Every finding on record at Annandale Healthcare Center

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess all residents so they could safely and independently leave the facility property specifically for the identified five of 63 residents in the survey sample, Residents #421, #164, #155, #52 and #125. Resident #421 left the facility and was involved in a hit-and-run accident with life-threatening injuries on [NAME] Pike, the four-lane divided highway in front of the facility, which placed this resident in the presence of immediate jeopardy at the time of the accident. The extent of this issue could result in serious injury, harm, impairment, or death, which constituted the determination of Immediate Jeopardy (IJ), as cited at level K. After Immediate Jeopardy was removed, the scope and severity were lowered to a level 3 isolated (G). The findings include: 1. For Resident #421 (R421), the facility staff failed to assess the resident to safely leave the facility property independently. Resident #421 left the faciity on [DATE] and was hit by a car when crossing [NAME] Pike, a four-lane divided highway resulting in life threatening injuries and admission to the local hospital's Intensive Care Unit. R421 was admitted to the facility with diagnoses that included but were not limited to history of falling, fracture of lumbar vertebra (1), traumatic spondylolisthesis of second cervical vertebra (2), alcohol use and major depressive disorder (3). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/14/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment further documented functional limitations in range of motion to both lower extremities, normally using a manual wheelchair and able to walk 150 feet in a corridor independently. It documented R421 having an external catheter, being frequently incontinent of bowel, receiving scheduled and as needed pain medication, and having had one fall with minor injury since admission or the previous assessment. On 10/7/24 a facility synopsis of events for R421 dated 9/13/24 was reviewed. It documented in part, .Describe incident, including location: [Name of R421] who resides in [Room number] and is a [Age and Sex of R421] with a BIMS score of 15, and diagnosis of Alcohol use unspecified with withdrawal, fall resulting in traumatic vertebral fracture, and chronic venous hypertension, Resident was out of the facility on LOA (leave of absence) and nurse supervisor notified by residents sister who confirmed that resident was involved in MVA (motor vehicle accident) and was taken to [Name of hospital] where he was admitted as a result of his injuries. Resident was involved in an MVA that was reported as a possible hit and run. Police initiated an on-going investigation. Ombudsman/APS (adult protective services)/RP (responsible party)/ MD (medical doctor)/ ED (executive director) and DON (director of nursing) notified . A Leave of Absence form dated 9/12/24 for R421 was included in the file which documented the time left as 1:50 p.m. with anticipated return time of 11:00 p.m. The LOA form documented the resident leaving independently. The final investigation summary dated 9/13/24 documented in part, .Nature of Incident: Unusual Occurrence/Collision with MVA while on LOA/Possible hit and run. Staff member: None. Including location: [Name of R421] who resides in [Room number] and is a [Age and Sex of R421] with a BIMS score of 15, and diagnosis of Alcohol use unspecified with withdrawal, fall resulting in traumatic vertebral fracture, and chronic venous hypertension. [Name of R421] signed himself out of the facility on LOA per his normal daily routine in the am, and failed to return to the facility at his signed expected time of return, the nurse supervisor- initiated call inquiry to nearby hospitals and was informed by [Name of hospital] nursing staff that resident was there but were unable to provide facility staff with any information, and advised supervisor to contact resident representative for further information. The facility nurse supervisor placed a call to resident representative (sister), no answer received, a message was left to return call to the facility. Resident sister returned call to the facility and supervisor confirmed admission to [Name of hospital] due to being involved in an MVA that resulted in major injuries and stated that the incident was a possible hit and run. On the following day [Name of R421]'s sister contacted social services to inform of resident in ICU (intensive care unit) pending surgical intervention, and that she would be coming to the facility to pick up residents' personal items due to discharging to the hospital. [Name of county police department] initiated and concluded post confirmation of signed LOA and the unusual occurrence transpired while on LOA . The physician orders for R421 documented in part, - May go out on pass with or without meds. Order Date: 5/7/24. End date: 9/13/24. - Aspen collar (4) on at all times. every shift Document refusal to wear. Order Date: 5/7/24. End date: 9/13/24. - Wear t shirt underneath the back brace. Monitor skin under the brace for redness or skin irritation. Do not sleep in TLSO (thoracic lumbar sacral orthosis) back brace (5) but keep Aspen collar on every shift. Order Date: 5/7/24. End date: 9/13/24. A review of the PT (physical therapy) evaluation dated 6/17/24 and the OT (occupational therapy) evaluation dated 5/8/24, progress report dated 5/21/24, and OT discharge summary dated 5/24/24 failed to reveal evidence that the resident was assessed for safety outside the building. Review of the completed Leave of Absence forms for R421 documented the resident leaving the facility independently on 96 occasions between 5/7/24 and 9/12/24. Review of the progress notes for R421 documented the resident returning from leave of absence intoxicated on 12 dates. Further review of the progress notes documented the police responding to staff calls for R421 being intoxicated at the facility on four dates and the police returning R421 to the facility from the community intoxicated once. A progress note dated 9/12/24 documented, Late Entry. Note Text: Resident alert and oriented to person, place, time and situation. He signed himself out on LOA from facility at 1:50 pm in an alert and stable condition with expected returned time of 11:00 pm on the same day. Around 9:10 pm, writer was informed that resident was involved in a motor vehicle accident while on LOA and was taken to the hospital via ambulance. [Name of hospital] ER called but writer was not able to get any information regarding resident's current status. ER nurse advised writer to call again later. Call placed to resident's sister, [Name of sister] and was updated about incident. On a follow up call to sister, she confirmed that upon calling the hospital, it was confirmed that resident was hit by a car while outside facility and is now in ICU. Telehealth was called and updated. Nursing staff will continue to follow up. Further review of the progress notes documented a follow up note dated 9/18/24 which documented, Note Text: Writer followed up on resident at the hospital, per the nurse report resident is still at the ICU intubated and waiting for spine effusion tonight. MD updated. The comprehensive care plan for R421 documented in part, [Name of R421] has history of falling with injury. At risk for further falling. had a fall with injury Abrasion to right shoulder. Date Initiated: 05/01/2024. Revision on: 08/05/2024. The emergency provider notes from [Name of hospital] for R421 dated 9/13/24 4:49 a.m. documented in part, . [Name, age and sex of R421] who presents with unknown past medical history presenting with pedestrian strike. EMS (emergency medical services) reports he was witnessed being hit by a jeep wrangler going 35 to 45 mph on the turnpike prompting EMS visit to ED. EMS states patient was in a c-collar (cervical collar) prior to arrival . Critical diagnosis: 1. Contusion of head, subsequent encounter. 2. Trauma shock, initial encounter . The history and physical for R421 from [Name of hospital] dated 9/12/24 at 10:47 p.m. documented in part, .Patient was a modified trauma activation status post pedestrian struck. In the trauma bay, patient was awake and following commands but confused. He was initially normotensive. He was noted to have facial lacerations, forehead hematoma, bilateral hip bruising and what appeared to be chronic bilateral toe wounds. [NAME] report, patient was noted to have a cervical spine prior to the arrival presumably from recent injury. Patient then became combative and therefore received 4mg of IM (intramuscular) Versed. Soon after, patient became hypotensive and lethargic. At this point, patient was upgraded to a full trauma activation .Given patient's ongoing hypotension, patient received units of whole blood .GI (gastrointestinal): Grade IV liver injury with active subcapsular hematoma and hemoperitoneum. Grade 2 splenic laceration w/subcapsular hematoma, anterior pancreas hematoma .Pt in critical condition . The discharge summary for R421 from [Name of hospital] dated 10/10/24 documented in part, .Hospital Course: Patient went to the OR for ex-lap (exploratory laparoscopy) and had ileum resection and packing. He was eventually closed and had return of bowel function. NSGY (neurosurgery) was consulted, and patient did not need aspen for dens fx and went for posterior decompression and fusion. He required a TLSO brace when OOB (out of bed). Patient was extubated but required a corpak 2/2 (secondary to) dysphagia. He was able to work with SLP (speech language pathologist) and his diet was advanced to a regular diet. His abdominal staples were removed and there was some superficial wound dehiscence that required iodofoam packing and dressing changes. He was restarted on his home medications. PT/OT worked with patient and recommended SNF (skilled nursing facility). At the time of discharge the patient was afebrile and his vital signs were within normal limits . On 10/2/24 at 3:49 p.m., ASM (administrative staff member) #5, the regional director of operations, was interviewed. She stated her understanding is that as long as residents have a BIMS score that is high enough, and the residents have been physically assessed as safe, the residents are allowed to sign themselves out on a leave of absence from the facility. On 10/2/24 at 4:52 p.m., an interview was conducted with ASM #1, the executive director and ASM #3, the regional director of clinical operations. ASM #1 stated that the resident needs an order to go out on LOA, needs to be assessed that they can go out, and typically by nursing, a cognition assessment. He stated that a functionally mobility is done by the IDT (interdisciplinary team). ASM #1 stated therapy is involved in the screening in Section GG on the MDS, when the admission and discharge from therapy assessment are completed. He stated that the MDS staff codes the functional abilities, goals and mobility devices used. ASM #3, the regional director of clinical operations, stated that if a resident wants to go out, the nurse initiates the Leave of Absence Form, and then the resident brings it to the executive director or director of nursing to sign. She stated that any nurse, executive director or director of nursing, could sign off this form. ASM #3 stated that the resident then takes the form to the front desk and gives it to the receptionist, who then logs it into the daily log. She stated that if the resident does not return at the anticipated time, the staff will call the resident or responsible party, then the staff calls 911. ASM #3 stated it is the nurse who monitors when the resident returns. On 10/2/24 at 5:05 p.m., an interview was conducted with ASM #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations. ASM #2 stated the facility uses the BIMS is used to assess a resident's ability to safely leave the facility. ASM #5 stated the BIMS assesses a resident for their ability to process new information and ability to recall. She stated the BIMS does not assess a resident's ability to determine danger from safety. On 10/7/24 at 12:31 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the facility staff had received a report that R421 had been involved in a hit and run and the staff had contacted the sister and the hospital who confirmed the resident was involved. She stated that R421 had signed out on LOA earlier that day and when he did not come back at the expected time, they had started calling around to the local hospitals checking and calling the family. She stated that she was not sure of the exact location of the hit and run other than it was the cross section outside of the facility on [NAME] Pike. She stated that the police had responded and spoken to the executive director and as far as she knew there were no witnesses to the accident. She stated that R421 would catch the bus sometimes when he went out on LOA and used a manual wheelchair. On 10/7/24 at 12:43 p.m., an interview was conducted with ASM #1, the executive director. ASM #1 stated that the police had come to the facility to ask him if there were any witnesses to the accident involving R421. He stated that there was a former resident of the facility who witnessed the accident, and he was unsure if the police officer questioned them or not. He stated that the hit and run happened on [NAME] Pike in the evening after he had left for the day and staff had called him at home. He stated that R421 would sign out LOA and catch the bus to go shopping or visit family using the manual wheelchair or walking behind it using it as a walker. He stated that no staff witnessed the accident that they knew of. ASM #1 stated that they had previously spoken to the police, VDOT and the county regarding the crosswalk. He stated that VDOT told them that the crosswalk was safe to be used the way it was designed, and the police told them that the residents were not violating any laws so they could not stop them from using it. He stated that the residents had to be in that corner to catch bus and the county told them that the facility could pursue getting a light put in, so they had contacted the North Virginia Emergency Response System however, they said that they did not see a need. He stated that if the resident was in an electric wheelchair or they could walk, there was no way to prohibit them if they were alert and oriented, were care planned, made their own decisions, and they signed themselves out. He stated that if they were to go out and be in a hit and run, they were not able to do anything. He stated that it was difficult due to having authorities tell them that residents were allowed to make bad decisions and as citizens they had rights that could not be taken away. On 10/7/24 at 2:43 p.m., an interview was conducted with RN (registered nurse) #3, MDS coordinator. RN #3 stated she completes functional abilities and goals assessments based on documentation the CNAs (certified nursing assistants) chart in the clinical record. RN #3 stated the assessments demonstrate what the residents can do in terms of their activities of daily living. RN #3 stated she did not think the assessments determined residents' safety abilities. RN #3 stated maybe the BIMS assessments determined residents' safety abilities but that would be hard to determine because she is not with the residents and does not know what they do when they leave the property. On 10/7/24 at 2:59 p.m., an interview was conducted with ASM #7, physician. ASM #7 stated that the leave of absence orders for the residents were intended for residents to go out with families for extended periods and then return to the facility. He stated that there were residents at the facility for long term care who had family that wanted to take them home for a long weekend or overnight and the order was intended for them to be able to do that and take their medications with them for the leave of absence. On 10/7/24 at 3:11 p.m., an interview was conducted with OSM (other staff member) #6, physical therapist. She stated she has never assessed a resident for his or her ability to maneuver safely outside of the facility on a daily basis. She stated she has told residents that attempting to cross the divided highway in front of the facility is not safe, and that she would not attempt it herself. She stated physical therapy assessments are designed to treat a resident with the goal of becoming as functional as possible in the facility, not out outside of it on a day-to-day basis. OSM #6 stated that all assessments and treatments completed for R421 were done in the facility gym or hallways. On 10/8/24 at 1:51 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated the executive director was initially signing for residents to go out on LOA but then the nurses were allowed to sign residents out on LOA. LPN #7 stated the nurses write a note that documents the time residents leave the facility then write a note when the residents return. LPN #7 stated there were no assessments completed to determine if residents are physically or mentally safe to leave the property. On 10/8/24 at 6:05 p.m., an interview was conducted with RN #1. RN #1 stated that another resident (identified as Resident #96) informed him around 9:00 p.m. on 9/12/24 that they thought R421 had been hit by a car outside of the facility. RN #1 stated that he had started calling around to the hospitals in the area and [Name of hospital] had confirmed that R421 was there and had been in an accident but could not give them any other information, so they had called R421's sister. He stated that R421's sister had contacted the hospital and called them back confirming that the resident had been in a hit in run on [NAME] Pike in front of the facility. He stated that he was unsure how the other resident knew that R421 had been hit by the car and he had started calling around because of the report from the other resident. He stated that Resident #96 did not say that R421 had been hit in front of the facility, that he witnessed the accident or how he knew that R421 had been hit by the car. RN #1 stated that he did not go outside or see the accident. He stated that he called and reported the incident to the director of nursing that night. On 10/9/24 at 7:49 a.m., an interview was conducted with RN #6. RN #6 stated that she was inside the facility and heard the sirens and saw the ambulance across the street on 9/12/24 as it was leaving the scene. She stated that several residents were coming inside the entrance and told her that R421 had been hit by a car crossing the street and was being taken to the hospital. She stated that she had checked the LOA form to see that the resident was actually out of the facility and then she and RN #1 had called the sister who confirmed that the resident was involved in a hit and run while crossing the street from the park bus stop on the opposite side of [NAME] Parkway. She stated that it was around 8:30 p.m. when the residents reported this, and it was dark outside. She stated that they expected the police to come to the facility, but no one ever did. She stated that they had reported the incident to the director of nursing and the physician. She stated that she did not recall the specific residents that reported the incident to her but there were a lot of them all rushing inside the lobby. On 10/9/24 at 8:25 a.m., an interview was conducted with Resident #96 (R96) in their room. R96 stated that they were sitting outside of the facility at the entrance the evening of 9/12/24 when they witnessed R421 get off the bus on the furthest side of [NAME] Pike and cross the road in the cross walk. R96 stated that R421 was almost across [NAME] Pike and was in the right lane closest to the facility when a car hit him, and he saw the car spin around and then keep going. He stated that he had reported it to multiple nurses but did not know their names and the next day the former social worker came in to speak with him and said that the police may come talk to him, but no one had. Review of the most recent MDS assessment for R96, a quarterly assessment with an ARD of 7/11/24 documented the resident being cognitively intact for making daily decisions. On 10/9/24 at 8:36 a.m., an interview was conducted with OSM (other staff member) #13, occupational therapist. OSM #13 stated the only time she completes an evaluation to determine if a resident can safely go outside of the building and into the community is if a resident is being discharged home. OSM #13 stated she has not completed any evaluation to determine if R421 can safely and independently go outside and off the facility property. On 10/9/24 at 10:53 a.m., an interview was conducted with OSM #21, detective. OSM #21 stated that the case involving R421 was still active and not completed at this time. He stated that they could only confirm that R421 was involved in the incident and the other person had left the scene. Additional interviews with staff identified on the as-worked schedule for 9/12/24 evening shift failed to evidence firsthand witnesses of the hit and run accident involving R421. Reference: (1) fracture lumbar vertebra The spine is made up of 33 bones. The individual bones of the spine are called vertebrae. The spine is divided into three sections: Cervical (upper), Thoracic (midback), Lumbar (lower back). Most spinal fractures occur in the thoracic and lumbar spine, or at the connection of the two (called the thoracolumbar junction). This information was obtained from the website: https://orthoinfo.aaos.org/en/diseases--conditions/fractures-of-the-thoracic-and-lumbar-spine/ (2) traumatic spondylolisthesis of second cervical vertebra Spondylolisthesis is a condition in which a bone (vertebra) in the spine moves forward out of the proper position onto the bone below it. This information was obtained from the website: https://medlineplus.gov/ency/article/001260.htm (3) major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. (4) Aspen Collar A cervical collar provides support and restricts movement in your neck while bones and tissues heal in the area where you had surgery. The Aspen collar is plastic with front and back panels lined with removable padding. It provides comfort and keeps sweat away from your skin. Openings on the front and the back panel of the collar allow your skin to breathe. This information was obtained from the website: https://www.healthsystem.virginia.edu/docs/per/at-home-with-aspen-cervical-collar/handout_view_patient/@@getDocument (5) TLSO brace If you have back pain, your physician or physical therapist may prescribe a brace to help control motion of your spine. A special back brace called a thoracic lumbar sacral orthosis (TLSO) may be prescribed for this. A TLSO is a brace that limits movement in your spine from the thoracic area (mid back) to your sacrum (low back). It does allow your neck to move freely. If you have a problem with your back that requires it to be kept in a neutral position while limiting excessive spinal motion, then a TLSO may be an option for you. Knowing what it is and how it is used can help you make an informed decision about using a TLSO. This information was obtained from the website: https://www.verywellhealth.com/thoracic-lumbar-sacral-orthosis-5203250 2. For Resident #164 (R164), the facility staff failed to assess the resident the resident to safely leave the facility property independently. Resident #164 was observed getting off public transportation in a motorized wheelchair onto the pavement linking [NAME] Pike and the [NAME] Pike service road, maneuvering around a van waiting to turn onto [NAME] Pike, meeting another resident in the parking lot and then was observed sitting in the wheelchair in the road on [NAME] Pike Service Road. R164 was admitted to the facility with diagnoses that included but were not limited to hemiplegia and hemiparesis (1), bipolar disorder (2) and supraventricular tachycardia (3). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/24/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment further documented functional limitations in range of motion to both lower extremities, normally using a motorized wheelchair and being occasionally incontinent of urine and frequently incontinent of bowel. It further documented R164 receiving as needed pain medication, taking antipsychotic, antidepressant and opioid medications. The assessment documented no falls since the previous assessment. On 10/2/24 at 3:22 p.m., Resident #164 was observed getting off public transportation in a motorized wheelchair onto the pavement linking [NAME] Pike and the service road, maneuvering around a van waiting to turn onto [NAME] Pike, into the facility parking lot. At 3:35 p.m., R164 was observed sitting in the right lane of [NAME] Pike Service Road on the west side of the facility with another resident. The physician orders for R164 documented an order dated 11/15/2023 May go out on pass with or without meds. A review of the PT (physical therapy) discharge summary dated 8/1/24 and the OT (occupational therapy) discharge summary dated 4/17/24 failed to reveal evidence that the resident was assessed for safety outside the building. Review of the completed Leave of Absence forms for R164 documented the resident leaving the facility independently on 22 occasions between 9/1/24 and 10/2/24. The comprehensive care plan for R164 documented in part, Fall: [Name of R164] is at risk for falls Gait/balance problems, Hemiplegia/Hemiparesis. Date Initiated: 02/28/2024. On 10/2/24 at 3:49 p.m., ASM (administrative staff member) #5, the regional director of operations, was interviewed. She stated her understanding is that as long as residents have a BIMS (brief interview for mental status) score that is high enough, and the residents have been physically assessed as safe, the residents are allowed to sign themselves out on a leave of absence from the facility. On 10/2/24 at 4:52 p.m., an interview was conducted with ASM #1, the executive director. ASM #1 stated the resident needs an order to go out on LOA, the resident has been assessed that they can go out, and typically by nursing, a cognition assessment. He stated that a functionally mobility is done by the IDT (interdisciplinary team). ASM #1 stated therapy is involved in the screening in Section GG on the MDS, when the admission and discharge from therapy assessment are completed. He stated that the MDS codes the functional abilities, goals and mobility devices used. ASM #3, the regional director of clinical operations, stated, if a resident wants to go out, the nurse initiates the Leave of Absence Form, the resident brings it to the executive director or director of nursing, to sign. She stated that any nurse, executive director or director of nursing, can sign off this form. ASM #3 stated that the resident then takes the form to the front desk and hands it to the receptionist, who then logs it into the daily log. She stated that if the resident does not return at the anticipate time, the staff will call the resident or responsible party, then the staff calls 911. ASM #3 stated it is the nurse who monitors when the resident returns. On 10/2/24 at 5:05 p.m., ASM #1, the executive director, ASM #2, the director of nursing, and ASM #5 were interviewed. ASM #2 stated the facility uses the BIMS is used to assess a resident's ability to safely leave the facility. ASM #5 stated the BIMS assesses a resident for their ability to process new information and ability to recall. She stated the BIMS does not assess a resident's ability to determine danger from safety. On 10/7/24 at 2:43 p.m., an interview was conducted with RN (registered nurse) #3, MDS coordinator). RN #3 stated she completes functional abilities and goals assessments based on documentation the CNAs (certified nursing assistants) chart in the clinical record. RN #3 stated the assessments demonstrate what the residents can do in terms of their activities of daily living. RN #3 stated she did not think the assessments determined residents' safety abilities. RN #3 stated maybe the BIMS assessments determined residents' safety abilities but that would be hard to determine because she is not with the residents and does not know what they do when they leave the property. On 10/7/24 at 2:51 p.m., an interview was conducted with OSM (other staff member) #5, PT (physical therapist). OSM #5 stated that PT staff did not do a formal safety assessment on residents for leaving the facility independently in the community. He stated that they barely took residents outside and did some wheelchair training with residents but did not leave the property. He stated that they had not been doing any formal safety assessments since he had been working at the facility in July of 2024. He stated that the assessments that he completed on Resident #164 were completed in the hallway of the facility or the gym. On 10/7/24 at 2:59 p.m., an interview was conducted with ASM #7, physician. ASM #7 stated that the leave of absence orders for the residents were intended for residents to go out with families for extended periods and then return to the facility. He stated that there were residents at the facility for long term care who had family that wanted to take them home for a long weekend or overnight and the order was intended for them to be able to do that and take their medications with them for the leave of absence. On 10/8/24 at 1:51 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated the executive director was initially signing for residents to go out on LOA but then the nurses were allowed to sign residents out on LOA. LPN #7 stated the nurses write a note that documents the time residents leave the facility then write a note when the residents return. LPN #7 stated there were no assessments completed to determine if residents are physically or mentally safe to leave the property. On 10/9/24 at 7:40 a.m., an interview was conducted with CNA (certified nursing assistant) #1. CNA #1 stated that he was coming in to work the evening shift on 10/2/24 when he saw the residents outside and came out to speak with them. He stated that he told them to move from the right end of the road because he thought it was not safe because they were in the street too much. He stated that there may be a serious accident, outcome, or someone could get harmed. On 10/9/24 at 8:36 a.m., an interview was conducted with OSM #13, occupational therapist. OSM #13 stated the only time she completes an evaluation to determine if a resident can safely go outside of the building and into the community is if a resident is being discharged home. OSM #13 stated she has not completed any evaluation to determine if R164 can safely and independently go outside and off the facility property. On 10/2/24 at 5:50 p.m., ASM #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of clinical operations, and ASM #5, the regional director of operations were informed of these concerns, and of immediate jeopardy. No further information was provided prior to exit. Reference: (1) hemiplegia and hemiparesis Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician of medications that were not administered for 2 of 63 residents in the survey sample, Residents #421 and #4. The findings include: 1. For Resident #421 (R421), the facility staff failed to notify the physician of medications not administered on multiple dates from May 2024 through September 2024. Review of R421's eMAR (electronic medication administration record) dated 5/1/24-5/31/24 documented the resident not receiving the following scheduled medications: - Gabapentin (1) 400mg (milligram) 2 capsules every 8 hours for neuropathy pain. On 5/14/24 at 10:00 p.m., 5/18/24 at 10:00 p.m., 5/21/24 at 2:00 p.m., 5/26/24 at 2:00 p.m., and 5/29/24 at 2:00 p.m. - Indomethacin (2) 50mg three times a day for pain. Afternoon doses on 5/19/24, 5/21/24, 5/26/24, and 5/29/24. - Methocarbamol (3) 500mg 2 tablets four times a day for muscle spasm. At 12:00 p.m. on 5/21/24, 5/26/24, and 5/29/24. Review of R421's eMAR dated 6/1/24-6/30/24 documented the resident not receiving the following scheduled medications: - Gabapentin 400mg 2 capsules every 8 hours for neuropathy pain. On 6/14/24 at 2:00 p.m., 6/17/24 at 2:00 p.m., and 6/25/24 at 2:00 p.m. - Indomethacin 50mg 1 capsule three times a day for pain. Afternoon doses on 6/4/24, 6/14/24 and 6/17/24. - Methocarbamol 500mg 2 tablet four times a day for muscle spasm. On 6/4/24 at 12:00 p.m., 6/14/24 at 12:00 p.m., 6/17/24 at 12:00 p.m. and 6/25/24 at 12:00 p.m. Review of R421's eMAR dated 7/1/24-7/31/24 documented the resident not receiving the following scheduled medications: - Lamotrigine (4) 100mg at bedtime for seizure. On 7/3/24 and 7/30/24. - Methadone (5) 10mg 7 tablets in the morning for chronic pain. On 7/29/24. - Trazodone (6) 75mg at bedtime for depression. On 7/7/24 and 7/30/24. - Gabapentin 400mg 2 capsules every 8 hours for neuropathy pain. On 7/7/24 at 10:00 p.m., 7/16/24 at 10:00 p.m., 7/24/24 at 6:00 a.m. and 2:00 p.m., 7/28/24 at 2:00 p.m. and 7/30/24 at 10:00 p.m. Review of R421's eMAR dated 8/1/24-8/30/24 documented the resident not receiving the following scheduled medications: - Lamotrigine 100mg at bedtime for seizure. On 8/16/24, 8/20/24, 8/25/24 and 8/26/24. - Trazodone 75mg at bedtime for depression. On 8/16/24, 8/19/24, 8/25/24 and 8/26/24. - Gabapentin 400mg 2 capsules every 8 hours for neuropathy pain. On 8/3/24 at 2:00 p.m., 8/19/24 at 2:00 p.m. and 10:00 p.m., 8/21/24 at 2:00 p.m. and 10:00 p.m., 8/23/24 at 2:00 p.m. and 8/25/24 at 10:00 p.m. - Methocarbamol 500mg 2 tablets four times a day for muscle spasm. On 8/2/24 at 4:00 p.m. and 8:00 p.m., 8/3/24 at 12:00 p.m., 8/16/24 at 4:00 p.m. and 8:00 p.m., 8/21/24 at 12:00 p.m., 8/21/24 at 12:00 p.m., 8/25/24 at 4:00 p.m. and 8:00 p.m., and 8/26/24 at 4:00 p.m. and 8:00 p.m. - Methadone 10mg 7 tablets in the morning for chronic pain. On 8/4/24 and 8/16/24. - Doxycycline (7) 100mg twice a day for cellulitis of the left third toe for 10 days. On 8/20/24 evening, 8/25/24 evening and 8/26/24 evening. Review of R421's eMAR dated 9/1/24-9/30/24 documented the resident not receiving the following scheduled medications. - Lamotrigine 100mg at bedtime for seizure. On 9/6/24. - Trazodone 75mg at bedtime for depression. On 9/6/24. - Gabapentin 400mg 2 capsules every 8 hours for neuropathy pain. On 9/6/24 at 10:00 p.m. - Methocarbamol 500mg 2 tables four times a day for muscle spasm. On 9/6/24 at 4:00 p.m. and 8:00 p.m. Review of R421's progress notes failed to evidence notification of the physician of the resident not receiving the scheduled medications listed on the above dates from May 2024 to September 2024. The progress notes documented either the resident being out on LOA (leave of absence), the medications held due to the resident returning to the facility intoxicated, the medications not available, or failed to document the reason the medications were not administered. Review of the completed Leave of Absence forms for R421 documented the resident leaving the facility independently on 96 occasions between 5/7/24 and 9/12/24. Review of the LOA forms for R421 documented the resident signing out on leave of absence from the facility LOA 23 of 26 dates listed above. On 10/9/24 at 7:49 a.m., an interview was conducted with RN (registered nurse) #6. RN #6 stated that medication administration was evidenced by the documentation on the eMAR. She stated that if the medication was not administered for any reason, the physician was notified that the medication was not given. She stated that if a resident was going on LOA overnight, they would send the medication with the family but if they were only going for the day the residents normally took the morning medications and came back to get their next scheduled medications. She stated that if the resident was due for medication and still out on LOA, they would call the physician and let them know to see if they could delay the dosage for when they returned and if they consistently missed their medications the physician should be notified to see if the schedule needed to be changed. On 10/9/24 at 8:57 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that if a medication was not given the staff were to notify the physician. She stated that she was not aware of any residents missing their medications while out on leave of absence and as far as she knew the residents would come back to get their medications. The facility policy Missed Medication/Medication Error undated, documented in part, . Resident's rights compliance includes providing for timely medical needs in which the physician has the opportunity to adjust and/or change medication(s) for the resident, including an awareness of risk factors when resident does not receive medication in an appropriate time frame . On 10/10/24 at 12:00 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. Reference: (1) Gabapentin is also sometimes used to relieve the pain of diabetic neuropathy (numbness or tingling due to nerve damage in people who have diabetes), and to treat and prevent hot flashes (sudden strong feelings of heat and sweating) in women who are being treated for breast cancer or who have experienced menopause (''change of life'', the end of monthly menstrual periods). Talk to your doctor about the risks of using this medication for your condition. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html (2) Indomethacin is used to relieve moderate to severe pain, tenderness, swelling, and stiffness caused by osteoarthritis (arthritis caused by a breakdown of the lining of the joints), rheumatoid arthritis (arthritis caused by swelling of the lining of the joints), and ankylosing spondylitis (arthritis that mainly affects the spine). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681027.html (3) Methocarbamol is used with rest, physical therapy, and other measures to relax muscles and relieve pain and discomfort caused by strains, sprains, and other muscle injuries. Methocarbamol is in a class of medications called muscle relaxants. It works by slowing activity in the nervous system to allow the body to relax. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682579.html (4) Lamotrigine extended-release (long-acting) tablets are used with other medications to treat certain types of seizures in patients who have epilepsy. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695007.html (5) Methadone is used to relieve severe and persistent pain in people who are expected to need an opioid pain medication around the clock for a long time and who cannot be treated with other medications. Methadone should not be used to treat mild or moderate pain, short-term pain, or pain that can be controlled by medication that is taken as needed. Methadone also is used to prevent withdrawal symptoms in patients who were addicted to opiate drugs and are enrolled in treatment programs in order to stop taking or continue not taking the drugs. Methadone is in a class of medications called opiate (narcotic) analgesics. Methadone works to treat pain by changing the way the brain and nervous system respond to pain. It works to treat people who were addicted to opiate drugs by producing similar effects and preventing withdrawal symptoms in people who have stopped using these drugs. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682134.html (6) Trazodone is used to treat depression. Trazodone is in a class of medications called serotonin modulators. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681038.html (7) Doxycycline is used to treat a variety of infections caused by certain types of bacteria. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682063.html 32642 2. For Resident #4 (R4) the facility staff failed to notify the physician when a medication was not available for administration. A review of R4's clinical record revealed the following order dated 9/6/24: Piperacillin Sod-Tazobactam So Solution (1) (Zosyn) Reconstituted 4-0.5 GM (grams) Use 4.5 gram intravenously every 6 hours for osteomyelitis (infection of the bone). A review of R4's progress notes revealed the following nurses' note dated 9/7/24: eMar - Medication Administration Note: Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM Use 4.5 gram intravenously every 6 hours for Osteomyelitis until 10/08/2024 .Resident meds (medications) are pending for pharmacy delivery. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3 was interviewed. After reviewing R4's progress notes and September 2024 MAR (medication administration record), she stated the Zosyn was ordered for R4 as a discharge medication from the hospital. The Zosyn was to treat an infection of the resident's bone. She stated the 12:00 noon Zosyn dose was not administered because it had not arrived from the pharmacy, and she could not see that the physician was notified. She stated if a medication is not available and not administered, it is a medication error. She stated the physician should have the opportunity to adjust the order. She added that the nurse should make a note of the physician's notification and response in the progress notes. On 10/8/24 at 1:08 p.m., LPN #8 was interviewed. She stated if a medication is not available in her medication cart, she checks the facility emergency medication supply. She stated if the medication is not in the emergency supply, she contacts the physician and the pharmacy. She added: I would document what I did, and what the physician wanted to do about it. She stated it is an error if the medication is not administered as the physician ordered it. On 10/5/24 at 6:17 p.m., ASM #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. No further information was available prior to exit. (1) Piperacillin and tazobactam injection is used to treat pneumonia and skin, gynecological, and abdominal (stomach area) infections caused by bacteria. Piperacillin is in a class of medications called penicillin antibiotics. It works by killing bacteria that cause infection. Tazobactam is in a class called beta-lactamase inhibitor. It works by preventing bacteria from destroying piperacillin. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694003.html#:~:text=Piperacillin%20is%20in%20a%20class,class%20called%20beta%2Dlactamase%20inhibitor.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to provide a clean, comfortable and homelike environment for three of 63 residents in the survey sample, Residents # 73 and #170 and on two of six units (East and [NAME] 1) and in , three of six shower rooms (South, [NAME] 1 and [NAME] 2). The findings include: 1. For Resident #73(R73), the facility staff failed to maintain a homelike environment, the staff were heard yelling from room to room, around the circular unit, for each other. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with a assessment reference date of 9/23/24, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted with R73 on 9/30/24 at approximately 6:50 p.m. The resident stated the staff yell back and forth to each other all through the day and sometimes through the night. She stated it was very disturbing when you are trying to rest. On 10/1/24 at 10:32 a.m. Observation of the unit on which R73 resides, it was noted that two CNAs (certified nursing assistants) calling out to each other from inside resident rooms. The female CNA called for the male CNA, and he answered and then the female CNA called out again for the male CNA. The surveyor was in the hallway and the CNA were not in close vicinity of each other. They were several rooms away from each other. An interview was conducted on 10/3/24 11:46 a.m. with CNA #4. CNA #4 stated she has not heard anyone calling out to each other, but this was not her normal unit to work. When asked why we should not call out for staff members, CNA #4 stated she could 't tell as she doesn't do that, and it was not making a homelike environment for the residents. No policy was received for a clean, comfortable and homelike environment. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations, were made aware of the above concerns on 10/8/24 at 6:16 p.m. No further information was provided prior to exit. 31753 2. For Resident #170 (R170), the facility staff failed to maintain the resident's toilet in a clean and homelike manner. A brown substance was observed splattered and smeared on the outside of the toilet bowl. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/25/24, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. On 10/1/24 at 9:21 a.m., 10/2/24 at 1:10 p.m., and 10/3/24 at 11:10 a.m., a brown substance was observed splattered and smeared on the outside front and side of R170's toilet bowl. On 10/1/24 at 11:10 a.m., an interview was conducted with R170. The resident stated he uses the toilet, and he likes for it to be nice and clean because if it is not, it is an eye sore. R170 stated the staff used to clean the toilet but he had not seen the toilet cleaned in a while. On 10/3/24 at 3:04 p.m., an interview was conducted with OSM (other staff member) #1 (the director of housekeeping). OSM #1 stated staff are supposed to clean resident bathrooms and wipe down the outside of the toilet bowls every day. At this time, R170's toilet was observed with OSM #1. OSM #1 stated the brown substance on the toilet was feces. OSM #1 stated the housekeeping staff should be observing for feces on the outside of the toilet bowl, but the CNAs (certified nursing assistants) have to wipe the feces off before the housekeepers can disinfect the toilet bowl. OSM #1 stated R170's toilet was not clean or homelike. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For the East unit and [NAME] one unit, the facility staff failed to maintain the hallways in a clean, comfortable, and homelike manner. A marijuana odor was observed on multiple occasions. On 10/1/24 at 12:50 p.m., 10/2/24 at 11:10 a.m., and 10/2/24 at 4:32 p.m., a marijuana odor was observed in the hallway on the east unit. On 10/2/24 at 6:27 p.m., a marijuana odor was observed in the hallway on the west one unit. On 10/7/24 at 4:53 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the east and west one unit manager). LPN #3 stated she has smelled cigarette smoke in the hallways when residents return inside after smoking, but she wasn't sure if she has smelled marijuana. LPN #3 stated the odor is not clean, comfortable, or homelike. On 10/7/24 at 5:07 p.m., an interview was conducted with ASM (administrative staff member) #5 (the regional director of operations). ASM #5 stated the marijuana odor in the facility had been brought to their attention, but no residents had been observed smoking marijuana. ASM #5 stated the residents had been provided education and are aware marijuana is not allowed in the facility. On 10/8/24 at 6:25 p.m., ASM #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 42106 4. The facility staff failed to provide a clean and homelike environment in three of six facility shower rooms, [NAME] 2, South and [NAME] 1 units. On 10/1/24 at 11:31 a.m., an observation was made of the shower room on the west 2 unit. Observation of the shower room revealed a black film covering the edging of the tile border along three of four walls. The film was observed along the grout area of the tiles and along the corners of the surface where the floor met the tile wall. On 10/1/24 at 1:20 p.m., observation of the shower room on the west 2 unit revealed the black film remained in the same locations as described above. A shower chair was observed in the shower room with a wet towel on the chair and a gown on top of the shower chair. On 10/2/24 at 1:17 p.m., an interview was conducted with OSM (other staff member) #1, the director of housekeeping. OSM #1 stated that housekeeping staff went in and cleaned the shower rooms daily. She stated that the CNA (certified nursing assistant) staff were responsible for picking up the linens and the housekeeping staff cleaned the walls and wiped down anything that was touched and then mopped the floors every day. She stated that once a week they did a scrubbing of the shower rooms using the floor buffer with a scrubbing pad on it. She stated that this was normally done on Saturdays but depended on the resident's shower schedules. On 10/2/24 at 1:27 p.m., an observation of the shower room on the South unit was made with OSM #1. Observation of the South unit shower room revealed a black film in the left and right corners of the floor and wall tile. OSM #1 stated that the staff kept the shower room door closed due to the dementia residents and there was no air circulation which caused the film to grow faster. On 10/2/24 at 1:44 p.m., an observation of the shower room on the [NAME] 2 unit revealed the findings documented above. OSM #1 stated that the shower room needed attention from housekeeping staff. On 10/2/24 at 1:48 p.m., an observation of the shower room on the [NAME] 1 revealed a black film on the right wall around 12 tiles, along the baseboard approximately 24 inches on the front wall and in the right corner. OSM #1 stated that the black film was not homelike, and they should not have a shower room looking like that. On 10/7/24 at 5:00 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was provided prior to exit.

