Every finding on record at Bayside Health & Rehabilitation Center

Based on observation, resident family member interview, and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 5 residents (Resident #5), in the survey sample. The findings included: Resident #5 was originally admitted to the facility 3/1/25 after an acute care hospital stay. The admission diagnoses included; cerebral infarction, type 2 diabetes mellitus with unspecified complications, unspecified congestive heart failure, and essential hypertension. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/7/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 02 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were severely impaired. On 3/5/25 at 10:10 AM during an observation tour for room [ROOM NUMBER], it was observed that there was large/deep gauges in the drywall behind the (A) bed headboard and the room light fixture cover was cracked. It was also observed that the floor between the (A) bed and the (B) bed had a large area that was black and very dirty. On 3/5/25 at 1:55 PM an interview was conducted with Family Member #1. Family Member #1 stated that Resident #5 was admitted to the facility over the weekend and the wall behind the headboard of the bed needs repair and the light fixture cover has a crack in the lens. Family Member #1 also stated that there is a large area on the floor between the residents beds that is very dirty and disgusting. Family Member #1further stated, this floor has looked like this all day, and no one should have to live like this. On 3/5/25 at 2:15 PM an interview was conducted with the Housekeeping Director. The Housekeeping Director stated that the floor in room [ROOM NUMBER] is not acceptable. The Housekeeping Director also stated, the housekeeper was probably going to come back and clean the floor however the facility only has (1) one housekeeper working today and she probably got busy doing something else. On 3/5/25 at 2:50 PM an interview was conducted with the Maintenance Director. The Maintenance Director stated, the wall behind the headboard and the light fixture in room [ROOM NUMBER] should not look like it does. He also stated, I will fix these issues as soon as I can. On 3/6/25 at approximately 4:22 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to administer significant medications on admission for 1 of 5 residents (Resident #3), a closed record resident, in the survey sample. The findings included: Resident #3 was originally admitted to the facility 12/31/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Malignant Neoplasm of Brain Unspecified and Convulsion Disorder. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/06/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated Resident #3 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with touch assistance with eating, Dependent with toileting hygiene, shower/bathe self, lower body dressing and personal hygiene. The Care Plan dated 1/01/25 read that the resident is at risk for complications related to Convulsive Disorder. The Goal is the resident will not have an adverse consequence due to their convulsive disorder. The interventions for Resident #3 Administer medication as ordered and notify MD as indicated. The Physician's Order Summary (POS) for December 2024 read: Keppra (levetiracetam) Oral Tablet 500 MG. Give 1 tablet by mouth every 12 hours for Progressive weakness. Order date: 12/31/2024. Dexamethasone Oral Tablet 4 MG. Give 1 tablet by mouth three times a day for Thrombocytopenia. Order date: 12/31/2024. The Medication Administration Record (MAR) for December 2024 read: Keppra oral Tablet 500 MG. Give 1 tablet by mouth every 12 hours (9:00 am and 9:00 pm) for Progressive weakness. Order date: 12/31/2024 at 5:28 PM. A review of the above MAR, for Resident #3 was coded as (5) meaning 5=Hold/See Nursing Progress Notes dated 12/31/24 at 8:52 p.m. A review of the admissions, progress and order note does not reveal the meaning of why the resident's Keppra or Dexamethasone was placed on hold. According to the Admissions note, Resident #3 arrived at the facility via stretcher on 12/31/24 at 5:06 PM. An interview was conducted on 3/05/25 at approximately 2:20 PM., with Licensed Practical Nurse (LPN) #1. LPN #1 said that the on-call physician was called on 12/31/24 to put the Keppra on hold because the medication wasn't available in the Omnicell (Medication Dispensing System). LPN #1 also said, If medications aren't in the Omnicell, a STAT order usually takes 4-6 hours. Typically medications are pulled from Omnicell or called in STAT which usually takes 4-6 hours if not in Omnicell. I would have called pharmacy. LPN #1 stated the resident was administered the Keppra the following day on 1/1/25. Keppra (levetiracetam) is used alone or together with other medicines to help control certain types of seizures (eg, partial-onset seizures, myoclonic seizures, or tonic-clonic seizures) in the treatment of epilepsy. This medicine cannot cure epilepsy and will only work to control seizures for as long as you continue to use it (https://www.mayoclinic.org/drugs-supplements/levetiracetam-oral-route/description/drg-20068010). Dexamethsone is used to provide relief for inflamed areas of the body. It is used to treat a number of different conditions, such as inflammation (swelling), severe allergies, adrenal problems, arthritis, asthma, blood or bone marrow problems, kidney problems, skin conditions, and flare-ups of multiple sclerosis (https://www.mayoclinic.org/drugs-supplements/dexamethasone-oral-route/description/drg-20075207). On 03/06/25 at approximately 4:25 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on interviews, clinical record review, and facility documentation the facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 2 Residents (#172 and #27) in a survey sample of 62 residents. The findings included: 1. For Resident #172 the facility staff failed to provide treatments for non-pressure wounds which became infected and resulted in hospitalization , this is harm. Resident #172 was admitted on [DATE] with 4 wounds and no orders, and when orders were obtained on 5/1/24 they were not transcribed to the MAR until 5/3/24. In addition, the care plan stated wound care as ordered however there were no wound care orders on 4/30/24. Resident #172's admission diagnoses included but were not limited to diabetes, hereditary lymphedema, non-pressure wound to left leg, Motor Vehicle Accident (MVA) driver resulting in lacerations with sutures to left lower leg and foot, muscle weakness and abnormal gait. On 6/6/24 a review of the clinical record revealed that on 5/1/24 the admitting nurse made the following entry: 5/1/24 at 12:00 AM (midnight) - Skilled Nursing Focus: Patient here for physical therapy (PT) and occupational therapy (OT) he has a wound to the left leg no wound orders present at the moment. The clinical record revealed that on 5/1/24 at 1:05 PM, Resident #172 was evaluated by the wound specialist. The wound doctor identified 4 wounds in total. Excerpts from the wound doctor's notes are as follows: WOUND ASSESSMENT: Wound 1: Location: Left anterior lower leg Primary Etiology: Skin tear/Laceration s/p suture repair Wound Status: Present on Admission Odor Post Cleansing: None Size: 8.9 cm x 2 cm x 0.1 cm. Calculated area is 17.8 sq cm. Wound Edges: Sutured, Peri-wound: Edema, Fragile Exudate: Moderate amount of Serosanguineous Wound Pain at Rest: 2 Wound 2: Location: Left medial ankle Primary Etiology: Skin Tear/Laceration s/p suture repair Wound Status: Present on Admission Odor Post Cleansing: None Size: 4 cm x 5 cm x 0.1 cm. Calculated area is 20 sq cm. Wound Edges: Sutured Peri wound: Edema, Fragile Exudate: Moderate amount of Serosanguineous Wound Pain at Rest: 2 Wound 3: Location: Left dorsal foot Primary Etiology: Skin Tear/ Laceration s/p suture repair Wound Status: Present on Admission Odor Post Cleansing: None Size: 5 cm x 6 cm x 0.1 cm. Calculated area is 30 sq cm. Wound Edges: Sutured Peri wound: Fragile, Edema Exudate: Moderate amount of Serosanguineous Wound Pain at Rest: 2 Wound 4: Location: Right posterior lower leg Primary Etiology: Lymphatic Stage/Severity: Full Thickness Wound Status: Present on Admission Odor Post Cleansing: None Size: 4 cm x 8 cm x 0.2 cm. Calculated area is 32 sq cm. Wound Base: 0% epithelial, 100% granulation, 0% slough, 0% eschar Exposed Tissues: Subcutaneous Wound Edges: Attached Peri wound: Fragile, Erythema exudate: Moderate amount of Serous drainage. PLAN: Wound # 1 Left anterior lower leg Skin Tear/Laceration Treatment Recommendations:1. Betadine. 2. apply Bacitracin ointment to base of the wound. 3. secure with ABD, Rolled gauze. 4. change Daily. Wound # 2 Left medial ankle Skin Tear/ Laceration Treatment Recommendations:1. Betadine. 2. apply Bacitracin ointment to base of the wound.3. secure with ABD, Rolled gauze. 4. change Daily. Wound # 3 Left dorsal foot Skin Tear/Laceration Treatment Recommendations:1. Betadine .2. apply Bacitracin ointment to base of the wound.3. secure with ABD, Rolled gauze 4. change Daily. Wound # 4 Right posterior lower leg Lymphatic Treatment Recommendations:1. Cleanse with wound cleanser .2. apply Triamcinolone ointment to peri wound-cover open ulcerations with silver alginate to base of the wound.3. secure with ABD, Rolled gauze 4. change Every other day. A review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) revealed that wound care orders were not transcribed to the TAR until 5/3/24 and were subsequently not signed off as being administered at any point during the admission. Resident #172 subsequently was seen by the wound doctor again on 5/6/24, excerpts from the wound doctor are as follows: WOUND ASSESSMENT: Wound: 1 Location: Left anterior lower leg Primary Etiology: Skin Tear/Laceration Stage/Severity: s/p suture repair Wound Status: Stable Odor Post Cleansing: None Size: 8.9 cm x 2 cm x 0.1 cm. Calculated area is 17.8 sq.cm. Wound Edges: Sutured Peri wound: Edema, Fragile Exudate: Moderate amount of Serosanguineous Wound Pain at Rest: 2 Wound: 2 Location: Left medial ankle Primary Etiology: Skin Tear/Laceration Stage/Severity: s/p suture repair Wound Status: Worsening Odor Post Cleansing: None Size: 4 cm x 5 cm x 0.1 cm. Calculated area is 20 sq cm. Exposed Tissues: Epithelium Wound Edges: Sutured Peri wound: Edema, Fragile Exudate: Moderate amount of Seropurulent Wound Pain at Rest: 2 Wound: 3 Location: Left dorsal foot Primary Etiology: Skin Tear/Laceration Stage/Severity: s/p suture repair Wound Status: Worsening Odor Post Cleansing: None Size: 5 cm x 6 cm x 0.1 cm. Calculated area is 30 sq cm. Wound Edges: Sutured, Unattached Peri wound: Fragile, Edema Exudate: Moderate amount of Seropurulent Wound Pain at Rest: 2 Wound: 4 Location: Right posterior lower leg Primary Etiology: Lymphatic Stage/Severity: Full Thickness Wound Status: Improving without complications Odor Post Cleansing: None Size: 4 cm x 8 cm x 0.2 cm. Calculated area is 32 sq cm. Wound Edges: Attached Peri wound: Fragile, Erythema Exudate: Moderate amount of Serous Wound Pain at Rest: 2 ASSESSMENT: Non-pressure chronic ulcer of unspecified part of the right lower leg with unspecified severity Hereditary lymphedema. Car driver injured in collision with other nonmotor vehicle in nontraffic accident, subsequent encounter. Laceration without foreign body, left ankle, subsequent encounter. Laceration without foreign body, left foot, subsequent encounter. Laceration without foreign body, left lower leg, subsequent encounter. 5/6/24: Left dorsal foot and left medial ankle wounds have worsened with moderate seropurulent drainage noted. Sutures dehisced with slough noted. Spoke with facility provider with recommendations to send him to the Emergency Department (ED) for evaluation of infection. He is diabetic and has lymphedema and is at an increased risk for wound complications to his feet. A review of the hospital record dated 5/6/24 revealed that Resident #172 was seen in the ED and was subsequently admitted to the hospital with a diagnosis of infected wounds. On 6/13/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 40711 2. For Resident #27 the facility staff failed to follow physicians orders by not ensuring Resident #27 received her necessary wound care treatments. Resident #27 was originally admitted to the facility 11/18/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included Pressure Ulcer of the Right Ankle and Peripheral Vascular Disease. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/05/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goal) Requires set up and or clean up assistance with eating, oral hygiene and personal hygiene. Requiring substantial/maximal assistance with toileting hygiene and lower body dressing. In Section M (Skin Conditions) Resident is coded as being at risk for Pressure Ulcers. Resident is coded as not having any unhealed Pressure Ulcers. Resident is coded as having 3 Venous and Arterial Ulcers. The Care Plan dated 11/22/22 and revised on 7/23/23 read that Resident #27 was at risk for pressure ulcers related to weakness, impaired mobility and incontinence, right hemiparesis status post (s/p) Cerebral Vascular Accident (CVA). The Goal for Resident #27 is that the resident will not have a skin impairment thru the review period, assess resident for risk of skin breakdown, assist the resident to turn and reposition often, keep skin clean and dry as possible. The Medication Administration Record (MAR) for May and June 2024: Solosite Wound Gel External Gel (Wound Dressings) Apply to buttocks, R lateral ankle topically every night shift every other day for Stage 4 pressure ulcer -Order Date 05/21/2024 9:41 AM -D/C Date 06/06/2024 10:24 AM. Missed treatment on 6/04/24. WOUND CARE: Buttocks, right lateral ankle: Cleanse and pat dry. Apply scant amount of Solosite to wound and cover with foam dressing. Change Q2 days or PRN for soiling. every night shift every other day -Order Date 05/21/2024 9:38 AM -D/C Date 06/06/2024 10:18 AM. Missed treatment on 6/04/24. WOUND CARE: Please apply betadine-soaked gauze, 4x4s, Kerlix, and a light ACE bandage to right foot every other day every night shift every other day -Order Date 05/21/2024 9:47 AM -D/C Date 06/06/2024 10:13 AM. Missed Treatment on 6/04/24. LEFT BUTTOCK: Cleanse with wound cleanser, pat dry, apply hydrogel, cover with bordered gauze. every night shift for pressure stage 3 wound -Order Date 05/09/2024 1315 -D/C Date 05/21/2024 0923. Missed treatments: 5/10/24, 5/12/24, 5/15/24, 5/16/24. Right Lateral ankle: Cleanse with normal saline, Pat dry, skin prep to surrounding tissue, Manuka HD alginate, Honey fiber to wound bed, Bordered foam, NO ACE BANDAGE OR KERLIX NO COMPRESSION OF ANY KIND one time a day for WOUND -Order Date 02/27/2024 4:30 PM. -D/C Date 05/21/2024 9:22 AM. Missed Treatments: 5/01/24, 5/02/24, 5/08/24. On 6/11/24 at approximately 2:55 PM., an interview was conducted with the Director of Nursing (DON) concerning skin assessments and missed wound care treatments. The DON said that it is expected that the nurses perform skin assessments and carry out wound care treatments on their residents. The DON also mentioned that if the CNAs notice any new areas on the residents' skin they would inform the nurse. On 6/12/24 at approximately 11:00 AM., an interview was conducted with Certified Nursing Assistant (CNA #6) concerning Resident #27. CNA #6 said that the resident didn't have any skin issues in January. On 6/12/24 at approximately 1:35 pm., an interview was conducted with the Wound Care Nurse Practitioner (WCNP). The WCNP said that she was not aware of any missed wound care treatments. On 06/13/24 at approximately 2:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, family interview, staff interviews, clinical record review, and facility document review, the facility staff failed to prevent, identify, assess and treat pressure sores for one (1) resident (Residents #165) resulting in harm in a survey sample of 62 Residents. The findings included: Resident #165's unstageable pressure wounds were never identified by the facility. No measurements nor descriptions of the wounds were ever placed in the clinical record by nursing staff. The 4-13-21 identification of multiple unstageable pressure wounds occurred at an outside orthopedics appointment and was not treated until the Resident was seen by the wound NP on 4-16-21, 3 days after identification. This was identified as harm. Resident #165 was admitted to the facility on [DATE] and discharged on [DATE] (29 days later) with diagnoses including; Diabetes type 2, acute hip fracture with surgical repair, Foley (brand name) urinary catheter placement after hip fracture, and congestive obstructive pulmonary disorder (COPD). Resident #165's most recent MDS (Minimum Data Set Assessment) was an admission assessment. The MDS coded Resident #165 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The resident was also coded as alert and able to make needs known, with some confusion at times. The Resident was coded as frequently incontinent of bowel and a Foley catheter for the bladder. The resident was no longer in the facility and a closed record review was conducted. The resident had no pressure wounds upon admission. Physician orders were reviewed and revealed that on 3-23-21 after admission the Resident was receiving an Allevyn cushion dressing to the sacrum from the hospital every day for protection, and skin prep wipes to heels every shift for protection before the development of the pressure sores. This indicated that the facility staff were aware of the risk potential for skin breakdown for Resident #165. No other preventive measures were put in place for the immobile resident with a surgical repair for her fractured hip which increased the likelihood of skin impairment. Resident #165's Activity of daily living sheets documented the incontinence/hygiene, and bathing care provided for the resident. A review of those documents revealed that during the month of April 2021 personal hygiene was not given for the following dates and shifts; On 4-9-21 and 4-14-21, (7 am to 3 pm) day shift staff documented extensive assistance from 1 staff member required by the Resident for personal hygiene care. No other day shifts were documented as hygiene care having been given on this 8-hour shift during the 20 days (18 days missed) from 4-1-21 through discharge on 4-20-21. On 4-1-21, 4-2-21, 4-4-21, 4-5-21, 4-13-21, 4-14-21, 4-16-21, and 4-19-21, (3 pm to 11 pm) evening shift staff documented total dependence from 1 staff member required by the resident for personal hygiene care. No other evening shifts were documented as hygiene care having been given on this 8-hour shift during the 20 days (12 evenings missed) from 4-1-21 through discharge on 4-20-21. Bathing care was documented as being planned for Monday, Wednesday, Friday 7 am to 3 pm shift (day shift). Those baths did not occur on 4-2-21, 4-5-21, 4-12-21, and 4-19-21, and the Resident was documented as completely dependent on one staff member for bathing. 8 opportunities for baths were planned from 4-1-21. through 4-20-21, and only 4 were given. Review of Resident #165's physician and nursing progress notes were reviewed and revealed a resident who was total care. The notes indicated that on 4-13-21 the resident went out of the facility for an Orthopedic appointment and returned to the facility later in the afternoon. In the nursing progress notes, on 4-13-21 at 3:15 pm, the nurse documented that the resident returned from her Orthopedic follow-up appointment with new orders and that a dressing change was provided to the resident's sacrum and heels, with some discomfort noted to sites. Will continue to monitor. Which indicated that the nursing staff was aware of the wounds. An interview was conducted with the family which revealed that they were present when the pressure sores on the sacrum and heels were identified for the resident at the Orthopedic appointment, and the information was communicated to the staff upon the resident's return to the facility. This indicated that the unstageable pressure sore of the sacrum was known by the staff on 4-13-21, and a skin assessment was partially completed by the nursing staff on that day which documented the unstageable sacral wound. Weekly skin Evaluation documents were reviewed and revealed that 4 existed in the clinical record. None were complete. Those were as follows: 1. 3-30-21 first weekly assessment skin intact without impairment. 2. 4-6-21 second weekly assessment skin intact without impairment. 3. 4-13-21 third weekly assessment site sacrum pressure 2.5 long, 2.0 wide unstageable, right heel pressure 2.2 long, 2.1 wide suspected deep tissue injury, left heel pressure 3.0 long, 2.5 wide suspected deep tissue injury. No further documentation nor description was given, and it is unknown if these measurements were centimeters or inches. 4. 4-20-21 fourth weekly assessment documented site left gluteal fold pressure, sacrum pressure. No measurements nor description were noted, however, the resident now had a new pressure ulcer added to the document on her left gluteal fold/ischium, and the bilateral heels were not mentioned. The pressure wound found on the right lateral leg was never mentioned. It is referred to later in the body of this investigation. The physician's progress notes and physician's order review further revealed that no orders nor indications that the facility doctor was ever made aware of the unstageable pressure sores on 4-13-21. Not until 4-16-21 (3 days later) did a progress note appear from the wound specialist practice. On 4-16-21 a wound Advanced Registered Nurse Practitioner (wound NP) completed an assessment and issued new orders after being made aware of the identification of the unstageable pressure sores identified on 4-13-21 at the Orthopedic doctor's appointment. The orders were as follows: Ordered 4-16-21- (7 items) 1. Prostat 30 milliliters (ml) two times per day supplement. 