Every finding on record at Beckley Healthcare Center

Based on Record review and staff interview, the facility failed to ensure medications were administered in accordance with physician orders. Specifically, a resident was ordered lorazepam 0.5 mg every six (6) hours; however, the resident received lorazepam 2 mg per dose on seven (7) occasions. The facility failed to identify and correct the medication administration error in a timely manner. This failed practice represented a pattern of noncompliance and had the potential for more than minimal harm, as the resident received a dosage of lorazepam significantly greater than ordered on multiple occasions. The incorrect administration placed the resident at risk for adverse effects including excessive sedation, altered mental status, and respiratory depression. Although no actual harm was identified, the repeated nature of the medication error demonstrated a pattern that could compromise resident safety. Resident Identifier: #149 Facility Census: 138Findings include:On 01/07/26 at approximately 9:00 AM, Corporate Nurse #220 informed the surveyor that while reviewing Resident #149's medication orders and controlled substance administration record, a medication error was identified involving Lorazepam. Corporate Nurse #220 stated, The order is for lorazepam 0.5 mg every six hours; however, the resident received lorazepam 2 mg per dose.Record review completed on 01/07/26 revealed Resident #149 had a physician order for Lorazepam 0.5 mg, give one tablet by mouth every six (6) hours as needed for end-of-life care, anxiousness, and shortness of breath for 14 days.Further review of the Controlled Substance Administration Record revealed Lorazepam 2 mg, one tablet by mouth every four (4) hours as needed for anxiety, was administered to Resident #149 on the following dates and times:01/01/26 at approximately 5:16 AM, 12:23 PM, and 10:30 PM01/02/26 at approximately 8:23 AM and 10:09 PM01/05/26 at approximately 7:30 PM01/06/26 at approximately 10:40 AMThis resulted in the resident receiving four times the ordered dose of a benzodiazepine medication on seven (7) occasions over multiple days.During an interview on 01/07/26 at approximately 10:00 AM, Corporate Nurse #229 confirmed that Lorazepam was administered at 2 mg instead of the ordered 0.5 mg on seven occasions.The facility failed to ensure medications were administered in accordance with physician orders, placing the resident at risk for oversedation, respiratory depression, and other adverse outcomes, and failed to identify and correct the error timely.

Based on observation, record review, and staff interview, the facility failed to develop and/or implement residents' comprehensive care plans. This deficient practice affected four (4) of 33 residents reviewed in the long-term care survey sample. Resident identifiers: #93, #43, #15, and #1. Facility census: 138. Findings included: a) Resident #1 On 01/07/26 at 2:19 PM, a record review was completed for Resident #1. The review found the care plan did not include the diagnosis of Major Depressive Disorder, single episode moderate. On 01/07/26 at 2:25 PM, Corporate Nurse #222 confirmed the diagnosis was not included in the care plan. b) Resident #43 Review of Resident #43's comprehensive care plan showed a focus initiated on 12/06/24 related to the resident's behaviors, including refusal of hygiene care. On 04/09/25, the intervention Resident prefers bed baths was initiated. Further review of Resident #43's comprehensive care plan showed a focus initiated on 10/30/24 related to a deficit in the resident's ability to perform activities of daily living. On 05/29/25, the intervention Resident prefers showers 2x week [twice a week] on nightshift was initiated. On 01/13/2026 at 10:39 AM, Resident #43 was interviewed regarding her preferences for hygiene. She stated she prefers bed baths in the evening after supper. On 01/13/2026 at 11:09 AM, Corporate Nurse #220 confirmed the conflicting care plan interventions regarding Resident #43's hygiene preferences. She stated she would clarify the matter and revise the care plan as needed. No further information was provided through the completion of the survey process. c) Resident #15 Observations of Resident #15 on the following dates and time found the following: 01/05/26 lunch meal: Resident #15 was served his meal around 12:30 pm. At approximately 3:00 PM this surveyor observed Resident #15's lunch meal still sitting on his over the bed table. The food was hardly disturbed and at least 90 % remained on his tray. Registered Nurse (RN) #115 was asked if Resident #15 needed help with his tray as it was still on his bedside table sitting in front of him. She replied, He sometimes does that I'll have to check. I'll go check on