have screws in my hip. I had surgery to fix it. At 8:41 AM, V6, CNA, stated, Since (R1) had her fall, she is now transferred by a mechanical lift. Prior to her fall, she was transferred with a gait belt and two person assist. On (MONTH) 25, 2020 at 10:00 AM, V2, Director of Nursing (DON), stated on (MONTH) 17, 2020, as V4, CNA, transferred R1 to the toilet, without the assistance of a second staff member, R1 slid off the toilet landing on the floor, on her left side. V2, DON, also stated he was unsure if V4, CNA, utilized a gait belt during the transfer of R1. V2 stated because R1 was to be transferred with the assistance of two staff, V4, CNA, should have gotten another staff member to assist in transferring R1 on (MONTH) 17, 2020. On (MONTH) 25, 2020 at 10:15 AM, V1, Administrator, stated, We realized right away (V4, CNA) made a mistake by transferring (R1) by herself so we started education immediately for staff. On (MONTH) 25, 2020 at 10:30 AM, V3, Nurse Practitioner (NP), stated, (R1) is cognitively intact, wheelchair-bound, and has no movement of her left arm or left leg due to a previous stroke. She cannot bear weight on her left leg. I don't know how she transfers as I rely on nursing to make that assessment and determination. If the facility had determined (R1) needed to be transferred safely by use of a gait belt and two staff members, then that's how she should have been transferred. The facility's Transfer Techniques Policy, dated (MONTH) 2019, showed, Purpose: To safely transfer the resident from bed to chair or from one location to another . Procedure .2. Obtain assistance of another individual if necessary for safe transfer .7. Place gait belt around resident's waist unless contraindicated . Prior to the survey date, the facility took the following actions to correct the noncompliance: 1. All nurses and CNA's had competencies checked in all different methods of transfers. Competencies completed by (MONTH) 18, 2020. 2. In-services to all staff on proper methods of transfer and how to identify how a resident should be transferred. In-services completed by (MONTH) 18, 2020. 3. Pop quizzes to all staff on information learned during the in-services. 4. Transfer audit QA's to ensure transfers were completed properly, are listed on the care plan, Kardex, and identified in the residents room. 5. Completed root cause analysis and determined that the resident request to transfer quickly superseded knowledge the CNA had learned on proper transferring. 6. Fall Risk assessment completed and reviewed. 7. Post occurrence completed. 8. Pain assessment completed. 9. Care Plan reviewed and determined to be accurate at the time of the incident. Updated post fall. 10. Audits throughout the facility occurred to ensure that all transfer statuses for each resident were current, care planned, and placed on the Kardex for CNA reference.

Based on interview and record review the facility failed to ensure necessary care and services were provided to a resident that experienced a fall and subsequently a condition change. This resulted in R1 having a delay in treatment for [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for change of condition in a sample of 3. The Findings include: R1's Admission Record printed (MONTH) 31, (YEAR) shows R1 is a [AGE] year old female with [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) dated (MONTH) 14, (YEAR), shows R1's Brief Interview for Mental Status (BIMS) score to be 00, cognitively impaired. The local hospital radiology report dated (MONTH) 20, (YEAR) at 12:11 AM shows History: headache, post trauma Findings: Large extensive left convexity acute subdural hematoma measuring up to 3 centimeters (cm) maximal thickness. There is also a small amount of acute subdural hemorrhage along the right side of the falx and also a small amount in the right frontal and temporal regions as well. Pronounced mass effect including left and right midline shift measuring up to 1.9 cm and transtentorial herniation. The left lateral ventricle is moderately compressed On (MONTH) 1, (YEAR) at 10:50 AM, V12 Registered Nurse (RN) stated when R1 was on the unit she did have behaviors of kicking her leg up to wiggle and change her position in her high back recliner. V12 stated R1 was alert and orientated times one. R1 did not need noxious stimuli (sternal rub) to interact with her. R1 could not have a meaningful conversation, but R1 would look at you, smile, and attempt to interact. R1's Care Plan printed on (MONTH) 31, (YEAR) shows (R1) is noted to be at high risk for falls .Frequently exhibits restless behaviors in dhair as evidence by moving her legs in a way that changes her position in chair. Date initiaited (MONTH) 9, (YEAR). On (MONTH) 31, (YEAR) at 12:35 PM, V8 Certified Nursing Assistant (CNA) stated during dinner on (MONTH) 19, (YEAR), about 5:15 PM, R1 pushed off the table with her foot, flipped over her high back reclining chair's arm rest, and landed on her head. R1 had a wound over her right eye which was bleeding. V8 stated after dinner (6:30-6:45 PM) I went to check on R1. R1 was less responsive and not herself. R1's eyes were closed, but you could see her eyes quickly moving back and forth under the eyelids. V8 stated V14 CNA supervisor was doing the post fall vitals for R1. V8 stated at 8:45 PM R1 was still less responsive and started vomiting. V8 stated V24 CNA had come to check on R1 at 9:00 PM. V24 performed a sternal rub to arouse R1 enough to open her eyes. R1 vomited again, and V15 RN was notified. V8 stated V2 Director of Nursing (DON) arrived after 9:30 PM. V2 had us (V8 and V14) place R1 in bed to get cleaned up before the ambulance arrived. V14 stated I left the facility close to 10:00 PM, and R1 had not left yet. V8 stated before R1's fall R1 would kick her leg up to change her position in her chair. R1 did this constantly. V8 stated R1 would nod and smile when you talked to her. R1 was easily aroused by talking to her, and would wake up if you moved her high back recliner. On (MONTH) 31, (YEAR) at 12:45 PM, V14 stated R1's was placed on a one to one status while post fall neurological (neuro) checks were started on (MONTH) 19, (YEAR) at 5:50 PM. V14 stated V16 Assistant Director of Nursing (ADON) was present at the start of the neuro checks. V14 stated R1 was awake at first then as time went on R1 declined in responsiveness and stopped her usual behaviors of moving her legs. V14 stated after 6:30 PM R1's blood pressure was going up and heart rate started slowing down. V14 stated V16 was contacted by phone again. V14 stated, (V16) told me to contact (V2) (DON) with any changes because R1 could have a head bleed. V14 stated V15 Registered Nurse (RN) and V2 DON was notified. V2 arrived to the facility before 7:00 PM. V14 stated R1 stayed less responsive and at 8:45 PM started to vomit. V14 stated after the vomiting V2 had arrived back to the facility about 9:40 PM. V2 had myself and V8 put R1 into bed to clean R1 up before the ambulance arrived to take her to the hospital. V14 stated on a regular day R1 would watch you when you talked to her. R1 had behaviors of swinging her legs around to change position in her high back chair. V14 stated R1 was definitely different after R1's fall. R1's Vital Summary printed on (MONTH) 31, (YEAR) shows R1's blood pressure on (MONTH) 19, (YEAR) at 5:50 PM started at 123/71 with a heart rate of 69. At 6:50 PM R1's blood pressure was 151/74 with a heart rate of 55. On (MONTH) 31, (YEAR) at 1:10 PM, V17 (CNA) stated between 6:30 and 7:00 PM I reported to V15 R1 was getting more sleepy and not acting herself. V17 stated when I went to check on R1 later in the evening (9:00 PM) R1 was still less responsive, needed a sternal rub to be aroused, and started vomiting. On (MONTH) 2, (YEAR) at 11:30 AM, V24 (CNA) stated on (MONTH) 19, (YEAR) around 9:00 PM, R1 was in her high back recliner still by the nurses station. R1 was lethargic and not responding to verbal stimuli. V24 stated I did a sternal rub to (R1's) chest. V24 stated R1 opened her eyes for a short time, and then started to vomit. V24 stated R1 was not like that right after the fall. V24 stated when R1 was on the floor in the dining room R1 had her eyes open and was looking around at us (staff). On (MONTH) 31, (YEAR) at 4:25 PM, V19 NP stated , the first message I received for R1 was on (MONTH) 19, (YEAR) at 9:27 PM. V19 stated the answering service texted me the facility name, R1's name, post fall with vomiting, and