Every finding on record at Allure of Lake Storey

Based on interview and record review, the facility failed to inform a resident's family (R1) of a positive COVID-19 test result, resulting in a family member being unknowingly exposed to COVID-19, in a sample of three. Findings Include:R1's Progress Note dated 12/30/2025 documents, Res (resident) tested positive for COVID, Mucinex, and Vitamin C in place. Res currently asymptomatic, DON (Director of Nursing), IMG (In home medical group/Nurse Practitioner) notified.R1's Care Plan dated 4/7/2026 documents, Resident is on strict isolation R/T (related to) COVID-19 d/c (discontinue) on 1/10/26. Date Initiated: 12/30/2025. Created on: 01/06/2026. Revision on: 01/06/2026.On 4/6/2026 at 12:30 PM, V11 (Complainant) stated when V6 (R1's family member) came to visit R1 at the facility no one informed V6 that R1 had COVID-19 prior to her visit. V11 stated once V6 was in R1's room for almost three hours a staff member finally told V6 she needs to wear a mask and personal protective equipment provided by the facility due to R1 having COVID-19. V11 stated how wrong it was to not inform anyone that R1 had COVID-19 especially since V6 cares for her infant grandchild at home.On 4/6/2026 at 2:23 PM, V7 (Licensed Practical Nurse) stated she was the nurse on duty when V6 (R1's family member) came to visit on 1/3/2026. V7 stated when she entered R1's room for cares she saw V6 was sitting on R1's bed without any PPE (person protective equipment).On 4/6/2026 at 2:39 PM, V9 (Certified Nurse Assistant) was the CNA (Certified Nurse Assistant) working on 1/3/2026 when V6 (R1's family member) came to visit R1. V9 stated she went into R1's room to lay R1's roommate down, when she saw V6 sitting on R1's bed without any PPE (person protective equipment). V9 asked V6 why she was not wearing any PPE and V6 stated she did not know she was supposed to. V9 stated R1 has COVID-19 and V6 stated, I did not know that, and no one told me.On 4/7/2026 at 1:05 PM, V10 (Registered Nurse) was the nurse who tested R1 on 12/30/2026. V10 stated she could not get ahold of R1's family that day and did not leave a message. V10 confirmed she did not tell any of R1's family members she tested positive for COVID-19.On 4/6/2026 at 3:01 PM, V2 (Director of Nursing/Infection Preventionist) stated when testing for COVID-19 it depends on when the resident is tested if I report to the resident family or not. V2 stated that when she does a facility wide testing, she will inform residents family members if, they are positive. V2 stated if a floor staff nurse tests a resident and the resident is positive it is the nurse's responsibility to call and tell the residents family.The facility's COVID-19 Prevention, Response, and Reporting policy dated 6/11/2025 documents, It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state and/or local health authority guidance. Policy explanation and compliance guidelines, 6. The facility will provide guidance about recommended actions for residents and visitors who have any of the above criteria.The facility's COVID-19 Visitation policy dated 9/9/2025 documents, The facility will allow resident visitation to all visitors and non-essential health care personnel. This can be conducted through different means based on the facility's structure and residents' needs, such as in resident rooms, dedicated visitation spaces, and outdoors. The visitation will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life. Exceptions will be in accordance with federal, state and/or local guidance. 9. Visits required under the federal disability rights laws and protection and advocacy programs will be allowed at all times. If the resident is in transmission-based precaution or quarantine, the resident and representative should be made aware of the potential risk of visiting and the visit should take place in the resident's room.

Based on interview and record review, the facility failed to develop a comprehensive care plan for significant weight loss for one of three residents (R24) reviewed for weight loss in the sample of 31. Findings include: The facility's Comprehensive Care Plan policy, dated 9/18/23, documents It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. R24's current electronic weight summary documents R24's weight on 1/2/24 was 166 pounds, on 5/21/24 136.5 pounds and on 7/5/24 was 143.0 pounds (13.86%/percent significant weight loss in 6 months). R24's Dietary Progress Notes, dated 6/25/24 and signed by V14 (Dietician), documents R24 is being monitored for significant weight loss at one, three and six months. R24's current Care Plan, dated 6/5/24, does not document a plan of care or interventions implemented for R24's significant weight loss. On 7/18/24 at 11:15 AM, V2 (Director of Nursing) confirmed that R24's current Care Plan does not address her significant weight loss. V2 stated, I do not see (R24's) weight loss on the care plan. I would expect it to be put on her plan of care and it's not.

Based on observation, interview, and record review, the facility failed to revise a care plan with a change in transfer status for one of one resident (R49) reviewed for Activities of Daily Living in a sample of 31. Findings include: The Facility's Care plan revisions upon Status Change policy, dated 4/3/23, documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Upon identification of change in status, the nurse will notify the MDS (Minimum Data Set) Coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect the current resident needs. R49's Physician orders, dated 7/16/24, document an order signed 6/27/24 to be right foot toe touch weight bearing. On 7/15/24 at 9:30 AM, R49 was sitting in manual wheelchair with a mechanical lift sling underneath of him. On 7/16/24 at 11:25 AM, R49 stated he is being transferred with a mechanical lift now because every time he puts weight on his right foot his heel bleeds through the dressing. R49 states, The very first time staff tried to do toe touch weight bearing, I put weight on my heel because I felt I was going to lose my balance. R49 further states, Staff attempted three times and each time I had difficulty. I am able to put weight on my left leg. The last time staff had me standing I was in a special shoe and my wound bled but not as much. The staff and I get scared. So, we stopped trying because we don't want it to bleed. I stood for a bit about a month ago and I felt more stable then, but the staff stopped attempting after because I was scared. R49's care plan, dated 7/16/24, documents R49's transfer status is one person assist with a slide board. R49's care plan has no documentation of a revision of his change in transfer status. On 07/17/24 10:44 AM, V10 (Certified Nursing Assistant) and V9 (Licensed Practical Nurse) transferred R49 with mechanical lift from his bed to his wheelchair. A transfer slide board was sitting on top of a bedside table in R49s room. On 7/17/24 at 9:55 AM, V7 (Director of Rehab) stated on 6/28/24 upon discharge from therapy R49 was one assist with slide board. On 7/17/24 at 10:30 AM, V4 (MDS Coordinator) verified that R49's care plan was not revised following his change in transfer status.

Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter was cleansed with a cleaning agent indicated for indwelling urinary catheter care for one of two residents (R31) reviewed for indwelling urinary catheters in the sample of 31. Findings include: The facility's Catheter care policy (revised 02/05/24) documents the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. This policy also documents, Male: Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). R31's current medical record documents R1's current diagnoses to include: Malignant Neoplasm of Prostate, Benign Prostate Hyperplasia, Obstructive and Reflux Uropathy, and Urinary Tract Infection. On 07/15/24 at 11:00 AM, R31 was sitting in a wheelchair near his bed watching television. An indwelling urinary catheter bag containing clear yellow urine was hanging on the lower aspect of R31's wheelchair, and R31 stated he has a history of urinary tract infections. On 07/17/24 at 09:35 AM, R31 was lying supine in bed watching television. An indwelling urinary catheter drainage bag containing clear, yellow urine was secured to the lower aspect of R31's bed. V3 (Registered Nurse) entered R31's room at this time to provide indwelling urinary catheter care. V3 assisted R31 to pull his pants and incontinence brief down, and an indwelling urinary catheter was in place and secured to R31's left leg with a securement device. V3 proceeded to clean R31's indwelling urinary catheter with several wipes obtained from a resealable package of disinfecting wipes. Once care was completed, V3 assisted R31 to pull up his pants and incontinence brief. V3 stated disinfecting wipes are what she utilizes to clean all indwelling urinary catheters. On 07/17/24 at 10:00 AM, V3 provided the package of disinfecting wipes, and the following active ingredients were documented on the packaging: Octyl decyl dimethyl ammonium chloride; Dioctyl dimethyl ammonium chloride; Didactyl dimethyl ammonium chloride; and Alkyl dimethyl benzyl ammonium chloride. The packaging label also documents the following: Do not use as a baby wipe or for personal cleansing. This is not a baby wipe! V3 then stated, I screwed up, and confirmed she should not have utilized the disinfecting wipes to provide R31's indwelling urinary catheter care. On 07/17/24 at 11:20 AM, V2 (Director of Nursing) stated that V3 should not have used disinfecting wipes to cleanse R31's indwelling urinary catheter.

Based on observation, interview and record review, the facility failed to serve a physician ordered dietary supplement for one of four residents (R50) reviewed for weight loss in the sample of 31. Findings include: The facility's Nutritional and Dietary Supplement policy, dated 4/9/24, documents, It is the policy of this facility that nutritional and dietary supplements will be used to compliment a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practical level of well-being. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs. R50's physician order dated 7/18/24 documents R50 has an order to receive gelato (supplement) twice a day at lunch and dinner dated 3/15/24. R50's dietary note, dated 7/10/24 at 1:57 PM, documents, (R50) discussed with IDT (Interdisciplinary Team) during Nutrition-At-Risk (NAR) meeting related to wound monitoring. R50s dietary note also documents that R50 receives fortified ice cream twice a day. On 7/16/24 at 12:23 PM, R50 was sitting at the dining room table with her lunch. R50's tray did not include the physician ordered gelato supplement. On 7/16/24 at 12:31 PM, V15 (Certified Nursing Assistant) began helping R50 with her meal. R50's meal card that was lying on the table documented that gelato should have been served with R50's lunch. V15 stated that R50 was not served gelato with her lunch meal.

