Every finding on record at Bartlesville Health and Rehabilitation Community

On [DATE], an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure CPR was administered in accordance with the AHA standards of practice, which states the primary goal is to ensure a firm, hard surface to maximize compression depth and the facility policy for resident #6. CPR was administered in Resident #6's bed without a back board and was ineffective. On [DATE] at 5:15 p.m., the OSDH was notified and verified the existence of the IJ related to the facility's failure to implement their CPR policy and provide effective CPR to Resident #6.On [DATE] at 6:00 p.m., the administrator, DON, and ADON were notified of the IJ situation and the IJ template was provided. On [DATE] at 2:38 p.m., an acceptable plan of removal was approved by the OSDH. The plan of removal, read in part, All nursing staff on duty received immediate education on code blue procedures, crash cart policy, and the location of emergency equipment, including the crash cart and back board, all remaining nursing staff completed their education prior to their next scheduled shift and acknowledged understanding of the procedures. Staff who had not completed education were not assigned to resident care duties.The IJ was lifted effective [DATE] at 3:35 p.m., when all components of the plan of removal had been reviewed and verified as completed. Seven staff interviews were conducted to assure they were in-serviced on AHA standards of practice for CPR, which states the primary goal is to ensure a firm, hard surface to maximize compression depth, and understood the information. Sign in sheets for in services were reviewed. Monitoring was done by the DON to ensure interventions were implemented and maintained by ensuring all staff attended inservices. This deficient practice remained at an isolated level within the potential for more than minimal harm. Based on record review and interview, the facility failed to ensure a resident who had become unresponsive received CPR by a staff member certified in CPR, according to the AHA and facility policy for 1 (#6) of 1 sampled resident who was reviewed for abuse. The ADON identified 75 residents resided in the facility.Findings: A review of an employee file for LPN #1 showed they had a CPR certification card that expired on 01/2024 and a CPR certification card that was issued on [DATE]. LPN #1 was not CPR certified from 01/2024 to [DATE]. An undated Code Blue and Crash Cart Policy and Procedure, read in part, It is the policy of Bartlesville Health and Rehab to provide an immediate and organized response to any resident experiencing cardiopulmonary arrest or life-threatening emergency. A fully stocked and easily accessible crash cart will be maintained and trained staff will respond to all code blue events according to facility protocol.An admission form, dated [DATE], showed Resident #6 had diagnoses which included atherosclerotic heart disease, peripheral vascular disease, and depression. The form showed a code status of full code. On [DATE] at 1:45 p.m., LPN #1 who performed CPR on Resident #6 was interviewed. LPN #1 stated on [DATE] at approximately 2:00 a.m., CNA #1 came to them and stated Resident #6 was acting different than usual. LPN #1 stated they went to the resident's room and found them to be clammy and nonresponsive. LPN #1 stated they attempted several sternal rubs and could not get a response. LPN #1 stated they went to the nurse's station, called 911, and when they returned to the resident's room the resident was not breathing and had no vital signs. LPN #1 stated they began CPR with the resident on the bed and did not use a back board or hard surface. LPN #1 stated emergency services arrived and took over CPR. LPN #1 stated the resident expired at the hospital. LPN #1 stated CPR was more effective when done on a hard surface. LPN #1 stated they did not use a back board or move the resident to the floor. LPN #1 stated Resident #6 expired at the hospital. On [DATE] at 11:20 a.m., the DON stated the CNAs were trained to call for the nurse and retrieve the crash cart during an emergency. The DON stated the nurses should know where the back board was and to use it for CPR. On [DATE] at 2:00 p.m., LPN #2 stated CNA #1 informed them something was not right with Resident #6. LPN #2 stated they went to the room of Resident #6. LPN #2 stated they saw LPN #1 begin CPR on Resident #6 on the bed. LPN #2 stated LPN #1 told them to retrieve the ambu bag from the crash cart. LPN #2 stated they did not know where the crash cart or the crash cart key was located, but the fire department entered the facility at that time and provided an ambu bag. LPN #2 stated CPR should be performed on a hard surface such as the floor or a back board. On [DATE] at 5:10p.m., the DON stated the nursing staff should be certified in CPR and know the AHA guidelines. The DON stated CPR certification was required bi-annually.

Based on record review and interview, the facility failed to ensure pre and post dialysis patient assessments were filled out completely and routinely by staff for one (#45) of one sampled resident reviewed for dialysis care. The DON identified one resident at the facility received dialysis services. Findings: The facility was unable to provide a policy for the care of residents that received dialysis services. An admission record for Resident #45 documented they had been readmitted to the facility on [DATE]. It further documented Resident #45 had diagnoses which included stage five chronic kidney disease and dependence on renal dialysis. A quarterly resident assessment, dated 09/25/24, documented Resident #45's cognition was intact. On 12/02/24 at 1:24 p.m., Resident #45 stated the nursing staff had not been doing their vitals as they were supposed to related to their dialysis care. On 12/03/24 at 9:46 a.m., LPN #2 stated there was a binder at the nurse station that held the dialysis assessment forms. They stated there was not pre and post dialysis assessment documentation for each treatment Resident #45 had received. They stated the resident was scheduled to have dialysis treatments three times weekly. A review of the binder found it contained 14 documents titled, Dialysis Communication, dated on and between 09/19/24 and 11/27/24. Of those documents, five were partially filled out, missing the return assessment data. A review of the resident medical record found the resident was documented as having been assessed on 14 of 28 days they had received dialysis. On 12/04/24 at 1:14 p.m., the DON stated they had been unaware the dialysis assessments had not been filled out and would retrain nursing staff on those procedures.

Based on observation and interview, the facility failed to ensure dietary staff wore hair nets and beard guards while preparing food for the residents. The administrator identified 74 residents routinely ate meals provided by the facility kitchen. Findings: On 12/02/24 at 8:05 a.m., cook #1 was observed preparing food without wearing a hair net or beard guard. On 12/02/24 at 8:10 a.m., cook #1 stated they should be wearing a hair net and beard guard and that the facility was out of beard guards until the truck came in. On 12/02/24 at 8:30 a.m., the dietary manager stated the dietary staff should be wearing hair nets and beard guards. On 12/03/24 at 3:08 p.m., the administrator stated dietary staff should be wearing hair nets and beard guards.

Based on observation, record review, and interview, the facility failed to ensure: a. a licensed practical nurse cleaned their hands during wound care and catheter care for one (#16) of two sampled residents reviewed for wound care and catheter care; and b. failed to maintain a water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water system. A resident matrix provided by the administrator documented seven residents had indwelling catheters. The DON stated 71 residents resided in the facility. Findings: A facility policy titled Water Management, dated 01/23, read in part, It is the policy of the facility to have a plan to reduce the risk of growth and spread of opportunistic pathogens including Legionnaires in the building water system .Procedure .Create the water management team .Identify and document the building description .Identify control measures .Document collection and transport methods. A facility policy titled Hand Hygiene, dated 01/31/24, read in part, Appropriate hand hygiene is essential in preventing transmission of infectious agents. 1. A physician's order, dated 03/29/24, documented Resident #16 was to receive care for their suprapubic urinary catheter daily on the day shift. On 12/02/24 at 12:57 p.m., Resident #16 stated they had been hospitalized multiple times for urinary tract infections. They stated they did have a suprapubic catheter at that time. On 12/04/24 at 9:30 a.m., LPN #3 was observed providing catheter care to Resident #16. LPN #3 was observed entering the resident's room and putting on gloves. LPN #3 was observed to uncover the resident then don gloves. They were observed cleaning the right posterior thigh with normal saline and a gauze. They discarded the dirty gauze and obtained a new gauze and dried the area. They discarded the gauze that gauze and picked up and applied xeroform to the wound. They then picked up a dressing and applied it to the wound. During the wound care portion of the care LPN #3 did not clean their hands or change gloves. LPN #3 then change their gloves. They then assisted the resident to roll onto their back. LPN #3 picked up gauze with a cleaning solution and cleaned around the area where the tubing entered the resident. They changed gloves. They dried the area they cleaned. They changed gloves. They then placed a section of gauze that had been slit and applied it around the catheter tubing. The LPN then threw away the last pair of gloves. LPN #3 did not clean their hands at any time during the wound and catheter care. Outside of the resident's room immediately following the care, LPN #3 was asked how they thought the care had gone. They stated they believed it went well. They were asked how many times they had changed their gloves during the care. They replied five or six times. They were asked how many times they cleaned their hands. They stated the had not cleaned their hands and had forgotten to do so. They stated they knew to clean their hands. On 12/04/24 at 1:14 p.m., the DON stated LPN #3 had made an error when the did not clean their hands between dirty and clean steps of providing care. They stated the staff get regular training in infection control, but they would go over it again with them. 2. On 12/04/24 at 11:45 a.m.,the maintenance supervisor stated they had a water management policy in place, but had not started monitoring yet.

Based on record review and interview, the facility failed to ensure a resident's representative was notified of a fall for one (#57) of one resident reviewed for notification of changes. The DON reported the facility census was 71. Findings: A facility policy titled Family Notification Policy, updated 01/2024, read in part, The facility should identify a primary contact person or POA to receive notification .Required notifications .Accidents or any injury including falls. Resident #57 had diagnoses which included dementia and weakness. A late entry nurse note, dated 09/13/24, documented Resident #57 had fallen. The note did not document the resident's representative had been contacted. On 12/04/24 at 9:37 am, LPN #1 stated they had spoken with Resident #57's representative on 09/18/24 and the representative was unaware the resident had fallen on 09/13/24. LPN #1 also stated that family should always be notified after a fall. On 12/04/24 at 1:19 p.m., the DON stated the family should have been notified of Resident #57's fall on 09/13/24.

Based on record review and interview, the facility failed to ensure the medical director and/or their representative participated in care plan development for one (#45) of 18 sampled residents whose care plans were reviewed. A Facility Listing Report, dated 12/02/24, documented 71 residents resided at the facility. Findings: A facility policy and procedure titled Policy and Procedure: Care Plans for Resident Care, dated 11/06/24, read in part, A comprehensive care plan will be developed within 7 days after the MDS has been completed. It should include measurable objectives and time frames to meet the resident's medical, nursing, mental and psychosocial needs that are identified during the MDS process. All interdisciplinary team members will help prepare this and review and revise it quarterly if a change in condition is noted. A quarterly resident assessment, dated 09/25/24, documented Resident #45's cognition was intact. A facility document titled Care Plan Conference Summary, dated 09/26/24, documented the individuals who attended the care plan meeting. The documented attendees did not include the medical director and/or their representative. The document did not include any documentation the medical director and/or their representative had reviewed the results of the meeting. On 12/02/24 at 1:36 p.m., Resident #45 stated they were not sure if they had gone to a care plan meeting. On 12/03/24 at 11:22 a.m., MDS coordinator #1 stated they were responsible for planning the resident care plan meetings. They stated all members of the interdisciplinary team were contacted for Resident #45's meeting on 09/26/24. They stated the physician had been notified of that meeting, but had not attended. They stated the physician had not been given the results of that meeting to review. They stated they usually do not involve the medical director unless they required an order for something that came up in the meeting. On 12/04/24 at 1:14 p.m., the DON stated the physician should participate in care planning for each resident and review the care plans.