2. Use pillows and wedges to keep the patient off of the backside at all times to decrease pressure and aid in healing. 3. Prevalon boots to bilateral heels at all times except when performing morning care. 4. Right ischial ulcer clean with dermal wound cleaner, apply thin duoderm to area change Monday, Wednesday, and Friday and as needed if it comes off, keep covered at all times. 5. Sacrum cleanse with dermal wound cleanser apply santyl nickel thick to gauze that is moistened with microcyn hydrogel cover with allevyn life sacral dressing change twice per day and as needed for incontinence episodes. 6. X-ray of sacral ulcer to assess bone condition. 7. Place on group 2 low air loss mattress for an unstageable ulcer to sacrum and left ischium. Ordered 4-17-21- (1 item) 1. Left heel deep tissue injury skin prep every other day and cover with allevyn life heel foam to help aid in pressure reduction, Ordered 4-19-21- (1 item) 1. Right lateral leg cleanse with dermal wound cleanser apply iodosorb gel cover with allevyn life foam to help with pressure reduction change on Monday, Wednesday, and Friday to necrotic wound. It is notable to mention that the right gluteal/Ichium ulcer and right lateral leg ulcers were never mentioned on the weekly skin assessments, and no treatment for the left gluteal/ischium ulcer was ever obtained. The Wound NP's progress note dated 4-16-21 at 2:48 pm included the following: Ulcer to sacral region, wound to right lower extremity, wound to left ischium, skin discoloration (deep tissue injury)to bilateral heels, fall with hip fracture, nonambulatory, deconditioning, .medication currently taking . then listed those medications. The note went on to describe the wounds as follows: Open sacral pressure ulcer unstageable 6 cm long, 7.5 centimeters (cm) wide, 0.1 cm deep, no granulation tissue, 100% black necrotic (dead) tissue within the wound bed Open right ischial pressure ulcer unstageable 1.5 cm long, 1.8 cm wide, 0.1 cm deep, no granulation tissue, 100 % yellow necrotic (dead) tissue within the wound bed. Open right lateral leg 10 cm long, 2.0 cm wide, 0.1 cm deep, no granulation tissue, 100% black eschar/necrotic (dead) tissue within the wound bed DTI to (deep tissue injury) bilateral heels. The note continued to state that the resident's daughter was called and made aware that the resident may require plastic surgery at some point for the wounds. Resident #165's Treatment Administration Record (TAR) was reviewed and revealed that the physician's orders for wound care treatment were not completed for the following wounds, on the following dates, as listed below: Sacrum - Omitted on 4-11-21, 4-16-21, 4-19-21. Ischium - The order was placed on the TAR, however, never signed as administered. Right lateral Leg - The order was placed on the TAR, however, never signed as administered. Bilateral heels - Omitted on 4-5-21, 4-6-21, 4-11-21, 4-12-21. The facility policies for Skin Assessments, and Wound/Skin Assessments were reviewed and revealed the following: Skin Assessments 1. A licensed nurse will ensure that a skin risk assessment using the Braden Scale is done upon admission, weekly for four weeks, and quarterly thereafter. 4. Care plan-specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. 5. Notify provider with updates and/or changes to skin integrity. 6. Notify responsible party with updates and/or changes to skin integrity.Documented upon admission, weekly, and as needed if the Resident or wound condition deteriorates. Wound/Skin Assessments 1. A licensed nurse will assess patients for any skin impairments, including surgical wounds, vascular wounds/ulcers, pressure ulcers/injuries, skin tears, etc 2. The skin observation tool will be completed by a licensed nurse at least every 7 days, detailing any wound/skin impairments These policy documents that were provided by the facility were accompanied by training materials from the facility's nursing practice standards (Mosby's and NCLEX) used to train nursing staff in the facility on wound care. The documents described current skincare preventative techniques, assessments, other prevention modalities, care planning, wound identification, measuring, and staging standards, treatment of wounds, and required documentation of wounds. The following elements were notated in the training materials, and accepted as a standard of practice for a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location b. Stage of the wound if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness) c. Measurements: height, width, depth, undermining, tunneling. d. Description of wound characteristics to include the following: i. Color of the wound bed ii. Type of tissue in the wound bed (i.e., granulation, slough, eschar/necrosis, epithelium) iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated) iiii. Presence, amount, and characteristics of wound drainage/exudate v. Presence or absence of odor vi. Presence or absence of pain, and wound treatments are also to be documented at the time of each treatment. No Braden scale skin assessment was completed at the time of admission, nor ever during the entire course of the resident's stay. The Resident had no pressure wounds upon admission. The Resident's care plan was reviewed and indicated the only care plan area mentioning skin was potential for skin impairment related to immobility, catheter. admitted with a non-removable dressing to her left hip. This entry described the fractured hip surgical wound dressing. The interventions were keep skin clean and dry, moisture barrier cream as needed for protection of skin, peri care with incontinence episodes, and weekly skin assessment. The Resident had a Foley catheter, so urinary incontinence was not a complicating factor in wound development. There was no care plan ever completed for the pressure ulcer wounds that developed on Resident #156's sacrum, ischium, leg, and both heels. Multiple staff nurses were interviewed by surveyors on two (2) shifts. Those interviews indicated that the nursing staff did not complete wound assessments as reported by all of those interviewed. The nurses stated that they contacted the contracted wound doctor's practice to come in and do the assessments. The nursing staff stated all skin assessments were in the computerized record, and they had no paper assessments. The wound physician was onsite during the survey and was interviewed by surveyors. She stated that no one asked me to teach the nurses how to assess wounds, so I haven't done that. The Director of Nursing (DON) was asked what her expectations was for incontinence rounds and skin breakdown assessment. Her reply was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNA's (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. The nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent worsening. The Resident's unstageable pressure wounds were never identified by the facility. No measurements nor descriptions of the wounds were ever placed in the clinical record by nursing staff. The 4-13-21 identification of multiple unstageable pressure wounds occurred at an outside orthopedics appointment and was not treated until the Resident was seen by the wound NP on 4-16-21, 3 days after identification. Resident #165 was not afforded timely bathing, nor hygiene/incontinence care, multiple unstageable pressure sores were not identified by the facility, orders and treatments were delayed, and not administered as per physician's order. No care plan ever existed for the pressure ulcers after they were identified. On 6-7-24 during the end of day meeting the Administrator and Regional Nurse Consultant were made aware of the above findings. The Administrator stated that this happened before her tenure and with a different owner. She stated she had no additional information to provide to the survey team before the survey's exit.

Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in substandard quality of care. The findings included: During the recertification survey conducted 6/4/24 through 6/7/24 and 6/10/24 through 6/13/24 residents were identified who could benefit from meaningful and individualized activity programs. A further review of the activities program revealed that the previous Director of Recreation separated from the facility on 3/28/2023 and a Certified Nursing Assistant (CNA) with an interest in activities volunteered to provide activities for the residents until a qualified professional was vetted. The CNA first assumed the role of Activity Assistant and was officially promoted to the role of Director of Recreation on 3/11/24, contingent the facility paid for the certification program and all testing associated. An interview was conducted with the unqualified Director of Recreation (DoR) on 6/11/24 at approximately 11:00 AM. The DoR stated she had received some training to the position from a DoR from a sister facility but she had not completed a certification program. The DoR further stated the corporate person responsible for the DoRs sent information for her to register for the certification program but when she presented the information to the Administrator after completing the registration form the Administrator stated to wait and never got back with her regarding the certification program. An interview was also conducted with the Administrator and the Corporate Consultant on 6/11/24 at approximately 11:09 A.M. The Administrator stated she was aware that the Activities Professional/Director of Recreation must be a qualified professional as stated in the regulations. At approximately 11:48 A.M., the Administrator provided a document from the National Certification Council for Activity Professionals which indicated a deposit was made to register the unqualified Director of Recreation for the certification program. The facility's Director of Recreation job description revised on 3/2023 stated the Director of Recreation Prerequisites, Skills and Abilities are Bachelor's Degree and qualification as a therapeutic recreation specialist or activities professional; or, Associate Degree and qualified as a therapeutic recreation specialist or activities professional via (1) two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program, (2) certification by the National Council of Activity Professionals or other recognized accrediting body, (3) completion of a state-approved activities training course, or (4) current licensure as an Occupational Therapist or Occupational Therapist Assistant. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator and two Corporate Nurse Consultants. They had no further comments regarding the above findings prior to survey exit.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care consistent with professional standards of practice for 3 Residents (R #23, R #258 and R# 31) in a survey sample of 62 Residents. The findings included: 1. For Resident # 23 the facility failed to ensure the Bi-Pap was placed on the resident as ordered by physician. Resident #23 was admitted to the facility on [DATE] with diagnoses that include but are not limited to hypertension, Paroxysmal Atrial Fibrillation, adult failure to thrive, history of Malignant Neoplasm of Prostate Protein -Calorie malnutrition, chronic respiratory failure with hypoxia, dependence on enabling machines or devices, pressure ulcers and dysphagia. On 6/10/24 at 11:40 AM Resident was observed in bed head of bed elevated, wearing hospital gown awake watching television. Resident # 23 was observed to have a Bi-Pap machine at the bedside however there was no date on tubing and there was no storage bag in site tubing was draped across the bedside table. When asked about the Bi-Pap the Resident stated he did not use it much. When asked why he said, They don't put it on me anymore. On 6/10/24 a review of the clinical record revealed that Resident #23 was admitted from the hospital with orders to wear the Bi-Pap at the hospital adjusted setting every night. A review of the physicians orders and the TAR (Treatment Administration Record) revealed the following orders for Bi-Pap: Please place BiPAP on every night at bedtime every evening and night shift -Order Date-05/08/2024 CPAP/BiPAP Oxygen tubing change weekly every evening and night shift -Order Date- 05/17/2024 -D/C Date- 06/05/2024. A review of the clinical record revealed that the BiPAP was on the TAR and marked as NO (not applied) on eve 6 of the 11-evening shifts and 2 of the 11-night shifts were marked as refused, and there no documentation of physician notification of refusal from 6/1/24 - 6/11/24. On 6/10/24 an interview was conducted with the DON who stated that Resident #23 is supposed to be using the Bi-Pap at night she stated that she knew he sometimes refused, however, she stated it should be offered to the resident and documented as refused if the Resident refuses. The DON stated Resident #23 should be encouraged to wear the BiPAP at night and the physician should be notified of repeat refusals. The DON stated she would see that the orders were corrected, and that the Resident was offered the Bi-Pap at night and that the weekly tube changing order be reinstated. On 6/11/24 during the end of day meeting the Administrator was made aware of the concern and no further information was provided 2. For Resident #258 the facility staff failed to change the oxygen tubing as per physician order. Resident #258 was admitted to the facility on [DATE] with diagnoses that included but were not limited to malnutrition, dementia, weakness, abnormality of gait, and history of falls, his most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/31/24 coded him as having a BIMS (Brief Interview of Mental Status) score was 7/15, indicating severe cognitive impairment. On 6/4/24 at 12:30 PM observation was made of Resident #258 in bed with oxygen being administered via oxygen concentrator the tubing was not labeled with a date that it was applied. On 6/5/24 at 10:00 AM the oxygen was observed with no date. On 6/5/24 a review of the MAR revealed that the oxygen tubing was signed off as being replaced on 6/2/24. On 6/6/24 at 2 PM Resident #258 was observed in his bed without the oxygen on the tubing was laying draped across the oxygen concentrator. Resident #258 was asked if he should have the oxygen in place and he stated he only used it when he needed it. On 6/7/24 at approximately 2:00 PM, LPN #2 was asked how frequently the oxygen tubing is changed, she stated that they are done on night shift on Sundays. When asked how I will know if the tubing was actually changed, she stated that the staff will put a date on the tubing. When asked if she could find the date on the tubing she stated, I don't see one. A review of the facility policy for respiratory care revealed the following excerpts: Paragraph 2 Cleaning and Storage in Room 2. Store tubing/masks/yanker, etc. in plastic storage bag when not in use. 3. Tubing / Masks/ yankers, etc. are to be changed weekly and prn. On 6/10/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 49916 3. For Resident #31, the facility staff failed to change Oxygen Humidifier Tubing per policy every 7 days. Resident #31 was originally admitted to the facility on [DATE]. The Resident went out to the hospital on 2/04/22 and returned on 04/15/22 to the facility with diagnoses including but not limited to, unspecified convulsions, aphasia, muscle weakness, acute respiratory failure with hypoxia, muscle weakness, essential hypertension, and dependence on supplemental oxygen. Resident #31's most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Reference Date (ARD) of 4-21-24. The MDS coded Resident #31 with a BIMS (Brief Interview for Mental Status) score of 6 out of 15 possible points, indicating severe cognitive impairment. The MDS coded Resident #31 as requiring extensive assistance with Activities of Daily Living (ADL's) and total dependent for toileting. Review of the care plan (dated 4-15-24) revealed: The resident is at risk for respiratory complications, secondary to (nothing listed). Interventions: Administer oxygen as ordered. Assess oxygen saturation and vitals needed. On 6/4/2024, at approximately 12:55 PM, during the initial tour of the facility, it was observed that Resident #31's oxygen humidification tubing was dated 05/26/2024. An interview was conducted on 6-4-24 at 12:55 PM, with Resident #31 and the resident's family member. The family member was asked if the residents oxygen tubing changed weekly. Both Resident #31 and the family member stated, The oxygen tubing is not changed weekly. Review of physician's orders revealed that the following oxygen orders for Resident #31: Ordered 5/20/24, oxygen therapy at 2 liters per minute via nasal cannula. Ordered 5/20/24, oxygen tubing change weekly on 11-7 shift (Sundays). On 6/5/24 at approximately at 11:00 AM, LPN (licensed practical nurse) #1 was interviewed and asked what was expected regarding changing residents' oxygen tubing and supplies. LPN #1 stated that oxygen settings, change orders and care should be administered per physician's order and documented in the Medical Administration Record (MAR) and Treatment Administration Record (TAR). The facility oxygen use policy was reviewed and indicated the following: Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per provider's orders and in accordance with standards of practice. Monitor and record saturation levels and vital signs as indicated, or by provider's order. Document oxygen delivery flow rate, method of delivery, date and time, saturation levels if indicated, in the electronic medical record. Document oxygen saturation level/and or vital signs in the electronic medical record as indicated, and any unusual findings and follow-up interventions including provider and responsible party notification. On 6/04/24, at approximately 4:00 PM, the Administrator and Corporate RN were made aware of the findings regarding the lack of care regarding Resident #31's oxygen tubing. No further Information was provided before survey exit.

Based on staff interviews, and facility documentation, the facility failed to have sufficient nursing staff to ensure resident safety and resident needs are met. The findings included: The facility staff failed to maintain Certified Nursing Assistant (CNA) staffing at sufficient numbers to ensure continuity of care and safety for the residents as documented in the as worked schedules for 5/11/2024-5/13/2024, 5/24/2024-5/31/2024, and 6/4/2024-6/24/2024. On 6/6/24 at 2:00 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the staffing of the units. The HR Director stated that the facility has been short-staffed and are currently supplementing staff with agency staff. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on staff interviews, and facility documentation, the facility staff failed to ensure that licensed nursing staff completed the required competencies necessary to care for residents' needs. The findings included: The facility failed to maintain the required nursing staff competencies necessary to care for residents. A review of the Training Transcripts for 19 licensed staff members revealed that nine (9) of the 19 licensed nursing staff members did not complete the required training courses. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resource (HR) Director who was asked about the licensed nursing staff competency training courses. The HR Director was not able to present evidence that the nine (9) licensed nursing staff had completed the required competency training courses. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey's exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that a Registered Nurse worked at least 8 consecutive hours within 24 hours, 7 days a week. The findings included: The facility failed to ensure that a Registered Nurse (RN) worked at least 8 consecutive hours within 24 hours, 7 days a week. A review of the as worked schedules for 5/11/24-5/13/24, 5/24/24-5/31/24, and 6/4/24-6/24/24, indicated there was no documentation that a Registered Nurse worked for 8 consecutive hours a day, 7 days a week. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about nursing staff RN coverage. The HR Director said that she was aware that an RN was required at least 8 consecutive hours, 7 days a week. The HR Director stated that the facility has been short-staffed and was currently supplementing staff with agency staff. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided prior to the survey's exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that the nurses' aides had performance reviews every 12 months and at least 12 hours of regular in-service education included on the aide's performance review. The findings included: The facility failed to conduct nurse aide performance reviews every 12 months and at least 12 hours of in-service education included on the aide's annual performance review per their hire date. A review of the training transcripts and staff education files revealed that not all nurse aides completed the mandatory in-services education. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the nurse aides' in-service education and stated that the employee files that included performance reviews and in-service records were correct and up to date. She had no additional records to provide for the nurse aides who did not have annual performance reviews with the required training hours. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey's exit.

