Every finding on record at Autumn Care of Chesapeake

Based on observation, Resident and staff interviews, and facility documentation review, the facility staff failed to maintain a Resident call system for Residents to call for staff assistance, on three of four nursing units. The findings included: On three of four nursing units, the facility staff failed to ensure that there was a Resident call system in the bathrooms and showers to allow Residents to call for staff assistance, if needed. On 12/5/23, during an initial tour of the facility it was noted that on three of the Resident care units, there was not a functional call bell system. The Residents were noted to have hand bells and/or tap bells at the bedside. There was no device noted in the Resident bathrooms, many of which also contained showers. During Resident interviews conducted 12/5/23-12/6/23, Resident #54 reported that the toileted and showered in his room's bathroom independently without any supervision or assistance from staff. When asked how he would call for assistance if he needed help, Resident #54 said, I have no way to call other than yell, the system has been broken for months because of lightening. Resident #77 reported that she toileted without staff assistance. When asked, if she needed help how she would notify the facility staff? The Resident said, I try to leave the door cracked so if I call out, they can hear me. On 12/6/23 at 10:20 AM, an interview was conducted with LPN #6. LPN #6 confirmed that Resident #54 is very independent and does toilet and shower without any staff assistance. LPN #6 also confirmed that Resident #77 can toilet herself without staff assistance. On 9/28/23, an inspection was conducted at this facility and at that time the facility reported their call bell system would be functioning withing 8 weeks. During that inspection, the facility provided a document from the VSC Fire & Security Company dated 09/28/23. The read in part: After hours of troubleshooting, we have discovered in multiple places the existing wiring is burned and multiple location with inoperative stations. It is recommended to replace the entire system with a new nurse call system. After contacting (name of company) there is enough materials to get started and can support with on time delivers as this system replacement progresses. The plan is to replace all the existing system including wire and will work on and complete one (1) 20 room/unit pod at a time. The intention is to complete each unit/pod within a two (2) week period or within 8 weeks for the entire facility. On the afternoon of 12/7/23, an interview was conducted with the facility Administrator. The Administrator reported that the facility had a lightning strike in July 2023, that had disabled their call bell system for the entire facility. They had contracted with an outside company who was in the process of having to re-wire and install a new system. They had completed the installation of the call bell system on one unit, and it was noted to be operational. The administrator reported that due to the facility having a COVID outbreak the contractors didn't work for two weeks in November, which delayed the installation as well as the fact that they prioritized the fire monitoring system before the call bell system. Review of the facility policy titled, Resident Communication System and Call Light Policy was conducted. The policy read, It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas . During the interview with the facility Administrator on 12/7/23, the above concerns were shared that the Residents on three nursing units did not have any means to call for assistance in the bathroom and shower if needed. The Administrator confirmed these observations. The administrator shared that each shift the nurses check to ensure that a call bell is in place at the bedside and every hour a staff member is to walk to hallway to identify if any hand bells and/or tap bells are heard. The Administrator further confirmed that this walk through doesn't include physically entering a Resident's room. On the morning of 12/8/23, the facility Administrator stated that in response to the concerns shared the day prior, they had procured enough tap bells and hand bells to place one in every bathroom as well. No further information was provided.

Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to maintain a safe environment, free of accident hazards on one of four Resident care units. The findings included: On the one hundred nursing unit, the facility failed to secure medications and chemicals to maintain a safe environment, free of accident hazards. 1a. On [DATE] at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included: a. Resident #42 had hair growth pills/supplement at bedside. b. Resident #54 had Nutririte-800 multivitamins on the bedside table. c. Resident #77 had refresh lubricating eye drops at the bedside and hemorrhoid cream in the bathroom. d. Resident #51 had a tube of hydrocolloid cream and a bottle of [NAME] anti-itch cream on the bedside table. The [NAME] lotion had a prescription label, which indicated it belonged to Resident #394. Per the clinical record and an interview with CNA #1, Resident #394 had expired on [DATE]. e. Resident #78 had refresh eye drops with a prescription label and a container of roll-on bio freeze at the bedside. On [DATE], at approximately 1 PM, an additional observation was made of Resident #78's room. The bio freeze was still noted to be at the bedside. On [DATE] at 02:14 PM, an interview was conducted with LPN #5. LPN #5 stated that all medications must be kept locked in the medication cart or medication room. When asked if medications can be kept in the Resident rooms, LPN #5 said, They should not keep meds in room, but it is based on their BIMS (brief interview for mental status) score. They must score over a certain thing, to even be considered. Being a nursing home though we don't keep medications in the rooms. We have had people where families are non-complaint and go against what we ask, so if we find something we take it and notify the DON (Director of Nursing) and unit manager. Following the above interview with LPN #5, LPN #5 accompanied the surveyors to Resident #78 and #77's room. LPN #5 confirmed the observations and removed the eye drops and hemorrhoid cream from Resident #77's room. LPN #5 also removed the eye drops from Resident #78's room but left the bio freeze. LPN #5 went on to say that they have difficulty with Resident #78 and her family with bringing items in. The surveyor explained that the items were easily identified upon observation and did not require that the Resident's personal items be inspected to locate the items. LPN #5 agreed that the items were easily identified and should have been removed by facility staff. The facility provided an undated document titled, Medication Storage. Excerpts from this document read, Proper medication storage is a standard of practice . Medication Carts: . Medication carts and cabinets should be locked when unattended . 1b. On [DATE] at approximately 12:30 PM, the following was observed on the 100 unit. Resident #85 had a bottle of Lysol spray at her bedside. In Resident #17's bathroom, which was in her room, there was a spray bottle of cleaning chemical that was green in color. The bottle had no label. On [DATE] at 02:10 PM, an interview was conducted with Other Employee #2, who was a housekeeper. The housekeeper explained that all chemicals are to be kept in the locked portion of the housekeeping cart. Other Employee #2, then proceeded to show the two surveyors that the cart lock was broken so she was not able to lock it. When asked why chemicals must be locked, the employee said, because patients can get to them, and it can be dangerous. On [DATE] at 3:40 PM, an interview was conducted with the Maintenance/Housekeeping Director (Other Employee #3). The unlabeled bottle with the cleaning chemicals was noted to be in his office. When asked if it is ok to leave chemicals in the Resident's room, he said, 100 percent no. When asked if the bottle was to have a label, he said, Yes that is an OSHA issue, that's not normal for us. On [DATE] at 02:54 PM, an interview was conducted with CNA #2. CNA #2 confirmed that on the 100 unit they have 3 Residents who wander and self-propel in their wheelchairs. When asked if they go into other Resident rooms, CNA #2 said yes. A review was conducted of the facility policy titled, Hazard Communication Program Policy. Excerpts from the policy read, .making sure that hazardous chemicals and substances have an HMIS type label on it before it is used in the workplace. Applying a HIMS label (if necessary) to containers . The Employee is responsible for: . following safe work methods and safety rules . On [DATE], in the late afternoon, the facility Administrator was made aware of the above findings. No further information was provided.

Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications that were at the bedside, for six Residents (Resident #42, 54, 77, 51, 78 and #7) in a survey sample of 55 Residents. The findings included: 1. For Residents #42, 54, 77, 51, and 78, all of whom had medications stored in their room, the facility staff failed to assess if the Residents were safe to self-administer medications. On [DATE] at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included: a. Resident #42 had hair growth pills/supplement at bedside. b. Resident #54 had Nutririte-800 multivitamins on the bedside table. The Resident said he takes 2 once a day, and reports he got them from dialysis and has been taking them about a year. c. Resident #77 had refresh lubricating eye drops at the bedside and hemorrhoid cream in the bathroom. d. Resident #51 had a tube of hydrocolloid cream and a bottle of [NAME] anti-itch cream on the bedside table. The [NAME] lotion had a prescription label, which indicated it belonged to Resident #394. Per the clinical record and an interview with CNA #1, Resident #394 had expired on [DATE]. e. Resident #78 had refresh eye drops with a prescription label and a container of roll-on bio freeze at the bedside. On [DATE], at approximately 1 PM, an additional observation was made of Resident #78's room. The bio freeze was still noted to be at the bedside. On [DATE] at 02:14 PM, an interview was conducted with LPN #5. LPN #5 stated that all medications must be kept locked in the medication cart or medication room. When asked if medications can be kept in the Resident rooms, LPN #5 said, They should not keep meds in room, but it is based on their BIMS (brief interview for mental status) score. They have to score over a certain thing, to even be considered. Being a nursing home though we don't keep medications in the rooms. We have had people where families are non-complaint and go against what we ask, so if we find something we take it and notify the DON (Director of Nursing) and unit manager. Following the above interview with LPN #5, LPN #5 accompanied the surveyors to Resident #78 and #77's room. LPN #5 confirmed the observations and removed the eye drops and hemorrhoid cream from Resident #77's room. LPN #5 also removed the eye drops from Resident #78's room but left the bio freeze. LPN #5 went on to say that they have difficulty with Resident #78 and her family with bringing items in. The surveyor explained that the items were easily identified upon observation and did not require that the Resident's personal items be inspected to locate the items. LPN #5 agreed that the items were easily identified and should have been removed by facility staff. On [DATE]-[DATE], clinical record reviews were conducted of each of the Resident's charts. The findings were as follows: a. Resident #42 had no assessment to determine if he/she was safe to self-administer medications. The care plan did not identify that the Resident was able to self-administer medications and keep them at the bedside. The physician orders did not include an order for any hair growth supplements. b. Resident #54's clinical record revealed no current physician order for a multi-vitamin supplement. On [DATE] at 5:26 PM, a progress note was entered into the record that read, This nurse in to eval resident for self-administration of Multivitamin. Pt has BIMS of 14 however pt has a d/x of major depressive and per facility assessment resident is unable to self-administer meds. Pt educated on self-administering meds along with the risks associated with doing this without nurse and MD being aware due to possible interactions with already prescribed meds being administered by nurse. Pt verbalized understanding. c. Resident #77's physician orders revealed an order dated [DATE], that read, Hemorrhoidal Relief Cream 5 % (Lidocaine (Anorectal)) Apply to rectum topically as needed for hemorrhoids apply to rectum as needed. On [DATE], an order was entered that read, Refresh Tears Solution (Carboxymethylcellulose Sodium) Instill 1 drop in right eye two times a day for dry eye syndrome. On [DATE] at 5:22 PM, the facility staff conducted an assessment to determine if Resident #77 could self-administer medications. The assessment identified that since Resident #77 had a diagnosis of dementia, they were not a candidate. d. Review of Resident #51's chart revealed that the Resident had not been assessed for the ability to self-administer medication. e. Resident #78 was assessed by facility staff for the ability to self-administer medications on [DATE] at 5:24 PM. The Resident was noted to not be a candidate. The Resident had not been previously assessed prior to being permitted to have medications at the bedside and had no physician order for the bio freeze. On [DATE] at 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that many of the Residents had assessments conducted the evening prior in response to the items found by the surveyors in the Resident's rooms. A review was conducted of the facility policy titled, Self-Administration of Medication. Excerpts from the policy read, 1. Verify physician's order in the resident's chart for self-administration of specific medications under consideration. 2. Complete the Self-Administration of Medications Assessment with the resident . 4. If the interdisciplinary Team has determined the resident safe to administer medication(s), administration of medication(s) will be Care Planned for approved self-administered medications . 6. When a resident is unable to self-administer medications, the medication will be held by the nurses until the resident can be reassessed by the Interdisciplinary Team. 7 . Medication(s) kept at the bedside must be kept in a locked drawer. On [DATE], in the late afternoon, the facility Administrator was made aware of the above findings. No further information was provided. 37828 2. The facility staff failed to reassess Resident #7 for self-application of medication Hydrocortisone external cream 1 percent (%). Resident #7 was admitted to the facility on [DATE]. Diagnosis for Resident #7 included but not limited to major depressive disorder. Resident #7's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of [DATE], under cognitive status was not coded on the Brief Interview for Mental Status (BIMS) but was coded as independent for decisions being consistent and reasonable. The care plan with a created on [DATE] and a revision date of [DATE] identified Resident #7 on antidepressant therapy. The goal set for the resident by the staff to remain free from discomfort or adverse effects of antidepressant therapy. Some of the interventions/approaches the staff would use to accomplish this goal is administer antidepressant medication as prescribed by the physician, and consult with pharmacist, MD, medical director for gradual dose reduction if appropriate and monitor for side effects of antidepressant medications, e.g., suicidal ideations. During the initial tour of the facility on [DATE] at approximately 1:59 p.m., observed on Resident #7's overbed table was an open tube of hydrocortisone cream 1%. The resident stated she has a rash to her upper arms, upper back and under her breast. She stated the cream dries up the rash and stops her skin from itching. She stated the hydrocortisone cream had been in her room for a while. A review of Resident #7's [DATE], Medication Administration Record (MAR) revealed the following order: Hydrocortisone External Cream 1 %, apply to chest, and arms topically every 4 hours as needed for itching starting on [DATE]. A Self-Administration medication assessment was completed on [DATE] and [DATE] documented the resident did not wish to self-administer her own medications. An interview was conducted with the Unit Manager on [DATE] at 10:07 a.m. She stated she had removed the hydrocortisone cream out of Resident #7's room. She stated the cream at beside was a house stock cream. She stated the nurse probably applied the mediation but forgot to remove it from the resident's room. An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:15 a.m., who stated Resident #7 had a self-administration assessment completed this morning and did not pass. She stated Resident #7 has a diagnosis of depression and with a diagnosis of depression who cannot self-administer your own medication. A final meeting was held with the Administrator, Director of Nursing, and Regional Director of Clinical Services on [DATE] at 1:30 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility policy titled Self-Administration of Medication with a revision date of [DATE]. Residents who have the desire to, and who have been assessed to be capable and safe to, may self-administer medications. Procedure read in part: 1. Verify physician's order in the resident's chart for self-administration of specific medications under considerations. 4. If the Interdisciplinary Team (IDT) has determined the resident safe to administer medication(s), administration of medication(s) will be care planned for approved self-administered medication. 5. Self-administration of medications must be reviewed by the (IDT) with each quarterly review. 6. When a resident is unable to self-administer medications, the medication will be held by the nurse until the resident can be reassessed by the (IDT). 7. The MAR must identity medications that are self-administered, and the medication nurse will need to follow-up with the resident as the documentation and storage of medications during each medication pass. Medication(s) kept at the bedside must be kept in a locked drawer. Definitions: -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 (https://medlineplus.gov/ency/article/000945.htm). -Hydrocortisone cream is used to treat redness, swelling, itching, and discomfort of various skin conditions. It works by activating natural substances in the skin to reduce swelling, redness, and itching (https://medlineplus.gov/ency/article/000945.htm).

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the medication error rate was less than 5%. There were 4 medication errors in 26 opportunities, affecting two (2) Residents (Resident #26 and #85), resulting in a 15.38% medication error rate. The findings included: On [DATE] at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26 & at 8:22 AM, administered medications to Resident #85. During the medication administration observation, LPN #6 prepared the medications and provided Resident #26 with 4 medications, Coenzyme Q10 Capsule 100 MG, Coreg Tablet 12.5 MG (Carvedilol), Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat), and boost (a nutritional supplement). Following the administration a record review was conducted to reconcile the administration. It was noted that LPN #6 had documented that Lasix Oral Tablet 20 MG (Furosemide), and MiraLAX Packet 17 GM (Polyethylene Glycol 3350) were administered when neither were given. On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked about the medications documented as having been given during the 8:16 AM, medication administration that was observed by two surveyors. LPN #6 confirmed that Lasix and MiraLAX had not been given because they were not available. When asked why they were documented as having been given, LPN #6 said, she was nervous. Another review of the clinical record revealed that LPN #6 had not documented that the medications were not administered, nor had it been indicated that the physician was made aware of the medications not being available. Review of the STAT box (emergency medication supply) contents listing revealed the Lasix was available in the STAT box and could have been retrieved to provide to the Resident. On [DATE] at 8:22 AM, LPN #6 was observed during the preparation and administration of medications to Resident #85. It was noted that Resident #85 was given 9 medications. There were 2 medications, a liquid iron supplement and Peridex Mouth/Throat Solution that were not given. The iron supplement that was in the medication cart had expired [DATE], and therefore was not administered and the Peridex mouth solution was not available in the medication cart. LPN #6 then continued her medication administration and moved on to the next resident to administer medications. LPN #6 took no measures to obtain the medications by checking the emergency medication supply or calling the pharmacy and did not notify the provider that the medications were not available for administration to see if the provider had another alternative order to provide. On [DATE] at approximately 9 AM, a clinical record review was conducted of Resident #85's chart. This review revealed no indication that the physician had been notified of the medication not being available and not being administered nor the pharmacy being contacted to obtain/order the needed medications. On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked to explain the process if a medication is not available. LPN #6 said, if a medication is not available, she would check the emergency supply box (STAT box) and see if the medication was available to be obtained/retrieved there and if not would call the pharmacy and doctor. When asked if this process had been followed for Resident #85, she indicated it had not been done. The facility administration was asked to provide a copy of their facility policy regarding medication administration. The facility submitted an undated document titled, Preparing for Medication Administration. Excerpts from this document read, . Medications Administered: Initial appropriate book of the MAR immediately after administration of the medication. Medication Availability: If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that medication pass can be completed. Document unavailable medications appropriately per facility protocol. Contact the pharmacy and arrange for delivery of the medication. On [DATE], in the later afternoon, the facility administration was made aware of the above observations. On [DATE], the facility Administrator provided the survey team with evidence that LPN #6 had received disciplinary action on [DATE] and was suspended pending an investigation. Additionally, the facility administration had provided education to LPN #6 regarding medication administration following them being made aware of the above findings. No further information was received.

Based on review of the Payroll Based Journal (PBJ) Staffing Data Report, review of the actual working schedules for nurse staff, and staff interviews, the facility staff failed to ensure they had a Registered Nurse (RN) providing services at least eight consecutive hours within each twenty-four hour period, 7 days a week. The findings included: The Fiscal Year Quarter 4 2023 (July 1 - September 30) PBJ Staffing Data Report triggered for four or more days within the quarter with no RN hours. A review of eleven months of actual nurse staffing from January 2023 through November 2023 revealed the facility was without an RN on duty eight consecutive hours on 2/12/23, 2/18/23 2/19/23, 3/4/23, 3/11/23, 3/19/23, 4/29/23, 7/9/23, 7/22/23, 7/23/23, 9/3/23, 9/9/23, 9/16/23, 9/30/23, 10/1/23, 10/14/23, 10/15/23, 11/23/23. On 12/7/23 at approximately 4:45 PM an interview was conducted with Licensed Practical Nurse (LPN) #11. LPN #11 stated a great deal of effort is expended to obtain RN coverage for the weekends and holidays but it is very challenging and occasionally they are not successful in meeting the requirement to have an RN on duty for eight consecutive hours every twenty-four hours. LPN #11 also stated many times the RN is scheduled, but calls out therefore the facility is without the supervision of the RN. The review also identified that many days in which RN coverage was not available it was because an RN had not been scheduled to work for eight consecutive hours within each twenty-four hour period Since a lack of RN coverage was identified for four or more days in quarters two and four, and already for quarter one which will end 1/1/2024, random days without RN coverage were reviewed for the potential for more than minimal harm due to the facility's RN staffing failure. The review failured to identify specific services could not be provided when an RN was not available for eight consecutive hours within each twenty-four hour period. On 8/21/23 at approximately 3:20 p.m., a final interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. The DON acknowledged the noncompliance but offered no additional information regarding a strategy to become compliant with RN staffing and the facility's team voiced no concerns regarding the above information.