V15's name. I called the facility immediately and gave orders to send R1 to the emergency room . V19 stated if a resident has an emergency the facility can send the resident to the emergency room even if they are on hospice unless the Power of Attorney has stated otherwise. On (MONTH) 1, (YEAR) at 11:45 AM, V1 Administrator stated if a resident is having a change in condition the nurse should contact the physician or NP. If they do not get a reply within a reasonable amount of time they call again or call the primary physician. V1 stated after 5:00 PM the paging service should be used to contact the on call nurse practitioner. On (MONTH) 31, (YEAR) at 3:10 PM, V2 (DON) stated R1 did have a fall on (MONTH) 19, (YEAR) during the dinner hour. R1 had received a laceration over her eye. V2 stated it is at the nurses' discretion to call the Emergency Medical System (EMS) if there is an emergent situation with a resident. V2 stated after a fall, accident, or change in condition the physician, Power of Attorney, and the family need to be notified per our policy. On (MONTH) 2, (YEAR) at 8:45 AM, V2 stated a fall with a head injury has the potential for a head bleed which could be emergent. V2 stated an increase of blood pressure and a decrease in heart rate are changes that can occur with a head bleed. V2 stated on (MONTH) 19, (YEAR) at 9:30 PM, V15 RN obtained and order to send R1 to the hospital. I do not know why there was a delay in the ambulance arriving to the facility. On (MONTH) 1, (YEAR) at 8:40 AM, V15 RN stated, I originally thought (R1) should go out to be seen because of the wound over her eye after she fell . I do not remember when I was told about any changes with (R1's) condition before she started vomiting (after 9:00 PM). V15 stated I received an order to send (R1) to the hospital at 9:30 PM. V15 stated I did not call 911 (EMS). I called a local ambulance service. V15 stated R1 left the facility around 11:15 PM. R1's Prehospital Care Report dated (MONTH) 19, (YEAR) shows the ambulance dispatch with a response mode of no lights and sirens. The dispatch time is 10:51 PM, arrived to the facility at 10:55 PM, and departed the facility at 11:15 PM. On (MONTH) 2, (YEAR) at 10:20 AM, V22 Ambulance Manager stated the call for an ambulance was called directly to our ambulance service. If a call is made through 911, the call would have been given to the local fire department. V22 stated the call time is shown on the run sheet as unit dispatch (10:51 PM). That is the time a call comes into the ambulance answering service. On (MONTH) 1, (YEAR) at 10:45 AM, V20 (R1's physician) stated when the facility has a problem getting the on call person they can always call me. I did not receive any calls or notification about R1's fall or when she was sent to the emergency room . The facility's Change of Condition Policy dated (MONTH) (YEAR) shows Attending physicians or physician on call Nurse Practitioner (NP) .will be notified of all changes in condition .Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received .follow framework for reporting changes in vital signs or laboratory values based on the American Medical Directors Association (AMDA) Guidelines See change of conditions and signs and symptoms from AMDA clinical practice guidelines . The facility's AMDA Clinical Practice Guidelines dated 2014 shows if an immediate sign or symptom occurs with a head injury Any head injury with change in level of consciousness, other mentation status change, or any focal neurological findings .Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A marked change (i.e. more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. The facility's Neurological Assessment Policy dated May, 2010 states Observe, assess and document the resident's level of consciousness, speech, pupils, hand grasp and vital signs .Notify physician immediately regarding any changes in the neurological assessment or other signs of possible increased pressure i.e., headache, change in mentation, vomiting, or irregular breathing.

Based on interview and record review the facility neglected to follow their policy and procedure by not notifying the physician when R1 fell and landed on their head injury, and when R1 started having mental changes. This resulted in a delay of treatment of [REDACTED]. This applies to 1 of 3 residents (R1) reviewed for neglect in the sample of 3. The findings include: The facility's Abuse and Neglect Policy dated (MONTH) (YEAR) states Neglect is the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm pain, mental anguish, or emotional distress. Serious bodily Injury is an injury involving extreme physical pain, involving substantial risk of death; involving protracted loss of impairment of the function of the bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. The facility's Change of Condition dated (MONTH) (YEAR) shows Attending physicians or physician on call Nurse Practitioner (NP) .will be notified of all changes in condition .Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received .follow framework for reporting changes in vital signs or laboratory values based on the American Medical Directors Association (AMDA) Guidelines See change of conditions and signs and symptoms from AMDA clinical practice guidelines . The facility's AMDA Clinical Practice Guidelines dated 2014 shows if an immediate sign or symptom occurs with a head injury Any head injury with change in level of consciousness, other mental status change, or any focal neurological findings .Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A marked change (i.e. more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. On (MONTH) 31, (YEAR) at 12:35 PM, V8 Certified Nursing Assistant (CNA) stated during dinner on (MONTH) 19, (YEAR), about 5:15 PM, R1 pushed off the table with her foot, flipped over her high back reclining chair's arm rest, and landed on her head. R1 had a wound over her right eye which was bleeding. On (MONTH) 31, (YEAR) at 12:20 PM, V15 Registered Nurse stated, after R1's fall (5:15 PM) I attempted to send a message to V18 Nurse Practitioner (NP) by the computer messaging service after 6:00 PM. On (MONTH) 1, (YEAR) at 1:00 PM, V15 stated I do not remember if V18 contacted me back. V15 stated after hour pages should be done with the paging service. On (MONTH) 31, (YEAR) at 3:50 PM, V18 NP stated after regular hours the facility knows to use the on call service. I was not on call on (MONTH) 19, (YEAR) so I would not have answered my phone. V18 stated I did not have any contact with the facility that night. On (MONTH) 1, (YEAR) at 10:45 AM, V20 (R1's physician) stated if the facility has a problem getting the on call person they can always call me. V20 stated I did not receive any calls about R1 on (MONTH) 19, (YEAR). On (MONTH) 2, (YEAR) at 8:44 AM, V2 Director of Nursing (DON) stated the physician, Power of Attorney, or family should be notified after an accident of fall. V2 stated it is our policy. The facility's Neurological Assessment Policy dated May, 2010 states Observe, assess and document the resident's level of consciousness, speech, pupils, hand grasp and vital signs .Notify physician immediately regarding any changes in the neurological assessment or other signs of possible increased pressure i.e., headache, change in mentation, vomiting, or irregular breathing. On (MONTH) 31, (YEAR) at 12:45 PM, V14 Certified Nursing Assistant (CNA) supervisor stated that during the 6:30 vital signs R1 was less responsive, had an increase in blood pressure, and a decrease in heart rate. V14 stated R1 was not herself. V14 stated V16 Assistant Director of Nursing (ADON) was contacted. V14 stated V15 was notified about R1's changes. On (MONTH) 31, (YEAR) at 1:10 PM, V17 stated I kept checking on R1 after the fall. After about an hour (between 6:30-7:00 PM) R1 was less responsive and was not acting like herself. On (MONTH) 31, (YEAR) at 1:45 PM, V8 stated after dinner was over I checked on (R1). V14 was doing vitals, and (R1) was not very responsive. V8 stated V16 was contacted by phone by V14 about 6:30 PM. V14 was told to contact V2 with R1's neurological check changes. On (MONTH) 31, (YEAR) at 4:25 PM, V19 NP stated I was initially contacted by the answering service on (MONTH) 19, (YEAR) at 9:27 PM by a text with R1's name, post fall, hit head, vomiting, and V15's name. V19 stated I had not received any information about R1 prior to the texting page at 9:27 PM.