Based on Staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for two (2) Residents (Resident #49, and #45) in a survey sample of 62 residents. The findings included: 1. For Resident #49, Facility staff failed to Administer Lovenox (anticoagulant) and Keflex (antibiotic) medication. Resident #49, was admitted to the facility on [DATE], and discharged to the emergency room with an infected wound on 4-19-24. The Resident returned on 4-24-24. Diagnoses included; After care following hip fracture, alzheimers disease, stage 4 sacral pressure sore, hypertension, hypothyroid, stroke, malnutrition, aphasia, dysphagia, and aspiration pneumonia. Resident #49 was a bed bound patient with severe cognitive impairment. Resident #49 was documented as being totally dependant on staff for all activities of daily living such as hygiene, transferring, and bed mobility. The Resident was incontinent of bowel and bladder. The Resident's physician orders were reviewed and revealed orders for anticoagulants and antibiotics. The orders were for the following; 1. Ordered 4-24-24 at 2:59 pm, Lovenox inject 0.4 milliliters subcutaneously one time per day for 20 days. 2. Ordered 5-13-24 at 9:43 am, Cephalexin/Keflex 500 milligrams tablet every 12 hours at 9:00 am, and 9:00 pm, for urinary tract infection for 8 administrations. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April and May of 2024 2024, and revealed the absence of nursing signatures on some occasions, and a signature with the number 5 added to it indicating the medications were not administered. Those follow; Lovenox not administered; 4-25-24, 4-26-24, 5-13-24, 5-14-24, 5-15-24, at which time it was discontinued with only 17 doses given omitting 3 doses. Keflex not administered: 5-15-24 at 9:00 am, and it was discontinued on 9-17-24 after the 9:00 am dose having administered 7 of 8 doses. Nursing medication administration notes do not indicate why the Lovenox and Keflex were not administered as ordered, and why they were omitted. Guidance for the administration of Antibiotics and Anticoagulants is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Antibiotics must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Antibiotics increases the likelihood of MDRO's (multi drug resistant organisms) such as Methycillin Resistant Staphyloccocus Aureus (MRSA), and can result in rebound infections which can be life threatening. National Institutes of Health & Medline.gov; Anticoagulant medication must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Resident #49's care plan was reviewed and revealed a care plan for Anticoagulant medications, however, it was not revised to include a care plan for urinary tract infections and antibiotic use. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 or a 5 on the medication administration record (MAR), that the medication was not administered. Nursing staff further agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks, and withholding antibiotics could cause a rebound infection. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, and that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to ensure medication administration per physician's orders. No further information was provided. 2. For Resident #45, Facility staff failed to Administer Eliquis/Apixaban (anticoagulant) medication. Resident #45, was initially admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on [DATE] back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. Resident #45 was also coded as requiring extensive dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders from the hospital were reviewed and revealed 2 orders for an anticoagulant. The orders were for the following; 1. 3-23-24 Apixaban (Eliquis) 5 mg (milligram) tablets take 2 tablets by mouth twice (20 mg per day) daily for 12 doses (6 days). Dispense 24 tablets. The original 10 mg dose ordered twice daily for 12 doses (6 days) was only given for 3 days on 3-25-24, 3-26-24, and 3-27-24. The Resident only received once daily 10 mg evening doses on 3-24-24, 3-28-24, and 3-29-24, for a half dose each day. The other 10 mg evening doses were omitted. 2. 3-23-24 Apixaban (Eliquis) 5 mg tablets start 3-29-24 take 1 tablet by mouth twice (10 mg per day) daily for 90 days. Dispense 60 tablets with 2 refills. The Medication and Treatment Administration Records (MAR/TAR) was reviewed for March, April, may, and June 2024, and revealed the absence of nursing signatures on multiple occasions. Those follow; 9:00 am dose - 4-14-24, 4-21-24, 4-25-24. 6:00 pm dose - 3-23-24, 3-24-24, 3-28-24, 3-29-24, 4-7-24, 4-17-24, 6-1-24, and 6-3-24. Nursing medication administration notes do not indicate why the medications were not administered as ordered, and why they were omitted. Guidance for the administration of anticoagulant medication is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Anticoagulant medication must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Anticoagulants increases the likelihood of blood clot formation which can be life threatening, to include stroke, heart attack and pulmonary emboli. Resident #45's care plan was reviewed and revealed no care plan revision for anticoagulant drug use for pulmonary embolus, nor assessments for potential bleeding. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted from 6-5-24 through 6-12-24 with nursing staff on separate halls and shift revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 or a 5 on the medication administration record (MAR), that the medication was not administered. Nursing staff further agreed that administering anticoagulants was to decrease the possibility of blood clots which caused strokes and heart attacks. On 6-7-24, and 6-10-24, the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, and that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 6-12-24 at approximately 1:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to ensure medication administration per physician's orders. No further information was provided prior to survey exit.

Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure pharmacist reported irregularities to the attending physician, the facility's medical director and the director of nursing, and were acted upon for four (4) of 62 residents (Resident #11, #172, #4 and #25), in the survey sample. The findings included: 1. The facility staff failed to ensure the physician and/or designee received the recommendations from the pharmacy review dated 4/20/24 for Resident #11. Resident #11 was originally admitted to the facility 4/18/24 after an acute care hospital stay. The current diagnoses included type 2 diabetes mellitus, acute bronchitis, hyperlipidemia, depression, muscle weakness, and unspecified dementia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/24/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #11's cognitive abilities for daily decision making were severely impaired. A review of the Consultant Pharmacist Medication Review for Resident #11 dated 4/20/24 at 7:53 PM read: see report for any noted irregularities and/or recommendations. On 6/10/24 at 3:05 PM an interview was conducted with the Corporate Nurse Consultant. The Corporate Nurse Consultant stated that the facility does not have documentation that the Physician and/or designee received the recommendations from the pharmacy review dated 4/20/24 regarding Resident #11. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information. 40026 2. For Resident # 172 the facility staff failed to document in the resident's medical record that the identified pharmacy recommendation had been reviewed and any actions taken as a result. On 6/10/24 a review of the clinical record revealed that Resident #172 was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes, hereditary lymphedema, non-pressure wound to left leg, MVA (Motor Vehicle Accident) driver resulting in lacerations with sutures to left lower leg and foot, muscle weakness and abnormal gait. On the morning of 6/10/14 a review of the clinical record was conducted, and it was found that during the month of May, a pharmacy drug regimen review was conducted, and it was found that the pharmacist made recommendations for Resident #172's drug regimen. The clinical record only revealed that the pharmacy review was done, and the box was checked to See report for Time Sensitive recommendation. On 6/10/24 at approximately 2:00 PM an interview was conducted with the Regional Nurse Consultant who was asked where to find the recommendations that were addressed by the physician, and she stated if they were not in the record, she would have to pull them from the website. On 6/10/24 at 3:10 PM the Clinical Nurse Consultant came back to submit the pharmacy reviews and stated, I will not waste any more of your time, the consults have not been addressed, and I have given them to the Nurse Practitioner to address at this time. Resident #172 was discharged from this facility and the Time Sensitive recommendations were not addressed during his stay. On 6/10/24, during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided prior to the survey's exit. 31199 3. For Resident #4, the facility staff failed to respond and act on the Pharmacy Consultant recommendations identified on Monthly Medication Reviews. Resident #4 was admitted to the facility on [DATE] and was a bed bound Resident with multiple medications. The Resident was cognitively impaired and was fully dependant on staff for all activities of daily living such as hygiene, dressing and eating. On 6-6-24 the Resident's clinical record was reviewed. The review revealed that on 4-8-24, Resident #4's medication regimen was reviewed by the Registered Pharmacist (RPH), and the pharmacy consultant (RPH) documented in the clinical record See report for noted irregularities and/or recommendations. The report could not be found. On 6-6-24, The Director of Nursing (DON) and Administrator were asked to supply the report. They responded an hour later and stated they could not locate the report which denoted irregularities. On 6-6-24, an interview was conducted with the Pharmacy (RPH) (Corporate #3). She stated that she and her colleague did perform monthly medication reviews. She went on to describe that those reviews were completed electronically and uploaded to a web site (name given) where the facility would go in and retrieve the reports and recommendations monthly. She stated that only the DON (Director of Nursing) and Administrator had password access credentials to get into the information. She further stated that the Medical Director for this facility did not have access granted and the Administrator or DON would have to print the report and give it to him to act upon. Both the Administrator and DON stated they had not done that, and so none of the reports nor recommendations had been reviewed nor acted upon by the doctor for approximately 3 months or longer. Review of the clinical record revealed no documentation of the Physician's response to the recommendations. On 6-6-24, and 6-7-24 the Administrator and DON were made aware of the non-compliance, and they stated the incident would be rectified immediately. 4. For Resident #25, the facility staff failed to respond and act on the Pharmacy Consultant recommendations identified on Monthly Medication Reviews. Resident #25 was admitted to the facility on [DATE]. The Resident was a recent leg amputee with confusion and psychiatric illness. The Resident was cognitively impaired and was extensively dependant on staff for all activities of daily living such as hygiene, dressing and eating. On 6-6-24 the Resident's clinical record was reviewed. The review revealed that on 4-27-24, Resident #4's medication regimen was reviewed by the Registered Pharmacist (RPH), and the pharmacy consultant (RPH) documented in the clinical record See report for noted irregularities and/or recommendations. The report could not be found. On 6-6-24, The Director of Nursing (DON) and Administrator were asked to supply the report. They responded an hour later and stated they could not locate the report which denoted irregularities. On 6-6-24, an interview was conducted with the Pharmacy (RPH) (Corporate #3). She stated that she and her colleague did perform monthly medication reviews. She went on to describe that those reviews were completed electronically and uploaded to a web site (name given) where the facility would go in and retrieve the reports and recommendations monthly. She stated that only the DON (Director of Nursing) and Administrator had password access credentials to get into the information. She further stated that the Medical Director for this facility did not have access granted and the Administrator or DON would have to print the report and give it to him to act upon. Both the Administrator and DON stated they had not done that, and so none of the reports nor recommendations had been reviewed nor acted upon by the doctor for approximately 3 months or longer. Review of the clinical record revealed no documentation of the Physician's response to the recommendations. On 6-6-24, and 6-7-24 the Administrator and DON were made aware of the non-compliance, and they stated the incident would be rectified immediately.

Based on staff interviews, and facility documentation, the facility failed to determine training needs based on its facility assessment and maintain a training program for all new and existing staff. The findings included: The facility failed to maintain a training program for all new and existing staff. A review of the staff Training Transcripts, and Staff Education files revealed that none of the 19 staff transcripts reviewed had completed all the mandatory training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the staff development and training program. She stated that the education and training files are up to date. On 6/13/2024, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment and care plan by a qualified Activities Professional for 4 of 62 residents (Resident #1, 170, 9, and 26), in the survey sample. The findings included: 1. On 6/12/24 at approximately 1:15 PM, Resident #1 was identified as an individual who could benefit from one to on or frequent short activities throughout the day. Resident #1 was originally admitted to the facility on [DATE] and he had never been discharged from the facility. The resident's diagnoses included dementia with behavioral disturbances. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/9/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 06 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired. Resident #1 was observed to stay in bed most of the day and to get up and roam the hallways in the afternoons. On 6/6/24 at approximately 4:35 PM an interview was conducted with Licensed Practical Nurse (LPN) #20. LPN #20 stated that the resident had been involved in altercations with other residents, wanders in others rooms in the evenings and is known to curse other residents and staff. LPN #20 also stated the resident is not redirectable. LPN #20 stated she was unaware that according to the resident's activity assessment that the resident enjoyed reading the newspaper, watching the news and car races but she would initiate the interventions going forward. The activity assessment dated [DATE] identified the resident as alert and oriented times for and identified the resident as a she, therefore it was not clear if this assessment was for the Resident #1. The resident's comprehensive person-centered care plan did not included an activities care plan. An interview was conducted with the uncertified/unregistered Activities Director (AD) on 6/11/24 at approximately 11:00 AM. The AD stated that Resident #1 does not participate in activities and if he happens to come into an activity he does not stay very long, never for the duration of the activity. 2. On 6/13/24 at approximately 1:30 PM, Resident #170 was observed in bed lying on her right side as she had been on 6/4/24 through 6/7/24 and 6/10/24 through 6/11/24. Resident #170 was identified as an individual who could benefit from activities. Resident #170 was originally admitted to the facility on [DATE] and she had never been discharged from the facility. The resident's diagnoses included afib, congestive heart failure and advanced stage pressure ulcers. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/Readmission Nursing Collection Tool dated 5/29/24. The tool revealed the resident was oriented to person, place, time and situation. During all interactions with the resident on 6/4/24 through 6/12/24 the resident was oriented in all four spheres. The resident's activity assessment dated [DATE] read the resident enjoyed all kinds of animals and news, as well as gardening, sewing and groups of people. On 6/4/24 at approximately 3:30 PM an interview was conducted with Resident #170. The resident lacked emotions and had to be asked questions to express herself. The resident was absent of a smile, talked about going home but initiated nothing to assist herself out of the current situation. On 6/12/24 she was out of bed sitting in a chair for the first time and only interacted when she was encouraged. The resident did not attend activities on 6/12/24. The resident's comprehensive person-centered care plan had not been developed and there was not an activities care plan included with the problems developed. An interview was conducted with the uncertified/unregistered Activities Director (AD) on 6/11/24 at approximately 11:00 AM. The AD stated that Resident #170 had not participated in group activities and she was not receiving one to one activities. 3. Resident #9 was observed in her room in bed much of the survey. The resident was not engaged in any type of activities to benefit from person-centered activities. Resident #9 was originally admitted to the facility 11/19/2020 and was last discharged from the facility 5/11/22 and returned to the facility 5/16/22. The resident's current diagnoses included depression and venous ulcers of bilateral lower extremities. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/25/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. The resident's last activities assessments in the clinical record was dated 4/16/23. It read the resident was activities interest including participating in painting, cards, reading mysteries, listening to oldies/country music, watching news, soap operas, game shows, word search, and socializing with peers. The comprehensive person-centered care plan was last revised on 12/28/2023. An interview was conducted with the uncertified/unregistered Activities Director (AD) on 6/11/24 at approximately 11:00 AM. The AD stated she had received some training to the position from an AD from a sister facility but she had not completed a certification program. The AD further stated the corporate person responsible for the ADs sent information for her to register for the certification program but when she presented the information to the Administrator after completing the registration form the Administrator stated to wait and never got back with her regarding the certification program. The facility's policy titled Activities Programming dated 11/1/23, stated that the recreation department would provide, based on the comprehensive assessment and care plan and the preferences of each resident an ongoing program to support residents in their choice of activities, both facility sponsored group, individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator and two Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings. 49917 4. Resident #26's Admission activity assessment had not been completed to identify activity preferences. Resident #26 was originally admitted to the facility 9/5/23 after an acute care hospital stay. The current diagnoses included hyperlipidemia, major depressive disorder, essential hypertension, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/13/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making were intact. On 6/12/24 at 2:55 PM an interview was conducted with Resident #26. Resident #26 stated that she rarely participates in activities due to no staff member's asking her if she would like to participate in the facilities activities. Resident #26 also stated that she requires to be transferred in a wheelchair to attend the activities and no staff member will take her to the activities. A review of Resident #26's clinical record revealed that an activity admission assessment was not completed. On 6/12/24 at 3:35 PM an interview was conducted with the Corporate Nurse Consultant. The Corporate Nurse Consultant stated that an activity admission assessment was not completed for Resident #26. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on resident interview, staff interview and clinical record review, the facility staff failed to provide care and services in accordance with professional standards for three resident (Resident #5, #173 and #27) in a survey sample of 62 residents. The findings included: 1. For Resident # 5, facility staff failed to administer, and/or document medications and treatments as administered, as ordered by the physician on several dates including but not limited to: 5/5/2024, 5/13/2024 and 5/30/2024. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. Review of Resident #5's clinical record was conducted on 6/4/2024-6/7/2024. Review of the physician orders and medication administration documentation revealed the following: Review of the facility policy entitled, Administering Medications, revised April 2019, heading Policy read, Medications are administered in a safe and timely manner, and as prescribed and subheading Policy Interpretation and Implementation, item 4 read, Medications are administered in accordance with prescriber's orders, including any required time frame. Review of the May 2024 Medication Administration Record revealed several medications that were not administered as ordered by the physician. The medications included but were not limited to: Amlodipine 10 mg (milligrams) - Give 1 tablet by mouth in the evening for Hypertension Order Date- 12/08/2023 1601 Scheduled 8 p.m. not given 5/5/2024, 5/13/2024 and 5/30/2024 at 8 p.m. Nortriptyline Oral Capsule 10 milligrams-Give 20 mg by mouth at bedtime related to Major Depressive Disorder Order Date-11/1/2023 -scheduled at 9:00 p.m. not given 5/5/2024 and 5/30/2024 at 9 p.m. Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (units per milliliter) (Insulin Glargine) Inject 40 unit subcutaneously at bedtime for Diabetes IF PT (patient) REFUSES, DOCUMENT AND NOTIFY PROVIDER. -Order Date-04/05/2024 1648 not given at 9 p.m. on 5/5/2024, 5/13/2024, 5/30/2024 Melatonin Tablet 5 mg-Give 1 tablet by mouth at bedtime for insomnia -Order Date- 05/19/2023 1040 Not given 9 p.m. on 5/5/2024, 5/30/2024 Trazodone HCl ( Tablet 50 MG-Give 1 tablet by mouth at bedtime for insomnia GDR (gradual dose reduction) -Order Date- 03/24/2023 1116 Not given 9 p.m. on 5/5/2024, 5/30/2024 Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for HTN Hold if SBP (systolic blood pressure) < (greater than)100 HR (heart rate) < (less than) 50 -Order Date- 01/10/2024 1624 Not given 9 p.m. on 5/5/2024, 5/30/2024 Eliquis Tablet 5 MG (Apixaban)-Give 1 tablet by mouth two times a day related to personal history of other venous thrombosis and embolism -Order Date- 01/10/2024 1621 Not given 9 p.m. on 5/5/2024, 5/30/2024 Review of the May 2024 Treatment Administration Record revealed missing documentation of treatments to include but not limited to: Skin care-sacrum, under bilateral breast, bilateral axilla, abdominal fold, cleanse area with soap and water, pat dry, apply skin prep to surrounding tissues, ketoconazole Cream 2% and petroleum-based barrier cream together and leave open to air. every day and evening shift for Treatment -Order Date-05/03/2024 1339 not administered on 5/5/2024 day and evening, 5/8/2024 day and evening, 5/9/2024 evening, 5/13/2024 evening and 5/17/2024 day shift. Guidance for nursing standards for the administration of medication provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705 stated Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. Resident 5's care plan was reviewed and revealed a care plan that instructed to administer medications and treatments as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medications had been omitted, nor that the doctor was made aware of the omissions. On 6/5/2024 at 10:20 a.m., an interview was conducted with Licensed Practical Nurse-1 who stated the expectation was for nurses to administer medications and treatments as ordered by the physician. She stated that nurses should document immediately after administration of medications and treatments. On 6/6/2024 at 2:25 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for the staff to administer medications and treatments as ordered by the physician. On 6/6/2024, during the end of day debriefing with all surveyors, the Administrator and Corporate Nurse Consultant were made aware of the failure of staff to administer medications as ordered. No further information was provided. 