Based on interview and record review the facility failed to ensure safe positioning in bed was maintained during incontinence care and failed to obtain an air mattress and safety devices for one of three residents (R4) reviewed for falls in the sample of 12. These failures resulted in R4 falling from bed, hitting head on floor, and obtaining a hematoma to her forehead. Findings include: The facility's Fall Prevention Program, dated 2023, documents, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. The facility's Safe Resident Handling/Transfers policy and procedure, dated 2023, documents, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The facility's Turning and Repositioning policy and procedure, dated 2023, documents, It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. Use the appropriate number of staff to perform the tasks safely. Utilize positioning devices as needed to maintain posture. The facility's Use of Support Surfaces dated 2/1/23, documents, Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. Support surface refers to a specialized mattress, mattress overlay, or a chair cushion designed to manage pressure, shear, microclimate, or friction forces on tissue. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident's specific situation. Considerations for utilizing specialized support surfaces: a. Medical condition; b. Size and weight; c. Mobility and activity levels. d. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. The facility's fall log, documents R4 had two un-witnessed falls on 3/10/24 and 3/11/24 and a witnessed fall on 3/25/24. The current Care Plan for R4, documents R4 returned from hospital visit with a terminal prognosis and diagnosis of acute renal failure, hyperkalemia, urosepsis, and protein calorie malnutrition and on hospice services with a stage 3 coccyx pressure ulcer. R4 is at risk for falls related to deconditioning, gait/balance problems, and psychoactive drug use with history of falls at home and prior nursing facility. R4 had falls on 3/10/24, 3/11/24, and 3/25/24. R4 is receiving hospice services, requires total assist of two staff for turning and repositioning at least every two hours in bed and for toileting. R4's Care Plan was revised with fall intervention added on 3/11/24 to include, Notify hospice to bring in air mattress with built in bolsters and on 3/25/24 Notify hospice (company) to exchange (R4's) bed for a large bed with air mattress with bolsters. The #499 Un-witnessed fall investigation for R4, dated 3/10/24 at 9:40 pm, documents R4 noted to be laying on floor next to her bed. Nurse assessed. R4 noted to have abrasion to head and discoloration to arm with complaints of head pain. R4 has impaired balance coordination and weakness with poor safety awareness. Resident has a terminal condition and on hospice services. Nurse initiated neuros (neurological checks) and R4 was assisted back to bed per mechanical lift. (R4's) Care plan was reviewed and revised to add: Bed to be in lowest locked position with fall mats next to bed. Nurse documented, (R4) has poor upper body control, tends to lean towards right side while in bed. Requires constant repositioning. The #501 Un-witnessed fall investigation for R4, dated 3/11/24 at 3:00 pm, documents, Prior fall note exact same incident on 3/10/24. R4 was observed on left side of bed on the floor, lying on her right side, with pillow under face with no injuries. The root cause was documented as poor balance, coordination, weakness, restlessness, and terminal condition. Hospice notified for an air mattress with bolsters. The #505 Witnessed fall investigation for R4, dated 3/25/24 at 10:15 pm, documents V9 LPN (Licensed Practical Nurse) and V10 CNA (Certified Nursing Assistant) repositioned R4 from the far right of the bed to the center of the bed, turned R4 to left side, facing V10 CNA and while (V10) CNA had (R4) turned towards him (V10 CNA) and (V10) was wiping (R4's) buttocks, (R4's) upper body slid off of air mattress. R4 complained of face and nose pain and rated pain a 5 out of 10 on pain scale. V9 LPN assessed R4 noting 6.0 cm (centimeter) x 5.0 cm hematoma (abnormal collection of blood outside of blood vessel) to middle of forehead and the tip of R4's nose was potentially crooked. The local hospice to order a bariatric air mattress and V2 DON (Director of Nursing) requesting air mattress with bolsters. Care Plan reviewed and revised to add: Notify hospice (company) to provide a larger bed, air mattress with bolsters. The Post Fall Evaluation for R4, dated 3/26/24 at 2:54 am, documents reason for R4's fall as slipped out of air mattress, needs a bigger bed and injury as hematoma to forehead. Contributing Factors Noted: slippery bed/air mattress. R4 verbalized pain of 4 out of 10 on pain scale with grimacing, withdrawing and shows non-verbal signs of pain. On 4/5/24 at 3:24 pm, V18 LPN/Licensed Practical Nurse stated she was called down to R4's room on 3/10/24 because R4 was on the floor. R4 was found on the floor next to her bed, face down with an abrasion to her forehead. R4 was not able to move her legs but could move her upper body some, could move her arms, had poor control and would lean to the right. R4 had an air mattress, that seemed a bit unleveled, floor mats on the floor, and the bed was kept as low as it would go but was not a low to the floor bed. V18 LPN stated R4 was not morbidly obese but was wide and round and needed a bigger bed and was requested from the hospice company. R4's bed and nightstand were also moved because it looked like (R4) may have hit her head on the nightstand. V18 LPN stated she called and requested the hospice company to come to the facility to see R4 and after coming they just said to monitor R4 and never brought a bigger mattress. On 4/3/24 at 2:45 pm, V5 LPN stated R4 returned from a hospital visit on hospice services due to kidney and cardiac issues and was actively dying prior to her last fall. V5 LPN stated on the morning of 3/26/24, during shift report, V9 LPN reported R4 had fallen out of bed during the night, while cares were being provided, and V5 LPN only recalls seeing bruising to R4's forehead but nothing abnormal to R4's face. V5 LPN stated R4 was restless at times but mostly at nighttime. V5 LPN stated the air mattresses are slick and R4 wore silky nightgowns which probably didn't help. V5 LPN stated R4 had previous falls on 3/10/24 and 3/11/24 and on 3/11/24 V5 LPN requested the hospice company bring a bariatric air mattress and bolsters for R4's bed so there was more room for R4, but they never brought anything. On 4/5/24 at 12:53 pm, V10 CNA/Certified Nursing Assistant stated on 3/25/24 he and V9 LPN went in to clean up R4 and care for R4's coccyx wound treatment. V10 CNA stated R4 had to be moved to the middle of the bed before starting due to R4 leaning to the right side. V10 CNA stated, We rolled R4 towards me, and V9 LPN started cleaning R4 up because R4 had a bowel movement. V10 CNA stated both he and V9 LPN were holding onto R4 and both trying to clean R4 up and R4 just slid off the bed. V10 CNA stated (R4) had an air mattress and had already fallen numerous times before. In my opinion air mattresses are not safe for all residents. V10 CNA stated there were no bolsters on R4's air mattress and (R4) should have had a bigger bed to start with. R4 was actively dying prior to the fall and wasn't able to help, she just rolled right out. V10 CNA stated, I told them on my witness statement that I told V9 LPN that (R4) needed a bigger bed and that I didn't think the air mattress was safe because (R4) had prior falls. V10 CNA stated, The only thing I can think of is that we could have gotten another person to help but we only had to have two before. On 4/5/24 at 4:20 pm, V9 LPN stated she and V10 CNA went in to do (R4's) coccyx wound treatment on 3/25/24 but R4 had a bowel movement and needed cleaned up first. V9 LPN stated R4 had to be moved to the middle of the bed because R4 tended to lean to her right. V9 LPN stated R4 was rolled onto her left side facing V10 CNA. V10 CNA was standing at about R4's pelvis area holding R4 at the hip area with one hand and was wiping R4's buttock with his other hand. V9 LPN stated she was on the back side of R4 and had hand on R4's shoulder or hip area and at times she and V10 CNA were both wiping stool from R4's buttocks at the same time. V9 LPN stated R4's bed was in the up position while they were giving care and R4's head and top half of body just slid right off the bed. V9 LPN stated they tried to stop R4 from falling but couldn't, it happened so fast. V9 LPN stated R4's body fell on to the fall mat but R4's head hit the floor, causing a goose egg on her forehead and her nose did look a little crooked at the tip but I honestly didn't know if it was already like that or not. V9 LPN stated, (R4) has fallen other times because of the air mattress and R4 needed a bigger bed because (R4) was very round and filled the mattress she had. V9 LPN stated the hospice company was asked to bring a bigger mattress and bolsters for R4 but never brought them. V9 LPN stated she did notify the hospice company who told her to just put ice wherever R4 was hurting. V9 LPN stated, A bigger bed or bolsters probably would have helped prevent (R4) from falling. V9 LPN also confirmed that if V10 CNA had just been holding her and not wiping (R4), might have had better control of R4 and prevented R4's fall. On 4/5/24 at 2:23 pm, V2 DON/Director of Nursing stated generally during incontinence care of residents requiring two assist; the staff member the resident is facing holds and secures the residents position while the staff member facing the residents back side does the incontinence care. V2 DON stated it was reported that V9 LPN and V10 CNA were in the room providing cares for R4 and R4 fell out of the bed. V9 LPN and V10 CNA were cleaning R4 up and preparing R4 for the wound treatment. V10 CNA tried to stop R4 but R4 was top heavy and fell to the floor. V2 DON stated the facility had been trying to get a larger air mattress or bolsters from the hospice company for some time. V2 DON stated a bariatric air mattress and bolsters were requested from the hospice company multiple times. V2 DON stated, We went back and forth with (hospice company) and evidently they have requirements based on the resident's condition in order to provide one. V2 DON confirmed not having a larger air mattress or bolsters may have potentially contributed to R4's fall and that V10 CNA should have had both hands on R4 securing R4's position on the bed. On 4/5/24 at 4:27 pm, V1 Administrator stated the facility was having trouble getting a bigger air mattress and bolsters from the hospice company, who said they weren't allowed to deliver one due to their rules and the cuts that were made. V1 Administrator stated she called the facility's corporate office who called the hospice company's corporate office and they finally agreed they would deliver one but would be a week or so. V1 Administrator stated R4 ended up passing before the hospice company delivered anything to the facility. V1 Administrator confirmed that V10 CNA should have had both hands holding onto R4 while V9 LPN performed the incontinence care, and she would make sure the nursing staff was educated.

Based on interview and record review the facility failed to prevent drug diversion of Oxycodone from occurring for one (R1) of three residents reviewed for narcotic medications in the sample of 12. Findings include: The facility's Abuse, Neglect, and Exploitation policy and procedure policy, dated 8/11/22, documents, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This policy defines willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This policy also defines misappropriation of Resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. The facility's Medication Administration policy and procedure, dated 2024, documents, Sign MAR (medication administration record) after administered and If medication is a controlled substance, sign narcotic book. The Controlled Drug Receipt/Record/Disposition Form, for R1, documents a bubble pack card of 60 Oxycodone-APAP (Tylenol) 5-325 mg (milligrams) tablets was delivered to the facility on [DATE]. This form documents R1 received Oxycodone two tablets on the following dates: 2/7/24 at 12:00 pm; 2/8/24 at 7:30 am; 2/9/24 at 8:30 pm; 2/20/24 at 8:00 am; and on 2/20/24 at 8:30 pm. All other days R1 received only one tablet with the last dose of one tablet being administered on 2/19/24 at 11:12 am. There is no Oxycodone signed out for R1 between 2/19/24 and 3/5/24. This form documents V4 Former RN/Registered Nurse signed out Oxycodone on the following dates and times: 3/6/24 at 7:05 pm two tablets; 3/6/24 at 11:45 pm one tablet; and 3/7/24 at 5:00 am two tablets. The facility's final report submitted to the state agency on 3/11/24, documents R1 was admitted to the facility on [DATE] and has a physician order for Oxycodone-APAP 5-325 mg (milligrams) one to two tablets every four hours as needed for pain. R1 is alert and oriented to person, place, and time. R1 as cognitively intact on 1/22/24. It was noted on 3/8/24 that the narcotic count sheet from 3/6/24 at 7:15 pm to 3/7/24 at 5:00 am 5 tablets were signed out by an agency nurse (V4 Former RN). Resident had not taken this medication since 2/19/24 prior to this shift. The Oxycodone was not signed out on the resident's medication administration records. (R1's) scheduled Tylenol was signed out by (V4 Former RN) with zero reported pain from (R1). (R1) was questioned by the Administrator (V1) and DON/Director of Nursing (V2) and reports she has not taken any Oxycodone for several weeks and that she has had no pain. Physician and Family have been notified of incident. (Local) Police Department was notified of incident and report was taken by V20 Police Officer with complaint #24-8835. (V4 Former RN) has not been back into facility since incident and has been placed on Do Not Rehire/Allow to work in facility and the agency, (Company) that (V4 Former RN) works for has suspended her pending the investigation. A complete narcotic count has been completed by the Administrator and DON with no further discrepancies noted. The DON and/or Administrator will monitor the narcotic count sheets for two nurse signatures daily. Pharmacy to replace the medication as soon as Physician can write a script for the replacement medication. The facility's investigation includes V20's (local) Police Officer business card with a complaint number 24-8835 having been filed by the facility. The EMAR, dated March 2024, documents R1 with no complaints of pain 3/6/24 through 3/7/24 and no Oxycodone being administered to R1. On 4/2/24 at 3:00 pm, V7 LPN/Licensed Practical Nurse stated V4 Former RN was his relief at shift change for two days and the narcotic count was spot on both times. V7 LPN stated, Because the count was correct, I didn't notice anything. V7 LPN stated (V4 Former RN) was a bit odd, I thought. I love my job but (V4 Former RN) was beyond happy and excited to be here. On 4/2/24 at 1:07 pm, V2 DON stated on 3/8/24 V19 LPN/Licensed Practical Nurse, discovered R1 was administered five doses of Oxycodone in two days when R1 had not been taking any of it since February and V19 LPN thought it was suspicious and contacted V2 DON. V19 LPN knew R1 and due to having worked with her for some time. V2 DON stated she and V1 Administrator started the investigation and did notice that R1 hadn't taken any Oxycodone since 2/19/24 and then received five doses within two days. V4 Former RN/Registered Nurse signed the Oxycodone out on R1's paper narcotic sheet but did not sign the medication out in the EMAR (electronic Medication Administration Record) and scored R1 as having no pain on the pain assessment and did not administer any Tylenol to R1. V2 DON stated she spoke to R1, who is alert and oriented and R1 stated she had not received any of Oxycodone for a while and was trying not to take Tylenol anymore. V2 DON stated she contacted the facility float pool agency where V4 Former RN worked, and V4 Former RN was suspended pending the investigation and was made a DNR (do not return) from the facility. V2 DON stated everyone was notified and a report was filed with the police and a few days later the float pool agency informed the facility they had terminated V4 Former RN's position and V4 would no longer be working in any of the company's facilities. On 4/2/24 at 1:25 PM, V1 Administrator stated she and V2 DON did the investigation and completed narcotic counts on all of the facility medication carts and the counts were all correct. V1 Administrator stated all residents receiving narcotic medications were interviewed and they all said they received their medications except for R1. R1 said she had not taken the Oxycodone for some time and was even trying not to take Tylenol. R1 said no nurse came in to give her the Oxycodone during the past few weeks. V1 Administrator stated V4 Former RN was made a DNR (do not rehire) to the facility and the float pool suspended V4 and a few days later terminated her from the company. V4 Former RN was new to the facility and only worked those few days and due to the narcotic count being correct at shift change no one noticed anything out of the ordinary. V19 LPN was familiar with R1 and noticed that after not taking the Oxycodone for some time, R1 was randomly given five doses in two days, thought it odd and reported it right away. V1 Administrator stated, Because the narcotic count was correct during shift change, no one noticed anything out of the ordinary. V4 Former RN literally signed the medications off on the narcotic sheet and noticed that V4 did not sign them off in the electronic charting and documented R1 not having pain. V1 said, (R1) was alert and oriented and did not appear to be medicated at all and so it was pretty obvious what had happened. The police were called, a report filed, and the narcotic count sign off forms were changed from three shifts to two shifts due to the nurses working 12-hour shifts.

Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication for two residents (R31, R33) with diagnosis of dementia of five residents reviewed for unnecessary medications in the sample of 22. Findings include: Facility Policy/Use of Psychotropic Medication dated 2023 documents: The indications for use of any psychotropic drug will be documented in the medical record. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Facility Policy/Antipsychotic medication Use dated/revised 2021 documents: Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Diagnoses alone do not warrant the use of antipsychotic medication. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find clothes or glasses) that can be expected to improve or resolve as the situation is addressed. Antipsychotic medications will not be used if the only symptoms are one or more of the following: Uncooperativeness Wandering Restlessness Mild Anxiety Impaired Memory 1) Current Physician's Order Report Summary indicates R31 is [AGE] years old with diagnoses that include Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Brief Psychotic Disorder (4/4/23); Mild Dementia with Behavioral Disturbance (10/1/22); Unspecified Psychosis (3/17/20). Order Summary indicates R31 has orders for Olanzapine (antipsychotic) 2.5mg (milligrams) every bedtime increased on 4/5/23 related to Unspecified Psychosis (4/23/23). Informed Consent for Psychotropic Medication indicates consent for Olanzapine Recommended Daily Total Dosage Range 5mg - 10mg, Anticipated Dosage Range 5mg with Reason for Use of Medication Psychosis, Mood Stabilizer on 2/14/19. Consent does not indicate specific, target behaviors. Behavior Monitoring and Interventions Report dated June/July 2023 indicates R31 continues to exhibit physically aggressive behaviors with care, expresses frustration/anger at others, attempts to scratch, kick and hit. On 7/13/23 at 9:45am V10, CNA (CNA) stated R31 pinches, scratches and hits anytime she needs to be changed, and it is worse with showers. V10 stated R31 is calm and has no behaviors except when staff are providing personal care. Telemedicine Psychiatric Periodic Evaluation dated 4/4/23 indicates, (R31) has had more psychotic and aggression symptoms with staff of recent. Evaluation does not indicate specific psychosis R31 was exhibiting. Telemedicine Psychiatric Periodic Evaluation dated 620/4/23 indicates, (R31) has had psychotic and aggression symptoms with staff associated with cares and ADL's (Activities of Daily Living) but none noted since 6/11/23. Evaluation does not indicate specific psychosis R31 was exhibiting. Care Plan dated 8/3/22 indicates, Olanzapine related to Unspecified Psychosis not due to a substance or known physiological condition. Care Plan indicates R31 is noncompliant with care/showers; verbally/physically aggressive; has a behavioral problem - strikes out at caregivers related to dementia. The Care Plan does not include any psychotic behaviors with main behaviors exhibited as aggressive to staff with cares. 2) Current Physician order Report Summary indicates R33 has orders for Seroquel (antipsychotic) 25mg twice daily ordered on 4/5/23 for Depression/Delusions. Physician Summary Report indicates R33 is [AGE] years old and has diagnoses that includes Alzheimer's Late Onset (1/4/21) and Delusional Disorder (12/31/20). Consent For Psychotropic Medication 2/17/21 indicates consent was given on that date for R33 to receive Seroquel (antipsychotic) 50mg daily. No indication for use, diagnosis or target behaviors were documented on the consent for Seroquel. Behavior Monitoring and Intervention Report for June/July 2023 indicates on 6/6/23, R33 entered other resident's rooms/personal space, was hoarding, pacing and wandering. Report indicates R33 did not display any other behavior(s) in 60 days. On 7/13/23 at 9:45am V10, CNA stated R33 doesn't display any behaviors anymore. V10 stated R33 previously would run in the hallway and try to go out the exit door. Current Care Plan dated 8/17/22 indicates R33 receives Seroquel for depression and delusions; wanders and is an elopement risk related to dementia. Care plan also indicates R33 has a behavior problem of striking out at caregivers related to dementia. No target behaviors or identification of delusions is documented in R33's care plan. Both R31 and R33 were observed during various times of the day - both in bed and in the milieu - on 7/11/23, 7/12/23 and 7/13/23 and both were calm with no observable behaviors. On 7/12/23 at 1:45pm V3, Nurse Consultant stated they are working on better behavior monitoring, more specific behaviors, and a new psychotropic consent form.

Based on observation, interview, and record review, the facility failed to attempt an annual GDR (Gradual Dose Reduction), document clinically indicated diagnoses and behaviors, and implement non-pharmacological interventions for the use of anti-psychotic medications for two of three residents (R3, R40) reviewed for anti-psychotic medication use with the diagnosis of Dementia/Alzheimer's in the sample of 24. Findings include: The facility's Gradual Dose Reduction (GDR) of [CONDITION(S)] Drugs policy dated 2-1-22 documents, Policy: Residents who use [CONDITION(S)] drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who receive [CONDITION(S)] drugs. Therefore, dose reductions and behavioral interventions are part of medication management. This policy pertains to gradual dose reductions. Within the first year in which a resident is admitted on a [CONDITION(S)] medication or after the prescribing practitioner has initiated a [CONDITION(S)] medication, the facility will attempt a GDR in two separate quarters. 3. After the first year, a GDR will be attempted annually, unless clinically contraindicated. 1. R3's Admission Orders dated 12-31-20 document, [MEDICATION(S)] 25 mg (milligram), two tablets every night for diagnoses of Depression and Delusions. R3's Physician's Order Sheets (POS's) dated 12-31-20 through 8-16-22 document R3 has received [MEDICATION(S)] 25 mg two tablets every night and has not had a GDR (Gradual Dose Reduction) attempt. These same POS forms document R3 has diagnoses of Major Depression, Delusional Disorder, Alzheimer's Disease with Late Onset, and Major Depression. R3's MDS (Minimum Data Set) Assessments dated 2-3-22, 5-6-22, and 8-5-22 document R3 receives an anti-psychotic medication daily and does not have physical, verbal, or other behavior symptoms. R3's Medication Administration Records (MAR) dated 6-1-22 through 8-16-22 document R3 has had no hallucinations and has only had delusions on two days during this time. These same MARs do not include documentation of non-pharmacological interventions used along with effectiveness of these interventions to treat R3's delusions. On 8/15/22 at 10:06 AM, R3 was walking up and down the 500 hallway. R3 had no adverse behaviors at this time and was easily re-directed by V5 (CNA\Certified Nursing Assistant). On 08/15/22 at 10:10 AM, V5 (CNA) stated, (R3's) only behavior is wandering and trying to exit the facility. (R3) never has verbal or physical behaviors that I am aware of. On 08/16/22 at 10:48 AM V2 (Director of Nursing) stated, (R3) has never had a GDR attempt of her [MEDICATION(S)] since (R3) was admitted . The facility has not had a psychiatrist to see the residents in a while and (V6/R3's Physician) does not like to mess with anti-psychotic medications if he was not the one to prescribe them. (R3) takes [MEDICATION(S)] for wandering and non-compliance with cares and re-direction. I know those behaviors are not justification for the use of [MEDICATION(S)] and we (the facility) should have attempted to reduce (R3's) [MEDICATION(S)]. There is also no documentation of non-pharmacological interventions attempted to treat (R3's) behaviors. 2. R40's current Physician Order Sheets dated 7/31/22 through 8/16/22, documents R40 receives [MEDICATION(S)] Tablet 2.5mg (milligrams) four times weekly for [CONDITION(S)]. This same POS documents R40 has diagnoses of Dementia with behavioral disturbances. R40's MARs dated 6/1/22 through 8/15/22 document Antipsychotic Behavior Tracking of document number of episodes of mood swings and suspicious behaviors every shift. This behavior tracking does not include any behaviors of harm to herself or harm to other residents, or any non-pharmacological interventions used along with effectiveness of these interventions. The behavior tracking for mood swing episode documents R40 has not had any of these behaviors. R40's MDS (Minimum Data Set) Assessments dated 4/26/22 and 7/26/22 document R40 receives an anti-psychotic medication daily and does not have any physical, verbal, or other behavior symptoms. On 8/15/22 at 11:30 am., R40 was sitting in her wheelchair exhibiting no adverse behaviors. On 8/16/22 at 11:35AM, V7/Registered Nurse stated, (R40) does not have behaviors of harm to herself or toward other residents. On 8/16/22 at 1:30 PM, V2/Director of Nursing stated, R40 did have behaviors in the past verbally and physically towards staff, but has had a stroke and does not have these behaviors. V2 also stated, they have not been tracking behaviors of aggression towards herself or others and there is no documentation of any harmful behaviors towards herself or other residents.

Based on interview and record review, the facility failed to develop and implement the required COVID-19 facility staff vaccination policy. This failure has the potential to affect all 58 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, Infection Control Policy and Procedure For COVID-19: Facility Response Strategy, dated (revised) 1/21/22 directs staff, Vaccinations: The facility shall ensure that staff are vaccinated and tested . Staff are required to be fully vaccinated or have a medical or religious exemption in place. This policy does not address the facility ensuring staff have received COVID -19 vaccination (s) prior to providing resident care, nor a process for ensuring all staff are fully vaccinated except those that have been granted a waiver, nor a process for ensuring the implementation of additional precautions for staff that are not fully vaccinated, nor a process for tracking and securely documenting the COVID-19 vaccination status of all staff nor the development of contingency plans for staff who are not fully vaccinated for COVID-19. The facility form, COVID-19 Staff Vaccination Status for Providers, completed on 2/24/2022 and verified as accurate on 2/28/22, by V1/Administrator documents 84 facility staff members as either direct facility hires or contracted hire. On 2/28/22 at 12:37 A.M., V1/Administrator verified that the facility does not have an updated COVID 19 policy.

Based on observation, record review and interview, the facility failed to label and store food products in a safe and sanitary manner. This failure has the potential to affect all 58 residents residing in the facility. Findings include: The Facility Resident Roster, dated 4/26/21, documents 58 residents residing in the facility. Facility Food Receiving and Storage Policy, revised 10/2017, documents that food shall be received and stored in a manner that complies with safe food handling practices; dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) and such foods will be rotated using a first in-first out system; all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date); beverages must be dated when opened and discarded after twenty-four (24) hours; and toxic substances will not be stored in the kitchen area or storerooms for food or food preparation equipment and utensils. On 4/27/21, at 9:08 am and 4/28/21, at 9:35 am, the dry shelf in the main kitchen preparation area had an undated open storage container of cereal (Fruit Loops), with a measuring scoop, with debris, sitting on top of the lid. The dry storage room had four undated bags of cereal, two undated open bags of potato chips and one undated open bag of marshmallows. The dry storage room had a bucket of floor epoxy stored on the floor. On 4/27/21, at 9:08 am and 4/28/21 at 9:35 am, the freezer had three undated packages of sausage patties, six undated bags of potatoes (tots), three undated packages of pancakes, three undated bags of chicken breast. At these times, the refrigerator had one undated package of [MEDICATION(S)] slices and one undated open bag of shredded cheese. On 4/27/21, at 9:08 am and 4/28/21 at 9:35 am, the refrigerator had one undated pitcher of yellow liquid, one undated pitcher of red liquid and one undated condiment bottle (ketchup). On 4/27/21, at 9:15 am, V4 (Dietary Manager) stated, I know this food is undated, it just came in Friday (4/23/21) and should have been dated. The kitchen has been going through a lot of changes, and I am trying to teach second shift to get the dates onto the food, but they are not always real good getting the dates onto the food when we get it. On 4/28/21, at 10:45 am, V5 (Maintenance Director) verified that there was floor epoxy stored in the dry storage room. V5 stated, I have been dealing with this for a few months (standing water in the dry storage room). The water is either coming from the air conditioning unit that is leaking or the ice-maker right outside of the door. It started leaking a couple of months ago and water got underneath the tile and caused the tile to chip and pull away. I have been trying to epoxy the tile back down. This should not be happening in the food storage room.

Based on observation, interview and record review, the facility failed to maintain a safe and functional flooring in the kitchen's dry storage room and community resident shower rooms. This failure has the potential to affect all 58 residents residing in the facility. Findings include: `The Facility Resident Roster, dated 4/26/21, documents 58 residents residing in the facility. Facility Food Receiving and Storage Policy, revised 10/2017, documents: that food shall be received and stored in a manner that complies with safe food handling practices; food services, or other designated staff, will maintain clean food storage areas at all times; and food in designated dry storage areas shall be kept clear of sewage/waste disposal pipes and vents. Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents Your facility must be safe, clean, comfortable, and homelike. Facility Maintenance Supervisor Job Description, undated, documents: The primary purpose of your job position is to plan, organize, develop, evaluate, supervise, direct and take part in the operations of the facility's Maintenance Department; to assure the quality of maintenance services provided on a daily basis; to safeguard the health, safety and welfare of all residents residing in the facility; to assure the Maintenance Department is operated in a clean, safe and sanitary manner; assure the proper maintenance and running condition of all plumbing in the entire facility, including the kitchen area; Air handlers; assure the proper maintenance and running condition of all equipment in the building, including the kitchen appliances and machinery and boilers and heating units in the boiler room; and to perform all repairs that do not fall under the purview of housekeeping. 1. Facility Resident Council Minutes, dated 11/4/21, document issues with Heating Ventilation Air Conditioning (HVAC) Unit not working properly. On 4/27/21, at 9:08 am, the dry storage room floor had a moderate amount of standing water on the floor. The floor had debris and multiple floor tiles were missing or chipped. On 4/28/21 at 9:35 am, the dry storage room floor had blankets covering standing water on the floor and a wet floor sign. The floor had debris and multiple floor tiles were missing or chipped. On 4/27/21, at 9:15 am, V4 (Dietary Manager) stated, I do not know where this water is coming from, it has been doing it for a while. I think it is coming from the air conditioning unit. They have been trying to fix it. On 4/28/21, at 10:45 am, V5 (Maintenance Director) stated, I have been dealing with this for a few months (water in the dry storage room). The water is either coming from the air conditioning unit that is leaking or the ice-maker right outside of the door. It started leaking a couple of months ago and water got underneath the tile and caused the tile to chip and pull away. I have been trying to epoxy the tile back down. This should not be happening in the food storage room. 2. On 4/27/21 at 11:35am, R46 stated I take a shower on (my hall) or an (adjoining hall) if the shower is being used because only one of the two showers work on (my hall). It has been broken for a while, has mold and broken tiles, and has a sign to not use the one shower. On 4/27/21 at 10:45am, R10 stated I want a shower but I take a bed bath instead because the showers are nasty, and only one shower of the two works down this hall. I don't want to shower because I would walk out dirtier than I am before I went in, there is mold, and broken shower tiles in the shower room. On 4/27/21 at 11:00am, 200 hallway shower had two shower stalls and the left shower stall had the shower curtain pulled with a note (no date) across the curtain that stated Do Not Use This Shower, Thank You V1 Administrator. This shower stall had 11 missing tiles and mildew on the walls. At that same time, V15 Licensed Practical Nurse stated I have been back to work for a month and the shower has been that way. 300 hallway shower had two shower stalls with the shower on the right that had a shower handle that would not turn on, was missing the shower wand, and mildew was in the shower corners; and the shower on the left had mildew on the walls and floor. Upon entrance to the 300 hallway shower room it was missing one 12x12 inch floor tile and another 12x12 inch floor tile was half missing. On 4/28/21 at 10:20am, a tour was conducted with V5 Maintenance Director. During this tour, V5 verified the issues with the 200 and 300 hallway showers. V5 also verified they had received a bid to fix the 200 hallway shower, and stated all the showers needed to be replaced in the building. V5 also stated staff are to notify him by work orders that are located at the Nurses' desks, outside of his office door, and also can be done online on the computer. At that same time, V5 provided a facility shower stall bid for a single shower stall in the shower room, dated 11/10/20 (by a local plumbing company). On 4/29/21 at 12:00pm, V12 Certified Nurse Aid stated The residents can use any of the showers here.