Based on family interview, staff interviews and clinical record review, the facility staff failed to ensure transportation arrangements were made for 1 resident's dental appointment in a survey sample of 55 residents (Resident #1). The findings included: Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included cerebral palsy. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/07/23 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionGG(Physical functioning) the resident was coded as being dependent on staff for eating, oral hygiene, toileting, shower and bathing. The person centered care plan created on 8/03/21 read Resident #1 has a potential oral health problem. The goal set for the resident was they will have proper nutrition and hydration and will be free of pain or bleeding in the oral cavity. (revised on 12/23/22). Some of the interventions/approaches the staff would use to accomplish this goal was to assess oral cavity for pain, sensitivity, presence of lesions, ulcers, inflammation, bleeding, swelling or rashes, assist/provide mouth care as needed and referral to dental services (8/03/21). On 12/06/23 at approximately 11:00 a.m., during the initial tour Resident #1 was observed lying in bed in a supine position, appeared restless at times and making sounds. A specialty wheel chair was observed near the resident's bed. On 12/06/23 at approximately 12:32 p.m., a phone call was made to Family Member (FM) #1 concerning Resident #1. FM #1 said that Resident #1, has a lot of dental cavities. FM #1 said that he has mentioned this to the social worker (SW) and nurse at care plan meetings. The family member also said that he was concerned that the resident's teeth could be bothering her, but because she is non-verbal, pain may not be communicated to the facility staff. On 12/08/23 at approximately 12:50 p.m. an interview was conducted with Other Staff Member (OSM) #6. OSM #6 was asked by the surveyor if resident could receive a Medicaid Advantage Plus (MAP) adjustment to receive dental services. She said that Resident #1 didn't qualify for a MAP adjustment. She was then ask if resident could be transported via wheelchair transport. She said that she would check with the staff. An interview was conducted with the Director of Nursing (DON) and with Registered Nurse (RN), (Regional Clinical Nurse/RCN) #1 on 12/08/23 at approximately 2:10 p.m., concerning Resident #1 receiving transport services to the dental office. The DON said that the dental service could not accommodate the resident via stretcher in their office. The following nurses' notes were received from RN #1 on 12/07/23 at 3:40 p.m., A call made to Doctor of Dental Surgery (DDS) at 2:45 p.m., Message left was regarding if they take [Name of Medicaid service]. A call was placed at 3:20 p.m., to Dental Services office to ask if they accepted the above insurance. Received a returned call from the Dental Services office at 3:25 p.m. They do accept Medicaid and their VA Beach office can accommodate patient's specialty wheelchair in their office. Appointment scheduled for 1/05/24 at 2:00 p.m. On 12/08/23 at approximately 3:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow standards of practice for two Residents (Resident #85 and #26) in a survey sample of 55 Residents. The findings included: 1. For Resident #85 the facility staff failed to follow standards of nursing practice by failing to implement physician orders to apply compression stockings in the morning for edema. Resident #85 has diagnosis of BLE (bilateral lower extremity) edema and CHF (congestive heart failure), and compression hose ordered for edema to be put on in the morning and removed in the evening. On 12/6/23 in the morning and again in the afternoon, Resident #85 was observed sitting in her room and no compression stockings were on her BLE. On 12/7/23 after lunch, Resident #85 was observed sitting in a wheelchair in her room and she didn't have on compression stockings. On 12/8/23 in the morning, after breakfast, Resident #85 was observed in her room sitting in the bathroom in a wheelchair and no compression stockings were on her bilateral lower extremities. A clinical record review was conducted and revealed a physician order for compression hose to be put on in the morning and removed in the evening due to the resident's edema. A nurses note from LPN #6 on 12/7/23 stated that the Resident would apply after shower and on 12/8/23 states resident didn't want applied now and would check back later. On 12/6/23 at 2:00pm, an interview was conducted with Resident #85, resident stated that laundry took the hose and didn't return hose after being washed, so she is waiting on more to be ordered for her. On 12/7/23 at 10:34am, an interview was conducted with LPN #6, and she verbalized that compression hose are put on the resident in the mornings and she tried to put them on yesterday and she disappeared off the unit. On 12/8/23 at 10:00am, Resident #85 was interviewed again. The resident was in her room and no compression hose were on her lower extremities, she stated she didn't receive hose until last night and staff applied hose at 7:00pm and removed at 9:00pm and staff is to apply this morning after her shower. Resident stated staff has to apply because she isn't able to put the hose on herself. The [NAME] Manual of Nursing Practice, eighth edition, was reviewed. On page 18, in box 2-3, Common Legal Claims for Departure from Standards of Care were noted to include, but not limited to: . failure to perform a nursing treatment or procedure properly, . failure to implement a physician/NP/PA order properly or in a timely fashion . Administrator and DON made aware of findings on 12/7/23. No further information was provided prior to the conclusion of the survey. 41449 2. For Resident #85, the facility staff failed to apply a lidocain patch to the correct location as ordered by the physician. On 12/6/23 at 8:22 AM, Resident #85 was observed and met during the survey teams observation of medication administration. it was noted that the Resident had a Lidcaine patch on her left posterior thigh. Following the medication administration observation, reconcilliation of physician orders was conducted. During this review it was noted that Resident #85 had a physician order that read, Lidoderm External Patch 5 % (Lidocaine) Apply to left lower back topically one time a day related to polyarthritis. The physician order stated to apply to the lower back, observations revealed it was applied to the thigh. On 12/6/23 at 9:04 AM, during an interview with Resident #85, it was noted that she had a lidocaine patch on her left posterior thigh. When asked about it, the Resident said she was unsure when it was put on but a nurse had applied it. On 12/06/23 at 09:08 AM, an interview was conducted with LPN #6. The LPN was asked about Resident #85's lidocaine patch and reported, it is supposed to go on at bedtime and come off in the morning. When asked who takes it off, LPN #6 said, the 11 p.m. -7 a.m. shift. When asked if the Resident is currently supposed to have one in place, the LPN said she was not. When asked if she had looked to verify this, LPN #6 said she had not looked even though it was visible to the surveyor during the medication administration observation conducted at 8:22 AM. Does she have one on, I have not looked. On 12/06/23 at 09:11 AM, LPN #6 accompanied the surveyors to the Resident's room and confirmed the patch was not on the correct location and removed it. On 12/6/23, in the late afternoon, the facility Administration was made aware of the above findings and confirmed the facility follows [NAME] standards of nursing practice. According to the [NAME] Manual of Nursing Practice, Eighth Edition, Common Legal Claims for Departure from Standards of Care were listed on page 18. The list included, but was not limited to, failure to administer medications properly and in a timely fashion . 3. For Resident #26, the facility staff failed to follow standards of nursing practice, as evidenced by documenting that medications were administered that were not. On 12/6/23 at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26. During the medication administration observation, LPN #6 prepared the medications and provided Resident #26 with 4 medications, Coenzyme Q10 Capsule 100 MG, Coreg Tablet 12.5 MG (Carvedilol), Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat), and boost (a nutritional supplement). Following the administration a record review was conducted to reconcile the administration. It was noted that LPN #6 had documented that Lasix Oral Tablet 20 MG (Furosemide), and MiraLAX Packet 17 GM (Polyethylene Glycol 3350) were administered when neither were given. On 12/6/23 at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked about the medications documented as having been given during the 8:16 AM, medication administration that was observed by two surveyors. LPN #6 confirmed that Lasix and MiraLAX had not been given because they were not available. When asked why they were documented as having been given, LPN #6 said, she was nervous. Another review of the clinical record revealed that LPN #6 had not documented that the medications were not administered, nor had it been indicated that the physician was made aware of the medications not being available. Review of the STAT box (emergency medication supply) contents listing revealed the Lasix was available in the STAT box and could have been retrieved to provide to the Resident. On 12/6/23 at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked to explain the process if a medication is not available. LPN #6 said, if a medication is not available, she would check the emergency supply box (STAT box) and see if the medication was available to be obtained/retrieved there and if not would call the pharmacy and doctor. When asked if this process had been followed for Resident #85, she indicated it had not been done. The facility administration was asked to provide a copy of their facility policy regarding medication administration. The facility submitted an undated document titled, Preparing for Medication Administration. Excerpts from this document read, . Medications Administered: Initial appropriate book of the MAR immediately after administration of the medication. Medication Availability: If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that medication pass can be completed. Document unavailable medications appropriately per facility protocol. Contact the pharmacy and arrange for delivery of the medication. On 12/6/23, in the later afternoon, the facility administration was made aware of the above observations and confirmed the facility follows [NAME] standards of nursing practice. According to the [NAME] Manual of Nursing Practice, Eighth Edition, Common Legal Claims for Departure from Standards of Care were listed on page 18. The list included, but was not limited to, failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately . On 12/8/23, the facility Administrator provided the survey team with evidence that LPN #6 had received disciplinary action on 12/7/23 and was suspended pending an investigation. Additionally, the facility administration had provided education to LPN #6 regarding medication administration following them being made aware of the above findings. No further information was received.

Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to respond to a Resident's request for ADL (activity of daily living) assistance for one Resident (Resident #48) in a survey sample of 55 Residents. The findings included: For Resident #48, the facility staff failed to respond to the Resident ringing the tap bell for an hour and a half to request assistance to bathe/wash up. On 12/6/23 at approximately 10:05-10:10 AM, Resident #48 was observed to be ringing her tap bell. The surveyor remained on the unit making ongoing observations and noted no staff entered to respond to the resident. Throughout this time, Resident #48 was ringing the bell. At approximately 11:20 AM, Resident #48 began banging profusely on the bell. On 12/6/23 at 11:29 AM, Resident #48 was asked by the surveyor what she needed and reported she had been waiting for staff to assist her with getting washed up. The Resident reported that this happens frequently that people don't come. She said she has waited as long as 3 hours because some people say they didn't hear the bell. During the above observations, LPN #6 was observed sitting at the nursing station working on the computer and various other staff members were observed on the nursing unit. Review of Resident #48's clinical record revealed that according to her ADL (activities of daily living) records and care plan, she required assistance of facility staff to complete her daily ADL's. A review was conducted of the facility's policy titled, Resident Communication System and Call Light Policy. This policy read, . 3. Staff will respond to call lights promptly. On the afternoon of 12/6/23, the facility's administration was made aware of the above findings. No further information was provided.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain quality of care and ensure care was in accordance with the Resident's care plan, for two Residents (Resident #54 and #72), in a survey sample of 55 Residents. The findings included: For Resident #54 and #72, who were both on a fluid restriction, the facility staff failed to maintain the restrictions of the fluid restrictions by providing water at the bedside. On 12/6/23 at approximately 10 AM, observations were made in Resident #54's room. Resident #54 was noted to have a water pitcher at the bedside which was 3/4 full of ice water. It was observed that on the wall behind the bed, a sign noted a 1000 cc fluid restriction. On 12/6/23 at approximately 10:21 AM, observations were made of Resident #72's room. On the over bed table there was a full water pitcher in his room, which contained approximately 960 cc., a 120-cc cup of juice was noted and another cup with approx. 120 cc of liquid was noted. A sign above bed says 1000 cc fluid restriction. On 12/7/23 at 8:23 AM, observations were made in Resident #54's room. He was noted to have a water pitcher on the over bed table which was 3/4 full of ice water. A canned 12-ounce diet coke on the bedside table. Resident #54 also receives medications where water is provided and is provided beverages with meals. By having the water pitcher and other fluids at the bedside, the 1000 cc fluid restriction per day is exceeded. Review of both Resident #54 and 72's care plan revealed they were both on a fluid restriction. There was no indication in the care plan that the Residents were non-compliant with the fluid restriction. Resident #54's physician order read, 1000ml fluid restriction: Dietary Breakfast 240ml, Lunch 120ml, Dinner 120ml==480ml total Nursing, A.M. 240ml, P.M. 220ml, NOC 60ml==520ml total every shift. Resident #72's physician order read, 1000ml Fluid restriction Dietary Breakfast=240cc, Lunch=240cc, dinner=240cc Total=720ml Nursing AM=120cc, PM=120cc, NOC=40cc Total=280ml every shift. On 12/7/23 at approximately 8:40 AM, an interview was conducted with LPN #6. When asked about the two Residents being on fluid restrictions, she confirmed they were both on fluid restrictions. When asked about the water pitcher being at the bedside and asked how they maintained the fluid restriction, LPN #6 said, she was not sure and perhaps the water pitcher was there just as facility protocol. On 12/7/23, in the late afternoon, the facility administration was made aware of the above findings. No further information was provided.

Based on a medication pass observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration to three (3) of 55 residents in the survey sample (Resident #69, #26, #85) and during a medication pass on one of four units (100 unit). The findings include: 1. Resident #69's medication Janumet was not available for administration resulting in five missed doses of the medication. Resident #69 (R69) was admitted to the facility with diagnoses that included diabetes, cerebral infarction, dysarthria, hypertension, protein-calorie malnutrition and dysphagia. The minimum data set (MDS) dated [DATE] assessed R69 as cognitively intact. Resident #69's clinical record documented a physician's order dated [DATE] for the medication Janumet ,d+[DATE] mg (milligrams) one tablet by mouth two times per day for type 2 diabetes. A physician's order was documented on [DATE] for Janumet ,d+[DATE] mg two times per day via gastric tube for management of type 2 diabetes. Resident #69's medication administration record (MAR) documented the 9:00 a.m. dose of Janumet was not administered on [DATE] and the 9:00 a.m. and 5:00 p.m. doses were not administered on [DATE]. The [DATE] MAR documented the Janumet was not administered on [DATE] at 9:00 p.m. and on [DATE] at 9:00 a.m. A nursing note dated [DATE] documented R69's Janumet was not administered because the drug was not available from the pharmacy. A nurse practitioner's note dated [DATE] documented, .missed Janumet .Per nurse, Janumet not given for 2 days . A nursing note dated [DATE] documented regarding the Janumet, .hold per MD [physician] awaiting pharmacy to deliver . and a note on [DATE] documented, .On hold per MD until received from pharmacy . On [DATE] at 9:37 a.m., the licensed practical nurse (LPN #1) caring for R69 was interviewed about the missed doses of Janumet. LPN #1 stated she sometimes experienced problems with timely deliveries from the pharmacy. LPN #1 stated she usually ordered refills on medicines when there were five or less doses on the supply card. LPN #1 stated she had reordered medications before and three days later, the medications had not been delivered. LPN #1 stated she was not sure why the Janumet was not available on [DATE], [DATE], [DATE] or [DATE]. On [DATE] at 10:30 a.m., the unit manager (LPN #2) was interviewed about R69's unavailable Janumet. LPN #2 stated the pharmacy usually sent a 14-day supply of the Janumet and at times the pharmacy requested additional information about this prescription because it was expensive. LPN #2 stated the Janumet was most recently reordered on [DATE] so she was not sure why it was not available on [DATE]. On [DATE] at 1:54 p.m., the unit manager (LPN #2) was interviewed again about R69's unavailable Janumet. LPN #2 stated the Janumet was not stocked in the back-up supply, so it had to be delivered from the pharmacy. LPN #2 stated nurses were expected to order medication refills several days in advance of running out. On [DATE] at 3:04 p.m., the director of nursing (DON) was interviewed about R69's unavailable Janumet. The DON stated regarding the pharmacy deliveries, We have problems at times. The DON stated the Janumet was not part of the back-up inventory. The DON stated nurses entered refill orders from the computer and were expected to reorder medicines at least two days in advance of running out to allow time for delivery. On [DATE] at 5:55 p.m., the facility's consultant pharmacist (other staff #1) was interviewed about R69's unavailable Janumet doses. The pharmacist stated R69's insurance did not like the medicine. The pharmacist stated sometimes a 14-day supply was provided and other times a 7-day supply was sent to the facility. The pharmacist stated Janumet had not been setup in the back-up inventory, and he was not sure if an alternate medication had been considered since there had been problems with keeping the Janumet in stock at the facility. The facility's policy titled Medication Storage (undated) documented staff should ensure, .Medication is available for all active resident orders . The facility's training protocol titled Medication Storage and Labeling Critical Element Pathway (CMS for 20089) documented, .Medications should be always available to be administered as ordered by following these steps: -Prompt re-ordering -Prompt receiving of medications - Prompt notification to provider or pharmacy if issue with medication order . This finding was reviewed with the administrator and director of nursing during a meeting on [DATE] at 9:35 a.m. with no further information provided regarding the unavailable medication. 41449 2. For Resident #26, the facility staff failed to ensure that medications were available for administration. On [DATE] at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26. LPN #6 administered 4 medications, Coenzyme Q10 Capsule 100 MG, Coreg Tablet 12.5 MG (Carvedilol), Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat), and boost (a nutritional supplement). Following the administration a record review was conducted to reconcile the administration. It was noted that LPN #6 had documented that Lasix Oral Tablet 20 MG (Furosemide) and MiraLAX Packet 17 GM (Polyethylene Glycol 3350) were administered when neither were. On [DATE] at 9:04 AM, an interview was conducted with Resident #26. Resident #26 reported that at about 5 AM, she was given a few medications. On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked about the medications documented as having been given during the 8:16 AM, medication administration that was observed by two surveyors. LPN #6 confirmed that Lasix and MiraLAX had not been given because they were not available. When asked why they were documented as having been given, LPN #6 said, she was nervous. Another review of the clinical record revealed that LPN #6 had not documented that the medications were not available for administration, nor had it been indicated that the physician was made aware of the medications not being available. Review of the STAT box (emergency medication supply) contents listing revealed the Lasix was available in the STAT box and could have been retrieved to provide to the Resident. 3. For Resident #85, the facility staff failed to ensure that two medications were available for administration as ordered by the physician. On [DATE] at 8:22 AM, LPN #6 was observed during the preparation and administration of medications to Resident #85. It was noted that Resident #85 was given 9 medications. There were 2 medications, a liquid iron supplement and Peridex Mouth/Throat Solution that were not given. The iron supplement that was in the medication cart had expired [DATE], and therefore was not able to be administered and the Peridex mouth solution was not available. LPN #6 then continued her medication administration and moved on to the next resident to administer medications. She made no efforts to take measures to obtain the medications or notify the provider that the medications were not available for administration. On [DATE] at approximately 9 AM, a clinical record review was conducted of Resident #85's chart. This review revealed no indication that the physician had been notified of the medication not being available nor the pharmacy being contacted to obtain/order the needed medications. On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked to explain the process if a medication is not available. LPN #6 said, if a medication is not available, she would check the emergency supply box (STAT box) and see if the medication was available to be obtained/retrieved there and if not would call the pharmacy and doctor. When asked if this process had been followed for Resident #85, she indicated it had not been done. The facility administration was asked to provide a copy of their facility policy regarding medication administration. The facility submitted an undated document titled, Preparing for Medication Administration. Excerpts from this document read, . Medications Administered: Initial appropriate book of the MAR immediately after administration of the medication. Medication Availability: If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that medication pass can be completed. Document unavailable medications appropriately per facility protocol. Contact the pharmacy and arrange for delivery of the medication. On [DATE], in the later afternoon, the facility administration was made aware of the above observations. On [DATE], the facility Administrator provided the survey team with evidence that LPN #6 had received disciplinary action on [DATE] and was suspended pending an investigation. Additionally, the facility administration had provided education to LPN #6 regarding medication administration following them being made aware of the above findings. No further information was received.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for one of fifty five residents in the survey sample (Resident # 62). The findings include: Resident # 62's (R62's) MDS dated [DATE] was incomplete. R62 was admitted with diagnoses that included alzhiemers, depression, dementia with psychotic disturbance, auditory hallucinations and epilepsy. The MDS daated 6/7/23 assessed R62 as being cognitively intact. R62's clinical record documented a MDS dated [DATE]. Sections C0200, C0300, CO400 and CO500 were blank. On 12/7/23 at 9:12 am, the licensed practical nurse MDS coordinator (LPN#4) responsible for completing the MDS was interviewed about R62's incomplete MDS. LPN#4 stated that social services usually completed section C and we help them. LPN#4 also stated the assessment was not completed during the look back period and it got missed. The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Chapter 3 page C-2 documents steps for coding mental statusas, Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) . (1) On 12/8/23 at 9:45 am these findings were reviewed with the administor, director of nursing and the regional nurse consultant with no further information presented. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, Centers for Medicare & Medicaid Services, Revised October 2023.

Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff for 7 of 55 residents: Resident #7, Resident #85, Resident #42, Resident #54, Resident #77, Resident #51 and Resident #78 in the survey sample. The findings included: 1. The facility staff failed to ensure Hydrocortisone cream 1 percent (%) was stored in a secured location, accessible to designated staff only. Resident #7 was admitted to the facility on [DATE]. Diagnosis for Resident #7 included but not limited to major depressive disorder. Resident #7's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 09/14/23, under cognitive status was not coded on the Brief Interview for Mental Status (BIMS) but was coded as independent for decisions being consistent and reasonable. During the initial tour of the facility on 12/05/23 at approximately 1:59 p.m., observed on Resident #7's overbed table was an open tube of hydrocortisone cream 1%. The resident stated applied the cream to a rash located to her upper arms, upper back, and under her breast. She stated the cream dries up the rash and stops her skin from itching. She stated the hydrocortisone cream had been in her room for a while. A review of Resident #7's December 2023, Medication Administration Record (MAR) revealed the following order: Hydrocortisone External Cream 1 %, apply to chest, and arms topically every 4 hours as needed for itching starting on 11/14/23. An interview was conducted with the Unit Manager on 12/08/23 at 10:07 a.m. She stated she removed the hydrocortisone cream out of Resident #7's room. She stated the cream at beside was a house stock cream and should have been locked in the treatment care and applied by the nurse. An interview was conducted with the Director of Nursing (DON) on 12/08/23 at 11:15 a.m., who stated Resident #7 had a self-administration assessment completed this morning and did not pass. She stated Resident #7 has a diagnosis of depression and with a diagnosis of depression who cannot self-administer your own medication. She stated Resident #7's hydrocortisone cream should have been stored in the medication cart and applied by the nurse. A final meeting was held with the Administrator, Director of Nursing, and Regional Director of Clinical Services on 12/08/23 at 1:30 p.m., who were informed of the above findings. No further information was provided prior to exit. The facility provided a document titled Medication Storage. -Proper medication storage is a standard of practice. Definitions: -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 (https://medlineplus.gov/ency/article/000945.htm). -Hydrocortisone cream is used to treat redness, swelling, itching, and discomfort of various skin conditions. It works by activating natural substances in the skin to reduce swelling, redness, and itching (https://medlineplus.gov/ency/article/000945.htm) 41449 2. On the 100 unit, the facility staff failed to ensure expired medications were removed from the medication cart and not available for administration. On 12/6/23 at 8:22 AM, observations were made with LPN #6, during medication administration. LPN #6 was preparing medications for Resident #85. When LPN #6 retrieved the liquid iron from the medication cart, she poured the dose into a disposable medicine cup and then checked the bottle. She noted that the iron expired November 2023. Upon identification of this, LPN #6 discarded the poured medication and placed the bottle in the bottom drawer of the medication cart. During the above observation, LPN #6 was interviewed. LPN #6 stated that expired medications are to be removed from the medication cart and discarded to ensure they are not given to Residents. Resident #85's orders and medication administration record were reviewed. This review revealed that Resident #85 had an order dated 11/4/23, that read, Ferrous Sulfate Oral Solution (Ferrous Sulfate) Give 5 ml by mouth one time a day for Supplement. The medication administration record revealed that the medication had been signed off as being given/administered the 5 days prior. When LPN #6 was asked if the expired medication was given, she stated she didn't know but had no other supply to administer at this time. The facility administration was made aware of the above observation. The facility policy for medication storage was requested. The facility provided an undated document titled, Medication Storage. Excerpts from this document read, Proper medication storage is a standard of practice . Medication Carts: . Discontinued and/or expired medications should be removed from medication carts . No further information was provided. 3. On the 100 unit of the facility, the facility staff failed to ensure medications were stored in a locked compartment and only authorized personnel had access. On 12/5/23 at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included: a. Resident #42 had hair growth pills/supplement at bedside. b. Resident #54 had Nutririte-800 multivitamins on the bedside table. The Resident said he takes 2 once a day, and reports he got them from dialysis and has been taking them about a year. c. Resident #77 had refresh lubricating eye drops at the bedside and hemorrhoid cream in the bathroom. d. Resident #51 had a tube of hydrocolloid cream and a bottle of [NAME] anti-itch cream on the bedside table. The [NAME] lotion had a prescription label, which indicated it belonged to Resident #394. Per the clinical record and an interview with CNA #1, Resident #394 had expired on 11/10/23. e. Resident #78 had refresh eye drops with a prescription label and a container of roll-on bio freeze at the bedside. On 12/6/23, at approximately 1 PM, an additional observation was made of Resident #78's room. The bio freeze was still noted to be at the bedside. On 12/05/23 at 02:14 PM, an interview was conducted with LPN #5. LPN #5 stated that all medications must be kept locked in the medication cart or medication room. When asked if medications can be kept in the Resident rooms, LPN #5 said, They should not keep meds in room, but it is based on their BIMS (brief interview for mental status) score. They have to score over a certain thing, to even be considered. Being a nursing home though we don't keep medications in the rooms. We have had people where families are non-complaint and go against what we ask, so if we find something we take it and notify the DON (Director of Nursing) and unit manager. Following the above interview with LPN #5, LPN #5 accompanied the surveyors to Resident #78 and #77's room. LPN #5 confirmed the observations and removed the eye drops and hemorrhoid cream from Resident #77's room. LPN #5 also removed the eye drops from Resident #78's room but left the bio freeze. LPN #5 went on to say that they have difficulty with Resident #78 and her family with bringing items in. The surveyor explained that the items were easily identified upon observation and did not require that the Resident's personal items be inspected to locate the items. LPN #5 agreed that the items were easily identified and should have been removed by facility staff. A review was conducted of the facility policy titled, Self-Administration of Medication. Excerpts from the policy read, . 6. When a resident is unable to self-administer medications, the medication will be held by the nurses until the resident can be reassessed by the Interdisciplinary Team. 7 . Medication(s) kept at the bedside must be kept in a locked drawer. The facility provided an undated document titled, Medication Storage. Excerpts from this document read, Proper medication storage is a standard of practice . Medication Carts: . Medication carts and cabinets should be locked when unattended . On 12/6/23, in the late afternoon, the facility Administrator was made aware of the above findings.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement care plan interventions for one Resident (Resident #5) in a survey sample of 55 Residents. The findings included: For Resident #5 the facility staff failed to ensure a mattress was at the immediate bedside of the Resident as identified in the care plan as a fall intervention to prevent injury. On 12/5/23 at approximately 12:30 PM, Resident #5 was observed lying in bed. In the room there was an additional mattress noted on the floor, but it was pushed mid-way of the room and not positioned beside the bed. On 12/7/23 at 8:33 AM., Resident #5 was observed again, lying in bed. The additional mattress was noted to be lying on the floor, but not by the bed, it was placed mid-way of the room between the bed and wall. On 12/7/23 at 8:35 AM, an interview was conducted with LPN #7, who is an MDS (minimum data set) nurse. When asked about the mattress in the floor, LPN #7 said it is to be positioned directly beside the bed as a fall precaution to protect from injury. LPN #7 was asked to observe the mattress and she said, They had to move it to clean in there, it was as if her catheter had leaked so housekeeping must have moved it. LPN #7 confirmed that it was to be directly beside the bed to prevent any injury if the Resident were to fall out of bed. On 12/7/23, a clinical record review was conducted. This review revealed Resident #5's care plan was reviewed and revised on 11/8/23. One focus area read, [Resident #5's name redacted] is at risk for fall r/t [related to] impaired mobility, impaired cognition. Resident also has behavior of placing self on floor. Interventions for this focus area included, mattress to floor for comfort. On 12/7/23, in the late afternoon, the facility administration was made aware of the above findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to have advanced directives accessible for five resident's (Resident #68, #14, #7, #45 and #84) in a survey sample of 37 residents. The findings included; 1. Resident #68 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), a Quarterly Revision assessment with an Assessment Reference Date (ARD) of 12/08/2019. The staff assessment for mental Status coded the Resident as having Short term and Long term memory problems. Section C1000-Coded the Resident's Cognitive Skills for Decision Making as being severely impaired. A review of the clinical record on 01/08/2019 revealed there was no advanced directive in the clinical record concerning an advance directive. On 1/9/20 at 1:45 p.m., an interview was conducted with OSM (other staff member) #4 the Director of Social Services. OSM #4 stated that if a resident has an advanced directive, she will ask the family or resident for a copy. OSM #4 stated that the copy is then placed in the electronic medical record. When asked the process if she could not obtain the advanced directive from the family or resident, OSM #4 stated that she did not do anything. When asked if she offers to formulate a new advanced directive with the resident and/or POA (power of attorney), OSM #4 stated that she did not. On 1/9/20 at 2:55 p.m., an interview was conducted with OSM #5, the business office manager. When asked the process of obtaining advanced directives for residents, OSM # stated that upon admission, she will go over advanced directives and ask the resident whether or not they have one. OSM #5 stated that if the resident has an advanced directive, she will ask the family to bring it in. OSM #5 stated that she will then upload the advanced directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advanced directive, OSM #5 stated that she did not do any further follow up. OSM #5 stated that she did not ask residents if they would like to formulate a new advanced directive if she could not obtain a copy. When asked if the advanced directive should be accessible for staff, OSM #5 stated that it probably should be. OSM #5 was asked if she could find an advanced directive for Resident #68. On 01/09/20 OSM #5 presented A Care Planning Report dated on 02/26/16. It reads the following: Focus: Advance Directive Needs: As evidenced by resident's wishes to be a Full Code. Care givers are aware of the wishes. Goal/Evaluation: Staff will adhere to resident/family's Advance Directive decisions through next review. Intervention:Code Status: Full Code started 02/04/14-continuing. OSM #5 was asked if nursing was aware of the document? She stated that she didn't know. Briefly, thereafter the DON (Director of Nursing) appeared concerning the above document. He said that he was not aware of the document and that it would be hard to talk to Resident's family about having an Advanced Directive. On 01/09/20 at approximately, 7:12 PM a Pre-exit interview was conducted concerning the above issues. The Administrator stated, that he felt like they were doing their job with the families concerning the Advanced Directives. 2. Resident #14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 10/14/2019 coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. A review of the clinical record on 01/08/2019 revealed there was no advanced directive in the clinical record. #3. Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 10/08/2019 coded Resident #7 with a BIMS (Brief Interview for Mental Status) score of 08 indicating moderate cognitive impairment. On 01/08/2020 a copy of Resident #7's Advance Directives - Acknowledgement form was received. Review of the form revealed that the resident's son had indicated that Resident #7 had a written advanced directive. On 01/09/2020 at approximately 2:55 p.m., an interview was conducted with the Director of Admissions and when she was asked if she could provide a copy of Resident #7's Advanced Directive, the Director of Admissions stated, No, unable to locate a copy. When asked the process of obtaining Advanced Directives, the Director of Admissions stated, Upon admission I go over advanced directives with the resident or resident's responsible party and ask them if they have one. If they have one I ask the family to bring it in and I upload the advance directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advance directive, the Director of Admissions stated, I do not do any further follow up. When the Director of Admissions was asked if the advanced directive should be accessible for staff, the Director of Admissions stated, It probably should be. The Director of Admissions stated, I have contacted the resident's family to bring in a copy of the advanced directive and I will add it to the resident's chart when I receive it. Moving forward I will have a follow up process in place. The Administrator, Director of Nursing and Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2019 at approximately 7:10 p.m. The facility did not present any further information about the finding. #4. Resident #45 was initially admitted to the facility on [DATE]. Resident #45's most recent discharge to the hospital was on 11/10/2019 and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #45's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/20/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On 01/08/2020 a copy of Resident #45's Readmission Agreement dated 11/18/2019 was received. Review of the 'Acknowledgements section revealed that the resident has a advance directive. On 01/09/2020 at approximately 2:55 p.m., an interview was conducted with the Director of Admissions and when she was asked if she could provide a copy of Resident #45's Advanced Directive, the Director of Admissions stated, No, unable to locate a copy. When asked the process of obtaining Advanced Directives, the Director of Admissions stated, Upon admission I go over advanced directives with the resident or resident's responsible party and ask them if they have one. If they have one I ask the family to bring it in and I upload the advance directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advance directive, the Director of Admissions stated, I do not do any further follow up. When the Director of Admissions was asked if the advanced directive should be accessible for staff, the Director of Admissions stated, It probably should be. The Director of Admissions stated, I have contacted the resident's family to bring in a copy of the advanced directive and I will add it to the resident's chart when I receive it. Moving forward I will have a follow up process in place. The Administrator, Director of Nursing and Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2019 at approximately 7:10 p.m. The facility did not present any further information about the finding. 5. Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #84's most recent MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 11/11/19. Resident #84 was coded as being cognitively intact scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #84's clinical record revealed a Readmission Agreement that documented in part, the following: I do/ I do not have an advanced directive. An X was marked by I do have an advanced directive. This form was signed by the resident on 12/19/19. Review of Resident #84's clinical record revealed a DNR (Do not Resuscitate Order) form that was signed by the Resident on 12/12/19. Further review of Resident #84's clinical record failed to evidence her advanced directive. On 1/8/20 at 4:06 p.m., an interview was conducted with ASM (administrative staff member) #1, the Administrator. ASM #1 stated that upon admission the resident completes the admission or readmission agreement and checks whether they have an advanced directive or do not have an advanced directive. ASM #1 stated that the business office manager was responsible for going over advanced directive information with the resident. ASM #1 stated that if the resident does not have an advanced directive, staff will offer to formulate one. ASM #1 stated that residents are not required to have an advanced directive. ASM #1 stated that if a resident already has an advanced directive, staff will ask family to bring it in. When asked the process if family does not bring in the advanced directive, ASM #1 stated, Sometimes we just don't get it. ASM #1 then stated that sometimes staff will ask the resident or POA (power of attorney) if they would like to create a new advanced directive at the facility. When asked who was responsible for following up with the family or resident on the status of their advanced directive, ASM #1 stated that the social worker did the follow up and also created a new advanced directive with the resident/POA if one could not be provided. When asked if follow up and if the resident declines to create another advanced directive should be documented in the clinical record, ASM #1 stated that he was not sure. On 1/9/20 at 1:45 p.m., an interview was conducted with OSM (other staff member) #4, the Director of Social Services. OSM #4 stated that if a resident has an advanced directive, she will ask the family or resident for a copy. OSM #4 stated that the copy is then placed in the electronic medical record. When asked the process if she could not obtain the advanced directive from the family or resident, OSM #4 stated that she did not do anything. When asked if she offers to formulate a new advanced directive with the resident and/or POA (power of attorney), OSM #4 stated that she did not. On 1/9/20 at 2:55 p.m., an interview was conducted with OSM #5, admissions. When asked the process of obtaining advanced directives for residents, OSM #5 stated that upon admission, she will go over advanced directives and ask the resident whether or not they have one. OSM #5 stated that if the resident has an advanced directive, she will ask the family to bring it in. OSM #5 stated that she will then upload the advanced directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advanced directive, OSM #5 stated that she did not do any further follow up. OSM #5 stated that she did not ask residents if they would like to formulate a new advanced directive if she could not obtain a copy. When asked if the advanced directive should be accessible for staff, OSM #5 stated that it probably should be. OSM #5 was asked if she could find an advanced directive for Resident #84. On 1/9/20 at 3:12 p.m., OSM #5 stated that she could not find Resident #84's advanced directive. On 1/9/20 at approximately 7:00 p.m., ASM #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the ADON (Assistant Director of Nursing) were made aware of the above concerns. Facility policy titled, Advanced Directives Policy documents in part, the following: An advanced directive is a written document that specified choices for health care services and/or names another individual(s) to make those choices on the Resident's behalf, and is every Resident's right to formulate such document. These choices may include the refusal or withdrawal of certain medical care and treatments. The Facility will honor advanced directives that are provided and developed in accordance with State law and appropriate to the level of care and services which the Facility is licensed to provide .If the Resident has an advanced directive, they must make it known, and provide the Facility with a copy for review and to be made part of the Residents medical record.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure RN coverage for 8 hours for four days. The findings included: On 01/09/20 at approximately 2:00 PM, the facility's actual worked schedule was reviewed with the DON (Director of Nursing) and revealed there was no RN coverage for the following days: 1/19/19, 1/20/19, 5/5/19, 5/27/19. The DON was asked what should have been done concerning providing Registered Nursing Coverage? He stated, We should have gotten RN coverage. On 01/09/20 at approximately, 7:12 PM a pre-exit interview was conducted with The Director of Nursing (DON), the ADON (Assistant Director of Nursing) and the facility Administrator concerning the above issue. No further information was provided by the facility staff.

Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow orders to change the nebulizer tubing every 7 days as ordered and failed to administer oxygen per physician orders, for one of 37 residents in the survey sample, Resident #12. The findings included: 1a. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set) assessment was a Quarterly Revision assessment with an ARD (assessment reference date) of 10/10/19. Resident #12 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #12 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy. Review of Resident #12's POS (physician order [REDACTED]. The TAR (Treatment Administration Record) included: Change any 02 tubing weekly on Sunday. On 01/07/20 at 12:20 PM an observation was made of Resident #12's Nebulizer machine located on a side table. The tubing was in a plastic bag with an outside label reading 01/06/19. The tubing inside of the bag had a label affixed reading 12/29/19. On 01/08/20 at 10:51 AM an observation was made of Resident #12's nebulizer machine. The tubing was inside a bag located on the side table. Labeling remained unchanged. On 01/09/20 at 9:23 AM There was no nebulizer machine or tubing found in the Resident's room. The ADON (Assistant Director of Nursing) was informed that the nebulizer tubing and machine was on the side table in Resident's room for last two days. On 01/09/20 at approximately, 1:30 PM an interview was conducted with LPN (Licensed Practical Nurse) #2. She was asked about Resident #12's nebulizer machine and tubing. She said she wasn't aware of anything concerning the nebulizer. The ADON (Assistant Director of Nursing) Confirmed that Resident #12's nebulizer machine and tubing had been removed from the resident's room by the Director of Nursing (DON). On 01/09/20 at approximately, 4:40 PM, the DON confirmed that he had removed the nebulizer machine and discarded the outdated tubing yesterday. He stated that Resident #12 receives Nebulizer treatments as needed and the tubing is changed on Sundays. He also stated that Resident hasn't used his nebulizer in a while so the tubing should have been discarded by nursing staff. 1b. Review of Resident #12's POS (physician order [REDACTED].@ (at) 4 L (liters) via N/C (nasal cannula) every shift. Resident #12's care plan revised on 12/20/19 documented in part, the following: Resident has potential risk for Altered cardiac/respiratory status in Gas exchange r/t (related to) [MEDICAL CONDITION] [MEDICAL CONDITION] and Heart Failure. Goal: No S/S of cardiac/Respiratory Issues. Initiated on 04/05/2016. Revised on: 07/22/2019. Interventions: Oxygen per MD order. Revised on 10/17/19. The MAR (Medication Administration Record) included: Oxygen @ 4 liters via Nasal Cannula every shift. The (MONTH) MAR indicated [REDACTED]. On 01/07/20 at 12:20 PM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set at 2 liters per minute. On 01/08/20 at 10:51 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters. On 01/09/20 at 9:23 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters. The reading was confirmed with the ADON (Assistant Director of Nursing). She was asked to provide a copy of the physicians order summary. On 01/09/20 at approximately, 1:30 PM An interview was conducted with LPN (Licensed Practical Nurse) #2. She was asked to confirm how many liters of oxygen Resident #12 be administered? She stated, I thought that he was on two. She was given the opportunity to look up the Resident's Oxygen orders. She then stated, Oh the orders say 4 liters. She was then asked how many liters of oxygen should resident #12 be receiving? She stated, He should have been set on 4 liters. The ADON (Assistant Director of Nursing) Confirmed that Resident #12 should be receiving 4 liters of Oxygen. On 01/09/20 at approximately, 7:12 PM a pre-exit interview was conducted concerning the above issues with the Administrator and DON. No additional information was provided by facility staff.

Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow physician orders [REDACTED].#12. The facility staff failed to administer the correct amount of oxygen per nasal cannula. The findings included: Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12's most recent MDS (minimum data set) assessment was a Quarterly Revision assessment with an ARD (assessment reference date) of 10/10/19. Resident #12 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #12 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy. Review of Resident #12's POS (physician order [REDACTED].@ (at) 4 L (liters) via N/C (nasal cannula) every shift. Resident #12's care plan revised on 12/20/19 documented in part, the following: Resident has potential risk for Altered cardiac/respiratory status in Gas exchange r/t (related to) [MEDICAL CONDITION] [MEDICAL CONDITION] and Heart Failure. Goal: No S/S of cardiac/Respiratory Issues. Initiated on 04/05/2016. Revised on: 07/22/2019. Interventions: Oxygen per MD order. Revised on 10/17/19. The MAR (Medication Administration Record) included: Oxygen @ 4 liters via Nasal Cannula every shift. The (MONTH) MAR indicated [REDACTED]. On 01/07/20 at 12:20 PM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set at 2 liters per minute. On 01/08/20 at 10:51 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters. On 01/09/20 at 9:23 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters. The reading was confirmed with the ADON (Assistant Director of Nursing). She was asked to provide a copy of the physicians order summary. On 01/09/20 at approximately, 1:30 PM An interview was conducted with LPN (Licensed Practical Nurse) #2. She was asked to confirm how many liters of oxygen Resident #12 be administered? She stated, I thought that he was on two. She was given the opportunity to look up the Resident's Oxygen orders. She then stated, Oh the orders say 4 liters. She was then asked how many liters of oxygen should resident #12 be receiving? She stated, He should have been set on 4 liters. The ADON (Assistant Director of Nursing) Confirmed that Resident #12 should be receiving 4 liters of Oxygen. On 01/09/20 at approximately, 7:12 PM a Pre-exit interview was conducted concerning the above issues. No further information was provided by the facility staff.

Based on observations, staff interviews and clinical record review the facility staff failed to ensure the quarterly Minimum Data Set (MDS) assessment accurately reflected 1 of 37 residents in the survey sample, Resident #48. The findings included: Resident #48 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #48's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/21/2019 coded Resident #48 with a BIMS (Brief Interview for Mental Status) score of 03. indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #48 as requiring extensive assistance of 1 with eating, total dependence with assistance of 1 for dressing, personal hygiene and bathing and total dependence with assistance of 2 for bed mobility, transfer and toilet use. On 01/09/2019 at approximately 4:30 p.m., review of Resident #48's clinical record revealed the following: Review of Resident #48's Quarterly Review Assessment with an Assessment Reference Date of 11/21/2019 revealed Section N N0410 Medications Received was coded as receiving an Antipsychotic during the last 7 days. Review of Resident #48's Order Summary Report dated with Active Orders As Of 11/01/2019 did not evidence any orders for Antipsychotic medications. On 01/09/2019 at 4:56 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #4, the MDS Coordinator. When the MDS Coordinator was asked if Resident #48 received an antipsychotic in (MONTH) 2019, the MDS Coordinator stated, No she did not. I made an error inputting the data. I should have coded the resident as receiving an anti anxiety medication. When asked if the assessment was an inaccurate assessment, the MDS Coordinator stated, Yes. The Administrator, Director of Nursing and the Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2019 at approximately 7:10 p.m. When the Director of Nursing was asked what his expectations were of the nurses when completing MDS's, the Director of Nursing stated, I will get back to you. On 01/09/2019 at approximately 7:30 p.m., the Director of Nursing stated, Our expectation is that MDS Assessments be completed accurately according to the RAI (Resident Assessment Instrument) manual.