34306 2. The facility staff failed to administer ophthalmic (eye) medications to Resident #173 as ordered. Resident #173 was originally admitted to the facility 6/3/24 after an acute care hospital stay. The resident's diagnoses included alcohol abuse and glaucoma. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/Readmission Nursing Collection Tool dated 6/3/24. The tool revealed at number 1. Cognitive state that the resident was oriented to person and place, at number 8. Gastrointestinal, the resident was continent of bowels, at number 9. Genitourinary, the resident was continent of bladder, at number 12.GG that the resident required set-up assistance with eating and oral care. The resident was not assessed for toileting hygiene, to move from sitting on side of bed to lying flat on the bed, to come to a standing position from sitting in a chair, and with transfers. An interview was conducted with the resident on 6/10/24 at approximately 1:40 P.M. Resident #173 stated he had not received his eye drops since admission to the facility. The resident further stated that his sister administered his ophthalmic drops when he was home. The resident also stated he had not experienced blurred vision, burning, itching, or a feeling as if something was his eye since he was not being administered the ophthalmic drops. The resident asked, when would he receive the ophthalmic drops. Resident #173 had the following ophthalmic orders dated 6/3/24; Latanoprost Ophthalmic Solution 0.005 % - Instill 1 drop in both eyes at bedtime and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 % - Instill 1 drop in both eyes two times a day. During the 6/10/24, medication storage task of the Hall 3 medication cart, the Dorzolamide HCl-Timolol Mal ophthalmic drops were not on the medication cart. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 6/10/24 at approximately 1:07 PM. LPN #6 stated she administered the resident's Dorzolamide HCl-Timolol Mal ophthalmic drops that morning and she threw the bottle in the trash afterwards because they were drops sent over from the hospital. The Medication administration Record (MAR) revealed on 6/6, 6/9 and 6/10 the 9:00 P. M., medication was documented as waiting for pharmacy and on order. A note was also written for the medication on 6/12/24. It stated Dorzolamide HCl-Timolol Mal Ophthalmic Solution 2-0.5 %. Instill 1 drop in both eyes two times a day for one time hold order per the Physician's Assistant because the family was providing the supplies and the resident is his own Responsible Party. An interview was conducted with the Pharmacist on 6/1/24 at 2:30 PM. The Pharmacist stated the Dorzolamide HCl-Timolol Mal ophthalmic drops were delivered to the facility on [DATE] and signed as received by Registered Nurse (RN) #4. The location of the ophthalmic drops which were delivered and signed as delivered was not determined by the facility's staff. On 6/10/24 at 12:40 PM during the medication storage task of the medication refrigerator, a sealed unopened bottle of Latanoprost Ophthalmic Solution 0.005 % was observed in the refrigerator. This ophthalmic drop was scheduled to given each night at bedtime. The bedtime dose was signed off as administered each night except 6/3, 6/6, 6/7 and 6/9. The progress notes regarding the medication read waiting for pharmacy, med not available, on order. At approximately 4:50 PM on 6/12/24 the sealed unopened bottle of Latanoprost Ophthalmic Solution 0.005 % was validated in the refrigerator by Corporate Nurse #1. They were still not in use. On 6/13/24 at approximately 12:00 P.M., a final interview was conducted with the Administrator, and two Corporate Nurse Consultants. They had no new information regarding the missing bottle of Dorzolamide HCl-Timolol Mal ophthalmic drops or comments on why the Latanoprost Ophthalmic Solution 0.005 % remained in the refrigerator unused. 40711 3. For Resident #27 the facility staff failed to follow physicians orders by not ensuring Resident #27 received her necessary wound care treatments. Resident #27 was originally admitted to the facility 11/18/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Pressure Ulcer of the Right Ankle and Peripheral Vascular Disease. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/05/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goal) Requires set up and or clean up assistance with eating, oral hygiene and personal hygiene. Requiring substantial/maximal assistance with toileting hygiene and lower body dressing. In Section M (Skin Conditions) Resident is coded as being at risk for Pressure Ulcers. Resident is coded as not having any unhealed Pressure Ulcers. Resident is coded as having 3 Venous and Arterial Ulcers. The Care Plan dated 11/22/22 and revised on 7/23/23 read that Resident #27 was at risk for Pressure Ulcers related to weakness, impaired mobility and incontinence, Right hemiparesis status post (s/p) Cerebral Vascular Accident (CVA). The Goal for Resident #27 is that the resident will not have a skin impairment thru the review period. assess resident for risk of skin breakdown, assist the resident to turn and reposition often, Keep skin clean and dry as possible. The Medication Administration Record (MAR) for May and June 2024 Solosite Wound Gel External Gel (Wound Dressings) Apply to buttocks, R lateral ankle topically every night shift every other day for Stage 4 pressure ulcer -Order Date 05/21/2024 9:41 AM -D/C Date 06/06/2024 10:24 AM. Missed treatment on 6/04/24. WOUND CARE: Buttocks, right lateral ankle: Cleanse and pat dry. Apply scant amount of Solosite to wound and cover with foam dressing. Change Q2 days or PRN for soiling. every night shift every other day -Order Date 05/21/2024 9:38 AM -D/C Date 06/06/2024 10:18 AM. Missed treatment on 6/04/24. WOUND CARE: Please apply betadine-soaked gauze, 4x4s, Kerlix, and a light ACE bandage to right foot every other day every night shift every other day -Order Date 05/21/2024 9:47 AM -D/C Date 06/06/2024 10:13 AM., Missed Treatment on 6/04/24. LEFT BUTTOCK - Cleanse with wound cleanser, pat dry, apply hydrogel, cover with bordered gauze. every night shift for pressure stage 3 wound -Order Date05/09/2024 1315 -D/C Date 05/21/2024 0923. Missed treatments: 5/10/24, 5/12/24, 5/15/24, 5/16/24. Right Lateral ankle: Cleanse with normal saline, Pat dry, skin prep to surrounding tissue, Manuka HD alginate, Honey fiber to wound bed, Bordered foam, NO ACE BANDAGE OR KERLIXNO COMPRESSION OF ANYKIND one time a day for WOUND -Order Date 02/27/2024 4:30 PM. -D/C Date 05/21/2024 9:22 AM. Missed Treatments. 5/01/24, 5/02/24, 5/08/24. On 6/11/24 at approximately 2:55 PM., an interview was conducted with the Director of Nursing (DON) concerning skin assessments and missed wound care treatments. The DON said that it is expected that the nurses perform skin assessments and carry out wound care treatments on their residents. The DON also mentioned that if the CNAs notice any new areas on the residents' skin, they will inform the nurse. On 6/12/24 at approximately 11:00 AM., an interview was conducted with Certified Nursing Assistant (CNA #6) concerning Resident #27. CNA #6 said that the resident didn't have any skin issues in January. On 6/12/24 at approximately 1:35 pm., an interview was conducted with the Wound Care Nurse Practitioner (WCNP). The WCNP said that she was not aware of any missed wound care treatments. On 06/13/24 at approximately 2:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents receive sufficient fluid intake to maintain proper hydration, and maintain acceptable parameters of nutritional status, and was offered a therapeutic diet when needed for 2 (R #258 and #13) residents in a survey sample of 62 residents. The findings included: 1. For Resident #258, the facility staff failed to ensure the resident was provided a diet that he could eat to maintain adequate nutritional status. Resident #258 was admitted to the facility on [DATE] with diagnoses that included but were not limited to malnutrition, dementia, weakness, abnormality of gait, and history of falls. On 6/5/24 observation made of Resident #258's lunch tray, resident only ate pudding and applesauce. On 6/6/24 observation of breakfast tray Resident #258 ate only hot cereal. On 6/7/24 at approximately 12:15 PM, an observation was made of Resident #258 in his room with his family at his bedside. An interview was conducted with Resident #258's family member who stated that Resident #258 does not eat much because his has no teeth. The family elaborated by saying he has dentures but does not use them because they do not fit right. A review of Resident #258's tray ticket revealed he was on a regular diet with regular texture and thin liquids. 6/7/24 at 4:00 PM a review of the clinical record revealed the following diet order: 5/25/24 Regular diet, Regular texture, Thin Liquids consistency. A review of the clinical record revealed a Malnutrition Universal Screening Tool (MUST) was completed on 5/30/24 and the results were as follows: Patient: [Name redacted] Category: High Risk (Treat) Description: Admission Score: 2.0 Date: 5/30/2024 11:24 The order was place for Med Pass 90 ml a day for prevention of malnutrition. On 6/10/24 an interview was conducted with the Nutritionist who stated she had not yet seen Resident #258 and was unaware of his edentulous status. She stated that some people do better than others without teeth so she would evaluate him later on that day. A review of the clinical record revealed that on admission Resident #258 weighed 122.2 lbs. On 6/10/24 CNA #'s 1, 5 and 6 accompanied the surveyor to check Resident #258's weight. Resident #258 weighed 116 pounds which was a 5.07 % weight loss since his admission (16 days), this represented a significant weight loss. 6/10/24 at 1:23 PM Note Text: RD was made aware that rsd (sic) has not been consuming much of his meals. RD visited w/ rsd who appears to have impaired dentition. RD spoke w/ rsd's RP (son) who reports he has been visiting the facility to assist rsd with consuming his meals. Son has noticed rsd has trouble with some of the bread items with his meals. RD asked son if he thinks rsd would benefit from some softer food items to which son stated yes. RD spoke w/ DOR about possible SLP screen r/t most recent BIMS of 7. Will downgrade diet to Dysphagia Advanced and refer to therapy for possible SLP evaluation. Rsd continues on Medplus 2.0 supplement Q Day [every day] for additional nutrition w/ good acceptance per staff. Currently awaiting an updated weight at this time. Will cont. to monitor. On 6/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #13, the facility staff failed to ensure sufficient hydration and to honor resident's choice for fluids. On 6/4/24 at approximately 2:00 PM an interview was conducted with Resident #13 who stated What I would like to get is some ice water. I can never seem to get them to keep this cup filled. Resident pointed to large Styrofoam cup on the bedside table. When asked if she tried ringing her call bell she stated, I would if I could reach it, they keep it wrapped around my rail and its above my head out of reach I cannot get to it like that. When asked if she had told the staff that it is a problem when they wrap cords around the rail, she stated that she had told them, but they continued to do it anyway. On 6/4/24 at 11:45 a.m., during initial tour of the facility Resident #8 was interviewed. The resident was sitting in bed consuming lunch and complained to the surveyor, Everything is fine here as long as they fill my water container with ice. I just can't drink it room temperature, and they don't fill it but one time a day some days, that's my only problem. The water pitcher was observed to have no ice in it and held approximately 1 quart of water when full. It was found to be half full of room temperature water. On 6/5/24 at approximately 10:30 a.m., Resident # 13's cup was empty of iced water and once again the call bell was observed to be out of her reach. On 6/6/24 at approximately 3:00 p.m., Resident #13 was out of iced water again and the call bell once again was out of her reach. At 3:05 PM on 6/6/24, an interview was conducted with CNA #3 who was asked why call bells would be wrapped around a bed rail, CNA #3 stated the staff sometimes did this to keep the call bell from falling off of the bed and onto the floor, some residents prefer the call bell to be wrapped around the rail so they can reach it. CNA #3 was asked if a call bell should be in the resident's reach at all times, CNA #3 stated that it should always be in reach of the Resident so in case they have an emergency they can reach the nurse. CNA #3 was then asked to view the call bell in Resident #13's room and see if there was a problem with the resident reaching it. CNA #3 came out of the room and stated it was up too high wrapped around the rail and she could not reach it. CNA #3 stated I fixed it for her know I am going to get her some iced water. On 6/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to maintain the self esteem/dignity of two resident (Resident # 5 and #10) in survey sample of 62 residents. The findings included: 1. For Resident # 5, the facility staff did not provide a dignified experience regarding incontinence care. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as always incontinent of bladder and frequently incontinent bowel. Review of the clinical record was conducted 6/4/2024-6/7/2024. During an interview on 6/4/2024 at 11:45 a.m., Resident # 4 stated the staff often did not provide incontinence care and she was left soiled for extended periods of time. The room had a pungent odor of urine and feces. Dark brownish colored liquid substance was observed on the bottom sheet with the line of demarcation reaching to level of Resident # 5's hips. The dark substance was noted on the bedspread and top sheet as well. The room was very foul smelling. On 6/4/2024 at 12:10 p.m., Licensed Practical Nurse-1 entered Resident # 5's room and obtained a finger stick blood sugar. LPN-1 was accompanied by a student nurse who stated she was in orientation. LPN-1 and the student nurse did not comment about the pungent odor in the room nor about the brown liquid substance that was evident on the bed sheets and linen. The nurse removed the lid on the lunch tray, Resident # 5 looked at the food and stated she did not want to eat the food. She said it did not smell good and she did not want an alternate meal. LPN-1 stated that Resident # 5 often ordered food from outside restaurants. Resident # 5 stated she did not want any restaurant food either. On 6/4/2024 at 1:15 p.m., Resident # 5 was observed still lying in bed. The room still had the pungent odor of urine and feces. The line of demarcation of the brownish colored liquid was creeping higher up the sheets to approximately the waist level. On 6/4/2024 at 1:45 p.m. and 2:15 p.m , there were observations of Resident # 5 still lying in bed with dark brown liquid stains on the sheets which had increased in size to reach to the middle of Resident # 5's back. There was a pungent odor of urine and feces in the room. During an interview on 6/4/2024 at 2:15 p.m., Resident # 5 stated they haven't changed me yet. They haven't done it since early this morning. Resident # 5 stated she needed to be changed. There were no nursing staff observed in the hallway. On 6/4/2024 at 2:19 p.m., the Corporate Nurse Consultant was asked to come to Resident # 5's room. The Corporate Nurse Consultant came to the room and immediately stated it was evident that Resident # 5 had not had incontinence care for an extended period of time. The room reeked of urine and feces. There were lines of demarcation indicating the urine and feces had crept up higher at different times. The Corporate Nurse Consultant stated she would get someone to provide are immediately. On 6/4/2024 at 2:30 p.m., Resident # 5's door was closed. One Certified Nursing Assistant was observed coming out of Resident # 5's room carrying two clear bags of soiled linen. Feces and urine stains could be visualized on the linens. The Certified Nursing Assistant was asked what she was doing. She stated she had just helped the other CNAs provide incontinence care to Resident # 5. She stated the resident had been incontinent of both urine and feces and all of the linens were soiled. The odor was pungent. She stated incontinence care should be provided every two hours and as needed. She stated she did not know why incontinence care had not been provided earlier. Review of Resident #5's physician orders, Medication and treatment administration records (MAR's/TAR's), Care plan, and progress notes indicated that the Resident suffered from moisture associated dermatitis (MASD) and had a history of a pressure ulcer on the sacrum. On 6/4/2024, the Director of Nursing (DON), and Administrator were interviewed and asked what their expectation for toileting and incontinence care timing was for this Resident. They stated every 2 hours, and as needed, and that the care must be documented after care. Certified Nursing Assistants (CNA's) were interviewed on all three units during survey, and indicated residents should be checked at least every 2 hours and as needed for incontinence care. On 6/5/2024 at 9:20 a.m., an interview was conducted with Certified Nursing Assistant-3 who stated they turn and reposition residents every 2 hours but sometimes every hour depending on the needs of the resident. CNA-3 stated incontinence care should be given every hour or even 30 minutes if needed. She also stated showers should be given at least twice a week and more often if needed or if the resident requests one. Resident # 5's point of care documentation by primary care staff to indicate care that was given every day was reviewed. The facility instituted 8 hour working shifts for staff, and those 3 shifts were 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. The records indicated that for the months of April 2024, May 2024 and June 2024, Resident # 5 was totally dependent on staff for toileting and incontinence care. The Corporate Nurse Consultant stated the facility did not have a policy on ADL (Activities of Daily Living) care. She stated the expectation was that care would be provided approximately every 2 hours every shift and PRN (as needed). She stated failure to provide timely incontinence care did not show treatment with dignity. Interviews were conducted with staff members by the survey team. Staff members stated that the expectation was to give incontinence care immediately after every incontinent episode. Resident # 5 was not afforded timely incontinence care and was not shown dignity and respect. The facility Administrator and Director of Nursing (DON) were made aware of the above findings at the end-of-day debriefing on 6/5/2024. No further information was provided. 49916 2. For Resident # 10, the facility staff failed to provide dignity related to the care of an indwelling urinary catheter (Foley brand name). Resident # 10 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Urinary Tract Infections, Aphasia, Muscle Weakness, Need for Assistance with Personal Care, Presence of Coronary Angioplasty Implant, Anemia, and Epilepsy. Resident #10's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 10 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 7 of 15 possible points on a brief interview for mental status (BIMS), indicating mild to moderate cognitive impairment. The resident was coded as indwelling catheter always incontinent of bladder and frequently incontinent bowel. During an initial tour on 6/4/2024 at 11:45 a.m., Resident # 10 was observed in the hall sitting in a wheel chair with his foley catheter bag visible with dark amber substance in the foley collection bag and the tubing hanging near the floor. Nursing staff was observed in the hallway during the initial tour. Review of Resident #10's physician orders revealed: that the resident has a Foley (brand name) Catheter. The Foley anchor should be changed each week, and Resident should have a leg bag during waking hours. On 6/5/2024, the Director of Nursing (DON), and Administrator were interviewed and asked what their expectation for foley care for this resident. They stated the indwelling urinary catheter should have a leg bag, bag anchor and cover for privacy and dignity. The Corporate Nurse Consultant stated the facility did not have a policy related to provision of indwelling catheter covers/bags to maintain the resident's dignity. On 5/13/2024 and 5/14/2024 during the end of day debriefings, the Administrator, and the DON (Director of Nursing) were notified the above findings. No further information was provided by the facility prior to survey exit.

Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to ensure residents environment remained as free of accident hazards as is possible for residents that used the dining room and for a resident who smoked, Resident #37. The findings included: 1. The facility staff failed to ensure chemicals were kept away from unattended residents reach, and out of public areas. On 6/4/24 at approximately 1:00 PM a bottle observation was made of a half full spray bottle of Wallpaper Remover sitting on the table on the right side of the dining room near the wall. Other Employee 3 was in the dining room and was asked if the bottle was something she was using. Other Employee #3 stated that she worked in the laundry and that it was not something housekeeping would generally use. On 6/4/24 at approximately 1:15 PM an interview was conducted with the maintenance director who stated he had not seen this chemical before and was unaware of who might be using it. He stated that he did not have an MSDS (Materials Safety Data Sheet) on the chemical as it is something he does not use. When asked the danger of having a chemical like this around the residents he stated that a resident could accidentally spray it on themselves or ingest it. On 6/5/24 at approximately 1:30 PM an interview was conducted with the Administrator who was asked about the chemical in the building, and she stated that she was unaware of it being in the dining room and unaware of anyone using it. When asked the danger of having a chemical like this in the open dining room, unsecured she stated there is a potential for unintentional ingestion or spraying in the eyes or on skin of the resident. On 6/12/24 at the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 49916 2. For Resident #37, the facility staff failed to ensure the resident was safe to smoke and supervised a designated smoking area to prevent injuries to themselves and other surrounding residents. Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE]/2024 with the diagnoses of, but not limited to acute respiratory failure with oxygen deficits, Chronic Obstructive Pulmonary Disease (COPD), low blood pressure, anemia, history of falling and tobacco use. Resident #37's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 06/01/2024 coded Resident #37 with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 possible points, indicating cognition intact. The MDS coded Resident #37 as requiring limited assistance with Activities of Daily Living (ADLs), supervision with eating, and limited assistance with toileting. A review of Resident #37 clinical record, including the resident's comprehensive care plan, revealed no evidence of a smoking safety assessment, or smoking agreement. On 6/4/24 at approximately 12:55 p.m., during an initial tour of the facility, Resident #37 was observed alert and unsupervised smoking sitting in a wheelchair in front of the building. On 6/4/24 at 3:50 p.m. Resident #37 was observed smoking unsupervised sitting in a wheelchair at the gazebo area at the back of the facility. On 6/4/24 at 2:20 p.m., the Administrator and Director of Nursing (DON) were interviewed and asked if there were any smoking residents in the building. The Administrator said there were none. When asked what was expected if there was a smoking resident, the Administrator responded that they would complete a Smoking Safety Screening, and have the resident sign a Smoking Agreement. No further information was provided before the survey's exit.