Based on staff interview and facility document review, the facility staff failed to maintain evidence of grievances for one of three years, the year 2022. The findings include: The facility staff failed to provide evidence of grievances for the year 2022. On 10/7/24 at 12:58 p.m., grievance/concern forms for the year of 2022 were requested. On 10/8/24 at 9:48 a.m., an interview was conducted with ASM (administrative staff member) #5 (the regional director of operations). ASM #5 stated the social worker who was employed during 2022 was no longer employed at the facility and the staff were not able to find all grievance/concern forms from that year. ASM #5 stated the staff were only able to find pieces of grievance/concern forms and she knew more were completed then the staff could find. On 10/8/24 at 10:15 a.m., an interview was conducted with OSM (other staff member) #2 (the current director of social services). OSM #2 stated grievances and the resolutions should be documented on a concern form and kept in a folder in the social services office. On 10/8/24 at 6:25 p.m., ASM #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Grievance 5. Documentation a. The facility will keep evidence of the resolution of all grievances for a period of three (3) years from the date the grievance decision is issued. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement a comprehensive care plan for eight of 63 residents in the survey sample, Residents #228, #170, #74, #421, #219, #4, #62, and #82. The findings include: 1. For Resident #228 (R228), the facility staff failed to develop a comprehensive care plan for activities. A review of R228's clinical record revealed an activity preference interview dated 9/23/23 that documented the resident reported a current interest in spending time outdoors and walking. R228's comprehensive care plan dated 9/20/23 failed to document information regarding activities. On 10/8/24 at 9:03 a.m., an interview was conducted with OSM (other staff member) #8 (the activities director). OSM #8 stated every resident should have an activities care plan because the activities staff must have a plan of care to know exactly what they are going to do with the residents. OSM #8 stated the activities care plan should be developed on admission and reviewed/revised annually or with significant changes. OSM #8 stated a lot of residents' activities care plans were not done when she began employment at the facility in January 2024 and she was still trying to complete the care plans. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Plan of Care Overview documented, II. Care Plan Team a. An interdisciplinary care team that participates in the planning and implementation of care may include but is not limited to: i. Clinical team, licensed and non-licensed personnel 1. The 'MDS (minimum data set) Coordinator' will oversee and coordinate the care team and PoC (Plan of Care) 2. Nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of residents they provide care for as the resident's condition warrants ii. Therapy team iii. Social services and Activities team iv. Nutritional dietary team v. Medical providers vi. Pharmacists or other ad hoc consultants, when appropriate vii. Business team, where applicable viii. Administrative team, where applicable ix. Family, resident, resident representative or other individual the resident requests to be present b. Members of the care planning team will coordinate care to meet resident preferences and care needs utilizing a holistic approach to care. No further information was presented prior to exit. 2. For Resident #170 (R170), the facility staff failed to implement the resident's comprehensive care plan for nutrition. R170's comprehensive care plan dated 10/12/23 documented, Potential for altered nutrition status/nutrition. Provide meals per diet order of Regular diet, Regular texture, Regular consistency. Cut food into bite-sized pieces . A review of R170's clinical record revealed a physician's order dated 4/10/24 for a regular diet and to cut food into bite-sized pieces. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/25/24, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. On 10/1/24 at 9:21 a.m., R170 was served a meal tray that contained toast with sausage gravy. The meal ticket on the tray documented, CUT FOOD INTO BITE SIZE PIECES. The toast with sausage gravy was not cut into bite-sized pieces. On 10/1/24 at 1:23 p.m., R170 was served a meal tray that contained spaghetti with meat sauce and a breadstick. The meal ticket on the tray documented, CUT FOOD INTO BITE SIZE PIECES. The spaghetti or breadstick was not cut into bite-sized pieces. R170 stated the facility staff never cut up his food. On 10/2/24 at 1:20 p.m., R170 was served a meal tray that contained sliced turkey, mixed vegetables, mashed potatoes, pears, and a roll. The meal ticket on the tray documented, CUT FOOD INTO BITE SIZE PIECES. None of the food was cut into bite-sized pieces. On 10/3/24 at 3:21 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated the CNAs are the primary staff who serve meal trays, and she looks at the meal tickets for special instructions. CNA #2 stated that if a meal ticket documents to cut a resident's food into bite-sized pieces, then the CNA is responsible for cutting the food. CNA #2 stated that if a resident's meal ticket documented to cut the resident's food into bite-sized pieces, she would cut the toast, the breadstick, the spaghetti, the sliced turkey, the carrot rounds in the vegetable blend, the pears, and the roll into bite-sized pieces. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1, regarding the purpose of the care plan. RN #1 stated, If there is no care plan, there is no care. RN #1 stated everything revolves around the care plan and if staff are not able to plan for the patient, then there is no way for staff to care for them. RN #1 stated staff have to follow the care plan to provide care. RN #1 stated nurses can access and look at residents' care plans and nurses communicate residents' needs to CNAs during shift report. On 10/4/24 at 10:32 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated R170's food is supposed to be cut into bite-sized pieces because the resident presents with left sided weakness. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 42106 3. For Resident #74 (R74), the facility staff failed to implement the comprehensive care plan to obtain laboratory testing as ordered. The comprehensive care plan for R74 documented in part, Parkinsons: [Name of R74] has Parkinsons. Date Initiated: 06/15/2024. Under Interventions/Tasks it documented in part, .Obtain and monitor lab/diagnostic studies, as ordered. Report abnormal findings to medical provider, resident and resident representative. Date Initiated: 06/15/2022 . The physician orders for R74 documented in part, TSH (thyroid stimulating hormone) every 6 month in December and June on 15 every night shift every 6 month(s) starting on the 15th for 168 day(s). Order Date: 07/24/2023. Start Date: 12/14/2023. End Date: 01/17/2024. The eTAR (electronic treatment administration record) for R74 dated 12/1/23-12/31/23 documented the TSH scheduled beginning on 12/15/23. Review of the clinical record failed to evidence results for a TSH completed on 12/15/23. The progress notes failed to evidence the resident refusing the laboratory testing or documentation of the laboratory testing completed as ordered in December of 2023. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1, regarding the purpose of the care plan. RN #1 stated, If there is no care plan, there is no care. RN #1 stated everything revolves around the care plan and if staff are not able to plan for the patient, then there is no way for staff to care for them. RN #1 stated staff must follow the care plan to provide care. On 10/8/24 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they had an outside lab company that came in to draw labs. She stated that the technician came in during the week early in the morning and was given a printout of the residents who were scheduled for lab testing. She stated that the nurse and the technician signed the forms, and they drew the labs. She stated that if there were any issues getting the specimen the technician let the nurse know and they called the physician and attempted on the next lab draw day. On 10/8/24 at 1:08 p.m., an interview was conducted with LPN #8. LPN #8 stated that the night nurse printed out all lab orders from the medical records and flagged them for the lab technician who came in early in the morning. She stated that the labs were normally done before she arrived for the day shift, so she watched for the results to come into the medical record during the day. She stated that the labs that were scheduled triggered on the eMAR or eTAR showing that they needed to be done. On 10/9/24 at approximately 6:15 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 4. For Resident #421 (R421), the facility staff failed to implement the comprehensive care plan to administer medications as ordered on multiple dates from July 2024 through September 2024. The comprehensive care plan for R421 documented in part, [Name of R421] uses, anti-depressant medication . Date Initiated: 07/06/2024. Under Interventions/Tasks it documented in part, .Provide anti-depressant medication per medical provider's orders. Date Initiated: 05/08/2024. The care plan further documented, Resident has cellulitis to left 3rd toe and on ABT (antibiotic) doxycycline. Date Initiated: 08/20/2024. Under Interventions/Tasks it documented in part, Administer antibiotics / antimicrobials per medical provider's orders . Date Initiated 08/20/2024. Review of R421's eMAR dated 7/1/24-7/31/24 documented the resident not receiving the following scheduled medications: - Trazodone 75mg at bedtime for depression. On 7/7/24 and 7/30/24. Review of R421's eMAR dated 8/1/24-8/30/24 documented the resident not receiving the following scheduled medications: - Trazodone 75mg at bedtime for depression. On 8/16/24, 8/19/24, 8/25/24 and 8/26/24. - Doxycycline 100mg twice a day for cellulitis of the left third toe for 10 days. On 8/20/24 evening, 8/25/24 evening and 8/26/24 evening. Review of R421's eMAR dated 9/1/24-9/30/24 documented the resident not receiving the following scheduled medications. - Trazodone 75mg at bedtime for depression. On 9/6/24. Review of R421's progress notes failed to evidence notification of the physician of the resident not receiving the scheduled medications listed on the above dates above. Review of the completed Leave of Absence forms for R421 documented the resident signing out on leave of absence on the dates listed above. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1, regarding the purpose of the care plan. RN #1 stated, If there is no care plan, there is no care. RN #1 stated everything revolved around the care plan and if staff were not able to plan for the patient, then there was no way for staff to care for them. RN #1 stated staff had to follow the care plan to provide care. RN #1 stated nurses could access and look at residents' care plans and nurses communicated residents' needs to CNAs (certified nursing assistants) during shift report. On 10/9/24 at 7:49 a.m., an interview was conducted with RN #6. RN #6 stated that medication administration was evidenced by the documentation on the eMAR. She stated that if the medication was not administered for any reason, the physician was notified that the medication was not given. She stated that if a resident was going on LOA overnight, they would send the medication with the family but if they were only going for the day the residents normally took the morning medications and came back to get their next scheduled medications. She stated that if the resident was due for medication and still out on LOA, they would call the physician and let them know to see if they could delay the dosage for when they returned and if they consistently missed their medications the physician should be notified to see if the schedule needed to be changed. On 10/9/24 at 8:57 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that if a medication was not given the staff were to notify the physician. She stated that she was not aware of any residents missing their medications while out on leave of absence and as far as she knew the residents would come back to get their medications. On 10/10/24 at 12:00 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 5. For Resident #219 (R219), the facility staff failed to implement the comprehensive care plan to provide incontinence care during dates in September and November of 2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 9/15/22, the resident was assessed as being severely impaired for making daily decisions, requiring extensive assistance of one person for toileting and being frequently incontinent of bowel and bladder. The comprehensive care plan for R219 documented in part, Resident has bowel and bladder incontinence disease process, immobility, dementia. Date Initiated: 09/11/2022. Under Interventions/Tasks it documented in part, Provide assistance with toileting as needed. Date Initiated: 09/11/2022 .Provide peri-care after each incontinence episode .Date Initiated: 09/11/2022 . Review of the ADL (activities of daily living) documentation for R219 dated 9/1/22-9/30/22 failed to evidence incontinence care, toileting assistance or personal hygiene assistance provided on night shift (11:00 p.m. to 7:00 a.m.) of 9/12/22 and 9/14/22. Review of the ADL documentation for R219 dated 11/1/22-11/30/22 failed to evidence incontinence care, toileting assistance or personal hygiene assistance provided on night shift of 11/5/22 and 11/11/22. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1, regarding the purpose of the care plan. RN #1 stated, If there is no care plan, there is no care. RN #1 stated everything revolved around the care plan and if staff were not able to plan for the patient, then there was no way for staff to care for them. RN #1 stated staff had to follow the care plan to provide care. RN #1 stated nurses could access and look at residents' care plans and nurses communicated residents' needs to CNAs (certified nursing assistants) during shift report. On 10/8/24 at 1:11 p.m., an interview was conducted with CNA #3. CNA #3 stated that incontinence care and toileting assistance were provided to residents throughout the shifts and at least every two hours. She stated that they evidenced the care they provided to the residents by their documentation in the ADL charting every shift. She stated that she remembered R219 but did not work the hallway that they resided on at the facility. On 10/9/24 at approximately 6:15 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 32642 6. For Resident #4 (R4), the facility staff failed to implement the care plan to treat an infection in the resident's bone. A review of R4's clinical record revealed the following order dated 9/6/24: Piperacillin Sod-Tazobactam So Solution (1) (Zosyn) Reconstituted 4-0.5 GM (grams) Use 4.5 gram intravenously every 6 hours for osteomyelitis (infection of the bone). A review of R4's progress notes revealed the following nurses' note dated 9/7/24: eMar - Medication Administration Note: Piperacillin Sod-Tazobactam So Solution Reconstituted 4-0.5 GM Use 4.5 gram intravenously every 6 hours for Osteomyelitis until 10/08/2024 .Resident meds (medications) are pending for pharmacy delivery. A review of R4's care plan dated 5/20/24 and updated 9/24/24 revealed, in part: Resident is currently on intravenous therapy r/t (related to) [osteomyelitis] .Administer IV medications per medical provider's orders. On 10/3/24 at 5:23 p.m., RN (registered nurse) #1 was interviewed. RN #1 stated, If there is no care plan, there is no care. RN #1 stated everything revolves around the care plan and if staff are not able to plan for the patient, then there is no way for staff to care for them. RN #1 stated staff have to follow the care plan to provide care. RN #1 stated nurses can access and look at residents' care plans and nurses communicate residents' needs to CNAs (certified nursing assistants) during shift report. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3 was interviewed. After reviewing R4's progress notes and September 2024 MAR (medication administration record), she stated the Zosyn was ordered for R4 as a discharge medication from the hospital. The Zosyn was to treat an infection of the resident's bone. She stated the 12:00 noon Zosyn dose was not administered because it had not arrived from the pharmacy. On 10/5/24 at 6:17 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 7. For Resident #62 (R62), the facility staff failed to implement the resident's care plan for a resting hand splint on his right hand. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) 6/25/24, R62 was coded as having no cognitive impairment according to the BIMS (brief interview for mental status). He was coded as having upper extremity range of motion impairment on one side. On 10/26/24 at 12:36 p.m. and 10/2/24 at 11:05 a.m., R62 was observed sitting up in bed. His right hand was contracted, and there was no splint visible. When asked if he ever was provided a splint for his right hand, he stated he had one in the past, but did not know what happened to it. He added that the staff did not know where the splint was located either. A review of R62's occupational evaluation dated 6//11/24 revealed, in part: Range of Motion UP (upper extremity) .RUE (right upper extremity) impaired .with contracture. Has a resting splint .Recs (recommendations) Splint/Orthotic Recommendations: It is recommended the patient wear a resting hand splint on right hand for 4 hours on/4 hours off in order to improve PROM (passive range of motion) for adequate hygiene and reduce pain caused by muscle tightening. A review of R62's physician's orders failed to reveal any information related to a splint for the resident's right hand. A review of R62's care plan dated 7/8/23 failed to reveal any information related to his contracture and the need for a resting hand splint. On 10/8/24 at 1:08 p.m., LPN (licensed practical nurse) #8 was interviewed. She stated she regularly takes care of R62. She stated she had never seen R62 with a splint, and did not know if he had ever used one. She stated she would check to see what interventions had been implemented for the resident's right hand contracture. On 10/8/24 at 3:01 p.m., LPN #8 stated she had checked on R62's right hand contracture and the occupational therapist was currently in the room working with the resident. She stated the therapy evaluation had been ordered just a few minutes ago. On 10/9/24 at 8:34 a.m., OSM (other staff member) #13, an occupational therapist, was interviewed. She stated she had written the report and recommendations on the 6/11/24 report for R62. She stated the resident was discharged from therapy services with a resting hand splint for his right hand. She stated there was an established schedule for putting it on and taking it off, and the CNAs (certified nursing assistants) helped him with it. She stated she evaluated the resident on 10/8/24 because the splint was misplaced. She confirmed that the discharge instructions she gave the staff on 6/11/24 contained recommendations for the resident to wear the hand splint. She stated she gives the recommendation to nurses, who are then responsible for transcribing the recommendations into orders. She stated there should be a care plan for the resident's contracture and interventions to treat it. On 10/5/24 at 6:17 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. No further information was provided prior to exit. 27660 8. For Resident #82 (R82), the facility staff failed to implement the comprehensive care plan for administering antibiotics per the physician order. The comprehensive care plan dated, 9/22/24, documented in part, Focus: Resident has an infection disease process R/T (related to) dx (diagnosis) of UTI. The Interventions documented in part, Administer antibiotics/antimicrobials per medical provider's orders. The physician order dated 9/20/24 documented, Ciprofloxacin HCL (hydrochloride) Oral Tablet 500 MG (milligrams); Give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days. The September 2024 MAR (medication administration record) documented the above order. On 9/20/24 the 6:00 p.m. dose documented a 5. A 5 indicates See Nurses Note. The nurse's note dated 9/20/24, documented, Not available. Review of the (Emergency backup medication system) contents revealed Ciprofloxacin 250 mg tablets were available in the backup system. An interview was conducted on 10/3/24 at 11:31 a.m. with LPN (licensed practical nurse) #6. LPN #6 stated the purpose of the care plan is to know what the patient needs and what care will be provided. LPN #6 stated the care plan should be followed. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM # 5, the regional director of operations, were made aware of the above findings on 10/8/24 at 6:15 p.m. No further information was obtained prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for five of 63 residents in the survey sample, Residents #48, #110, #123, #162, #190. The findings include: 1. For Resident #48 (R48), the facility staff failed to review and revise the resident's comprehensive care plan for bed rails. R48's comprehensive care plan, revised on 8/22/24, failed to document information regarding bed rails. On 10/1/24 at 12:05 p.m., R48 was observed lying in bed with bilateral grab bars (bed rails) in the upright position. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1, regarding the purpose of the care plan. RN #1 stated, If there is no care plan, there is no care. RN #1 stated everything revolves around the care plan and if staff are not able to plan for the patient, then there is no way for staff to care for them. RN #1 stated residents' care plans should include documentation regarding grab bars because this communicates the use of grab bars to staff in case they have a question. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Plan of Care Overview documented, II. Care Plan Team a. An interdisciplinary care team that participates in the planning and implementation of care may include but is not limited to: i. Clinical team, licensed and non-licensed personnel 1. The MDS Coordinator will oversee and coordinate the care team and PoC (Plan of Care) 2. Nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of residents they provide care for as the resident's condition warrants ii. Therapy team iii. Social services and Activities team iv. Nutritional dietary team v. Medical providers vi. Pharmacists or other ad hoc consultants, when appropriate vii. Business team, where applicable viii. Administrative team, where applicable ix. Family, resident, resident representative or other individual the resident requests to be present b. Members of the care planning team will coordinate care to meet resident preferences and care needs utilizing a holistic approach to care. No further information was presented prior to exit. 2. For Resident #110 (R110), the facility staff failed to review and revise the resident's comprehensive care plan when the resident hit another resident on 5/13/24. A review of R110's clinical record revealed a nurse practitioner's note dated 5/13/24 that documented the resident hit another resident on that date. Further review of R110's clinical record revealed the resident was transferred to another unit and evaluated by a psychiatrist but failed to reveal R110's comprehensive care plan (initiated on 10/1/21) was reviewed and revised regarding the incident. On 10/3/24 at 2:38 p.m., an interview was conducted with OSM (other staff member) #2 (the director of social services). OSM #2 stated if a resident hits another resident, his or her care plan should be reviewed and revised because it's important for all staff to observe and be mindful of potential interventions. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 3. For Resident #123 (R123), the facility staff failed to review and revise the resident's comprehensive care plan when the resident hit another resident on 5/1/24. A review of R123's clinical record revealed a nurse's note dated 5/1/24 that documented the resident hit another resident on that date. Further review of R123's clinical record revealed the resident was transferred to another unit and evaluated by a psychiatrist but failed to reveal R123's comprehensive care plan (initiated on 1/29/22) was reviewed and revised regarding the incident. On 10/3/24 at 2:38 p.m., an interview was conducted with OSM (other staff member) #2 (the director of social services). OSM #2 stated if a resident hits another resident, his or her care plan should be reviewed and revised because it's important for all staff to observe and be mindful of potential interventions. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 4. For Resident #162 (R162), the facility staff failed to review and revise the resident's comprehensive care plan when the resident was hit by another resident on 5/1/24 and 5/13/24. A review of R162's clinical record revealed progress notes that documented a resident hit R162 on 5/1/24 and another resident hit R162 on 5/13/24. Further review of R162's clinical record revealed the resident was evaluated by a psychiatrist but failed to reveal R162's comprehensive care plan (initiated on 7/25/23) was reviewed and revised regarding both incidences. On 10/3/24 at 2:38 p.m., an interview was conducted with OSM (other staff member) #2 (the director of social services). OSM #2 stated if a resident is hit by another resident, his or her care plan should be reviewed and revised so staff are aware of potential triggers, any potential safety concerns of the resident not feeling safe, and to provide coping skills if needed. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit. 27660 5. For Resident #190, the facility staff failed to review and revise the comprehensive care plan for the treatment of a urinary tract infection (UTI). The physician order dated, 9/30/24, documented, Levofloxacin (an antibiotic used to treat infection) Tablet 250 MG (milligrams); Give 1 tablet by mouth one time a day for UTI for 3 days. Review of the comprehensive care plan last updated on 10/1/24, failed to evidence documentation related to the treatment of a uriary tract infection. An interview was conducted with LPN (licensed practical nurse) #6 on 10/3/24 at 11:26 a.m. LPN #6 stated the unit manager and supervisors update the care plans, the floor nurses do not update the care plans. She stated the treatment of a urinary tract infection should be on the care plan. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM # 5, the regional director of operations, were made aware of the above findings on 10/8/24 at 6:15 p.m. No further information was obtained prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide activities based on resident preferences for two of 63 residents in the survey sample, Residents #219 and #228. The findings include: 1. For Resident #219 (R219), the facility staff failed to provide activities based on the comprehensive assessment and care plan preferences. On the admission MDS (minimum data set) with an ARD (assessment reference date) of 9/8/22, the resident scored 2 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented preferences for music being very important and participating in activities, doing things with groups of people, being around animals, having books and magazines, going outside and participating in religious services being somewhat important to the resident as reported by the family or significant other. The activity preferences interview for R219 dated 9/2/22 documented past interest in playing checkers, reading, golfing, football, cooking, news, outings, religious services, and attending social events. It further documented current interest in walking, music, game shows, spending time outdoors, and talking. It documented that R219 preferred to participate in morning activities in the day/activity room and was cooperative and interested in activities per the responsible party interview. The comprehensive care plan for R219 documented in part, The resident has impaired cognitive function Alzheimer's Dementia. Date Initiated: 09/11/2022. Under Interventions/Tasks it documented in part, Provide a program of activities that accommodates abilities. Date Initiated: 09/11/2022 . The care plan further documented, I have no plans for discharge secondary to community. Date Initiated: 9/13/2022. Revision on: 11/16/2022. Under Interventions/Tasks it documented in part, .Invite and encourage [Name of R219] to attend activities of interest. Date Initiated: 09/13/2022. Revision on: 11/16/2022. On 10/8/24 at 8:26 a.m., an interview was conducted with OSM (other staff member) #8, activities director. OSM #8 stated that they had worked at the facility since January of 2024 and had started tracking activity participation then. She stated that they did not have any records of activity participation prior to then. She stated that when she started working at the facility there was an activities assistant running the program and had been for about three or four months before. She stated that assessments were completed on all residents to gather the information they needed to determine which activities were the best fit for the residents based on their preferences. She stated that they currently offered activities such as one to one in rooms, patio activities, carnivals, basketball games, cookouts, sports days, Hawaiian days, Western days, shopping trips, restaurant trips and music activities. She stated that on the dementia unit they also brought residents outside on the patio to participate in fresh air activities. On 10/8/24 at 10:30 a.m., an interview was conducted with OSM #19, activity leader. OSM #19 stated that they were working on the dementia unit during the time that R219 resided there. She stated that they were doing activities such as music therapy, balloon batting, arts and crafts, coloring, ball, hot potato, sing alongs, snacks, drinks, and movies. She stated that she would check to see if there was any evidence of R219 participating in any activities in September to November of 2022, but they did not remember the resident. The facility policy Activities Program undated, documented in part, .It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents . The activity program is: a. Designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident's needs. b. Scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program. c. Consists of individual and small and large group activities which are designed to meet the needs and interests of each resident and includes, at a minimum: i. Social activities. ii. Indoor and outdoor activities. iii. Activities away from the facility. iv. Religious programs. v. Creative activities. vi. Intellectual and educational activities. vii. Exercise activities. viii. Individualized activities. ix. In-room activities. x. Community activities . On 10/9/24 at approximately 6:15 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the concern. No further information was provided prior to exit. 31753 2. For Resident #228 (R228), the resident was assessed as reporting a current interest in spending time outdoors. The facility staff failed to provide this desired activity. R228 was admitted to the facility on [DATE]. A review of R228's clinical record revealed an activity preference interview dated 9/23/23 that documented the resident reported a current interest in spending time outdoors and walking. R228's comprehensive care plan dated 9/20/23 failed to document information regarding activities. Further review of R228's clinical record (including nurses' notes and activities program documentation forms for January 2024 through June 2024) failed to reveal the resident spent any time outdoors. R228 discharged from the facility on 6/26/24. On 10/8/24 at 9:03 a.m., an interview was conducted with OSM (other staff member) #8 (the activities director). OSM #8 stated an assessment to determine residents' preferred activities is completed so staff can gather information and determine an activities plan for residents. OSM #8 stated that when activities staff take residents outside for fresh air, they should write that activity on the activities program documentation forms and document the activity occurred. OSM #8 stated R228 didn't want to go outside and was very content in her own space inside. Further review of R228's clinical record failed to reveal the resident was offered to be taken outside or refused to go outside. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for four of 63 residents in the survey sample, Residents #48, #166, #187, and #221. The findings include: 1. For Resident #48 (R48), the facility staff failed to attempt alternatives prior to bed rail use, assess the resident for risk of entrapment, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent. A review of R48's clinical record revealed an admission evaluation dated 5/24/22 that failed to document information regarding bed rails. A bed safety evaluation dated 8/26/24 documented, 7. Has the resident expressed the desire to have an assist device on their bed? No. A review of physician's orders for October 2024 failed to reveal an order for bed rails. On 10/1/24 at 12:05 p.m., R48 was observed lying in bed with bilateral grab bars (bed rails) in the upright position. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated he did not recall that staff assess residents for appropriate alternatives prior the use of bed rails. RN #1 stated an assessment for risk of entrapment, education regarding the risks of benefits and benefits of bed rails and obtaining informed consent should be done during the admission process and documented on the admission assessment. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Safe Use of Bed Rails documented, Procedure: 1. Assessment of residents with bed rails include: a. Level of independence with bed mobility b. Review of prior interventions and outcomes prior to the initiation of bed rails c. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms should be evaluated prior to initiation d. Bed meets manufacturer's recommendations and specifications pertaining to resident's height and weight. 2. Consent a. Disclosure of the needs, risk and benefits of use b. Education provided to the resident or resident representative c. Signed by the resident or, if applicable, the resident representative. No further information was presented prior to exit. 42106 2. For Resident #166 (R166), the facility staff failed to evidence a consent for the use of bed rails, alternatives attempted prior to installing bed rails, and review of the risks and benefits of bed rails prior to installation. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 6/3/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The resident was coded as requiring set up assistance with bed mobility and dependent for transfers. On 10/1/24 at 8:44 a.m., an observation was made of R166 in bed with bilateral bar shaped bed rails in place. At that time, an interview was conducted with R166 who stated that they grabbed on the bar when turning in the bed. R166 stated that the bed had always that the bars on it and they used them and had never used anything else. An additional observation of R166 in the bed with the bilateral bar shaped bed rails in place were made on 10/1/24 at 2:18 p.m. and 10/2/24 at 8:10 a.m. The physician orders for R166 failed to evidence an order for the bed rails. The comprehensive care plan for R166 failed to evidence the use of bed rails. The admission assessment for R166 dated 9/27/24 failed to evidence the use of bed rails. A bed safety evaluation dated 9/27/24 for R166 documented the use of grab bar currently for bed mobility or support. The evaluation documented in part, Has the resident expressed the desire to have an assist device on their bed? No . The evaluation failed to evidence review of risk and benefits, use of alternative prior to bed rail installation and consent for use. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that bed rails were included in the admission process and that during the nursing admission assessment they determined if the resident were going to use the bed rails to turn and reposition themselves. He stated that he did not recall if there was an option for alternate devices prior to the bed rails or not. He stated that they did assess for the risk of entrapment during the admission assessment, and he believed that in the bed evaluation there was a risk and benefit and consent. On 10/7/24 at 5:00 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 3. For Resident #187 (R187), the facility staff failed to evidence a consent for the use of bed rails, alternatives attempted prior to installing bed rails, and review of the risks and benefits of bed rails prior to installation. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 9/4/24, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were severely impaired for making daily decisions. The resident was coded as being dependent for bed mobility and transfers. On 10/1/24 at 9:02 a.m., an observation was made of R187 in bed with bilateral bar shaped bed rails in place. An additional observation of R187 in the bed with the bilateral bar shaped bed rails in place were made on 10/1/24 at 1:14 p.m. and 10/2/24 at 8:14 a.m. The physician orders for R187 failed to evidence an order for the bed rails. The comprehensive care plan for R187 failed to evidence the use of bed rails. The admission assessment for R187 dated 8/29/24 failed to evidence the use of bed rails. A bed safety evaluation dated 8/29/24 for R187 documented the resident not capable of decision making and use of grab bar currently for bed mobility or support. The evaluation documented in part, Has the resident expressed the desire to have an assist device on their bed? No . The evaluation failed to evidence review of risk and benefits, use of alternative prior to bed rail installation and consent for use. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that bed rails were included in the admission process and that during the nursing admission assessment they determined if the resident were going to use the bed rails to turn and reposition themselves. He stated that he did not recall if there was an option for alternate devices prior to the bed rails or not. He stated that they did assess for the risk of entrapment during the admission assessment, and he believed that in the bed evaluation there was a risk and benefit and consent. On 10/7/24 at 5:00 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 4. For Resident #221 (R221), the facility staff failed to evidence a consent for the use of bed rails, alternatives attempted prior to installing bed rails, and review of the risks and benefits of bed rails prior to installation. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/20/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The resident was coded as requiring limited assistance for bed mobility and independent with transfers. The progress notes for R221 documented in part, 12/15/2022 17:29 (5:29 p.m.) Admission note .Requires Grab bar(s) . The progress notes failed to evidence review of risk and benefits, use of alternative prior to bed rail installation and consent for use. The physician orders for R221 failed to evidence an order for the bed rails. The comprehensive care plan for R221 failed to evidence the use of bed rails. The admission assessment for R221 dated 12/15/22 documented the resident verbalizing/demonstrating the use of side rails/helping handles/grab bars and using bed assist bars. The assessment failed to evidence review of risk and benefits, use of alternative prior to bed rail installation and consent for use. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that bed rails were included in the admission process and that during the nursing admission assessment they determined if the resident were going to use the bed rails to turn and reposition themselves. He stated that he did not recall if there was an option for alternate devices prior to the bed rails or not. He stated that they did assess for the risk of entrapment during the admission assessment, and he believed that in the bed evaluation there was a risk and benefit and consent. On 10/9/24 at approximately 6:15 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to make required physician visits for four of 63 residents in the survey sample, Residents #52, #164, #48, and #155. The findings include: 1. For Resident #52, the facility staff failed to ensure the physician made the required visits. Review of the clinical record failed to evidence the physician did any required visits since 3/21/24. On 10/7/24 at 2:59 p.m., an interview was conducted with ASM (administrative staff member) #7, the physician. ASM #7 stated he tries to see residents every 60 days. On 10/9/24 at 9:00 a.m., and interview was conducted with ASM #2, the director of nursing. ASM #2 stated the medical records employee is responsible for tracking physician visits and notifying the physicians of a need for visits. The facility policy, Physician Visit Logs documented in part, Policy: It is the policy of this facility to maintain a system to monitor physician's visits for all in-house residents to ascertain routine visits are conducted as outlined in state and federal regulations. The physician visit log may be maintained manually or electronically. Procedure: 1. The clinical records coordinator will maintain the Physician's Visit Log. 2. The Physician's Visit Log will be maintained in the electronic record. 3. The date of each physician's visit will be recorded and updated in the E MAR .5. If the resident is on an alternate visitation schedule, the clinical records coordinator will monitor and follow up on visits as follows: a. If the physician fails to visit within 50 days of the last visit, the clinical records coordinator will notify the physician by telephone that the visit is now due within the next 10 days and document the notification on a notification log. b. If the physician fails to visit within 60 days of the last visit, the clinical records coordinator will notify the physician by telephone that the visit is due and document the notification on the log. c. Notify the Executive Director and director of nursing services, in writing, that the physicians visit is overdue and include the physician's name, date of last visit, resident's name and Medical record number. Request administrative intervention such as a letter or phone call to the physician, medical director and the resident or resident's representative. d. Repeat this step weekly until the physician visits, there is a change of physician, or a physician has assumed care for this resident. ASM #1, the executive director, ASM #2, and ASM # 5, the regional director of operations, were made aware of the above findings on 10/8/24 at 6:15 p.m. No further information was obtained prior to exit. 42106 2. For Resident #164 (R164), the facility staff failed to provide timely physician visits. R164 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/24/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. On 10/1/24 at 8:24 a.m., an interview was conducted with R164 who stated that they had been at the facility for about nine months and had a good relationship with the nurse practitioner who they saw often. R164 stated that they rarely saw the physician and had not seen him in months now. Review of the clinical record for R164 documented physician visits 11/15/23, 2/22/24 and 8/15/24. On 10/7/24 at 2:59 p.m., an interview was conducted with ASM (administrative staff member) #7, physician. ASM #7 stated that he tries to see residents every 60 days. On 10/9/24 at 9:00 a.m., and interview was conducted with ASM #2, the director of nursing. ASM #2 stated the medical records employee is responsible for tracking physician visits and notifying the physicians of a need for visits. On 10/9/24 at approximately 6:15 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 31753 3. For Resident #48 (R48), the facility staff failed to ensure the resident was seen by a physician between 1/4/24 and 5/23/24 (a total of 140 days). A review of R48's clinical record revealed the resident was seen by a physician on 1/4/24. Further review of R48's clinical record revealed the resident was seen by a nurse practitioner on multiple dates but was not seen by a physician again until 5/23/24 (a total of 140 days). On 10/7/24 at 2:59 p.m., an interview was conducted with ASM (administrative staff member) #7 (the physician). ASM #7 stated he tries to see residents every 60 days. On 10/8/24 at 6:25 p.m., ASM #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. On 10/9/24 at 9:00 a.m., ASM #2 stated the medical records employee is responsible for tracking physician visits and notifying the physicians of a need for visits. No further information was presented prior to exit. 32642 4. For Resident #155 (R155), the facility staff failed to provide physician visits between his admission on 4/11/23 and 4/16/24 (371 days). A review of R155's clinical record revealed he was admitted on [DATE], but was not seen by a physician until 4/16/35, a total of 371 days later. On 10/7/24 at 2:59 p.m., ASM (administrative staff member) #7, the physician, was interviewed. ASM #7 stated he tries to see residents every 60 days. On 10/9/24 at 9:00 a.m., ASM #2, the director of nursing, was interviewed. ASM #2 stated the medical records employee is responsible for tracking physician visits and notifying the physicians of a need for visits. On 10/5/24 at 6:17 p.m., ASM #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to perform laboratory tests as ordered by the physician/provider for two of 63 residents in the survey sample, Residents #130 and #74. The findings include: 1. For Resident #130, the facility staff failed to perform Hemoglobin A1C (test to measure long term blood sugar levels), lipid, and CMP (comprehensive metabolic panel) laboratory tests for multiple months in 2023. A review of R130's orders revealed, in part: 4/3/23 Hemoglobin A1C every three months. 8/11/23 HgbA1c, CMP One time. A review R130's of laboratory results for 2023 revealed no Hemoglobin A1C results between 4/1/23 and 12/2/23. This review revealed no CMP between 8/11/23 and 12/2/23. On 10/8/24 at 1:08 p.m., LPN (licensed practical nurse) #8 was interviewed. She stated the night nurses are responsible for acknowledging when the EMR (electronic medical record) generates a reminder for a resident lab test. The night nurses print out the laboratory orders and put these in a book. When the outside laboratory company staff arrive at the facility to draw residents' blood, they perform the tests according to the orders in their book on each unit. She stated laboratory tests show up on either the MAR (medication administration record) or TAR (treatment administration record) as needing to be done. She stated the night nurse on each unit provides a list of lab tests that have been done to the day nurse, and the day nurse is responsible for looking for the results. On 10/8/24 at 2:27 p.m., LPN #3, a unit manager, was interviewed. She stated the night shift nurses produce the orders and lab slips for the laboratory staff. On 10/5/24 at 6:17 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. A review of the facility policy, Laboratory and Radiological Services and Results Reporting, revealed, in part: The facility is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource .There are clinical and physiological risks when laboratory .services are not performed in a timely manner. No further information was provided prior to exit. 42106 2. For Resident #74 (R74), the facility staff failed to obtain laboratory testing as ordered. The physician orders for R74 documented in part, TSH (thyroid stimulating hormone) every 6 month in December and June on 15 every night shift every 6 month(s) starting on the 15th for 168 day(s). Order Date: 07/24/2023. Start Date: 12/14/2023. End Date: 01/17/2024. The eTAR (electronic treatment administration record) for R74 dated 12/1/23-12/31/23 documented the TSH scheduled beginning on 12/15/23. The comprehensive care plan for R74 documented in part, Parkinsons: [Name of R74] has Parkinsons. Date Initiated: 06/15/2024. Under Interventions/Tasks it documented in part, .Obtain and monitor lab/diagnostic studies, as ordered. Report abnormal findings to medical provider, resident and resident representative. Date Initiated: 06/15/2022 . Review of the clinical record failed to evidence results for a TSH completed on 12/15/23. The progress notes failed to evidence the resident refusing the laboratory testing or documentation of the laboratory testing completed as ordered in December of 2023. On 10/7/24 at approximately 5:00 p.m., a request was made to ASM (administrative staff member) #1, the executive director, for evidence of the TSH ordered for 12/15/23 for R74. On 10/8/24 at 9:28 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they had an outside lab company that came in to draw labs. She stated that the technician came in during the week early in the morning and was given a printout of the residents who were scheduled for lab testing. She stated that the nurse and the technician signed the forms, and they drew the labs. She stated that if there were any issues getting the specimen the technician let the nurse know and they called the physician and attempted on the next lab draw day. On 10/8/24 at 1:08 p.m., an interview was conducted with LPN #8. LPN #8 stated that the night nurse printed out all lab orders from the medical records and flagged them for the lab technician who came in early in the morning. She stated that the labs were normally done before she arrived for the day shift, so she watched for the results to come into the medical record during the day. She stated that the labs that were scheduled triggered on the eMAR or eTAR showing that they needed to be done. On 10/9/24 at approximately 6:15 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, facility staff interview, and clinical record review, the facility staff failed to conduct required bed inspections for four of 63 residents in the survey sample, Residents #48, #166, #187, and #221. The findings include: 1. For Resident #48 (R48), the facility staff failed to conduct an inspection of the resident's bed rails to identify areas of possible entrapment. A review of R48's clinical record revealed an admission evaluation dated 5/24/22 that failed to document information regarding bed rails. A bed safety evaluation dated 8/26/24 documented, 7. Has the resident expressed the desire to have an assist device on their bed? No. Further review of R48's clinical record failed to reveal an inspection of the resident's bed rails to identify areas of possible entrapment. On 10/1/24 at 12:05 p.m., R48 was observed lying in bed with bilateral grab bars (bed rails) in the upright position On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated an assessment for risk of entrapment should be done during the admission process and documented on the admission assessment. On 10/8/24 at 9:16 a.m., an interview was conducted with OSM (other staff member) #9 (the maintenance director). OSM #9 stated he tests the beds every year to make sure they are functional, and the electrical components are working. OSM #9 stated the facility uses quarter bed rails and grab bars, so it doesn't seem like there is a risk of entrapment and he does not complete a formal assessment to identify areas of possible entrapment. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Safe Use of Bed Rails documented, 6. Documentation .b. Completion of Bed Safety Evaluation. No further information was presented prior to exit. 42106 2. For Resident #166 (R166), the facility staff failed to conduct an inspection of the resident's bed rails to identify areas of possible entrapment. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 6/3/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The resident was coded as requiring set up assistance with bed mobility and dependent for transfers. On 10/1/24 at 8:44 a.m., an observation was made of R166 in bed with bilateral bar shaped bed rails in place. At that time, an interview was conducted with R166 who stated that they grabbed on the bar when turning in the bed. R166 stated that the bed had always that the bars on it and they used them and had never used anything else. An additional observation of R166 in the bed with the bilateral bar shaped bed rails in place were made on 10/1/24 at 2:18 p.m. and 10/2/24 at 8:10 a.m. The admission assessment for R166 dated 9/27/24 failed to evidence the use of bed rails. A bed safety evaluation dated 9/27/24 for R166 documented the use of grab bar currently for bed mobility or support. The evaluation documented in part, Has the resident expressed the desire to have an assist device on their bed? No . The evaluation failed to evidence inspection of the resident's bed rails to identify areas of possible entrapment. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that an assessment for risk of entrapment should be done during the admission process and documented on the admission assessment. On 10/8/24 at 9:16 a.m., an interview was conducted with OSM (other staff member) #9, maintenance director. OSM #9 stated he tested the beds every year to make sure they were functional, and the electrical components were working. OSM #9 stated the facility used quarter bed rails and grab bars, so it didn't seem like there was a risk of entrapment and he did not complete a formal assessment to identify areas of possible entrapment. On 10/7/24 at 5:00 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 3. For Resident #187 (R187), the facility staff failed to conduct an inspection of the resident's bed rails to identify areas of possible entrapment. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 9/4/24, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were severely impaired for making daily decisions. The resident was coded as being dependent for bed mobility and transfers. On 10/1/24 at 9:02 a.m., an observation was made of R187 in bed with bilateral bar shaped bed rails in place. An additional observation of R187 in the bed with the bilateral bar shaped bed rails in place were made on 10/1/24 at 1:14 p.m. and 10/2/24 at 8:14 a.m. The admission assessment for R187 dated 8/29/24 failed to evidence the use of bed rails. A bed safety evaluation dated 8/29/24 for R187 documented the resident not capable of decision making and use of grab bar currently for bed mobility or support. The evaluation documented in part, Has the resident expressed the desire to have an assist device on their bed? No . The evaluation failed to evidence inspection of the resident's bed rails to identify areas of possible entrapment. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that an assessment for risk of entrapment should be done during the admission process and documented on the admission assessment. On 10/8/24 at 9:16 a.m., an interview was conducted with OSM (other staff member) #9, maintenance director. OSM #9 stated he tested the beds every year to make sure they were functional, and the electrical components were working. OSM #9 stated the facility used quarter bed rails and grab bars, so it didn't seem like there was a risk of entrapment and he did not complete a formal assessment to identify areas of possible entrapment. On 10/7/24 at 5:00 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 4. For Resident #221 (R221), the facility staff failed to conduct an inspection of the resident's bed rails to identify areas of possible entrapment. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/20/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The resident was coded as requiring limited assistance for bed mobility and independent with transfers. The progress notes for R221 documented in part, 12/15/2022 17:29 (5:29 p.m.) Admission note .Requires Grab bar(s) . The progress notes failed to evidence inspection of the resident's bed rails to identify areas of possible entrapment. The admission assessment for R221 dated 12/15/22 documented the resident verbalizing/demonstrating the use of side rails/helping handles/grab bars and using bed assist bars. The assessment failed to evidence inspection of the resident's bed rails to identify areas of possible entrapment. On 10/3/24 at 5:23 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that an assessment for risk of entrapment should be done during the admission process and documented on the admission assessment. On 10/8/24 at 9:16 a.m., an interview was conducted with OSM (other staff member) #9, maintenance director. OSM #9 stated he tested the beds every year to make sure they were functional, and the electrical components were working. OSM #9 stated the facility used quarter bed rails and grab bars, so it didn't seem like there was a risk of entrapment and he did not complete a formal assessment to identify areas of possible entrapment. On 10/9/24 at approximately 6:15 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to promote dignity for two of 63 residents in the survey sample, Residents #142 and #162. The findings include: 1. For Resident #142 (R142), the facility staff failed to serve lunch in a dignified manner. R142's roommate was served lunch on 10/2/24 at 1:20 p.m. and R142 was not served lunch until ten minutes later. On 10/2/24 at 1:20 p.m., R142 and the resident's roommate was observed in their bedroom. At this time, R142's roommate was served lunch. R142 was not served and fed by a CNA (certified nursing assistant) until 1:30 p.m. (ten minutes later). On 10/3/24 at 3:21 p.m., an interview was conducted with CNA #2. CNA #2 stated she does not serve and feed residents who require assistance until residents who eat independently are served. CNA #2 stated that if one resident in a room is eating and his roommate requires assistance, she will ask other CNAs to finish passing meal trays so she can feed the resident who requires assistance. CNA #2 stated a resident who requires assistance should be served and fed within two to three minutes of his roommate being served. CNA #2 stated that if she required assistance with eating and she was sitting in a room with a resident who was eating, she would feel bad because the other person is eating, and she is not. CNA #2 stated ten minutes is too long of a wait for a resident to be served and fed while his roommate is eating. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Rights documented, The purpose of this policy is to guide employees in the general principles of dignity and respect of caring for residents . No further information was presented prior to exit. 2. For Resident #162 (R162), the facility staff failed to maintain the resident's shirt in a dignified manner. On 10/1/24 at 10:06 a.m., R162 was observed in a hallway wearing a shirt with the resident's first name and room number written on the front of the shirt. On 10/3/24 at 3:21 p.m., an interview was conducted with CNA (certified nursing assistant) #2. CNA #2 stated residents' names and room numbers are written on resident's shirts for laundry purposes, but the names and room numbers are supposed to be written on the inside of the back collar of the shirt. CNA #2 stated that if she was wearing a shirt with her name and room number written on the front of the shirt, she would feel bad because everybody would know her personal information. CNA #2 stated that is a dignity issue. On 10/4/24 at 11:41 a.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, resident interview, staff interview and facility document review it was determined the facility staff failed to assess a resident for self-administration of over-the-counter eye drops that were on the over the bed table, for one of 63 residents in the survey sample, Resident #65. The findings include: For Resident #65 (R65), over the counter Opcon A eye drops were found on her over the bed table, there was no evidence of an assessment for self-administration of medications. Observation was made on 9/30/24 at approximately 6:35 p.m. of Opcon A eye drops, an over-the-counter medication, was observed on the over the bed table. The bottle of eye drops was noted again on the bedside table on 10/1/24 at 3:50 p.m. An interview was conducted with R65 on 9/30/24 at 6:35 p.m. R65 stated she uses these drops to help her eyes. Review of the physician orders failed to evidence a physician order for the above stated drops. Further review of the clinical record failed to evidence an assessment for the self-administration of medications. An interview was conducted with LPN (licensed practical nurse) #6 on 10/3/24 at 11:31a.m. LPN #6 stated the resident cannot keep over the counter drops at their bedside and stated sometimes residents overuse them and it's not safe for them to have medications with them. LPN #6 further stated that sometimes they have them and we don't have an order for them (eye drops). The facility policy, Resident Self-Administration of Medications documented in part, 1. Determine if the resident desires to self-administer their own medication; a. Resident may not self-administer medication until the assessment is completed by the IDT team and determined to be safe to do so. c. Physician/ Provider order is required for residents to self-administer medication. 2. Resident may self-administer some or all of their medications; a. If only some of the medications will be self-administered clearly indicate which drug(s) including time and route, by physician order. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, regional director of operations, were made aware of the above concern on 10/8/24 at 6:15 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to report an injury of unknown origin within the required time frame for one of 63 residents in the survey sample, Resident #68. The findings include: For Resident #68 (R68), the facility staff failed to report a left-hand fracture of unknown origin to the state agency within two hours. A review of R68's clinical record revealed a nurse's note dated 3/14/24 that documented the resident presented with left hand swelling. Tylenol was administered with an effective effect and an x-ray was ordered. An x-ray result dated 3/16/24 documented, Undisplaced fracture mid portion left fourth metacarpal (a bone in the hand). Further review of R68's clinical record failed to reveal a known cause of the fracture. A facility synopsis of events submitted to the state agency documented, Report date: 3/18/24. Incident date: 3/14. Incident type: Injury of unknown origin. The facility received X ray results stating undisplaced fourth metacarpal of the left hand. The resident is not fearful and exhibits no pain or limited range of motion. Resident continues with routines [sic] activities and was evaluated by Nursing staff and physician extender. Resident received pain evaluation, skin assessment and there were no noted findings. On 10/4/24 at 9:10 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated a fracture of unknown origin should be reported to the state agency as soon as possible but within two hours to make the agency aware. On 10/4/24 at 11:41 a.m., ASM #1 (the executive director) and ASM #2 were made aware of the above concern. The facility policy titled, Abuse, Neglect and Exploitation Policy-Virginia documented, Injury of Unknown Origin: an injury should be classified as an injury of unknown origin when both of the following conditions are met: a) the source of the injury was not observed by any person. b) the source of injury could not be explained by the resident AND the injury is suspicious because of: a. the extent of the injury; or b. the location of the injury; or c. the number of injuries observed at one particular point in time; or d. the incidence of injuries over time .V. Reporting of Incidents and Facility Response. 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide written notification to the resident and/or responsible party and failed to notify the ombudsman upon transfer for two of 63 residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to evidence a written notice was provided to the resident and/or responsible party and failed to notify the ombudsman upon transfer to the hospital on 7/4/25. The nurse's note dated, 7/4/24 at 3:31 p.m. documented, Critical Lab (laboratory) value: Creatinine 10.78, BUN (blood urea nitrogen) 121. Contributing DX (diagnosis) CKD (chronic kidney disease) Stage 4. Currently on Bumetanide (used to treat edema/fluid retention) (1) 6 mg daily. VS (vital signs) 128/70 (blood pressure), 97.8 (temperature), 72 (pulse), 17 (respirations)[NAME], sat (oxygen saturation) 98% RA (room air). NP (nurse practitioner) review results with resident via video conference with nurse at bedside. Order obtained to transfer resident to ER (emergency room ) for further evaluation and treatment. (Name of ambulance service) notify of transfer and will be in facility within an hour. Daughter made aware. The nurse's note dated, 7/4/24 at 6:09 p.m. documented, Resident was picked up at about 5 pm with (name of ambulance company). Review of the clinical record failed to evidence the facility provided the resident and/or responsible party with a written notification of the reason for the transfer. An interview was conducted with LPN (licensed practical nurse) #6 on 10/3/24 at 11:31 a.m. LPN #6 stated if the family is here at the time of transfer, then they give them a notice, if they are not here, they do not give the resident and/or the responsible party anything in writing when they are transferred to the hospital. A request was made for the evidence that the ombudsman was notified of the transfer. None was provided. An interview was conducted with OSM (other staff member) #2, the director of social services, on 10/3/24 at 2:32 p.m. OSM #2 stated the process for notifying the ombudsman of resident transfers is to send a list at the end of the month of all discharges, schedule, unscheduled and against medical advice. OSM #2 stated she could not find any evidence that the ombudsman had been notified for the year 2024. OSM #2 had just started working at the facility on 9/27/24. The facility policy, Admission, Discharge and Transfers, documented in part, a. Notice before transfer. I. Before a facility transfers or discharges a resident, the facility must:1. Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations, were made aware of the above concerns on 10/8/24 at 6:16 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a684051.html. 32642 2. For Resident #4 (R4), the facility staff failed to provide evidence of written notification of the resident's discharge to the hospital on 6/2/24 and 6/24/24. A review of R4's clinical record revealed she was transferred to the hospital on 6/2/24 for a dislodged nephrostomy tube, and on 6/24/24 for an acute change in mental status. Further review revealed no evidence that the resident/RR (resident representative) and ombudsman were informed in writing of the reason for the discharge. On 10/3/24 at 11:31 a.m., LPN (licensed practical nurse) #6 was interviewed. She stated if a resident is sent to the hospital, she calls the family to let them know about the transfer. If the RR is in the building, they are given a written notification about the discharge. She stated this should be included in the discharging nurse's progress notes. She stated nurses do not provide a written discharge notice to the ombudsman. On 10/3/24 at 2:32 p.m., OSM (other staff member) #2, director of social services, was interviewed. She stated the facility sends the ombudsman a monthly list at the end of each month to notify the ombudsman of all the discharges. She stated she had just started in this position, and was not able to locate evidence that the ombudsman had been notified of R4's discharges in June 2024. On 10/4/24 at 12:40 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations were informed of these concerns. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a bed hold notice at the time of transfer for two of 63 residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1, the facility staff failed to evidence a bed hold notice was provided to the resident and/or responsible party at the time of transfer to the hospital on 7/4/24. The nurse's note dated, 7/4/24 at 3:31 p.m. documented, Critical Lab (laboratory) value: Creatinine 10.78, BUN (blood urea nitrogen) 121. Contributing DX (diagnosis) CKD (chronic kidney disease) Stage 4. Currently on Bumetanide (used to treat edema/fluid retention) (1) 6 mg daily. VS (vital signs) 128/70 (blood pressure), 97.8 (temperature), 72 (pulse), 17 (respirations)[NAME], sat (oxygen saturation) 98% RA (room air). NP (nurse practitioner) review results with resident via video conference with nurse at bedside. Order obtained to transfer resident to ER (emergency room ) for further evaluation and treatment. (Name of ambulance service) notify of transfer and will be in facility within an hour. Daughter made aware. The nurse's note dated, 7/4/24 at 6:09 p.m. documented, Resident was picked up at about 5 pm with (name of ambulance company). Review of the clinical record failed to evidence a bed hold notice was provided to the resident upon transfer on 7/4/24. An interview was conducted with LPN (licensed practical nurse) #6 on 10/3/24 at 11:31 a.m. LPN #6 stated they have to give the resident the bed hold policy, the nurse should document in the progress notes that it was given to the resident and keep a copy of it for the record. The facility policy, Bed Hold Policy documented in part, Procedure: 1. In the event a resident returns to the hospital or goes on a leave, the following process will be followed by the facility: a. The nurse or designee will present the Acute Transfer Letter at time of transfer with a copy going with the resident and a copy going to the Business Office Manager. Designee will scan to the ombudsman. b. If applicable according to state law if the bed hold authorization form cannot be signed prior to the resident leaving and needs to be mailed, it must be mailed certified return receipt requested by the Business Office Manager or designee. c. The Admissions Director or designee will notify the resident and/or responsible party of the days available under their Medicaid benefits or the private pay cost associated with holding the bed will be explained, within 24 hours of the patient leaving the facility, or the following business day if the patient leaves on the weekend or a holiday. ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations, were made aware of the above concerns on 10/8/24 at 6:16 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a684051.html. 32642 2. For Resident #4 (R4), the facility staff failed to provide evidence of providing a bed hold notification for her 6/2/24 and 6/24/24 hospital discharges. A review of R4's clinical record revealed she was transferred to the hospital on 6/2/24 for a dislodged nephrostomy tube, and on 6/24/24 for an acute change in mental status. Further review revealed no evidence that the resident received a bed hold notice for these discharges. On 10/3/24 at 11:31 a.m., LPN (licensed practical nurse) #6 was interviewed. She stated if a resident is sent to the hospital, the nurse is required to give the resident or RR a copy of the bed hold policy. She stated the nurse who discharges the resident should write a progress note that she has done this, and should make a copy for the clinical record. On 10/4/24 at 12:40 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #5, the regional director of operations were informed of these concerns. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete MDS (minimum data set) assessment for one of 63 residents in the survey sample, Resident #125. The findings include: For Resident #125 (R125), the facility staff failed to assess the resident's BIMS (Brief Interview for Mental Status) for the 8/27/24 quarterly MDS assessment. Section C Cognitive Patterns of R125's quarterly MDS assessment with an ARD of 8/27/24 documented, C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents. A dash was coded, indicated the resident's BIMS was not assessed. On 10/8/24 at 10:23 a.m., an interview was conducted with RN (registered nurse) #2 (the mobile MDS coordinator). RN #2 stated the BIMS on R125's 8/27/24 MDS assessment was accidentally missed. RN #2 stated staff was in the process of completing a corrected MDS. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. On 10/9/24 at 1:21 p.m., ASM #5 (the regional director of operations) stated the facility did not have a policy regarding MDS assessments and the staff follow the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual. The CMS RAI manual documented, SECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions. Item Rationale Health-related Quality of Life -Most residents are able to attempt the Brief Interview for Mental Status (BIMS), a structured cognitive interview. -A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. - Without an attempted structured cognitive interview, a resident might be mislabeled based on their appearance or assumed diagnosis. Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care. Coding Tips -Attempt to conduct the interview with ALL residents . No further information was presented prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide the resident/RR (resident representative) with a written summary of the baseline care plan for two of 63 residents in the survey sample, Residents #468 and #469. The findings include: 1. For Resident #468 (R468) the facility staff failed to provide a written summary of the baseline care plan after admission on 9/28/24. A review of R468's clinical record revealed she was admitted to the facility on [DATE]. A review of her clinical record, including assessments and progress notes, failed to reveal evidence that the resident and/or her RR had been given a written summary of her baseline care plan. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated the nursing and social services are responsible for developing the baseline care plan. She stated the social worker is responsible for giving the resident a written copy of the summary of the baseline care plan. On 10/8/24 at 10:08 a.m., OSM (other staff member) #2, the director of social services stated the baseline care plan covers the first 24 to 72 hours of a resident's stay in the facility. She stated the baseline care plan triggers from the nursing assessment. She stated every member of the IDT (interdisciplinary team) should be giving the resident/RR a written copy of their portion of the baseline care plan, and should document this in the progress notes. On 10/9/24 at 8:57 a.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the resident's baseline care plan is initiated on admission by the admitting nurse. She stated the IDT talks about the resident's plan of care once the orders are in, and discusses the baseline care plan with the resident/RR. She stated social services is responsible for printing the summary out and giving it to the resident/RR. On 10/5/24 at 6:17 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. A review of the facility policy, Care Planning Overview, revealed, in part: The facility will provide a summary of the baseline care plan to the resident and their representative. No further information was provided prior to exit. 2. For Resident #469 (R469), the facility staff failed to provide a written summary of the baseline care plan after admission on 9/25/24. A review of R469's clinical record revealed he was admitted to the facility on [DATE]. A review of his clinical record, including assessments and progress notes, failed to reveal evidence that the resident and/or his RR had been given a written summary of his baseline care plan. On 10/8/24 at 9:28 a.m., LPN (licensed practical nurse) #3, a unit manager, was interviewed. She stated the nursing and social services are responsible for developing the baseline care plan. She stated the social worker is responsible for giving the resident a written copy of the summary of the baseline care plan. On 10/8/24 at 10:08 a.m., OSM (other staff member) #2, the director of social services stated the baseline care plan covers the first 24 to 72 hours of a resident's stay in the facility. She stated the baseline care plan triggers from the nursing assessment. She stated every member of the IDT (interdisciplinary team) should be giving the resident/RR a written copy of their portion of the baseline care plan, and should document this in the progress notes. On 10/9/24 at 8:57 a.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the resident's baseline care plan is initiated on admission by the admitting nurse. She stated the IDT talks about the resident's plan of care once the orders are in, and discusses the baseline care plan with the resident/RR. She stated social services is responsible for printing the summary out and giving it to the resident/RR. On 10/5/24 at 6:17 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, and ASM #5, the regional director of operations, were informed of these concerns. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice for one of 63 residents in the survey sample, Resident #164. The findings include: For Resident #164 (R164), the facility staff failed to clarify physician orders for administration of Acetaminophen and Ibuprofen. The physician orders documented in part, - Acetaminophen Oral Tablet 325 MG (milligram) (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for PAIN GIVE WITH IBUPROFEN. Order Date: 05/29/2024. - Ibuprofen Oral Tablet 200 MG (Ibuprofen) Give 2 tablet by mouth every 4 hours as needed for PAIN scale 1-3, GIVE WITH APAP. Order Date: 11/21/2023. The eMAR (electronic medication administration record) for R164 dated 8/1/24-8/31/24 documented the resident receiving the Acetaminophen 325mg 1 tablet on 8/24/24 at 1:38 p.m. The eMAR failed to evidence the resident receiving Ibuprofen. The eMAR for R164 dated 9/1/24-9/30/24 documented the resident receiving the Acetaminophen 325mg 1 tablet on 9/28/24 at 4:41 p.m. The eMAR failed to evidence the resident receiving Ibuprofen. On 10/7/24 at 4:39 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 reviewed the acetaminophen and ibuprofen orders for R164 documented above and stated that they would read the orders as that the medications could be given either together or by themselves depending on the pain level because the timing was different. On 10/8/24 at 1:08 p.m., an interview was conducted with LPN #8. LPN #8 reviewed the acetaminophen and ibuprofen orders for R164 documented above and stated that the orders were complicated, and she would need to clarify them with the physician. The facility policy, Physician Orders failed to evidence guidance on clarifying the physician orders. On 10/9/24 at approximately 6:15 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #5, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to develop a complete post-discharge plan of care for one of 63 residents in the survey sample, Resident #227. The findings include: For Resident #227 (R227) (who discharged on [DATE]), the facility staff failed to develop a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of medications. The facility staff also failed to ensure R227 was able to obtain medications after discharge. A review of R227's clinical record revealed a nurse's note dated 3/30/24 that documented the resident discharged home, was provided discharge instructions, verbalized understanding, and signed. The note failed to document any further information regarding the discharge. A discharge summary dated 3/29/24 documented the resident's vital signs and a social services section that included the discharge date , discharge location, and discharge goals. The following sections of the discharge summary were blank: nursing final summary, labs and radiology tests, physical function, dietary services final summary, and an activity director final summary. There was a section that documented to provide the resident/resident representative a copy of the completed and signed discharge summary and a space for the resident/resident representative to sign. This section was blank. Further review of R227's clinical record failed to reveal the facility staff completed a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of pre-discharge and post-discharge medications, and failed to reveal the facility staff provided R227 (or the resident's representative) with prescriptions so the resident's medications could be obtained after discharge. On 10/8/24 at 1:09 p.m., an interview was conducted with LPN (licensed practical nurse) #8 (the nurse who documented the 3/30/24 note). LPN #8 stated that when a resident is scheduled for discharge, she obtains prescriptions from the physician, gives the prescriptions to the resident, gives the resident a copy of the personal belongings inventory list that was completed on admission, and packs the resident's belongings. LPN #8 stated a RN (registered nurse) is responsible for completing and providing a discharge summary and discharge instructions. LPN #8 stated nurses should evidence prescriptions, a discharge summary, and discharge instructions are provided by documenting this in the clinical record. LPN #8 could not remember R227. On 10/8/24 at 6:25 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Discharge Planning documented, 10) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. a) The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays n [sic] the resident's discharge or transfer. No further information was presented prior to exit.