Based on interview and record review the facility failed to ensure a resident (R20) at high risk for dehydration received fluids to meet his hydration needs. The facility failed to assess and and notify the physician for a resident who had no documented urinary output for eight consecutive hours. These failures resulted in R20 being transferred to the the Emergency Department (ED) for unresponsiveness and being admitted to the Intensive Care Unit (ICU) with severe dehydration. This applies to 1 of 14 residents (R20) reviewed for hydration/nutritional status in the sample of 14. The finding include: The facility's Physician order [REDACTED]. Z8's (R20's Primary Care Physician) letter dated 8/19/11 states, R20 "is a [AGE] year old male with multiple morbidities and overall very poor general health. As a result, he has continued to decline and has had frequent infections, some of which have resulted in hospitalization s. His multiple morbidities include diabetes, hypertension, stroke, [MEDICAL CONDITION] from alcoholism, [MEDICAL CONDITIONS], chronic skin wounds, [MEDICAL CONDITIONS] with chronic Foley catheter use, recurrent urinary tract infections, dysphagic with [DEVICE] placement, recurrent aspiration pneumonia, high cholesterol, [MEDICAL CONDITION], pancreatitis, [MEDICAL CONDITION], depression and anxiety." The ED records dated 08/18/11 states, R20 "is a 62 y.o. Caucasian male who is a NH (Nursing Home) resident and has been here multiple times (in the past) with [MEDICAL CONDITION] and acute [MEDICAL CONDITION] as a result of UTIs and Pneumonias and was just discharged in the beginning of the month...(Today) pt is lethargic, unresponsive, not actively vomiting, does not wince with pain when any area of his body is palpated. He had a sodium of 169, blood sugars of 400's for which he was given 10 units of SQ insulin, no antibiotics given so far. Pt was given 2 liters of fluids in the ER... Physical Exam HENT: Mouth/Throat: Mucous membranes are dry..." R20 is "very dehydrated with Na (Sodium) of 169 (Normal 135 to 145 MMOL/L)...IV (Intervenous) fluids given. ABGs 7.45/39/101 despite persistent resp rate in the high 30s-low 40s. Has elevated [MEDICATION NAME] of 3.8 and WBC 12.3 CXR shows improving left pneumonia. CT brain NAP (No Apparent Pathology). admitted to ICU." The Facility's Nurse Practitioner note from 08/18/11 states, "Staff reported to me that (R20's) temperature is 102.8 this morning and he does not look good. Vitals: (Temperature) 102.8, (Blood Pressure) 96/47, (Pulse) 100, (Respiratory Rate) 40." On 08/18/11 at 3:55 PM, Z7 (ED Physician/Emergency Department Medical Director) said she was the physician who treated (R20). She had seen (R20) in the past for similar issues. Today, R20 was "profoundly dehydrated", R20's labs showed hypoperfusion (decreased blood flow) related to "not taking in enough fluids." R20's change in condition "could have been prevented, if he would have received more fluids. R20's white blood count (WBC) was ok. It was only 12.3 (Normal 4-12 THOUS/UL). (R20's) urinalysis was normal and his chest x-ray showed improvement." Z20 continued to explain R20's temperature was because of hypoperfusion from inadequate fluid intake." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Flush [DEVICE] with 250 cc water q4h" and "Glucerna 1.5 @ 77 cc/hr to infuse 1500 cc/day." There is no documentation of additional water flushes being given to R20 with medication administration or with dietary supplements. The POSs show R20 receives 1000 cc of water from flushes and 1,138.50 water from 1500 cc of Glucerna 1.5 each day, for a total of 2,138.50 cc. The manufacture nutritional breakdown shows there is 759 cc of free water per 1000 cc of Glucerna 1.5. (Abbot Nutritional Products Web Page, 2011) The Nutritional assessment dated [DATE] shows R20's "Estimated Daily Needs for Fluid: 2340-2730." R20's documented fluid intake was less than R20's assessed need for fluids. The Minimum data set of 7/27/11 shows R20 receives tube feeding and is totally dependent on staff for intake. The facility's Care Plan updated 08/01/11 shows R20 has a swallowing problem related to Dysphagia. Pt does not take any food or water orally. [DEVICE], receives tube feeding and water flushes. The same plan shows the following approaches: "Assess for dehydration (dizziness on sitting/standing, change in metal status, decreased urine output, concentrated urine, poor skin turgor, dry cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance." The careplan shows R20 "has significant weight loss...Has been noted to unplug feeding tube and drink from his own PEG tube." The facility's Output Record (dated August 2011) shows R20 had no urinary output on the PM shift, for two of the three days before R20 was admitted to the hospital with [REDACTED]. The same output record shows five occurrences in August where R20 had no documented output for an entire eight hour shift. On 08/18/11 at 2:00 PM, E2 (Director of Nursing) and E40 (Corporate RN ) stated, "Output should be recorded every shift." E2 and E40 explained if there is no documented urinary output for an eight-hour shift the resident should be assessed and the physician should be notified. The online Merck Manual (2011) defines Oliguria (low-urine output) as less than 0.5 mL/kg/h in an adult.

Based on Observation, Interview and Record Review the facility failed to provide safety for R8 by not using a gait belt or two person transfer when R8 was transferred from her wheelchair to her bed on 6/3/11. R8 fell and had a staff member fall on her or got her leg caught in the side rail on 6/3/11 when being transferred by one Certified Nursing Assistant (CNA). This failure resulted in R8 being sent to the hospital on [DATE] and being diagnosed with [REDACTED]. The facility failed to provide supervision for a confused resident (R8) while on the toilet. The facility failed to provide safety for residents on the dementia unit by leaving a tube of zinc oxide in a residents room unsecured. This applies to 2 of 24 residents reviewed for safety and supervision in the sample of 24 and for 26 out of 32 residents on the dementia unit that are independently mobile (R8, R9, R3, R4, R5, R16, R17, R36 - R61). The findings include: 1. On 6/7/11 at 10:15am, R8 was observed, in her room, sitting in a wheelchair with her right leg elevated on the footrest. R8's shin area was red and purple in color with pitting edema to her lower leg, ankle and foot. R8 stated, "It happened a few nights ago. A girl half my size and weight moved me from the wheelchair to the bed by herself. I told her not to do it. I fell , my leg buckled under me and she fell on me. They did an xray (of hip and knee) and said there were no broken bones. I have a lot of pain but I will just have to deal with it. It hurts a lot to stand on it (right lower leg)." E8 (Certified Nursing Assistant - CNA) stated, "It's severely bruised. R8 asked to have E19 (Licensed Practical Nurse - LPN) come down and look at R8's right leg because of the pain but E19 told me that she has already seen R8's leg and wasn't coming down." E8 and E9 (CNA) placed R8's wheelchair next to her bed so R8's right leg was closest to the bed. E8 and E9 transferred R8 using a gait belt and two person assist from the wheelchair to the bed. The Occurrence Report dated 6/3/11 at 1:30pm for R8 showed, "Called to room by CNA's. Informed that while transferring to bed from wheelchair, noticed R8's foot between bars of the side rail. Removed foot and laid R8 down on bed. R8 denied pain/discomfort with range of motion (ROM). No pain with pelvic rock. No deformities noted. While writer at the foot of resident's bed, noticed and heard R8 moan. Assessed right hip and knee, again. No swelling, bruising or redness of hip, knee, leg, ankle feet new. New orders for xray of right hip/knee. Rule out fracture." The "witness" was E20 (CNA) and the writer was E19 (LPN). On 6/8/11 at 11:00am, E21 (CNA) stated, "R8 was in her wheelchair and I put the wheelchair next to the foot of the bed. I put my arm under R8's and grabbed the back of R8's pants and twisted her. R8's leg got caught because R8 was sliding down and I had to lift R8 up. When I went to put R8 up in her bed she wouldn't move. That is when i saw her leg was inside the bed rail. I lifted R8's leg out and then put her to bed. I called another CNA to get the nurse." E21 stated she transferred R8 by herself and did not use a gait belt for the transfer. E21 was asked if she did a proper transfer for R8 on 6/3/11? E21 stated, "No." E21 was asked why? E21 replied, "I don't know." R8's Nurses Notes showed, "6/3/11 at 4:20pm - Xray done of right knee and hip.; 6/3/11 at 9:00pm - Xray results to right knee and right hip show no fracture or dislocation nurse practitioner needs to be informed.; 6/5/11 at 5:50am - Right leg, foot, hip discomfort noted upon 3 person assist from shower chair to wheelchair. Endorsed to am nurse to call for order for as needed pain medication.; 6/5/11 at 6:30am - Late Entry for 6/4/11 at 2:00pm - Placed call to Z5 (Certified Nurse Practitioner - CNP) in regards to right leg swollen/warm. Order received for ice pack to right lower extremity knee and ankle four times a day for two days. R8 stated that feels good after ice pack applied.; 6/5/11 at 2:00pm - Placed call to Z5. Order received for Tylenol 650mg by mouth every 4 hours as needed for pain/fever.; 6/6/11 at 12:33am - Late charting for pm shift. Alert and oriented to person, place and time. Complains of pain in leg. As needed Tylenol given times 1. Right leg edema, very generalized to touch/movement, warm to touch. Applied cool compress. R8 vomited one time.; 6/6/11 at 2:55pm - Emesis times 2. Received orders for blood work...." On 6/8/11 at 9:22am, E2 (Director of Nursing - DON) stated, "They (staff) have to notify me anytime something like this happens. I was told that R8's foot got caught in the side rail when they were transferring her from the wheelchair to the bed. R8 was sent out after the meeting (Daily Status Meeting with Illinois Department of Public Health on 6/7/11) yesterday because in the meeting they said R8 had pain, swelling and discoloration to her right lower leg. R8 was sent to the emergency room . R8 has a comminuted tibia/fibula fracture. I saw R8 yesterday but I didn't assess her I assumed the nurse had. I know R8 had an Xray of her hip and knee. Her knee was really swollen. I was told R8 just had knee pain." E2 was asked how many CNA's it takes to transfer R8? E2 replied, "It takes two CNA's. We changed that at our last meeting because R8 had a fall. R8 will stiffen her legs sometimes." The Hospital Admitting History and Physical dated 6/8/11 for R8 showed, "Chief Complaint: Fall with comminuted fracture in the distal third of the tibia and fibula on the right.; History of Present Illness: This is an [AGE] year-old female...presenting from the nursing home today to the emergency room at a local hospital after she fell down at the nursing home while the nurse was trying to get her into bed. As per the patient, she states that the nurse was half her size and she told the nurse not to do this, but she still tried getting her into the bed or out of the bed, which made the patient fall down then the nurse fell on top of her as per the patient.; Physical Examination - General: Is very emotional, wants her friends at church to be notified that she is here in the hospital so that they can come and visit her and give her support. She is alert, oriented to person, place and time. Extremities: There is a splint present on the right lower extremity.; Assessment and Plan: 1. Fall which was accidental. Considering the patient's age and history, a cerebrovascular accident, right hemiparesis and the patient is wheelchair bound, we will put her on fall precautions. Is at bed rest right now considering her fracture with a soft splint at present. 