Based on staff interview and review of facility documents, the facility staff failed to keep identified systems functioning properly, and to implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee; including to identify deficiencies in the area of Qualifications of an Activity Professional as well as repeated deficiencies, and to have the Director of Nursing (DON) and/or a designee participate in the 7/23/24 QAPI meeting. The findings include: On 8/7/24 at 4:10 PM a QA&A (Quality Assessment and Assurance) interview was conducted with the Administrator regarding the QAPI meeting that took place on 7/23/24. The Administrator stated that during the QAPI meeting all of the deficient citations from the Plan of Corrections survey ending 6/13/24 were discussed. The Administrator also stated that all of the audits were discussed related to the Plan of Corrections. During this interview the Administrator stated that the facility currently does not have a qualified professional directing the facility activities program. In the following areas the facility repeated deficient practices; Services Provided Meet Professional Standards, ADL Care Provided for Dependent Residents, Activities Meet Interest/Needs Each Resident, Qualifications of Activity Professional, Pharmacy services, Label/Store Drugs and Biologicals, Frequency of Meals/Snacks at Bedtime, Food Procurement, Store/Prepare/Serve-Sanitary, Use of Outside Resources, and Use of Transfer Agreement. At the conclusion of the QA&A interview with the Administrator on 8/7/24 at 4:10 PM, the Administrator stated that the Director Of Nursing was not present and did not participate in the QAPI meeting on 7/23/24. A review of the QAPI sign in sheet failed to identify the DON or an individual designated to represent the DON participated in this meeting. On 8/8/24 at approximately 7:45 PM, a final interview was conducted with the Administrator, Director of Nursing, and the Regional Nursing Consultant. They had no further comments and voiced no concerns regarding the above information.

Based on staff interview and review of facility documents, the facility staff failed to keep identified systems functioning properly, and to implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee; including to identify deficiencies in the area of Qualifications of an Activity Professional as well as repeated deficiencies, and to have the Director of Nursing (DON) and/or a designee participate in the 7/23/24 QAPI meeting. The findings include: On 8/7/24 at 4:10 PM a QA&A (Quality Assessment and Assurance) interview was conducted with the Administrator regarding the QAPI meeting that took place on 7/23/24. The Administrator stated that during the QAPI meeting all of the deficient citations from the Plan of Corrections survey ending 6/13/24 were discussed. The Administrator also stated that all of the audits were discussed related to the Plan of Corrections. During this interview the Administrator stated that the facility currently does not have a qualified professional directing the facility activities program. In the following areas the facility repeated deficient practices; Services Provided Meet Professional Standards, ADL Care Provided for Dependent Residents, Activities Meet Interest/Needs Each Resident, Qualifications of Activity Professional, Pharmacy services, Label/Store Drugs and Biologicals, Frequency of Meals/Snacks at Bedtime, Food Procurement, Store/Prepare/Serve-Sanitary, Use of Outside Resources, and Use of Transfer Agreement. At the conclusion of the QA&A interview with the Administrator on 8/7/24 at 4:10 PM, the Administrator stated that the Director Of Nursing was not present and did not participate in the QAPI meeting on 7/23/24. A review of the QAPI sign in sheet failed to identify the DON or an individual designated to represent the DON participated in this meeting. On 8/8/24 at approximately 7:45 PM, a final interview was conducted with the Administrator, Director of Nursing, and the Regional Nursing Consultant. They had no further comments and voiced no concerns regarding the above information.

Based on clinical record review, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to immediately notify the Physician of a significant change in condition that included signs of an acute stroke for over 5 days for 1 of 2 residents in the survey sample, Resident #2. Subsequently, Resident #2 was sent to the emergency roiagnom on [DATE] and was diagnosed with a late acute versus subacute left anterior cerebral artery infarct and was deemed not a candidate for Tissue Plasminogen Activator (tPA) due to late presentation to the acute care setting, which constitutes harm. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses to include but not limited to High Blood Pressure, Diabetes Mellitus, Heart Disease, and a history of Cerebral Infarction without Residual Deficits. Resident #2's recent comprehensive Minimum Data Set (MDS) was an Admission/5-Day assessment with an Assessment Reference Date (ARD) of 8/22/21. The Brief Interview for Mental Status (BIMS) for Resident #2 was coded as 00, indicating the resident was severely cognitively impaired. Under Section B Hearing, Speech, and Vision; B0600 Speech Clarity the resident was coded 0 (Clear Speech-distinct intelligible words). Under B0700 Makes Self Understood Resident #2 was coded 0 (Understood-able to express ideas and wants). Under Section G Functional Status; G0400 Functional Limitation in Range of Motion Resident #2 was coded 0 (no impairment) for upper extremity and was coded 1(impairment on one side) for lower extremity. Tissue Plasminogen Activator (tPA) Alteplase is a thrombolytic agent used in the lysis of acute thromboembolism. Approved indications for alteplase include ischemic stroke when given within 3 hours of the start of symptoms, but no longer than 4.5 hours, after symptom onset. Alteplase allows for the dissolution of the clot and re-establishment of blood flow. Source obtained on 9/17/21, dated 3/21/2021: www.ncbi.nlm.nih.gov. The Occupational Therapy Treatment Encounter Notes for Resident #2 were reviewed and are documented in part, as follows: Date of Service: 8/31/2021 Summary of Daily Skilled Services: Attempted to perform sit to stand, Patient unable to follow verbal or tactile cueing or commands. Patient at that time unable to form comprehendible words, attempted to speak, however, patient only able to mumble at that time. Reported behavior and observations to nursing. Response to Treatment: Patient presented with increase confusion, and unable to follow 1 step commands. Reported to nursing. Date of Service: 9/2/2021 Summary of Daily Skilled Services: Assessed patient during bed mobility Max A (maximum assistance), to EOB (edge of bed) with cues for hand and foot placement and for scooting forward, in order to perform UB (upper body) dressing, assessed patients sitting balance EOB, Max A, while performing UB dressing with max cues to correct lateral and posterior lean to the right. Response to Treatment: Patient presents with increase confusion, not able to answer questions. Nursing notified. Date of Service: 9/3/2021 Summary of Daily Skilled Services: Assessed patient during bed mobility from supine to sit EOB, patient unable to bend UB to go into sitting with max cues for technique, reported to nursing. Response to Treatment: Unable to tolerate session, increased confusion. Date of Service: 9/6/2021 Summary of Daily Skilled Services: Assessed patient during bed mobility rolling right at moderate assistance with cues for hand and foot foot placement in order to sit EOB, however, patient unable to sit EOB due to increased rigidness, increased confusion, reported to nursing. Response to Treatment: Unable to participate, increased confusion, and rigidness throughout body. On 9/14/21 at 2:07 p.m. a interview was conducted with Occupational Therapy Assistant, Other Staff Member(OSM) #3 regarding her above treatment notes for Resident #2. OSM #3 stated, On 8/31/21 I noticed a change in her, she was unable to follow one step commands and her confusion was increased. She was also unable to speak, she could only mumble. Prior to this she was able to speak. I reported the changes daily to nursing, to Name (Licensed Practical Nurse) LPN #3 because she is the consistent nurse on the unit. On 9/7/21 I started treatment with her (Resident #2) for a stroke and did all the passive range of motion for her, she did tolerate that well. When I reported to Name (LPN #3) she said 'I wrote it down on the PA (physician assistant) book.' The Physical Therapy Treatment Encounter Notes for Resident #2 were reviewed and are documented in part, as follows: Date of Service: 9/2/21 Summary of Daily Skilled Services: Patient shook head yes to agree to PT, attempted sit to stand times 2 patient not following commands to complete task with max assist; anterior/posterior lean and attempted to have patient initiate movement with right knee approximation; patient not following commands. Response to Treatment: Patient continues to require increased verbal cues for task completion and patient with increased need for assistance for completion of task; nursing aware of patient deficits. Date of Service: 9/3/21 Summary of Daily Skilled Services: Supine to sit maximum assistance; bed mobility scooting dependent with 2 person assistance; patient with increased rigidity on right upper extremity and lower extremity and decreased mobility, nursing notified and addressing. Response to Treatment: Per previous section, patient continues to require assistance for all functional mobility. Date of Service: 9/5/21 Summary of Daily Skilled Services: AROM on the left lower extremity and PROM on the right lower extremity. Response to Treatment: Patient willing to work with therapy, does not verbally speak but smiles occasionally, roommate says patient use to speak. Patient able to move the left lower extremity through gravity with AROM, however the right upper extremity and right lower extremity can only be moved through PROM. Nursing notified. Date of Service: 9/6/21 Summary of Daily Skilled Services: Assessed patient during bed mobility rolling right at moderate assistance with cues for hand and foot placement in order to sit EOB, however, Patient unable to sit EOB due to increased rigidness, increased confusion, reported to nursing. Response to Treatment: increased confusion, and rigidness throughout the body, unable to participate, reported to nursing. On 9/14/21 an interview was conducted with Licensed Physical Therapy Assistance (LPTA), OSM #2 regarding her treatment notes for Resident #2. OSM #2 stated, On 8/31/21 nursing informed me that she was being treated for a UTI, which I thought could be the reason for the confusion. I noticed deficits on 9/3/21, she had increased rigidity on her right upper and right lower extremities. I reported the deficits to nurse Name (LPN #3) because she is the consistent nurse we have right now. On 9/15/21 at 1:52 p.m. a phone interview was conducted with LPTA, OSM #1 regarding her treatment note dated 9/5/21 for Resident #2. OSM #1 stated, So that day when I went in, I had never seen her before. She was not speaking to me, her roommate told me she used to speak and could understand. The roommate also said that when she eats food drops out of her mouth and that she had a stroke. I could not get her to move. Her right arm and right leg had no muscle contractions at all. Nothing on the right side was working at all. After her treatment I left a note at the nurses desk about her not having any movement on her right side. Resident #2's Progress Notes were reviewed and are documented in part, as follows: 9/5/2021 15:56 (3:56 p.m.). Skilled Nursing Note Late Entry: Physical Therapy reported no movement in RUE (right upper extremity) or RLE (right lower extremity). Roommate reports cannot tolerate solids food. Patient's roommate states that when she eats she chokes. 9/6/2021 12:50 Skilled Nursing Note: pt remains immobile on right side of body, complaint was put in PA (physician assistant) communication book. 9/7/2021 01:00 P.M. Visit Type: Acute/Sub-Acute Progress Note: Chief Complaint Decreased mentation and noted weakness of RUE/RLE History Of Present Illness: [AGE] year-old female being seen today at request of nursing staff secondary to notable decreased movement of right upper extremity, right lower extremity with therapy. Reported and noted that the patient has had progressive loss of use of the right upper extremity, right lower extremity. Noted patient previously able to ambulate some to not at all. Noted that patient's mentation has decreased and she has become much more nonverbal and presentation she has been over the past couple days. No reported nausea vomiting fevers chills headaches blurry visions or dizziness at this time. Review Of Systems General: Noted difficult to obtain detail ROS(review of systems) as patient has become non verbal in response. Physical Exam: General: Sitting in wheelchair at bedside with minimal to no response to questions or commands attempting to hold right arm with left hand. Musculoskeletal: RUE/RLE Strength 0/5 and LUE (left upper extremity)/LLE ( left lower extremity) 4/5. Neurological: Cranial nerves: noted some facial drooping of the right side of face, decreased to loss of use of the RUE/RLE noted during visit today. Psychiatric: Judgment/insight: mild confusion. Thinks it is 1965 but oriented to self, city and state during previous visit but today non responsive to questions but looks as if she is attempting to. Diagnosis and Assessment Assessment: Acute CVA (cerebrovascular accident): given patient presentation and changes in strength, mentation and neurological presentation will have patient evaluated in ER (emergency room ) for possible Stroke. Right leg weakness: worsened to point of non use. 9/7/2021 15:15(3:15 p.m.) Health Status Nursing Note: pt has been sent to Name (hospital) per PA for suspected stroke. The Physician/NP (Nurse Practitioner) Non-Emergency Concerns/Communication Form Book was reviewed from 9/1/21 through 9/7/21 for any information regarding Resident #2 and is documented in part, as follows: Entered by LPN (Licensed Practical Nurse) #3 Date: 9/6/21 Resident Name/Room: Name (Resident #2). Concern: No movement in RUE and RLE per therapy. MD (Medical Doctor)/NP Note: signed off on 9/7/21 by Physician Assistant, OSM #4. No other entries for Resident #2 were identified for the date listed above. On 9/15/21 at 1:30 p.m. an interview was conducted with LPN #2 who was Resident #2's nurse on 9/5/21 for the 7-3 shift. LPN #2 was asked about the progress noted she wrote for Resident #2 that day. LPN #2 stated, Rehab usually comes in early and that day the therapist wrote a note about Name (Resident #2) and left it on the computer. The note said she had no movement in her right upper extremity or right lower extremity. The first time I saw her (Resident #2) when I was passing meds she didn't talk, she was just looking at me. After I saw the therapist's note I went back in to see her and she still wasn't talking, she would just look at me. LPN #2 was asked if she assessed Resident #2. LPN #2 stated, I don't think I did. I just looked at her to see if she could focus, she just didn't say anything. I told the next nurse (LPN #4) in report what rehab had said. LPN #2 was asked if she called the on-call provider for any of her findings with Resident #2 on the shift. LPN #2 stated, No, I didn't. On 9/15/21 at 10:30 a.m. an interview was conducted with LPN #4 who was Resident #2's nurse on 9/5/21 for the 3-11 shift. LPN #4 was asked about what information she received in report from LPN #2 regarding Resident #2 and what were her findings if any for the resident on her shift. LPN #4 stated, In report I know she said to crush her medications because she was having trouble swallowing. When I saw her she was unable to swallow and she couldn't communicate, she couldn't talk. The last time I had her she was talking, she could say yes or no to communicate. LPN #4 was asked if she assessed Resident #4. LPN #4 stated, No, because Name (LPN #2) had already told me she couldn't swallow, she had already checked her. LPN #4 was asked if she called the on-call provider for any of her findings with Resident #2 on the shift. LPN #4 stated, No, I didn't call anyone. On 9/14/21 at 2:43 p.m. an interview was conducted with CNA #2. CNA #2 was asked if she had noticed any change of condition with Resident #2 and if so whom did she report it too. CNA #2 stated, I worked with her on 9/5/21 and 9/6/21. She looked like she had a stroke. Her mouth was twisted to the side and pulling and she wasn't talking no more. I noticed she would look at me and was confused. She couldn't more her right arm or her right leg. I asked the nurse, Name (LPN #3) if she had had a stroke. On 9/14/21 at 2:59 p.m. an interview was conducted with CNA #1. CNA #1 was asked if she had noticed any change of condition with Resident #2 and if so whom did she report it too. CNA #1 stated, 9/6/21 was the first time I ever cared for her (Resident #2). She was paralyzed on the right side. When I fed her she opened her mouth, but chewed with her mouth sideways. Her mouth was twisted. When I bathed her I had to move her right arm and right leg, she couldn't move it. It was like she had a stroke. She used to talk because I would see her when I walked by, but she wasn't talking no more. I told the nurse Name (LPN #3), she said she knew and went in to look at her. On 9/15/21 at 11:47 a.m. an interview was conducted with LPN #3. LPN #3 was asked if any of the therapists had reported a change of condition with Resident #2 to her. LPN #3 stated, I was told about her a lot because I was usually her primary nurse. I remember them reporting that she was having aphasia. LPN #3 was asked if therapy had reported to her that Resident #2 was unable to move her right upper and right lower extremities. LPN #3 stated, I honestly don't remember. I did get in report on 9/6/21 that she couldn't move her right side. I went down and had her squeeze my hands. She could squeeze with her left hand but nothing on the right. I also had her push my hands with her legs and there was no movement on the right side. She would not move her head. I put her name down in the PA (physician assistant) communication book that she had no movement on her right upper or lower extremities so he could check her when he came in. On 9/7/21 Name (Physician Assistant, OSM #4) came in to see her and he sent her out because he suspected a stroke. During the above interview LPN #3 stated, Looking back on Name (Resident #2) I saw she was having an acute change of condition. I should have assessed her and called the provider with my findings. I should have not put the findings in the communication book. I should have called the provided immediately because it was an acute change of condition. On 9/15/21 at 11:20 a.m. a phone interview was conducted with Physician Assistant OSM #4. OSM #4 was asked when was he made aware that Resident #2 was showing signs of an acute change of condition. OSM #4 stated, When I came to the facility on ,d+[DATE], I looked at the Physician Communication Book and saw there was a note that she had no movement in her right upper or lower extremities. I went to see the patient and she seemed different to me from the week before. I went to talk to the therapists to see if they had seen any changes. They said she had some changes in her ambulation, and a decrease in right sided use. She was also not following commands and was not talking. I went back in to assess her. I spoke to her and all she did was give me a grunt response. She had right sided progressive weakness and I was wondering if she had another stroke. I had staff send her to the emergency room . OSM #4 was asked if he had been alerted to the change in Resident #2's condition prior to him entering the facility on 9/7/21. OSM #4 stated, No ma'am, no one from the facility called me. If I had know I would have sent her out to the hospital. If a resident is having an acute change I would expect for the nursing staff to do an assessment and call the on-call provider. If they are unsure of their findings tell a supervisor. We have to act quickly with stroke symptoms so the patient can get treatment. On 9/15/21 at 2:30 p.m. an interview was conducted with Unit Manager Registered Nurse (RN) #1. RN #1 was asked when she was made aware of Resident #2's acute change of condition. RN #1 stated , I wasn't aware of anything going on with Name (Resident #2) until the PA came in to assess her and said to send her out to the emergency room because of a stroke. The next day I told Name (LPN #3) that you don't put something like this in the doctor book and that it was an acute change of condition and you have to call the doctor immediately not put in the book. On 9/15/21 at 9:56 a.m. an interview was conducted with Resident #2's Attending Physician OSM #5. OSM #5 was made aware of the above findings and asked what she would have expected from the staff regarding Resident #2 having a change of condition for more than 5 days before receiving immediate care and services for signs and symptoms of an acute stroke. OSM #5 stated, She should have been assessed. Over the span of 7 days someone should have alerted me, the