Based on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure 1 of 4 residents (Resident #2) in the survey sample were free of significant medication errors. Resident #2 was administered three blood pressure medications (Losartan 100 mg, Carvedilol 12.5 mg, and Amlodipine 10 mg) that were prescribed for another resident. On 04/12/22, Resident #2 was noted hypotensive with a blood pressure reading of 86/52, pulse rate of 58, and complaints of dizziness. Resident #2 was transferred via 911 (emergent) to the local hospital on 04/12/22. Resident #2 received fluids bolus via intravenous (IV) en route to the hospital for hypotension and bradycardia. This deficiency is cited as past non-compliance, with sufficient evidence of correction The findings included: Resident #2's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 02/09/22 coded Resident #2's Brief Interview for Mental Status (BIMS) scored a 12 out of a possible score of 15 indicating moderate cognitive impairment. The MDS coded Resident #2 requiring total dependence of two with bathing, extensive assistance of two with bed mobility, transfer, and toilet use, and extensive assistance of one with dressing, eating, and personal hygiene for Activities of Daily Living (ADL) care. Resident #2's person-centered care plan with a revision date of 04/13/22 identified the resident received hypertensive medications. The goal set for the resident by the staff was that the resident will have no ill effects from medication(s). Some of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered, observe and document signs and symptoms of effectiveness and side effects, do labs as ordered, and monitor vital signs as ordered. A review of Resident #2's nurse's notes revealed the following documentation entered on 04/12/22 by License Practical Nurse (LPN) #1: Around 8:15 a.m., Resident #2 was administered the incorrect medications. The medication administered to Resident #2 was prescribed for another resident. The nurse immediately informed the Unit Manager, Nurse Practitioner (NP), and physician with new orders from the NP to monitor the resident closely by obtaining vital signs assessment every 15 minutes. Within minutes of monitoring the resident's vital signs, the Resident ' s blood pressure went from 129/75 to 100/60 and pulse rate at 60. The second blood pressure was completed with a reading of 86/52 (normal = 120/80), and heart rate at 58 (normal = 60 to100 beats per minute). The resident was given a dose of Midodrine at 9:30 a.m., (for his low blood pressure). Resident #2 remained alert and oriented x 4 but complaint of severe dizziness. The NP and physician were informed of Resident #2's change in condition (continuous drop in blood pressure) with a new order to send Resident #2 to (name of the hospital) for further evaluation. An interview was conducted with LPN #1 on 04/26/22 at approximately 4:29 p.m., who stated, I pulled medication for one resident but accidentally administered the meds pulled to Resident #2. I got the beds mixed up. The LPN stated, I immediately reported the incident to the Unit Manager, Supervisor, Director of Nursing (DON), and NP. The LPN stated, I was immediately removed from the floor and was in-service on the 5 Rights of medication administration and was not able to return to the floor to pass medication until I was observed administering medication by the Staff Development Coordinator (SDC). On 04/12/22, at approximately 10:00 a.m., the NP progress note revealed the following information: LPN #1 requested for me to assess Resident #2 for post medication error this morning. The nurse (LPN #1) stated Resident #2 was given another resident's hypertensive medications which included Losartan 100 mg, Carvedilol 12.5 mg, and Amlodipine 10 mg. The resident was alert with no acute distress noted. Resident #2's blood pressure (B/P) was 100/60 and pulse was 61. New orders were given to check vital signs every hour, STAT Complete Metabolic Panel (CMP), Midodrine 5 mg tablet - give one tablet by mouth every 8 hours as needed for hypotension - give if systolic blood pressure is less than 100. The NP note also included the Medical Director was informed of the above incident with a new order for Sodium Chloride Solution 0.9 %, use 100 ml/hr., (IV) as needed for hypotension until 04/13/2022 for systolic less the 90. Resident #2's blood pressure went down to 60/52 (hypotensive), Midodrine 5 mg was administered to the patient around 9:30 a.m. After the Midodrine 5 mg was administered, Resident #2's blood pressure increased to 86/52 and pulse at 58. Resident #2 is now complaining of being extremely dizzy. New orders were given to send Resident #2 out to the hospital for hypotensive and bradycardia (low pulse) episodes. On 04/27/22 at approximately 12:22 p.m., an interview was conducted with the Unit Manager who said, LPN #1 informed her that she administered Resident #2 another resident's medication. The medication administered were three different hypertensive medications. The Unit Manager stated an order was given for IV fluids if needed and Stat CMP but before the labs were drawn and the IV was placed, Resident #2 became hypotensive and was sent out to the hospital for further evaluation. An interview was conducted with NP on 04/27/22 at approximately 1:45 p.m., who stated she was in the facility when LPN #1 accidentally administered Resident #2 another resident's blood pressure medication. She said the nurse asked if I could assess Resident #2 because his blood pressure was dropping. The NP said the resident was assessed with new orders given for Stat CMP (looking for electrolyte imbalance) vital signs every shift, and to give Midodrione 10 mg (for the decrease in blood pressure if needed). She said the Medical Director was notified that resident #2 received three blood pressure medications that were prescribed for another resident. New orders were given IV fluids if needed. On 04/27/22 at approximately 2:03 p.m., an interview was conducted with (name of physician) who stated, Resident #2 received blood pressure medication that was not prescribed from him making him at risk for becoming hypotensive (drop in blood pressure) and bradycardia (drop in pulse) so the IV fluids as needed to provide blood volume which will increase the resident's blood pressure. A phone interview was conducted with the SDC on 04/29/22 at approximately 9:00 a.m., who stated she was informed that LPN #1 had accidentally administered Resident #2 another resident's medication. She said the LPN was immediately removed from the medication cart and was in-serviced right away on the 5 Rights of Medication Administration by the DON. She said the LPN was not allowed to return to the floor until medication observation was made to ensure she (LPN) was able to pass administering medication without error. The SDC stated, I completed a medication administration observation on 04/15/22 with LPN #1 with no medication errors made. A review of the hospital records revealed the following: Resident #2 presented to the Emergency Department (ED) on 04/12/22 at approximately 10:49 a.m. after he accidentally received another resident's blood pressure medication at the skilled nursing facility. Prior to his arrival, he developed hypotension with his blood pressure in the ' 80s (systolic) along with lightheadedness. According to the Emergency Medical Services (EMS), Resident #2 received a fluid bolus (via IV) while en route to the hospital with the improvement of symptoms. The resident's blood pressure in the (ED) was 146/70 but still, he was still complaining of mild lightheadedness but had improved since fluids were administered. An interview was conducted with the Administrator on 04/27/22 at approximately 2:15 p.m., who stated a Plan of Correction was put in place on the same day LPN #1 administered Resident #2 another resident's blood pressure medications. On the same day at approximately 2:45 p.m., the Administrator presented a Correction Action Plan dated 04/12/22. The Action Plan document the following: Medication Error dated 04/12/22 - Quality Assurance Performance Improvement (QAPI). Step 1a. - Resident was administered antihypertensive medication in error. The nurse who administered medications was immediately pulled from the floor and educated by the DON on the 5 Rights of Medication Administration and use of 3 checks for proper resident identification. Step 1b. What immediate interventions were for the affected resident? Medication Pass Observation was performed for the nurse by the DON on 04/12/22. The nurse ' s preceptorship documents were reviewed by the SDC on 04/12/22. Step 2a. What immediate actions were taken to identify all potential affected? Education for all charge nurses on the use of 5 Rights of medication administration and use of three checks for proper identification of residents, completed by the SDC on 04/15/22. Step 2b. What continued and immediate interventions were implemented for the identified resident or systems? Audits are to be reviewed monthly in QAPI. Step 2c. Results of the audits will be submitted to the QAPI Committee monthly for three months, the Committee will determine the need for further audits and/or action plans. This deficiency is cited as past non-compliance, with sufficient evidence of correction, and was in compliance at the time of the survey. A debriefing was conducted with the Administrator and Director of Nursing on 04/28/22 at approximately 2:00 p.m., who was informed of the above findings; no further information was provided prior to exit. On 04/28/22 at approximately 7:09 p.m., the Administrator provided a document titled Medication Administration Observation. The document provided information that all nursing staff was observed for the 5 Rights for administering medication and the three checks for proper identification of residents. The facility's policy titled Medication Administration was revised on 01/05/22. Policy: It is the policy of this facility to provide resident-centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The safety of the residents, visitors, and employees is a top priority of care. The purpose of this policy is to provide guidance for general medication administration to be provided by personnel recognized as legally able to administer. Procedures include but are not limited to: 1. a. Administer medication only as prescribed by the provider. 1. b. Licensed or authorized personnel may administer prescribed medication. 1. c. Observed the five rights: in giving medication: the right resident, the right time, the right medicine, the right dose, and the right route. 1. j. Full attention should be given during preparing of medications. Avoiding distractions is important for infection prevention and reducing errors. Definitions -Hypotension, also known as low blood pressure, is a blood pressure under 90/60 mm/Hg. In many people, it has no symptoms. When it does cause symptoms, these are usually unpleasant or disruptive, including dizziness, fainting, and more. In some cases, hypotension is dangerous, so early diagnosis and treatment are important. One way to directly treat hypotension is by increasing blood volume. This method, also known as fluid resuscitation, involves infusing fluids into your blood. Examples of this include intravenous (IV) fluids, and plasma or blood transfusions (https://my.clevelandclinic.org/health/diseases/21156-low-blood-pressure-hypotension). -Complete Metabolic Panel is a test that measures 14 different substances in your blood. It provides important information about your body's chemical balance and metabolism (https://medlineplus.gov/lab-tests/comprehensive-metabolic-panel-cmp). -Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine works by causing blood vessels to tighten, which increases blood pressure (https://medlineplus.gov/druginfo/meds). COMPLAINT DEFICIENCY

Based on observations, record review, complaint investigation and staff interviews the facility staff failed to ensure one resident (Resident #259) was provided with supervision and a safe environment to prevent a fall with serious injury in the survey sample of 51 residents. The findings included: Resident #259 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and impaired decision making, muscle weakness, difficulty walking, cognitive communication deficit, repeated falls, [CONDITION(S)], and occasional hallucinations. Resident #259 fell down a flight of steps after going through an unsecured gate. Resident #259 received serious injury's as a result of the fall. A Quarterly Minimum Data Set (MDS) dated [DATE] with an ARD date of 2/19/20 assessed this resident as having moderately impaired vision. In the area of Cognitive Patterns this resident was coded a (03) out of (15) on the Brief Interview for Mental Status (BIMS) assessment. In the area of Activities of Daily Living (ADL's) this resident was coded as requiring one person physical assist in the area of bed mobility (3/2). In the area of Transfer this resident was coded as requiring one person physical assist (3/2). In the area of eating this resident was coded as requiring one person physical assist (3/2). In the area of toileting this resident was coded as requiring one person physical assist (3/2). In the area of personal hygiene this resident was coded as requiring one person physical assist (3/2). In the area of Mobility devices this resident was coded as using a wheelchair for mobility. A Care Plan with a revision date of 10/04/19 indicated: Focus- Resident is high risk for falls due to unawareness of safety needs. Goals- Will not sustain a significant fall related injury. Interventions- Check resident frequently during the 11-7 shift to ensure that her blanket is not wrapped around her. Anticipate and meet resident's needs. Bed at lower level. Ensure call light is within reach and encourage resident to use it for assistance as needed. Provide prompt response to all requests for assistance. Provide a safe environment with: (Specify: even floors free from spills and/or clutter; adequate, glare free light; a working and reachable call light, the bed in low position at night. Resident #259 uses [CONDITION(S)] medications due to disease process- goal- will remain free of drug related complications related to cognitive/behavioral impairment: Interventions- monitor for frequent falls. blurred vision and behavior symptoms not usual to the person. Focus- Impaired cognitive function/dementia or impaired communication due to impaired decision making Dementia. Goal: maintain current level of decision making/cognitive function; Interventions- Provide approaches that maximize involvement in daily decision making and (limit choices, use cueing). A physician order dated 03/01/20 indicated: [MEDICATION(S)] capsule 250 (mg) milligram - give one capsule by mouth two times a day for mood stabilizer. A Nursing note dated 03/07/20 at 18:20 (6:20 P.M.) indicated: At 6:15 p.m. while staff were with the residents in the dinning area, awaiting dinner. Patient room 330 C opened the middle exit door walking down to the crystal room and resident in 308 A followed him immediately. Resident has false safety awareness related to dementia. By the time staffs could run to resident, Resident had already rolled down the stairs, hitting the head and sustained a cut to the left lower leg. First aid given, cut cleaned wrapped with Kerlix and ice applied. Tylenol 500 mg P.O. given due to facial grimacing. Called 911 and paramedics arrived at 6:25 p.m. and patient was taken to ER for further eval. MD notified. Unable to contact emergency contact. Emergency contact #2 and daughter were notified. Neurocheck initiated. V/S=120/70, 18, 72, 97% on room air. A Fall Details report dated 03/07/20 indicated: Fall type: Visually observed fall- Environmental conditions (No areas checked). Footwear (no areas checked). Preventive measures at time of fall (wheelchair in use). A 03/08/20 (11:06) Nursing Note indicated: Resident returned from ER via stretcher accompanied by two paramedics and transferred onto her bed in her room. Medicated with Tylenol prior wound assessment, per MD's orders. Head to toe assessment done noted with closed area to right side of scalp with four staples intact measuring 3 x 1 with wound edges well approximated, minimal bleeding noted. Cleansed with wound cleanser pat dry and covered with dry dressing. Also noted with skin tear to right lateral elbow measuring 2 (cm) centimeters x 0 cm with steri strips intact, skin tear to right lower leg with sutures noted to part of the wound and had moderate amount of sanguineous drainage, measuring 10cmx8cm with no depth. Cleansed with wound cleanser pat dry, applied [MEDICATION(S)] and wrapped with [MEDICATION(S)], and also noted with sutures to right ear. Resident observed with minimal pain as evidence by facial grimacing rating pain at a level of 3/10 prior to wound assessment. Resident has new order for [MEDICATION(S)] 500 mg to be given two times a day for five days prophylaxis to prevent wound infection. X-rays and CT scans results to chest, right shoulder, head to cervical spine, showed no evidence of fractures or any intracranial abnormalities. A 03/09/20 Skin Wound Note indicated: Resident head to toe assessment completed. She was with open area to her right lower leg with 15 sutures, right ear with 3 sutures, open area on her right side of scalp with staples 4, right elbow area with sterile strip intact. Resident noted with multiple purplish discoloration to her left hand, right shin, right hand, right above the hand, right knee, right lateral knee, right shoulder, and left 3rd index finger. Resident #259 had a history of falls including an 08/08/19 nursing notes indicated: Resident alert no distress noted. During rounds at 06:45 A.M. assigned CNA found resident on the floor wrapped in bed linen. Resident stated she was trying to get out of bed to catch the bus to go to school. ROM (range of motion) within limit. On skin assessment noted open area 5 cm x 1 cm to resident right elbow. Neuro checks initiated. T 97.5, P 70, R 22, B/P 112/77. A Facility Time Line for 03/07/20 indicated: Resident #259 fell [DATE] at 18:15 (6:15 P.M.). Resident was observed propelling her wheel chair very fast towards the swing door in the dining room that was just opened by another resident. 1). Resident was immediately assessed by nursing supervisor, open area observed to left lower leg, right forearm, right ear, and right scalp, first aid given, areas were cleaned with wound cleanser, and wrapped with kerlix and pain medication was administered. 911 was called at 6:19 P.M. Paramedics arrived at 6:25 P.M. and transferred resident to the hospital. Facility root cause revealed that residents incident occurred related to latch not being on the swing door on West 2. Swing door was monitored by staff from 6:15 P.M. to 7:07 P.M. when maintenance placed a lock on the swing door on the West 2 unit on 03/07/20. A Maintenance work order was requested from the facility Director on 03/04/21. The Administrator stated, there was no work order. A written statement from the Maintenance Department dated 3/7/20 indicated: Maintenance staff came into the facility and secured the two gates in the facility. One on West 1 unit and one on the West 2 unit. Maintenance staff writes he ensured that the gates would be secured and gave the keys to the nurse on duty. During interview with Administrator, the question was asked when was the latch secured to the gate by maintenance staff ? The Administrator stated, she was not sure because she was not there at the time. During an interview on 03/04/21 at 10:15 A.M. with the West 2 Charge Nurse LPN #6 (Licence Practical Nurse) who was on duty on 03/07/20. She stated, Staff were screaming - staff educator was doing an in-service training with staff. Resident is confused rolls in and out not aware of where she is going. One resident open the door to the stairs to the Crystal Room. resident went through the gate and fell down the stairs in wheelchair. Resident had cuts and lots of blood on her right side. A written statement given by staff CNA #3 (certified nursing assistant) indicated the following: CNA on West 2 Unit 3/7/20: At about 6:15 pm on the above date (CNA #3 was in the dining area with three other staff members and the staff educator who was doing an in-service, we all saw resident in room 308 A on her wheelchair self-propelling around the dining room. Suddenly we had resident in room 330 C who was in the dining room yelling loudly the resident is going we all ran towards the resident to prevent her from going down the stairs but we could not catch her on time. A facility Fall Prevention Program Guideline indicated: Guidelines: Environment: Environmental modification as a component of fall prevention strategies. Examining the environment for wet areas, clutter, poor lighting, and other environment factors can reduce the risk of falling. Assessment: The clinical guidelines recommend assessing fall risks on admission, then weekly times four, after a fall, quarterly, annually and with a significant change. Knowing who is at risk for falls is important in deciding who needs to be in the fall prevention program. Assessing after a fall assists with doing the root cause analysis and the implementation of interventions to prevent future falls and the importance in determining if the current fall prevention interventions are even effective. The facility staff failed to provide one resident with supervision and ensure the environmental devices (gate) were in good operating condition. Complaint Deficiency (Harm) 2. Facility staff failed to ensure an environment free of fall hazards for Resident #47 per plan of care. Resident #47 was admitted to the facility on [DATE] with diagnoses that included but were not limited to status post stroke with [CONDITION(S)], high blood pressure, diabetes, and CAD (Coronary Artery Disease). Resident #47's most recent MDS (Minimum Data Set Assessment) was a quarterly assessment with an ARD (Assessment Reference Date) of 12/13/20. Resident #47 was coded as being intact in cognitive function scoring 14 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #47 was coded as needing set up help only with walking on and off the unit; and one person physical assistance with toileting. Resident #47 was coded in Section G0300, as not being steady with walking, but able to stabilize without human assistance. Resident #47 was also coded as not being steady moving on and off the toilet but able to stabilize with human assistance. Resident #47 was coded as using a wheelchair and walker in Section G0600 (Mobility Devices). On 3/3/21 at 10:34 a.m., an observation of Resident #47's room was conducted. The bathroom in Resident #47's room had a big pile of debris on the floor pushed to the side of the wall; however some debris was in front of the toilet. There was a huge hole observed to the bottom of the wall. The debris on the floor was observed to be pieces of the wall. A yellow caution sign was also standing up in the bathroom; partly in the way of the toilet. On 3/3/21 at 10:34 a.m., an interview was conducted with Resident #47. Resident #47 stated that he wasn't sure how long the bathroom had been like that, that he was just moved into the room not too long ago. Resident #47 stated that the bathroom wall had always been like that since he'd been in that room. Resident #47 then stated that he gets caught up on the debris on the floor. Resident #47 then wished to stop the interview so he could use the bathroom. Resident #47 was observed walking behind his wheelchair into the bathroom. Resident #47's gait was observed to be unsteady. On 3/3/21 at 1:00 p.m., a second observation was made of Resident #47's bathroom. Resident #47's bathroom was in the same condition it was at 10:34 a.m. Review of Resident #47's clinical record revealed a Fall Risk assessment dated [DATE] that documented in part, the following: .Gait. b. Weak walking and short, shuffled steps, lightly touching furniture, for support .Balance: 2. Balance problem while standing .Predisposing diseases/conditions .1-2 present .After completing this assessment, is there a statement displayed in Section 'E' about that identifies the resident as a potential risk for falls? A check was documented under Yes. Review of Resident #47's fall care plan dated 5/24/16 documented in part, the following: Name of Resident #47 remains at risk for falls related to: unsteady gait due to right sided weakness .Resident will not have Fall related significant injuries until review period .Keep environment well lit and free of clutter. Review of a work order dated 3/3/21 at 7:47 a.m. documented the following: 108 bathroom wall need to be fixed ASAP .Please fix wall ASAP (As soon as possible) .East Unit . On 3/4/21 at 12:04 p.m., an interview was conducted with OSM (Other Staff Member) #4, the Housekeeping Accounts Manager. OSM #4 stated that the debris in Resident #47's bathroom was cleaned that morning (3/4/21). OSM #4 stated that he was told Resident #47 had kicked in the wall and debris was on the floor. OSM #4 stated that he was not aware until that morning about the bathroom and that his housekeeping staff probably didn't think that the bathroom floor was their responsibility. OSM #4 stated that his housekeeping staff had probably thought the bathroom floor was a maintenance issue. On 3/4/21 at 12:40 p.m., an interview was conducted with RN (Registered Nurse) #2, the unit manager. When asked if Resident #47 was a fall risk, RN #2 stated that he was a fall risk due to an unsteady gait. When asked how he goes to the bathroom, RN #2 stated that Resident #2 was able to take himself by bringing his wheelchair in the bathroom. When asked how long Resident #47's bathroom wall had been torn up, RN #2 stated that Resident #47 had just done that himself. RN #2 stated that Resident #47 had picked or kicked at the wall. When asked how she determined it was Resident #47 who had damaged the wall, RN #2 stated it was because the bathroom did not look like that prior to Resident #47 being moved into that room and that the roommate could not get out of bed to use the bathroom. RN #2 stated that Resident #47 denied causing damage to the wall. RN #2 stated she saw the wall and the debris on the floor Wednesday morning (3/3/21). RN #2 stated that she alerted housekeeping to clean up the debris. When asked when she expected the debris to be cleaned up, RN #2 stated, immediately. RN #2 stated that she stayed in the building until approximately 7:00 p.m. that day. RN #2 stated that the Debris was picked up by the time she left for the night. RN #2 stated that she wasn't sure what time the debris had been cleaned up. On 3/5/21 at 5:15 p.m., ASM (Administrative Staff Member) #1, the Executive Director and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. Facility policy titled, Occurrence Reporting did not address the above concerns.