him. 01/06/26 and 01/07/26 Noontime Meal: Resident #15 was served his tray at approximately the same time each day. The staff was observed sitting his tray up for him on his over the bed table and then exited the room and provided no feeding assistance to him. 01/12/26 -- Noontime Meal - Resident #15 was served his tray at approximately 12:30 pm. About 15 to 20 Minutes later the surveyor entered the resident's room to see how he liked his lunch. His right hand was covered with chocolate pudding, and his food was barely disturbed. Resident #15 then asked this surveyor if she could help him eat because he could not get it. The surveyor alerted RN #115 of the observation immediately and asked her if she could help the resident. 01/12/26 - Supplement - Between 2:00 pm and 3:00 pm this surveyor entered Resident #15's room to see if the facility had provided him with his frozen nutritional supplement. The resident had the supplement and was attempting to eat it a spoon. The resident was obviously struggling and when he saw the surveyor he again asked her if she could help him eat his supplement because he could not get it. RN #115 was alerted to Resident #15's request for help. She stated, I will go help him now. A review of Resident #15's medical record found the following: A review of the resident's care plan found, and intervention related to Resident #15's need for help with ADL's which read: EATING totally dependent X1 (times one) assist. This was initiated on 11/13/25. A review of Resident #15's ADL flow sheets related to assistance with eating from 11/14/25 through 11/12/26 found out of 177 meals Resident #15 was dependent with assistance (meaning a staff member fed him his meal) as directed by the care only 74 times or 41.8 % of the time. On all other occasions Resident #15's care plan was not implemented and he did not get the assistance needed with eating he required. During an intrview with Corporate Registered Nurse (CRN) #220 at 10:10 am on 01/13/25 the above findings were discussed. She agreed that according to the observations and the ADL flow sheet documentation Resident #15 did not always receive the assistance he needed with eating. d) Resident #93 A review of Resident #93's care plan found an intervention which said, Bed in lowest position. This was added to care plan on 11/18/25 as an intervention for the following focus statement: The resident had a fall with fracture related to gait balance problems muscle weakness reduced mobility history of falls An observation with Corporate Registered Nurse (CRN) #220 on 01/05/26 at 1:55 pm found Resident #93 resting in bed. Her bed at the time of this observation was not in the lowest position. CRN #220 agreed the residents care plan had not been implemented.

Based on observation, record review and staff interview the facility failed to ensure a resident who was dependent on staff for Activities Of Daily Living received the care they needed to maintain and/or attain the highest practicable physical, mental and psychosocial well being. Resident #15 was not provided assistance with eating as required. Resident #51 did not receive the assistance with bathing they required This was true for two (2) of four (4) residents reviewed during the long term care survey process. Resident Identifier: #15 and #51. Facility Census: 138. Findings include: a) Resident #15 Observations of Resident #15 on the following dates and time found the following: 01/05/26 lunch meal: Resident #15 was served his meal around 12:30 pm. At approximately 3:00 PM this surveyor observed Resident #15's noon time meal still sitting on his over- the- bed table. The food was hardly disturbed and at least 90 % remained on his tray. Registered Nurse (RN) #115 was asked if Resident #15 needed help with his tray as it was still on his bedside table sitting in front of him. She replied, He sometimes does that I'll have to check. I'll go check on him. 01/06/26 and 01/07/26 Lunch Meal - Resident #15 was served his tray at approximately the same time each day. The staff was observed sitting his tray up for him on his over- the- bed table and then exited the room and provided no feeding assistance to him. 01/12/26 Lunch Meal - Resident #15 was served his tray at approximately 12:30 pm. About 15 to 20 Minutes later the surveyor entered the residents room to see how he liked his lunch. His right hand was covered with chocolate pudding and his food was barely disturbed. Resident #15 then asked this surveyor if she could help him eat because he could not get it. The surveyor alerted RN #115 of the observation immediately and asked her if she could help the resident. 