Based on record review and interview, the facility failed to monitor a resident after a fall for one (#57) of one resident reviewed for falls. The DON reported the facility census was 71. Findings: A facility policy titled Fall Policy and Procedures, updated 11/06/24, read in part, If a fall does occur .Assess resident .Neuro checks as necessary .Provide treatment/immediate nursing interventions as needed .Notify the family .Notify the DON/ADON .Provide continuous documentation as follows: Observed fall without head injury V/S every shift x 24 hours. Unobserved fall without head injury V/S with neuro checks every shift X 48 hours .All falls must be documented on every shift for 72 hours along with the intervention and how it is working. Resident #57 had diagnoses which included dementia and weakness. A late entry nurse note, dated 09/13/24, documented Resident #57 had fallen. The note did not document the resident's representative or the DON/ADON had been notified. It did not document if the fall was witnessed or unwitnessed. The note did not document neuro checks had been initiated. No additional post-fall documentation was located in Resident #57's health record. On 12/04/24 at 9:37 a.m., LPN #1 stated after a fall a complete assessment should be completed, the physician, family and DON should be notified, and if the fall was unwitnessed by staff or the resident had a head injury that neuro checks should be implemented immediately. The LPN also stated the resident should be on priority charting for three days after the fall. On 12/04/24 at 1:19 p.m., the DON stated they did not know if the fall was witnessed or unwitnessed. They also stated facility policy had not been followed after Resident #57's fall on 09/13/24.

Based on record review and interview, the facility failed to ensure an antianxiety medication was not prescribed on an as needed basis without a 14-day limit or a physician's explanation why it should be used beyond 14 days for one (#69) of five residents reviewed for unnecessary medications. The ADON reported 29 residents at the facility were prescribed psychotropic medications. Findings: A facility policy titled Antipsychotic P&P, dated 09/2014, read in part, Residents who receive antipsychotic, sedative, hypnotic, antidepressant, or any other medications prescribed to modify behavior are evaluated to determine the effectiveness of the medication for the identified problems .The use of antipsychotics should include .Use of the medication only for the duration needed, and at the lowest effective dose. Resident #69 had diagnoses which included anxiety disorder and depression. A physician order, dated 11/13/24, documented the resident was to receive alprazolam (an antianxiety medication) 0.25mg every 8 hours as needed. The physician's order did not have a stop date. A review of Resident #69's medical record did not document a rationale from the physician as to why the PRN order did not have a stop date of 14 days. On 12/04/24 at 9:06 a.m., the DON stated no rationale from the physician had been located. They also stated PRN psychotropic medications should be limited to 14 days without a rationale from the physician.

Based on record review and interview, the facility failed to implement their abuse policy for screening potential employees for the prevention of abuse for three (CNA #1, CNA #7, and LPN #3) of five sampled personnel files reviewed. The administrator identified 64 residents resided in the facility. Findings: A facility policy and procedure titled Abuse, Neglect, and Exploitation, dated 10/2022, read in part, .Abuse prevention activities for the prevention of resident abuse .screening of potential employees . 1. A Provisional Employment Form and Consent and Release Form, dated 09/27/23, documented CNA #1 affirmed the condition for provisional employment related to a background check. An undated background summary, documented CNA #1 was eligible for employment. There was no documentation when CNA #1 was hired, registry checks were completed, and CNA #1 enrolled for criminal history monitoring under the facility. 2. A Provisional Employment Form and Consent and Release Form, dated 11/02/23, documented CNA #7 affirmed the condition for provisional employment related to a background check. An undated background summary, documented CNA #7 was eligible for employment. An employee roster, dated 03/04/24, documented CNA #7 was hired on 11/02/23. There was no documentation when CNA #7 was hired, registry checks were completed and CNA #7 enrolled for criminal history monitoring under the facility. 3. A Provisional Employment Form and Consent and Release Form, dated 10/17/23, documented LPN #3 affirmed the condition for provisional employment related to a background check. An undated background summary, documented LPN #3 was eligible for employment. An employee roster, dated 03/04/24, documented LPN #3 was hired on 10/16/23. There was no documentation registry checks were completed and LPN #3 enrolled for criminal history monitoring under the facility. On 03/06/24 at 9:32 a.m., the administrative assistant was asked about the background checks for CNA #1, CNA #7, and LPN #3. They stated after they received their provisional employment forms and consent to release forms they entered their basic information into the background check system. They stated the system indicated they were eligible for employment so there were no further searches conducted. They stated new registry checks were not completed and the employees were not enrolled for criminal history monitoring with the facility.

Based on record review and interview, the facility failed to ensure allegations of abuse were thoroughly investigated for two (#1 and #2) of three sampled residents reviewed for abuse. The administrator identified 64 residents resided in the facility. Findings: A facility policy and procedure titled Abuse, Neglect, and Exploitation, dated 10/2022, read in part, .Abuse allegation steps .Conduct a thorough investigation . 1. Res #1 had diagnoses which included vascular dementia, communication deficit, history of falls with injury, and cerebellar stroke syndrome. A significant change assessment, dated 02/27/24, documented the resident's cognition was severely impaired. OSDH incident report forms, incident date 02/28/24, documented intital reports of an abuse allegation for Res #1 were made to OSDH on 02/29/24 at 12:32 p.m. and 1:01 p.m. It was documented suspected abuse by CNA #1 was visualized on a video monitoring device in Res #1's room on 02/28/24 at 3:30 a.m. It was documented LPN #3 reported the video appeared to show CNA #1 physically restraining Res #1. It was documented LPN #3 reported the incident to the ADON and was advised to meet the ADON on 02/29/24 at 7:00 a.m. to review the footage. It was documented the ADON reported the incident to the DON on 02/29/24 at 9:30 a.m. It was documented the video footage was reviewed by the DON and the administrator and the police department was called. It was documented Res #1 was assessed by the DON and the ADON for injuries. It was documented no injuries were noted. It was documented CNA #1 was placed on suspension pending further investigation. An OSDH incident report, incident date 02/28/24, documented a final report of an abuse allegation for Res #1 was made to OSDH on 03/04/24. It was documented the police conducted an investigation. It was documented CNA #1 was terminated for violating policy. There was no documentation residents or additional staff were interviewed related to the incident. 2. Res #2 had diagnoses which included dementia, paranoid personality disorder, iron deficiency anemia, and brain stem stroke. A quarterly resident assessment, dated 12/08/23, documented the resident's cognition was moderately impaired. An OSDH incident report form, incident date 02/29/24, documented an initial report of certain injuries and an abuse allegation for Res #2 were made to OSDH on 02/29/24. It was documented LPN #2 reported scattered bruising to Res #2's chest and upper extremities. It was documented the DON and LPN #3 assessed Res #2 and Res #2 stated a boy had hit them. It was documented Res #2 was not able to state when the incident happened. It was documented the incident was reported to the police. An OSDH incident report, incident date 02/29/24, documented a final report of certain injuries and an abuse allegation for Res #2 was made to OSDH on 03/04/24. It was documented the police conducted an investigation. It was documented an employee was terminated for violating policy and there was no further action taken. There was no documentation of additional resident or staff interviews related to the incident. On 03/04/24 at 3:27 p.m., the DON was asked if there was additional documentation related to the investigations conducted for Res #1 and Res #2. They stated they did not have additional documentation of interviews conducted with residents or staff. They stated what they submitted to OSDH is what they had. They stated the incidents for Res #1 and Res #2 were discovered around the same time and both residents shared a room. They stated Res #2 stated a boy had hit them and CNA #1 was terminated for violating policy.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported to OSDH no later than two hours after the allegation was made for one (#1) of three sampled residents reviewed for abuse. The administrator identified 64 residents resided in the facility. Findings: A facility policy and procedure titled Abuse, Neglect, and Exploitation, dated 10/2022, read in part, .Facility reporting .The facility will immediately report all alleged violations involving .abuse .as required by State law .Immediately .within two hours of occurrence . Res #1 had diagnoses which included vascular dementia, communication deficit, history of falls with injury, and cerebellar stroke syndrome. OSDH incident report forms, incident date 02/28/24, documented intital reports of an abuse allegation for Res #1 were made to OSDH on 02/29/24 at 12:32 p.m. and 1:01 p.m. It was documented suspected abuse by CNA #1 was visualized on a video monitoring device in Res #1's room on 02/28/24 at 3:30 a.m. It was documented LPN #3 reported the video appeared to show CNA #1 physically restraining Res #1. It was documented LPN #3 reported the incident to the ADON and was advised to meet the ADON on 02/29/24 at 7:00 a.m. to review the footage. It was documented the ADON reported the incident to the DON on 02/29/24 at 9:30 a.m. It was documented the video footage was reviewed by the DON and the administrator and the police department was called. It was documented Res #1 was assessed by the DON and the ADON for injuries. It was documented no injuries were noted. It was documented CNA #1 was placed on suspension pending further investigation. There was no documentation the initial incident report was reported to OSDH no later than two hours after the allegation was made. On 03/04/24 at 3:37 p.m., the DON was asked what was the protocol for reporting allegations of abuse. They stated they had two hours total to report the incident. They were asked when the initial incident report for Res #1 was submitted to OSDH. They stated the report was not submitted no later than two hours after the incident.