2. Comminuted fracture right distal third of the tibia and fibula. Closed soft splint has been applied right now. Will get cast once swelling decreases. 9. Deep vein thrombosis with Lovenox 40mg daily." R8's Minimum Data Set with an Assessment Reference Date of 3/1/11 showed a score of 15 out of 15 for the Brief Interview for Mental Status.; No signs of delirium.; No mood problems.; No Behaviors.; Extensive assistance needed for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The current Care Plan on R8's chart showed, "3/1/11 - Problem: Impaired physical mobility related to impaired strength and balance....; Approach: Monitor for any changes in level of participation and in functional ability. Apply gait belt. Restorative transfer program. All transfers should go to the left side." R8's Physician order [REDACTED]. 2. The physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment reference date of 12/10/10 assessed R9 as severely impaired in cognitive skills for decision making and having long and short term memory problems. R9 was assessed occasionally incontinent of bladder and required extensive assistance of 1 for toilet use and transferring. The assessment showed R9 had 2 or more falls since admission. Bowel and Bladder assessment dated [DATE] assessed R9's functional abilities as: not able to go to the toilet independently, not able to manipulate clothing for toileting and not able to cleanse or wipe self after toileting. The nurse's notes dated 11/30/10 at 3:45pm documented, "R9 observed in the bathroom sitting on the floor." Nurse's notes dated 12/4/10 at 1pm showed R9 put on the toilet per CNA (Certified Nursing Assistant). CNA explained to R9 to put on the call light when she done using the bathroom. R9 got up on her own without using the call light and fell while trying to get back to the wheel chair that was located in her room. "CNA stated she thought (R9) would pull the call light." R9's nurse's note of 12/5/10 at 8pm showed "Uses call lite at times, other times, does not." R9's Rehabilitation assessment dated [DATE] showed R9 leans or slides in her chair, is unsteady and unable to rise without help. On 6/7/11 at 10:20am, R9 was observed in a "bowling" activity. R9 was confused and unable to hold the ball or understand what to do after E22 (Activities) explained several times. 3. On 6/7/11 at 9:00 AM, in room 7 on the D wing (Dementia Unit) a tube of Zinc Oxide was found unsecured in the drawer of the night stand. The label on the tube read: "Keep out of reach of children- If swallowed contact poison control." The facility confirmed that out of a census of 32 residents on the Dementia Unit, 26 of them are independently mobile, either ambulatory or in a wheelchair, around the unit. On 6/7/11 at 9:45 AM, E12 (Dementia Unit Coordinator) stated that the Zinc Oxide should be in a locked drawer next to the bed. According to Medicinenet.com accessed on 6/9/11, "This medication may be harmful if swallowed. If swallowing or overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline."

I. Based on observation, record review, and interview, the facility failed to prevent the development of a stage II pressure ulcer. The facility failed to assess the risk of skin breakdown, identify a new pressure ulcer, and get a treatment order. The facility failed to develop individualized turning and repositioning schedules. The facility failed to reposition residents unable to reposition themselves. The facility failed to ensure that prevention measures were in place for residents at risk of developing pressure ulcer. These failures contributed to R2 developing a new stage II pressure ulcer on his right buttock of which the facility was unaware. This applies to 4 of 8 residents reviewed for pressure ulcer development in the sample of 24. (R2, R13, R14,R8) The examples include: 1. R2's Minimum Data Set (MDS) Assessment of 4/13/11 showed that R2's [DIAGNOSES REDACTED]. The same assessment documented that R2 was dependent on 2 or more staff for bed mobility and transfer. R2 had an indwelling urinary catheter and was always incontinent of bowel. The assessment showed that R2 had no open areas on his skin. No skin risk assessment was documented. R2's physician's orders [REDACTED]. R2's Initial Nursing assessment dated [DATE] documented that R2 had a red, blanching area on his sacrum. No other skin conditions were identified. On 6/6/11 at 12:40 PM, E38 Registered Nurse (RN) was interviewed. E38 said that R2 gets [MEDICATION NAME] cream to his buttocks as a prevention, and that he had no open areas. On 6/7/11 at 10:00 AM E6 Certified Nursing Assistant (CNA) was asked to assist in checking R2's skin. E6 rolled R2 on his right side. A stage II pressure ulcer was observed on the right ischium. E6 confirmed the open area but said she had not worked with R2 before today. A sign posted above R2's bed documented to not turn R2 onto his left side. The turning schedule placed on the inside door of R2's closet did not eliminate left side laying position. The scheduled times to turn R2 was every 2 hours. On 6/6/11 at 12:40 PM, R2 was observed laying in is bed, with the head of the bed elevated 30 degrees. R2 had a tube feeding, and [MEDICAL CONDITION] with humidified oxygen. R2's Skin Integrity Care Plan dated through 8/26/11 shows to turn and reposition every 2 hours and as needed. There were no turning surfaces to avoid on the care plan. The facility Policy and Procedure for the Treatment and Prevention of Skin Breakdown showed: Policy: It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers, to implement preventative measures; and to provide appropriate treatment modalities for ulcers according to industry standards of care. The same policy showed under Potential Risk Conditions: Head of bed elevated the majority of the time due to medical necessity. Prevention: Establish an individualized turning and repositioning schedule if the resident is immobile. While in bed not to exceed 2 hours and while sitting position and/or if the head of the bed is greater than 30 degrees not to exceed 1 hour. Frequency of position changes is titrated for individual residents. Stage II pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. (National Pressure Ulcer Advisory Panel) definition. The facility Certified Nursing Assistant Job Description showed under item JJ of essential job duties: Does complete check of skin condition when dressing, undressing, turning/repositioning, etc. Reports the presence of pressure areas and skin breakdown to the staff nurse. 2. R13 is a [AGE] year-old resident with severe cognitive impairment who is totally dependent on staff for bed mobility and all activities of daily living according to the 4/14/11 Minimum Data Sets (MDS). R13 is ventilator dependent, has a history of a stage IV pressure ulcer, and is on a turning/repositioning program according to the MDS. On 6/6, 6/7 and 6/8/11 R13 was noted in bed with multiple contractures. On 6/7/11 at 10:18 AM R13 was positioned in bed facing the window. R13 should be facing the door per the turning schedule posted in the room. At 11:10 AM and 12:00 PM R13 was in bed still facing the window. On 6/7/11 at 12:00 PM E11 (CNA) stated that she was supposed to turn R13 toward the door at 11:00 AM but she was at lunch. On 6/8/11 at 9:18 AM R13 was in bed facing the window. R13's turning schedule shows that he should be facing the door. 3. R14 is a [AGE] year old resident with severe cognitive impairment who is totally dependent on staff for bed mobility according to the 3/13/11 MDS. R14 is ventilator dependent, has multiple contractures, and is at risk for developing pressure ulcers according to the 3/13/11 MDS and 12/12/10 CAA's(Care Area Assessments). On 6/6, 6/7 and 6/8/11 R14 was observed in bed with multiple contractures. On 6/7/11 at 10:32 AM R14 was in bed positioned on her back (facing the ceiling). R14 should have been positioned facing the door according to the turning schedule posted in the room. On 6/7/11 at 11:11 AM R14 was positioned with a bolster cushion under her right side with her body slightly turned toward the door. R14 should have been facing the window according to the turning schedule. At 12:23 PM R14 remained in the same position with the bolster cushion under her right side. 4 On 6/7/11 at 10:15am, R8 was transferred from her wheechair to her bed by E8 (Certified Nursing Assistant - CNA) and E9 CNA to use the bedpan. R8's incontinence brief and pants were removed. Redness was observed on R8's left buttock and deep creases in her skin on her buttoks and upper legs. On the seat of R8's wheelchair there was a partially folded over and wrinkled cloth incontinence pad. There was no pressure reduction cushion in R8's wheelchair. The Care Plan dated 3/1/11 for R8 showed, "Problem: At risk for skin integrity....; Intervention: Pressure reduction sitting/wheelchair surface." R8's Minimum Data Set with an Assessment Reference Date of 3/1/11 showed a score of 15 out of 15 for the Brief Interview for Mental Status.; No signs of delerium.; No mood problems.; No Behaviors.; Extensive assistance needed for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. R8's Physician order [REDACTED].