Based on staff interviews, family interviews, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to follow professional standards of nursing practice. The facility staff failed to assess, acknowledge and act upon a significant change of condition in Resident #1 in a timely manner. Resident #1 was admitted to the hospital on [DATE] with hypercapnic [MEDICAL CONDITION], exacerbation of [MEDICAL CONDITION], and aspiration pneumonia. Resident #1 expired on [DATE] at 3:50 p.m. cause of death, [MEDICAL CONDITION]. The findings included: Resident #1 was a [AGE] year old who was admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]: a sudden inability of the lungs to maintain normal respiratory function. The condition may be caused by an obstruction in the airways or by failure of the lungs to exchange gases in the alveoli. *Obstructive Chronic [MEDICAL CONDITION]: a very common, debilitating [MEDICAL CONDITION] disease, characterized by greatly increased production of mucous by the glands of the trachea and bronchi and resulting in a cough with expectoration for at least 3 months of the year for more than 2 consecutive years. *[MEDICAL CONDITION]: an abnormal condition that may affect the heart's arteries and produces various pathologic effects, especially reduced flow of oxygen and nutrients to the myocardium. *Sick Sinus Syndrome: a complex of arrhythmia's associated with sinus node dysfunction. The condition may result from a variety of [MEDICAL CONDITION], ranging from [MEDICAL CONDITION] to [MEDICAL CONDITIONS] disease. *Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of ,[DATE] mm Hg (milligrams of mercury) in an adult. *[MEDICAL CONDITION]: a decrease in quality hemoglobin(a complex protein-iron compounding the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells) in the blood to levels below normal range of 12 to 16 for women. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was a 14 day with an assessment reference date of [DATE]. The Brief Interview for Mental Status (BIMS) was a 14 of a possible 15, indicating that Resident #1 was cognitively intact and possessed skills for daily decision making. The comprehensive plan of care dated [DATE] identified Resident #1 to have Impaired Communication due to: confusion with a goal indicating that the resident will be able to communicate basic needs. The plan of care included the following facility interventions: *Listen carefully, validate verbal and non-verbal expressions. *Monitor for ability to make needs known and report significant findings. *Utilize family or interpreter as needed. Under the plan of care focus, 'Alteration in Respiratory Status due to [MEDICAL CONDITION]' the goal for Resident #1 indicated the patient will not experience a decline in activities of daily living function related to respiratory symptoms, dated [DATE]. The interventions included to administer oxygen as needed per physician order, to monitor oxygen saturation on room air and oxygen, and to monitor oxygen flow rate and response. Resident #1's admission physician orders that were signed and dated for [DATE] indicated that the resident was a Full Code. A review of the facility's Admission Record both of Resident #1's daughters are listed as Emergency Contacts. On [DATE] at 1:05 p.m. an interview was conducted with the Certified Occupational Therapy Assistant (COTA). The COTA explained that she had treated Resident #1 over the weekend and that she was talkative, requesting her lipstick to be put on before they went to the therapy gym with no altered mental status or complaints. On [DATE] the COTA treated Resident #1 from 8:30 a.m. until 9:40 a.m. The COTA stated, She (Resident #1) was in bed asleep when I went to treat her, I sat her on the side of the bed. She was usually only contact guard assist with transfers but this day she was maximum assist of one person to transfer. When I finally got her in the chair she just fell out, her arms dropped down and her head went back. She was limp and her eyes were half closed. What I saw going on with her was not like she was yesterday when I treated her. I rolled her in her wheelchair to the nurse (RN #1). The nurse told me that this was how she (Resident #1) is, she didn't sleep last night, she was agitated and she was just started on [MEDICATION NAME]; just but her back to bed. The COTA did not recall RN #1 checking any vitals on Resident #1. The COTA put Resident #1 back to bed as instructed by RN #1. Based on hospital and facility medical review Resident #1 was taking [MEDICATION NAME] during her hospital stay with admission date of [DATE] and was maintained on the medication when admitted to the facility on [DATE] with a dose reduction from the hospital with no documented side effects while at the facility. *[MEDICATION NAME]- is a atypical anti-psychotic. The above definition was derived from McGraw-Hill Nurse's Drug Handbook &7th Edition. A facility record review of the 24 Hour Report Log for [DATE] for the ,[DATE] shift stated, Alert and stable 02 (oxygen) 97% on 2 liters, denies pain, afebrile, ambulate to the bathroom with assistance. The ,[DATE] entry stated, Slept @ (at) long intervals, 02 on. There was no mention in the 24 Hour Report or the nurse's notes on [DATE] or on [DATE] (the end of the ,[DATE] shift) that Resident #1 was agitated or did not sleep through the night. The COTA also stated that a family meeting was held on [DATE] around 1:00 p.m. with Resident #1's two daughters in attendance. During the family meeting the COTA stated that Resident #1 was, in bed opening and closing her eyes, with no understandable words. The COTA was asked to explain to the surveyor what was being said during the family meeting and she stated, I said this is not her, something is going on and the daughter said the last time mom acted like this she was in kidney failure. The daughters wanted the nurse (RN #1) to send their mother out to the hospital, one daughter was upset and hyper and the other daughter was calm. RN #1 was explaining to the daughters about their mom's medication and she told the daughters if you want me to send her out I can but she is fine. I never saw the nurse (RN #1) assess the patient (Resident #1). She (Resident #1) is very motivated; she had a drastic change. On [DATE] at 1:55 p.m. an interview was conducted with the Lead Occupational Therapist working with Resident #1 who had treated her on [DATE] and she stated, She was fine, she was at a supervision level to contact guard - minimal assist level and she was totally normal that day, very talkative. An interview was conducted with Resident #1's Speech Therapist that treated her on [DATE] from 11:56 a.m. to 12:26 p.m. The Speech Therapist stated, I worked with her (Resident #1) on Sunday ([DATE]) and I helped her to the bathroom, she was a little off mentally but nothing drastic. On Monday [DATE] I saw her for lunch and I couldn't get her to eat anything. I approached the nurse (RN #1) and asked if she (Resident #1) was ok she said she is just tired. I checked her pulse Ox (oxygen saturation) and it was 91 and she was incoherent. During the family meeting on Monday ([DATE]) the patient (Resident #1) was lying in bed, I told the family she seemed different, that she was not doing well today with her tasks, and she was not following directions well. (Name of RN #1) came into the room and the family asked her about their mother's medications and how she was doing. (Name of RN #1) told the daughters that the medications were causing the drowsiness and the nurse and the daughters were going back and forth about sending her out or letting her stay. (Name of RN #1) told the daughters they need to get the patient's acrylic nails removed because they were preventing her from checking her oxygen level. The Speech Therapist was asked to compare Resident # 1's condition from [DATE] to [DATE] and she stated, It was a significant change. She was confused, I could not have a conversation with her, she was incoherent with her speech, she was really out of it. The Speech Therapist's treatment note for Resident #1 on [DATE] documented in part, as follows: Pt. (patient) inconsistently responsive during session with increased lethargy and drowsiness. Therapeutic speech-language session targeting communication with identification of ADL (activities of daily living) objects and attempts with formulation of basic phrases/sentence length words. Pt. performed with 100% visual, verbal, and tactile with inconsistent responsiveness and inability to maintain topic of formulate sentence. ST (Speech Therapy) participated in skilled interdisciplinary meeting with pt, family, NSG (Nursing), SW (Social Work), PT (Physical Therapy), OT (Occupational Therapy), and ST present providing education related CLOF (clinical level of function) and progress with skilled services. ST to continue per POC (plan of care) targeting communication of wants/needs with safety awareness within immediate environment. An interview was conducted on [DATE] at 1:30 p.m. with the Physical Therapy Assistant (PTA) that treated Resident #1 on [DATE] and who also attended the family meeting. The PTA stated, During the meeting she (Resident #1) was lethargic and the daughters were questioning the staff about whether their mom should be sent out. I treated her after the meeting, I didn't push her real hard. She was pretty lethargic, not paying attention, and couldn't follow 50% of my commands. A review of Resident #1's nurse's notes dated [DATE] at 1:30 p.m. entered by the Social Services documented in part, as follows: Family meeting held with pt, (Resident #1) pt's two daughters (Name of daughters), rehab staff (PT, OT, ST) RN (RN #1) and SS (Social Services) to discuss plan of care. Rehab discussed pt's progress in therapy. Nurse was present to review clinical's. Care plan team will cont (continue) with plan of care; SW (Social Worker) will cont to provide support and assist with d/c (discharge) planning. A phone interview was conducted with Resident #1's daughter on [DATE] at 4:00 p.m. inquiring about Resident #1's condition and her account of the sequence of events that occurred on [DATE] when she arrived at the facility. Resident #1's daughter stated the following: My sister and I arrived at the facility at 1:00 p.m. for a care meeting. The Physical Therapist, Occupational Therapist, Speech Therapist, Social Worker, and the nurse (RN #1) were all in my mother's room. The therapists were telling us how my mom was doing in therapy but I said look at her; she isn't even moving or responding and I asked why aren't you all doing something for her? I kept saying she is worse, she is worse. The nurse (RN #1) started smacking my mom on her arm and was screaming at her, calling her name and my mom could barely open her eyes. The Nurse (RN #1) told us that mom was on too much medicine and she was just sleepy. No one in the room other than my sister and I questioned or even said anything about calling 911. I asked the nurse what were her vital signs and she said they were fine but that she couldn't test her oxygen level because of her nails; my mom's nail beds were exposed because it had been over a month since she had had them done. I told the nurse (RN #1) if you can't test her oxygen level then you shouldn't have her here. The nurse never did any assessment on my mom when we were in the room. After the therapists left the room the nurse (RN #1) told my sister and I that my mom was fine and I kept saying no she isn't fine something is wrong. By this point my sister and I were so upset because the nurse just kept arguing back and forth with us we left to get a sandwich and discuss our mother's condition between ourselves. We were only gone for a brief while and came back to the facility within 45 minutes and told the nurse (RN #1) that we wanted our mom to go to the hospital, she said I can send her to the hospital if you want but she is fine. We kept going back and forth with the nurse (RN #1) that we wanted the doctor called and our mom to go to the hospital. Finally, the nurse said she would beep the doctor if that was what we wanted; it was after 3:00 p.m. by this point. About 3:30 p.m. her nurses aide (CNA #1) came in the room to see mom and we asked her what she thought about mom's condition and what would she advise us to do and she said send her to hospital. We told her thank you, thank you for validating our concerns then we told the aide to tell the nurse we wanted our mother to go to the hospital and she left the room. The nurse (RN #1) came back in the room and told us the doctor had ordered some blood work and we said no she is going to the hospital, then the nurse said ok I will do it and she went to call 911. When 911 arrived my mother's oxygen level was in the 80's and they had no problem getting a reading over her nail bed. We just don't want someone else to go through what we did, no one was acknowledging she wasn't herself and we have to keep arguing with them to get help for our mother. My mother was off the ventilator for about 2 days before she died and she told me I told you they were not taking care of me there and I was scared I was gonna die. On [DATE] at 3:40 p.m. and interview was conducted with CNA #1. CNA #1 was asked if she was Resident #1's caregiver on [DATE] for the ,[DATE] shift and if she recalled anything about that day. CNA #1 stated, Yes I work on that day because I was off the weekend, I doing rounds and went into (name of Resident #1's) room her condition so worse, I called her name and she didn't answer. I know her, I said what is wrong with you? I was shocked because she was not like this on Friday ([DATE]). Her two daughters were in the room and told me, we have been asking the nurse (RN #1) to send her to the hospital since earlier. The daughter asked me what's your advice, I said send her to hospital. I told (name of RN #1) her daughters want her to go to hospital, and she said ok. Her daughters were crying and saying I'm going to call 911. An nurses note entry for Resident #1 by RN #1 on [DATE] at 12:10 p.m. documented in part, as follows: Resident alert and responsive, total care provide, turn and reposition q2hrs (every 2 hours), no distress will continue with plan of care. The Nursing Supervisor for the ,[DATE] shift on [DATE] RN #3 was interviewed on [DATE] at 2:50 p.m. RN #3 was asked to walk the surveyor through the events that occurred on [DATE] during her shift in regards to Resident #1. RN #3 stated, I was making my rounds and I got a call from my ,[DATE] nurse on the Emerald unit. She said there is a situation over here. (Name of Resident #1) and her daughters want her to go to the hospital, but (name of RN #1) said Resident #1 is stable, vitals stable, and sats (oxygen saturations) ok. RN #1 called the doctor and said to get stat labs. I (RN # 3) told the ,[DATE] nurse you know my rule - she (Resident #1) is going to go to hospital. Tell RN #1 to send her to hospital. She is not gonna leave patient here, get her out. My rule is if family want their loved one to go to hospital I send them because that is their loved one they know them better than I do. At 4:04:44 p.m. on [DATE], 911 was dispatched to the facility for Resident #1. A review of the Emergency Medical Service (EMS) Prehospital Report indicated that when they arrived to the facility at Resident #1's bedside at 16:11:02 p.m. (4:11:02 p.m.) Resident #1 presented with altered mental status, oriented to person, and her oxygen saturation was *83% on 2 liters of oxygen. Resident #1 was able to say her name but could not answer any other questions or follow commands. EMS increased her oxygen to 15 liters via mask and her oxygen saturation increased to 100%. Resident #1 was transported to the hospital at a priority one level with lights and sirens. Resident #1's mental status improved during transport to the hospital. A Situation-Background-Assessment-Recommendation (SBAR) nurses note entry for Resident #1 by RN #1 on [DATE] at 4:41 p.m. documented in part, read as follows: Situation: Altered Mental Status, sleeping and confuse Background: [AGE] year old female with admitting dx (diagnosis): Fatigue, [MEDICAL CONDITIONS], Confusion, Hypertension, Acute [MEDICAL CONDITION], Sinus Sick Syndrome, Obstructive Chronic [MEDICAL CONDITION] with acute [MEDICAL CONDITION]. NKDA (no known drug allergies [REDACTED].>Assessment: Resident respond verbally, arousable to verbal, Sleeping all day, on oxygen at 2 liters. VS (vital signs) in AM ,[DATE] (blood pressure), 18 (respiration), 97.4 (temperature), sat (oxygen saturation) was check resident has nail acrylic over the nail, unable to get accurate reading nurse mention to the daughters that the acrylic need to be removed, skin pink. VS ,[DATE] (blood pressure), 73 (pulse), 18 (respirations), 97.4 (temperature) Response: Nurse notify doctor, stated to get lab work and if no change to transfer resident to ER (emergency room ) for evaluation. all medication was taken well, resident swallow well, when given whole medication and breathing treatment given. During an interview with the Administrator on [DATE] at 11:30 a.m. he shared that RN #1 was taken off the nursing floor and suspended on [DATE] because she did not document what she did for Resident #1 when she sent her out to the hospital on [DATE]. The Administrator also shared that RN #1 was terminated on [DATE] stating, We can only give someone so many chances. The Unit Manager for the Emerald Unit RN #2 was interviewed on [DATE] at 10:10 a.m. RN #2 shared that she was not on the unit on [DATE]. She was in an all day long meeting at the facility. RN #2 was asked what she would have expected RN #1 to have done regarding Resident #1 on [DATE]. Unit Manager RN #2 stated, I expect all my nurses to send the patient to the emergency room , no questions asked. The family members know their love one more than we do, (name of Resident #1) was only here for a few days. If I see a change, I send her. You do your assessment and see something wrong let the family know, send them out and let the doctor know. That's my priority the patient. RN #2 also stated, In my experience when you call the doctor and say the family wants the resident to go, the doctor says send them. On [DATE] at 11:15 a.m. an interview was conducted with Resident #1's physician who is also the facility's Medical Director. The above information regarding Resident #1's significant change of condition that was reported around 10:00 a.m. on [DATE] and the daughters' concerns during the family care meeting were discussed. Based on this information the Medical Director stated, If I had been made aware that the resident was this critical I would have told to nurse to get her out the door. A nurse, especially a Registered Nurse, has the capacity to make that judgement call that is the difference between a nurse and a certified nursing assistant. That is the Nursing Duty. I strictly depend on the nurse, she is my eyes and ears. You can ask anyone my policy is that if the family wants to send the patient to the hospital the nurse does not even have to call me just do it, send them out. I was not informed an emergency was occurring with this resident. Resident #1's daughter also shared that she had filed a complaint with the facility's corporate office. On [DATE] at 11:00 a.m. an interview was conducted with the facility's Field Compliance Investigator. During this interview the Field Compliance Investigator stated, I called the daughter and made her aware that the nurse involved in her mother's care was no longer at the facility and that some extra training would be occurring in the facility. I sent an email on [DATE] to (name of Administrator) and the Director of Nursing with recommendations for the facility. The recommendations were: 1. when new admissions come in to verify the orders with in 48 hours in the standup meeting, 2. people on oxygen have a oxygen saturation checked daily, 3. inservice the staff on oxygen tanks so they know to look at the gauge to read the content amount, 4. Inform female residents they may have a male caregiver, 5. that psychiatric medications have appropriate diagnosis, 6. immediate interventions with a resident with a change of condition. When asked what she would expected a nurse to do if a resident had a change of condition, the Field Compliance Investigator stated, I would expect the nurse to intervene, assess the resident, call the doctor and take action. The Administrator was asked if he had received the email with the recommendations from the Field Compliance Investigator and he stated, No. He also shared that the facility had been without a Staff Development Coordinator since [DATE]. No documentation was provided to show that any training or inservices had been completed as stated to Resident #1's daughter by the Field Compliance Investigator as part of their complaint resolution to the daughter. A review of the facility policy Clinical Health Status-Change of Condition Guideline, updated [DATE] documented , in part reads as follows: Change of Condition-SBAR: The process for identification of change on condition includes gathering objective data and documenting assessment findings, resident/patient response, and physician and family notification. Communication both written and verbal, are integral parts of actions needed for change of condition. The SBAR process assists in coordinating change of condition information for concise communication with the Physician/Physician Extender. Resident #1 was admitted to the hospital on [DATE] with hypercapnic [MEDICAL CONDITION], exacerbation of [MEDICAL CONDITION], and aspiration pnuemonia. The emergency room record states in part: Pt (patient) rouses with some difficulty. Speech is markedly garbled. Breath sounds diminished bilaterally. Resident #1 expired on [DATE] at 3:50 p.m. cause of death, [MEDICAL CONDITION]. Prior to the exit no further documentation was provided. *According to AACN (American Association of Critical Care Nurses) Procedure manual for Critical Care, fourth Edition, oxygen saturation is an indicator of the percentage of hemoglobin saturated with oxygen at the time of the measurement. Normal oxygen saturation values are 97% to 99% in a patient with a normal hemoglobin level. The Lippincott Manual of Nursing Practice, Fifth Edition on pages ,[DATE], had the following information: If the Sao2 (oxygen saturation) drops below 80%, a critical situation arises with the need for immediate intervention. Cyanosis (blueness to the skin) occurs as a late sign when Sao2 is equal or less to 45%. According to the Science Journal for the American Association of Respiratory Care, AARC Clinical Practice Guideline Oxygen Therapy for Adults- 2002 Revision & Update, Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of [MEDICAL CONDITION]. [MEDICAL CONDITION] is defined as a SaO2 of < (less than) 90%. According to Lippincott Manual of Nursing Practice, Eighth Edition 2006, Respiratory Disorders Chapter's 10 & 11, pages 258, ,[DATE] read, in part: Nursing Interventions: Administer oxygen to maintain. Sao2 > 90% . Standards of Care Guidelines Respiratory Compromise: Be aware of the status of the patient when assuming care .Perform through systematic assessment. This is a Complaint Deficiency

Based on staff interviews, family interviews, clinical record review, facility document review and during the course of a complaint investigation the facility failed to ensure that Resident #1 received timely necessary care and services to maintain their highest practicable physical and mental well-being, in accordance with the comprehensive assessment and plan of care. The facility staff failed to acknowledge and act upon a significant change of condition in Resident #1 in a timely manner. Resident #1 was admitted to the hospital on [DATE] with hypercapnic [MEDICAL CONDITION], exacerbation of [MEDICAL CONDITION], and aspiration pneumonia. Resident #1 expired on [DATE] at 3:50 p.m. cause of death, [MEDICAL CONDITION]. The findings included: Resident #1 was a [AGE] year old who was admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]: a sudden inability of the lungs to maintain normal respiratory function. The condition may be caused by an obstruction in the airways or by failure of the lungs to exchange gases in the alveoli. *Obstructive Chronic [MEDICAL CONDITION]: a very common, debilitating [MEDICAL CONDITION] disease, characterized by greatly increased production of mucous by the glands of the trachea and bronchi and resulting in a cough with expectoration for at least 3 months of the year for more than 2 consecutive years. *[MEDICAL CONDITION]: an abnormal condition that may affect the heart's arteries and produces various pathologic effects, especially reduced flow of oxygen and nutrients to the myocardium. *Sick Sinus Syndrome: a complex of arrhythmia's associated with sinus node dysfunction. The condition may result from a variety of [MEDICAL CONDITION], ranging from [MEDICAL CONDITION] to [MEDICAL CONDITIONS] disease. *Hypertension: a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressure over normal values of ,[DATE] mm Hg (milligrams of mercury) in an adult. *[MEDICAL CONDITION]: a decrease in quality hemoglobin(a complex protein-iron compounding the blood that carries oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells) in the blood to levels below normal range of 12 to 16 for women. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was a 14 day with a assessment reference date (ARD) of [DATE]. The Brief Interview for Mental Status (BIMS) was a 14 of a possible 15 indicating that Resident #1 was cognitively intact and possessed skills for daily decision making. The comprehensive plan of care dated [DATE] identified Resident #1 to have Impaired Communication due to: confusion with a goal indicating that the resident will be able to communicate basic needs. The plan of care included the following facility interventions: *Listen carefully, validate verbal and non-verbal expressions. *Monitor for ability to make needs known and report significant findings. *Utilize family or interpreter as needed. Under the plan of care focus, 'Alteration in Respiratory Status due to [MEDICAL CONDITION]' the goal for Resident #1 indicated the patient will not experience a decline in activities of daily living function related to respiratory symptoms dated [DATE]. The interventions included to administer oxygen as needed per physician order, to monitor oxygen saturation on room air and oxygen, and to monitor oxygen flow rate and response. Resident #1's admission physician orders that were signed and dated for [DATE] indicated that the resident was a Full Code. On [DATE] at 1:05 p.m. an interview was conducted with the Certified Occupational Therapy Assistant (COTA). The COTA explained that she had treated Resident #1 over the weekend and that she was talkative, requesting her lipstick to be put on before they went to the therapy gym with no altered mental status or complaints. On [DATE] the COTA treated Resident #1 from 8:30 a.m. until 9:40 a.m. The COTA stated, She (Resident #1) was in bed asleep when I went to treat her, I sat her on the side of the bed; she was usually only contact guard assist with transfers but this day she was maximum assist of one person to transfer. When I finally got her in the chair she just fell out, her arms dropped down and her head went back she was limp and her eyes were half closed. What I saw going on with her was not like she was yesterday when I treated her. I rolled her in her wheelchair to the nurse, RN #1. RN #1 told me that this was how she (Resident #1) is, she didn't sleep last night, she was agitated and she was just started on [MEDICATION NAME] just put her back to bed. The COTA did not recall RN #1 checking any vitals on Resident #1. The COTA put Resident #1 back to bed as instructed by RN #1. Based on hospital and facility medical review Resident #1 was taking [MEDICATION NAME] during her hospital stay with admission date of [DATE] and was maintained on the medication when admitted to the facility on [DATE] with a dose reduction from the hospital with no documented side effects while at the facility. *[MEDICATION NAME]- is a atypical anti-psychotic. The above definition was derived from McGraw-Hill Nurse's Drug Handbook &7th Edition. A facility record review of the 24 Hour Report Log for [DATE] for the ,[DATE] shift stated, Alert and stable 02 (oxygen) 97% on 2 liters, denies pain, afebrile, ambulate to the bathroom with assistance. The ,[DATE] entry stated, Slept @ (at) long intervals, 02 on. There was no mention in the 24 Hour Report or the nurse's notes on [DATE] or on [DATE] (the end of the ,[DATE] shift) that Resident #1 was agitated or did not sleep through the night. The COTA also stated that a family meeting was held on [DATE] around 1:00 p.m. with Resident #1's two daughters in attendance. During the family meeting the COTA stated that Resident #1 was, in bed opening and closing her eyes, with no understandable words. The COTA was asked to explain to the surveyor what was being said during the family meeting and she stated, I said this is not her, something is going on and the daughter said the last time mom acted like this she was in kidney failure. The daughters wanted the nurse (RN #1) to send their mother out to the hospital. RN #1 was explaining to the daughters about their mom's medication and she told the daughters if you want me to send her out I can but she is fine. I never saw the nurse (RN #1) assess the patient (Resident #1). She (Resident #1) is very motivated she had a drastic change. On [DATE] at 1:55 p.m. an interview was conducted with the Lead Occupational Therapist working with Resident #1 whom had treated her on [DATE] and she stated, She was fine, she was at a supervision level to contact guard - minimal assist level and she was totally normal that day, very talkative. An interview was conducted with Resident #1's Speech Therapist that treated her on [DATE] from 11:56 a.m. to 12:26 p.m. The Speech Therapist stated, I worked with her (Resident #1) on Sunday ([DATE]) and I helped her to the bathroom; she was a little off mentally but nothing drastic. On Monday [DATE] I saw her for lunch and I couldn't get her to eat anything. I approached the nurse (RN #1) and asked if she was ok, she said she is just tired. I checked her pulse Ox (oxygen saturation) and it was 91 and she was incoherent. During the family meeting on Monday ([DATE]) the patient (Resident #1) was lying in bed, I told the family she seemed different, that she was not doing well today with her tasks, and she was not following directions well. (Name of RN #1) came into the room and the family asked her about their mothers medications and how she was doing. (Name of RN #1) told the daughters that the medications were causing the drowsiness and the nurse and the daughters were going back and forth about sending her out or letting her stay. (Name of RN #1) told the daughters they need to get the patient's acrylic nails removed because they were preventing her from checking her oxygen level. The Speech Therapist was asked to compare Resident # 1's condition from [DATE] to [DATE] and she stated, It was a significant change. She was confused, I could not have a conversation with her, she was incoherent with her speech, she was really out of it. The Speech Therapist's treatment note for Resident #1 on [DATE] documented in part, read as follows: Pt. (patient) inconsistently responsive during session with increased lethargy and drowsiness. Therapeutic speech-language session targeting communication with identification of ADL (activities of daily living) objects and attempts with formulation of basic phrases/sentence length words. Pt. performed with 100% visual, verbal, and tactile with inconsistent responsiveness and inability to maintain topic of formulate sentence. ST (Speech Therapy) participated in skilled interdisciplinary meeting with pt, family, NSG (Nursing), SW (Social Work), PT (Physical Therapy), OT (Occupational Therapy), and ST present providing education related CLOF (clinical level of function) and progress with skilled services. ST to continue per POC (plan of care) targeting communication of wants/needs with safety awareness within immediate environment. An interview was conducted on [DATE] at 1:30 p.m. with the Physical Therapy Assistant (PTA) that treated Resident #1 on [DATE] and who also attended the family meeting. The PTA stated, During the meeting she (Resident #1) was lethargic and the daughters were questioning the staff about whether their mom should be sent out. I treated her after the meeting, I didn't push her real hard. She was pretty lethargic, not paying attention, and couldn't follow 50% of my commands. A review of Resident #1's nurse's notes dated [DATE] at 1:30 p.m. entered by the Social Services documented in part, reads as follows: Family meeting held with pt, (Resident #1) pt's two daughters (Name of daughters), rehab staff (PT, OT, ST) RN (RN #1) and SS (Social Services) to discuss plan of care. Rehab discussed pt's progress in therapy. Nurse was present to review clinical's. Care plan team will cont (continue) with plan of care; SW (Social Worker) will cont to provide support and assist with d/c (discharge) planning. A phone interview was conducted with Resident #1's daughter on [DATE] at 4:00 p.m. inquiring about Resident #1's condition and her account of the sequence of events that occurred on [DATE] when she arrived at the facility. Resident #1's daughter stated the following. My sister and I arrived at the facility at 1:00 p.m. for a care meeting. The Physical Therapist, Occupational Therapist, Speech Therapist, Social Worker,and the nurse (RN #1) were all in my mother's room. The therapist were telling us how my mom was doing in therapy but I said look at her she isn't even moving or responding and I asked why aren't you all doing something for her? I kept saying she is worse, she is worse. The nurse (RN #1) started smacking my mom on her arm and was screaming at her, calling her name and my mom could barely open her eyes. The Nurse (RN #1) told us that mom was on too much medicine and she was just sleepy. No one in the room other than my sister and I questioned or even said anything about calling 911. I asked the nurse what were her vital signs and she said they were fine but that she couldn't test her oxygen level because of her nails, my mom's nail beds were exposed because it had been over a month since she had had them done. I told the nurse (RN #1) if you can't test her oxygen level then you shouldn't have her here. The nurse never did any assessment on my mom when we were in the room. After the therapists left the room the nurse (RN #1) told my sister and I that my mom was fine and I kept saying no she isn't fine something is wrong. By this point my sister and I were so upset because the nurse just kept arguing back and forth with us we left to get a sandwich and discuss our mother's condition between ourselves. We were only gone for a brief while and came back to the facility within 45 minutes and told the nurse (RN #1) that we wanted our mom to go to the hospital. She said I can send her to the hospital if you want, but she is fine. We kept going back and forth with the nurse (RN #1) that we wanted the doctor called and our mom to go to the hospital. Finally, the nurse said she would beep the doctor if that was what we wanted it was after 3:00 p.m. by this point. About 3:30 p.m. her nurses aide (CNA #1) came in the room to see mom and we asked her what she thought about mom's condition and what would she advise us to do and she said send her to hospital. We told her thank you, thank you for validating our concerns then we told the aide to tell the nurse we wanted our mother to go to the hospital and she left the room. The nurse (RN #1) came back in the room and told us the doctor had order some blood work and we said no she is going to the hospital, then the nurse said ok I will do it and she went to call 911. When 911 arrived my mother's oxygen level was in the 80's and they had no problem getting a reading over her nail bed. We just don't want someone else to go through what we did, no one was acknowledging she wasn't herself and we have to keep arguing with them to get help for our mother. My mother was off the ventilator for about 2 days before she died and she told me I told you they were not taking care of me there and I was scared I was gonna die. On [DATE] at 3:40 p.m. and interview was conducted with CNA #1. CNA #1 was asked if she was Resident #1's caregiver on [DATE] for the ,[DATE] shift and if she recalled anything about that day. CNA #1 stated, Yes I work on that day because I was off the weekend, I doing rounds and went into name (Resident #1's) room her condition so worse, I called her name and she didn't answer. I know her, I said what is wrong with you? I was shocked because she was not like this on Friday ([DATE]). Her two daughters were in the room and told me, we have been asking the nurse (RN #1) to send her to the hospital since earlier. The daughter asked me what's your advice I said send her to hospital. I told (name of RN #1) her daughters want her to go to hospital, and she said ok. Her daughters were crying and saying I'm going to call 911. A nurses note entry for Resident #1 by RN #1 on [DATE] at 12:10 p.m. documented in part, read as follows: Resident alert and responsive, total care provide, turn and reposition q2hrs (every 2 hours), no distress will continue with plan of care. The Nursing Supervisor for the ,[DATE] shift on [DATE] RN #3 was interviewed on [DATE] at 2:50 p.m. RN #3 was asked to walk the surveyor through the events that occurred on [DATE] during her shift in regards to Resident #1. RN #3 stated, I was making my rounds and I got a call from my ,[DATE] nurse on the Emerald unit. She said there is a situation over here (name of Resident #1) and her daughters want her to go to the hospital, but (name RN #1) said Resident #1 is stable, vitals stable, and sats (oxygen saturations) ok. RN #1 called the doctor and said to get stat labs. I (RN # 3) told the ,[DATE] nurse you know my rule - she (Resident #1) is going to go to hospital. Tell RN #1 to send her to hospital; she is not gonna leave patient here, get her out. My rule is if family want their loved one to go to hospital I send them because that is their loved one they know them better than I do. At 4:04:44 p.m. on [DATE], 911 was dispatched to the facility for Resident #1. A review of the Emergency Medical Service (EMS) Prehospital Report indicated that when they arrived to the facility at Resident #1's bedside at 16:11:02 p.m. Resident #1 presented with altered mental status, oriented to person, and her oxygen saturation was *83% on 2 liters of oxygen. Resident #1 was able to say her name but could not answer any other questions or follow commands. EMS increased her oxygen to 15 liters via mask and her oxygen saturation increased to 100%. Resident #1 was transported to the hospital at a priority one level with lights and sirens. Resident #1's mental status improved during transport to the hospital. A Situation-Background-Assessment-Recommendation (SBAR) nurses note entry for Resident #1 by RN #1 on [DATE] at 4:41 p.m. documented in part, read as follows: Situation: Altered Mental Status, sleeping and confuse Background: [AGE] year old female with admitting dx (diagnosis): Fatigue, [MEDICAL CONDITIONS], Confusion, Hypertension, Acute [MEDICAL CONDITION], Sinus Sick Syndrome, Obstructive Chronic [MEDICAL CONDITION] with acute [MEDICAL CONDITION]. NKDA (no known drug allergies [REDACTED].>Assessment: Resident respond verbally, arousable to verbal, Sleeping all day, on oxygen at 2 liters. VS (vital signs) in AM ,[DATE] (blood pressure), 18 (respiration), 97.4 (temperature), sat (oxygen saturation) was check resident has nail acrylic over the nail, unable to get accurate reading nurse mention to the daughters that the acrylic need to be removed, skin pink. VS ,[DATE] (blood pressure), 73 (pulse), 18 (respirations), 97.4 (temperature) Response: Nurse notify doctor, stated to get lab work and if no change to transfer resident to ER (emergency room ) for evaluation. all medication was taken well, resident swallow well, when given whole medication and breathing treatment given. During an interview with the Administrator on [DATE] at 11:30 a.m. he shared that RN #1 was taken off the nursing floor and suspended on [DATE] because she did not document what she did for Resident #1 when she sent her out to the hospital on [DATE]. The Administrator also shared that RN #1 was terminated on [DATE] stating, We can only give someone so many chances. The Unit Manager for the Emerald Unit RN #2 was interviewed on [DATE] at 10:10 a.m. RN #2 shared that she was not on the unit on [DATE]; she was in an all day long meeting at the facility. RN #2 was asked what she would have expected RN #1 to have done regarding Resident #1 on [DATE]. Unit Manager RN #2 stated, I expect all my nurses to send the patient to the emergency room , no questions asked. The family members know their love one more than we do, (name of Resident #1) was only here for a few days. If I see a change I send her. You do your assessment and see something wrong let the family know, send them out and let the doctor know. That's my priority - the patient. The Surveyor asked if you should ever disagree with the family or resident and RN #2 stated, No. RN #2 also stated, In my experience when you call the doctor and say the family wants the resident to go, the doctor says send them. On [DATE] at 11:15 a.m. an interview was conducted with Resident #1's physician who is also the facility's Medical Director. The above information regarding Resident #1's significant change of condition that was reported around 10:00 a.m. on [DATE] and the daughters' concerns during the family care meeting were discussed. Based on this information the Medical Director stated, If I had been made aware that the resident was this critical I would have told the nurse to get her out the door. A nurse, especially a Registered Nurse, has the capacity to make that judgement call. That is the difference between a nurse and a certified nursing assistant. That is the Nursing Duty. I strictly depend on the nurse, she is my eyes and ears. You can ask anyone, my policy is that if the family wants to send the patient to the hospital the nurse does not even have to call me just do it, send them out. I was not informed an emergency was occurring with this resident. Resident #1's daughter also shared that she had filed a complaint with the facility's corporate office. On [DATE] at 11:00 a.m. an interview was conducted with the facility's Field Compliance Investigator. During this interview the Field Compliance Investigator stated, I called the daughter and made her aware that the nurse involved in her mother's care was no longer at the facility and that some extra training would be occurring in the facility. I sent an email on [DATE] to (name of Administrator) and the Director of Nursing with recommendations for the facility. The recommendations were: 1. when new admissions come in to verify the orders with in 48 hours in the standup meeting, 2. people on oxygen have a oxygen saturation checked daily, 3. inservice the staff on oxygen tanks so they know to look at the gauge to read the content amount, 4. Inform female residents they may have a male caregiver, 5. that psychiatric medications have appropriate diagnosis, 6. immediate interventions with a resident with a change of condition. When asked what she would expected a nurse to do if a resident had a change of condition, the Field Compliance Investigator stated, I would expect the nurse to intervene, assess the resident, call the doctor and take action. The Administrator was asked if he had received the email with the recommendations from the Field Compliance Investigator and he stated, No. He also shared that the facility had been without a Staff Development Coordinator since [DATE]. No documentation was provided to show that any training or inservices had been completed as stated to Resident #1's daughter by the Field Compliance Investigator as part of their complaint resolution to the daughter. A review of the facility policy Clinical Health Status-Change of Condition Guideline, updated [DATE] documented , in part reads as follows: Change of Condition-SBAR: The process for identification of change on condition includes gathering objective data and documenting assessment findings, resident/patient response, and physician and family notification. Communication both written and verbal, are integral parts of actions needed for change of condition. The SBAR process assists in coordinating change of condition information for concise communication with the Physician/Physician Extender. Resident #1 was admitted to the hospital on [DATE] with hypercapnic [MEDICAL CONDITION], exacerbation of [MEDICAL CONDITION], and aspiration pneumonia. The emergency room record states in part: Pt (patient) rouses with some difficulty. Speech is markedly garbled. Breath sounds diminished bilaterally. Resident #1 expired on [DATE] at 3:50 p.m. cause of death, [MEDICAL CONDITION]. Prior to the exit no further documentation was provided. *According to AACN (American Association of Critical Care Nurses) Procedure manual for Critical Care, fourth Edition, oxygen saturation is an indicator of the percentage of hemoglobin saturated with oxygen at the time of the measurement. Normal oxygen saturation values are 97% to 99% in a patient with a normal hemoglobin level. The Lippincott Manual of Nursing Practice, Fifth Edition on pages ,[DATE], had the following information: If the Sao2 (oxygen saturation) drops below 80%, a critical situation arises with the need for immediate intervention. Cyanosis (blueness to the skin) occurs as a late sign when Sao2 is equal or less to 45%. According to the Science Journal for the American Association of Respiratory Care, AARC Clinical Practice Guideline Oxygen Therapy for Adults- 2002 Revision & Update, Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of [MEDICAL CONDITION]. [MEDICAL CONDITION] is defined as a SaO2 of < (less than) 90%. According to Lippincott Manual of Nursing Practice, Eighth Edition 2006, Respiratory Disorders Chapter's 10 & 11, pages 258, ,[DATE] read, in part: Nursing Interventions: Administer oxygen to maintain. Sao2 > 90% . Standards of Care Guidelines Respiratory Compromise: Be aware of the status of the patient when assuming care .Perform through systematic assessment. This is a Complaint Deficiency

Based on observation, clinical record review and staff interview it was determined for Residents #5 and #7, two of 29 residents in the survey sample, that facility staff failed to provide care and services to identify and treat pressure areas. For Resident #5 staff failed to identify five Stage III pressure ulcers and provide treatment and identify a heel pressure area before it became unstageable. The right heel was also incorrectly identified as a blood blister. For Resident #7 staff failed to identify a pressure ulcer before it was unstageable. The wound was also incorrectly identified as a blister. The findings included: 1. Resident #5 was admitted to the facility on [DATE] and at the time of the survey she was [AGE] years old. The resident's [DIAGNOSES REDACTED]. This resident was also noted to have an old sacral surgical wound that had not healed. The sacral wound was being treated with a [DEVICE] (to draw off excess drainage and promote healing). The resident was also noted to have a feeding tube and a Foley catheter for bladder drainage. Review of the 10/15/14 Significant Change MDS (Minimum Data Set) evidenced the resident rarely makes herself understood and only sometimes understands others. Resident #5 was unable to complete the brief interview for mental status and staff noted she had short and long term memory loss. Resident #5 never made decisions regarding her daily life. Resident #5 required the assistance of two persons for activities of daily living. Section M or Skin Conditions noted the resident to have a surgical wound. The resident was noted to be at risk of developing pressure ulcers. Review of the Care Plan: date initiated 5/31/11 and current " Pressure ulcer risk due to surgical wound to repair pressure ulcer on sacrum, history of pressure ulcer, bedfast, skin desensitized, incontinent. " Goal, " will remain free from further breakdown. " The interventions included weekly skin assessments, floating her heels, pressure reduction mattresses and turning and repositioning every two hours. " (a) Review of the clinical record evidenced that on 1/23/15 a skin assessment identified a "blister" on Resident #5's right (R) heel. Review of the clinical record evidenced that treatment of [REDACTED]. At 6 pm on 2/4/15 the Unit Manager accompanied the surveyor to observe Resident #5"s right heel. The UM pulled the covers off the resident's feet. Resident #5's feet rested on the mattress. The resident was on a pressure reduction mattress. The resident's left foot was over the right foot, in a scissoring position. The UM separated the feet. The left foot had rested on the "blister" on the inner right foot. The resident's right foot turned slightly outward. The "blister" was not on the back of the heel but on the inner side in contact with the left foot. Also noted on the right foot next to the blister was scar tissue from a prior pressure area. The resident's feet were not floated as ordered by the physician on 1/28/15. Floating is done by elevating the feet with a pillow or specially designed device to relieve pressure from the heels. The UM stated that there should have been a pillow between the feet so that there was not "skin on skin." When asked why the pillow to separate the resident's feet was important the UM replied, "to prevent pressure." Following the interview the UM was observed to reposition the resident's feet by placing a pillow under and between her feet. Without the pillow to separate Resident #5's legs would cross left over right as they were noted to do during the observation. The UM had to physically separate the lower legs for the observations and to place the pillows between them. The following morning (11:00 am) two surveyors requested the UM to again assist in observing the resident's feet. Resident #5's feet were again observed on the mattress with the left foot resting on the right without benefit of pressure relief such as a pillow to separate one foot from the other. The Unit Manager again stated that the heels should have been floated and a pillow between her feet to prevent pressure. The UM still described the area as a "blister" but described the area as "hard." The area was about the size of a quarter, did not appear fluid filled as a blister, and the skin over the area was darker than surrounding skin. (b) The UM was also requested to turn Resident #5 on her side so that the wound vac on her sacral area could be observed. When the resident was turned on her side and the resident's brief removed,. (the wound vac on the sacral wound was above the brief) multiple open areas were observed on the residents buttocks, and inner folds of her thighs. A dressing covers the wound and a tubing attached to the vacuum pulls fluids that have collected around the wound, reducing swelling, and creating an environment resistant to infection. Wound vac's are mostly used for chronic wounds or surgical wounds that have reopened. An 11:30 am interview was then conducted with the wound nurse who stated she was only treating the sacral area with the wound vac and the last treatment had been completed on 2/3/15 with the wound doctor. The clinical record contained documentation from the wound doctor that the treatment had been completed. The wound nurse stated that since the surgical wound and wound vac were above the brief area, the brief was not removed and the area not observed on 2/3/15. At 11:35 am the Assistant Director of Nurses (ADON) was interviewed and stated the only wound Resident #5 was being treated for [REDACTED]. At 12:12 pm the ADON and the wound nurse were requested to observe the Resident #5's buttocks/ischeal areas. Five areas were observed and identified by the wound nurse as Stage III"s. The areas were reddened and areas of yellow slough were present in all wounds. The wound nurse stated that the areas appeared to be caused by pressure. Stage III are defined as full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss, may include undermining or tunneling. An unstageable area is not stageable due to the wound being covered by slough and/or eschar. Slough is yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Eschar is brown, black or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Skin assessments were done each week, most recent on 1/14/15, " continue to treat sacral wound. No new areas noted. " On 1/21/15, there were no new open areas. On 1/23/15 the " blister to the right heel was noted. The last skin assessment was the evening before (2/4/15) by LPN #3 and no new areas were noted. The ADON reviewed the assessment sheet, "she (LPN #3) didn't note these areas on her assessment, did she?" The certified nursing assistant (CNA) who cared for the resident that morning was interviewed at 1:20 p.m.. CNA #4 stated that she had noticed the open areas and blood when she cared for the resident and had notified the registered nurse (RN). RN #5 was then interviewed and stated CNA #4 had informed her of the open areas and bleeding, "I told her to make the resident comfortable and I would look at her later, I just got busy." RN #5 stated that she also had the resident the day before but no one reported any concerns. At 4 pm the Licensed Practical Nurse (LPN) #3 (who had completed the 2/4/15 skin assessment) was interviewed. LPN #3 stated she had completed a head to toe assessment checking bony prominences, "I undid her diaper I just pulled it back a little..." When asked if she lifted apart the thigh fold areas, she stated, "no." The LPN continued that the resident can't be laid flat for too long, you have to do a "quick look and move on." When asked what she would have done differently LPN #3 stated she would have gotten more help so she could see better and would have looked at the skin folds. During other observations of Resident #5 two staff members were needed to hold the resident on her side for observations. The wound nurse was requested to measure the Stage III wounds and provide the information to the survey team. For the resident's heel, "Resident also noted with unstageable pressure ulcer to right heel measuring 2 centimeters (cm) X (by) 2.5 cm wound bed is 100% black eschar, no drainage and no odor..." The documentation regarding the new areas done by the wound nurse team, all were determined to be Stage IIIs. "(1) right upper sacrum measuring 0.7 cm X 2.7 cm X 0.1 cm, wound bed 5% yellow slough and 95% granulation. (2) right ischum measuring 0.6 cm X 3.5 cm X 0.2 cm wound bed is 5% yellow slough and 95% granulating tissue. (3) left upper ischium 0.5 cm X 2 cm X 0.1 cm with 3% slough and 97% granulating tissue. (4) left middle ischism 0.8 cm X 4.2 cm X 0.1 cm, 60% slough and 40% granulation (5) left lower ischium 0.3 cm x 0.6 cm x 0.1 cm 4% yellow slough and 96 % granulating tissue." Granulation tissue is pink or red with shiny moist, granular appearance. The MAR (medication administration record) evidenced that the sacral wound was treated twice a week by the wound nurse and wound physician. The right heel received skin prep every shift as ordered. 2. Resident #7 was originally admitted to the facility in 2011 with a readmitted 10/03/14. The Minimum Data Set with an assessment date of 1/6/15 evidenced the resident was severely impaired with a brief interview for mental status review of 4/15. Resident #7 required the assistance of two persons for transfer, dressing and bed mobility. Once out of bed the resident was unable to propel herself. Resident #7's [DIAGNOSES REDACTED]. During the review of Resident # 7's clinical record it was noted that the resident had a blister on her right heel. Review of the skin sheet evidenced that on 1/26/15 the resident's skin was dry and no skin issues were identified. On 1/28/15 the Unit Manager noted that the area was on the resident's right heel was a blister. Review of the nursing notes for 1/28/15 evidenced that the nurse who identified the area described it as, "scar on right heel with black tissue surrounding site." The responsible party and the physician were notified and an order for [REDACTED]. The area was noted to be 4 centimeters (cm) by 3.5 cm, without drainage. The resident ' s plan of care was updated on 1/29/15 to change the problem from a potential for breakdown to " FLUID BLISTER R. HEEL " Skin assessments revealed on 1/26/15 " skin dry and warm to touch, no new skin issues noted. " On 1/28 15 the UM documented on the skin sheet, " Rt (right) heel blister " . On 2/2/15 the assessment was treatment in progress no new areas noted. On 2/5/15 at 5:45 p.m., the UM and the wound nurse were requested to accompany the surveyor to observe the resident's right heel. During the prior two days the resident was observed and interviewed in bed. The resident's roommate was also in the sample and a surveyor was in the room to observe the roommate. The resident was always observed on her back with her legs stretched straight and heels in contact with the mattress and her arms at her side. Her hands had pronounced tremors. The resident was covered only with a sheet and a thin blanket, evidence that the resident's heels had been floated with pillows or another device would have been obvious under the thin covers. None had been noted. The UM asked the wound nurse if she remembered seeing the wound when it was first noted. The wound nurse did not recall seeing the wound. The UM stated that she had asked the wound nurse to look at it and they had gone in together. The wound nurse stated she did not recall and was usually only asked to see residents with open areas and requiring a treatment other than skin prep. When the resident's feet were uncovered there was nothing under them to relieve pressure and the right foot rested on the previously identified "blister" area. The wound nurse examined the heel and stated that the area was unstageable. The wound was half moon shaped with a blacked area around the perimeter, the wound nurse described this as eschar. The UM was interviewed regarding documenting the area as a "blister", when there was eschar present. She stated that the wound had changed since she had seen it. (However, the nurse discovering the wound described the black area). When interviewed regarding the need to float Resident #7's heels she stated that she had seen the resident with pillows under her feet and if the the surveyor did not see the feet floated, the resident must have kicked the pillow off the bed. The wound nurse stated that the current treatment was appropriate for the wound. .