Based on observations, staff interviews and facility documentation, the facility staff failed to ensure infection control practices were followed during wound care for 1 of 37 residents in the survey sample, Resident #302. The findings included: Resident #302 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #302's Nurse Admission Evaluation with an evaluation date of 12/30/2019 revealed that the resident was AOx4 (Alert and Oriented times 4). In addition, the Nurse Admission Evaluation revealed that the resident was evaluated as requiring assistance of 1 with ADL's (Activities of Daily Living). On 01/08/2020 at 11:35 a.m., Resident #302's wound care was observed. Licensed Practical Nurse (LPN) #3, Wound Care Nurse, was assisting the physician during wound care. LPN #3 performed hand hygiene and then placed a barrier on the bedside table top. LPN #3 obtained needed wound care supplies from the treatment cart outside the resident's room. LPN #3 used her bandage scissors to cut the dirty kling wrapping from around Resident #302's right heel. LPN #3 then removed the dirty kling wrapping and dressing from around the right heel and then cleansed the wound with wound cleanser and 4x4 gauze sponge. The physician measured the resident's right heel wound and then used a scalpel to debride the wound while LPN #3 held the resident's leg. LPN #3 then laid the resident's foot down on a barrier pad and the LPN removed her gloves. LPN #3 performed hand hygiene, applied clean gloves and then applied [MEDICATION NAME] with a applicator to the right heel wound. LPN #3 covered the wound with a dry 4x4 gauze dressing and wrapped the heel with gauze kling. LPN #3 removed her dirty gloves and performed hand hygiene. LPN #3 failed to remove her dirty gloves and perform hand hygiene after removing the dirty dressing from the right heel and prior to cleansing the wound. On 01/08/2020 at approximately 12:48 p.m., observation was reviewed and an interview was conducted with LPN #3. When LPN #3 was asked what she should do when going from a dirty procedure to a clean procedure, LPN #3 stated, I should have removed my gloves and washed my hands after removing the dirty dressing and before I cleaned the wound on the right heel. I always do that but I guess I was nervous. Observation was reviewed and an interview was conducted with the Director of Nursing (DON) on 01/09/2010 at 2:20 p.m., and when the DON was asked what his expectations were of nurses when performing wound care, the DON stated, I expect them to wash their hands and don new gloves between feet. The Administrator, Director of Nursing and Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2020 at approximately 7:10 p.m. The facility did not present any further information about the finding.

Based on a complaint investigation, medical record review, staff interviews, and facility document review the facility staff failed to ensure that the licensed nurses had specific competencies and skill sets to identify a significant change of condition, thoroughly assess, monitor and obtain emergent care for 1 of 2 residents in the survey sample that was experiencing new onset signs and symptoms of an acute stroke on 4/8/19 resulting in an acute [MEDICAL CONDITION] which constitutes harm, Resident #1. The facility staff failed to ensure that the licensed nurses had specific competencies and skill sets to identify a significant change of condition, thoroughly assess, monitor and obtain emergent care for 1 of 2 residents in the survey sample that was experiencing new onset signs and symptoms of an acute stroke on 4/8/19 resulting in an acute [MEDICAL CONDITION] which constitutes harm, Resident #1. The findings included: Resident #1 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Comprehensive Minimum Data Set (MDS) was an Admission Assessment with an Assessment Reference Date (ARD) of 2/4/19. The Brief Interview for Mental Status (BIMS) was a 7 out of a possible 15 indicating that Resident #1 was cognitively impaired but capable of some daily decision making. Under Section G Functional Status Resident #1 was coded as requiring Extensive (resident involved in activity, staff provide weight-bearing support) One person physical support for bed mobility and transfers. Under Functional Limitation in Range of Motion Resident #1 was coded as having No Impairment in upper or lower extremities. Resident #1's Progress Notes were reviewed and are documented in part, as follows: 4/8/2019 14:50 (2:50 P.M.): SBAR (Situation, Background, Assessment, Recommendation): S Situation:Change in condition, symptoms or signs I am calling about is/are: Other: change in condition, increased sedation noted. This started on 04/08/2019 and the time of day: Afternoon. A Assessment: Vitals: BP (blood pressure) 170/62-4/8/19 14:50 (2:50 PM) Position: sitting r/arm (right arm), P (pulse) 61-4/8/19 14:51 (2:51 P.M.) Resident has decreased level of consciousness (sleepy, lethargic), No changes observed in functional status, no behavioral changes, no respiratory changes observed. [MEDICAL CONDITION] noted. No changes observed with abdominal. No urinary changes observed. Other neurological symptoms observed. Resident received [MEDICATION NAME] at 8-12-4-8 changed times of [MEDICATION NAME] to every 6 secondary to sedation. Resident appears to be sedated. Medication reviewed and [MEDICATION NAME] changed to every 6. Labs ordered and UA (urinalysis). Weakness on left side noted. Responds to verbal and tactile stimuli. Addendum: for additional and more in depth assessment see assessment (einteract Change of Condition Evaluation) R Request: Reported to primary care clinician: Name (Nurse Practitioner) on 4/8/2019 3:00 P.M. Orders obtained : Blood tests Urinalysis or culture. Name of Family/healthcare agent notified: Name (Resident #1's Daughter #2) This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 14:52 (2:52 P.M.): Nursing Note Residents daughter in to visit and states mother is different and not responding. VSS (vital signs stable) WNL (within normal limits), noted [MEDICAL CONDITION] of bilateral lower extremities which is not different for this resident. Feet elevated. Resident responds to tactile and verbal stimuli readily. Name (Nurse Practitioner) called and updated on vss and residents daughter concerns. New orders for stat CBC (complete blood count), BMP (basic metabolic panel) and UV & C&S (urinalysis culture and sensitivity). This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/20 15:21 (3:21 P.M.): Nursing Note [MEDICATION NAME] scheduled for 4 times daily. Times changed to every 6 hours and she has the extra dose as needed. She also takes a sleeping medication. Awaiting lab to draw labs. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 15:50 (3:50 P.M.): Nursing Note Per charge nurse resident is moving left side without problem. According to daughter resident has hx (history) of TIA's ([MEDICAL CONDITION]). Will continue to monitor. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 16:01 (4:01 P.M.): Nursing Note Lab her and labs drawn. UA obtained via straight cath and lab called for pickup. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 16:17 (4:17 P.M.): Medication Administration Note [MEDICATION NAME] Tablet 25 MG (milligram) give 0.5 tablet by mouth two times a day for hypertension held d/t (due to) sedation. This note was completed by LPN (Licensed Practical Nurse) #2. 4/8/2019 16:18 (4:16 P.M.): Nursing Note Name (Nurse Practitioner) updated. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/9/2019 00:42 (12:42 A.M.): Nursing Note Resident sent to ER (emergency room ) per family request for stroke like symptoms. Resident left via ambulance accompanied by family. This note was completed by LPN (Licensed Practical Nurse) #3. Resident #1's SBAR Communication Form dated 4/8/19 at 15:45 (3:45 P.M.) was reviewed and is documented in part, as follows: SITUATION: The change of condition, symptoms or signs I am calling about is/are: Other change in condition: Increased sedation noted. This started on: 04/08/2019 What time of day did this start? Afternoon Since this has started has it: Stayed the same. This condition, symptom or sign has occurred before: No. 1. Mental Status Evaluation (compared to baseline): Decreased level of consciousness (sleepy, lethargic). 1a. Specify the decreased level of consciousness: Gradual change in level of consciousness not associated with other criteria for immediate notification. 2. Functional Status Evaluation: No changes observed. 10. Neurological Evaluation (compared to baseline): Other neurological symptoms. 10f. Describe symptoms or signs: Appears sleepy, Responds to verbal and tactile stimuli. ASSESSMENT (RN) Registered Nurse or APPEARANCE (LPN) Licensed Practical Nurse: For RNs: Blank For LPNs: Resident appears to be sedated. Medication reviewed and [MEDICATION NAME] changed to every 6. Labs ordered and UA. Weakness on left side noted. Responds to verbal and tactile stimuli. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. Resident #1's eInteract Transfer Form dated 4/9/19 at 6:35 A.M. completed by LPN #3. was reviewed and is documented in part, as follows: 2. Transfer/Discharge Details Date: 4/8/19 23:00 (11:00 P.M.) Reason(s) for: Other Is the reason for transfer: Unplanned 3. Code Status: FULL CODE B. Key Clinical Information: 3. Vital Signs 1. Most Recent Blood Pressure: Blood Pressure: 170/62 Position: Sitting right arm Date: 4/8/2019 14:50 (2:50 P.M.) 2. Most Recent Pulse: Pulse: 61 Pulse Type: Regular Date: 4/8/2019 15:40 (3:40 P.M.) 3. Most Recent Respiration: Respiration: 18 Date: 4/8/2019 14:50 (2:50 P.M.) 4. Most Recent Temperature: Temperature: 98.0 Route: Axilla Date: 4/8/2019 14:50 (2:50 P.M.) 5. Most Recent O2 (oxygen) Saturations: O2 Sats: 99% Method : Room Air Date: 4/8/2019 14:50 (2:50 P.M.) C. Additional Clinical Information 1. Usual Mental/Cognitive Function before Acute Change In Condition: Alert, oriented, follows instructions. 2. Usual Functional Status before Acute Change In Condition: Ambulated Independently. Resident #1's Activities of Daily Living Documentation Sheets were reviewed and are documented in part, as follows: Intervention/Task: Transferring Date: 4/8/2019 Time: 15:00 (3:00 P.M.) 4,3: Total Dependence with 2 + person assist Date: 4/8/2019 Time: 19:00 (7:00 P.M.) 8,8: Activity Did Not Occur Intervention/Task: Amount Eaten-Dinner Date: 4/8/2019 Time: 18:00 (6:00 P.M.) 0=0 to 25% Intervention/Task: Intake Date: 4/8/2019 Time: 15:00 (3:00 P.M.) 0 cc's Date: 4/8/2019 Time: 19:00 (7:00 P.M.) 60 cc's The Emergency Medical Services Prehospital Care Report dated 4/8/19 at 23:36:08 (11:36 P.M.) at Resident #1's bedside was reviewed and is documented in part, as follows: Dispatch Complaint: Stroke/[MEDICAL CONDITIONS] Response Mode: Emergency (Immediate Response) Symptoms: Primary Symptom: Weakness Symptom Onset: 4/8/2019 13:45 (1:45 P.M.) Last Known Well: 4/8/2019 12:00 P.M. Vital Signs: Time: 23:40:56 (11:40 P.M.) Pulse: 74 Regular Blood Pressure: 174/90 Respirations: 18 Oxygen Saturation: 97% Blood Glucose: 71 Neurological: Weakness-Left Sided, Speech Slurring Narrative: Patient's family insists 911 be called about 12 hours later for assessment of patient. On 4/13/19 at 1:45 P.M. a phone interview was conducted with Resident #1's Daughter #1. Daughter #1 was asked to describe what occurred with her mother on 4/8/19. Daughter #1 stated, I call my mother everyday on the phone. I called her at 11 A.M. no answer, tried again at 12 noon but still no answer. So I went up to the nursing home around 2:30 P.M. and mother was in her recliner, she looked asleep. I said good afternoon mother, her eyes were just rolling around and she was acting like she didn't recognize me. When she briefly spoke her speech was slurred and then her head fell over like she had no control. I knew something was wrong because my mother is always alert , I visit her everyday. I went to the nurses stated and told them something is wrong with mother I thinks she has had a stroke. Three nurses came down and 2 of them took her vitals and said they were fine. Name (Unit Manager LPN #8) said she didn't know if this was normal for my mother, I told her no it wasn't normal at all. Mother couldn't move her left arm the nurse at the bed picked it up and it just fell back down on the bed. Her right shoulder is frozen so she uses her left arm for most everything. Name (Unit Manager LPN #8) asked me if mother has a history of [MEDICAL CONDITION] and I said yes she does mini [MEDICAL CONDITION] TIA's. She went to call the doctor and came back and told me that blood work was ordered to be done and that it would show us if she was having a stroke. The 2 other nurse's put her in bed and my mother never needs that much help she can stand and get in bed with just one person standing by her. Name (Unit Manager LPN #8) or the other 2 nurses never came back in the room after they put mother in bed. Her dinner came and my sister tried to feed her but she couldn't open her mouth. After dinner we still hadn't heard anything about the blood worked so I went to the nurse's station about 7:30 and asked the nurse (LPN#4) if they had the results because mother was still very unresponsive. Name (LPN #4) said no we are still waiting on the lab work. I asked her if we could call the paramedics to take mother to the hospital, she said no there was no facility order to send her to the hospital and that the blood work would show id she has had a stroke, She also said if we went to the hospital they would just repeat the blood work so we should just wait. At 10:30 P.M. I went up to the nurse's station and asked another nurse if mother's blood work was ready. The Head Nurse said it still wasn't ready but that it is up to the family if we wanted to call 911. I went back to mother's room and told my sister what the Head Nurse said and we decided we wanted her to go to the hospital because we knew something was wrong. When (11 got there they asked my sister and I why did we wait so long to call. No nurse came into my mother's room from 5:00 to 11:00 P.M. to check on her or even monitor to see how she was. The next day I came in to get mother's things and Name (Director of Nursing) said that the lab results weren't back yet and just wanted to know about the type of stroke mother had. My mother had a stroke and now she is paralyzed on her left side. I knew something was wrong with her and I kept telling the nurses, but no one came in to check on her. No one ever told us until 10:30 P.M. that we could request for our mother to go to the hospital to be checked out. On 5/13/19 at 2:42 P.M. an interview was conducted with CNA (Certified Nursing Assistant) #1. CNA #1 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. CNA #1 stated, I was not the assigned CNA for her that day but around 2:30 P.M. I assisted Name (CNA #3) to reposition her back in the chair. She (Resident #1) wasn't her perky self, she didn't talk. She looked like someone who had a stroke. It usually only takes 1 person to transfer her but today it took 2 people. I thought something was wrong with her to take 2 people to reposition her. She was better in the morning but much different in the afternoon. The daughter said she thought she was having a stroke. On 5/13/19 at 2:53 P.M. an interview was conducted with CNA #2. CNA #3 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. CNA #3 stated, Her daughter came to the desk and said something is wrong with her mother and she was low in her chair, so I got Name (CNA #1) to help me pull her up in the chair. She looked like she was asleep and her speech was real low. She was real sassy that morning when I got her up but now she couldn't reposition herself, it took 2 of us and she looked real tired. The nurses came down and checked her and then I left. On 5/13/19 at 2:55 P.M. an interview was conducted with LPN #2. LPN #2 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #2 stated, Her daughter came up to the desk and said that her mother didn't seem right, so me, Name (LPN #4), and Name (Unit Manager LPN #8) went down to the room to check on her. It took a minute to rouse her, she was difficult to get to her to rouse. It took two of us to get her from the chair to the bed, she pushed a little but not much. We had to lift her legs up on the bed for her and then she leaned back. Her vitals were good. I know we got Stat labs ordered and we monitored her some after that. LPN #2 was asked if she assessed the resident for the change of condition. LPN #2 stated, No I did not because I was new and was still precepting. LPN #2 was asked what she would do for a resident who was have a change of condition with signs and symptoms of a stroke. LPN #2 stated, I would check the grips on both sides, and their pupils and call the doctor. I would send them out to the hospital just because if it is a stroke there is nothing we can do here for them. On 5/13/19 at 3:17 P.M. an interview was conducted with Unit Manager LPN #8. Unit Manager LPN #8 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19 and what actions she took. Unit Manager LPN #8 stated, It was about 2:45 P.M. Name (LPN #4) who was orienting LPN #2 came and told me that Name (Resident #1's) daughter was concerned because her mom was not acting right, not acting herself. I went down to Name (Resident#1's ) room and Name (Resident #1) was sitting in her chair. I called her name she opened her eyes and she responded to tactile and verbal stimuli. I had her grasp my hands and she had left sided weakness. Her daughter kept insisting that something was wrong. She was new to me I had only had her on my floor for 4 or 5 days so I wasn't sure if she was acting different. There were 2 other nurses were getting her vitals for me. I went back and called Name (Nurse Practitioner) and told her that Name (Resident #1 was sleepy and seemed sedated. I thought it was her [MEDICATION NAME] so we changed the times of it and she ordered stat labs. I went down to tell her daughter that the labs had been ordered and that the lab would be here shortly to drawl them. The other nurses had put the resident back in bed The daughter told me that her mother had a history of [REDACTED]. She texted back and said we could send her to the hospital if the family requested. I told her they said they were just gonna wait for the lab results. Unit Manager LPN #8 was asked if she wrote the order from the Nurse Practitioner that the resident may be sent to the emergency room per family request and if she documented in the resident's medical record so the other nurse's where aware. Unit Manager LPN #8 stated, No, I didn't take it as an order. I didn't document it in the nurse's notes either. I should have and I usually do, I just didn't document it there was a lot going on that day. Unit Manager LPN #8 was also asked why she felt Resident #1 did not need to be further evaluated when she assessed her that day. Unit Manager LPN #8 stated because I thought it was just from her [MEDICATION NAME] because I didn't know her that well and later I found out that she had been on that medication for a long time. Also is she was having a TIA they will usually resolve themselves. Thinking about it now I would have sent her out 911 because the family know her better than me. On 5/13/19 at 3:40 P.M. an interview was conducted with CNA #2. CNA #2 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. CNA #2 stated, I work 3-11 and when I got there she was already in bed and not saying a whole lot. Her daughter was in the room with her. I though it was odd she was in bed so early because she always stays up late, usually until way after 11 P.M. She never gets in the bed early. I took her her dinner but she didn't eat she was sleeping a lot. On 5/13/19 at 3:47 P.M. an interview was conducted with LPN #3. LPN #3 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN#3 stated, I got here at 7 P.M. and in report I was told that Name (Resident #1) was having stroke like symptoms , that labs had been done and that the family was wanting her to go out to be checked. I was still in orientation then. The family came up to me around 8 P.M. and asked if the labs were back yet and I told them they were back yet and they were asking if she (Resident #1) should go to the hospital. I told then the labs would show if she was having a stroke. I don't know what labs were ordered but I was just trying to calm the family down. LPN #3 was asked if she ever went in to assess Resident #1 during her shift. LPN #3 stated. No I never went in to assess her or did any paperwork I was new, Name (LPN #5) and Name (LPN #6) went to talk to the family. On 5/13/19 at 5:30 P.M. a phone interview was conducted with LPN #5. LPN #5 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #5 stated, We were short nurses that night so I got pulled to Unit 200, I usually work Unit 300. Name (LPN#3) called me to come over to help her with a resident that had fallen. In her defense she was new and was still in orientation. When I was at the desk Name (Resident #1's ) family came up asking about the status of her lab work. I had heard earlier in the day that she was having stroke symptoms. I called the lab the results were not back yet and they said to call them back in an hour. I then went back to finish my work on Unit 2. Later she called me back over to help her because the family wanted the resident to be sent out. LPN #3 said she could not raise her arms and she did not have equal strength in her hands, I called 911 and started getting the paperwork ready. LPN #5 was asked what should you do for a resident who is experiencing signs and symptoms of a stroke. LPN #5 stated, I would do an assessment to check strength, speech and vitals then I would get help for the resident immediately to prevent permanent damage. I would send them out to the hospital. On 5/13/19 at 6:00 P.M. a phone interview was conducted with LPN #4. LPN was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #4 stated, He daughter came up to the desk and said she didn't seem right. Myself and Name (LPN #2) went down to checked her and get vitals. Name (Unit Manager LPN #8 ) also came down to check her. I checked her pupils and had her grab my hands. Her left hand was weaker. She looked like she had too much pain medicine. She looked very tired. We (myself and LPN #2) put her in bed with 2 person transfer assist provided. We gave her weight bearing assist by holding on to her by her pants. Name (Unit Manager LPN #8) called the Nurse Practitioner and labs were ordered. LPN #4 was asked if labs could determine if someone was having a stroke and what did she report on Resident #1 to the oncoming shift at 7:00 P.M. LPN #4 stated, No only the hospital determine if someone is having a stroke. In report I told the Name (LPN #3) that Name (Resident #1) had a change of condition today and that labs had been drawn. The family was concerned that maybe she wasn't doing too good. Daughter also reported that the resident had a history of [REDACTED]. LPN #4 was asked if she documented her assessment of Resident #1 and any follow-up monitoring. LPN #4 stated, I don't remember, I don't think so, probably not. I reported my findings to the supervisor. On 5/14/19 at 11:00 A.M. an interview was conducted with Unit Manager LPN #7. Unit Manager LPN #7 was asked what she would do if she had a resident whom was having signs and symptoms of a stroke. Unit Manager LPN #7 stated, I would immediately assess the resident by checking the pupils, hand grasps, range of motion, any weakness, speech,and cognition. I would not waste a lot of time on the assessment because we have a very short window with a stroke like 3 to 4 hours. I would call the doctor and send them out to the hospital because there is nothing we can do to treat a stroke in the facility. We do have some worrisome families, but we need to value their input because they know them better than we do. On 5/14/19 at 11:05 A.M. a phone interview was conducted with the facility Nurse Practitioner. The Nurse Practitioner was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. The Nurse Practitioner stated, I got a call from Name (Unit Manager LPN #8) around 2:50 P.M. stating the Name (Resident #1) had increased swelling in her legs, that the family was saying she wasn't right, her vitals were stable and good, oxygen saturations good, she was responding to verbal and tactile stimuli. I ordered stat lab work and gave an order that the resident could be sent out to the hospital per the family request because I know this family. She never indicated that the resident was having stroke like symptoms. I If I would have know that I would not have ordered labs but would have sent her out to the hospital immediately. At 3:10 P.M. I received a text from Name (Unit Manager LPN #8) stating the resident has some left sided weakness also and that the family was concerned. I texted back that they could sent her out if that is what the family wanted. Name (Unit Manager LPN #8) sent me another text at 4:16 P.M. saying the family was gonna wait for the lab results. That she (Resident #1) was alert and oriented, moving better and that they changed the dosage times of her [MEDICATION NAME]. She also texted that the daughter stated the resident had a history of [REDACTED]. Not one time did anyone ay she was going downhill or having any signs or symptoms of a stroke. If I had known she was having stroke symptoms I would have sent her out 911. The Nurse Practitioner was asked why is it important so sent someone out tot he hospital if there are having signs or symptoms of a stroke. The Nurse Practitioner stated, Because they need medications to help reverse the stroke and there is a very short window to provide these medications. I should have been called not texted about her condition and symptoms. They failed to provide me with an accurate assessment of the resident's condition. This family is very adamant about their mother's care. I just found out today she did actually have a stroke that day and I see there is no documentation where I told them to send her out if that was what the family requested and no order as well. On 5/14/19 at 10:30 A.M. a phone interview was conducted with Resident #1's daughter #2. Daughter #2 was asked if anyone had made them aware that the Nurse Practitioner had stated that the resident could be transported to the hospital per the family request prior to her being transported to the hospital. Daughter #2 stated, No, no one ever told us that until around 10:30 P.M. when I inquired again about her labs that we had been waiting all night for and them my sister and I decided we could not wait on the labs any longer and requested she be sent to the hospital. We were relying on what they were telling us. That the lab work would tell us if she was having a stroke and that if she went out the hospital would just have to start over and repeat everything. On 5/14/19 at 1:15 P.M. a phone interview was conducted with LPN #6. LPN #6 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #6 stated, Name (LPN#5) asked me to go over to Unit 3 and help Name (LPN #3) because a family member had some concerns and she was still passing medications. I went to the resident's room (Resident #1) and the family was sitting at the bedside with her. They recognized me and asked me if her labs had come back yet. She (Resident #1) was not acting herself and appeared different, she was not talking. I know her. My grandmother and her grew up in the same town and she always asks me about her. Tonight she looked asleep, eyes closed. She finally opened her eyes and nodded her head but did not speak which was very different for her. Also she couldn't really move her left side. She will usually turn over with only limited assist, but she wouldn't turn at all. I told the family I would go check on the labs. I asked Name (LPN #3) what was going on with her, she said she had a change of condition and we were waiting on the labs. I called the lab and the results were still not available. I checked the nurse's notes to see what was going on with the resident. I went back and told the family that the labs were still not available. The daughter stated if the labs are not back soon we are going to want her to go to the hospital. I told they family they could always request for her to be sent out and that I would make it my business to come back in 20 to 30 minutes to check on her. She (Resident #1) was not acting herself, there was definitely a change of condition from what I'm used to seeing in her. I went back to my floor and soon after I was told she was going out to the hospital. LPN #6 was asked if she was aware that earlier in the day the Nurse Practitioner had given an order that if the family wanted the resident to go to the hospital the facility should send her. LPN #6 stated, No, I didn't know that. I did think it was a possibility she was having a stroke because she wasn't as verbally responsive as she usual is and she was weaker on her left side, but I saw where the Nurse Practitioner was notified. On 5/14/19 a phone interview was conducted with the Medical Director who was also the Attending Physician for Resident #1. The Medical Director was asked what are his expectation of the facility if a resident is experiencing signs or symptoms of a stoke. The Medial Director stated, Any new neurological deficit indicates a possible stroke. Left sided weakness is a focal deficit that should be treated as an emergency and the resident needs to be sent to the emergency room . Only a CT (Computed Tomography) Scan can determine if a stroke as occurred. With a stroke we have a very short 3 to 4 hour window to start tPA (Tissue Plasminogen Activator- works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow). No long term facility has the ability to Do A CT of the brain. A CT is the first evaluation for a stroke. When rely on the nurse's assessment and the facility failed to communicate a through assessment of Name (Resident #1) to Name (Nurse Practitioner). If the nurse had called and said we have new onset left sided weakness, the resident is lethargic and the family states there is a history of TIA's then we would have said to send to to the emergency room immediately. The facility also has the Telemed System where they call roll the computer into the resident's room and a doctor is on the other side looking at the resident, doing an assessment and giving orders to the facility in realtime. This is available 24 hours a day. On 5/14/19 at approximately 4:00 P.M. debriefing was held with the Administrator, the Director of Nursing, the Assistant Director of Nursing and the Regional Director of Clinical Services where the above finding were shared. The Regional Director of Clinical Services stated, It looks like we did have a delay in treatment, and we need more education on [MEDICAL CONDITION] and monitoring. Also there is no documentation to support what was done for the resident. The Administrator stated, We did give her the care, we just failed to document it. The Regional Director of Clinical Services stated, If it wasn't documented it was not done. Everyone exited the room except for the Director of Nursing. The Director of Nursing stated, Thank you for finding this, something's I just can't fix in just 6 months. If they don't document I can't help them. I agree we failed this resident, if I had documentation I could have defended it. On 5/14/19 at 11:15 A.M. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was asked who was responsible for providing education to the staff members and when was the last time training in acute change of condition and sign and symptoms of a stroke were provided. The ADON stated, I'm responsible for the facility training and those topics are on my calendar to teach this month to the nursing staff. Name (Director of Nursing) started training on Change of Condition last night. Resident #1's Stat Lab work that was ordered on [DATE] was not received in the facility and reviewed until 4/9/18 at 7:45 A.M. Resident #1's Hospital emergency room Treatment Report dated 4/9/19 at 12:17 A.M. was reviewed and is documented in part, as follows: Chief Complaint: Altered Mental Status Physical Exam: Constitutional: She appears lethargic. Neurological: She appears lethargic. She displays facial symmetry. Dysarthic. Lying on the stretcher with her eyes closed. Will wake up and answer questions. States that she just feels tired. Does not squeeze left hand. Does not withdrawal left leg to noxious stimuli. Impression and Management Plan: Based on physical exam with left arm and left leg weakness I am concerned about the possibility of stroke. We will check for metabolic abnormalities as well as infectious etiology. I have asked the charge nurse to activate stroke alert to and have requested tele-neurology consultation. Unfortunately the last known well time is difficult to assess and is mostly hearsay from what was told to the family. I have ordered CT scan unenhanced of the head and will consult tele-neurology. ED (Emergenc