Based on Observation, Interview and Record Review the facility neglected to follow written policies on how to transfer a resident. The facility neglected to have any policy for assessment of a resident with an injury. These failures resulted in R8 falling during a transfer on 6/3/11 and sustaining a comminuted tibia/fibula fracture to her right lower leg that was not identified until 6/8/11. The neglect began on 6/3/11. This is for 1 of 24 residents reviewed for neglect in the sample of 24 (R8). The findings include: 1. On 6/7/11 at 10:15am, R8 was observed, in her room, sitting in a wheelchair with her right leg elevated on the footrest. R8's shin area was red and purple in color with [MEDICAL CONDITION] to her lower leg, ankle and foot. R8 stated, "It happened a few nights ago. A girl half my size and weight moved me from the wheelchair to the bed by herself. I told her not to do it. I fell , my leg buckled under me and she fell on me. They did an Xray (of hip and knee) and said there were no broken bones. I have a lot of pain but I will just have to deal with it. It hurts a lot to stand on it (right lower leg)." E8 (Certified Nursing Assistant - CNA) stated, "It's severely bruised. R8 asked to have E19 (Licensed Practical Nurse - LPN) come down and look at R8's right leg because of the pain but E19 told me that she has already seen R8's leg and wasn't coming down." E8 and E9 (CNA) placed R8's wheelchair next to her bed so R8's right leg was closest to the bed. E8 and E9 transferred R8 using a gait belt and two person assist from the wheelchair to the bed. The Occurrence Report dated 6/3/11 at 1:30pm for R8 showed, "Called to room by CNA's. Informed that while transferring to bed from wheelchair, noticed R8's foot between bars of the side rail. Removed foot and laid R8 down on bed. R8 denied pain/discomfort with range of motion (ROM). No pain with pelvic rock. No deformities noted. While writer at the foot of resident's bed, noticed and heard R8 moan. Assessed right hip and knee, again. No swelling, bruising or redness of hip, knee, leg, ankle feet new. New orders for Xray of right hip/knee. Rule out fracture." The "witness" was E20 (CNA) and the writer was E19 (LPN). R8's Nurses Notes showed, "6/3/11 at 4:20pm - Xray done of right knee and hip.; 6/3/11 at 9:00pm - Xray results to right knee and right hip show no fracture or dislocation nurse practitioner needs to be informed.; 6/5/11 at 5:50am - Right leg, foot, hip discomfort noted upon 3 person assist from shower chair to wheelchair. Endorsed to am nurse to call for order for as needed pain medication.; 6/5/11 at 6:30am - Late Entry for 6/4/11 at 2:00pm - Placed call to Z5 (Certified Nurse Practitioner - CNP) in regards to right leg swollen/warm. Order received for ice pack to right lower extremity knee and ankle four times a day for two days. R8 stated that feels good after ice pack applied.; 6/5/11 at 2:00pm - Placed call to Z5. Order received for Tylenol 650mg by mouth every 4 hours as needed for pain/fever.; 6/6/11 at 12:33am - Late charting for pm shift. Alert and oriented to person, place and time. Complains of pain in leg. As needed Tylenol given times 1. Right leg [MEDICAL CONDITION], very generalized to touch/movement, warm to touch. Applied cool compress. R8 vomited one time.; 6/6/11 at 2:55pm - Emesis times 2. Received orders for blood work...." On 6/8/11 at 9:22am, E2 (Director of Nursing - DON) stated, "They (staff) have to notify me anytime something like this happens. I was told that R8's foot got caught in the side rail when they were transferring her from the wheelchair to the bed. R8 was sent out after the meeting (Daily Status Meeting with Illinois Department of Public Health on 6/7/11) yesterday because in the meeting they said R8 had pain, swelling and discoloration to her right lower leg. R8 was sent to the emergency room . R8 has a comminuted tibia/fibula fracture. I saw R8 yesterday but I didn't assess her I assumed the nurse had. I know R8 had an Xray of her hip and knee. Her knee was really swollen. I was told R8 just had knee pain." E2 was asked how many CNA's it takes to transfer R8? E2 replied, "It takes two CNA's. We changed that at our last meeting because R8 had a fall. R8 will stiffen her legs sometimes." On 6/8/11 at 11:00am, E21 (CNA) stated, "R8 was in her wheelchair and I put the wheelchair next to the foot of the bed. I put my arm under R8's and grabbed the back of R8's pants and twisted her. R8's leg got caught because R8 was sliding down and I had to lift R8 up. When I went to put R8 up in her bed she wouldn't move. That is when i saw her leg was inside the bed rail. I lifted R8's leg out and then put her to bed. I called another CNA to get the nurse." E21 stated she transferred R8 by herself and did not use a gait belt for the transfer. E21 was asked if she did a proper transfer for R8 on 6/3/11? E21 stated, "No." E21 was asked why? E21 replied, "I don't know." The Hospital Admitting History and Physical dated 6/8/11 for R8 showed, "Chief Complaint: Fall with comminuted fracture in the distal third of the tibia and fibula on the right.; History of Present Illness: This is an [AGE] year-old female...presenting from the nursing home today to the emergency room at a local hospital after she fell down at the nursing home while the nurse was trying to get her into bed. As per the patient, she states that the nurse was half her size and she told the nurse not to do this, but she still tried getting her into the bed or out of the bed, which made the patient fall down then the nurse fell on top of her as per the patient.; Physical Examination - General: Is very emotional, wants her friends at church to be notified that she is here in the hospital so that they can come and visit her and give her support. She is alert, oriented to person, place and time. Extremities: There is a splint present on the right lower extremity.; Assessment and Plan: 1. Fall which was accidental. Considering the patient's age and history, a [MEDICAL CONDITION], right [MEDICAL CONDITION] and the patient is wheelchair bound, we will put her on fall precautions. Is at bed rest right now considering her fracture with a soft splint at present. 2. Comminuted fracture right distal third of the tibia and fibula. Closed soft splint has been applied right now. Will get cast once swelling decreases. 9. [MEDICAL CONDITION] with [MEDICATION NAME] 40mg daily." The facility's policy and procedure on Transfer Techniques showed, "General Instructions: Resident should move toward the unaffected side. The employees should use good body mechanics, bend knees and pivot to turn. Do not twist or lift with back bent.; Procedure: Brakes on the wheelchair should be locked, foot pedals raised and chair placed at an angle at the side of the bed nearest the resident's unaffected side. Obtain the assistance of another individual if necessary for safe transfer. Place a gait belt around residents waist unless contraindicated." On 6/9/11 at 2:42pm, E2 (Director of Nurses - DON) confirmed the facility does not have a policy and procedure for assessment of residents when an injury occurs. E2 stated, "They use nursing judgement that they learned in school. Neurological checks, head to toe assessments, vital signs, range of motion and resident pain. They notify me, administrator, doctor and family." R8's Minimum Data Set with an Assessment Reference Date of 3/1/11 showed a score of 15 out of 15 for the Brief Interview for Mental Status.; No signs of [MEDICAL CONDITION].; No mood problems.; No Behaviors.; Extensive assistance needed for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The current Care Plan on R8's chart showed, "3/1/11 - Problem: Impaired physical mobility related to impaired strength and balance....; Approach: Monitor for any changes in level of participation and in functional ability. Apply gait belt. Restorative transfer program. All transfers should go to the left side." The Care Plan showed no changes since the 5/31/11 Care Plan Meeting including the identification of the number of people needed to transfer R8. R8's Physician order [REDACTED].