Based on observation, record review, and interview, the facility failed to: a. implement interventions to prevent the reoccurrence of falls; b. complete incident reports and neurological checks according to policy and procedure; and c. revise the care plan with new interventions to prevent falls for one (#23) of two sampled residents reviewed for accident hazards. Resident #23 experienced 15 falls between 08/18/22 and 07/27/23. On 09/06/22, Res #23 fell and sustained a traumatic subdural hemorrhage, laceration on the left side of their face, and left sided fifth and seventh rib fractures, resulting in the resident being admitted to the hospital ICU. On 06/12/23, the resident fell and sustained a left fractured shoulder. The Resident Census and Conditions of Residents form, dated 08/22/23, documented 60 residents resided in the facility. Findings: An undated facility policy, titled Fall Protocol, read in part, 1. Assess resident .2. Document in the nurses notes the entire incident and resident assessment in detail. 3. Notify family and physician .4. Notify DON/ADON .5. Obtain, transcribe, and implement any physician orders as necessary. 6. Complete the incident report and post fall assessment. 7. Provide continuous documentation as follows .Unobserved fall w/o head injury. VS w/neuro checks q shift x 48 hours. Fall with head injury. VS w/neuro checks q 15 minutes x one hour then hourly x next seven hours, then q two hours for next 16 hours. Then next 24 hour VS w/neuro checks q four hours. Then next 24 hours VS w/neuro checks q shift. 8. Complete a new intervention on the care plan. Res #23 had diagnoses which included Alzheimer's, dementia, traumatic subdural hemorrhage without loss of consciousness, fractured left shoulder, and history of falling. A care plan, initiated 08/13/20, documented the following interventions: a. Keep environment simple and uncluttered. b. Monitor for fatigue and other risk factors of tendency for falls. c. Respond promptly for request for toilet. d. Review resident fall assessment every three months and PRN occurrence. e. Supervise and assist resident with transfers. f. Provide activities for resident that minimize the potential for falls while providing diversion and distraction. g. Provide a safe environment with even floors; free from spills; clutter free; adequate glare-free lighting; and h. Provide working and reachable call light. i. Keep bed in low position at night and personal items within reach. j. Resident ambulates at lib without device. k. Anticipate and meet needs. An incident report, dated 8/18/22 at 11:00 p.m., documented Res #23 experienced an unobserved fall without injury in another resident's room by their bed on the floor. The incident report documented an intervention of resident needed better fitting shoes. There was no documentation the fall care plan had been updated with the intervention to prevent fall reoccurrence. An incident report, dated 08/24/22 at 3:20 p.m., documented Res #23 experienced an unobserved fall in the dining room resulting in a skin tear to their left forearm. There was no root cause analysis and no interventions documented on the incident report. There was no documentation the fall care plan had been updated with an intervention to prevent fall reoccurrence. A nurse note, dated 09/03/22 at 9:44 p.m., documented Res #23 experienced an unobserved fall without injury in the hallway. There was no documentation a neurological assessment was completed. There was no incident report, no root cause analysis, and the fall care plan was not updated with an intervention to prevent fall reoccurrence. An incident report, dated 09/05/22 at 5:25 a.m., documented Res #23 experienced an observed fall with no injury. The incident report documented the resident was ambulating in the dining room and lost balance and fell . The incident report documented an intervention to prevent reoccurrence of falls was to continue all previous interventions and to complete hourly checks for 48 hours. The hourly checks for 48 hours were not completed, a root cause analysis was not completed, and the fall care plan was not updated with an intervention to prevent falls. An incident report, dated 09/06/22 at 3:15 a.m., documented Res #23 experienced an unobserved fall resulting in a laceration to the left side of their face, left hematoma to their head, and left fifth and seventh rib fractures. Resident #23 was admitted to the hospital ICU. The fall care plan was not updated. A discharge return anticipated MDS assessment, dated 09/06/22, documented Res #23's cognition was severely impaired and required assistance ADLs. The assessment documented the resident had two falls with no injuries, one fall with injury except major, and one fall with major injury. A nurse note, dated 09/09/22 at 3:12 p.m., documented the resident returned from the hospital. The note documented the resident had been treated for a left subdural hematoma and left fifth and seventh rib fractures. A care plan, last updated 12/13/22, documented an intervention of encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. An incident report, dated 01/04/23 at 5:20 p.m., documented Res #23 experienced an observed fall with no injury. The incident report documented the resident was holding a Styrofoam plate and stumbled and lost balance and fell on their left side. There was no root cause analysis, and no interventions documented on the incident report. The fall care plan was not updated with an intervention to prevent reoccurrence of falls. A nurse note, dated 01/06/23 at 4:20 a.m., documented Res #23 experienced an unobserved fall without injury in the dining room. There was no neurological assessment, no root cause analysis, no incident report, and no interventions documented on the fall care plan. A nurse note, dated 02/13/23 at 5:15 a.m., documented Res #23 experienced an unwitnessed fall without injury in the resident's room near her bed. There was no neurological assessment, no incident report, no root cause analysis, and the fall care plan was not updated with an intervention to prevent fall reoccurrence. A quarterly assessment, dated 03/22/23, documented the Res #23's cognition was severely impaired; required extensive assist with bed mobility; and limited assistance with transfers and walking. The assessment documented the resident had one fall with no injury. A nurse note, dated 04/25/23 at 1:12 a.m., documented Res #23 experienced a witnessed fall without injury. The nurse note documented the resident was standing at nurse station, then staggered backward and fell . There was no neurological assessment, no incident report, no root cause analysis, and the fall care plan were not updated with an intervention to prevent fall reoccurrence. An incident report, dated 05/07/23 at 4:00 a.m., documented Res #23 experienced a witnessed fall with no injury. The report documented the resident attempted to sit on pillow in the hallway and dropped to the floor. There were no interventions and root cause analysis documented on the incident report. The fall care plan was not updated with an intervention to prevent reoccurrence of falls. An incident report, dated 05/22/23 at 8:05 a.m., documented Res #23 experienced a witnessed fall. The incident report documented the resident was ambulating through the dining room and tripped over someone's oxygen tubing and fell face first onto the floor resulting in a laceration to the bridge of their nose. There were no interventions and root cause analysis documented on the incident report. The fall care plan was not updated with an intervention to prevent reoccurrence of falls. An incident report, dated 06/12/23 at 5:45 p.m., documented Res #23 experienced a witnessed fall while standing by the medication cart. The report documented the resident was carrying a long blanket, turned quickly, lost their balance, fell , and hit their shoulder on the floor. This fall resulted in a fractured left shoulder. The intervention on the incident report was for staff to monitor Res #23 when up and ambulating. When staff were interviewed about what monitoring meant, there was not a consistent answer. An annual assessment, dated 06/20/23, documented the Res #23's cognition was severely impaired and required extensive assist with most ADLs. The assessment documented the resident had two falls with no injuries, one fall with injury except major, and one fall with major injury. A nurse note, dated 07/27/23 at 1:29 a.m., documented Res #23 experienced an unobserved fall without injury. There was no neurological assessment, no root cause analysis, no incident report, and the fall care plan was not updated with an intervention to prevent fall reoccurrence. On 08/23/23 at 4:20 p.m., Res #23 was observed sitting at a table in the dining room. One CNA was observed in the dining room feeding another resident with their back to Res #23. No other staff were observed in the dining room. On 08/24/23 at 8:10 a.m., the resident was observed ambulating throughout the facility until 9:00 a.m. Res #23 had gray tennis shoes on with a two-inch gap at the back of the shoes. Res #23 was observed to ambulate without an assistive device. On 08/24/23 at 8:43 a.m. Res #23 was observed to open a linen storage closet door on hall 600. No staff were on the hallways during that time. On 08/24/23 at 8:54 a.m. Res #23 was observed to open another linen storage closet door on hall 600. No staff were on the hallways during that time. On 08/24/23 at 9:25 a.m., CNA #4 was asked how long they had worked for the facility. They stated almost five years. CNA #4 was asked what the process was for residents at risk for falls. CNA #4 stated the staff make sure the residents were wearing shoes or nonskid socks. They stated they did not place the overbed table too close to the resident's bed, fall mats were in place, and ensured the hallways were not cluttered. CNA #4 was asked if they provided care for Res #23. They stated, Yes. CNA #4 was asked what they did to prevent Res #23 from falls. They stated Res #23 was a hard one, but they made sure they had their shoes on, they keep an eye on the resident, redirect them, and tried to keep the door open to the resident's room. On 08/24/23 at 9:44 a.m., CNA #9 was asked how long they had worked for the facility. They stated three months. CNA #9 was asked what is the process for residents at risk for falls. They stated make sure their call light was within reach and frequent checks. CNA #9 was asked how they were aware of interventions in place for residents at risk for falls. They stated, they learned through caring for the resident, CNA change of shift report, and the nurses communication with them. CNA #9 was asked if Res #23 was ever assisted to activities. They stated, No. On 08/24/23 at 10:45 a.m., LPN #3 was asked what their process was when a resident experienced a fall. They stated they would complete an incident report, begin neuro checks, and follow the facility fall protocol. LPN #3 was asked who was responsible for updating care plans. They stated the MDS coordinator should update the care plan with each fall. LPN #3 was asked how do you know who was a fall risk. LPN #3 stated they know because of the residents' mental and mobility status, also certain diagnoses such as, fractures. LPN #3 was asked how do you prevent falls. They stated they keep their eyes constantly on the residents and try to keep the residents' door open. LPN #3 stated they ensure all residents' needs were met such as, keeping them clean and dry and keeping their most used items within reach. LPN #3 was asked what care do you provide for Res #23. They stated the resident redirects easily and the staff offer them snacks throughout the day. LPN #3 was asked how do you ensure the fall interventions on the care plan are implemented. LPN #3 stated the staff had fall meetings to discuss ideas for new interventions, but that stopped about a month ago. All the staff communicate with each other at shift change. On 08/24/23 at 11:05 a.m., the MDS coordinator was asked if they were responsible for updating care plans. They stated they were. They were asked how often they update care plans. They stated as needed. The MDS coordinator was asked if they updated the care plan when a fall occurred. They stated, Yes. The MDS coordinator was shown Res # 23's fall care plan and asked if it had been updated with any new interventions from Res #23's falls from the following dates: 08/18/22, 08/24/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/09/22, 01/04/23, 01/06/23, 02/13/23, 04/25/23, 05/07/23, 05/22/23, 06/12/23, and 07/27/23. They stated, No. The MDS coordinator was asked whenever an incident report's intervention was to monitor the resident hourly for 48 hours or to monitor a resident while up and ambulating where would this be documented. The MDS coordinator stated it would be documented on the hourly check list form. The MDS coordinator was shown Res #23's hourly check list form from 09/05/22 through 09/06/22 and was asked what the blanks indicated. They stated the hourly check were not done. On 08/24/23 at 11:31 a.m., the ADON was asked what the process was when a resident experienced a fall. The ADON stated the nurse was to assess the resident, notify family and physician, notify the DON/or nurse on call, implement any physician orders, document in nursing notes, perform a post fall assessment, completed an incident report with an intervention, the care plan should be updated, monitor the resident, and document for 72 hours. The ADON was asked who was responsible for updating the care plan. They stated the MDS coordinator. The ADON was asked if Res #23's care plan had been updated with any new intervention to prevent fall reoccurrence. The ADON stated it was not and the care plan was the main framework that drives the resident's care. The ADON was asked if instructing staff to monitor Res #23 when up and ambulating was an appropriate intervention. The ADON stated it is not an appropriate intervention. We cannot even do that, it's not realistic. The ADON stated the intervention was not appropriate and not obtainable. The ADON stated the fall care plan was not updated with an appropriate intervention to prevent reoccurrence of falls. On 08/24/23 at 12:46 p.m., the PTA and the COTA were asked when Res #23 last received therapy. The COTA stated it was two years ago. On 08/24/23 at 1:42 p.m. the DON was asked what interventions were currently in place to prevent Res #23 from falls. The DON presented a list of the following fall interventions: a. anti-glare lights-initiated 03/31/2021 b. call light within reach-initiated 08/13/2020 c. proper footwear- initiated 08/13/2020 d. uncluttered environment initiated 03/31/2021 On 08/24/23 at 1:47 p.m., the DON was asked when there was a fall intervention to monitor a resident hourly for 48 hours what was their expectations of their staff. The DON stated the nurses should be documenting in the nurse notes because we need proof of the monitoring. The DON was asked if the care plan had been reviewed and revised after Res #23 had a fall. They stated it was not. On 08/24/23 at 2:14 p.m., CNA #8 was asked if the CNAs have access to the resident's care plan. CNA #8 stated we have chrome books and we can access the care plans on them. On 8/24/23 at 2:43 p.m. the DON was asked to review the intervention of hourly checks for the 48-hour documentation. The DON was asked if the intervention had been completed. She stated, No. On 8/24/22 at 2:54 p.m. the DON was asked if they saw the breakdown for the fall on 09/05/22. They stated, Yes absolutely. The DON was asked when should the nursing staff be completing neuro checks. The DON stated with a fall resulting in a head injury per facility protocol. The DON was shown Res #23s hourly check sheet from 09/05/23 and 09/06/23 and was asked what the blanks on the hourly check sheet indicated. The DON stated if there were blanks, it was not documented, then it was not done, the hourly check sheets were our proof. The DON was asked who was responsible for updating the care plans. The DON stated the MDS coordinator. The DON was asked should the care plan be updated with each fall. They stated, Yes. The DON was asked when should new fall interventions be implemented. The DON stated the incident report triggers the fall assessment which triggers the care plan to be updated. On 08/28/23 at 11:13 a.m., RN #1 was interviewed via phone. RN #1 was asked who was responsible for ensuring the intervention of performing hourly checks on a resident after a fall. RN #1 stated primarily the CNAs and CMAs, but all nursing staff can do it. RN #1 was asked who was responsible for ensuring the hourly checks were completed. RN #1 stated the charge nurse. RN #1 was asked if there were blanks on the hourly check list form, what did it indicate. RN #1 stated it meant the hourly check was not performed.