PA or the NP (Nurse Practitioner) right away. With something that acute we stop and go assess the resident right away. That's what I do when I'm in the facility and there is a change with a resident. They should have called immediately after she was assessed, because that is a significant change of condition. We only have a 6 hour window with the onset of stroke symptoms for treatment. If they notice a change and stroke symptoms it is important to get the resident to the hospital immediately. We have to know the severity of certain conditions, this was a acute change. The staff need to know when the resident needs to get to a higher level of care. We are only a phone call away. On 9/15/21 at 2:57 p.m. a phone interview was conducted with the Medical Director regarding the above findings for Resident #2. The Medical Director stated, We educated the nurses that the communication book is only for non-emergent issues. For urgent issues we have a 24 hour on call system. Nursing should have notified the on-call person immediately. She was having an acute change of condition and signs of a stroke and she need an acute level of care. With strokes you only have a 3 to 6 hour window for tPA to be administered to attempt to dissolve the clot. On 9/15/21 at 12:30 p.m. an interview was conducted with the Administrator regarding Resident #2. The Administrator was asked what she had determined went wrong with Resident #2's care from 8/31/21 until 9/7/21 when she was sent to the emergency room with signs of a stroke. The Administrator stated, I think lack of communication was the issue. The nurses should have stopped what they were doing and immediately assessed the resident after therapy reported a change of condition. They should have alerted the Unit Manager and called the provider immediately. We also failed to notify the Medical Doctor with the change of condition immediately, because we have to send the resident to the hospital for treatment. Resident #2 Hospital Records dated 9/7/21 were reviewed and are documented in part, as follows: admitted : 9/7/21 History of Present Illness: Chief Complaint: Aphasia, Right sided weakness. [AGE] year-old female presented with new onset right-sided weakness and aphasia. Most of the history was provided by EMS (emergency medical service) providers and apparently she started with right-sided weakness and aphasia 4 days ago. Patient was seen by physical therapy and they noted that she could not use her right side at all. Patient history is limited due to her aphasia. In the emergency room CT (computed tomography) of the head showed a moderate sized late acute versus early subacute infarction( lack of blood supply to an organ or region of tissue) and was recommended admission to the hospital. Patient is not TPA candidate due to late presentation. Review of Systems: General: awake Musculoskeletal: Decreased ROM (range of motion) RUE/RLE. Can not move right side at all. No tenderness to palpation or movement of extremities. Neuro Exam: Aphasic (unable to speak). Comprehension is decreased, limited following of commands. Affect is flat. Cranial Nerves: Face with right facial droop. Assessment and Plan: Acute CVA (stroke). Patient has aphasia and right sided weakness. One week duration. Follow-up MRI (magnetic resonance imaging) of the brain. Active Hospital Problems: Diagnosis CVA (cerebral vascular accident). MRI of the head with contrast on 9/9/21: 1. Areas of acute infarct involving the left cerebral hemisphere. The facility policy titled Significant Change of Condition effective 11/1/19 was reviewed and is documented in part, as follows: Policy: All staff members shall communicate any information about patient status change to appropriate licensed personnel immediately upon observation. 3. This assessment shall be reported to primary physician or designated alternate. 8. Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a patient should be transferred to an acute care setting. On 9/15/21 at 5:06 p.m. a pre-exit debriefing was held with the Administrator and the Regional Nurse Consultant where the above information was shared. The Regional Nurse Consultant stated, We should have called the doctor with the first indication that something was going on, the change in her condition so she could have been sent immediately to an acute care setting. Prior to exit no further information was shared. Complaint Deficiency

Based on clinical record review, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to physically assess for and identify signs and symptoms of an acute stroke for a period of over 5 days, and seek acute level of care for 1 of 2 residents in the survey sample, Resident #2. Subsequently, Resident #2 was sent to the emergency roiagnom on [DATE] and was diagnosed with a late acute versus subacute left anterior cerebral artery infarct and was deemed not a candidate for Tissue Plasminogen Activator (tPA) due to late presentation to the acute care setting, which constitutes harm. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses to include but not limited to High Blood Pressure, Diabetes Mellitus, Heart Disease, and a history of a Cerebral Infarction without Residual Deficits. Resident #2's recent comprehensive Minimum Data Set (MDS) was an Admission/5-Day assessment with an Assessment Reference Date (ARD) of 8/22/21. The Brief Interview for Mental Status (BIMS) for Resident #2 was coded as 00, indicating the resident was severely cognitively impaired. Under Section B Hearing, Speech, and Vision; B0600 Speech Clarity the resident was coded 0 (Clear Speech-distinct intelligible words). Under B0700 Makes Self Understood Resident #2 was coded 0 (Understood-able to express ideas and wants). Under Section G Functional Status; G0400 Functional Limitation in Range of Motion Resident #2 was coded 0 (no impairment) for upper extremity and was coded 1(impairment on one side) for lower extremity. Tissue Plasminogen Activator (tPA) Alteplase is a thrombolytic agent used in the lysis of acute thromboembolism. Approved indications for alteplase include ischemic stroke when given within 3 hours of the start of symptoms, but no longer than 4.5 hours, after symptom onset. Alteplase allows for the dissolution of the clot and re-establishment of blood flow. Source obtained on 9/17/21, dated 3/21/2021: www.ncbi.nlm.nih.gov. The Occupational Therapy Treatment Encounter Notes for Resident #2 were reviewed and are documented in part, as follows: Date of Service: 8/30/2021 Summary of Daily Skilled Services: Assessed patient during sit to stand times 3 trials with cues for hand and foot placement and cues for proper body mechanics. Assessed patient during transfer to commode at CGA (contact guard assistance), from wheelchair level, with use of hand rail. Assessed patient during standing balance activity with cues for upright posture standing for less than 1 minute with cues to maintain standing while patient is reaching back to sit down. Assessed patient during clothing management CGA with cues to get pants down all the way and up over right hip, (pants only) performed, assessed patient during hand washing with cues for thoroughness, and to dry hands completely. Response to Treatment: Patient presenting with increased confusion, with ability to follow 1 step commands. Date of Service: 8/31/2021 Summary of Daily Skilled Services: Attempted to perform sit to stand, Patient unable to follow verbal or tactile cueing or commands. Patient at that time unable to form comprehendible words, attempted to speak, however, patient only able to mumble at that time. Reported behavior and observations to nursing. Response to Treatment: Patient presented with increase confusion, and unable to follow 1 step commands. Reported to nursing. Date of Service: 9/2/2021 Summary of Daily Skilled Services: Assessed patient during bed mobility Max A (maximum assistance), to EOB (edge of bed) with cues for hand and foot placement and for scooting forward, in order to perform UB (upper body) dressing, assessed patients sitting balance EOB, Max A, while performing UB dressing with max cues to correct lateral and posterior lean to the right. Response to Treatment: Patient presents with increase confusion, not able to answer questions. Nursing notified. Date of Service: 9/3/2021 Summary of Daily Skilled Services: Assessed patient during bed mobility from supine to sit EOB, patient unable to bend UB to go into sitting with max cues for technique, reported to nursing. Response to Treatment: Unable to tolerate session, increased confusion. Date of Service: 9/6/2021 Summary of Daily Skilled Services: Assessed patient during bed mobility rolling right at moderate assistance with cues for hand and foot foot placement in order to sit EOB, however, patient unable to sit EOB due to increased rigidness, increased confusion, reported to nursing. Response to Treatment: Unable to participate, increased confusion, and rigidness throughout body. Date of Service: 9/7/2021 Summary of Daily Skilled Services: Assessed patient during PROM (passive range of motion) of right upper extremity, to decrease rigidness. Techniques to facilitate gross motor control and function of right side. Response to Treatment: Actively participated with skilled interventions. On 9/14/21 at 2:07 p.m. a interview was conducted with Occupational Therapy Assistant, Other Staff Member(OSM) #3 regarding her above treatment notes for Resident #2. OSM #3 stated, On 8/29/21 she was able to perform activities of dressing and was able to move her right upper extremity and her right lower extremity. On 8/31/21 I noticed a change in her, she was unable to follow one step commands and her confusion was increased. She was also unable to speak, she could only mumble. Prior to this she was able to speak. I reported the changes daily to nursing, to Name (Licensed Practical Nurse) LPN #3 because she is the consistent nurse on the unit. I also told her that I document everything I report to nursing. On 9/7/21 I started treatment with her (Resident #2) for a stroke and did all the passive range of motion for her, she did tolerate that well. When I reported to Name (LPN #3) she said 'I wrote it down on the PA (physician assistant) book.' The Physical Therapy Treatment Encounter Notes for Resident #2 were reviewed and are documented in part, as follows: Date of Service: 8/30/21 Summary of Daily Skilled Services: seated hip flexion, abduction, adduction and knee extension, AAROM (active assisted range of motion) on right lower extremity and initiation of task times 15 each; verbal/tactile/visual cues to form complete ROM (range of motion). Gait use of FWW (front wheeled walker) times 10 feet, 3 trials minimum assistance. Response to Treatment: Patient with improved tolerance to PT (physical therapy) as noted by improved gait. Date of Service: 8/31/21 Summary of Daily Skilled Services: Attempted sit to stand multiple trials dependent, patient not following commands and requiring UE (upper extremity) placement. Spoke with nursing regarding patient having increased confusion and not following commands. Response to Treatment: Patient needing increased assistance for task completion, nursing reported UTI (urinary tract infection). Date of Service: 9/1/21 Summary of Daily Skilled Services: Attempted sit to stand multiple trials, patient not following commands. Care Plan with daughter, discussed current level of assistance and few days with ambulation, but then return to patient not following commands during PT session. Response to Treatment: Patient continues to require assistance with all functional mobility. Date of Service: 9/2/21 Summary of Daily Skilled Services: Patient shook head yes to agree to PT, attempted sit to stand times 2 patient not following commands to complete task with max assist; anterior/posterior lean and attempted to have patient initiate movement with right knee approximation; patient not following commands. Response to Treatment: Patient continues to require increased verbal cues for task completion and patient with increased need for assistance for completion of task; nursing aware of patient deficits. Date of Service: 9/3/21 Summary of Daily Skilled Services: Supine to sit maximum assistance; bed mobility scooting dependent with 2 person assistance; patient with increased rigidity on right upper extremity and lower extremity and decreased mobility, nursing notified and addressing. Response to Treatment: Per previous section, patient continues to require assistance for all functional mobility. Date of Service: 9/4/21 Summary of Daily Skilled Services: Sat EOB 1.5 minutes GCA (contact guard assistance) with cues to continue to sit EOB as patient attempting to lay down. Response to Treatment: Patient non-verbal today, did not follow commands with verbal and visual cues. Date of Service: 9/5/21 Summary of Daily Skilled Services: AROM on the left lower extremity and PROM on the right lower extremity. Response to Treatment: Patient willing to work with therapy, does not verbally speak but smiles occasionally, roommate says patient use to speak. Patient able to move the left lower extremity through gravity with AROM, however the right upper extremity and right lower extremity can only be moved through PROM. Nursing notified. Date of Service: 9/6/21 Summary of Daily Skilled Services: Assessed patient during bed mobility rolling right at moderate assistance with cues for hand and foot placement in order to sit EOB, however, Patient unable to sit EOB due to increased rigidness, increased confusion, reported to nursing. Response to Treatment: increased confusion, and rigidness throughout the body, unable to participate, reported to nursing. Resident #2's Physician Progress Notes were reviewed and are documented in part, as follows: 8/31/2021 01:00 p.m. Visit Type: Routine Chief Complaint / UTI (Urinary Tract Infection) History Of Present Illness: [AGE] year old female being seen today for follow up of abnormal U/A (urinalysis). previous U/A obtained and patient was started on macorbid prophylactiically and noted that symptoms have since improved. continues PT/OT as it is effective and improving. No other issue or complaints reported at this time. Neurological: No loss of consciousness, transient ischemic symptoms, or seizures. Psychiatric: No change in cognition. Musculoskeletal: strength bilateral upper extremity and lower extremity are 5 out of 5. Neurological: Cranial Nerves II-XII are grossly intact. On 9/14/21 an interview was conducted with Licensed Physical Therapy Assistance (LPTA), OSM #2 regarding her treatment notes dated 8/30/21, 8/31/21, 9/1/21, 9/2/21, and 9/3/21 for Resident #2. OSM #2 stated, On her evaluation she was using both right and left upper body and lower body extremities. She could walk five feet with a walker and contact guard assistance. On 8/31/21 nursing informed me that she was being treated for a UTI, which I thought could be the reason for the confusion. I noticed deficits on 9/3/21, she had increased rigidity on her right upper and right lower extremities. I reported the deficits to nurse Name (LPN #3), because she is the consistent nurse we have right now. On 9/15/21 at 1:52 p.m. a phone interview was conducted with LPTA, OSM #1 regarding her treatment note dated 9/5/21 for Resident #2. OSM #1 stated, So that day when I went in, I had never seen her before. She was not speaking to me, her roommate told me she used to speak and could understand. The roommate also said that when she eats food drops out of her mouth and that she had a stroke. I could not get her to move. Her right arm and right leg had no muscle contractions at all. Nothing on the right side was working at all. After her treatment I left a note at the nurse's desk about her not having any movement on her right side. 9/5/2021 15:56 (3:56 p.m.). Skilled Nursing Note Late Entry: received pt(patient) sitting up in bed. Patient's BP.(blood pressure) 181/78 P (pulse) 63. Pt did not not complain of any pain on this shift. Pt is an extensive assist with ADLs (activities of daily living). Physical Therapy reported no movement in RUE (right upper extremity) or RLE (right lower extremity). Roommate reports cannot tolerate solids food. Patient's roommate states that when she eats she chokes. Pt is sitting up in bed with call light within reach. 9/6/2021 12:50 Skilled Nursing Note: pt vitals were 135/77, pulse 72, O2 (oxygen saturation) 96% on room air, resp (respirations) 16, pt remains immobile on right side of body, complaint was put in PA (physician assistant) communication book took all medications with no s/s (signs or symptoms) of adverse reaction or aspiration, pt is total assist, call bell within reach. 9/7/2021 01:00 P.M. Visit Type: Acute/Sub-Acute: Physician Progress Note: Chief Complaint: Decreased mentation and noted weakness of RUE/RLE History Of Present Illness: [AGE] year-old female being seen today at request of nursing staff secondary to notable decreased movement of right upper extremity, right lower extremity with therapy. Reported and noted that the patient has had progressive loss of use of the right upper extremity right lower extremity. Noted patient previously able to ambulate some to not at all. Noted that patient's mentation has decreased and she has become much more nonverbal and presentation she has been over the past couple days. No reported nausea vomiting fevers chills headaches blurry visions or dizziness at this time. Review Of Systems General: Noted difficult to obtain detail ROS(review of systems) as patient has become non verbal in response. Physical Exam: General: Sitting in wheelchair at bedside with minimal to no response to questions or commands attempting to hold right arm with left hand. Musculoskeletal: RUE/RLE Strength 0/5 and LUE (left upper extremity)/LLE ( left lower extremity) 4/5. Neurological: Cranial nerves: noted some facial drooping of the right side of face, decreased to loss of use of the RUE/RLE noted during visit today. Psychiatric: Judgment/insight: mild confusion. Thinks it is 1965 but oriented to self, city and state during previous visit but today non responsive to questions. Diagnosis and Assessment Assessment: Acute CVA (cerebrovascular accident): given patient presentation and changes in strength, mentation and neurological presentation will have patient evaluated in ER (emergency room ) for possible Stroke. Right leg weakness: worsened to point of non use. 9/7/2021 15:15(3:15 p.m.) Health Status Nurses Note: pt has been sent to Name (hospital) per PA for suspected stroke, care goal plan goals, a copy of bed hold policy is in hand and POA (power of attorney) is aware of situation. The Physician/NP (Nurse Practitioner) Non-Emergency Concerns/Communication Form Book was reviewed from 9/1/21 through 9/7/21 for any information regarding Resident #2 and is documented in part, as follows: Entered by LPN(Licensed Practical Nurse) #3: Date: 9/6/21 Resident Name/Room: Name (Resident #2). Concern: No movement in RUE and RLE per therapy. MD (Medical Doctor)/NP Note: signed off on 9/7/21 by Physician Assistant, OSM #4. No other entries for Resident #2 were identified for the date listed above. Resident #2's eInteract Change of Condition Evaluation dated 9/7/21 at 2:55 p.m. was reviewed and is documented in part, as follows: A. Signs and Symptoms Identified: 26. Stroke/CVA/TIA(transient ischemic attach)/new neurological signs. A1. Mental Status Evaluation: 7. No changes observed. A2. Functional Status Evaluation: 1. Needs more assistance with ADLs (activities of daily living). 2. General weakness. 