Based on Observation, Interview and Record Review the facility failed to assess R8's entire right lower leg including below her knee to her ankle and foot after her fall on 6/3/11. The facility failed to continually assess R8's right lower extremity from 6/3/11 to 6/8/11 as her pain increased and ability to bear weight decreased. On 6/8/11 R8 was sent to the hospital, was admitted and diagnosed with [REDACTED]. This is for 1 of 24 residents reviewed for a leg fracture in a sample of 24 (R8). The findings include: 1. On 6/7/11 at 10:15am, R8 was observed, in her room, sitting in a wheelchair with her right leg elevated on the footrest. R8's shin area was red and purple in color with [MEDICAL CONDITION] to her lower leg, ankle and foot. R8 stated, "It happened a few nights ago. A girl half my size and weight moved me from the wheelchair to the bed by herself. I told her not to do it. I fell , my leg buckled under me and she fell on me. They did an Xray (of hip and knee) and said there were no broken bones. I have a lot of pain but I will just have to deal with it. It hurts a lot to stand on it (right lower leg)." E8 (Certified Nursing Assistant - CNA) stated, "It's severely bruised. R8 asked to have E19 (Licensed Practical Nurse - LPN) come down and look at R8's right leg because of the pain but E19 told me that she has already seen R8's leg and wasn't coming down." E8 and E9 (CNA) placed R8's wheelchair next to her bed so R8's right leg was closest to the bed. E8 and E9 transferred R8 using a gait belt and two person assist from the wheelchair to the bed. The Occurrence Report dated 6/3/11 at 1:30pm for R8 showed, "Called to room by CNA's. Informed that while transferring to bed from wheelchair, noticed R8's foot between bars of the side rail. Removed foot and laid R8 down on bed. R8 denied pain/discomfort with range of motion (ROM). No pain with pelvic rock. No deformities noted. While writer at the foot of resident's bed, noticed and heard R8 moan. Assessed right hip and knee, again. No swelling, bruising or redness of hip, knee, leg, ankle feet new. New orders for Xray of right hip/knee. Rule out fracture." The "witness" was E20 (CNA) and the writer was E19 (LPN). R8's Nurses Notes showed, "6/3/11 at 4:20pm - Xray done of right knee and hip.; 6/3/11 at 9:00pm - Xray results to right knee and right hip show no fracture or dislocation nurse practitioner needs to be informed.; 6/5/11 at 5:50am - Right leg, foot, hip discomfort noted upon 3 person assist from shower chair to wheelchair. Endorsed to am nurse to call for order for as needed pain medication.; 6/5/11 at 6:30am - Late Entry for 6/4/11 at 2:00pm - Placed call to Z5 (Certified Nurse Practitioner - CNP) in regards to right leg swollen/warm. Order received for ice pack to right lower extremity knee and ankle four times a day for two days. R8 stated that feels good after ice pack applied.; 6/5/11 at 2:00pm - Placed call to Z5. Order received for Tylenol 650mg by mouth every 4 hours as needed for pain/fever.; 6/6/11 at 12:33am - Late charting for pm shift. Alert and oriented to person, place and time. Complains of pain in leg. As needed Tylenol given times 1. Right leg [MEDICAL CONDITION], very generalized to touch/movement, warm to touch. Applied cool compress. R8 vomited one time.; 6/6/11 at 2:55pm - Emesis times 2. Received orders for blood work...." On 6/8/11 at 9:22am, E2 (Director of Nursing - DON) stated, "They (staff) have to notify me anytime something like this happens. I was told that R8's foot got caught in the side rail when they were transferring her from the wheelchair to the bed. R8 is transferred by two CNA's. R8 was sent out after the meeting (Daily Status Meeting with Illinois Department of Public Health on 6/7/11) yesterday because in the meeting they said R8 had pain, swelling and discoloration to her right lower leg. R8 was sent to the emergency room . R8 has a comminuted tibia/fibula fracture. I saw R8 yesterday but I didn't assess her I assumed the nurse had. I know R8 had an Xray of her hip and knee. Her knee was really swollen. I was told R8 just had knee pain." On 6/8/11 at 10:00am, Z5 (Certified Nurse Practitioner - CNP) stated, "On 6/3/11, I think it was Friday, I was told R8's leg was caught in the bed rail and that she complained of knee and hip pain so I ordered a hip and knee Xray. If R8 had complained of pain in the ankle I would have ordered a tibia and fibula Xray. It's just common sense." Z5 was asked if she had been called on 6/5/11 about R8's leg? Z5 stated, "I think so, Sundays are very busy for me." Z5 was given the Nurses Notes for R8 and reviewed them. Z5 stated, "I don't recall being told R8 had any pain in the ankle. I know I wasn't told there was any bruising. I was told that the swelling had gone down. I think R8's fracture is from what happened on 6/3/11. I am not sure why R8 was admitted to the hospital. It can't be just from the fracture." On 6/8/11 at 10:00am (E19 was present with Z5 for interview) E19 stated, "I assessed R8 early yesterday (6/7/11) morning. R8 didn't have any redness or bruising. I did range of motion and R8 didn't have any pain." E19 was asked how she did ROM for R8? E19 stated, "I lifted R8's leg up and down and then out to the side. I was checking her hip and she had no pain." E19 was told that E8 (CNA) and E9 (CNA) stated they told her that R8 had swelling and bruising to her right lower extremity and that E19 wasn't going to come down because E19 had already knew about R8's leg? E19 replied, "Yes, I had already assessed R8 around 7am. R8 didn't complain about pain." E19 reviewed R8's Nurses notes and stated, "On 6/5/11, I wrote a late entry for 6/4/11 at 2:00pm. I called Z5 for R8's leg swelling. The order I received was for ice packs to R8's right lower extremity, knee and ankle four times a day for two days." The Hospital Admitting History and Physical dated 6/8/11 for R8 showed, "Chief Complaint: Fall with comminuted fracture in the distal third of the tibia and fibula on the right.; History of Present Illness: This is an [AGE] year-old female...presenting from the nursing home today to the emergency room at a local hospital after she fell down at the nursing home while the nurse was trying to get her into bed. As per the patient, she states that the nurse was half her size and she told the nurse not to do this, but she still tried getting her into the bed or out of the bed, which made the patient fall down then the nurse fell on top of her as per the patient.; Physical Examination - General: Is very emotional, wants her friends at church to be notified that she is here in the hospital so that they can come and visit her and give her support. She is alert, oriented to person, place and time. Extremities: There is a splint present on the right lower extremity.; Assessment and Plan: 1. Fall which was accidental. Considering the patient's age and history, a [MEDICAL CONDITION], right [MEDICAL CONDITION] and the patient is wheelchair bound, we will put her on fall precautions. Is at bed rest right now considering her fracture with a soft splint at present. 2. Comminuted fracture right distal third of the tibia and fibula. Closed soft splint has been applied right now. Will get cast once swelling decreases. 9. [MEDICAL CONDITION] with [MEDICATION NAME] 40mg daily." R8's Minimum Data Set with an Assessment Reference Date of 3/1/11 showed a score of 15 out of 15 for the Brief Interview for Mental Status.; No signs of [MEDICAL CONDITION].; No mood problems.; No Behaviors.; Extensive assistance needed for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. The current Care Plan on R8's chart showed, "3/1/11 - Problem: Impaired physical mobility related to impaired strength and balance....; Approach: Monitor for any changes in level of participation and in functional ability. Apply gait belt. Restorative transfer program. All transfers should go to the left side." R8's Physician order [REDACTED].

Based on observation, interview and record review the facility failed to assess, develop, and implement a plan to provide Range of Motion (ROM) for 1 resident (R13) who was admitted to the facility with severe contractures. The lack of assessment, program development, implementation, and evaluation most likely contributed to additional contractures and limitations for R13. Additionally, the facility failed to develop a method of measurement to determine changes in ROM. The facility failed to provide ROM as ordered by the physician. The facility failed to follow their policy to document residents' tolerance and progress towards goals. The facility failed to schedule ROM during hours that the residents are normally awake. This is for 4 residents (R13, R14, R15, R21) of 9 reviewed for range of motion in the sample of 24, and 17 additional residents who are scheduled to receive ROM between the hours of 11:00 PM and 7:00 AM. The findings include: 1. R13 was admitted to the facility on [DATE] with multiple diagnoses, including severe Mental [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and multiple orthopedic surgeries for Contractures according to hospital notes dated 10/27/10. R13 is severely cognitively impaired and totally dependent on staff for all care needs per the 4/14/11 Minimum Data Sets (MDS). R13 has range of motion limitation of his upper and lower extremities, but does not receive range of motion services according to documentation in the 4/14/11 (MDS). The Functional Limitation in Range of Motion Assessment form dated 11/2/10 documents that R13 has limitations in every body part. There is no description as to the extent of the limitations. The 11/2/10 assessment form states that Passive Range of Motion (PROM) is not recommended at this time. Subsequent ROM assessment forms dated 1/16/11 and 4/14/11 also identify limitations in all extremities but do not describe the extent of the limitations. These forms state that PROM is "N/A". There is no ROM care plan for R13. On 6/8/11 at 9:48 AM E3 (LPN) identified herself as the Restorative Nurse. E3 confirmed that R13 does not receive restorative ROM therapy and does not have a ROM care plan. E3 said she did not know why R13 was not getting ROM. E3 also confirmed that there are no measurements as to the extent of R13's contractures. E3 said that measurements are not done by the restorative nurses, only by occupational therapy (OT). E3 stated that R13 has never been assessed by OT. E3 confirmed that R13 has multiple severe contractures. R13 has multiple limitations in ROM of both the upper and lower extremities according to an assessment completed by Z6 (Physical Therapist) on 6/9/11. On 6/9/11 at 1:39 PM Z6 confirmed that he had measured R13 and that R13 had multiple limitations and contractures. Z6 said that R13's muscles are tight and display [DIAGNOSES REDACTED]. Z6 said that R13 would benefit from PROM especially because of the [DIAGNOSES REDACTED] R13 displays. R13 was observed in bed on 6/6, 6/7 and 6/8. On all observations R13's arms were pulled in toward his body and both his wrists were flexed forward. R13's knees were pulled upward toward his chest. 