Based on observation and interview, the facility failed to ensure the kitchen was maintained to promote food safety and sanitation. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. The CDM identified all residents received services from the kitchen. Findings: On 08/22/23 at 10:18 a.m., a tour of the kitchen and dining area were conducted. The following observations were made: a. Multiple precooked pieces of chopped chicken in a plastic bag was stored in the two compartment sink. There was no water running over the bag. The meat was still partially frozen, b. Multiple pieces of raw of chicken breasts in a plastic bag were stored on the preparation surface of the Continental three door cold preparation cooler. The meat was still partially frozen. c. There was an accumulation of lint and grease on the oven hood and oven hood filters. d. There was an accumulation of grease and food on the floor and the wall behind the cook line. e. There was material peeling off of the wall behind the cook line. f. There was an accumulation of black residue and lint on the clean dish rack across from the stand mixer. g. There was an accumulation of white and black residue on the dish machine. h. There was an accumulation of black residue on the wall behind the dish machine. i. There was no date on an opened container of ready to eat hot dogs in the Continental three door reach in cooler. j. There was a container of raw hamburger patties stored on a shelf above containers of deli salads and ready to eat hot dogs in the Continental three door reach in cooler, k. There was accumulation of lint and grease on the electrical conduit on the walls. l. There was an accumulation of food on the conveyor belt on the toaster oven. m. There was an accumulation of lint on the fan guards in the walk in cooler. n. There was an accumulation of lint on the ceiling in the walk in cooler. o. There was an accumulation of black and brown residue on the floor and the walls in the walk in cooler. p. The condensation line from the condenser in the walk in cooler was draining into a five gallon bucket near the entrance to the walk in cooler. There was standing water in the bucket and the line was below the level of the water. q. There was an opened container of leftover chili dated 07/31/23 on a shelf in the walk in cooler. There was no use by date. r. There was an accumulation of white and black residue on the racks in the walk in cooler. s. There was standing water on the floor in the walk cooler near the entrance to the walk in freezer. There was ice buildup on the wall between the walk in cooler and walk in freezer. The base board was separating from the wall. t. A raw hamburger meat roll and package of raw chicken breasts were stored on top of ready to eat hot dogs in the walk in cooler. u. There was an accumulation of lint on the fan guards in the walk in freezer. v. There was ice and food debris on the floor in the walk in freezer. w. In-use cleaning cloths were laying on equipment and not stored in a sanitizer solution. x. An employee drink in a foam cup with no lid was stored on the table next to the stand mixer. y. Dietary Cook #1 was observed making deli sandwiches and was observed to place a metal lid over the hand sink blocking the hand sink from being accessible. z. There was an accumulation of pink and black residue inside of the ice machine. aa. There was an accumulation of brown residue inside of the ice shoot located on the ice dispenser. On 08/23/23 at 10:24 a.m., the CDM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated staff cleaned daily and there was a maintenance book where they wrote what repairs were needed. They were asked what was the policy for date marking food products. They stated food products should be labeled and dated. They stated opened perishables could be held for 24 hours and non-perishables 48 hours. The CDM was asked what was the policy for thawing foods. They stated foods could be thawed in the cool or in the sink with running water. They were asked what was the policy for storing in use cleaning cloths. They stated they only used the cleaning cloth once for each task. They stated after use the cloth was to be put in the dirty tub near the restroom. They were asked how staff prevented cross-contamination. They stated raw meat was to be stored in the bottom shelf and employee drinks were to be stored in a designated area. They were asked how staff ensure the hand sink was accessible for hand washing. They stated the hand sink should not be blocked. The CDM was made aware of the above observations.

Based on record review and interview, the facility failed to ensure residents' code status was accurate for two (#41 and #43) of two sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. Findings: 1. Res #41 had diagnoses which included paraplegia, dementia, respiratory failure, paranoid schizophrenia, depression, anxiety, and pain. An admission record, dated 01/04/22, documented the resident was their own responsible party. There was no documentation the resident had a POA or a legal guardian. A DNR consent form, dated 01/11/23, documented consent for DNR was signed by administrator #2 and witnessed by the DON and SSD. A physician order, dated 01/11/23, documented a DNR status for the resident. A quarterly assessment, dated 01/24/23, documented the resident's cognition was moderately impaired. There was no documentation the resident gave consent for the DNR. On 08/23/23 at 10:01 a.m., CNA #3 was asked if the resident had a POA, legal guardian, or if they were their own responsible party. They looked in the resident's hard chart and stated the resident was their own responsible party. They stated they just recently signed a waiver for their food. On 08/23/23 at 12:50 p.m., the DON and ADON were asked if the resident had a POA, legal guardian, or if they were their own responsible party. They stated the resident was their own responsible party. They were asked about the resident's DNR. They stated the resident gave verbal consent to Administrator #2 to sign the form. They were asked to locate documentation consent was given by the resident. On 08/23/23 at 1:41 p.m., the ADON stated there was no documentation the resident gave verbal consent for the DNR form to be signed in their behalf. They stated the resident should be a full code. 2. Res #43 had diagnoses which included heart failure, depression, HTN, and macular degeneration. A DNR form, dated 05/12/21, was located in the resident's hard chart. A physician order, dated 01/12/23, documented a living will. There was no physician order for code status. The special instructions in the EHR under the care profile documented the resident was a full code. On 08/23/23 at 9:53 a.m., CNA #3 was asked how a resident's code status in case of an emergency was determined. They stated there were two ways to determine code status. They stated there was a code status book and they looked in the residents chart. They stated if there was not a DNR form the resident was a full code. They looked in the code status book and stated there was not a DNR form for the resident. They looked in the resident's hard chart and stated the resident was DNR status. They stated they needed to updated the code status book. On 08/23/23 at 10:06 a.m., LPN #2 was asked how a resident's code status was determined. They stated there was a code status book and they looked in the residents chart. They stated they could also look in the care profile in the EHR. They reviewed the resident's care profile and stated the resident was a full code. They were asked if the resident had a physician order for code status. They stated there should be one, but they did not see an order for the resident. They were made aware the resident had a signed DNR form in their hard chart. On 08/23/23 at 12:50 p.m., the DON and ADON were made aware of the above observations.

Based on observation, record review, and interview, the facility failed to ensure AAT was maintained below 81 degrees F. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. Findings: Temperature reading logs were reviewed for 08/23/23. There were no documented AAT. On 08/23/23 at 4:50 p.m., a tour of hall 300 was conducted. There was a large floor fan on the hall blowing towards the nurses station. The AAT on the thermostat on the wall for was 84.6. degrees F. The AAT with a handheld thermometer was 85.2 degrees F. On 08/23/23 at 5:05 p.m., the AAT in Res #5 and Res #53's room was 85.1 degrees F. Res #53 was observed with a floor fan on their side of the room. Both residents were asked how the air temperature was in their room. Res #5 stated the temperature was good for them, but they could not have visitors due it being too hot. Res #53 stated they used a fan to circulate the air in their room. On 08/23/23 at 5:08 p.m., the AAT in Res #7 and Res #21's room was 87.6 degrees F. Res #7 was observed with a small fan on located on their over the bed table and Res #21 had a floor fan on. Both residents were asked how the air temperature was in their room. Res #7 stated they were hot. Res #21 stated it was hot in their room. On 08/23/23 at 5:11 p.m., the AAT in Res #36's room was 84.2 degrees F. They were asked how the air temperature was in their room. They stated it was too hot. On 08/23/23 at 5:13 p.m., the AAT in Res #24 and Res #63's room was 83.9 degrees F. They were asked how the air temperature was in their room. Res #24 stated it was too hot. Res #63 stated if their door was left open and they could feel the air from the fan in the hall, they were good. They stated if not, it was too hot. On 08/23/23 at 5:17 p.m., the facilities director was asked what was the protocol for monitoring air temperatures. They stated air temperatures were obtained daily and logged on Mondays and Fridays. They were asked what temperatures were to be maintained at in the facility. They stated 70 degrees F to 80 degrees F. The were asked if air temperatures were checked today. They stated they had another staff member check them. They were made aware of the AAT on hall 300 being above 81 degrees F.