01/12/26 - Supplement - Between 2:00 pm and 3:00 pm this surveyor entered Resident #15's room to see if the facility had provided him with his frozen nutritional supplement. The resident had the supplement and was attempting to eat it with a spoon. The resident was struggling and when he saw the surveyor he again asked her if she could help him eat his supplement because he could not get it. RN #115 was alerted to Resident #15's request for help. She stated, I will go help him now. A review of Resident #15's medical record found the following: A review of the residents care plan found an intervention related to Resident #15's need for help with ADL's which read: EATING totally dependent X1 assist. This was initiated on 11/13/25. A review of Resident #15's ADL flow sheets related to assistance with eating from 11/14/25 through 11/12/26 found out of 177 meals Resident #15 was dependent with assistance (meaning a staff member fed him his meal) as directed by the care plan 74 times or 41.8 % of the time. On the other occasions Resident #15's care plan was not implemented and he did not get the assistance needed with eating he required. During an interview with Corporate Registered Nurse (CRN) #220 at 10:10 am on 01/13/25 the above findings were discussed. She agreed that according to the observations and the ADL flow sheet documentation Resident #15 did not always receive the assistance he needed with eating. b) Resident #51 On 01/05/2026 at 12:23 PM, Resident #51 stated, I don't always get showers. Sometimes it can be every two (2) weeks. Review of Resident #51's shower and bathing task report for the last 30 days showed the resident received showers on 12/18/25, 01/01/26, and 01/08/26. The resident received bed baths on 12/21/25, 12/24/25, 12/27/25, and 01/04/26. No refusals were documented in the task report or in the progress notes. Resident #51's comprehensive care plan stated the resident preferred showers twice a week on night shift. The care plan also stated the resident was totally dependent for assistance with showering and bathing. On 01/13/26 at 10:58 AM, Corporate Nurse #220 confirmed the documentation failed to show Resident #51 received twice weekly showers. She stated she was unable to locate any further documentation of showers or any documentation of refusals of showers during the time period. No further information was provided through the completion of the survey sample.

Based on observation, record review, staff interview and resident interview the facility failed to ensure Resident #15 received care to enable them to maintain and or attain acceptable parameters of hydration and nutrition status. The facility failed to ensure Resident #15 had access to water and/or fluid of his preference at bedside and accessible at all times. In addition the facility has failed to provide Resident #15 with assistance with meals to ensure the best possible meal consumption. This is true for one (1) of six (6) residents reviewed for the care areas of hydration and/or nutritional status during the long term care survey process. Resident Identifier: #15. Facility Census: 138. a) Resident #15 a1) Hydration On 01/05/26 at 3:00 pm Resident #15 was observed in his bed with his lunch tray still present. No additional fluid other than what was on his tray was observed. The three (3) cups on his tray were empty. On 01/06/26 during the course of the day from 8:30 am to 4:00 pm multiple observations of Resident #15 were made. The only fluids observed were delivered on his breakfast and lunch tray. The resident was observed multiple times laying in his bed with his over the bed table at bedside but no fluids were observed on the over- bed table or anywhere else accessible to the resident. On 01/07/26 at 9:00 am an observation found the resident in his room. His bedside table was cleared off and no breakfast or drinks remained. The nurse aide was asked if the resident ate his breakfast and he said yes and showed the surveyor the tray. There were 3 drink cups on the tray and all were empty. An observation and Resident interview on 01/07/25 at 10:45 am revealed the resident had no drink or cups in his room. When asked if the staff brought him drinks between his meals he indicated they did not. He stated that he was thirsty right now and would like to have two (2) cups of apple juice. Immediately after this observation and interview the Nursing Home Administrator was asked to accompany this surveyor to the residents room. The resident again was asked if they brought him drinks between his meals and he stated they did not. When asked if he had to wait until his next meal to get a drink, he replied, Yes He was asked if he was thirsty and he said that he was and he would like some juice and he wanted two (2) cups. While interviewing the resident prior to requesting the NHA come to the resident room the Nurse Practitioner came by and then left stating she would