Based on observation, interview, and record review, the facility failed to ensure a resident had enough clothing for daily living for one (R3) of 32 residents reviewed for dignity in a sample of 32. Findings include: Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents Your facility must treat you with dignity and respect, and must care for you in a manner that promotes your quality of life. Facility Illinois Long-Term Care Ombudsman Program, revised 11/18, documents, Your personal property rights are: You have the right to keep and wear your own clothing. R3's medical record documents R3 was admitted to the facility on [DATE], cognitively intact, and walks with limited assistance of one person. R3's medical record has no inventory sheet of belongings. R3's shopping receipts dated 4/19/21, 4/20/21, and 4/23/21 has no pants listed as being bought. R3's current trust fund receipt documents R3 has a balance of $1783.02 dated 4/26/21. On 4/27/21 at 11:00am, R3 stated I have two pairs of pants and just got two pairs of shorts. That is all I own. I don't always make it to the bathroom in the morning and I wet myself. They (staff) have to get more pants from laundry for me to wear when I run out of pants. They (activities) just went shopping for me and got the two pairs of shorts. The staff know I only have two pairs of pants because they are the ones that have to go to the lost and found or donated pile of clothes to get some pants for me while I wait. I use the lost and found pants or donated ones but I want my own pants instead of ones that are too big and fall off of me while I am trying to walk. At that same time, R3's closet was observed and contained a few t-shirts, two pairs of shorts and no pants. On 4/27/21 at 12:00pm, V12 Certified Nurse Aid, stated, I told (V13 Activity Director/Resident Service Director) that (R3) needed pants, I work on (R3's) hall a lot, (R3) only has two pairs of pants, she has a favorite pair. If she has none in her closet, then we get (pants) from the donated or lost and found or we have to wait until pants are clean from laundry. I go daily for her pants, she just got two pairs of shorts, and she recently went on a shopping trip and got stuff but no pants. She is incontinent (of urine) a lot in the morning, and she has only had two pairs of pants since she admitted here. On 4/27/21 at 12:25pm V13 Activity Director/Resident Service Director stated We are doing bi-weekly shopping for residents, and (R3) does not have an issue of no money because I think she has $90 on the books. On 4/28/21 at 1:00pm, V13 Activity Director/Resident Service Director stated I just went shopping for her and I did not buy her any pants. On 4/28/21 at 2:30pm, V2 Director Of Nursing (DON) stated, (R3) does not have an inventory sheet for belongings because she did not come here with any clothes. We have given her some clothing from the lost and found and donated clothing. Ideally a resident would have seven pairs of everything so they have something for each day of the week. We have donated clothing we could give to her, and she has a son that could bring her things but I do not know if he was notified she needed clothing. At that same time, V2 verified R3 had been in the building since 12/18/20. On 4/28/21 at 2:30pm, V14 Business Office Manager (BOM) stated We just got a trust fund set up for (R3) in February (2021). She has money in her personal checking account she transferred into her trust fund account here in February. Her insurance is Medicaid.

Based on observation, interview, and record review, the facility failed to assess a resident for pain and ensure an ordered pain management regimen was implemented for one (R46) of two residents reviewed for pain in a sample of 32. Findings include: Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents, Your facility must provide services to keep your physical and mental health at their highest practical levels. R46's medical record documents R46 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's current Care Plan documents under focus, I have chronic pain, I take scheduled Oxycodone-Acetaminophen related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one half hour before treatments or care, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/record pain characteristics such as quality (sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (continuous, intermittent); Aggravating factors; Relieving factors, and Monitor/record/report to Nurse any signs and symptoms of non-verbal pain. R46's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This form further documents that on 4/26/21 at 8:00 pm and 4/27/21 at 8:00 am, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A corresponding Nurses' note documented, On order. On 4/27/21 at 11:35am, R46 was in her room in her manual wheelchair answering questions quickly and appropriately while rubbing her right hip. R46 stated she was having pain severity rating as a 6/10, and has chronic pain from arthritis. R46 stated her right hip is bone on bone from the arthritis and she did not get her pain medication of Oxycodone last night (4/26/21 at 8:00 pm), or today (4/27/21 at 8:00 am) due to the staff stating they had none to give to her. R46 stated she has pain all the time and the pain medications just barely keep it under control and her right hip pain was sharp and burning but this pain was not different than the pain she feels all the time. On 4/28/21 at 12:40pm, V2 Director of Nursing stated We have some Oxycodone in the narcotic box but they were all out (two pills seen in narcotic box at this time that was locked on the nursing unit the resident resides). The nurses are supposed to assess pain every time they give pain medication. The pharmacy will only issue so many doses per law without a new script, this script has to be signed and sent over to the pharmacy by the physician (V10-R46's Medical Doctor/MD), we faxed (V10 MD) for the script multiple times but we never got a signed script before (R46) ran out of her medication. (V10 MD) sends the signed pharmacy order by fax to our pharmacy since her pain medication is a controlled medication. Our pharmacy is out of Chicago, and they deliver here two times a day, we do have a back up pharmacy that is local, and we try to re-order medications before we run out which is usually three days ahead of time. I was here when she ran out and I had to call the Physician's office to get the order filled. She only missed two doses but for (R46) that is a lot because she has a lot of pain. We did offer her Tylenol but I don't see where she was offered any other type of pain pill, or whether the Physician was called.

Based on observation, interview, and record review, the facility failed to obtain and dispense a scheduled pain medication for one (R46) of two residents reviewed for pain medication in a sample of 32. Findings include: Facility Administering Medications policy, revised April 2019, documents Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. R46's medical record documents R46 is cognitively intact and has Chronic Pain. R46's Medication Administration Record for April 2021 documents Oxycodone-Acetaminophen Tablet 5-325 MG (milligram), give 1 tablet by mouth two times a day (8:00 am and 8:00 pm) related to pain. This form further documents that on 4/26/21 at 8:00 pm and 4/27/21 at 8:00 am it had a 9 in the spot where their is normally a check mark with the nurses initials. The 9 is a chart code for Other/See Progress Notes. The progress notes for 4/26/21 at 8:00 pm and 4/27/21 at 8:00 am documents on order. On 4/27/21 at 11:35am, R46 was in her room in her manual wheelchair answering questions quickly and appropriately. R46 stated she did not get her pain med of Oxycodone last night (4/26/21 at 8:00 pm), or today (4/27/21 at 8:00 am) due to the staff stating they had none to give to her. On 4/28/21 at 12:40pm, V2 Director of Nursing stated We have some Oxycodone in the narcotic box but they were all out because the staff had already given her them (two pills seen in narcotic box at this time that was locked on the nursing unit the resident resides.) This script has to be signed and sent over to the pharmacy by the Physician but we never got a signed script before (R46) ran out of her medication. She missed two doses of the medication. On 4/28/21 at 1:02pm, V11 Pharmacist stated (R46) has a current order for Oxycodone 5/325mg one tablet twice a day, the last time we sent Oxycodone was on 4/16/21 when we sent 18 pills to the facility. We cannot fill a script like (R46)'s unless we have a signed current script on file that is why she got only 18 pills on 4/16/21 which would last her only nine days. After we got the signed script we sent 60 pills on 4/27/21 that were delivered (to the facility in the afternoon).

Based on observation, interview and record review the facility failed to ensure State survey results were readily accessible to residents. This failure has the potential to affect all 58 residents in the facility. Findings include: On 4/28/21 at 10:30am the State agency Group Interview was conducted. All eight residents (R12, R15, R21, R27, R40, R51, R56) in attendance stated that they were never told that a State Survey results binder was available to review and had no idea where it was kept. On 4/29/21 at 10:30am V1, Administrator stated that the Activity staff - who is no longer employed with the facility - would have been responsible for letting residents know where the survey binder was located. On 4/28/21 at 12:30pm, the State Survey results binder was not visible in the reception area of the facility. At this time V14, Receptionist/Business Office Manager, was asked where the State Survey book was located. V14 pointed to two white binders on the reception counter against the wall and beyond a computer desk - held in place by a metal bookend. The bookend completely blocked the title of the survey binder title. V14 stated that the survey results have been kept there since September (2020) when the new company took over the facility. On 4/29/21 at 10:30am, V1 stated that the State Survey binder has been moved to ensure it can be easily accessible by all residents and stated, Even residents in wheelchairs. The Resident Census and Conditions of Residents form dated 4/27/21 documents that there were 58 residents in the facility on that date.

Based on interview and record review, the facility failed to notify a resident's family of a positive Covid-19 result for one of four residents (R2) reviewed for notification and failed to update the resident representatives of the single positive Covid-19 resut in their facility for all 53 residents currently residing in the facility. FINDINGS INCLUDE: The (undated) facility policy, Covid-19 Reporting Policy, directs staff, In addition to reporting the occurrence of either a single confirmed infection of Covid-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other to the local health department and the state health department Covid-19 cases, the facility will: Inform residents, their representatives, and families of those residing in the facilities by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of Covid-19, or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other. This information must not include personally identifiable information; include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered and include any cumulative updates for residents, their representatives, and families at least weekly or by 5:00 P.M. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of Covid-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. R2's facility Face Sheet documents that R2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. This same form documents R2's daughter as the; Emergency Contact, Responsible Party of R2. R2's Covid -19 [DIAGNOSES REDACTED]/Covid Test, performed on 10/13/2020 and resulted on 10/15/2020, documents Positive for Covid-19. A review of R2's electronic Nursing Progress Notes, dated 10/13/2020 through 10/17/2020, shows no documentation that R2's emergency contact/responsible party (daughter) was notified of R2's Covid-19 diagnosis. On 10/20/2020 at 12:38 P.M., V16/(R2's) daughter stated,My father called me this past Friday (October 16,2020) and told me he was Covid positive. The facility has never called me to let me know. The facility has never called me at any time to let me know of the Covid-19 status in the facility or any mitigating factors they have put in place, since my father's admission. On 10/20/2020 at 1:30 P.M., V15/Social Services Director stated, I guess I'm the one that is supposed to call the resident's families if they test positive for Covid-19 and I am supposed to call every family each week and update them. I haven't made any weekly calls to the families. I did not call R2's daughter about his positive test. The facility Room Roster, dated 10/19/2002, and verified by V1/Administrator, documents 53 residents currently reside in the facility.

Based on observation, interview, and record review, the facility failed to implement active screening for respiratory symptoms for three of three residents (R6, R9 and R10), currently residing in the facility Covid-19 Quarantine Unit, reviewed for infection control, in a sample of ten. FINDINGS INCLUDE: The (revised 7/23/2020) facility policy, Infection Control Policy and Procedure for Covid-19 Facility Response Strategy, directs staff, Resident Management: The facility will implement active screening of residents for respiratory symptoms and vital signs consisting of temperature, respirations, pulse and pulse oximetry every 8 hours. 1. R6's current Physician order [REDACTED]. R6's Nursing Progress Notes, dated 10/14/2020, document, Moved from room shared with spouse, who tested positive for Covid-19 on 10/13/2020 to an Isolation room in Covid Unit. These same Nursing Progress Notes only include vital signs and respiratory symptom screening one time on 10/14/2020. No vital signs or respiratory screening were completed on 10/15/2020, 10/16/2020, 10/18/2020 or 10/19/2020. On 10/20/2020 at 10:00 A.M., R6 was seated in a wheelchair, in a resident room, on the facility Covid-19 Unit. A sign on the door read, Droplet/Contact Precautions. 2. R9's current Physician order [REDACTED]. R9's Nursing Progress Notes, dated 10/6/2020, document, Moved to Isolation in Covid Unit. These same Nursing Progress Notes from 10/6/2020 through 10/20/2020 do not document the required every 8 hour vital signs and respiratory screening. On 10/20/2020 at 10:05 A.M., R9 was asleep in bed, in the facility Covid-19 Unit. A sign on the door read, Droplet/Contact Precautions. 3. R10's current Physician order [REDACTED]. R10's Nursing Progress Notes, dated 10/13/2020, document, Readmitted on [DATE] after hospitalization for shortness of breath, to the Covid-19 Unit. These same Nursing Progress Notes from 10/13/2020 to 10/20/2020 lack the required vital signs and respiratory screening every 8 hours. On 10/20/2020 at 10:15 A.M., R10 was seated in a wheelchair, in a room, on the facility Covid-19 Unit. A sign posted on the door read, Contact/Droplet Precautions. On 10/20/2020 at 12:30 P.M., V11/Licensed Practical Nurse (LPN) was seated at the facility Covid-19 Unit nursing desk, documenting on resident charts. At that time, V11/LPN verified that R6, R9, and R10 medical records did not contain the required vital signs and respiratory screening assessment completed every 8 hours, while residing on the facility Covid-19 Unit.