Based on record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised after falls for one (#23) of 24 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 08/22/23, documented 60 residents resided in the facility. Findings: An undated facility policy titled Fall Protocol read in part: .8. Complete a new intervention on the care plan. Res #23 had diagnoses which included Alzheimer's, dementia, traumatic subdural hemorrhage, fractured left should, and history of falling. A care plan, initiated 08/13/20, documented the following interventions: a. Keep environment simple and uncluttered. b. Monitor for fatigue and other risk factors of tendency for falls. c. Respond promptly for request for toilet. d. Review resident fall assessment every three months and PRN occurrence. e. Supervise and assist resident with transfers. f. Provide activities for resident that minimize the potential for falls while providing diversion and distraction. g. Provide a safe environment with even floors; free from spills; clutter free; adequate glare-free lighting; and h. Provide working and reachable call light. i. Keep bed in low position at night and personal items within reach. j. Resident ambulates at lib without device. k. Anticipate and meet needs. An incident report, dated 8/18/22, documented Res #23 experienced an unobserved fall without injury. The incident report documented an intervention of resident needed better fitting shoes. There was no documentation Res #23's fall care plan had been updated with an intervention to prevent fall reoccurrence. An incident report, dated 08/24/22, documented Res #23 experienced an unobserved fall resulting in a skin tear to their left forearm. There were no interventions documented on the incident report. The was no documentation Res #23's fall care plan had been updated with an intervention to prevent fall reoccurrence. A nurse note, dated 09/03/22 at 9:44 p.m., documented Res #23 experienced an unobserved fall without injury. The fall care plan was not updated with an intervention to prevent fall reoccurrence. An incident report, dated 09/05/22, documented Res #23 experienced an observed fall with no injury. The incident report documented an intervention to prevent reoccurrence of falls was to continue all previous interventions and to complete hourly checks for 48 hours. There was no documentation the intervention was not carried out and the fall care plan was not updated with an intervention to prevent fall reoccurrence. An incident report, dated 09/06/22, documented Res #23 experienced an unobserved fall resulting in a laceration to the left side of their face and left hematoma to their head. and rib fractures. The fall care plan was not updated with interventions to help prevent reoccurrence of falls. A discharge return anticipated MDS assessment, dated 09/06/22, documented Res #23's cognition was severely impaired and required assistance ADLs. The assessment documented the resident had two falls with no injuries, one fall with injury except major, and one fall with major injury. A care plan, last updated 12/13/22, documented an intervention of encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. An incident report, dated 01/04/23, documented Res #23 experienced an observed fall with no injury. There were no interventions documented on the incident report and the fall care plan was not updated with an intervention to prevent reoccurrence of falls. A nurse note, dated 01/06/23 at 4:20 a.m., documented Res #23 experienced an unobserved fall without injury and the fall care plan was not updated with an intervention to prevent fall reoccurrence. A nurse note, dated 02/13/23 at 5:15 a.m., documented Res #23 experienced an unwitnessed fall without injury. The fall care plan was not updated with an intervention to prevent fall reoccurrence. A quarterly assessment, dated 03/22/23, documented the Res #23's cognition was severely impaired; required extensive assist with bed mobility; and limited assistance with transfers and walking. The assessment documented the resident had one fall with no injury. A nurse note, dated 04/25/23 at 1:12 a.m., documented Res #23 experienced a witnessed fall without injury. The fall care plan was not updated with an intervention to prevent fall reoccurrence. An incident report, dated 05/07/23, documented Res #23 experienced an observed fall with no injury. The fall care plan was not updated to prevent reoccurrence of falls. An incident report, dated 05/22/23, documented Res #23 experienced an observed fall resulting in a laceration to the bridge of their nose. The fall care plan was not updated with an intervention to prevent reoccurrence of falls. An incident report, dated 06/12/23, documented Res #23 experienced an observed fall resulting in a fractured left shoulder. The intervention on the incident report to prevent fall reoccurrence was to instruct staff to monitor Res #23 when up and ambulating. The fall care plan was not updated with an intervention to prevent reoccurrence of falls. An annual assessment, dated 06/20/23, documented the Res #23's cognition was severely impaired and required extensive assist with most ADLs. The assessment documented the resident had two falls with no injuries, one fall with injury except major, and one fall with major injury. A nurse note, dated 07/27/23 at 1:29 a.m., documented Res #23 experienced an unobserved fall without injury. The fall care plan was not updated with an intervention to prevent fall reoccurrence. On 08/24/23 at 10:45 a.m., LPN #3 was asked what their process was when a resident experienced a fall. They stated they would complete an incident report, begin neuro checks, and follow the facility fall protocol. LPN #3 was asked who was responsible for updating care plans. They stated the MDS coordinator. On 08/24/23 at 11:05 a.m., the MDS coordinator was asked if they were responsible for updating care plans. They stated they were. They were asked how often they update care plans. They stated as needed. The MDS coordinator was asked if they would update the care plan with a fall. They stated, Yes. The MDS coordinator was shown Res # 23's fall care plan and asked if it had been updated with any new interventions related to the falls from the following dates: 08/18/22, 08/24/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/09/22, 01/04/23, 01/06/23, 02/13/23, 04/25/23, 05/07/23, 05/22/23, 6/12/23, and 7/27/23. They stated there was no interventions related to the falls. On 08/24/23 at 11:31 a.m., the ADON was asked if Res #23s care plan had been updated with any new intervention to prevent fall reoccurrence. The ADON stated it was not and the care plan is the main framework that drives the resident's care. On 08/24/23 at 12:16 p.m., the MDS coordinator was shown Res #23's fall care plan and asked when was it last updated. The MDS coordinator stated 12/13/2022. On 08/24/23 at 1:42 p.m. the DON was asked what interventions from the care plan were currently in place to prevent Res #23 from falls. The DON presented the following list of fall interventions: a. anti-glare lights-initiated 03/31/2021 b. call light within reach-initiated 08/13/2020 c. proper footwear- initiated 08/13/2020 d. uncluttered environment initiated 03/31/2021 On 08/24/23 at 1:48 p.m. the DON was asked if the care plan had been reviewed and revised. They stated it was not.

Based on record review and interview, the facility failed to ensure a physician order for a blood pressure medication was accurately transcribed for one (#12) of five sampled residents reviewed for medications. The DON identified seven residents who had physician orders for BP medications with parameters. Findings: Res #12 had diagnoses which included HTN. A physician order, dated 05/12/23, documented clonidine HCL (an antiphypertensive) 0.1 mg two times a day. Hold if SBP greater than 120. The June 2023 MAR was reviewed and documented clonidine HCL was administered 43 out of 43 opportunities when SBP was greater than 120. It was documented clonidine HCL was was held three out of nine opportunities when SBP was less than 120. The July 2023 MAR was reviewed and documented clonidine HCL was administered 52 out of 52 opportunities when SBP was greater than 120. It was documented clonidine HCL was held two out of seven opportunities when SBP was less than 120. The August 2023 MAR was reviewed and documented clonidine HCL was administered 37 out of 37 opportunities when SBP was greater than 120. It was documented clonidine HCL was held one out of three opportunities when SBP was less than 120. On 08/24/23 at 12:26 p.m., the ADON reviewed the resident's physician order for their clonidine HCL and verified the medication was to be held if the SBP was greater than 120. They stated the physician order documented the medication was to be held if the SBP was greater than 120. They were made aware the MARs documented the medication was administered when the SBP was greater than 120 and held when the SBP was less than 120. They stated the physician order should have read to hold the medication if the SBP was less than 120.

Based on record review and interview, the facility failed to ensure residents were being monitored for side effects for the use of an anticoagulant and/or diuretic for two (#4 and #55) of five sampled residents reviewed for medications. The DON identified 19 residents who had physician orders for an anticoagulant and 28 residents who had physician orders for a diuretic. Findings: 1. Res #4 had diagnoses which included atrial fibrillation. A care plan, revised 10/19/17, documented the resident was on anticoagulant therapy. It was documented to monitor for side effects and effectiveness every shift. A physician order, dated 12/03/21, documented Xarelto (an anticoagulant) 20 mg at bedtime. The order was discontinued on 08/02/23. A physician order, dated 06/02/23, documented to monitor for anticoagulant medication. A physician order, dated 08/02/23, documented Xarelto 15 mg in the evening. There was no documentation the resident was being monitored for side effects. On 08/24/23 at 8:15 a.m., the DON was asked to provide documentation the resident was being monitored for the use of Xarelto for for the months June through August 2023. On 08/24/23 at 9:15 a.m., the DON and MDS coordinator #1 stated there was no documentation the resident was being monitored for the use of an anticoagulant. They stated the order was not selected to be scheduled in the EHR, so it did not generate on the TAR to be monitored. 2. Res #55 had diagnoses which included edema and lymphedema. A physician order, dated 03/24/23, documented furosemide (diuretic) 20 mg in the morning. The order was discontinued on 07/12/23. A care plan, revised 04/07/23, documented the resident was on diuretic therapy. It was documented to monitor for side effects and effectiveness every shift. A physician order, dated 06/07/23, documented to monitor for diuretics. A physician order, dated 08/02/23, documented furosemide 20 mg one time a day. There was no documentation the resident was being monitored for side effects. On 08/28/23 at 9:46 a.m., the DON was asked to locate documentation the resident was being monitored for the use of furosemide. On 08/28/23 at 10:15 a.m., the DON stated there was no documentation the resident was being monitored. They stated there should have been documentation the resident was being monitored for taking a diuretic.

Based on record review and interview, the facility failed to ensure behaviors and/or side effects were monitored for the use of psychotropic medications for four (#4, 12, 17, and #55) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 40 residents received psychoactive medications. Findings: 1. Res #4 had diagnoses which included bipolar disorder and depression. Physician orders, dated 12/03/21, documented Zoloft (an antidepressant) 50 mg in the morning, and mirtazapine (an antidepressant) 30 mg at bedtime. A care plan, revised 08/05/22, documented the resident received psychotropic medications. It was documented to monitor for side effects and effectiveness every shift. It was documented to monitor for targeted behaviors. A physician order, dated 06/02/23, documented to monitor for the use of a antipsychotic medication. A physician order, dated 06/12/23, documented to monitor for the use of antianxiety medications. A physician order, dated 08/02/23, documented Seroquel (an antipsychotic) 100 mg at bedtime. A physician order, dated 08/04/23, documented clonazepam (an antianxiety medication) 0.5 mg two times a a day. On 08/24/23 at 8:15 a.m., the DON was asked to provide documentation that behaviors and side effects had been monitored June through August 2023 for the resident's use of psychotropic medications. On 08/24/23 at 9:15 a.m., the DON and MDS Coordinator #1 stated behavior and side effect monitoring were documented on paper. They provided monitoring for June through July 2023. They stated there was no documentation monitoring had been conducted for August 2023. They stated it should have been completed. On 08/24/23 at 11:20 a.m., the DON was shown the behavior and side effect monitoring sheets they had provided. They were asked what the blanks indicated. They stated it indicated staff did not document they monitored for behaviors or side effects. 2. Res #12 had diagnoses which included major depressive disorder, anxiety, and insomnia. A physician order, dated 09/27/19, documented mirtazapine 15 mg at bedtime. A physician order, dated 11/23/22, documented buspirone (an antianxiety medication) HCL 5 mg give two tabs three times a day. A physician order, dated 12/03/22, documented duloxetine HCL (an antidepressant) 30 mg give three capsules by mouth one time a day. The June 2023 behavior and side effects monthly flow sheets were reviewed. It was documented 15 out of 270 opportunities behaviors were not monitored and one of out 180 opportunities side effects were not monitored. The July 2023 behavior and side effects monthly flow sheets were reviewed. It was documented 18 out of 270 opportunities behaviors were not monitored and 28 out of 186 opportunities side effects were not monitored. The August 2023 behavior and side effects monthly flow sheets were reviewed. It was documented 18 out of 270 opportunities behaviors were not monitored and 69 out of 138 opportunities side effects were not monitored. On 08/24/23 at 12:11 p.m., the DON was shown the blanks on the resident's behavior and side effects monthly flow sheets. They stated if it was not documented it was not done. 3. Res #17 had diagnoses which included anxiety and depression. Physician orders, dated 01/11/23, documented escitalopram oxalate (an antidepressant) 10 mg one time a day, and monitor for the use of antianxiety medications. A physician order, dated 01/18/23, documented alprazolam (an antidepressant) 0.5 mg give one tab by mouth two times a day. A care plan, initiated 01/27/23, documented the resident uses antidepressant medication. It was documented to monitor and document side effects and effectiveness every shift. The June 2023 behavior and side effects flow sheets were reviewed. It was documented 12 out of 270 opportunities the resident was not monitored for side effects. The July 2023 behavior and side effects flow sheets were reviewed. It was documented 21 out of 270 opportunities the resident was not monitored for side effects. The August 2023 behavior and side effects flow sheets were reviewed. It was documented 55 out of 138 opportunities the resident was not monitored for side effects. On 08/24/23 at 11:18 a.m., the DON was shown the behavior and side effects flow sheets and asked what the blanks indicated. They stated if it was not documented then it was not done. 4. Res #55 had diagnoses which included unspecified psychosis not sue to a substance or known physiological condition, insomnia, and anxiety. A physician order, dated 03/24/23, documented mirtazapine 15 mg at bedtime. The order was discontinued on 07/12/23. A care plan, dated 04/07/23, documented the resident uses psychotropic medications. It was documented to monitor for side effects and targeted behaviors. A physician order, dated 06/07/23, documented to monitor for the use an antipsychotic medication. A physician order, dated 06/16/23, documented trazadone HCL (an antidepressant) 100 mg at bedtime. The order was discontinued on 07/12/23. A physician order, dated 07/12/23, documented risperidone (an antipsychotic) 0.25 mg two times a day. The July 2023 behavior and side effect monthly flow sheets were reviewed. It was documented 276 out of 279 opportunities behaviors were not monitored and 32 out of 186 opportunities side effects were not monitored. The August 2023 behavior and side effect monthly flow sheets were reviewed. It was documented 37 out of 210 opportunities behaviors were not monitored and 30 out of 69 opportunities side effects were not monitored. On 08/24/23 at 3:15 p.m., the DON was shown the effects flow sheets and asked what the blanks indicated. They stated if it was not documented then it was not done.