Based on a complaint investigation, medical record review, staff interviews, and facility document review the facility staff failed to thoroughly assess, monitor and obtain emergent care for 1 (Resident #1) of 2 residents in the survey sample that was experiencing new onset signs and symptoms of an acute stroke on 4/8/19 resulting in an acute [MEDICAL CONDITION] which constitutes harm. The facility staff failed to thoroughly assess, monitor and obtain emergent care for Resident #1 who was experiencing new onset signs and symptoms of an acute stroke on 4/8/19 resulting in an acute [MEDICAL CONDITION] which constitutes harm. The findings included: Resident #1 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Comprehensive Minimum Data Set (MDS) was an Admission Assessment with an Assessment Reference Date (ARD) of 2/4/19. The Brief Interview for Mental Status (BIMS) was a 7 out of a possible 15 indicating that Resident #1 was cognitively impaired but capable of some daily decision making. Under Section G Functional Status Resident #1 was coded as requiring Extensive (resident involved in activity, staff provide weight-bearing support) One person physical support for bed mobility and transfers. Under Functional Limitation in Range of Motion Resident #1 was coded as having No Impairment in upper or lower extremities. Resident #1's Progress Notes were reviewed and are documented in part, as follows: 4/8/2019 14:50 (2:50 P.M.): SBAR (Situation, Background, Assessment, Recommendation): S Situation:Change in condition, symptoms or signs I am calling about is/are: Other: change in condition, increased sedation noted. This started on 04/08/2019 and the time of day: Afternoon. A Assessment: Vitals: BP (blood pressure) 170/62-4/8/19 14:50 (2:50 PM) Position: sitting r/arm (right arm), P (pulse) 61-4/8/19 14:51 (2:51 P.M.) Resident has decreased level of consciousness (sleepy, lethargic), No changes observed in functional status, no behavioral changes, no respiratory changes observed. [MEDICAL CONDITION] noted. No changes observed with abdominal. No urinary changes observed. Other neurological symptoms observed. Resident received [MEDICATION NAME] at 8-12-4-8 changed times of [MEDICATION NAME] to every 6 secondary to sedation. Resident appears to be sedated. Medication reviewed and [MEDICATION NAME] changed to every 6. Labs ordered and UA (urinalysis). Weakness on left side noted. Responds to verbal and tactile stimuli. Addendum: for additional and more in depth assessment see assessment (einteract Change of Condition Evaluation) R Request: Reported to primary care clinician: Name (Nurse Practitioner) on 4/8/2019 3:00 P.M. Orders obtained : Blood tests Urinalysis or culture. Name of Family/healthcare agent notified: Name (Resident #1's Daughter #2) This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 14:52 (2:52 P.M.): Nursing Note Residents daughter in to visit and states mother is different and not responding. VSS (vital signs stable) WNL (within normal limits), noted [MEDICAL CONDITION] of bilateral lower extremities which is not different for this resident. Feet elevated. Resident responds to tactile and verbal stimuli readily. Name (Nurse Practitioner) called and updated on vss and residents daughter concerns. New orders for stat CBC (complete blood count), BMP (basic metabolic panel) and UV & C&S (urinalysis culture and sensitivity). This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/20 15:21 (3:21 P.M.): Nursing Note [MEDICATION NAME] scheduled for 4 times daily. Times changed to every 6 hours and she has the extra dose as needed. She also takes a sleeping medication. Awaiting lab to draw labs. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 15:50 (3:50 P.M.): Nursing Note Per charge nurse resident is moving left side without problem. According to daughter resident has hx (history) of TIA's ([MEDICAL CONDITION]). Will continue to monitor. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 16:01 (4:01 P.M.): Nursing Note Lab her and labs drawn. UA obtained via straight cath and lab called for pickup. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/8/2019 16:17 (4:17 P.M.): Medication Administration Note [MEDICATION NAME] Tablet 25 MG (milligram) give 0.5 tablet by mouth two times a day for hypertension held d/t (due to) sedation. This note was completed by LPN (Licensed Practical Nurse) #2. 4/8/2019 16:18 (4:16 P.M.): Nursing Note Name (Nurse Practitioner) updated. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. 4/9/2019 00:42 (12:42 A.M.): Nursing Note Resident sent to ER (emergency room ) per family request for stroke like symptoms. Resident left via ambulance accompanied by family. This note was completed by LPN (Licensed Practical Nurse) #3. Resident #1's SBAR Communication Form dated 4/8/19 at 15:45 (3:45 P.M.) was reviewed and is documented in part, as follows: SITUATION: The change of condition, symptoms or signs I am calling about is/are: Other change in condition: Increased sedation noted. This started on: 04/08/2019 What time of day did this start? Afternoon Since this has started has it: Stayed the same. This condition, symptom or sign has occurred before: No. 1. Mental Status Evaluation (compared to baseline): Decreased level of consciousness (sleepy, lethargic). 1a. Specify the decreased level of consciousness: Gradual change in level of consciousness not associated with other criteria for immediate notification. 2. Functional Status Evaluation: No changes observed. 10. Neurological Evaluation (compared to baseline): Other neurological symptoms. 10f. Describe symptoms or signs: Appears sleepy, Responds to verbal and tactile stimuli. ASSESSMENT (RN) Registered Nurse or APPEARANCE (LPN) Licensed Practical Nurse: For RNs: Blank For LPNs: Resident appears to be sedated. Medication reviewed and [MEDICATION NAME] changed to every 6. Labs ordered and UA. Weakness on left side noted. Responds to verbal and tactile stimuli. This note was completed by LPN (Licensed Practical Nurse) #8 Unit Manager. Resident #1's eInteract Transfer Form dated 4/9/19 at 6:35 A.M. completed by LPN #3. was reviewed and is documented in part, as follows: 2. Transfer/Discharge Details Date: 4/8/19 23:00 (11:00 P.M.) Reason(s) for: Other Is the reason for transfer: Unplanned 3. Code Status: FULL CODE B. Key Clinical Information: 3. Vital Signs 1. Most Recent Blood Pressure: Blood Pressure: 170/62 Position: Sitting right arm Date: 4/8/2019 14:50 (2:50 P.M.) 2. Most Recent Pulse: Pulse: 61 Pulse Type: Regular Date: 4/8/2019 15:40 (3:40 P.M.) 3. Most Recent Respiration: Respiration: 18 Date: 4/8/2019 14:50 (2:50 P.M.) 4. Most Recent Temperature: Temperature: 98.0 Route: Axilla Date: 4/8/2019 14:50 (2:50 P.M.) 5. Most Recent O2 (oxygen) Saturations: O2 Sats: 99% Method : Room Air Date: 4/8/2019 14:50 (2:50 P.M.) C. Additional Clinical Information 1. Usual Mental/Cognitive Function before Acute Change In Condition: Alert, oriented, follows instructions. 2. Usual Functional Status before Acute Change In Condition: Ambulated Independently. Resident #1's Activities of Daily Living Documentation Sheets were reviewed and are documented in part, as follows: Intervention/Task: Transferring Date: 4/8/2019 Time: 15:00 (3:00 P.M.) 4,3: Total Dependence with 2 + person assist Date: 4/8/2019 Time: 19:00 (7:00 P.M.) 8,8: Activity Did Not Occur Intervention/Task: Amount Eaten-Dinner Date: 4/8/2019 Time: 18:00 (6:00 P.M.) 0=0 to 25% Intervention/Task: Intake Date: 4/8/2019 Time: 15:00 (3:00 P.M.) 0 cc's Date: 4/8/2019 Time: 19:00 (7:00 P.M.) 60 cc's The Emergency Medical Services Prehospital Care Report dated 4/8/19 at 23:36:08 (11:36 P.M.) at Resident #1's bedside was reviewed and is documented in part, as follows: Dispatch Complaint: Stroke/[MEDICAL CONDITIONS] Response Mode: Emergency (Immediate Response) Symptoms: Primary Symptom: Weakness Symptom Onset: 4/8/2019 13:45 (1:45 P.M.) Last Known Well: 4/8/2019 12:00 P.M. Vital Signs: Time: 23:40:56 (11:40 P.M.) Pulse: 74 Regular Blood Pressure: 174/90 Respirations: 18 Oxygen Saturation: 97% Blood Glucose: 71 Neurological: Weakness-Left Sided, Speech Slurring Narrative: Patient's family insists 911 be called about 12 hours later for assessment of patient. On 4/13/19 at 1:45 P.M. a phone interview was conducted with Resident #1's Daughter #1. Daughter #1 was asked to describe what occurred with her mother on 4/8/19. Daughter #1 stated, I call my mother everyday on the phone. I called her at 11 A.M. no answer, tried again at 12 noon but still no answer. So I went up to the nursing home around 2:30 P.M. and mother was in her recliner, she looked asleep. I said good afternoon mother, her eyes were just rolling around and she was acting like she didn't recognize me. When she briefly spoke her speech was slurred and then her head fell over like she had no control. I knew something was wrong because my mother is always alert , I visit her everyday. I went to the nurses stated and told them something is wrong with mother I thinks she has had a stroke. Three nurses came down and 2 of them took her vitals and said they were fine. Name (Unit Manager LPN #8) said she didn't know if this was normal for my mother, I told her no it wasn't normal at all. Mother couldn't move her left arm the nurse at the bed picked it up and it just fell back down on the bed. Her right shoulder is frozen so she uses her left arm for most everything. Name (Unit Manager LPN #8) asked me if mother has a history of [MEDICAL CONDITION] and I said yes she does mini [MEDICAL CONDITION] TIA's. She went to call the doctor and came back and told me that blood work was ordered to be done and that it would show us if she was having a stroke. The 2 other nurse's put her in bed and my mother never needs that much help she can stand and get in bed with just one person standing by her. Name (Unit Manager LPN #8) or the other 2 nurses never came back in the room after they put mother in bed. Her dinner came and my sister tried to feed her but she couldn't open her mouth. After dinner we still hadn't heard anything about the blood worked so I went to the nurse's station about 7:30 and asked the nurse (LPN#4) if they had the results because mother was still very unresponsive. Name (LPN #4) said no we are still waiting on the lab work. I asked her if we could call the paramedics to take mother to the hospital, she said no there was no facility order to send her to the hospital and that the blood work would show if she has had a stroke, She also said if we went to the hospital they would just repeat the blood work so we should just wait. At 10:30 P.M. I went up to the nurse's station and asked another nurse if mother's blood work was ready. The Head Nurse said it still wasn't ready but that it is up to the family if we wanted to call 911. I went back to mother's room and told my sister what the Head Nurse said and we decided we wanted her to go to the hospital because we knew something was wrong. When 911 got there they asked my sister and I why did we wait so long to call. No nurse came into my mother's room from 5:00 to 11:00 P.M. to check on her or even monitor to see how she was. The next day I came in to get mother's things and Name (Director of Nursing) said that the lab results weren't back yet and just wanted to know about the type of stroke mother had. My mother had a stroke and now she is paralyzed on her left side. I knew something was wrong with her and I kept telling the nurses, but no one came in to check on her. No one ever told us until 10:30 P.M. that we could request for our mother to go to the hospital to be checked out. On 5/13/19 at 2:42 P.M. an interview was conducted with CNA (Certified Nursing Assistant) #1. CNA #1 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. CNA #1 stated, I was not the assigned CNA for her that day but around 2:30 P.M. I assisted Name (CNA #3) to reposition her back in the chair. She (Resident #1) wasn't her perky self, she didn't talk. She looked like someone who had a stroke. It usually only takes 1 person to transfer her but today it took 2 people. I thought something was wrong with her to take 2 people to reposition her. She was better in the morning but much different in the afternoon. The daughter said she thought she was having a stroke. On 5/13/19 at 2:53 P.M. an interview was conducted with CNA #3. CNA #3 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. CNA #3 stated, Her daughter came to the desk and said something is wrong with her mother and she was low in her chair, so I got Name (CNA #1) to help me pull her up in the chair. She looked like she was asleep and her speech was real low. She was real sassy that morning when I got her up but now she couldn't reposition herself, it took 2 of us and she looked real tired. The nurses came down and checked her and then I left. On 5/13/19 at 2:55 P.M. an interview was conducted with LPN #2. LPN #2 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #2 stated, Her daughter came up to the desk and said that her mother didn't seem right, so me, Name (LPN #4), and Name (Unit Manager LPN #8) went down to the room to check on her. It took a minute to rouse her, she was difficult to get to her to rouse. It took 2 of us to get her from the chair to the bed, she pushed a little but not much. We had to lift her legs up on the bed for her and then she leaned back. Her vitals were good. I know we got Stat labs ordered and we monitored her some after that. LPN #2 was asked if she assessed the resident for the change of condition. LPN #2 stated, No I did not because I was new and was still precepting. LPN #2 was asked what she would do for a resident who was having a change of condition with signs and symptoms of a stroke. LPN #2 stated, I would check the grips on both sides, and their pupils and call the doctor. I would send them out to the hospital just because if it is a stroke there is nothing we can do here for them. On 5/13/19 at 3:17 P.M. an interview was conducted with Unit Manager LPN #8. Unit Manager LPN #8 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19 and what actions she took. Unit Manager LPN #8 stated, It was about 2:45 P.M. Name (LPN #4) who was orienting LPN #2 came and told me that Name (Resident #1's) daughter was concerned because her mom was not acting right, not acting herself. I went down to Name (Resident#1's ) room and Name (Resident #1) was sitting in her chair. I called her name she opened her eyes and she responded to tactile and verbal stimuli. I had her grasp my hands and she had left sided weakness. Her daughter kept insisting that something was wrong. She was new to me I had only had her on my floor for 4 or 5 days so I wasn't sure if she was acting different. There were 2 other nurses were getting her vitals for me. I went back and called Name (Nurse Practitioner) and told her that Name (Resident #1 was sleepy and seemed sedated. I thought it was her [MEDICATION NAME] so we changed the times of it and she ordered stat labs. I went down to tell her daughter that the labs had been ordered and that the lab would be here shortly to draw them. The other nurses had put the resident back in bed The daughter told me that her mother had a history of [REDACTED]. She texted back and said we could send her to the hospital if the family requested. I told her they said they were just gonna wait for the lab results. Unit Manager LPN #8 was asked if she wrote the order from the Nurse Practitioner that the resident may be sent to the emergency room per family request and if she documented in the resident's medical record so the other nurse's where aware. Unit Manager LPN #8 stated, No, I didn't take it as an order. I didn't document it in the nurse's notes either. I should have and I usually do, I just didn't document it there was a lot going on that day. Unit Manager LPN #8 was also asked why she felt Resident #1 did not need to be further evaluated when she assessed her that day. Unit Manager LPN #8 stated because I thought it was just from her [MEDICATION NAME] because I didn't know her that well and later I found out that she had been on that medication for a long time. Also is she was having a TIA they will usually resolve themselves. Thinking about it now I would have sent her out 911 because the family know her better than me. On 5/13/19 at 3:40 P.M. an interview was conducted with CNA #2. CNA #2 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. CNA #2 stated, I work 3-11 and when I got there she was already in bed and not saying a whole lot. Her daughter was in the room with her. I though it was odd she was in bed so early because she always stays up late, usually until way after 11 P.M. She never gets in the bed early. I took her her dinner but she didn't eat she was sleeping a lot. On 5/13/19 at 3:47 P.M. an interview was conducted with LPN #3. LPN #3 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN#3 stated, I got here at 7 P.M. and in report I was told that Name (Resident #1) was having stroke like symptoms, that labs had been done and that the family was wanting her to go out to be checked. I was still in orientation then. The family came up to me around 8 P.M. and asked if the labs were back yet and I told them they were back yet and they were asking if she (Resident #1) should go to the hospital. I told then the labs would show if she was having a stroke. I don't know what labs were ordered but I was just trying to calm the family down. LPN #3 was asked if she ever went in to assess Resident #1 during her shift. LPN #3 stated. No I never went in to assess her or did any paperwork I was new, Name (LPN #5) and Name (LPN #6) went to talk to the family. On 5/13/19 at 5:30 P.M. a phone interview was conducted with LPN #5. LPN #5 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #5 stated, We were short nurses that night so I got pulled to Unit 200, I usually work Unit 300. Name (LPN#3) called me to come over to help her with a resident that had fallen. In her defense she was new and was still in orientation. When I was at the desk Name (Resident #1's) family came up asking about the status of her lab work. I had heard earlier in the day that she was having stroke symptoms. I called the lab the results were not back yet and they said to call them back in an hour. I then went back to finish my work on Unit 2. Later she called me back over to help her because the family wanted the resident to be sent out. LPN #3 said she could not raise her arms and she did not have equal strength in her hands, I called 911 and started getting the paperwork ready. LPN #5 was asked what should you do for a resident who is experiencing signs and symptoms of a stroke. LPN #5 stated, I would do an assessment to check strength, speech and vitals then I would get help for the resident immediately to prevent permanent damage. I would send them out to the hospital. On 5/13/19 at 6:00 P.M. a phone interview was conducted with LPN #4. LPN was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #4 stated, He daughter came up to the desk and said she didn't seem right. Myself and Name (LPN #2) went down to checked her and get vitals. Name (Unit Manager LPN #8 ) also came down to check her. I checked her pupils and had her grab my hands. Her left hand was weaker. She looked like she had too much pain medicine. She looked very tired. We (myself and LPN #2) put her in bed with 2 person transfer assist provided. We gave her weight bearing assist by holding on to her by her pants. Name (Unit Manager LPN #8) called the Nurse Practitioner and labs were ordered. LPN #4 was asked if labs could determine if someone was having a stroke and what did she report on Resident #1 to the oncoming shift at 7:00 P.M. LPN #4 stated, No only the hospital determine if someone is having a stroke. In report I told the Name (LPN #3) that Name (Resident #1) had a change of condition today and that labs had been drawn. The family was concerned that maybe she wasn't doing too good. Daughter also reported that the resident had a history of [REDACTED]. LPN #4 was asked if she documented her assessment of Resident #1 and any follow-up monitoring. LPN #4 stated, I don't remember, I don't think so, probably not. I reported my findings to the supervisor. On 5/14/19 at 11:00 A.M. an interview was conducted with Unit Manager LPN #7. Unit Manager LPN #7 was asked what she would do if she had a resident whom was having signs and symptoms of a stroke. Unit Manager LPN #7 stated, I would immediately assess the resident by checking the pupils, hand grasps, range of motion, any weakness, speech,and cognition. I would not waste a lot of time on the assessment because we have a very short window with a stroke like 3 to 4 hours. I would call the doctor and send them out to the hospital because there is nothing we can do to treat a stroke in the facility. We do have some worrisome families, but we need to value their input because they know them better than we do. On 5/14/19 at 11:05 A.m. a phone interview was conducted with the facility Nurse Practitioner. The Nurse Practitioner was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. The Nurse Practitioner stated, I got a call from Name (Unit Manager LPN #8) around 2:50 P.M. stating the Name (Resident #1) had increased swelling in her legs, that the family was saying she wasn't right, her vitals were stable and good, oxygen saturations good, she was responding to verbal and tactile stimuli. I ordered stat lab work and gave an order that the resident could be sent out to the hospital per the family request because I know this family. She never indicated that the resident was having stroke like symptoms. If I would have know that I would not have ordered labs but would have sent her out to the hospital immediately. At 3:10 P.M. I received a text from Name (Unit Manager LPN #8) stating the resident has some left sided weakness also and that the family was concerned. I texted back that they could sent her out if that is what the family wanted. Name (Unit Manager LPN #8) sent me another text at 4:16 P.M. saying the family was gonna wait for the lab results. That she (Resident #1) was alert and oriented, moving better and that they changed the dosage times of her [MEDICATION NAME]. She also texted that the daughter stated the resident had a history of [REDACTED]. Not one time did anyone ay she was going downhill or having any signs or symptoms of a stroke. If I had known she was having stroke symptoms I would have sent her out 911. The Nurse Practitioner was asked why is it important so sent someone out tot he hospital if there are having signs or symptoms of a stroke. The Nurse Practitioner stated, Because they need medications to help reverse the stroke and there is a very short window to provide these medications. I should have been called not texted about her condition and symptoms. They failed to provide me with an accurate assessment of the resident's condition. This family is very adamant about their mother's care. I just found out today she did actually have a stroke that day and I see there is no documentation where I told them to send her out if that was what the family requested and no order as well. On 5/14/19 at 10:30 A.M. a phone interview was conducted with Resident #1's daughter #2. Daughter #2 was asked if anyone had made them aware that the Nurse Practitioner had stated that the resident could be transported to the hospital per the family request prior to her being transported to the hospital. Daughter #2 stated, No, no one ever told us that until around 10:30 P.M. when I inquired again about her labs that we had been waiting all night for and them my sister and I decided we could not wait on the labs any longer and requested she be sent to the hospital. We were relying on what they were telling us. That the lab work would tell us if she was having a stroke and that if she went out the hospital would just have to start over and repeat everything. On 5/14/19 at 1:15 P.M. a phone interview was conducted with LPN #6. LPN #6 was asked to tell the surveyor about Resident #1's change of condition on 4/8/19. LPN #6 stated, Name (LPN#5) asked me to go over to Unit 3 and help Name (LPN #3) because a family member had some concerns and she was still passing medications. I went to the resident's room (Resident #1) and the family was sitting at the bedside with her. They recognized me and asked me if her labs had come back yet. She (Resident #1) was not acting herself and appeared different, she was not talking. I know her. My grandmother and her grew up in the same town and she always asks me about her. Tonight she looked asleep, eyes closed. She finally opened her eyes and nodded her head but did not speak which was very different for her. Also she couldn't really move her left side. She will usually turn over with only limited assist, but she wouldn't turn at all. I told the family I would go check on the labs. I asked Name (LPN #3) what was going on with her, she said she had a change of condition and we were waiting on the labs. I called the lab and the results were still not available. I checked the nurse's notes to see what was going on with the resident. I went back and told the family that the labs were still not available. The daughter stated if the labs are not back soon we are going to want her to go to the hospital. I told they family they could always request for her to be sent out and that I would make it my business to come back in 20 to 30 minutes to check on her. She (Resident #1) was not acting herself, there was definitely a change of condition from what I'm used to seeing in her. I went back to my floor and soon after I was told she was going out to the hospital. LPN #6 was asked if she was aware that earlier in the day the Nurse Practitioner had given an order that if the family wanted the resident to go to the hospital the facility should send her. LPN #6 stated, No, I didn't know that. I did think it was a possibility she was having a stroke because she wasn't as verbally responsive as she usual is and she was weaker on her left side, but I saw where the Nurse Practitioner was notified. On 5/14/19 a phone interview was conducted with the Medical Director who was also the Attending Physician for Resident #1. The Medical Director was asked what are his expectation of the facility if a resident is experiencing signs or symptoms of a stoke. The Medial Director stated, Any new neurological deficit indicates a possible stroke. Left sided weakness is a focal deficit that should be treated as an emergency and the resident needs to be sent to the emergency room . Only a CT (Computed Tomography) Scan can determine if a stroke as occurred. With a stroke we have a very short 3 to 4 hour window to start tPA (Tissue Plasminogen Activator- works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow). No long term facility has the ability to Do A CT of the brain. A CT is the first evaluation for a stroke. When rely on the nurse's assessment and the facility failed to communicate a through assessment of Name (Resident #1) to Name (Nurse Practitioner). If the nurse had called and said we have new onset left sided weakness, the resident is lethargic and the family states there is a history of TIA's then we would have said to send to to the emergency room immediately. The facility also has the Telemed System where they call roll the computer into the resident's room and a doctor is on the other side looking at the resident, doing an assessment and giving orders to the facility in realtime. This is available 24 hours a day. On 5/14/19 at approximately 4:00 P.M. debriefing was held with the Administrator, the Director of Nursing, the Assistant Director of Nursing and the Regional Director of Clinical Services where the above finding were shared. The Regional Director of Clinical Services stated, It looks like we did have a delay in treatment, and we need more education on [MEDICAL CONDITION] and monitoring. Also there is no documentation to support what was done for the resident. The Administrator stated, We did give her the care, we just failed to document it. The Regional Director of Clinical Services stated, If it wasn't documented it was not done. Everyone exited the room except for the Director of Nursing. The Director of Nursing stated, Thank you for finding this, something's I just can't fix in just 6 months. If they don't document I can't help them. I agree we failed this resident, if I had documentation I could have defended it. On 5/14/19 at 11:15 A.M. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was asked who was responsible for providing education to the staff members and when was the last time training in acute change of condition and sign and symptoms of a stroke were provided. The ADON stated, I'm responsible for the facility training and those topics are on my calendar to teach this month to the nursing staff. Name (Director of Nursing) started Change of Condition training last night. Resident #1's Stat Lab work that was ordered on [DATE] was not received in the facility and reviewed until 4/9/18 at 7:45 A.M. Resident #1's Hospital emergency room Treatment Report dated 4/9/19 at 12:17 A.M. was reviewed and is documented in part, as follows: Chief Complaint: Altered Mental Status Physical Exam: Constitutional: She appears lethargic. Neurological: She appears lethargic. She displays facial symmetry. Dysarthic. Lying on the stretcher with her eyes closed. Will wake up and answer questions. States that she just feels tired. Does not squeeze left hand. Does not withdrawal left leg to noxious stimuli. Impression and Management Plan: Based on physical exam with left arm and left leg weakness I am concerned about the possibility of stroke. We will check for metabolic abnormalities as well as infectious etiology. I have asked the charge nurse to activate stroke alert to and have requested tele-neurology consultation. Unfortunately the last known well time is difficult to assess and is mostly hearsay from what was told to the family. I have ordered CT scan unenhanced of the head and will consult tele-neurology. ED (Emergency Department) Course/Medical Decision Making: 1:23 A.M. I discussed the patient with tele-neurolgy, at the bedside with the family. Given the time of onset and last known well she would clearly not be a candidate for alteplase (tPA). Final Diagnosis: [REDACTED]. [MEDICAL CONDITION] 2. Acute [MEDICATION NAME] with hematuria. 3. Left Sided Weakness Resident was admitted to telementry unit. Resident #1's Hospital Discharge Sum