3. Decreased mobility. B8. Neurological Status Evaluation: Neurological Changes-2. Weakness or hemiparesis. On 9/15/21 at 1:30 p.m. an interview was conducted with LPN #2 who was Resident #2's nurse on 9/5/21 for the 7-3 shift. LPN #2 was asked about the progress noted she wrote for Resident #2 that day. LPN #2 stated, Rehab usually comes in early and that day the therapist wrote a note about Name (Resident #2) and left it on the computer. The note said she had no movement in her right upper extremity or right lower extremity. The first time I saw her (Resident #2) when I was passing meds she didn't talk, she was just looking at me. After I saw the therapist's note I went back in to see her and she still wasn't talking, she would just look at me. LPN #2 was asked if she assessed Resident #2. LPN #2 stated, I don't think I did. I just looked at her to see if she could focus, she just didn't say anything. I told the next nurse (LPN #4) in report what rehab had said. LPN #2 was then asked what she considered signs and symptoms of a stroke to be and if she was aware of the treatment window for acute onset stroke symptoms. LPN #2 stated, You would see facial drooping, weakness and slurred speech. It's important to get the patient to the emergency room as fast as possible to break up the clot that is causing the stroke. We can't do anything here for a stroke. No, I don't know about a time window. LPN #2 was asked if she called the on-call provider for any of her findings with Resident #2 on the shift. LPN #2 stated, No, I didn't. On 9/15/21 at 10:30 a.m. an interview was conducted with LPN #4 who was Resident #2's nurse on 9/5/21 for the 3-11 shift. LPN #4 was asked about what information she received in report from LPN #2 regarding Resident #2 and what were her findings if any for the resident on her shift. LPN #4 stated, In report I know she said to crush her medications because she was having trouble swallowing. I don't believe I got in report about her having right upper and lower extremity weakness. When I saw her she was unable to swallow and she couldn't communicate, she couldn't talk. The last time I had her she was talking, she could say yes or no to communicate. LPN #4 was asked if she assessed Resident #4. LPN #4 stated, No, because Name (LPN #2) had already told me she couldn't swallow, she had already checked her. LPN #4 was asked what are the signs and symptoms of a stroke and what would she would do if she thought a resident was having a stroke. LPN #4 stated, I think you would see half of their face drooping, slurred speech and not being able to move one side of their body. If I thought someone was having a stroke I would call the on-call person and then call 911 to get them sent out to the emergency room as soon as possible so no brain damage happens or anything. LPN #4 was asked if she was aware of the treatment window for acute onset stroke symptoms or stroke protocol. LPN #4 stated, No, I'm not aware of any stroke protocol. LPN #4 was asked if she called the on-call provider for any of her findings with Resident #2 on the shift. LPN #4 stated, No, I didn't call anyone. On 9/15/21 at 2:09 p.m. a phone interview was conducted with LPN #5 who was Resident #2's nurse on 9/5/21 and 9/6/21 for the 11-7 shift. LPN #5 was asked what information she received in report from LPN #4 regarding Resident #2 and what were her findings if any for the resident on her shift. LPN #5 stated, I didn't get anything in report about that resident. But I know she couldn't move, because the CNA (certified nursing assistant) told me. She usually doesn't move. LPN #5 was asked if she did any assessment on Resident #2. LPN #5 stated, I don't remember doing any assessments on her. I just look at her and she would look at me. She don't talk. LPN #5 was asked what are the signs and symptoms of a stroke and what would she would do if she thought a resident was having a stroke. LPN #5 stated, Face drooping and having trouble moving on one side. I would call the doctor and let him know what I saw. LPN #5 was asked if she was aware of the treatment window for acute onset stroke symptoms or stroke protocol. LPN #5 stated, No, I don't know anything about that. On 9/14/21 at 2:43 p.m. an interview was conducted with CNA #2. CNA #2 was asked if she had noticed any change of condition with Resident #2 and if so whom did she report it too. CNA #2 stated, I worked with her on 9/5/21 and 9/6/21. She looked like she had a stroke. Her mouth was twisted to the side and pulling and she wasn't talking no more. I noticed she would look at me and was confused. She couldn't more her right arm or her right leg. I asked the nurse, Name (LPN #3) if she had had a stroke. Name (LPN #3) told me no not that she knew of. CNA #2 was asked if she saw LPN #3 go into to assess Resident #2 after she told her about what she found with the resident. CNA #2 stated, No, I did not see her go in and check Name (Resident #2) when I said something. On 9/14/21 at 2:59 p.m. an interview was conducted with CNA #1. CNA #1 was asked if she had noticed any change of condition with Resident #2 and if so whom did she report it too. CNA #1 stated, 9/6/21 was the first time I ever cared for her (Resident #2). She was paralyzed on the right side. When I fed her she opened her mouth, but chewed with her mouth sideways. Her mouth was twisted. When I bathed her I had to move her right arm and right leg, she couldn't move it. It was like she had a stroke. She used to talk because I would see her when I walked by, but she wasn't talking no more. I told the nurse Name (LPN #3), she said she knew and went in to look at her. I would talk to her and she would just stare at me, she wouldn't eat but would drink for me. On 9/15/21 at 1:20 p.m. an interview was conducted with CNA #3. CNA #3 was asked if she had noticed anything out of the ordinary with Resident #2 on 9/5/21 and if so whom did she report it too. CNA #3 stated, Now that I think about it yes. I noticed on Saturday the 4th that she wasn't doing any talking, she wasn't speaking at all. She was unable to move her right arm also. I did not tell anyone because I thought nursing already knew, because her roommate told me it had been going on. I only work every other weekend and I could tell there was a difference in her since the last time I was there. The last time I took care of her I brought her dinner and she jumped up and sat on the edge of the bed and was trying to get in her chair. She was talking and moving then. I did not tell anyone on Saturday or Sunday that she was different. If I had known that someone didn't know I would have definitely brought it to their attention. On 9/15/21 at 11:47 a.m. an interview was conducted with LPN #3. LPN #3 was asked if any of the therapists had reported a change of condition with Resident #2 to her. LPN #3 stated, I was told about her a lot because I was usually her primary nurse. I remember them reporting that she was having aphasia (inability to speak). LPN #3 was asked if therapy had reported to her that Resident #2 was unable to move her right upper and right lower extremities. LPN #3 stated, I honestly don't remember. I did get in report on 9/6/21 that she couldn't move her right side. I went down and had her squeeze my hands. She could squeeze with her left hand but nothing on the right. I also had her push my hands with her legs and there was no movement on the right side. She would not move her head. I put her name down in the PA (physician assistant) communication book that she had no movement on her right upper or lower extremities so he could check her when he came in. I didn't wanna call it a stroke if it wasn't a stroke, her vitals were fine and she was taking her medicines. On 9/7/21 Name (Physician Assistant, OSM #4) came in to see her and he sent her out because he suspected a stroke. I called 911 and told them she was exhibiting right sided weakness and aphasia. During the above interview LPN #3 was asked if any CNA's had reported any changes in Resident #2 to her. LPN #3 stated, No I don't remember any CNA's coming and telling me anything or asking about her. LPN #3 was asked what are the signs and symptoms of a stroke and what would she would do if she thought a resident was having a stroke. LPN #3 stated, Droopy face, weakness, slurred words, nothing else off the top of my head. I would call the on-call person and send the resident to the hospital immediately to prevent permanent damage. There is nothing we can do here for someone who is having a stroke. LPN #3 was asked if she was aware of the treatment window for acute onset stroke symptoms or stroke protocol. LPN #3 stated, I don't remember if I was aware of one. Looking back on Name (Resident #2) I saw she was having an acute change of condition. I should have assessed her and called the provider with my findings. I should have not put the findings in the communication book. I should have called the provided immediately because it was an acute change of condition. On 9/15/21 at 11:20 a.m. a phone interview was conducted with Physician Assistant OSM #4. OSM #4 was asked when was he made aware that Resident #2 was showing signs of an acute change of condition. OSM #4 stated, When I came to the facility on ,d+[DATE], I looked at the Physician Communication Book and saw there was a note that she had no movement in her right upper or lower extremities. I went to see the patient and she seemed different to me from the week before. I went to talk to the therapists to see if they had seen any changes. They said she had some changes in her ambulation, and a decrease in right sided use. She was also not following commands and was not talking. I went back in to assess her. I spoke to her and all she did was give me a grunt response. She had right sided progressive weakness and I was wondering if she had another stroke. I had staff send her to the emergency room . OSM #4 was asked if he had been alerted to the change in Resident #2's condition prior to him entering the facility on 9/7/21. OSM #4 stated, No ma'am, no one from the facility called me. If I had known I would have sent her out to the hospital. If a resident is having an acute change I would expect for the nursing staff to do an assessment and call the on-call provider. If they are unsure of their findings tell a supervisor. We have to act quickly with stroke symptoms so the patient can get treatment. On 9/15/21 at 2:30 p.m. an interview was conducted with Unit Manager Registered Nurse (RN) #1. RN #1 was asked when she was made aware of Resident #2's acute change of condition. RN #1 stated , I was off the 4th, 5th and 6th. I wasn't aware of anything going on with Name (Resident #2) until the PA came in to assess her and said to send her out to the emergency room because of a stroke. The next day I told Name (LPN #3) that you don't put something like this in the doctor book and that it was an acute change of condition and you have to call the doctor immediately not put in the book. I was never informed by any of the nurses of any change of condition with the resident. On 9/15/21 at 9:56 a.m. an interview was conducted with Resident #2's Attending Physician OSM #5. OSM #5 was made aware of the above findings and asked what she would have expected from the staff regarding Resident #2 having a change of condition for more than 5 days before receiving immediate care and services for signs and symptoms of an acute stroke. OSM #5 stated, She should have been assessed. Over the span of 7 days someone should have alerted me, the PA or the NP (Nurse Practitioner) right away. With something that acute we stop and go assess the resident right away. That's what I do when I'm in the facility and there is a change with a resident. They should have called immediately after she was assessed, because that is a significant change of condition. We only have a 6 hour window with the onset of stroke symptoms for treatment. If they notice a change and stroke symptoms it is important to get the resident to the hospital immediately. We have to know the severity of certain conditions, this was an acute change. The staff need to know when the resident needs to get to a higher level of care. We are only a phone call away. On 9/15/21 at 2:57 p.m. a phone interview was conducted with the Medical Director regarding the above findings for Resident #2. The Medical Director stated, We educated the nurses that the communication book is only for non-emergent issues. For urgent issues we have a 24 hour on call system. I'm would say the UTI would be the reason for the increased confusion, but not for the facial drooping, one sided weakness or aphasia. It seems that she was having a gradual decline. The PA called and consulted with me after he assessed her and felt she had a stroke and I agreed with his assessment and decision to send her to the hospital. Nursing should have notified the on-call person immediately. She was having an acute change of condition and signs of a stroke and she needed an acute level of care. With strokes you only have a 3 to 6 hour window for tPA to be administered to attempt to dissolve the clot. I will call the Administrator and offer to come in and do a power-point on recognizing the signs and symptoms of a stroke and the actions to take. On 9/15/21 at 12:30 p.m. an interview was conducted with the Administrator regarding Resident #2. The Administrator was asked what she had determined went wrong with Resident #2's care from 8/31/21 until 9/7/21 when she was sent to the emergency room with signs of a stroke. The Administrator stated, I think lack of communication was the issue. The nurses should have stopped what they were doing and immediately assessed the resident after therapy reported a change of condition. They should have alerted the Unit Manager and called the provider immediately. We failed to assess on the day the significant changes/symptoms were reported by therapy. We also failed to notify the Medical Doctor with the change of condition immediately, because we have to send the resident to the hospital for treatment. I do see where she (Resident #2) was neglected based on us not following up on the first day she was having a change of condition. We continued to let it go on longer and not follow-up with after repeated notifications for the staff that she was having a change of condition. Resident #2 Hospital Records dated 9/7/21 were reviewed and are documented in part, as follows: admitted : 9/7/21 History of Present Illness: Chief Complaint: Aphasia, Right sided weakness. [AGE] year-old female presented with new onset right-sided weakness and aphasia. Most of the history was provided by EMS (emergency medical service) providers and apparently she started with right-sided weakness and aphasia 4 days ago. Patient was seen by physical therapy and they noted that she could not use her right side at all. Patient history is limited due to her aphasia. In the emergency room CT (computed tomography) of the head showed a moderate sized late acute versus early subacute infarction( lack of blood supply to an organ or region of tissue) and was recommended admission to the hospital. Patient is not TPA candidate due to late presentation. Review of Systems: General: awake Musculoskeletal: Decreased ROM (range of motion) RUE/RLE. Can not move right side at all. No tenderness to palpation or movement of extremities. Neuro Exam: Aphasic (unable to speak). Comprehension is decreased, limited following of commands. Affect is flat. Cranial Nerves: Face with right facial droop. Assessment and Plan: Acute CVA (stroke). Patient has aphasia and right sided weakness. One week duration. Follow-up MRI (magnetic resonance imaging) of the brain. Active Hospital Problems: Diagnosis CVA (cerebral vascular accident). MRI of the head with contrast on 9/9/21: 1. Areas of acute infarct involving the left cerebral hemisphere. Current Facility Education titled Symptoms of a Stroke from the facilities training portal Kramesondemand that was provided to the nursing staff was reviewed and is documented in part, as follows: During a stroke, blood stops flowing to parts of the brain. This can damage areas in the brain that control the rest of the body. Know the symptoms of a stroke: *Weakness. You may feel a sudden weakness, tingling, or a loss of feeling on one side of your face or body including yo [TRUNCATED]

Based on staff interviews, clinical record review and facility document review the facility staff failed to implement interventions consistent with the residents needs, goals and person-centered care plan to reduce an avoidable accident for 1 of 17 residents in the survey sample, Resident #4, resulting in a fall and fracture resulting in harm. On 4/6/17 Resident #4 fell off the bed, landed on the floor and sustained a right hip fracture during the provision of care by one staff. The resident's person-centered care plan indicated the resident was at risk for falls and the resident's needs required two person assist with ADL's (Activities of Daily Living) to prevent falls. The findings included: Resident #4 was admitted to the facility on [DATE] with history of a stroke with left sided hemiparesis (1) and left sided contractures (2). The MDS (Minimum Data Set) a quarterly with an assessment reference date of 2/2/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident was coded as requiring two person physical assistance with bed mobility, dressing, toileting, and personal hygiene. The resident was coded as totally dependent on one staff for bathing. The resident had impairment to both upper and lower extremities on one side (left) and was bed bound. The comprehensive person-centered care plan created on 8/2/15 identified the resident was risk for falls related to hemiparesis. The goal was that the resident would remain free of falls and free of minor and major injury. Interventions listed to achieve and maintain the goals were to anticipate and meet the resident's needs, 2 person assist with ADL's, transfer and bed mobility. During the initial tour of the nursing unit by surveyor #2 on 5/23/17, it was reported that Resident #4 had a recent fall with a fracture. Further investigation of the fall evidenced a progress note dated 4/6/17 that read, in part: The patient fell out of bed while receiving ADL care. The patient was on her left side; the aide was pulling the brief from under the patient and the patient fell out of the bed. The patient c/o (complaint) to the right side of her head and right leg, right knee and right thigh . Resident #4 was sent to the emergency room for evaluation. An X-ray was obtained. The X-ray report fromER on [DATE]-Lucent line across the right trochanter, highly concerning for nondisplaced intratrochanteric fracture .discharge diagnosis-hip fracture, right, closed. The fracture did not require surgical intervention. The resident was sent back to the facility with an order for [REDACTED]. The nurse assigned to care for the resident (Licensed Practical Nurse #1) on the morning of the fall was interviewed on 5/24/17 at 11:30 am. She stated the CNA #1(Certified Nurse Aide) came to her that day and stated, . Ms. (resident name) is on the floor. The nurse then went to get the Director of Nursing (DON) and both entered the resident's room. The resident was observed on the floor between the two resident beds, the resident's head was half way under a chair and the resident was on her right side. The resident was assessed and then placed back into the bed by way of a mechanical lift. The resident stated her right leg was hurting. The LPN stated she asked the CNA what happened. The CNA stated the resident was laying on her left side she was going to pull the resident's brief off and the resident fell off the bed. The nurse stated, She (the resident) had to have flipped, as the resident was found facing the bed frame. The nurse stated the CNA should have had another staff with her during all ADL care to include, brief changing, bed repositioning, bed mobility and bathing. On 5/24/17 at 11:45 am, the DON was interviewed. She stated she was in her office when LPN #1 came to get her. She stated she went to the resident's room and found the resident on the floor. After assessing and placing the resident back to bed she questioned the CNA as to what happened. The CNA stated she was providing care, was busy, in a hurry. The DON stated the CNA knew the resident required two staff for all ADLS and expected the CNA to have asked for help. She stated the resident had a sign above the head of the bed that indicated the resident required two staff. The DON stated in response to the fall an Action Plan was developed, the CNA was given an Employee Corrective Action, suspended for three days and subsequently terminated. The Employee Corrective Action dated 4/10/17 read, in part: On 4/6/17 employee (name) CNA failed to get assistance while providing ADL care to resident in room (#) Resident had a fall and sustained a fracture to the right hip. On 5/25/17 at 12:30 pm, CNA #2 assigned to care for the resident was interviewed. She stated the resident, has always required two staff for all ADL's to include personal care. The resident had been observed several times during the survey in bed with her eyes closed. On 5/25/17 at 12:45 pm, the resident was observed awake. The resident was asked about the fall and stated that she had fallen off the bed. When questioned further the resident was not able to provide any additional details. A posting of a sign that indicated the resident required two staff for assistance was above the resident's bed. The Corrective Action Plan dated 4/6/17 included the following with a corrective action completion date of 4/9/17 read as follows: Issue-Fall with Injury. Comments-resident sustained [REDACTED]. Action: -Resident evaluated at ER with a fracture to R (right) hip. Completed-4/6/17 -Reviewed list of resident(s) requiring two-person assist for bed, and ensure that sign is posted to indicate this need. Completed-4/6/17. -Educate CNA staff on proper positioning of resident during provision of care. Completed 4-9-17. -Review fall(s) every weekday to identify trends, review appropriate interventions. On going. -Review resident(s) upon admission or with change of condition for fall interventions. On going. -Monitor provision of ADL care to ensure that two-person assist is used as indicated. Corrective action process will follow as indicated. On going. -Present findings to QA (Quality Assurance) meetings for review and recommendations. On going. Based on the aforementioned interviews with facility staff, review of the corrective action plan and that the deficient practice did not reoccur after 4/9/17 or exist during the current survey, it was determined the facility met Past Non Compliance for this specific regulatory requirement. The following medical Definitions were obtained from Taber's Cyclopedic Medical Dictionary Edition #20: (1) Hemiparesis-Paralysis of one side of the body. (2) Contracture-Fibrosis of connective tissue in skin, fascia, muscle, or a joint that prevents normal mobility of the related tissue or joint.