Based on record review and interview, the facility failed to ensure labs were collected as ordered by the physician for two (#4 and #12) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 08/22/23, documented 60 residents resided in the facility. Findings: 1. Res #4 had diagnoses which included DM and kidney failure. A physician order, dated 02/28/20, documented CBC, CMP, and fasting lipid every 12 months starting on 04/11/20. A physician order, dated 10/12/20, documented to draw A1C every six months starting on 11/11/20. The was no documentation an A1C was collected in November 2022. There was no documentation a CBC, CMP, and fasting lipid were collected in April 2023. A physician order, dated 08/02/23, documented BMP on 08/05/23 then weekly for 30 days every Saturday. There was no documentation a BMP was collected on 08/05/23 and on Saturday 08/12/23. On 08/24/23 at 9:15 a.m., MDS Coordinator #1 and the DON were asked for documentation a A1C was collected in November 2022, a CBC, CMP, and fasting lipid were collected in April 2023, and a BMP was collected on 08/05/23 and on 08/12/23. On 08/24/23 at 10:46 a.m., the DON stated the A1C was collected in November 2022, but the lab indicated it had been lost. They stated the lab was not collected and there was no documentation the rest of the labs had been collected as ordered. 2. Res #12 had diagnoses which included DM, chronic kidney disease, and hypothyroidism, A physician order, dated 01/17/23, documented to collect A1C, CMP, and thyroid profile per the request of the pharmacist. There was no documentation a thyroid profile was collected. On 08/24/23 at 12:11 p.m., the DON was asked asked to locate documentation a thyroid profile had been collected as ordered on 01/17/23. On 08/24/23 at 12:32 p.m., the DON stated a TSH was collected on 01/18/23. They stated they would verify what was to collected when a thyroid profile was to be collected. On 08/24/23 at 12:44 p.m., the DON stated a thyroid panel included a TSH, T3, T4, and T7. They stated the lab was not collected as ordered.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls and failed to consistently identify and implement interventions to aid in the prevention of falls for one (#8) of three sampled residents reviewed for falls. Resident #8 experienced eleven falls which resulted in a right [MEDICAL CONDITION], a fractured pelvis, a new left [MEDICAL CONDITION] involving the left acetabulum with abnormal ileopectineal line, and an acute right superior and inferior pubic ramus fracture. The resident list report identified 71 residents resided in the facility. Findings: Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 11/12/18, documented: Focus .The resident is High risk for injury r/t hx of falls at home resulting in lt femur fracture, intermittent confusion, poor safety awareness, Gait/balance problems, Muscle weakness and impaired mobility, hearing problems (minimal), Wandering . Goal The resident will not have an interruption in normal activities due to pain/injury through review date. Interventions . Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs . Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility . Ensure that The resident is wearing appropriate footwear or non-skid socks when ambulating or mobilizing in w/c . Fit this resident with a wander guard to alert staff of attempts to leave the facility unaided . Keep environment simple and uncluttered . Monitor resident for fatigue and other risk factors of tendency for falls . Provide residents assistive device (wheelchair/walker) and assist with mobility as needed . Respond promptly to request to toilet . Review residents fall assessment every three months and PRN occurrence . Review this resident's non-restrictive device monthly to ensure appropriateness . Supervise and assist this resident with transfers . A progress note, dated 12/10/18, documented the resident was discovered sitting on her buttocks in front of the recliner. The note documented there was no injury. The note documented there were no interventions to prevent future falls. A care plan problem, initiated on 12/11/18, documented, .Focus .The resident has had an actual fall . Goal .The resident will resume usual activities without further incident through the review date . Interventions . Continue interventions on the at-risk plan . For no apparent acute injury, determine and address causative factors of the fall . Monitor/document/report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation . Pharmacy consult to evaluate medications . A progress note, dated 02/09/19, documented the resident was discovered sitting on the floor in front of her bed. The note documented the resident was transferred to the emergency room and was admitted for ORIF of the right hip. A progress note, dated 02/12/19, documented the resident returned to the facility. The note documented there were no new interventions to prevent future falls. A progress note, dated 02/24/19, documented the resident was discovered on her right side facing the bed with her wheelchair beside her. The note documented, .the resident was attempting to transfer self to bed . A significant change assessment, dated 02/24/19, documented the resident was severely cognitively impaired, required extensive assistance with most ADLs, had an impairment to one lower extremity, and had no falls since admission/entry or reentry or prior assessment. The assessment documented the resident had a surgical wound with application of ointment/medications. A progress note, dated 02/25/19, documented .negative for acute fx . A progress note, dated 03/12/19, documented the resident was observed on the floor in her room near her recliner. The note documented the resident was unable to explain what happened. The note documented, .resident stood up became entangled in lap blanket .no injury .x-ray coccyx, pelvis negative for fx . The note documented there were no interventions to prevent further falls. An update to the care plan, dated 04/02/19, documented, Anticipate and meet The resident's needs. An incident report, dated 04/16/19 at 7:00 a.m., documented the resident had experienced a fall, sustained two skin tears to her left arm, and a laceration/hematoma to her left upper eyebrow. The note documented the resident was transferred to the hospital and returned the same day with the [DIAGNOSES REDACTED]. Updates to the care plan, dated 04/16/19, documented, The resident uses a pressure alarm as a non-restrictive device while in bed and wheelchair. Ensure the device is in place as needed . The resident requires use of a low bed with a floor mat as a nonrestrictive device . A nurse's note, dated 04/20/19, documented, .because of resident's impaired cognitive diagnosis, her walker is kept within her reach as well as her call light. She is reminded often where her call light is and to use it. Staff is aware she will not always use her light and checks on her often . A progress note, dated 05/14/19, documented, .the resident alarm sounded, arrived within 1 minute .resident on floor hourly checks for 24 hours .c/o hip pain R An incident report note, dated 05/15/19, documented, .Resident fell while attempting to transfer from w/c to bed unassisted. Call light within reach and resident did not ask for assistance. Resident denied hitting head but did c/o R hip pain. Physician and family was notified of fall no new orders. Resident was medicated for pain. Resident continued to c/o R hip pain. Received order for xray. Mobile x ray arrived and performed x ray of R hip and pelvis. X ray results showed fracture of L hip. Medical director states to medicate for pain as needed. Family notified . An x ray report dated 05/15/19 at 11:53 a.m., documented, .new fx involving the left acetabulum with abnormal ileopectineal line .healed fixated right femoral neck fracture .left hip prosthesis . The note documented, . resident to be monitored at all times when in the w/c . A progress note, dated 05/16/19, documented the resident's physician, ordered .limited weight bearing, no ambulating, sit and stand only . Updates to the care plan, dated 05/16/19, documented, Supervision when up in wheelchair. Do not leave this resident in wheelchair alone . This resident requires use of fall mat beside recliner as a nonrestrictive device . An incident report, dated 06/19/19 at 4:00 p.m., documented, .was observed on floor in room by bed and recliner. Res fully dressed c shoes on. Hip within normal alignment. Res able to bear weight to BLE with/out pain .Res states was sitting in recliner and tried to transfer self and slide out of recliner .Pressure alarm battery was low changed battery Family, Dr. notified . An intervention to change battery to pressure alarm was documented on the incident report. A Mobile X-ray report, dated 06/19/19 at 8:11 p.m., documented .Acute right superior and inferior pubic ramus fracture . An incident supplement report, dated 06/20/19, documented, .Resident found in floor by staff. Resident attempted to transfer self from recliner. Pressure alarm was in place. X-ray was ordered by physician. Family was notified. X-ray results reveal acute right superior and inferior pubic ramus fracture. Resident was instructed to use call light for assistance. Physician and family notified. Pressure alarm to be in place at all times. Battery to be checked daily . A progress note, dated 06/25/19, documented, . the resident's physician (name withheld), ordered Part B PT to evaluate . Updates to the care plan for actual falls, dated 06/26/19, documented, . Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound . PT consult for strength and mobility . Vital signs: Take BP lying/sitting/standing x1 in first 24hr . A care plan problem initiated on 06/26/19, documented, Focus The resident has [MEDICAL CONDITION] . Goal .The resident will remain free from or at a level of discomfort acceptable to the resident through the review date . The resident will remain free of injuries or complications related to [MEDICAL CONDITION] through review date . Interventions . Encourage physical activity and daily ambulation. Use assistive device if necessary . Encourage weight bearing, exercise as tolerated to help maintain bone mass . Give [MEDICATION NAME] PRN for pain. Resident may complain of pain, stiffness or weakness. Document complaints . Monitor/document for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. (If resident has a care plan for falls, refer to this) . A PT evaluation, dated 07/10/19, documented, .Patient requires skilled PT services to assess functional abilities, increase independence with gait, facilitate (I) with all functional mobility, promote safety awareness, enhance rehab potential, facilitate motor control, increase coordination, improve dynamic balance, enhance fall recovery abilities, increase functional activity tolerance, increase LE ROM and strength, minimize falls, decrease complaints of pain, teach compensatory/adaptation techniques and facilitate anticipatory reactions in order to enhance patient's quality of life by improving ability to safely maneuver in/out of bed, prepare for transfers and perform steady gait . The evaluation documented the certification period as 07/10/19 through 08/08/19 with therapy three times per week. An OT evaluation, dated 07/10/19, documented, .The patient requires skilled OT services to increase (I) w/ADLs, maximize (I) with ADLs, facilitate (I) w/ADLs, facilitate dynamic standing balance and increase functional activity tolerance in order to enhance patient's quality of life by improving ability to be able to return to prior level of living . The evaluation documented the certification period as 07/10/19 through 08/08/19 with therapy three times a week. A progress note, dated 07/18/19, documented the resident had slid from her wheelchair. The note documented, .no orders . An update to the care plan, dated 07/18/18, documented, I would benefit from PT/OT/ST to evaluate and treat as ordered. A progress note, dated 07/19/19, documented, .pharmacy consult .no recommendations . A care plan intervention, dated 07/24/19, documented, .Gripper material in wheelchair when up . A progress note, dated 08/04/19, documented, .alarm sounding .on floor in doorway, walker in front of her . The note contained no interventions to prevent future falls. A quarterly assessment, dated 08/27/19, documented the resident was severely impaired cognitively, required extensive assistance with most ADLs, and had an impairment to her bilateral lower extremities. The assessment documented the resident had one non-injury fall, one fall with non-major injury, and one fall with major injury since admission/reentry or reentry or prior assessment. A progress note, dated 09/01/19, documented, .resident on floor .slid from recliner .taken to nurses desk . A progress note, dated 09/18/19, documented, .observed on floor mat .slid to floor mat . The note contained no interventions to prevent future falls. A progress note, dated 09/27/19 at 7:53 p.m., documented, .found on floor at end of bed .pressure alarm was sounding and CNA was on another hall . The note contained no interventions to prevent future falls. A progress note, dated 09/29/19, documented the resident was sitting on the floor against her recliner. The note contained no interventions to prevent future falls. On 09/30/19 at 2:26 p.m., the resident was observed resting on a low bed with a fall mat in place. A pressure alarm was in place beneath the resident. On 10/01/19 at 12:00 p.m., the resident was observed in her wheelchair self-propelling in the common areas, the dining room, common areas, and administrative offices. A cushion was observed in place to the wheelchair. No gripper material was observed. On 10/01/19 at 12:40 p.m., the DON was asked what type of recliner the resident used. She stated at one time the resident had a lift chair recliner. She would raise the chair to the point of sliding from the chair. The DON stated the recliner was removed and a manual leg lift recliner was placed in the resident's room. She stated she was unsure when the chair was changed. The DON was asked if she was aware of any gripper material used in the resident's wheelchair or recliner. She stated she was unaware of a gripper material being used. On 10/01/19 at 12:45 p.m., a CNA was asked if she had observed gripper material to the resident's wheelchair or recliner. She stated she was unaware of gripper material being used. On 10/01/19 at 1:00 p.m., the charge nurse was asked if she had observed gripper material to the resident's wheelchair or recliner. She stated no. She stated a pressure alarm was placed in the resident's wheelchair or recliner while up or in the resident's bed when she laid down.