Based on observation, interview, and record review, the facility failed to offer palatable and appetizing food temperature. This failure has the potential to affect 64 of the 65 residents that consume food. Findings include: Facility Resident Roster, dated 9/5/20, documents 65 residents reside in the facility. On 9/8/20 at 9:07 am, V1 (Administrator) verified that one Resident (R10) does not eat anything by mouth. Facility Meal Time, undated, documents that breakfast is at 8:00 am, lunch at 12:00 noon, and dinner at 6:00 pm. Facility Dietary Policy, dated 2009, documents: The Food Service record provides valuable history of resident preferences the food service manager will analyze this information to spot trends, evaluate menu combinations, and identify changes that need to be made within the menu to continually improve resident dining satisfaction; food will be prepared to conserve maximum nutritive value; foods will be cooked to proper temperatures using standardized recipes (155 degrees for ground meat and pork) and hot foods will be held at a minimum of 135 degrees and cold food will be a maximum of 41 degrees; standardized recipes will be used in preparation of foods to assure adequate amounts of available and consistently high-quality food products are served; some standardized recipes also include nutrient analysis; revisions to standardized recipes due to resident preferences may be made by the food service manager; meats and vegetables will be prepared to conserve maximum nutritive value to develop and enhance flavor and appearance in a safe and sanitary method; food will be cooked to the appropriate internal temperatures to prevent food borne illness; major causes of food borne illness are improper cooking and holding temperatures; hold all hot foods at 135 degrees and check temperatures frequently. Food temperatures will be maintained during transportation to prevent food borne illness; carriers will be rated to maintain hot food at 135 or above, food will be put in appropriate containers, put into the food carriers and transported in clean trucks, the internal temperature of the food will be taken after the food is received at the remote site; and Danger Zone means the temperature range between 41 and 135 degrees that favors growth of pathogenic microorganisms.' Facility Concern/Complaint Form, dated 3/25/20, documents Food is cold and small portions. Facility Concern/Complaint Form, dated 5/6/20, documents Certified Nursing Assistant/CNA's Are not asking residents what they want for lunch and dinner. Facility Concern/Complaint Form, dated 5/6/20, documents Hot chocolate is not good and coffee is still not hot, food has no flavor and food is always cold. The Complaint Form also documents that, Residents are tired of eggs and want something different and complained about not having a substitute for spaghetti. Facility Resident Council Minutes, dated 8/4/20, document Food being cold still a problem. Facility Concern/Complaint Form, dated 8/4/20, documents Food being served cold, meat overcooked and vegetables and potatoes still hard. Facility Concern/Complaint Form, dated 8/12/20, documents I would like edible food, vegetables are not cooked all the way, I cannot eat them. Facility Concern/Complaint Form, dated 8/12/20, documents I would like to have a banana. I cannot eat the oatmeal because it will make me vomit. Oatmeal was in a ball form and rubber like. Facility Concern/Complaint Form, dated 8/18/20, documents I was told that the kitchen was out of food so I could not get a replacement hamburger for the ham salad on the menu. My heart doctor told me not to eat ham or cured meat. Facility Concern/Complaint Form, dated 9/2/20, documents Resident placed supper order at lunch time requesting a chef salad with eggs and chicken. Resident wrote everything on the ticket at lunch time. When supper came she was served a plate of lettuce and cheese. Kitchen staff told nurse they did not have any eggs or chicken. Director of Nursing (V2) had to address the kitchen staff before they would cook any eggs or chicken for this diabetic resident. On 9/5/20, at 8:55 am, R8 stated, My food is cold really all the time. They even have plate warmers but they never use them. There is usually one Aide on the the hallway delivering the trays. I have never been offered an alternative meal if I do not like what they are serving. On 9/5/20 at 9:10 AM , R4 stated, I have lost almost 25 pounds since I have been here. I honestly do not care for the food and it is always cold. I usually just eat grilled cheese or peanut butter and jelly. I fill out my meal form and they do not offer an alternative meal replacement of same nutritional value, I usually just ask for a sandwich that is all they have. They do not offer an alternative meal replacement of same nutritional value. On 9/5/20, at 9:10 AM, R4 (500 Hall) was sitting in the recliner with a bowl of cereal on the bedside table. Seventy five percent cereal, twenty five percent milk and approximately half of an eight ounce glass of fluid were consumed. No other food was observed at R4's bedside. R4's Weight Record, dated 9/5/20, documents R4 weighed 141.0 pounds on 3/18/20 and on 9/4/20 R4 weighed 121.3 pounds. On 9/5/20 8:53 AM, V11 (Certified Nursing Assistant/CNA) stated, All meal trays come out on 400 and 500 Hall together on same server. This server is not heated and there plates are covered with plastic wrap. Usually only one CNA serves the meals. I know the meal times are 8:00 anAMd 12:00 noon but we usually never start serving at the scheduled time. Once I get the trays, it takes me at least a half an hour to pass them all out. I have had lots of people complain about not liking the food and that it is cold, I try and warm it up if I can. On 9/5/20, at 8:46 AM, V8 (Certified Nursing Assistant/CNA) stated, I am just starting to serve the room trays on 300 Hall, the full serving cart was on the front of the 300 Hall Wing. On 9/5/20 at 8:37 AM, V9 (Dietary Aide) stated, We usually just take their order off of their meal ticket. We do not have a set way of serving, we just ask which hallway is ready and then the CNA's deliver the food on the carts. I do not know why we only have two warmer carts but we use a regular cart for the 400 Hall and 500 Hall. On 9/5/20 at 8:40 AM, V10 (Dietary Aide) stated, I have to keep a cover over the food on one side of the steam table, as I am serving food because the burner is broken, and it makes the food cold. On 9/5/20 at 8:40 AM, the sausage temperature on the steam table was 122 degrees and the eggs were 132 degrees. On 9/8/20 at 8:34 AM, the 400 and 500 Hall trays were all sitting on the unheated serving cart at the 400/500 Hall Wing. On 9/8/20 at 8:17 AM, V18 (Dietary Cook) temped the food on the 200 Hall food cart (eggs were 99.8 degrees and the ground sausage was 123 degree) that was at the beginning of the 200 Hall Wing. All the plates were covered with plastic and no plate warmers or plate covers were used. The staff had not started distributing the breakfast trays; they were all still on the cart. On 9/8/20 at 9:08 AM, R11 was in the 400/500 Hall dining room and R11's eggs were temped at 93 degrees. On 9/8/20, at 8:17 AM, V18 stated, We do not use plate covers or warmers because we just do not have enough. On 9/5/20 at 11:55 AM, V16 (Dietary Manager) stated, The residents write on their meal ticket what they want, we do not normally offer an alternative. I am keeping an eye on the steam table burner problem, but I am now going to put in a work order for it to be looked at. I have heard about the complaints with cold food. Honestly, I am just going to keep it real, the Facility had cut so many hours in all departments that it affected the meal service. We only have two closed carts that hold the heat and they go to the 200 and 300 Hall. The cart that goes to the 400 and 500 Hall is just a regular cart that is not heated and we just cover those plates with plastic wrap. We do have a plate warmer that we can use. The CNA's are the only ones that take the meal tickets and that deliver the food. No one else helps them. The Resident's in the Dining Room get fed last after everyone else is served because we need a nurse and CNA in the dining room.

Based on interview and record review, the facility failed to assess a pressure wound upon admission, and failed to assess the nutritional impact on pressure wounds for one of three residents (R2), reviewed for pressure wounds, in a sample of 11. FINDINGS INCLUDE: The facility policy, Skin Condition Assessment and Monitoring-Pressure and Non-Pressure, dated (revised) 6/8/18, directs staff, To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. A skin condition assessment and pressure ulcer risk assessment will be completed at the time of admission/readmission. Measure length vertically in relation to head to toe position. Measure width horizontally in relation to hip-to-hip. Measure depth down into the deepest part of the wound. The (undated) facility policy, Nutrition Documentation: Comprehensive Nutrition Assessment, directs staff, Each resident is to have a comprehensive nutritional assessment initiated within 48 hours (of admission) and completed within 14 days of admission and whenever a new MDS (Minimum Data Set) is completed. To determine (the) resident nutritional status, assess the need for interventions and to note and honor resident food preferences. R2's (facility) Admission Record documents that R2 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R2's (hospital) Patient Transfer Form, dated 5/19/20, documents, Skin impairment: stage 3 (pressure wound) to coccyx. R2's Nurse's Notes, dated 5/19/20, document, (R2) arrived to the facility via wheelchair. Open area to coccyx. R2's Nursing Admission Assessment, dated 5/19/20, documents, Section E: Oral, broken or carious teeth. R2's Nursing Admission Assessment, dated 5/19/20, documents, Section D: Skin Integrity, coccyx open area, treatment applied as ordered. No wound measurements are included. On 9/8/20, R2's electronic medical record included no Comprehensive Nutritional Assessment. R2's Wound Care Initial Evaluation, dated 5/22/20 and signed by V17/Wound Physician, documents, At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. Site 1: Sacrum Wound size 0.9 CM (centimeters) X 0.6 CM X 0.1 CM. Periwound: macerated. Exudate: light serous. Site 2: Upper Ischium Wound size 0.43 CM X 0.32 CM X 0.1 CM. Exudate: light serous. Site 3: Lower Ischium Wound size 0.34 CM X 0.32 CM. On 9/8/20 at 9:11 AM, V2/Director of Nurses (DON) confirmed no initial wound assessment was performed by staff on R2's pressure wounds, upon (R2's) admission to the facility. On 9/8/20 at 9:11 AM, V2/Director of Nurses (DON) verified a nutritional risk assessment was not completed on R2. At that same time, V2/DON stated, (R2) was at high risk for weight loss due to her lack of appetite, cancer [DIAGNOSES REDACTED]. one (nutritional risk assessment).

Based on observation, interview, and record review, the facility staff failed to perform a mechanical lift transfer in a manner which would avoid injury, for one of three residents (R1), reviewed for incident/accidents, in a sample of three. This failure resulted in R1 falling from the mechanical lift sling to the floor, and sustaining a [MEDICAL CONDITION] requiring R1 to be sent to local hospital to have the laceration closed with staples. FINDINGS INCLUDE: The facility document entitled, Report to (the State Agency) Regional Office, dated 6/10/2019, documents, Date of Occurrence: 6-5-2019. Time of Occurrence 13:40 (1:40 p.m.). (R1) had a witnessed fall and bleeding from posterior scalp after sliding from mechanical lift sling during transfer. (R1) was transferred to the emergency room for evaluation and treatment and returned to the facility the same day with two sutures in place to posterior head. Resident has a BIMS (Brief Interview for Mental Status) score of 4 (indicating resident is not cognitively intact). The facility's untitled document, written and signed by V3(Certified Nursing Assistant), dated 6/5/2019, documents, (V3) and (V4) were getting (R1) up out of (R1's) chair to go to bed. I had thought the (mechanical lift) straps were hooked up correctly, but the bottom was not crossed. I did not know that they needed crossed because I am still not familiar with (mechanical lift) slings. Usually the person I am working with helps me and tells me if I do anything wrong. When (R1) was up in the air, (R1's) butt started slipping and (R1) fell . (V4) wasn't near (R1) at the time-I tried to get (R1) to the bed but (R1) fell and hit (R1's) butt first and then (R1's) head on the (mechanical lift) leg. The local hospital emergency room document, dated 6/5/19 (printed 6/19/2019), documents, R1 had, Laceration repair. Date/Time 6/5/2019 3:25 p.m.; Location details: Scalp; Laceration length: 2 cm (centimeters); Skin closure: staples; Number of sutures: 2. On 6/19/2019, at 3:25 p.m., V6 (Licensed Practical Nurse-Restorative Care Nurse) confirmed staff should, Always make sure the straps (mechanical lift sling) are crossed (between tthe resident's legs) for safety. On 6/20/2019, at 9:30 a.m., R1's [MEDICAL CONDITION] was observed. Location-middle left, back of R1's head. Size-approximately one-half inch long. Laceration is closed/scabbed over. Staples previously removed.