Based on observations, staff interviews, clinical record review and facility document review the facility staff failed to provide the necessary care and services to prevent pressure ulcer development, prevent infection, and promote healing for 1 of 21 residents in the survey sample, Resident #5. Resident #5 entered the facility on [DATE] without a pressure ulcer. On [DATE] the resident was identified with a pressure ulcer at an advanced stage, a stage III to the left buttock. Formal Skin Risk Assessments conducted by the facility staff failed to identify Resident #5 was at risk for the development of pressure ulcers. The facility staff failed to identify the presence of pressure ulcers. During the survey on [DATE] the resident presented with three new stage II pressure ulcers. Two of the new skin breakdown areas were observed earlier by the assigned CNA (certified nurse aide). The CNA failed to notify the nurse, stating she assumed the nurse already knew. The new open areas were located on each of the lower buttocks (ischial tuberosity), and presented as superficial abrasions (Stage II). The third stage II pressure ulcer was identified by the surveyor, not by the facility staff. This stage II was on the resident's left heel. The facility staff failed to promote the healing of the stage III pressure ulcer by failing to reduce pressure duration while in a sitting position and without an opportunity for off loading (relieving pressure). Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. Agency for Health Care Policy and Research (AHCPR). A stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Agency for Health Care Policy and Research (AHCPR). A stage III pressure ulcer is described 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. Agency for Health Care Policy and Research (AHCPR). The findings include: Resident #5 was admitted to the facility for skilled services following a hospitalization on [DATE]. The admission [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an assessment reference date of [DATE] coded the resident as scoring a 15 out of 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact. The resident required extensive assistance of two staff for bed mobility and transfers. Section M. Skin Conditions assessed the resident as at risk for pressure ulcers. The resident did not have a pressure ulcer. The resident was wheelchair bound. A formal Skin Risk Assessment was conducted upon admission to the facility on [DATE] and readmission on [DATE] for Resident #5. These assessments evidenced the resident scored a 4 both times. Per corporate administrative staff clarification, a formal Skin Risk Assessment score of 10 or greater is considered High Risk for skin breakdown. The corporate administrative staff stated there is no low or medium risk, only no risk or high risk. Based on Resident #5's score of 4, the facility identified the resident was not at risk for the development of pressure ulcers. The comprehensive plan of care effective [DATE] through [DATE] on page 65 of 79 identified Skin Integrity Needs and read, in part: Assist to turn in bed, monitor skin am & pm, R/T (related to) physical medical condition .Interventions listed included to turn and reposition the resident in bed on care rounds and as needed, observe the skin daily during care and report findings, weekly skin checks, and low air loss mattress. The comprehensive care plan did not include modified interventions to reduce or remove underlying risk factors of sitting in the wheelchair for extended periods of time such as: off-loading (reducing pressure), shifting, and/ or a time limit for sitting in the wheelchair. Weekly skin checks dated from [DATE] through [DATE] evidenced a section that included devices in use. The box to check for pressure reducing device in chair (such as a pressure relieving cushion) was blank. A nurses notes dated [DATE] at 10:22 pm, read, in part: Resident noted with round open area to inner aspect of left buttocks, slough tissue noted no foul odor no drainage noted . On [DATE] the initial wound care assessment was completed by the unit one manager. It read, in part: Resident noted with open area to inner aspect left buttocks. Resident has hx (history) of chronic excoriation to same site. Resident noted with preference for lying on left side. Frequently noted scooting self in bed also on left side . Wound measures 4.5 cm (centimeter) x 2.0 cm x 0.2 cm and is currently staged as a 3. Wound bed presents with 40% necrotic tissue and 60% granulated tissue. Peri wound (skin surrounding the wound) tissue pink with diffuse blanchable redness. Prevention: Low air loss mattress, position from side to side while in bed, pressure relieving cushion to wheelchair. According to National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages: Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons (a heralding sign of risk) Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. The resident's nutritional intake from [DATE] through [DATE] was reviewed. The resident averaged eating 75% of breakfasts, 53% of lunches, and 83% of dinners. The resident's wound was being cared for by the wound care specialist, and assessed on a weekly basis from [DATE] through [DATE]. The wound care specialist documented the following: 1. [DATE] Stage III pressure ulcer of the left buttock, 4.5 cm x 2.0 cm x 0.2 cm with 40% yellow necrotic (dead) tissue, 60% granulation tissue (healthy tissue). Recommendation: Off-load wound, reposition per facility protocol. Appetite-Fair. 2. [DATE] Stage III left buttock, 2.6 cm x 2.0 cm x 0.2 cm, 40 % yellow necrotic tissue, 60% granulation tissue, wound progress-Improved, decreased surface area. Appetite-Fair. 3. [DATE] Stage III left buttock, 2.8 cm x 2.0 cm x 0.2 cm, 40% yellow necrotic tissue, 60% granulation tissue, wound progress - Deteriorated due to patient non-complaint with wound care, favors the left buttock to lay on and sit on. Needs to offload. Procedure: Surgical excisional debridement of subcutaneous tissue (remove dead tissue). Appetite-Fair. The comprehensive plan of care was not revised to include interventions to reduce pressure ulcer development for the identified risk factors, i.e., the resident's preference for lying on the left side or behaviors of scooting in bed until after the development of the stage III pressure ulcer. The revised interventions dated [DATE] included: Resident to be positioned off left side when in bed every shift, and limit time up in wheelchair to 3 hours every shift as recommended by the wound care specialist. The comprehensive plan of care was not revised to include interventions to address the resident's non-compliance with wound care identified by the wound care specialist on [DATE]. The stage III pressure ulcer showed improvement per the wound care specialist assessments on [DATE] and [DATE]. On [DATE] the wound measured 0.8 cm x 0.7 cm x 0.1 cm with 100% granulation. The residents appetite was documented as Fair. The stage III pressure ulcer deteriorated on [DATE] and measured 1.0 cm x 1.4 cm x 0.1 cm, with 20% yellow necrotic tissue, 80% granulation. The wound care specialist documented that the wound deteriorated due to generalized decline of patient. The residents appetite was documented as Fair. The resident's meal intake for [DATE] was breakfast 100%, lunch 25% and supper 50%. The wound care specialist documented on [DATE] and [DATE] that the wound continued to deteriorate. The resident was made comfort care on [DATE]. On [DATE] the wound care specialist documented the wound was surgically debrided and was staged as unstageable due to the necrotic tissue. The wound measured 3.5 cm x 4.5 cm, the depth was not measured due to necrotic tissue. The wound care specialist documented that the wound deteriorated due to generalized decline of patient, nutritional decline, and prolonged time up in chair. Recommendations were: Off load wound, reposition every 2 hours, time up in chair is not to exceed 2 hours. The residents appetite was documented as Fair. The resident's meal consumption that day was breakfast 0%, lunch 95% and supper 25%. On [DATE] the wound care specialist documented the wound improved due to decreased surface area and increased granulation. The wound measured 2.5 cm x 3.0 cm, wound depth not measured due to necrotic tissue. Necrotic black tissue 20%, 50% yellow necrotic tissue and 30% granulation. Appetite-Fair. The resident's meal consumption that day was breakfast 0%, lunch 0% and supper 25%. On [DATE] the wound care specialist documented the wound deteriorated. The wound measured 3.4 cm x 3.2 cm, wound depth not measured due to necrotic tissue. Necrotic black tissue 40%, yellow necrotic tissue 50% and granulation tissue 10%. Deteriorated due to generalized decline of patient, not eating, declining. Appetite-Fair. The resident's meal consumption that day was breakfast 0%-25%, lunch 0%-25% and supper 25%-50%. The registered dietician (RD) had been following the resident's nutritional status due to weight loss. The RD's last progress notes dated [DATE] read, in part: CBW (current body weight) 143.9# (pounds) .Resident with 5# weight loss in 2 weeks. Resident currently receives pureed diet with ground meats and nectar thickened liquids, Magic cup TID (three times a day) with meals, 90 ml (milliliters) H Cal TID and ProStat AWC-advance wound care (a protein supplement) 30 ml BID (twice a day). PO (by mouth) intake has been poor, per staff records, ,[DATE]% of meals and variable consumption of supplements. [MEDICATION NAME] on [DATE] was low, 15 mg/dL (Milligrams per Deciliter), but slightly improved from [DATE] [MEDICATION NAME] of 13mg/dL. The RD recommended to increase the Hi Cal to 120 ml TID. [MEDICATION NAME] and [MEDICATION NAME] are two indicators used to assess protein status at the visceral level. If someone is having wounds, they will need ample protein so that wound healing can take place. Normal lab reference range for [MEDICATION NAME] varies lab to lab, normal range is 19.38 mg/dL. Per the wound care specialist recommendation on [DATE] the staff was to limit the resident's time up in the chair to not exceed 2 hours due to deterioration of the wound. The Treatment Administration Record (TAR) for February 2016 failed to evidence the recommendation was followed. Instead, the TAR had an order dated [DATE] to limit time up in wheelchair to 3 hours. The facility staff failed to promote the healing of the stage III pressure ulcer by failing to reduce pressure duration while in a sitting position and without an opportunity for off loading. On [DATE] at 4:00 pm, the resident was observed asleep in bed on a low air loss mattress. The resident was positioned on his back, both heels were not floated. On [DATE] at 9:30 am, the resident was observed sitting up in the unit 2 common area in a high back wheelchair. The resident was awake and had on white tennis shoes. An attempt to interview the resident was made. The resident was not able to communicate clearly and did not answer questions appropriately. The resident was calm and smiling. At this time the certified nurse aide assigned to care for the resident was interviewed (CNA#1). She was asked what time was the resident transferred into the wheelchair that morning. She stated night shift is assigned to get the resident up in the mornings at approximately 6:30 am. CNA #1 stated she routinely puts the resident back to bed after breakfast at approximately 9:30 am, and then gets him up again for lunch. At 10:30 am, the resident was observed still sitting up in the high back wheelchair in the common area. A gel cushion was on the seat. The resident had now been sitting up in the wheelchair for approximately four hours per staff interview and observations. The physician orders [REDACTED]. Dakin's Solution® Quarter Strength is a broad-spectrum topical antimicrobial solution, effective against bacteria, viruses, molds, fungi and yeast. Also used for odor control. On [DATE] at 2:30 pm, the resident was transferred to bed for a dressing change observation. While LPN #3 (licensed practical nurse) was setting up for the dressing change, CNA #1 began to remove the resident's brief. After removing the brief, the CNA removed the soiled dressing. Two new breakdown areas were noted to the resident's lower buttocks. The CNA stated she first observed these new areas earlier at 10:30 am; after placing the resident back to bed after breakfast. The CNA was asked if she had informed LPN#3 of these new findings, she first stated she did, then later she stated she assumed the nurse knew. When LPN #3 assessed the left buttock wound she stated it had deteriorated from the last time she had seen it. She observed the two new breakdown areas and stated she had not been made aware of these new areas. The LPN stated she would notify the doctor for orders and notify the responsible party. The left buttocks pressure area wound base had 90% yellow slough and 10% black tissue. The new right lower buttock open area presented as a stage II, the wound bed had 100% granulated tissue, irregular in shape and approximately 1 cm x 1 cm, the surrounding tissue was dark pink in color. The new left lower buttock open area presented as a stage II, was larger, irregular shaped with 100% granulated tissue, the skin around the wound was dark pink in color. The nurse described the two new areas as abrasions. After the nurse left the room the CNA was asked to remove the resident's socks. The surveyor observed a stage II blister to the resident's left heel. The CNA stated she was not aware of the blister due to the resident being dressed by the night shift. The unit manager then entered the room and measured the newly identified left heel blister. The resident was then transferred back into the wheelchair at 3:00 pm. The nurse failed to implement appropriate hand washing on eight occasions during the dressing change. The nurse washed her hands for a count of 10 seconds or less prior to the dressing change, during the dressing change, after cleaning the left upper buttock stage III wound, and prior to leaving the resident room. On [DATE] at 3:20 pm, LPN #3 was interviewed. She stated she would have expected the CNA to have informed her of any new open areas immediately. She further stated the length of time for handwashing with soap should be 30 seconds. The nurse was asked to describe a stage I pressure ulcer, she stated,Redness that blanches. She was asked to describe a stage II pressure ulcer, she stated, Slow return-dark red .LPNs don't stage .if we could, it would be a good thing. The LPN's descriptions of a stage I and stage II pressure ulcer were incorrect. On [DATE] at 5:30 pm, the resident was observed asleep in the high back wheelchair in the common area on unit 2. The resident had white tennis shoes on. At 7:35 pm, the resident was observed in bed. Heels were not floated (suspended to relieve pressure to heels). The CNA assigned to care for the resident on the 3 pm-11 pm shift was interviewed. She was asked what time was the resident placed back into bed. She stated, Ten minutes ago. The resident had been sitting up in the wheelchair from 3:00 pm -7:25 pm, approximately 4.5 hours per staff interview. The unit manager documented on [DATE] at 6:45 pm the following: During wound care resident was noted with intact blister to left heel measuring 2 cm x 3 cm. Area cleansed and covered with [MEDICATION NAME] dressing. Zero gravity boots applied to bilateral heels. Also noted shearing to left buttock directly below stage III wound measuring 3 cm x 4 cm x <0.1 cm in depth. Area cleansed with wound cleanser, Triad applied and left open to air . There was no measurement of the observed second open area to the right lower buttock. Friction (when two surfaces move across one another) and shear (a mechanical force that acts on an area of skin in a direction parallel to the body's surface) contribute to pressure ulcer formation. The tissue injury resulting from these forces may look like a superficial skin injury. Agency for Health Care Policy and Research (AHCPR). On [DATE] at 9:30 am, the resident was observed sitting in the high back wheelchair in the common area on unit 2. The resident was wearing white tennis shoes. At 10:30 am, the resident was observed in bed, asleep. The [MEDICATION NAME] dressing to the left heel was peeled back and not directly on the blister. The resident's heels were directly on the bed and not floated. On [DATE] at 2:00 pm, the resident was observed sitting in the high back wheelchair in the common area on unit 2. Pressure relieving boots were observed to both feet. The resident was asleep. At this time CNA #1 was interviewed. She stated the resident was placed back to bed at 9:40 am today and was transferred back up into the wheelchair at 11:30 am. The resident had been sitting up in the wheelchair from approximately 6:30 am to 9:30 am (a 3 hour duration), and from 11:30 am to 2:00 pm (2.5 hours) without off loading. The CNA was asked if there was a time limit on how long the resident was to remain up in the high back wheelchair. She stated,I don't know what the order says, I put him back after breakfast, I get him up before lunch and if he falls asleep in the chair I will put him back to bed, but if he is awake the next shift will put him back to bed .we don't want him up too long because of the pressure ulcer . The CNA was asked if the resident is shifted to relieve pressure while in the wheelchair, she stated, Yes, when he is slouching .it takes two people. The CNA was asked about the pressure relieving boots and stated, We just got those two hours ago .he is supposed to wear them at all times, when in bed and when up. The CNA was asked about the resident's meal consumption this shift. She stated the resident had eaten 25% of breakfast and 75% of lunch. The above findings was shared with the administrative team during the pre-exit meeting conducted on [DATE] at 3:30 pm. The Quick Reference Guide for Clinicians Number 15 titled Pressure Ulcer Treatment by the U.S. Department of Health and Human Services Agency for Health Care Policy and Research (AHCPR) read, in part: The recommended treatment program should focus on 1. Assessment of the patient and pressure ulcer. 2. Managing tissue loads. 3. Ulcer care. 4. Managing bacterial colonization and infection. 5. Operative repair of the pressure ulcer(s). 5. Education and quality improvement. Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer. The goal of tissue load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s). While sitting avoid pressure on the ulcer. A patient who has a pressure ulcer on a sitting surface should avoid sitting. If pressure on the ulcer can be relieved, limited sitting may be allowed. Reposition the sitting individual so the points under pressure are shifted at least every hour. If this schedule cannot be kept or is consistent with overall treatment goals, return the patient to bed. Review of the facility's policy titled Pressure Sores dated [DATE] read, in part: The first step in prevention will be through identification of the patient at risk of developing pressure ulcers. This will be followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. 1. Upon admission and at least quarterly, patients will be assessed for risk of developing pressure ulcers. 2. A standardized pressure ulcer risk assessment tool will be used to determine patient's risk. Monitoring: 2. Patients will be monitored every shift to ensure that measures are in place as specified on care plan to prevent and promote skin breakdown.