2. R14 is a severely cognitively impaired resident, with multiple [DIAGNOSES REDACTED]. R14 has multiple contractures according to the hospital note dated 3/30/07. R14 has full loss of voluntary movement and limitations of all extremities according to the Functional Limitation in Range of Motion Score Sheet dated 4/6/07. The Functional Limitation in Range of Motion Assessments dated 7/8/10, 9/27/10 and 12/12/10 document that R14 has limitations in all extremities. There is no documentation as to the extent of the limitations. The Restorative Nursing Program Quarterly Progress Note dated 12/12/10 and signed by E3 states a goal to be free from further decrease in ROM. The Quarterly note states "Goal met, per ROM assessment there has been no noted (change) in range to joint areas. Remains @(at) risk for contracture formation..." There are no measures listed regarding R13's ROM capacity or limitations. On 6/8/11 at 9:55 AM E3 confirmed that R13's limitations in ROM are not measured. E3 could not explain how she determined that there have been no changes in R13's range areas. R14 was observed in bed on 6/6, 6/7 and 6/8/11. R14's wrists were flexed forward and her knees and hips were pulled upward. 3. R21 has a [DIAGNOSES REDACTED]. R21 has no voluntary movement of any body parts except her head according to the medical record. R21 has bilateral functional limitations in Range of Motion of both the upper and lower extremities according to the 4/10/11 MDS. R21 has a physician's orders [REDACTED]. E3 stated that she could not locate any other Functional Limitation in Range of Motion Assessments for R21. E3 confirmed that she has no measures of R21's limitations in range of motion. On 6/8/11 at 10:20 AM E39 (Restorative Aide) was observed doing passive range of motion on R21. E39 held R21's left arm extended and bent it at the elbow inward toward the biceps muscle. E39 could only bend R21's arm about half way toward the biceps muscle. E39 stated that R21's arm would not move any further past the half way point. R21 has no cognitive impairment according to the 4/10/11 MDS. R21 was interviewed on 6/8/11 at 10:30 AM. R21 stated that she is supposed to receive PROM 7 days a week but only receives it 5 days a week when E39 is working. R21 said that the floor CNA's do not do her PROM's on the weekend when E39 is off. 4. E3 presented a list of all residents who receive ROM. Seventeen of the residents were noted to receive ROM on the night shift (11:00 PM - 7:00 AM shift). E3 said that the CNA's provide ROM during the night when they are providing care. 5. The facility's PROM/AROM Nursing Restorative Policy dated 09/10 states that the nurse and/or therapist will evaluate any resident who is unable to demonstrate functional ROM of any extremity for placement in a PROM/AROM program and that the nurse will complete a quarterly progress note that will reflect the resident's tolerance and progress towards the goal. 6. The physician's orders [REDACTED]. R15's physician's orders [REDACTED]." The Minimum Data Set (MDS) assessment reference date of 2/17/11 assessed R15 as severely impaired in cognitive skills for decision making and having long and short term memory problems. R15 was assessed as having functional limitations in range of motion on both sides in the lower and upper extremities. R15 did not walk or transfer during the assessment period and was totally dependent on staff for locomotion in the wheelchair. R15 was assessed to require the use of a trunk restraint daily. The Physical Restraint assessment dated [DATE] showed the soft lap belt restraint was implemented for the medical reasons of Severe Kyphosis and poor/inconsistent trunk control. The assessment says the device will help the resident maintain better sitting balance and Physical Therapy and Occupational Therapy referrals had been made. On 6/7 at 10:15am, R15 was sitting in the wheelchair with the soft waist belt attached (in her room). R15's head was leaning forward toward the right arm rest. E20 (CNA) took a pillow roll from the bed and placed it under R15's right arm at this time. E20 was asked why there were no pillows under R15's arm. E20 said, "She (R15) might swing at me." On 6/7 at 11:40am and 12:20pm, and on 6/8/11 at 8:20am, R15 was observed sitting in her wheelchair with the soft lap belt attached. R15 was leaning forward and her head was resting on the arm rest of the wheel chair. There were no positioning devices in the chair to help R15 "maintain better sitting balance." On 6/8/11, E3 (LPN-Licensed Practical Nurse) stated, "I think the leaning forward is a behavior." E3 thought that an over-the-shoulder support had been used to help R15 maintain an upright position. E3 could not show documentation of other alternatives being used or that R15 had been assessed by therapy for a positioning device. The policy and procedure for the Treatment and Prevention of Skin Breakdown under subtitle: activity, mobility and positioning documents, "Occupational therapy to evaluate for wheel chair positioning as needed."

Based on interview and record review, the facility failed to notify the physician of R60's continued elevation of temperature while on antibiotic therapy and of a change in his oral condition. The 10 day delay in notification contributed to R60's decline resulting in his hospitalization and need for treatment of [REDACTED]. This is for 1 of 4 residents reviewed for physician notification in the sample of 11 (R60). The findings include: R60 is a [AGE] year old male resident with [DIAGNOSES REDACTED]. The Nursing Notes document the following: 04/03/11 20:40 PM Call to Z1 (Primary Care Physician) then to Z9 (Medical Doctor- MD) on call for Z1, gave order to send to (local hospital) Emergency Room for evaluation. 04/04/11 10:45 AM Spoke with Z5 (Registered Nurse (RN) in Z1's office) to notify of new orders for [MEDICATION NAME] (antibiotic) for 10 days and [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. 04/05/11 01:00 AM Temp = 100 04/05/11 13:00 PM Remains on Antibiotic 04/06/11 12:00 PM Continues on Antibiotic 04/07/11 24:00 PM Temp 101.1 04/07/11 02:00 AM Temp 100.8 04/07/11 18:40 PM Continues on Antibiotic 04/09/11 06:00 AM Temp 100.4, Tylenol given, continues on antibiotic 04/10/11 06:30 AM Temp 100.5, Tylenol given, continues on antibiotic 04/13/11 24:00 PM Temp 100.9 04/14/11 05:30 AM Temp 101.4, Tylenol given, received last dose of antibiotic, fax sent to notify MD of continued elevation of temperature. 04/14/11 12:00 PM Temp 101.2 On 4/20/11 at 12:20 PM, this surveyor spoke with Z5 (RN) on the phone. Z5 stated phone calls made to the office are documented in the computer. Z5 stated two calls were made to Z1's office regarding R60 and those occurred on 4/4/11 and 4/14/11. The Emergency Transfer Sheet dated 4/14/11 at 21:15 PM, identified Increased Temperature post completion of Antibiotic Therapy as the reason for requiring transfer to local hospital emergency room for evaluation and treatment. On 4/20/11 at 2:50 PM, E6 (RN) stated if residents have an increased temperature, some interventions would be to increase fluids, administer Tylenol, call the physician and/or apply cold compresses. On 4/21/11 at 08:00 AM, Z3 (Hospital Charge Nurse RN) was interviewed regarding R60's condition on admission. Z3 stated she was called to the admission unit to visualize R60's physical condition. Upon arrival, Z3 stated Z10 (Hospital RN) was cleaning R60's eyes which were crusted shut with yellow drainage and his eyelashes stuck inside the eye socket. Z3 stated R60's tongue was covered with thrush and cleansing with a swab was ineffective. Z3 stated she "brushed" R60's tongue with a washcloth which removed "layers" of film. Z3 said R60's lips were dry and cracked with crust on them. Z3 added R60's "skin turgor was poor" and he appeared dry and emaciated. Z3 said water [MEDICATION NAME] were given through R60's PEG tube. Z3 said R60's increased temperature for 10 days contributed to his dehydration and the severity of his subsequent illnesses/hospitalization . Hospital Nursing documentation dated 4/15/11 at 04:30 AM, written by Z10, showed: "Patients eyes were crusted shut with the eyelashes matted with yellow drainage where the patient could not open them...The patients mouth was very dry with layers of white (thrush) on his tongue..." On 4/20/11 at 12:45 PM, E3 (Director of Nursing) said E6 (RN) had tried to call R60's physician regarding his mouth condition but received no response. On 4/20/11 at 3:15 PM, E6 stated she had not cared for R60 since 4/7/11 (1 week prior to hospitalization ). The facility provided no evidence of notifying the physician of R60's oral condition between 4/7/11 and 4/14/11. On 4/20/11 at 2:55 PM, E7 (Certified Nursing Assistant-CNA) stated she provided AM care on R60 the morning of 4/14/11. E7 said R60 had "mucousy green boogary stuff" in his mouth for which she used swabs to clean "as much as I could." E7 said R60 also had "crusty stuff-eye boogars " in his eyes in the AM but did not notice any more the remainder of the day. E7 then qualified her statement saying R60 "never opened his eyes the rest of the day". On 4/20/11 at 3:10 PM, E8 (CNA) stated he cared for R60 the afternoon of 4/14/11. E8 said he provided care to R60 prior to him leaving for the hospital. E8 said R60 had a lot of oral secretions which causes his mouth and lips to get "sticky". E8 stated he was aware that R60 had been running a temperature for at least a couple of days. Review of the MD Progress Notes from the facility showed no physician visits since 12/16/2010. The facility's policy on "Change of Condition (Resident)" dated 05/10 states: "The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition....Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received....".