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure residents were free of significant medication errors for 2 of 17 residents (Resident #12 and #13) in the survey sample. 1. Resident #12 was administered medications that were ordered for his roommate which resulted in altered mental status and confusion and consequences that lead to hospitalization resulting in harm. 2. Resident #13 was administered medications that were ordered for his roommate. The resident required medical intervention at a local hospital emergency department. The findings include: 1. Resident #12 was admitted to the nursing facility on 1/24/17 with [DIAGNOSES REDACTED]. The Admission Minimal Data Set (MDS) assessment dated [DATE] coded the resident with a score of 7 out of a possible score of 15 on the Brief Interview for Mental Status which indicated he was severely impaired in the skills required for daily decision making. He required extensive assistance of two staff for transfers, bed mobility, extensive assistance of 1 staff for locomotion on and off the unit and used a walker, as well as a wheelchair. The resident was coded not able to independently walk. The resident was not coded with diabetes or depression. He was assessed with [REDACTED]. The care plan dated 1/24/17 identified the resident was at risk for falls related to gait/balance problems, had a recent hemorrhagic stroke, a pacemaker for irregular heart rhythms. The goal set for the resident by the staff was that he would be free of falls and injuries. Resident #12 had physician orders [REDACTED].*[MEDICATION NAME] HCL (to treat irregular heart rhythms) tablet 200 milligrams (mg) and *Fludrocortisone Acetate (to increase blood pressure) tablet 0.1 mg tablet to be administered every day at 9:00 a.m. *[MEDICATION NAME] HCL is used to treat life threatening heart arrhythmia problems called ventricular arrhythmias (www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 87/). *Fludrocortisone is used to increase blood pressure(www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 87/). On 2/11/17 during the morning medication pass at 9:00 a.m., Resident #12 was not administered [MEDICATION NAME] and Fludrocortisone Acetate morning medications at 9:00 a.m. on 2/11/17, but instead was administered his roommate's 9:00 a.m. medications: [REDACTED]*Carvedilol 3.125 mg one tablet to treat high blood pressure, *[MEDICATION NAME] 20 mg to treat depression, *[MEDICATION NAME] 2.5 mg to treat high blood pressure and *[MEDICATION NAME] 7.5 mg to treat arthritis. *Acarbose is used (with diet only or diet and other medications) to treat type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) (https://medlineplus.gov/druginfo/meds/a 5.html). *Capecitabine is in a class of medications called anti-metabolites. It works by stopping or slowing the growth [MEDICAL CONDITION] cells (https://medlineplus.gov/druginfo/meds/a 3.html). *Carvedilol is used to treat high blood pressure and heart failure (https://medlineplus.gov/druginfo/meds/a 2.html). *[MEDICATION NAME] is used to treat depression and anxiety (https://medlineplus.gov/druginfo/meds/a 5.html). *[MEDICATION NAME] is used to treat high blood pressure (https://medlineplus.gov/druginfo/meds/a 1.html). *[MEDICATION NAME] is used to treat arthritis. It reduces pain, swelling, and stiffness of the joints. [MEDICATION NAME]/[MEDICATION NAME] is known as a nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID) (http://www.webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details). https://medlineplus.gov/druginfo/meds/a 2.html The Nurse's Notes dated 2/11/14 at 12:44 p.m. indicated the following: The signs/symptoms of the changes of condition: Abnormal vital signs, functional decline, loss of consciousness. Other change in condition. This started on 2/11/17 during the morning .Assessment (RN)/Appearance (LPN): Vital signs: BP (blood pressure) 116/67-2/11/17 12:48 p.m.-position lying L/arm, P (pulse) 62, R (respiratory) 18.0, T (temperature) 97.1, pulse oximetry 96.0 (95-100=normal-measures arterial oxygen-mayoclinic.org). The SBAR dated 2/11/17 further indicated: .Decreased level of consciousness compared to baseline (sleepy/lethargic), increased confusion/disorientation . The nurse's note and the SBAR (Situation/Situation/Appearance/Review) indicated the physician was called 2/11/17 at 10:00 a.m. and the Resident Representative was notified on 2/11/17 at 10:00 a.m. The physician ordered to monitor the resident's BP every 2 hours times 12 hours, but the physician also ordered the resident be sent to the Emergency Department per request of the family. The Licensed Practical Nurse (LPN) #2 who wrote the aforementioned nurse's note and completed the SBAR was interviewed on 5/25/17 at 11:20 a.m. The LPN stated on 2/11/17 between 9:30 a.m. and 10:00 a.m., she was approached by LPN #3 (no longer employed by nursing facility) who told her she may have switched the resident's morning medications that resided in the same room. LPN #2 said she confirmed that LPN #3 switched the morning medications for both residents. LPN #2 stated she and another licensed nurse assessed Resident #12 and roommate Resident #13. The LPN stated she called both resident's attending physician, who happened to be the same physician and was given orders to take vital signs every two hours for 12 hours and continue to monitor. According to the LPN, Resident #12 was hypotensive and had a decreased level of consciousness that was different from his baseline compared to previous nurse's notes and staff comments. She said Resident #12 refused his breakfast that morning, which he never did, and heavily slurred his words. During the above interview, LPN #2 stated she proceeded to call the Director of Nursing (DON) to inform her and make sure she covered all resident needs. She said both of the resident's families were present and Resident #12's family wanted him sent out to the hospital, followed by Resident #13's family also wanting him sent out. According to LPN #2, Resident #12 was sent out via 911. The LPN said she called the ED (Emergency Department), to follow up on Resident #12's condition, and was informed he was admitted to the hospital, but was not told his admitting [DIAGNOSES REDACTED]. Review of the hospital records revealed Resident #12 was seen in the ED on 2/11/17 at 3:57 p.m. The resident was assessed to be lethargic, but could open eyes to verbal/tactile stimuli. The family was at the bedside and stated the resident's lethargy was sudden and not his usual presentation. It was reported from the nursing facility that the resident had received his roommate's medications. The resident's blood pressure was 117/65, pulse 60 and oxygen saturation was 94%. The resident was assessed as confused, with malaise and fatigue. The primary [DIAGNOSES REDACTED]. In light of receiving oral anti-hyperglycemic medications, the resident's serum glucose level was stable at 104. A routine urinalysis was positive for white blood cells and subsequent urine culture resulted e-coli and the resident was started on antibiotics. The resident was discharged in the care of his family with home health services on 2/14/17. On 5/24/17 at 4:45 p.m., an interview was conducted with the Administrator, DON (Director of Nursing) and Corporate Nurse. They stated LPN #3 immediately recognized she had switched up both Resident's #12 and #13's morning medications. The DON stated LPN #2 adequately assessed both residents, called physician, obtained orders for each resident and respected the wishes of the families by sending the residents to be evaluated at local EDs. The DON said LPN #3 was suspended pending investigation of the incident, neurological checks were initiated for both residents. LPN #3 was suspended pending full investigation, but independently tendered her resignation. This surveyor asked would a Urinary Tract Infection [MEDICAL CONDITION] cause the sudden change the staff recognized within the hour of administering the incorrect medications to Resident #12 ([MEDICAL CONDITION], lethargy, malaise, slurred speech) the Corporate Nurse said, Not likely. During the above interview, they further presented their corrective action plan that included the following with a corrective action completion date of 2/22/17: -100% audit of arm bands, room names and identifying pictures were completed. -Licensed nurses completed medication pass observations. -All medication errors for the past year were reviewed to identify any concerns and no trends were noted. -Education was provided to all licensed nurses on the five rights of medication administration, replacing missing arm band as indicated. (The education was reviewed with original staff sign in sheets). -Continue medication pass observations on an annual basis and as a part of orientation (must pass prior to working alone on the floor). -Any nurse who has not had a successful medication pass observation completed within the past year would have the observation done on their next shift worked. (The medication pass observation sheets were reviewed for the five rights, techniques and all medication routes). -Medication pass observations would be monitored on a random weekly basis to ensure that medications are administered to the correct person. -Results of the observations and medication error reports would be reviewed by the Physician and the Quality Assurance committee for review and recommendation (ongoing). Based on the aforementioned interviews with facility staff, review of the corrective action plan and that the deficient practice did not reoccur after 2/22/17 or exist during the current survey, it was determined the facility met Past Non Compliance for this specific regulatory requirement. The facility's policy and procedures titled General Dose Preparation and Medication Administration revised 1/1/13 indicated .Facility staff should verify that the medication name and dose are correct .identify the resident per facility policy .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . 2. Resident #13 was administered medications that were ordered for his roommate. The resident required medical intervention at a local hospital emergency department. Resident #13 was admitted to the nursing facility on 1/24/17 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] coded Resident #13 with a score of 8 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was moderately impaired in the skills needed for daily decision making. The resident was assessed to require extensive assistance from two staff for be mobility; one staff for toilet use, personal hygiene, dressing and one staff for locomotion on and off the unit with the wheelchair as her primary mode of locomotion. He was totally dependent on one staff for bathing. The care plan dated 2/1/17 identified limited physical mobility due to decline in Activities of Daily Living (ADL), diabetes mellitus, risk for falls, depression, actively receiving [MEDICAL CONDITION] (rectal and [MEDICAL CONDITION]). The staff were to monitor the resident for episodes of fear, distress, hopelessness and anxiety. They were to administer all medications per physician orders [REDACTED]. Resident #13 had physician orders [REDACTED].*Acarbose 50 milligram (mg) one tablet for diabetes mellitus to lower blood sugar, *Capecitabine 500 mg three tablets to [MEDICAL CONDITION], *Carvedilol 3.125 mg one tablet to treat high blood pressure, *[MEDICATION NAME] 20 mg to treat depression, *[MEDICATION NAME] 2.5 mg to treat high blood pressure and *[MEDICATION NAME] 7.5 mg to treat arthritis. *Acarbose is used (with diet only or diet and other medications) to treat type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) (https://medlineplus.gov/druginfo/meds/a 5.html). *Capecitabine is in a class of medications called anti-metabolites. It works by stopping or slowing the growth [MEDICAL CONDITION] cells (https://medlineplus.gov/druginfo/meds/a 3.html). *Carvedilol is used to treat high blood pressure and heart failure (https://medlineplus.gov/druginfo/meds/a 2.html.) *[MEDICATION NAME] is used to treat depression and anxiety (https://medlineplus.gov/druginfo/meds/a 5.html). *[MEDICATION NAME] is used to treat high blood pressure (https://medlineplus.gov/druginfo/meds/a 1.html). *[MEDICATION NAME] is used to treat arthritis. It reduces pain, swelling, and stiffness of the joints. [MEDICATION NAME]/[MEDICATION NAME] is known as a nonsteroidal anti-[MEDICAL CONDITION] drug (NSAID) (http://www.webmd.com/drugs/2/drug- /[MEDICATION NAME]-oral/details). https://medlineplus.gov/druginfo/meds/a 2.html On 2/11/17 during the morning medication pass at 9:00 a.m., Resident #13 was not administered the physician ordered morning medications Acarbose, Capecitabine, Carvedilol, [MEDICATION NAME] and [MEDICATION NAME] at 9:00 a.m. on 2/11/17, but instead was administered his roommate's 9:00 a.m. medications: [REDACTED] *[MEDICATION NAME] HCL is used to treat life threatening heart arrhythmia problems called ventricular arrhythmias (www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 87/). *Fludrocortisone is used to increase blood pressure(www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 87/). The Nurse's Notes dated 2/11/14 at 1:18 p.m. indicated the physician was called because Resident #13 did not receive his ordered morning medications, but medications that were ordered for his roommate. The licensed nurse also completed a SBAR (Situation/Situation/Appearance/Review) because of the medication error. The resident's vital signs were: BP 108/67, P 59, R 18, the resident already had oxygen at 2 liters/minute via nasal cannula for the treatment of [REDACTED]. The Licensed Practical Nurse (LPN) #2 who wrote the aforementioned nurse's note and completed the SBAR was interviewed on 5/25/17 at 11:20 a.m. The LPN stated on 2/11/17 at between 9:30 a.m. and 10:00 a.m., she was approached by LPN #3 (no longer employed by nursing facility) who told her she may have switched the resident's morning medications that resided in the same room. LPN #2 said she confirmed that LPN #3 switched the morning medications for both residents. LPN #2 stated she and another licensed nurse assessed Resident #13 and roommate Resident #12. The LPN stated she called both resident's attending physician, who happened to be the same physician, and no further orders were given for Resident #13. She stated the staff continued to monitor the resident's vital signs and mental status. During the above interview, LPN #2 stated she proceeded to call the Director of Nursing (DON) to inform her and make sure she covered all resident needs. She said both of the resident's families were present and Resident #12's family wanted him sent out to the hospital, followed by Resident #13's family also wanting him sent out. According to LPN #2, Resident #13 was sent out via non-emergent medical transport. The LPN said she called the ED, to follow up on Resident #13's condition, and was informed he was evaluated, treated and after monitoring in the ED was discharged home with family and home health. Review of the hospital records revealed Resident #13 was seen in the ED on 2/11/17 at 3:09 p.m. The resident was assessed with [REDACTED]. The ED diagnosed Resident #13 with accidental medication error with nausea and vomiting. The resident's condition did not require admission to the hospital. The resident received intravenous fluids, was treated for [REDACTED]. The ED notes indicated the resident required more skilled care, but the family refused to send the resident back to the nursing facility and opted for rehabilitation via home health. On 5/24/17 at 4:45 p.m., an interview was conducted with the Administrator, DON and Corporate Nurse. They stated LPN #3 immediately recognized she had switched up both Resident's #12 and #13's morning medications. The DON stated LPN #2 adequately assessed both residents, called physician, obtained orders for each resident and respected the wishes of the families by sending the resident's to be evaluated at local EDs. The DON said LPN #3 was suspended pending investigation of the incident, neurological checks were initiated for both residents. LPN #3 was suspended pending full investigation, but independently tendered her resignation. During the above interview, they further presented their corrective action plan that included the following with a corrective action completion date of 2/22/17: -100% audit of arm bands, room names and identifying pictures were completed. -Licensed nurses completed medication pass observations. -All medication errors for the past year were reviewed to identify any concerns and no trends were noted. -Education was provided to all licensed nurses on the five rights of medication administration, replacing missing arm band as indicated. (The education was reviewed with original staff sign in sheets). -Continue medication pass observations on an annual basis and as a part of orientation (must pass prior to working alone on the floor). -Any nurse who has not had a successful medication pass observation completed within the past year would have the observation done on their next shift worked. (The medication pass observation sheets were reviewed for the five rights, techniques and all medication routes) -Medication pass observations would be monitored on a random weekly basis to ensure that medications are administered to the correct person. -Results of the observations and medication error reports would be reviewed by the Physician and the Quality Assurance committee for review and recommendation (ongoing). Based on the aforementioned interviews with facility staff, review of the corrective action plan and that the deficient practice did not reoccur after 2/22/17 or exist during the current survey, it was determined the facility met Past Non Compliance for this specific regulatory requirement.

Based on staff interview, clinical record review and during the course of a complaint investigation the facility staff failed to promote safety and prevent an avoidable accident, a fall contributing to the death for 1 of 3 residents in the survey sample, Resident #3. Resident #3 had an avoidable fall from the bed to the floor on [DATE] during the provision of care. The resident required two staff for bed mobility. The CNA (certified nurse aide) placed the resident too close to the edge of the bed, glanced away to obtain a brief from behind her and the resident fell . At the time of the fall there was only one staff instead of the required two staff. The resident was sent to the emergency room for evaluation and then sent back to the facility. Three hours after returning from the emergency room the resident was discovered without vital signs. The resident was pronounced deceased by EMTs (emergency medical technicians) at 2:14 am. The coroners Certificate of Death indicated the manner of death was accidental; the fall contributed to the resident's death. The findings included: Resident #3 was a [AGE] year old who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A contracture is a tightening of muscle, tendons, ligaments, or skin that prevents normal movement. www. nih.gov The current MDS (Minimum Data Set) with an assessment reference date of [DATE] coded the resident as having long and short-term memory deficits and severely impaired cognition. The resident required two staff for bed mobility-how the resident moves to and from lying position, turns side to side, and positions body while in bed. Resident #3 was a DNR (Do Not Resuscitate). On [DATE] at approximately 5:30 pm, the resident was receiving incontinent care by CNA #1 (certified nurse aide). The resident was positioned too close to the edge of the bed according to the CNA. When the CNA turned away from the resident to grab a brief from the bedside table, the resident fell to the floor. The resident was assessed for injury by the nursing staff. A physician was in the building and gave an order to send the resident to the emergency room for evaluation. The hospital report evidenced multiple X-rays and CT scans were obtained. Each result came back with no injury or fracture. The resident was sent back to the facility with a notable bruise to the left side of the forehead. The resident returned to the building at 10:40 pm. At 1:45 am, the resident was found by CNA #1 to have had a change in condition. The CNA immediately notified the nurses who then went in to assess the resident. The nurses entered the resident's room and documented the following: Nurses entered the room immediately to assess patient as CNA was retrieving vitals. Nurse assessed breathing and patients pulse. No respiration present, no radial pulse, no carotid pulse, no apical pulse. CNA stated she could get a bp (blood pressure) on pt. One Nurse went to notify family, on-call Dr. and 911. (Daughter name) pt daughter and husband argued in back ground as nurse informed RP (responsible party) of news, daughter and husband argued on decision to keep patient DNR status or not from 1:52 am to 2:05 am. (Daughter) stated she wanted (resident) to stay DNR. EMT (Emergency Medical Technician) and police officers arrived at the same time. EMT pronounced death at 2:14 am. The Police Department Incident Report dated [DATE] timed for 3:00 am read, Crime#1: Death Investigation. There was no other information visible on the report obtained from the online electronic police reports. The Certificate of Death dated [DATE] read, in part: Immediate Cause of Death-Part I. 1. Respiratory Failure 2. Recurrent Aspiration 3. Dementia. Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in part I. COMPLICATIONS OF ACUTE FALL. 39. If external, to what extent it contributed to cause of death? Contributing. 40. Manner of Death: Accident. 47. Describe how injury relating to death occurred: (Gender) fell out of bed to floor. On [DATE] at 2:35 pm, the medical examiners office was called. An interview was conducted with one of the investigators. The Death Certificate was reviewed. The medical examiner's investigator stated, The fall contributed to the death, if there was no fall he/she would have lived longer.this was an accidental death, the stress of the accident, hitting the floor, played a determining factor in his/her death. On [DATE] at approximately 3:15 pm, an interview was conducted with CNA #1. She stated at approximately 5:30 pm she was providing incontinent care to Resident #3. She stated, I didn't realize how close to the edge of the bed the resident was when I turned him/her. I glanced back to grab a brief and he/she fell off the bed. The CNA indicated the bed was raised approximately 3 feet from the floor and the resident was turned away from her. CNA #1 stated she had taken care of the resident plenty of times before and always had another CNA assist her with bed mobility/ turning the resident during the provision of care. She was asked why didn't she not have another CNA assist her this time. She responded, That night there were only four of us (CNAs), I really didn't have extra help.normally we have five CNAs working. When asked if she could have asked for help, she stated, Yes.I could have.but there was other stuff going on.a lot of busy. Review of time sheets evidenced there were 5 CNAs and 4 nurses on shift at that time. CNA #1 continued to work through the night shift. She stated she entered the resident's room at approximately 1:45 am and discovered the resident was very yellow.I saw the resident take his/her last breath. On [DATE] at 12:45 am, an interview with the director of nursing (DON) and the nurse consultant (NC) in attendance was conducted in the DON's office. The DON stated, The CNA was providing incontinent care, rolled the resident to his/her side while reaching for a brief she took her eyes off the resident and the resident rolled off the bed. The NC stated, We felt the resident was positioned too close to the edge of the bed.approximately 5 inches from the edge. They were asked what could have been done to prevent this fall. The DON stated, If we would have provided two assistants, knowing he/she was bed bound. The facility indicated in response to this fall an action plan was initiated. Part three of the action plan was to inservice/ educate CNA staff on proper positioning of a resident in bed during the provision of care. The completion date for this education was [DATE]. As of [DATE] only 36% of the CNA staff had been educated. The Safe Resident Handling- Positioning Resident to a Side-Lying-Position obtained from Mosby's Textbook for Long-term Care Nursing Assistants, 6th Edition 2011, obtained from the staff development coordinator that was part three of the action plan for all CNA staff read, in part: Assisting residents to turn and reposition in bed is best done by at least 2 staff members. When turning a resident away from the caregiver, a 2nd staff member is recommended.the resident should not be turned away from a caregiver without validating that safety measures are in place to prevent the resident from falling out of the bed for example have a co-worker on the other side of the bed to prevent a potential fall from occurring. Further review of the electronic record failed to evidence any additional close monitoring was provided to Resident #3 after returning to the facility. The staff did not obtain on going neurological assessments or vital signs. The Nursing Policies and Procedures Falls Management Program effective [DATE] read, in part: Evaluate, monitor, and document patient response for the first 24 hours (3 consecutive shift) post fall, include a neurological assessment if the fall was unwitnessed and /or the patient hit his/her head. For the next 48 hours a comprehensive assessment will be documented daily. The Nursing Policies and Procedures Neurological Assessment effective [DATE] read, in part: A Neurological Assessment will be completed by a licensed nurse in order to detect potential early signs of brain injury usually in response to a traumatic patient event. 2. Assess level of consciousness 3. Assess pain response 4. Assess pupil response 5 Assess muscle strength 6. Assess reflexes 7. Obtain vital signs (temperature, pulse, respirations, blood pressure). 8. Record findings on the Neurological Assessment Form. Complete assessment every 15 minutes for the first hour, every 30 minutes for the next two hours, and every hour for the next four hours. A pre-exit meeting was conducted with the administrator, the director of nursing (DON) and the nursing consultant (NC) on [DATE] at 1:30 pm. The facility's staff failure to have the required two staff during bed mobility and positioning for Resident #3 was shared. They were also asked why the resident did not have close monitoring or neurological assessments after returning from the hospital from a witnessed fall resulting in a hit to the head. The NC stated, We probably should have started (obtaining neurological assessments) from the beginning (cycle-as noted above). The DON and NC both indicated there was no Neurological Assessment Form found for Resident #3.