Based on observation, record review and interview the facility failed to notify the family and/or the physician for a change in condition for two of four residents (R23 and R20) reviewed for notification of changes in a total sample of 16. This failure resulted in R23's pressure ulcer deteriorating and requiring surgical excisional debridement. Findings Include: 1. The facility's Skin Care/Wound Management Policy (revised 10/2004) documents Contact physician when a Pressure Ulcer progresses from one stage to another or when there is any significant change in the condition of a wound. R23's Wound Care Specialist Evaluation dated 5/19/17 documents an improved stage 3 pressure wound of the coccyx measuring 0.3 cm (centimeters) X (by) 0.3cm X 0.1cm with 100% (per cent) granulation tissue. R23's Wound Documentation (weekly wound monitoring sheet) dated 5/19/17 documents R23's pressure wound of the coccyx as stage 3, measuring 0.3cm (centimeters) X 0.3cm X 0.1cm, surface area 0.09cm2 (centimeters squared), with 100% granulation tissue. R23's Wound Documentation's form contains no further wound assessments until 6/15/17. On 6/15/17 at 11:00am, R23's coccyx wound bed was 100% devitalized yellow tissue. On 6/15/17 at 12:30pm, E8 stated R23's pressure wound bed was covered with yellow slough on 6/14/17 at 4:15pm when E8 completed R23's treatment. E8 stated (E8) did not notify the physician of a change in the wound because (E8) was unaware that the wound bed had changed. E8 stated the yellow tissue covering the wound bed indicated the wound condition had deteriorated and was now unstageable. On 6/15/17 at 3:10pm, E2, Director of Nursing, stated (E2) expects nurses to immediately notify the physician if there is a change/decline in a resident's wound. On 6/6/17 at 12:10pm, Z4, Wound Physician, stated I was not notified of the change in R23's wound until last evening (6/15/17). I saw (R23's) coccyx wound today (6/16/17) and it had deteriorated. I expected it to be healed by now. The last time I saw the wound it was very small. Wounds are to be measured weekly, somebody is supposed to do it. I expect to be notified right away if there is a change in a wound. I was on vacation last week, but they could have sent (R23) to the wound clinic to have the wound assessed. I had to surgically debride the necrotic tissue today, and the wound is larger. R23's Wound Care Specialist Evaluation dated 6/16/17 documents the following: Unstageable Coccyx (wound); Etiology - Pressure; Stage -Unstageable necrosis; Wound size - 0.6 (cm) X 0.4(cm) X not measurable cm; Surface Area - 0.24cm2 (centimeters squared); Thick Adherent Devitalized Necrotic Tissue 100%; Wound Progress - Deteriorated; Procedure - Surgical excisional debridement of 0.24cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3cm. 2. The Change of Condition Reporting policy dated 02/2013 states (Facility) will notify the resident's physician and the resident's representative whenever: there is a significant change in the resident's health, mental or psychosocial status; there is a change in the resident's condition that although not significant is prudent to report using good nursing judgement. R20's Nurse's Notes show a late entry for 05/30/17 at 4:00 A.M. by E7 (Licensed Practical Nurse) showing resident continues episodes of vomiting. Emesis brownish orange thin consistency. Plan of action discussed with administrator, doctor to be notified of condition decline during office hours. R20's Nurse's Notes show a late entry for 05/30/17 at 10:20 P.M. by E6 (Registered Nurse) saying resident had an emesis that was thick and brown. On 05/31/17, R20's Nurses Notes document E5 (Licensed Practical Nurse) called Z1 (R20's family member) and Z3 (R20's physician) at 12:45AM after R20 had large dark brown coffee ground emesis. R20's Nurse's Notes document R20 was being admitted with urosepsis and possible left lower lobe pneumonia on 05/31/17 at 4:30 P.M. On 06/14/17 at 10:00 A.M. Z1 (R20's family) stated I should have been called when (R20) vomited the first time. That is a definite change for her, and I deserve to be part of the wheel of making decisions in regards to her care. By the time they (facility staff) got her to the hospital, she was septic. She deserved to receive treatment as soon as possible, not when the doctor's office is open. Z1 also stated I spoke with the Administrator and she told me that they don't normally call the doctor in the middle of the night unless it is serious. I don't understand how this wasn't considered serious, I almost lost (R20). On 06/14/17 at 3:10 P.M. E6 (Registered Nurse) stated No, I did not notify the doctor of R20's status change. E6 also stated Vomiting is not normal for this resident; the resident remained sick all night and into the day. E6 confirmed no assessments or vital signs were documented until the next day. E6 stated It does look like we didn't do a timely assessment or notify the family and physician of a change in condition. On 06/15/17 at 8:45 A.M. E1 (Administrator) stated I was in the building the night (R20) was sick; I told the nurse if she felt it was serious she should notify the doctor. I am not a nurse. On 06/14/17 E5 (Licensed Practical Nurse) stated I got in verbal report that (R20) was puking bile, and the stomach flu had been going around so I was going to monitor the situation. Then, after the first time I observed R20's vomit I immediately called Z1 (R20's family) and Z3 (R20's physician), because the emesis was coffee ground in nature. On 06/15/17 at 8:30 A.M. Z2 (Physician Assistant for Z3) stated We (Z2 and Z3) would expect to be notified of any significant change in a resident's condition. If it is not during office hours, there is a paging system to reach the person on call.

Based on record revew and interview, the facility failed to monitor, assess, and notify the physician/family for one of one residents (R20) at the onset of vomiting. This failure resulted in R20 developing episodes of brown, coffee ground emesis, with no documented assessment, monitoring, or physician notification for over 20 hours, resulting in R20's hospitalization with urosepsis. Findings include: The Change of Condition Reporting policy dated 02/2013 states (Facility) will notify the resident's physician and the resident's representative whenever: there is a significant change in the resident's health, mental or psychosocial status; there is a change in the resident's condition that although not significant is prudent to report using good nursing judgement. R20's Nurse's Notes show a late entry for 05/30/17 at 4:00 A.M. by E7 (Licensed Practical Nurse) showing resident continues episodes of vomiting. Emesis brownish orange thin consistency. Plan of action discussed with administrator, doctor to be notified of condition decline during office hours. Clinical record did not contain any assessment of the resident other than the vomiting. R20's Nurse's Notes show a late entry for 05/30/17 at 10:20 P.M. by E6 (Registered Nurse) saying resident had an emesis that was thick and brown. On 05/31/17, R20's Nurses Notes document E5 (Licensed Practical Nurse) called Z1 (R20's family member) and Z3 (R20's physician) at 12:45AM after R20 had large dark brown coffee ground emesis. On 06/14/17 E5 (Licensed Practical Nurse) stated I got in verbal report that (R20) was puking bile, and the stomach flu had been going around so I was going to monitor the situation. Then, after the first time I observed R20's vomit I immediately called Z1 (R20's family) and Z3 (R20's physician), because the emesis was coffee ground in nature. On 06/14/17 at 3:10 P.M. E6 (Registered Nurse) stated No, I did not notify the doctor of R20's status change. E6 also stated Vomiting is not normal for this resident; the resident remained sick all night and into the day. E6 confirmed no assessments or vital signs were documented until the next day. E6 stated It does look like we didn't do a timely assessment. R20's Nurse's Notes document R20 was being admitted with urosepsis and possible left lower lobe pneumonia on 05/31/17 at 4:30 P.M. On 06/14/17 at 3:10 P.M. E6 (Registered Nurse) stated No, I did not notify the doctor or family of R20's status change. On 06/15/17 at 8:45 A.M. E1 (Administrator) stated I was in the building the night (R20) was sick; I told the nurse if she felt it was serious she should notify the doctor. I am not a nurse. On 06/15/17 at 8:30 A.M. Z2 (Physician Assistant for Z3) stated We (Z2 and Z3) would expect to be notified of any significant change in a resident's condition. If it is not during office hours, there is a paging system to reach the person on call.

Based on observation, interview, and record review, the facility failed to assess, document, and report the condition of a pressure ulcer for two of two residents (R23, R24) reviewed for pressure ulcers in the sample of 16. This failure resulted in R23's pressure ulcer deteriorating and requiring surgical excisional debridement. Findings include: The facility's Skin Care Pressure Ulcer/Wound Management Policy (revised 10/04) documents the following: 3. Re-assess the wound weekly or more often as necessary to measure progress or decline in wound status. 4. Document the wound status on the Wound Documentation Form weekly. 6. Contact physician when a pressure ulcer progresses from one stage to another or when there is any significant change in the condition of a wound. The DON (Director of Nursing) will review the reports: Weekly Pressure Ulcer Report, Weekly Skin Report and the Weekly Pressure Ulcer Recap (Recapitulation) weekly. 1. On 6/15/17 at 11:00am, R23's coccyx wound bed was 100% (percent) devitalized yellow tissue (slough). R23's Wound Care Specialist Evaluation dated 5/19/17 documents an improved stage 3 pressure wound of the coccyx measuring 0.3 cm (centimeters) X (by) 0.3cm X 0.1cm, surface area 0.09cm2 (centimeters squared), with 100% (percent) granulation tissue. R23's Wound Documentation form (weekly wound monitoring sheet) dated 5/19/17 documents R23's pressure wound of the coccyx as stage 3, measuring 0.3cm X 0.3cm X 0.1cm, with 100% granulation tissue. On 6/15/17 at 12:30pm, E8 stated R23's pressure wound bed was covered with yellow slough on 6/14/17 at 4:15pm when E8 completed R23's treatment. E8 stated (E8) did not notify the physician of the change in the wound because (E8) did not know at that time that the condition of the wound bed had changed. E8 stated the yellow tissue covering the wound bed indicated the wound condition had deteriorated and was now unstageable. R23's Wound Care Specialist Evaluation (written by Z4, Wound Physician) dated 6/16/17 documents the following: Unstageable Coccyx (wound); Etiology - Pressure; Stage -Unstageable necrosis; Wound size - 0.6 (cm) X 0.4(cm) X not measurable cm; Surface Area - 0.24cm2 (centimeters squared); Thick Adherent Devitalized Necrotic Tissue 100%; Wound Progress - Deteriorated; Procedure - Surgical excisional debridement of 0.24cm2 of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3cm. On 6/15/17 at 3:10pm, E2, Director of Nursing (DON), stated that weekly wound measurements/assessments had not been provided since 5/19/17 because the facility did not have a Restorative Nurse to assess the pressure ulcers. E2 stated that (E2) reviewed the pressure ulcer assessments/reports weekly until 5/19/17, but has not reviewed pressure ulcer assessments/reports since 5/19/17. E2 stated (E2) expects that the nurse providing a resident's wound treatment will notify the physician immediately if there is a change in the wound. On 6/15/17 at 12:30pm, E8, Restorative Nurse, stated that no wound measurements or assessments had been documented for R23 since 5/19/17 because E10, previous Restorative Nurse who assessed wounds, changed work status to PRN (as needed) and no longer assessed wounds. On 6/6/17 at 12:10pm, Z4, Wound Physician, stated I saw (R23's) coccyx wound today (6/16/17) and it had deteriorated. I expected it to be healed by now. I do not know why the wound deteriorated - the skin around the wound is normal, (R23) is compliant with treatment, eats well, and I saw no moisture of the wound. The last time I saw the wound it was very small. Wounds are to be measured weekly, somebody is supposed to do it. I expect to be notified right away if there is a change in a wound. I was on vacation last week, but they could have sent (R23) to the wound clinic to have the wound assessed. I had to surgically debride the necrotic tissue today, and the wound is larger. 2. On 6/14/17 at 7:45am, a pressure ulcer was present on R24's sacrum. R24's Wound Documentation (weekly wound monitoring sheet) dated 5/19/17 documents R24's pressure wound of the sacrum. R24's next sacral pressure wound assessment documented on the Wound Documentation form is dated 6/15/17. On 6/16/17 at 9:30am, E2, DON, stated R24's medical record contained no measurements/assessments of R24's sacral pressure ulcer from 5/19/17 to 6/14/17.