Based on observations, record review, family and staff interviews and a complaint investigation, the facility staff failed to provide supervision for 1 resident (Resident #1) while toileting. Resident #1 fell and sustained a fractured femur; staff failed to provide safety devices for 2 residents (Resident #1 and #2) in the survey sample of 22 residents; the facility also failed to ensure water temperatures did not exceed 120 degrees Fahrenheit. The findings included: 1. Resident #1 was originally admitted to the facility 8/18/10 with a re-admission on 1/12/15. [DIAGNOSES REDACTED]. The facility failed to provide Resident #1 with supervision to prevent falls with injuries and elopement. A Quarterly Minimum Data Set ((MDS) dated [DATE] assessed Resident #1 as having disorganized thinking with signs and symptoms of Delirium. In the area of Activities of Daily Living (ADL) this resident was coded as requiring Extensive assistance of one person physical assist for Transfers and Toilet Use. In the area of Balance During Transitions and Walking this resident was coded as Not steady, only able to stabilize with staff assistance - Turning around and facing the opposite direction while walking and Moving on and off toilet. Resident #1 was coded as utilizing a wheelchair (manual) for mobility. In the area of falls this resident was coded as having falls. In the area of Medications this resident was assessed as receiving anti-anxiety, antibiotic and diuretic medications. Resident #1 was assessed on the Brief Interview for Mental Status (BIMS) on a re-entry MDS dated [DATE] score of 8 out of possible 15 indicating moderate cognitive impairment. A revised Care Plan dated 06/14/14 indicated Ambulation needs cognitive Impairment non-ambulatory - follow with wheelchair when ambulation, needs rest stops during walks. Bathing Needs- 1 staff to transfer resident on and off shower chair. Bed mobility needs Extensive assist needed - Cognitive limits. Behavior- Monitor for changes in mood and changes in mental status, monitor risk for falling. Bladder Elimination -total assist needed observe for complaint of back/flank pain, burning with urination. Cognitive Needs - Vertigo- Needs cueing re-directing/ distracting needs wander guard bracelet Poor Safety Awareness- resident assess as at risk for falls. Progress Note Summary dated 6/17/14 indicated: "Resident was found sitting on the floor mat yelling for help to get up." Falls Risk Needs - History of Impulsive behavior, 10/27/14, 11/3/14, 1/06/15, 1/25/15 and 1/28/15. Bed alarm, chair alarm. Personal hygiene assist needed perform personal hygiene as tolerated and able. Set up supplies for partial baths in room, assist with grooming/hygiene as needed. Safety Needs- self release belt, mattress on floor, bed against wall, bed alarm/ chair alarm. Toileting Needs- total assist needed Extensive assist with hygiene. Transfer Needs- Needs stand assist with transfers. Elopement- Poor Safety Awareness 10/30/14 resident left bldg.(building) unattended- Wanderguard and project lifesaver bracelet. On 10/27/14 Resident #1 had a fall requiring ER (emergency room ) visit after sustaining facial lacerations. Progress notes were as follows: A 11/4/14 (1913) (7:13 p.m.) Progress Note Summary indicated: "Fall Risk Needs-call light in reach, Low bed, Poor Safety Awareness 10/27/14 -witnessed fall. 11/3/14 fall. Chair Alarm-LATE ENTRY for 11/3/2014 (2045) (8:45 p.m.) Was called by CNA (certified nursing assistant) to resident room, resident noted to be sitting on the floor in doorway, legs crossed, facing nursing station, resident had blood in bilateral hands, noted to be bleeding from the orifices of her nose, on the bridge of her nose and under left eye. Resident agitated and fighting this nurse. Supervisor called to unit. Nose and eye area cleansed and pressure applied. daughter and MD (medical doctor) made aware, order received to transport to ER (emergency room ) for evaluation." An IDT (interdisciplinary team) indicated: IDT met on 10/31/14 to discuss resident's fall and elopement r/t confusion caused by UTI. A 11/4/14 (0023) Progress Note Summary indicated: "This nurse called ER and ER nurse said "resident had CAT Scan (computed tomography- diagnosic medical test) head, face and neck and all negative results. Nose laceration glued and stitch/stitches to laceration left eye." A 11/4/14 (0259)(2:59 a.m.) Progress Note Summary indicated: "Resident returned from ER at 0140 (1:40 a.m.) via medical transport accompanied by her daughter. Resident continues to be confused Bruising to face around eyes. Laceration with suture to to be removed in 7 days Fall precautions in place Bed alarm in place and functioning Fall mats in place bed in low position Neuro checks continue 144/90, 97.6, 78, 18 Will continue to monitor. There was no fall assessment or investigation provided during the survey. On 11/3/14 Resident #1 had a fall sustaining a facial laceration. Progress notes were as follows: A Progress Note dated 11/4/14 (0230) (2:30 A.M.) indicated: This nurse called ER and ER nurse said Resident had a CT-scan head, face, neck and all negative results. Nose laceration glued and stitch/stitches to laceration left eye. Resident waiting for transport to return to facility. Interventions on a Progress Note on 11/4/14 included: call light in reach, low bed, R/T (related to) Poor safety awareness, Chair alarm, floor mat. Alarm checks were part of the interventions. A Progress Summary Note dated: 11/6/14 indicated- 11/3/14 Resident #1 had an unwitnessed fall. Upon entering room staff noted resident sitting on floor in doorway bleeding from nose and laceration under left eye. Resident was very agitated and combative with staff as they were assisting resident. Resident transported to hospital and laceration to left side of nose glued and 1 stitch applied under left eye. Resident is positive for UTI ( urinary tract infection) which causes increased confusion with resident who is already impulsive with poor safety awareness A hospital radiology report dated 11/3/14 indicated: " Clinical History/ Indication for Exam: S/P (status [REDACTED]. superficial laceration to bridge of nose, and under L (left) eye. H/O (history of) fall today, Unwitnessed, hit head per family. On 1/6/15 Resident #1 had a fall sustaining a fractured femur. Progress notes were as follows: A 1/6/15 (2026) (8:26 P.M.) Progress Note Summary indicated: "Late entry for 1/6/15 @ (at) 1900 (7:00 p.m.). Resident noted sitting on buttocks with both legs extended in front of her on bathroom floor in room. Resident attempted to self transfer from w/c (wheelchair) to commode while CNA at bathroom sink retrieving towel and washcloth to provide ADL care. CNA witnessed resident fall to floor. Resident did not hit her head. Resident denies any pain at this time and states "This leg feels sore" Resident pointed to it. Resident able to move all extremities without difficulty. No c/o (complaint of) headache, dizziness or visual changes. Assisted to w/c (wheelchair) with weak, unsteady gait noted. ADL care rendered. No other complaints of pain or discomfort. R.P. (responsible party) made aware, MD (physician) made aware. V/S (vital signs) 146/72, 62, 98.1, 18. Resident resting in bed." A 1/7/15 (0244) (2:44 A.M.) Progress Note Summary indicated: "Resident c/o (complained of) left hip pain and having difficulty with ROM (range of motion). Notification sent to NP (Nurse Practitioner) alerting her to X-ray of left hip and pain. Call placed to X-ray vendor. Resident received APAP 650 mg (milligrams) for pain, she rated pain on scale 1-10 as "really bad." A 1/7/15 (1000) (10:00 A.M.) Progress Note Summary indicated: "Received resident as alert and responsive, cooperative with her care today. Stayed in bed on supine position. Resident is voicing of pain at 9:45 located to her left hip pointing to her left hip. Not tearful but grimacing and clenching his (sic) teeth. Pain level at 4/10. Given PRN (as needed) pain level, 2 tablets of Tylenol by mouth. X-RAY report was received and shows acute intertrohanteric fracture of the proximal left femur with "varus angulations and displacement." Received new physician's orders [REDACTED]. to send resident to hospital for evaluation and treatment. Called daughter and medical transport. Family in resident's room waiting. Resident has no skin breakdown noted when left the facility." A 1/12/15 (2004) (8:04 p.m.) Progress Note Summary indicated: "Resident admitted to facility [DIAGNOSES REDACTED]. left hip fracture. Abdomen soft and positive bowel sound 4 quads. Left ORIF incision in left thigh with drsg. (dressing) intact (do not remove Aquacel drsg. Staples should be removed in 2 weeks with Stri-strips placed. Follow-up x-rays in 4 weeks. Stage 2 sacral pressure ulcer with drsg. intact. Abduction pillows in between legs in place and bilat.(bilateral) Resident appears tired and sleepy and sleeps off and on. Both sons stayed for a while and have gone home but encouraged to call unit to be updated with resident's condition. V/S (vital signs) 98.7 100, 18, 141/78." During an interview on 2/12/15 at 3:03 P.M. with CNA #3, who was caring for Resident #1 when she fell [DATE], she stated, "Resident #1 was in (room #207) on the left side of the short hall of 200 unit. "I was in the room providing toileting care and was about to wash her up after she finished using the commode. Resident #1 was on the commode. Her wheelchair was over to the side in front of her. I was at sink getting the washcloth. Resident #1 had stood up using the grab bars and fell before I could reach her." CNA #3 was asked if she had her back to the resident she stated, "I was at the sink getting the wash cloth so I could wash her up." When asked if her back was to Resident #1, she stated ,"She was not sure. She just got up fast and fell before I could turn around." The bathroom was noted to have a commode on the left side of the wall when facing the sink. The sink area and the commode area is offset by a wall divide which measure approximately 18 inches from the commode to the sink area by another 18 inch wide divide wall from the sink. This area is offset from the commode to the sink and does not permit side by side full visual monitoring when facing the sink area. A written statement by CNA #3 dated 1/6/15 addressed to the Director of Nursing (DON) indicated: "Getting (name of Resident #1) ready for bed. She was on the toilet and I was at the sink getting her was (sic) cloth ready for pericare and she jump up quick and reach for the safety bell, all I seen was she was falling." Progress Note Summary dated 1/25/15 indicated: Resident #1 had a fall. Progress Note Summary dated 1/28/15 indicated: Resident #1 had a fall. During an interview on 2/12/14 at 4:00 P.M. the Administrator stated the resident would take the alarm off. There were no notes or care plan interventions for the resident removing the alarm. Resident #1 eloped from the facility on 6/18/14. Event Investigations and Progress Note Summary's dated 6/18/14 indicated: "Resident #1 was found on the North side of exit doors at fountain on the 100-200 units." Progress Note indicated: "Resident observed by Restorative staff wheeling self out the building. Resident entered code into door and wheeled self out the door. Resident appears very confused and looking of (sic) her son." Resident was found outside near facility's side walk after opening after hours visiting door with alarm code. Resident stated she was attempting to go home and cont.(continue) with argumentive/yelling behavior." Resident #1 eloped form the facility on 11/09/14; wanderguard not functioning upon re-entry. A Progress Note Summary dated: 11/10/14 indicated: "Safety Needs- On 11/09/14 @ (at)1340 (1:40 P.M.) resident was observed outside the fountain door between units 3 and 4. resident very confused and combative. Attempted to kick staff members that were assisting her back in the building. Wanderguard noted not working at the time of re-entry to building. wander guard changed. maintenance advised to check all door alarms." An Event Investigation Report dated 11/09/14 indicated: "Resident wander guard not working." At 2:45 P.M. Unit 4 called this nurse to their unit and when got there (sic) was told resident had went out by fountain, was brought back in and was trying to fight staff. The wander-guard didn't sound and was changed to a new working one." During the survey Unit II Manager (LPN #2) Licensed practical nurse was asked for wander guard audits to ensure wander guards were being monitored for functioning and reliability. The Unit Manager was not able provide wander guard audits for functioning reliability during the survey. Facility Policy indicated: "The Wanderguard will be checked every shift to ensure that it is in place and operational." During a family interview with the daughter on 2/12/14 at 10:45 A.M. she stated, "A request was made to the facility to change rooms so that staff could better monitor her for falls and elopement risk." Resident #1's room was located at the far end of hall. The Administrator was asked on 2/12/15 at 4:20 P.M. during an interview, "If the facility was aware that Resident #1 knew the code to exit the building why was the code not changed?' The Administrator stated, "there was no need to change the code." During this interview, the Administrator was asked if residents had assess to the code and she stated, "No." Progress Note Summary dated 10/30/14 indicated: "Resident #1 was found at side of building 300-400 unit. An Elopement Risk assessment dated [DATE] indicated this resident was assessed as a (16) considered an elopement risk indicating/acknowledging to update Elopement Risk needs on resident's focus list. An Elopement Risk assessment dated [DATE] assessed this resident as a (18). No updates were acknowledged to add to Elopement Risk needs for Resident #1. During an interview on 2/12/15 at 4:00 P.M. with the Administrator and the Director of Nursing (DON), the DON stated, "When Resident #1 was found outside in June in the parking lot, staff actually found her at the fountain. Resident #1 sat by the door as a routine." A facility policy dated 3/1/13 indicated Accidents- Addendum- Elopement- "It is the policy of this facility to identify and safeguard any patient who is at risk for elopement. Procedure: 1. An Elopement Risk Assessment will be completed on all patients on admission. 3. Those noted to be at risk will have an Elopement Risk Assessment completed at least quarterly. 4. Those noted to be at risk for elopement will have a Wanderguard bracelet applied. 5. The Wanderguard will be checked every shift to ensure that it is in place and operational. During the survey an audit of safety devices (wander guard, chair and bed alarms) was requested. The facility did not provide audits that Resident #1's assistive device were being monitored and assessed to be functioning or provided. 2. For Resident #2 the facility failed to ensure that when Resident #2 went on an outing in the facility van that the resident's seat belt was secure to prevent her from sliding to the floor and receiving a sprained neck and a left shin wound. Resident #2 was originally admitted to the facility 06/15/12. [DIAGNOSES REDACTED]. Review of the Resident #2's clinical record revealed a Significant Change Comprehensive MDS (minimum data set-an assessment protocol) with an ARD (assessment reference date) of 07/22/14. The resident's BIMS (brief interview for mental status) score was coded as 15 which indicated the resident was cognitively intact and able to make safe and consistent decisions regarding ADLs (activities of daily living). Further review noted the following: Resident #2 was coded as requiring extensive to dependent assistance of two plus facility staff members for bed mobility, transferring from surface to surface, dressing, personal hygiene and toileting. The resident was further coded as not ambulating in room or on the unit, totally dependent on staff for locomotion in a wheelchair in room and off unit and totally dependent for bathing. The resident was also coded as being totally incontinent of bladder and bowel. The resident's balance was coded as follows: "A. Moving from seated to standing position-not steady, only able to stabilize with human assistance; B. Walking (with assistive device if used)-Activity did not occur; C. Turning around and facing the opposite direction while walking-Activity did not occur; D. Moving on and off toilet-Not steady, only able to stabilize with human assistance; E. Surface-to-surface transfer (transfer between bed and chair or wheelchair-Not steady, only able to stabilize with human assistance." The resident was assessed and coded as not having any impairment with range of motion for both upper extremities and lower extremities. An interview was conducted on 02/11/15 at approximately 1:45 p.m., with Resident #2 and her RP (responsible party-daughter). During the interview the RP pointed to an abraded area on her mother's left shin. She reported that on 12/12/14, her mother was on an outing from the facility in the facility bus, she slipped off of the seat, slipped to the floor and hit her leg causing the leg wound that she had pointed out still present on the resident's left leg. The resident agreed with her daughter regarding the incident. An interview was conducted on 02/12/15 at approximately 8:45 a.m., with Administration #3-Activity Director. The Activity Director stated: "The outing was for the residents to go to an activity called (name of event) and to then go to a local restaurant for lunch." She went of further: "There is eight seats and two areas in the back of the van for residents who use electric wheelchairs. The resident had been placed in a seat in the front row and the seat belt had been secured. I then decided to change Resident #2's seat to the second row so I could sit next to her and be able to be in the middle of the group for safety purposes if a resident should have need of help." Additionally she stated: "The resident is a large lady and had on a shiney long coat that looked slippery. I must have missed making sure her seat belt was secure. During the ride to the (name of event)-we had made reservations to see the exhibit-the driver made a quick stop. When the van stopped Resident #2 slid forward, landed on the floor between her seat and the seat in front of her. The resident was then asked if she was hurt and she said she wasn't. My activities assistant (the driver) and I then tried to get the resident up and were unsuccessful. I called the facility and asked for the maintenance men to come and help them get the resident up as the resident insisted that she was alright. The maintenance men arrived and were able to get the resident back onto her seat and the seat belt was secured. The resident was again asked if she was alright and she stated she was okay and did not want to return to the facility. We then continued on to our planned activities. We got back to the facility around 4 p.m." The Activity Director stated: "I've been an activity director for a long time and I have never had this type of thing happen." The Activity Director then escorted the surveyors outside to the van for an inspection. On the eight seats seat belts were observed as well as tie downs for the two spaces in the back of the van for residents with electric wheelchairs. Review of the nurses notes dated 12/12/15, revealed the following: "Resident returned from outing and was placed in bed. A full body assessment was performed. The resident complained of pain in her left shoulder, left hip, left side of ribs and left leg. Small abrasion noted on left lower shin. Resident sent to the emergency room for evaluation due to incident during activity." Documentation was found in resident's clinical record from the emergency room visit dated 12/12/15: "Final diagnosis-acute cervical strain." An interview was conducted on 02/12/15 at 10:20 a.m., with the Administrator. When asked about the incident she supported what the Activity Director had reported previously. When asked if the facility had sent a FRI (facility reported incident) she stated: "I wasn't in the facility on the day of the incident-it was a Friday. Because the incident was observed I didn't send in a FRI until I had returned to the facility the following Monday 12/15/15." Administration was informed of the findings at a briefing on 02/11/15 at approximately 4:15 p.m., at which time the Administrator was informed that the incident would be part of a complaint deficiency. No additional information was submitted for review. 3. The facility staff failed to ensure an environment that was as free as possible from accident hazards as evidenced by hot water temperatures exceeding 134 degrees in resident rooms. The findings included: On 2/11/15 at 9:45 a.m. while washing my hands in the facility restroom I discovered the water temperature to be extremely hot, to the point that I had to remove my hands from the running water. On 2/11/15 at 10:00 a.m. the water temperature was checked by touch in resident rooms on each of the 4 units. In each room this surveyor was only able to submerge her hands under the running hot water for approximately 5-6 seconds due to the extreme hot temperature. An interview was conducted on 2/11/15 at 10:30 a.m. with the Plant Operations Supervisor regarding the hot water temperature in the residents' rooms. When asked what temperature should the hot water be maintained at in the resident's rooms the Plant Operations Supervisor stated, "It should be 120 degrees or lower." The Plant Operations Supervisor also stated, "The hot water temperatures are checked on each unit every morning around 6 a.m. by my assistant, and this morning they were running between 117-119 degrees." After further discussion with the Plant Operations Supervisor he explained how he had two mixing valves that controlled the water temperatures for the facility. Units 100 and 200 were on one mixer valve and Units 300 and 400 were on the other mixer valve. The mixer valve blends hot water with cold water to ensure constant safe water temperatures to prevent scalding and burns which the Plant Operations Supervisor controls. The Plant Operations Supervisor was asked to obtain a thermometer. After doing so, he said, "I thought it was always calibrated." Next resident room 321 was entered and the hot water temperature was taken at the bathroom sink faucet by the Plant Operations Supervisor. Per the Plant Operations Supervisor's calibrated thermometer the hot water temperature at the sink read 131 degrees. The Plant Operations Supervisor and the surveyor preceded to resident room 321. Again, the hot water temperature at the bathroom sink was tested . Based on the calibrated thermometer reading the hot water temperature was 134.5 degrees. The Plant Operations Supervisor acknowledged both temperatures and stated, "This water is too hot, I can't hold my hand under it." Water temps on the Unit II (200) exceeded 120 degrees Fahrenheit. The following temperatures were taken on 2/11/5 at 11:47 A.M. with the Maintenance Technich. In room 208- temp- (121.8), Room- 221- temp - (124.0), Room-219- temp- (124.3), Room - 221- temp (122), Room- 214 temp (124.3), and Room -215 - temp (123.1). An interview was conducted with CNA #1 on 2/11/15 at 11:30 a.m. When asked about the water temperatures she stated, "It's been hot almost everyday. It was cold and they had someone come in and fix it." The Plant Operations Supervisor was made aware of the above statement but had no recollection of anyone coming in to check the water temperatures. At 1:00 p.m. on 2/11/15 the Plant Operations Supervisor made this surveyor aware that the hot water temperatures on all halls were down to 112 degrees and this was verified by the surveyor and thermometer readings. The Plant Operations Supervisor did provide water temperature logs for January and February 2015 that were unremarkable. When the Plant Operations Supervisor was asked how this could have happened he stated, "I guess my assistant didn't let the hot water run long enough before taking the temperatures he will let it run longer now." On 2/12/15 at approximately 5:45 p.m. during the pre-exit interview with the Administrator and the Director of Nursing the above findings were shared. No additional information was provided. COMPLAINT DEFICIENCY