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to assess, monitor and intervene in a timely manner for two residents who had a change in condition. One resident was in respiratory distress and one resident had severe pain. ~ Resident #102 had a recent history of bilateral [MEDICAL CONDITION] emboli and bilateral [MEDICAL CONDITION] of the lower extremities. On [DATE] at 10:45 a.m., the resident had complained of difficulty breathing and had an erratic pulse rate of 80 to 100 beats per minute and respirations that were 34 to 44 times a minute. The oxygen saturation was documented as 9% on 3 liters of oxygen per nasal cannula. The nurse assisted the resident to sit up in bed and coached him on deep breathing. At 11:18 a.m., the resident was found to be unresponsive, with no pulse or respirations. CPR was started and 911 was called. CPR continued until EMS arrived and took over. The resident was transferred to the hospital. An emergency department note, dated [DATE] at 11:45 a.m., documented the resident had presented to the ER in full [MEDICAL CONDITION]. The note documented the resident had expired. ~ On [DATE] at 1:48 p.m., Resident #100's right lower extremity and right foot was observed to be pale white and cool to touch. The note documented the resident had not complained of pain and the nurse would continue to monitor. On [DATE] at 1:13 p.m., the resident had been begging the staff to call for an ambulance for most of the shift. The resident had been complaining of severe pain in her right upper leg, lower leg, and knee. The resident's right leg was cool to touch and discolored from the knee down. On [DATE] at 1:59 p.m., the resident was transferred to the hospital due to severe pain in her right leg. A hospital discharge summary, dated [DATE], documented the resident had presented to the hospital with an acutely ischemic right leg. The summary documented the resident had an occlusion to the common femoral artery and an extensive [MEDICAL CONDITION] in her right lower extremity. The summary documented the resident had been admitted to the ICU and had developed slurred speech and left sided weakness. The summary documented it was felt the resident likely had an extensive embolic [MEDICAL CONDITION]. The summary documented the resident had been discharged to a hospice house under the care of hospice. A facility health status note, dated [DATE] at 10:34 p.m., documented the resident had passed away. On [DATE] the OSDH was notified and verified the existence of the IJ situation. At 1:35 p.m., the administrator was informed of the IJ situation regarding the failure to assess, monitor, and intervene for a resident with severe pain and a resident in respiratory distress. The administrator was informed this placed the facility in an extended survey and a plan of removal was required. At 3:29 p.m., an acceptable plan of removal was received from the director of nursing. The plan of removal documented: Plan of correction: All licensed nursing staff will attend inservice pertaining to Policy and Procedure regarding the Removal of Residents at 5:00 PM on [DATE], or participate in teleconference covering new Policy on [DATE]. All licensed staff will be educated on new Policy by 6:00 PM on [DATE]. Plan of Removal Policy POLICY: It is the policy of this facility to assess resident status and intervene when needed to ensure resident health and safety. PR(NAME)EDURE: 1. The charge nurse will, within 30 minutes of noting change in resident condition: * Notify attending physician of the change in resident condition * Notify resident family of the change in resident condition * Notify DON office of the change in resident condition 2. Resident will be assessed by a nurse every 15 minutes until problem is abated or resident is transported to emergency room (ER). 3. If physician has not responded to call within 30 minutes, the resident will be transported to the emergency room (ER). 4. In the event of a life-threatening situation, the charge nurse will immediately call 911 for transport and notify the DON/ADON. Other notifications will be made when the emergency is abated. INSERVICE: [DATE] Policy and Procedure regarding Plan of Removal Policy * Review with nursing staff: assessment details that would require contact with physician * Review with nursing staff assessment details that would require immediate transport to ER * Go over new policy--any change in condition of any resident sets new policy in motion. * When in any doubt, communicate with DON/ADON. The IJ was removed effective [DATE] at 5:55 p.m., when all components of the plan of removal had been completed. The deficiency remained at a pattern level of actual harm. Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene in a timely manner for two (#100 and #102) of five sampled residents who had a change in condition. ~ Resident #102 had a recent history of bilateral [MEDICAL CONDITION] emboli and bilateral [MEDICAL CONDITION] of the lower extemities. On [DATE] at 10:45 a.m., the resident had complained of difficulty breathing and had an erratic pulse rate of 80 to 100 beats per minute and respirations that were 34 to 44 times a minute. The oxygen saturation was documented as 9% on 3 liters of oxygen per nasal cannula. The nurse assisted the resident to sit up in bed and coached him on deep breathing. At 11:18 a.m., the resident was found to be unresponsive, with no pulse or respirations. CPR was started and 911 was called. CPR continued until EMS arrived and took over. The resident was transferred to the hospital. An emergency department note, dated [DATE] at 11:45 a.m., documented the resident had presented to the ER in full [MEDICAL CONDITION]. The note documented the resident had expired. ~ On [DATE] at 1:48 p.m., Resident #100's right lower extremity and right foot was observed to be pale white and cool to touch. The note documented the resident had not complained of pain and the nurse would continue to monitor. On [DATE] at 1:13 p.m., the resident had been begging the staff to call for an ambulance for most of the shift. The resident had been complaining of severe pain in her right upper leg, lower leg, and knee. The resident's right leg was cool to touch and discolored from the knee down. On [DATE] at 1:59 p.m., the resident was transferred to the hospital due to severe pain in her right leg. A hospital discharge summary, dated [DATE], documented the resident had presented to the hospital with an acutely ischemic right leg. The summary documented the resident had an occlusion to the common femoral artery and an extensive [MEDICAL CONDITION] in her right lower extremity. The summary documented the resident had been admitted to the ICU and had developed slurred speech and left sided weakness. The summary documented it was felt the resident likely had an extensive embolic [MEDICAL CONDITION]. The summary documented the resident had been discharged to a hospice house under the care of hospice. A facility health status note, dated [DATE] at 10:34 p.m., documented the resident had passed away. The administrator identified seven residents had been transferred to the hospital in the last four months. The resident census and condition report identified 69 residents resided in the facility. Findings: 1. Resident #102 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was moderately impaired cognitively, required limited to extensive assistance with ADLs, had shortness of breath, weighed 261 lbs., and had no oxygen treatment. A care plan, dated [DATE], documented all triggered areas were care planned. A health status note, dated [DATE] at 10:19 p.m., documented the resident had been non-responsive/minimally responsive, pale and ashen, having difficulty breathing and c/o chest pain. The note documented EMS had been called and the resident had been transferred to the hospital. VS- 95.3, 124, 93%, ,[DATE], resp-34, FSBS-316 left via ambulance in stable condition A health status note, dated [DATE] at 4:47 p.m., documented the resident had returned to the facility with new orders for Eliquis 10 mg by mouth twice a day for seven days, then 5 mg twice a day and Klonopin 1 mg twice a day for anxiety. A hospital discharge summary, dated [DATE], documented the resident had bilateral [MEDICAL CONDITION] embolisms and bilateral [MEDICAL CONDITION] of the lower extremities. A health status note, dated [DATE] at 11:18 a.m., documented at 10:45 a.m., the resident had complained of difficulty breathing and his vital signs were: BP:,[DATE], T:97.3, SaO2:9:% on 3 LPM N/C, P: ,[DATE] very erratic, and R:,[DATE]. The note documented the nurse assisted the resident to sit up in bed straight and coached him on deep breathing. The note documented the resident had been very anxious that morning and the nurse had been in his room several times to help the resident calm his anxiousness with deep breathing. The note documented at 11:18 a.m., the resident was found to be unresponsive with no pulse or respirations. The note documented CPR was started and 911 was called. The note documented CPR continued until EMS arrived and took over at 11:30 a.m. and transferred the resident to the hospital. A hospital emergency department note, dated [DATE] at 11:45 a.m., documented the resident had presented to the ER by local EMS in full [MEDICAL CONDITION]. The note documented EMS had found the resident unresponsive and pulseless and had immediately started ACLS protocols. The note documented the resident had been asystolic for approximately 30 minutes and he remained pulseless. On [DATE] at 9:05 a.m., LPN #1 was asked about resident #102. She stated the resident had returned to the facility from the hospital the night before. She stated the resident was much weaker when he returned. She stated they had to transfer him with a Hoyer lift and feed him. She stated after breakfast on [DATE] the resident had wanted to sit up in his recliner and he kept stating he could not breath. LPN #1 stated she sat with the resident and tried to calm him with breathing exercises. She stated the resident would become very anxious at times. She stated she had checked his vital signs and they were normal for him except his pulse rate was erratic. LPN #1 stated she just did not think the resident looked right. She stated the resident had calmed down so she left the room for 15 or 20 minutes and then she was called back to the resident's room. She stated when she returned to the resident's room he was not breathing so she started CPR. LPN #1 was asked if she was concerned the resident might have another [MEDICAL CONDITION] embolism. She stated yes. She was asked when she would call 911 or send the resident to the hospital since the resident was in distress. She stated the resident had not been in distress. She stated he would just get anxious but would calm down after she sat with him. She stated she had called 911 when she started CPR. At 10:40 a.m., the ADON was asked about the incident with resident #102. She stated the staff should have called 911 and transferred the resident to the hospital as soon as they became aware he was having trouble breathing. 2. Resident #100 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated [DATE], documented the resident was moderately impaired cognitively for daily decision making skills, had short and long term memory loss, required extensive assistance with most ADLs, and had no pain. A care plan, dated [DATE], was complete for all triggered areas. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Once on [DATE] at 9:04 a.m. for a pain level of 7. A health status note dated, [DATE] at 1:48 p.m., documented the CNA had called the nurse to the room to check the resident's right lower extremity and right foot. The note documented the resident's right leg/foot was pale white and cool to touch. The note documented the resident had not complained of pain and nursing would continue to monitor. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Medication Administration Record, [REDACTED]. A health status note, dated [DATE] at 1:13 p.m., documented, .Resident has been begging the staff To call the ambulance for most of the shift . The note documented the resident had complained of severe pain in her right lower leg, right knee, and right upper leg. The note documented the resident's right leg was cool to touch and discolored from the knee down. The note documented the nurse called and spoke with the resident's POA/daughter about the resident's condition. The note documented the daughter was okay with the resident being transferred to the hospital and an order to transfer the resident had been obtained from the physician. A health status note, dated [DATE] at 1:59 p.m., documented, .Resident transferred to stretcher & escorted out of facility by EMT's. Stable condition when exiting the facility. A hospital discharge summary, dated [DATE], documented the resident had been admitted on [DATE] with an acutely ischemic right leg and was found to have an occlusion to the common femoral artery. The summary documented the resident had been admitted to the ICU where she developed slurred speech and left sided weakness. The summary documented the resident's deficits continued and the physician felt the resident likely had an extensive embolic [MEDICAL CONDITION]. The summary documented the resident's family had been counseled and the decision was made to place the resident on hospice/comfort care measures only. The summary documented the resident had been discharged to a hospice house. A facility health status note, dated [DATE] at 10:34 p.m., documented the resident had passed away. On [DATE] at 8:57 a.m., LPN #1 was asked about resident #102. She stated after she had received report at the beginning of her shift she had checked the resident's right leg. She stated it was around 7 a.m., or 8 a.m. She stated the resident's right leg was cold and the resident was complaining of pain. LPN #1 stated she thought the resident had a [MEDICAL CONDITION]. She stated she had reported her findings to the DON and asked her to assess the resident's leg with her. LPN #1 stated the DON had told her to call the physician and try to get the resident's pain medication increased. LPN #1 stated she had not heard back from the physician's office and the resident had continued to complain of pain and was begging to go to the hospital. She stated she had called the resident's daughter and the daughter wanted the resident transferred to the hospital. LPN #1 stated she then told the DON she had not heard back from the physician's office and the resident's daughter wanted the resident transferred to the hospital. LPN #1 stated she called the physician's office and told them she was transferring the resident to the hospital. LPN #1 was asked how long she would wait to hear back from the physician's office in a situation where the resident was in severe pain. She stated she would usually try to call the physician a couple of times. She stated she had called the physician's office again when she had transferred the resident to the hospital. LPN #1 was asked what she should do if the DON did not respond when she had reported a resident with a change in condition. She stated she should have reported it to the administrator. LPN #1 was asked if she thought the delay in getting the resident treatment had caused any problems. She stated she did not think so. She stated the resident's vital signs were stable and there had not been a change in her condition other than the resident's complaint of pain. LPN #1 was asked if she thought the resident had suffered. She stated yes. At 10:40 a.m., the ADON was asked about the incident with resident #100. The ADON stated the physician should have been called and if no immediate response the resident should have been sent to the hospital.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents maintained their highest level of well-being for one (#3) of four sampled residents reviewed for well-being. The facility failed to: a. notify the resident's physician of a change in the resident's condition. b. accurately document resident #3's skin issues on a quarterly assessment. c. update and revise a skin integrity care plan for resident #3. A hospital history and physical documented "IMPRESSION...Sepsis probably secondary to [MEDICAL CONDITION] of the arms...PLAN OF CARE...Patient now has been started on intravenous antibiotic and will be admitted as an inpatient for continued antibiotics and IV fluids...." The minimum data set (MDS) coordinator identified six residents with a change of condition in the last two months. Findings: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 04-23-13, documented resident #3 was moderately impaired cognitively; required limited assistance for dressing; required supervision with transfers, eating, and hygiene; was continent of bowel and bladder; had no pressure ulcers; and had an infection of the foot with surgical wound care. A skin integrity care plan, dated 04-24-13 and reviewed on 01-16-14, documented, "...POTENTIAL IMPAIRED SKIN INTEGRITY...Related to: 1. Diabetes mellitus...2. Hx (history) non-resolving diabetic ulcer to left heel...3. Hx Surgically repaired diabetic ulcer to left heel...4. Refuses to take insulin's...5. Hx Non-compliant with very limited weight bearing restrictions to left heel...6. Hx Surgical wound dehiscence to left foot...7. [MEDICAL CONDITION]...8. Hx scabies...9. [MEDICAL CONDITION] to bilateral feet...Goals: 1. Skin will be free of breakdown...Approaches: 1. Notify Physician of any changes in skin health..." A nurse's note, dated 01-08-14 at 11:30 p.m., documented, "...Several scratches noted to Res (resident) L (left) et (and) R (right). Bleeding from two 2cm (centimeter) areas on L arm et res cont (continues) to say 'It needs to be off there'...Area cleaned bandage applied. Faxed physician..." The clinical record did not contain documentation the physician received or responded to a fax, dated 01-08-14, or family notification had occurred. A weekly skin assessment, dated 01-08-14, documented, "...L,R upper arms (picking at scabs)...treatment Y (yes)... new N (no)...healed N...improved N...same N...declined N..." A nurse's note, dated 01-13-14 at 9:00 a.m., documented, "...Res. has dry, crusty areas to upper arms bil. (bilateral). She will pick @ (at) them until bright red drng (drainage)..." The clinical record did not contain documentation the physician was updated or family notification had occurred. A skin integrity care plan update, dated 01-13-14, documented, "...Dry crusty areas to BUE (bilateral upper extremities), picks at these areas...Goals: Be free of infection..." A quarterly assessment, dated 01-15-14, documented resident #3 was moderately impaired cognitively; required extensive assistance with dressing, hygiene, and bathing; required limited assistance with transfers; independent in eating; was frequently incontinent of bowel and bladder; had fluctuating altered level of consciousness; and did not have pressure ulcers or other skin problems. A nurse's note, dated 01-15-14 at 4:30 p.m., documented, "...Observed scratching et picking L upper arm. Covered arm c (with) Kerlix to deter res from picking..." A weekly skin assessment, dated 01-15-14, documented, "...L, R upper arms (picking at scabs)...treatment Y...new N...healed N...improved N...same N...declined Y..." The clinical record did not contain documentation the physician was updated or family notification had occurred. A nurse's note, dated 01-15-14 at 11:45 p.m., documented, "...Bandage to L. upper arm, changed, res had picked et pulled @ bandage et it was in shreds. applied TAO (triple antibiotic ointment) et covered c (with) foam border dressing. Wrapped c gauze to prevent picking..." The clinical record did not contain documentation the physician was updated, the facility had received an order for [REDACTED]. A nurse's note, dated 01-16-14 at 5:40 a.m., documented, "...CNA (certified nurse assistant) came to get this nurse stating 'She has blood all over her sheets.' Nurse noted res had picked bandage off and was picking @ her scabes (sic) to L upper arm. 2-2cm gashes noted to area. Area cleaned TAO applies (sic). Foam border et wrapped c gauze..." The clinical record did not contain documentation the physician was notified, the facility had received orders for ointment and dressing changes, or family notification had occurred. A nurse's note, dated 01-21-14 at 7:15 a.m., documented, "...Res in lobby, this nurse noted Res grooning (sic), asked Res if Res hurting, Res stated "Yes," Res vomited large amount, T (temp) 99.6..." A nurse's note, dated 01-21-14 at 1:00 p.m., documented, "...0 (no) further vomiting or c/o (complaints of) nausea, noted pallor, physician to be notified via fax..." A nurse's note, dated 01-21-14 at 2:45 p.m., documented, "...Physician faxed Re: (regarding) increased temp, vomiting, lethargy..." A nurse's note, dated 01-21-14 at 4:30 p.m., documented, "...Check lab CBC (complete blood count), chem (chemistry) 14, UA (urinalysis) and urine culture..." A nurse's note, dated 01-22-14 at 1:30 p.m., documented, "...Ax (axillary) temp. (temperature) 102.4, Loose stool x (times) 2 this 8 hrs. LCTA (lungs clear to auscultation) bil. Res. not eating or drinking. Lab et UA results faxed to (physician name deleted) office... attached is res. condition update-awaiting reply..." A nurse's note, dated 01-22-14 at 3:00 p.m., documented, "...(physician name deleted) returned call et stated to send Resident to ER (emergency room ) for poss. (possible)[MEDICAL CONDITION]" A nurse's note, dated 01-22-14 at 3:20 p.m., documented, "...Resident's daughter notified of condition et intent to send to ER..." On 02-06-14 at 2:00 p.m., licensed practical nurse (LPN) #1 was asked if she had notified the physician on 01-08-14. She stated, "Yes, I did fax the physician." LPN #1 was asked if the physician responded to her fax. She stated she was not aware of any new orders. LPN #1 was shown the fax she had written which was located in the physician folder at the nurses' station. LPN #1 was asked if she had faxed the physician on 01-08-14. LPN #1 stated when she faxed the physician, she did not stamp the fax as sent nor did she write the day and time she sent the fax to the physician. LPN #1 was asked if she had physician orders [REDACTED]. She stated no. LPN #1 was asked if she had updated the resident's family regarding the skin sores. She stated no. On 02-06-14 at 2:15 p.m., LPN #2 was asked if she had called the physician or updated the family regarding the skin sores. LPN #2 stated no. On 02-06-14 at 2:45 p.m., the physician was asked if he was aware of the sores on resident #3's arm prior to her hospitalization . He stated no. The physician stated the sores went back a long time to possibly the summer when he thought she had scabies and was treated with a topical ointment at the time. He stated the sores would get better then worse especially as the resident tended to scratch them and kept them irritated. On 02-06-14 at 3:20 p.m., the director of nursing (DON), assistant director of nursing (ADON) and minimum data set (MDS) coordinator were asked if the skin integrity care plan was reflective of resident #3's skin integrity. The ADON stated no. The DON and ADON stated they were not aware of the ongoing bleeding from the sores, dressing changes, and ointments being applied to resident #3's arm. The ADON stated resident #3 had a long history of picking at sores on her arm. She further stated the facility believed it was a behavior. The MDS coordinator was asked if the care plan was reflective of the the scratching behaviors. She stated no. During the interview on 02-06-14 at 3:20 p.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked if they were aware of the skin sores and the treatments. They stated no. The ADON stated resident #3 had an ongoing problem with skin sores which she picked at periodically. The ADON stated the sores would bleed, then heal, then bleed again when resident #3 picked at them. The ADON stated, "It's just (resident name deleted), it's what she does." The DON and ADON were asked how they were made aware of skin problems in the facility. The ADON stated if a resident had a new skin problem, the information was then placed on the weekly skin assessment sheet. She stated the skin assessment sheet was given to her to follow-up however, the nurses were supposed follow-up on any new issues and call the physician if needed. The DON and ADON were asked if the physician was updated or if the family was notified prior to resident #3's hospitalization . The ADON and DON stated, "No, it appears from the documentation the physician and family were not notified or updated in a timely manner.