Based on interview and record review, the facility neglected to follow their policy on change of condition for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 being found with a grossly deformed left thigh and remaining in the facility without emergent care for seven hours before being hospitalized . R1 was hospitalized with a spiral [MEDICAL CONDITION] femur resulting in blood loss requiring transfusion. R1 subsequently died after R1's hospitalization . This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level II as the facility continues to conduct ongoing training of all staff, including the Administration, regarding the definitions of abuse, including neglect, timely reporting of serious incidents and accidents that result in a resident injury, the regulatory reporting requirements, facility staff obligation to safeguard all residents and development of ongoing quality assurance measures to ensure facility protocol has been followed. Facility policy Change of Condition Reporting revised ,[DATE], documents the following: (Facility) will notify the resident's physician and the resident's representative whenever: · There is a significant change in the resident's health, mental or psychosocial status. · There is an accident (incident or unusual occurrence). The same policy also documents the following: Notify the physician of the change of condition/incident/accident/unusual occurrence and assessment findings. (Change of condition/incidents/accidents/unusual occurrences may be reported to the physician via fax, unless the the resident's condition requires immediate response from the physician). R1's medical record documents that R1 was admitted to facility on [DATE] with the following Diagnoses: [REDACTED]. R1's most recent MDS (Minimum Data Set) dated [DATE] documents that R1 is rarely understood and is transferred using a mechanical lift with extensive assistance with bed mobility. Facility Incident/Accident Report dated [DATE] and signed by E4 (LPN/Licensed Practical Nurse) documents the following: Called to room by CNA's (E5 and E6, Certified Nurse Aides) to check left thigh. Noted lower femur pushing up against the skin causing whitish discoloration with bluish discoloration around the perimeter. Internal rotation of foot noted. Left leg slightly shorter than the right. Also a 2 cm (centimeter) x 1 cm abrasion below left knee. Complaints of discomfort with range of motion. Nurses notes for R1 dated [DATE] documents the following: Called to room by CNA at 4:00 AM. Noted left lower femur pushing up, against the skin causing a whitish discoloration with bluish discoloration around perimeter. Internal rotation of foot noted. Left leg slightly shorter than the right. Also a 2 cm x 1 cm abrasion below left knee. Complains of discomfort with range of motion. On [DATE] at 11:56 AM, E5 (CNA) stated that on [DATE] at 4:00 AM, It (R1's left leg) looked like her bone was going to pop out of her skin .(R1) was incontinent and (E6, CNA) and me were going to clean her up. That's when we rolled her and she made a noise and grimaced. And that's when we (E5 and E6, CNA's) saw it (R1's leg). So (E6) went and got (E4, LPN). (E4) checked (R1) out. I don't think (E4) called anyone right away .that bone looked like it was going to pop out of her skin. I (E5) almost fainted when I saw it. I (E5) think someone should have called 911 because (R1's) leg looked so bad . On [DATE] at 3:37 PM, E6 (CNA) stated, (E4, LPN) put it (addressing R1's left leg deformity) off. (E4) continued caring for the other residents. I think someone should have called 911. I asked (E4) about (R1's) leg after (E4) looked at it, and (E4) said to me that she felt like it was arthritis and she would call the doctor later. On [DATE] at 1:07 PM, E4 (LPN) stated, The aides (E5 and E6, CNA's) came and got me from (another room). They said we need you down in (R1's) room. They pulled back her covers and there was the bone sticking up against her skin. Bruising and white skin tinting from the bone pushing up against the skin wall with a small superficial abrasion on her left lateral knee. Her leg was obviously broken. It was internally rotated. I don't know how she got the abrasion on her left knee. I did a body assessment and there were no other findings than her leg. I asked the girls what happened and they couldn't give me an answer. They didn't know. They said they didn't notice anything on a previous bed check. R1 had feces between her toes. (R1) can't turn herself in bed. It was wrong but I continued trying to care for other residents. I told the aides to leave her still for the time being. I called the doctor around 7:10 AM once I caught up with cares. Sometimes he can be a difficult doctor to deal with. Facility interview conducted and signed by E7 (Corporate) dated [DATE] documents the following: (E4) stated she went to the nurses station to sit down and think about the situation as to what had occurred, why they didn't see the leg earlier. I asked (E4) what she did from the time she found the injury to the time she called the physician and she stated 'I did dressing changes on (other residents). She also responded 'I took care of all the other residents answering call lights, etc.' I asked (E4) why she waited three hours to call the physician and three and a half hours to call the son and she replied, 'It was just so crazy that night, I can't really answer that question.' Nurses notes for R1 dated [DATE] documents that R1's physician (Z1) was not notified until 7:20 AM of R1's injury when an on-site x-ray was ordered. The same nurses noted document mobile x-ray unit arrived and did x-ray at 9:00 AM. Nurses notes for R1 dated [DATE] at 10:00 AM document the following: Sons stated they want (R1) sent to the emergency room . Informed getting Dr. (doctor) order to send and getting x-ray results to (Z1). 10:45 AM Left per (local ambulance service). On [DATE] at 11:37 AM, Z1 stated, I would expect to be notified of a change of condition immediately. They did not notify me until after 7:00 AM on [DATE] and I don't know why. I would have expected to have been notified of this type of injury immediately. On [DATE] at 1:48 PM, Z5 (local ambulance Emergency Medical Technician) stated that Z5 arrived to the facility on [DATE] around 10:30 AM to transport R1 to the hospital. Z5 stated that Z5 found R1 lying in bed with a grossly deformed left leg. Z5 then stated, No one could explain what happened. Her left leg was obviously broken. It was just loose from the area fractured down to her foot. They (facility) did not have her leg splinted. I can't believe that she'd been lying there since 4:00 AM with a fracture of that degree. On [DATE] at 11:23 AM, Z6 (local hospital Emergency Department Registered Nurse) stated that R1 arrived to the Emergency Department around 11:00 AM on [DATE]. Z6 stated, I was very concerned about the way (R1) looked when she came in. The timeline was suspicious. (R1) had an obvious visible fracture that was found at 4:00 AM and (R1) didn't arrive to the ER (emergency room ) until 11:00 AM. I don't think (Z1, R1's Physician) was even aware of her condition for a few hours. On [DATE] at 4:51 PM, Z4 (local hospital emergency room Physician) stated that R1 arrived to the emergency roiagnom on [DATE] with an obvious deformity to (R1's) left femur. Z4 stated, She had a spiral fracture of her left femur .the bone was going to protrude through her skin if we would have left it the way that it was .I would have expected a doctor to be notified immediately with an obvious fracture of that nature and I would have expected her to be sent in right away. Z2's (R1's Orthopedic Physician) Consultation Report for R1 dated [DATE] documents the following: (R1) was apparently found to have a fracture of her left femur in the supracondylar area above total knee prosthesis. (R1) is severely demented and at best would get up in a chair with a (mechanical) lift. On examination, (R1) has moderate swelling and moderate deformity of the distal femur. I personally evaluated her x-ray. She has a spiral supracondylar fracture of her left femur. On [DATE] at 10:25 AM, Z2 (R1's Orthopedic Physician) stated that R1 arrived to the emergency room with an obvious deformity of the left femur. Z2 stated, She (R1) had a spiral fracture of her left femur .That fracture didn't happen by itself. It was caused by some type of trauma, possibly a twisting injury or a fall .she shouldn't have been moved or rolled unless her leg was splinted. I wouldn't want her leg flopping all over the place .(R1) had a large amount of bruising to her left knee. It was a complication of a large amount of bleeding from her fracture. Moving her leg around could have caused her to bleed more. If she would have been splinted or sent in sooner, it would have made a difference in her amount of blood loss. On [DATE] at 10:53 AM, Z3 (R1's Hospitalist) stated that R1 was acutely anemic the next morning after R1 was admitted to the hospital, and R1 received a blood transfusion with little to no improvement and was then placed on comfort measures. On [DATE] at 9:15 AM, Z7 (R1's family member) stated that it was determined after R1 was hospitalized on [DATE] that there was nothing more they could do for R1. Z7 then stated the decision was made to make R1 comfort measures, and R1 expired on [DATE]. On [DATE] at 3:00 PM, an Immediate Jeopardy was identified to have begun on [DATE] at 4:00 AM when R1's left femur fracture was identified and Z1 was not immediately notified. E1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 3:00 PM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1) On [DATE], E2 (Director of Nursing) and E3 (Assistant Director of Nursing) received education regarding implementation of ongoing quality assurance measures that includes reviewing facility incident reports to ensure the resident's clinical record is reflective of the facility's policies and procedures. On [DATE] at 9:25 AM, E1(Administrator) verified that these actions were initiated on [DATE] and remain ongoing. 2) On [DATE], facility staff education was provided and remains ongoing regarding the definitions of abuse, including neglect; timely reporting of serious incidents and accidents that result in a resident injury; the regulatory reporting requirements; and facility staff obligation to safeguard all residents. Facility staff also received in-servicing on [DATE] on the following facility policies: Change of Condition Reporting (Revised ,[DATE]); and Incidents and Accidents (Revised ,[DATE]). On [DATE] at 9:25 AM, E1(Administrator) verified that these actions were initiated on [DATE] and remain ongoing. 3) On [DATE], E2 (Director of Nursing) and E12 (Regional Nurse) reviewed the facility's current Accident/Incident log to ensure that necessary follow-up was provided in accordance with the facility's policies and procedures. On [DATE] at 9:25 AM, E1(Administrator) verified that these actions were initiated on [DATE] and remain ongoing.