Based on observation, staff interview, resident interview and clinical record review the facility staff failed to provide the necessary care and services to prevent an avoidable pressure ulcer for 1 of 22 residents in the survey sample, Resident #8. The findings include: Resident #8 is an [AGE] year old with a readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 2/25/14 assessed the resident as scoring a 15 out of 15 on the Brief Interview for Mental Status (BIMS). The resident required extensive assistance of 1 staff for bed mobility and transfers. The resident was assessed as at risk for developing pressure ulcers and was coded as having one (1) stage II healed pressure ulcer on the prior assessment. The resident's skin was intact. A stage II pressure ulcer is described as partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact blister. Review of the comprehensive plan of care dated 2/14/14 identified as a focus skin integrity needs. The goal was the resident will experience no skin breakdown through the next review. Linked interventions included to follow the skin/ wound care protocols PRN (as needed), and weekly skin checks. Another focus area was identified as urinary device- urethral catheter. The goal was the resident will experience no complications from use of the urinary device. Linked interventions included to anchor the catheter tubing and check for placement. The electronic record evidenced a nursing note entered by the unit manager dated 3/24/14 at 10:26 A.M., that read "Was asked by CNA (certified nurse aide) to evaluate an area to resident's buttocks. Linear area noted, measuring 1.0 cm (centimeter) x 7.0 cm x 0.1 cm and extending from left buttocks to right buttocks. Wound bed noted with approximately 75% black adherent eschar and 25% beefy red tissue. New treatment order obtained as follows: Cleanse site with seaclens, pat dry, apply Santyl ointment to areas of eschar to wound bed and cover with 4 x 4: [MEDICATION NAME] dressing qd (every day) and PRN (as needed). Wound discussed with (name of nurse practitioner) and daughter (name) POA (power of attorney) was aware." The unit manager also documented on the wound management progress note; "Resident presents with unstageable wound to left posterior buttocks extending to right posterior buttocks...Wound noted to be linear pattern possible r/t (related to) IFC (indwelling Foley catheter) tubing. Resident is paraplegic and unable to turn and reposition in bed without staff assistance..." An unstageable pressure ulcer is not stageable due to the wound bed being covered by slough and/ or eschar (black dead tissue). On 3/26/14 at 2:00 P.M., the resident was observed laying on a low air loss mattress on her back with the head of the bed at approximately 45 degrees. The resident was awake and alert. The resident was questioned as to how she developed the wound to her backside (buttocks). She was asked "Did you lay on top of the (Foley) tubing?" Resident #8 stated," That's what they (nursing staff) seem to think happened". On 3/26/14 at 2:20 P.M., the 300 hall unit manager was interviewed about the wound. She stated, "I suspect it is pressure related from the catheter or the linen...but I am almost sure it was from the catheter". The unit manager stated she assessed the resident's skin last week and did not note any breakdown, but could not provide any proof of this such as documentation. The unit manager stated after discovering the wound, "I spoke with my nurses and CNA's, I know that it was not there Friday...one CNA (CNA#1) said she saw it as a reddened area and reported this to the nurse, but could not recall exactly which nurse she informed." The unit manager stated she would have expected the nurse to have then assessed the area, document findings and implement appropriate treatment as ordered. She also would have expected the nurse to have notified her in person and through the 24 hour report sheet. There were no nurses notes to support the nurse assessed the area after being notified by the CNA or documentation on the 24 hour report sheet. The unit manager indicated that she could not locate any weekly skin checks for Resident #8 on the electronic medical records (EMR) from September 12, 2013 to March 24, 2014. She stated she would ask the MDS Coordinator to assist her further with this. At 3:20 P.M., CNA#1 was interviewed. She stated she noted last week the resident "..had a dark area that looked like a bruise...on her right buttocks..." The CNA described the wound as linear shaped using her right pointer finger as an example. The CNA stated it appeared as though it could have been from the Foley catheter. The CNA could not remember what day of the week she noted this, but stated it was before the weekend. She stated she had informed the nurse of this finding. The CNA could not recall which nurse this was. At 3:30 P.M., the 300 hall unit manager handed the surveyor the weekly skin checks for Resident #8. Review of the weekly skin checks evidenced weekly skin checks were not conducted from September 12, 2013 through March 24, 2014 as care planned for Resident #8. The director of nursing (DON) was able to back track in the electronic medical records when and who discontinued the weekly skin checks. The skin checks were discontinued in the EMR by a supervisor on 9/19/13. The DON could explain why this was done. On 3/27/14 at 10:00 A.M., the 300 hall unit manager approached the surveyor and stated, "We weren't doing the weekly skin checks but we were checking her skin daily due to the [MEDICATION NAME] treatments we were applying to her old pressure ulcer site (right ischeal area). I discontinued that ([MEDICATION NAME]) treatment on March eleventh (2014)". On 3/27/14 at 10:20 A.M., a dressing change observation was conducted with licensed practical nurse #1. The pressure ulcer was noted to be linear in shape on the right buttocks approximately 7 cm in length. In the center of the wound was eschar surrounded by pinkish red colored tissue. LPN #1 stated on Monday (3/24/14) morning she observed the resident had a dressing on. The nurse stated night shift did not report to her that the resident had any wounds to this area. The nurse stated she removed the dressing and discovered the wound. She immediately notified the unit manager. LPN#1 was asked what caused the pressure ulcer and stated, "The first impression I got was that it was from the catheter (Foley)". Further investigation evidenced the weekend 7am-3pm shift nurse (LPN#3) had applied a [MEDICATION NAME] dressing to the area on Saturday 3/22/14. LPN #3 was interviewed on 3/28/14 at 9:50 A.M., she stated she applied the dressing as a [MEDICATION NAME] dressing. The nurse was asked why she applied the dressing when the order was discontinued on 3/11/14 by the unit manager. She stated the order was there on Saturday but not on Sunday. The nurse stated there was no evidence of skin breakdown to the buttocks on Saturday, and she did not look on Sunday. She observed the wound this morning and stated, "It looks like it could have been caused by the Foley catheter". On 3/27/14 at 5:20 P.M., the director of nursing (DON) was interviewed. The above findings was shared. The DON indicated she was made aware of the pressure ulcer by the 300 hall unit manager. When asked what was the cause of the unstageable pressure ulcer she stated, "It's shaped like the catheter...we suspect the pressure ulcer was related to the catheter." The above findings was shared with the administrator and the DON at the pre-exit meeting on 3/28/14. No other documentation or evidence was provided prior to exit.

Based on observations, record review and staff interview, the facility staff failed to apply assistive devices as ORDERED/CARE PLANNED for 1 of 22 residents s in the survey sample, Resident #1 who experienced a fall with injury. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was not provided an assistive device which resulted in a fall with injury requiring sutures. A Quarterly Minimum Data Set ((MDS) dated [DATE] assessed this resident in the area of Hearing, Speech, and vision wears glasses. This resident was accessed as makes self understood and Sometimes understands. Resident #1 was not able to participate in the Brief Interview for Mental Status (BIMS) assessment according to the MDS. In the area of Mood this resident was assessed as no response. In the area of Behaviors this resident was assessed as having behaviors of hitting, kicking, pushing, scratching, and grabbing. This resident was assessed as having behaviors of resisting care and wandering. In the area of Activities of Daily Living (ADL) this resident was assessed as needing extensive assistance with one person physical assist in the area of transfer, not able to ambulate. Able to move in corridor, and move around in wheel/chair. This resident was assessed as having falls with injury. This resident was assessed as receiving antianxiety, and antidepressant medications. This resident was assessed as using a safety belt and a lap buddy safety while in wheelchair. Care Plan prior to fall with injury: Care Planning Report- Effective date from January 1, 2012 to March 26,2014 Uses self-releasing belt, Uses lap buddy (Approved July 18, 2013) Check Bed alarm- Pressure sensitive alarm activated pad in bed Q-shift (started November 15, 2013-continuing). Check Chair Alarm- Velcro alarm activated self release belt in W/C q-shift (Started November 15, 2013 continuing). A review of physician orders [REDACTED]. Resident is constantly redirected and cured to no avail. A June 19, 2013 Progress Note Indicated: " Safety Committee review of incident of 6/18/13 witnessed fall at 20:00 (8:00 P.M.). It is noted that resident has behavioral issues due to cognition with severe poor safety awareness. Resident is at baseline confused. She frequently attempts to ambulate without assistance, continuously attempts to get out of bed, and she does not use the call bell to call for assistance. Safety measures of low bed, fall mats, bed alarm, sensor, concave mattress are being utilized. RP and RP sister met with UM (unit manger and discussed music, Geri tent, Meri-walker, non-release restraint seat belt, antiroll back and front anti-tippers to the w/c. RP states she does not like to even think about a Geri-tent but might possibly consider it, but she wanted staff to know that resident is " claustrophobic " and she thinks it might not be a good idea. Resident #1 had experienced a prior fall with injury as evidence by a 5/20/13 hospital discharge instruction that noted the following: Closed head injury. scalp laceration 3.5 cm simple repair. You have been seen in the emergency department and treated for [REDACTED]. Your wound has been repaired with sutures (no amount given). Test Performed-CT head W/O contrast Suture set-up combined." When presented to the facility staff how-many sutures Resident #1 received during this ER visit, no information was brought forth. A Progress Note dated [DATE] (00:54) indicated: "Resident fell this morning at 2:44 A.M. resident was assisted into restroom by assigned aide to toilet. Resident was then transferred into wheel-chair without Velcro-safety seatbelt placed on. Aide noted resident falling out of wheel-chair to floor and injuring right side of face by hitting fore head against the wheel-chair. Resident noted to have open area above right eye 0.5 inch length x 0.5 inch width, appearing to need stitches. first Aide administered with drsg applied. On- call physician made aware with T. O. (telephone order) to send resident to ER (emergency room ) for evaluation. POA called times 3 with no answer. Message left on answering machine notifying POA of resident's condition. No change in LOC noted. Neuro-checks/ROM performed without difficulty. Resident currently resting in bed r/t (due to) refusing to sit-up in wheel chair. Fall precautions in place with low bed and mats. Bed alarm in place. No s/s of active bleeding noted at this time. Stable. Refused vital signs r/t confusion. Call bell within reach. Will cont. to monitor." A Hospital emergency room report dated 2/22/14 indicated: The patient is a [AGE] year old female who lives in a nursing home. Apparently, she was sitting in her wheelchair overnight and leaned all the way over forward, just fell right out of the wheelchair and hit her right forehead on a very hard floor. Apparently, her behavior was not any different immediately thereafter than it usually is. They stated she was a little more agitated than she usually is. She does have a small laceration and a large hematoma on her right forehead. Procedure: Laceration repair. laceration was 2.5 cm straight laceration on her right forehead overlying a hematoma after a fall. Usual sterile prep and drape were used. Irrigated with sterile saline. Closed with 5-0 Ethilon 4 simple interrupted sutures." A review of an incident listing regarding Resident #1's falls, a total of 42 falls were recorded from 1/06/13 through 3/22/14. Two falls resulted in injury's requiring sutures. A revised Care Plan, dated 3/5/14 (post-fall), indicated the following: Focus-Restraint Usage- Assess for least restrictive device PRN (as needed) Bed alarm, call light in reach, chair alarm, monitor for changes in mood/behaviors, monitor safety awareness/needs, needs re-directing/distracting, Velcro alarm activated self release belt in wheelchair. Goal- Resident will use the least restrictive device possible through next review. Intervention- Resident assessed as at risk for falls, call light within reach, bed alarm chair alarm, bed sensor. ROM (range of motion) walking/ambulation, restoration exercises. Concave mattress, Hi-lo bed, matt on floor (landing strip) uses self-releasing belt-uses lap buddy. Focus-Safety Needs- Bed alarm, calll bell light in reach, chair alarm, environment free of clutter hazards, floor mats, low bed, (R/T) due to phycical/medical condition, R/T poor safety awareness, unsteady gait, noncompliant- removes safety devices, lap buddy, Velcro self release belt. Goal- Resident will use the least restrictive device possible though the next review. Resident #1 was observed during the days of the survey seated in a wheelchair with a safety belt and lap buddy with chair alarm wandering from unit to unit. Unit Managers were asked how often did this resident come onto there unit and each stated, she will come two to three times a day. We make sure we know where she is at all times on the unit. During an interview on 3/27/14 at 2:30 P.M. with the Administrator she stated, "We have done all we can to keep Resident #1 safe. We are at our wits end. We have tried every thing we can." When the Administrator was asked for a policy on Assistive device, A Physical Restraint guideline was provided. The guideline indicated: "Basic responsibility: Licensed nurse, nursing assistant (under the supervision of a licensed nurse and Interdisciplinary Team. In the area of Alternate method and less restrictive measures (To Restraint Use) Residents' risk of fall and injury may be reduced by use of many of these devices in bed, in chair, in the bathroom, and while walking." During an interview on 3/28/14 at 2:00 P.M. with Resident #1's family member, she stated, "Resident #1 was not being observed enough to prevent her from falling. She fell again a few days ago." Complaint Deficiency