Based on Interview and Record Review, the Facility failed to implement interventions between 4/4/11 to 4/14/11, for a resident (R60) with increased risk factors for dehydration. These failures contributed to R60's admission to a local hospital with complications secondary to a [DIAGNOSES REDACTED]. This is for 1 of 4 residents reviewed for dehydration in the sample of 11(R60). The findings include: R60 is a [AGE] year old male resident with [DIAGNOSES REDACTED]. The facility Nursing Notes were reviewed with the following documentation noted: 04/03/11 20:40 PM Call to Z1 (Primary Care Physician) then to Z9 (Medical Doctor- MD) on call for Z1, gave order to send to (local hospital) emergency room for evaluation. 04/04/11 10:45 AM Spoke with Z5 (Registered Nurse (RN) in Z1's office) to notify of new orders for [MEDICATION NAME] (antibiotic) for 10 days and [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. 04/05/11 01:00 AM Temp = 100 04/05/11 13:00 PM Remains on Antibiotic 04/06/11 12:00 PM Continues on Antibiotic 04/07/11 24:00 PM Temp 101.1 04/07/11 02:00 AM Temp 100.8 04/07/11 18:40 PM Continues on Antibiotic 04/09/11 06:00 AM Temp 100.4, Tylenol given, continues on antibiotic 04/10/11 06:30 AM Temp 100.5, Tylenol given, continues on antibiotic 04/13/11 24:00 PM Temp 100.9 04/14/11 05:30 AM Temp 101.4, Tylenol given, received last dose of antibiotic, fax sent to notify MD of continued elevation of temperature. 04/14/11 12:00 PM Temp 101.2 The Physician order [REDACTED].[REDACTED] ? [MEDICATION NAME] Patch 1.5 mg every 72 hours ? [MEDICATION NAME]-4mg/ml syrup ([MEDICATION NAME]) 25 ml (100 mg) per [DEVICE] two times daily ? Milk of Magnesium Suspension 30 ml per [DEVICE] two times daily ? [MEDICATION NAME] 160 mg/5 ml [MEDICATION NAME], 20 ml per [DEVICE] every 4 hours as needed (Not to Exceed 3 gm in 24 hours) ? [MEDICATION NAME] HCL 50 mg tab, 1 tab per [DEVICE] every 6 hours as needed ? [MEDICATION NAME] 750 mg, 1 tab daily for 10 days (4/4/11 to 4/14/11) ? [MEDICATION NAME] 10 mg, 1 tab per [DEVICE] two times daily. ? Is on Promote with fiber tube feedings at 90cc/hour for a total volume of 1900cc's in a 24 hour period. The Nursing Notes document on 4/4/11 at 10:45 AM, R60 began treatment with [MEDICATION NAME] for an active infection, ([DIAGNOSES REDACTED]. Davis's Drug Guide 2011 states [MEDICATION NAME] can: ? Cause a furry overgrowth to the tongue, ? May interfere with elimination, monitor bowel function, ? Absorption can be impaired with enteral feeding. R60's Medication Administration Record (MAR) dated 4/9/11 to 5/8/11 showed he received all his medications as ordered. According to the same MAR, R60 had an order to Flush GT (Gastrostomy Tube) with 250 ml of water every shift. These flushes were documented as completed providing 750 ml of free water a day. Another hand written order was written on the MAR which read "flush GT with 30cc of water before and after meds". No signatures were documented on the MAR to show this order was followed. R60's Dehydration Risk assessment dated [DATE] identified him as at risk for dehydration. R60's Care Plan for "Risk for imbalanced fluid volume", up-dated 1/25/11, documented the following: Problems: ? NPO (nothing by mouth), (unable to reach) ? [MEDICAL CONDITION] ? Stool Softener/Laxative ? [MEDICATION NAME] Interventions: ? Promote with fiber ? Assess for dehydration....poor skin turgor, dry, cracked lips, dry mucus membranes, constipation, fever, infection, electrolyte imbalance ? Labs as ordered ? Report abnormal labs ? Follow Dietary Recommendations ? Monitor Monthly Weights, report significant changes The Minimum (MDS) data set [DATE] identified R60 as being Severely Cognitively Impaired and dependant on staff for all Activities of Daily Living. The facility's hydration policy, dated 5/10, states #4. A care plan will be developed utilizing identified risk factors based on resident's individualized needs. The facility's policy on Intake and Output Monitoring, dated 5/10, states Intake and Output will be recorded for all residents on intravenous fluids . . . and for others as ordered by physician or assessed as needed by and RN, LPN. . . . Note: . . . If there is not a physician's orders [REDACTED].A.R. (Medication Administration Record.)" On 4/20/11 at 2:50 PM, E6 (Registered Nurse-RN) stated if residents have an increased temperature, some interventions would be to increase fluids, administer Tylenol, call the physician and/or apply cold compresses. E6 stated R60 had no fluid restrictions and that no contraindications for increasing R60's free water intake existed. E6 also stated R60 tends to be hot and sweat and therefore has a fan blowing on him at all times. The Hospital physician progress notes [REDACTED]. This note also showed the ED (emergency department) Course of treatment was for [DIAGNOSES REDACTED]. Lab results for R60 dated 4/14/11 at the hospital included abnormal results as follows: ? Sodium 146 Normal 137-145 (MMOL/L) ? Chloride 109 Normal 98-107 (MMOL/L) ? BUN 31 Normal 9-20 (MG/DL) ? [MEDICATION NAME] .57 Normal 0.70-1.30 (MG/DL) ? [MEDICATION NAME] 3.4 Normal 3.5-5.0 (GM/DL) ? MCV 99.6 Normal 82.0-96.0 (FL) ? MCH 34.3 Normal 26.32 (PG) According to Davis's Lab and Diagnostic Tests, 2011, ? Sodium increases in dehydration ? Chloride increases in dehydration secondary to hemoconcentration ? [MEDICATION NAME] decreases with inadequate protein intake ? [MEDICATION NAME] decreases in insufficient intake, malabsorption, and [MEDICAL CONDITION] ? MCV/MCH increases with hemoconcentration The physician progress notes [REDACTED]. The Progress Note also documented, "Supine and upright views of the abdomen demonstrated excessive colonic stool most concentrated in the rectosigmoid compatible with fecal impaction." On 4/21/11 at 08:00 AM, Z3 (Hospital RN) was interviewed regarding R60's condition on admission. Z3 stated R60 was so dehydrated on admission, the Emergency Department had to call in surgeon to achieve the placement of a cental line. The Emergency Department (ED) Nurses Note dated 4/15/11 at 03:56 AM documented, "Z4 (emergency room Medical Doctor- ER, MD) attempted central line placement X 2 unsuccessful. Z3 also stated the hospital has had difficulty with R60 experiencing hypotensive problems secondary to his being dehydrated. Z3 stated R60's increased temperature for 10 days "definitely" contributed to his dehydration and the severity of his subsequent illnesses and need for hospitalization . The hospital Admission [DIAGNOSES REDACTED]. On 4/21/11 at 08:00 AM, Z3 (RN) stated she was called to the admission unit to visualize R60's physical condition upon his arrival. Z3 stated Z10 (Hospital RN) was cleaning R60's eyes which were crusted shut with yellow drainage and his eyelashes stuck inside the eye socket. Z3 stated R60's tongue was covered with thrush and cleansing with a swab was ineffective. Z3 stated she "brushed" R60's tongue with a washcloth which removed "layers" of film. Z3 said R60's lips were dry and cracked with crust on them. Z3 added R60's "skin turgor was poor" and he appeared dry and emaciated. Z3 said water [MEDICATION NAME] were given through R60's PEG tube. Hospital Nursing documentation dated 4/15/11 at 04:30 AM, written by Z10, showed: "Patient's eyes were crusted shut with the eyelashes matted with yellow drainage where the patient could not open them...The patients mouth was very dry with layers of white (thrush) on his tongue..." According to the hospital laboratory results, the following culture results were obtained: ? 4/18/11 Right Eye Small growth Staphylococcus Aureus ? 4/19/11 Left Eye Small growth of [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) On 4/20/11 at 12:45 PM, E3 (Director of Nursing) said E6 (RN) had tried to call R60's physician regarding his mouth condition but received no response. On 4/20/11 at 3:15 PM, E6 stated she had not cared for R60 since 4/7/11 (1 week prior to hospitalization ). The facility provided no evidence of efforts to notify the physician of R60's oral condition between 4/7/11 and 4/14/11. On 4/20/11 at 2:55 PM, E7 (Certified Nursing Assistant-CNA) stated she provided AM care on R60 the morning of 4/14/11. E7 said R60 had "mucousy green boogary stuff" in his mouth for which she used swabs to clean "as much as I could." E7 said R60 also had "crusty stuff-eye boogars " in his eyes in the AM but did not notice any more the remainder of the day. E7 then qualified her statement saying R60 "never opened his eyes the rest of the day".