Based on interview and record review, the facility failed to implement interventions regarding immediate treatment for [REDACTED]. This failure resulted in R1 being improperly turned and positioned by facility staff without any intervention for pain management or stabilization of an unsecured left femur fracture. R1 remained in the facility without emergent care for seven hours before being hospitalized . R1 was hospitalized with a spiral [MEDICAL CONDITION] femur resulting in blood loss requiring a transfusion. Findings include: This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level II as the facility continues to conduct ongoing training of all staff, including the Administration, regarding the definitions of abuse, including neglect, timely reporting of serious incidents and accidents that result in a resident injury, the regulatory reporting requirements, facility staff obligation to safeguard all residents and development of ongoing quality assurance measures to ensure facility protocol has been followed. R1's medical record documents that R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R1's most recent MDS (Minimum Data Set) dated [DATE] documents that R1 is rarely understood and is transferred using a mechanical lift with extensive assistance with bed mobility. Facility Incident/Accident Report dated [DATE] and signed by E4 (LPN/Licensed Practical Nurse) documents the following: Called to room by CNA's (E5 and E6, Certified Nurse Aides) to check left thigh. Noted lower femur pushing up against the skin causing whitish discoloration with bluish discoloration around the perimeter. Internal rotation of foot noted. Left leg slightly shorter than the right. Also a 2 cm (centimeter) x 1 cm abrasion below left knee. Complaints of discomfort with range of motion. Nurses notes for R1 dated [DATE] document the following: Called to room by CNA at 4:00 AM. Noted left lower femur pushing up, against the skin causing a whitish discoloration with bluish discoloration around perimeter. Internal rotation of foot noted. Left leg slightly shorter than the right. Also a 2 cm x 1 cm abrasion below left knee. Complains of discomfort with range of motion. On [DATE] at 11:56 AM, E5 (CNA) stated that on [DATE] at 4:00 AM, It (R1's left leg) looked like her bone was going to pop out of her skin .(R1) was incontinent and (E6, CNA) and me were going to clean her up. That's when we rolled her and she made a noise and grimaced. And that's when we (E5 and E6, CNA's) saw it (R1's leg deformity). So (E6) went and got (E4, LPN). (E4) checked (R1) out. I don't think (E4) called anyone right away. (E4) made us (E5, E6 and E8, CNA's) clean her up around 6:00 AM. We had (E3, ADON/Assistant Director of Nursing) stand in while we cleaned her. That bone looked like it was going to pop out of her skin. I almost fainted when I saw it. We (E5, E6 and E8, CNA's) wanted someone in there because we had to roll her and we were scared. (R1) grimaced and yelled when we moved her. She cried out. I never heard anyone mention calling 911. I think someone should have because (R1's) leg looked so bad. On [DATE] at 3:37 PM, E6 (CNA) stated, (E5, CNA) came down to ask me to help clean (R1) up for a shower around 4:00 AM. (R1) was incontinent of stool. I went to roll (R1) over and that's when she made a noise - and when I rolled her back over that's when we saw the bone sticking out. It was her left femur. It looked like it was protruding through her skin. We (E5, E6 and E8, CNA's) were told to clean (R1) up so we had (E3, ADON) come down around 6:00 AM and watch while we cleaned (R1) up because we were afraid to move her. We thought that her bone was going to pop through her skin if we moved her too much. (E4, LPN) put it (addressing R1's leg deformity) off after (E4) was made aware of (R1's) deformity. (E4) continued caring for the other residents. I think someone should have called 911. I asked (E4) about (R1's) leg after (E4) looked at it, and (E4) said to me that she felt like it was arthritis and she would call the doctor later. On [DATE] at 11:48 AM, E8 (CNA) stated that on [DATE], I think (E5 and E6) found it (R1's left leg deformity) between 2:00 AM - 3:30 AM. I (E8) was told that they (E5 and E6) went in to get (R1) ready for a bed bath, they rolled her over and they rolled her back because she yelled. I helped them clean (R1) up between 6:00 AM and 6:30 AM. (R1) was incontinent of feces. (E4, LPN) and (E9, RN/Registered Nurse) told us (E5, E6 and E8) to clean (R1). We had to roll her. Honestly, we didn't want to move her at all because we were scared to. I was scared that the bone was going to pop through. You could see the bone moving around even if we barely moved her. (R1's) leg was never splinted that I saw. We just held her leg when we moved her. (E3, ADON) was just in the room for direction. She did not assist in cleaning (R1) up. It looked like (R1) was in pain because she grimaced when we moved her. On [DATE] at 1:07 PM, E4 (LPN) stated, The aides (E5 and E6, CNA's) came and got me from (another room). They said we need you down in (R1's) room. They pulled back her covers and there was the bone sticking up against her skin. Bruising and white skin tinting from the bone pushing up against the skin wall with a small superficial abrasion on her left lateral knee. Her leg was obviously broken. It was internally rotated. I don't know how she got the abrasion on her left knee. I did a body assessment and there were no other findings other than her leg. I asked the girls what happened and they couldn't give me an answer. They didn't know. They said they didn't notice anything on a previous bed check. R1 had feces between her toes. (R1) can't turn herself in bed. It was wrong but I continued trying to care for other residents. I told the aides to leave her still for the time being. I called the doctor around 7:10 AM once I caught up with cares. Sometimes he can be a difficult doctor to deal with. E4 then stated that E4 did not administer any of R1's morning medications or any pain medication to R1. Facility interview conducted and signed by E7 (Corporate) dated [DATE] documents the following: (R1) only hollered out when she was turned or the leg was moved .(E4) stated she went to the nurses station to sit down and think about the situation as to what had occurred, why they didn't see the leg earlier. I asked (E4) what she did from the time she found the injury to the time she called the physician and she stated 'I did dressing changes on (other residents).' She also responded 'I took care of all the other residents answering call lights, etc.' I asked (E4) why she waited three hours to call the physician and three and a half hours to call the son and she replied, 'It was just so crazy that night, I can't really answer that question.' On [DATE] at 9:06 AM, E3 (ADON) stated that E4 (LPN) approached E3 on [DATE] between 5:00 AM - 5:30 AM requesting that E3 take a look at R1's left leg. E3 stated, I saw an obvious deformity. (R1's) femur bone was pushing against the skin slightly to the left of the knee cap. It seemed to be internally rotated to the right. I did not check for a pedal pulse. I went out and instructed (E5, E6 and E8, CNA's) to clean (R1) up. I told (E4, LPN) that she needed to contact the doctor and then went into my office to do my duties .(R1's) leg was never splinted. I didn't direct anyone to splint her. On [DATE] at 9:24 AM, E10 (CNA) stated that E3 (ADON) came and got E10 from the other end of the building on [DATE]. E10 stated, I usually work on ,[DATE] hall and we have a resident down there that broke her femur about 2 months ago. So (E3) asked me to help roll (R1) since I'm familiar with rolling someone that has a fractured femur. So I went into (R1's) room, but I didn't help. Once I saw (R1's) leg, I said 'that's way worse than what I'm used to' .(R1's) leg looked awful. Nurses notes for R1 dated [DATE] documents that R1's physician (Z1) was not notified until 7:20 AM of R1's injury when an on-site x-ray was ordered. The same nurses noted document mobile x-ray unit arrived and did x-ray at 9:00 AM. Nurses notes for R1 dated [DATE] at 10:00 AM document the following: Sons stated they want (R1) sent to the emergency room . Informed getting Dr. (doctor) order to send and getting x-ray results to (Z1). 10:45 AM Left per (local ambulance service). On [DATE] at 11:37 AM, Z1 stated I would expect to be notified of a change of condition immediately. They did not notify me until after 7:00 AM on [DATE] and I don't know why. I would have expected to have been notified of this type of injury immediately. When I was called, the staff was not descriptive of the extent of (R1's) injuries. If I knew how bad it was, I would have just sent her in. On [DATE] at 1:48 PM, Z5 (local ambulance Emergency Medical Technician) stated that Z5 arrived to the facility on [DATE] around 10:30 AM to transport R1 to the hospital. Z5 stated that Z5 found R1 lying in bed with a grossly deformed left leg. Z5 then stated, No one could explain what happened. Her left leg was obviously broken. It was just loose from the area fractured down to her foot. They (facility) did not have her leg splinted. I can't believe that she'd been lying there since 4:00 AM with a fracture of that degree. I applied a splint to her left leg. She grimaced when we moved her. She was nonverbal, but you could tell by the look on her face that she was very uncomfortable. On [DATE] at 4:51 PM, Z4 (local hospital emergency room Physician) stated that R1 arrived to the emergency roiagnom on [DATE] with an obvious deformity to (R1's) left femur. Z4 stated, She had a spiral fracture of her left femur .the bone was going to protrude through her skin if we would have left it the way that it was .I would have expected a doctor to be notified immediately with an obvious fracture of that nature and I would have expected her to be sent in right away. Z2's (R1's Orthopedic Physician) Consultation for R1 dated [DATE] documents the following: (R1) was apparently found to have a fracture of her left femur in the supracondylar area above total knee prosthesis. (R1) is severely demented and at best would get up in a chair with a (mechanical) lift. On examination, (R1) has moderate swelling and moderate deformity of the distal femur. I personally evaluated her x-ray. She has a spiral supracondylar fracture of her left femur. On [DATE] at 10:25 AM, Z2 (R1's Orthopedic Physician) stated that R1 arrived to the emergency room with an obvious deformity of the left femur. Z2 stated, She had a spiral fracture of her left femur .that fracture didn't happen by itself. It was caused by some type of trauma, possibly a twisting injury or a fall .she shouldn't have been moved or rolled unless her leg was splinted. I wouldn't want her leg flopping all over the place .(R1) had a large amount of bruising to her left knee. It was a complication of a large amount of bleeding from her fracture. Moving her leg around could have caused her to bleed more. If she would have been splinted or sent in sooner, it would have made a difference in her amount of blood loss. On [DATE] at 10:53 AM, Z3 (R1's Hospitalist) stated that R1 was acutely anemic the next morning after R1 was admitted to the hospital, and R1 received a blood transfusion with little to no improvement and was then placed on comfort measures. On [DATE] at 9:15 AM, Z7 (R1's family member) stated that it was determined after R1 was hospitalized on [DATE] that there was nothing more they could do for R1. Z7 then stated the decision was made to make R1 comfort measures, and R1 expired on [DATE]. On [DATE] at 11:40 AM, an Immediate Jeopardy was identified to have begun on [DATE] at 4:00 AM when R1's left femur fracture was identified and Z1 was not immediately notified and no immediate interventions were implemented to secure R1's left leg fracture or address R1's pain. E2, Director of Nursing, was notified of the Immediate Jeopardy on [DATE] at 11:40 AM. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1) On [DATE], E2 (Director of Nursing) and E3 (Assistant Director of Nursing) received education regarding implementation of ongoing quality assurance measures that includes reviewing facility incident reports to ensure the resident's clinical record is reflective of the facility's policies and procedures. On [DATE] at 9:25 AM, E1(Administrator) verified that these actions were initiated on [DATE] and remain ongoing. 2) On [DATE], facility nursing staff education was provided and remains ongoing regarding the definitions of abuse, including neglect; their reporting requirements under current regulations; their obligation to safeguard all residents; injury identification; the need for professional judgement and prioritizing need for further action (including but not limited to splinting or securing a fracture, securing the head and neck if a possible spinal injury has occurred, etcetera). On [DATE] at 9:25 AM, E1 verified that these actions were initiated on [DATE] and remain ongoing.

Based on interview and record review, the facility failed to notify the physician of a change in condition for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 being found with a grossly deformed left thigh and remaining in the facility without emergent care for seven hours before being hospitalized . R1 was hospitalized with a spiral [MEDICAL CONDITION] femur resulting in blood loss requiring transfusion. Findings include: Facility policy Change of Condition Reporting revised ,[DATE], documents the following: (Facility) will notify the resident's physician and the resident's representative whenever: · There is a significant change in the resident's health, mental or psychosocial status. · There is an accident (incident or unusual occurrence). The same policy also documents the following: Notify the physician of the change of condition/incident/accident/unusual occurrence and assessment findings. (Change of condition/incidents/accidents/unusual occurrences may be reported to the physician via fax, unless the the resident's condition requires immediate response from the physician). R1's medical record documents that R1 was admitted to facility on [DATE] with the following Diagnoses: [REDACTED]. R1's most recent MDS (Minimum Data Set) dated [DATE] documents that R1 is rarely understood and is transferred using a mechanical lift with extensive assistance with bed mobility. Facility Incident/Accident Report dated [DATE] and signed by E4 (LPN/Licensed Practical Nurse) documents the following: Called to room by CNA's (E5 and E6, Certified Nurse Aides) to check left thigh. Noted lower femur pushing up against the skin causing whitish discoloration with bluish discoloration around the perimeter. Internal rotation of foot noted. Left leg slightly shorter than the right. Also a 2 cm (centimeter) x 1 cm abrasion below left knee. Complaints of discomfort with range of motion. Nurses notes for R1 dated [DATE] documents the following: Called to room by CNA at 4:00 AM. Noted left lower femur pushing up, against the skin causing a whitish discoloration with bluish discoloration around perimeter. Internal rotation of foot noted. Left leg slightly shorter than the right. Also a 2 cm x 1 cm abrasion below left knee. Complains of discomfort with range of motion. On [DATE] at 11:56 AM, E5 (CNA) stated that on [DATE] at 4:00 AM, It (R1's left leg) looked like her bone was going to pop out of her skin .(R1) was incontinent and (E6, CNA) and me were going to clean her up. That's when we rolled her and she made a noise and grimaced. And that's when we (E5 and E6, CNA's) saw it (R1's leg). So (E6) went and got (E4, LPN). (E4) checked (R1) out. I don't think (E4) called anyone right away .that bone looked like it was going to pop out of her skin. I almost fainted when I saw it. I think someone should have called 911 because (R1's) leg looked so bad . On [DATE] at 3:37 PM, E6 (CNA) stated, (E4, LPN) put it (addressing R1's left leg deformity) off. (E4) continued caring for the other residents. I think someone should have called 911. I asked (E4) about (R1's) leg after (E4) looked at it, and (E4) said to me that she felt like it was arthritis and she would call the doctor later. On [DATE] at 1:07 PM, E4 (LPN) stated, The aides (E5 and E6, CNA's) came and got me from (another room). They said we need you down in (R1's) room. They pulled back her covers and there was the bone sticking up against her skin. Bruising and white skin tinting from the bone pushing up against the skin wall with a small superficial abrasion on her left lateral knee. Her leg was obviously broken. It was internally rotated. I don't know how she got the abrasion on her left knee. I did a body assessment and there were no other findings than her leg. I asked the girls what happened and they couldn't give me an answer. They didn't know. They said they didn't notice anything on a previous bed check. R1 had feces between her toes. (R1) can't turn herself in bed. It was wrong but I continued trying to care for other residents. I told the aides to leave her still for the time being. I called the doctor around 7:10 AM once I caught up with cares. Sometimes he can be a difficult doctor to deal with. Facility interview conducted and signed by E7 (Corporate) dated [DATE] documents the following: (E4) stated she went to the nurses station to sit down and think about the situation as to what had occurred, why they didn't see the leg earlier. I asked (E4) what she did from the time she found the injury to the time she called the physician and she stated 'I did dressing changes on (other residents).' She also responded 'I took care of all the other residents answering call lights, etc.' I asked (E4) why she waited three hours to call the physician and three and a half hours to call the son and she replied, 'It was just so crazy that night, I can't really answer that question.' Nurses notes for R1 dated [DATE] documents that R1's physician (Z1) was not notified until 7:20 AM of R1's injury when an on-site x-ray was ordered. The same nurses noted document mobile x-ray unit arrived and did x-ray at 9:00 AM. On [DATE] at 11:37 AM, Z1 stated, I would expect to be notified of a change of condition immediately. They did not notify me until after 7:00 AM on [DATE] and I don't know why. I would have expected to have been notified of this type of injury immediately. When I was called, the staff was not descriptive of the extent of (R1's) injuries. If I knew how bad it was, I would have just sent her in. On [DATE] at 4:51 PM, Z4 (local hospital emergency room Physician) stated that R1 arrived to the emergency roiagnom on [DATE] with an obvious deformity to (R1's) left femur. Z4 stated, She had a spiral fracture of her left femur .the bone was going to protrude through her skin if we would have left it the way that it was .I would have expected a doctor to be notified immediately with an obvious fracture of that nature and I would have expected her to be sent in right away. Z2's (R1's Orthopedic Physician) Consultation for R1 dated [DATE] documents the following: (R1) was apparently found to have a fracture of her left femur in the supracondylar area above total knee prosthesis. (R1) is severely demented and at best would get up in a chair with a (mechanical) lift. On examination, (R1) has moderate swelling and moderate deformity of the distal femur. I personally evaluated her x-ray. She has a spiral supracondylar fracture of her left femur. On [DATE] at 10:25 AM, Z2 (R1's Orthopedic Physician) stated that R1 arrived to the emergency room with an obvious deformity of the left femur. Z2 stated, (R1) had a spiral fracture of her left femur .that fracture didn't happen by itself. It was caused by some type of trauma, possibly a twisting injury or a fall .she shouldn't have been moved or rolled unless her leg was splinted. I wouldn't want her leg flopping all over the place .(R1) had a large amount of bruising to her left knee. It was a complication of a large amount of bleeding from her fracture. Moving her leg around could have caused her to bleed more. If she would have been splinted or sent in sooner, it would have made a difference in her amount of blood loss. On [DATE] at 10:53 AM, Z3 (R1's Hospitalist) stated that R1 was acutely anemic the next morning after R1 was admitted to the hospital, and R1 received a blood transfusion with little to no improvement and was then placed on comfort measures. On [DATE] at 9:15 AM, Z7 (R1's family member) stated that it was determined after R1 was hospitalized on [DATE] that there was nothing more they could do for R1. Z7 then stated the decision was made to make R1 comfort measures, and R1 expired on [DATE].