come back. After we left the room with the NHA another nurse was seen taking the resident a cup of juice. The NHA then told him to take him two (2) cups since he had asked for them. A later interview with the NHA on 01/07/26 indicated the nurse was taking him a cup of juice and the nurse aide said he had three (3) cups with breakfast and three (3) cups right after breakfast. He further stated they do not leave them at bedside because the consistency can change. During an interview with Nurse Aide (NA) #10 at 2:45 pm on 01/07/26 when asked about Resident #15's fluid today the Nurse Aide stated, he had those four (4) on the tray I showed you then he had another on his table he spilt and I cleaned it up and then they brought two (2) more later on. He stated, He used to have one of those little pitchers. And motioned hands in a manner to demonstrate the size which was smaller than other pitchers observed in the facility. Then he said we had to take that because he kept spilling it in his bed. So now we just take him cups in. An observation of the other residents found most residents had larger blue water pitchers which all contained ice water. The five (5) other residents who receive thickened liquids like Resident #15 all had a small blue water pitcher at their bedside with the exception of Resident #73 who had a two handled cup at bedside with thickened water in it. The smaller pitchers were the size NA #10 described while speaking with the surveyor earlier. After the interview with NA #10 and the observations of the other residents who were ordered thickened liquids, another interview was conducted with the NHA. When asked why the other five (5) residents who receive thickened liquids had fresh water at bedside, he stated, I misspoke earlier the thickened liquids can be left at bedside we just recently switched to pre thickened drinks which can be left at bedside. The NHA was made aware of the statement NA #10 made about taking Resident #15's water pitcher. The NHA stated, Let me clarify that with him under no circumstances should we take his pitcher because he spills it. Later in the afternoon the NHA advised the surveyor that NA #10 was just trying to convey he was having a hard time drinking from the blue pitcher, so they started not giving him one and began giving him the smaller cups of fluid when he needed them. The NHA further stated, We are getting him a two handled cup for him to keep at his bedside with fresh water in it. Observations of Resident #15 on the following dates and time found the following: 01/05/26 Noontime meal: Resident #15 was served his meal around 12:30 pm. At approximately 3:00 PM this surveyor observed Resident #15's noon time meal still sitting on his over- bed table. The food was hardly disturbed and at least 90 % remained on his tray. Registered Nurse (RN) #115 was asked if Resident #15 needed help with his tray as it was still on his bedside table sitting in front of him. She replied, He sometimes does that I'll have to check. I'll go check on him. 01/06/26 and 01/07/26 Noontime Meal: Resident #15 was served his tray at approximately the same time each day. The staff was observed sitting his tray up for him on his over-bed table and then exited the room and provided no feeding assistance to him. 01/12/16 Lunch Meal - Resident #15 was served his tray at approximately 12:30 pm. About 15 to 20 Minutes later the surveyor entered the resident's room to see how he liked his lunch. His right hand was covered with chocolate pudding, and his food was barely disturbed. Resident #15 then asked this surveyor if she could help him eat because he could not get it. The surveyor alerted RN #115 of the observation immediately and asked her if she could help the resident. 01/12/26 - Supplement - Between 2:00 pm and 3:00 pm this surveyor entered Resident #15's room to see if the facility had provided him with his frozen nutritional supplement. The resident had the supplement and was attempting to eat it with a spoon. The resident was obviously struggling and when he saw the surveyor he again asked her if she could help him eat his supplement because he could not get it. RN #115 was alerted to Resident #15's request for help. She stated, I will go help him now. A review of Resident #15's medical record found the following: A review of the resident's care plan found an intervention related to Resident #15's need for help with ADL's which read: EATING totally dependent X1 assist e. This was initiated on 11/13/25. The following Weights were recorded: 09/23/25 -- 176.8 Lbs. (pounds) 09/30/25 - 175.Lbs. 10/03/25 -- 176.2 Lbs. 10/14/25 -- 173.3 Lbs. 10/21/25 -- 176 lbs. 10/27/25 -- 178.2 lbs. 11/07/25 -- 170.1 lbs. 11/12/25 -- 164.8 lbs. 11/18/25 -- 164.2 lbs. 11/24/25 -- 163 lbs. 12/01/25 -- 163.8 lbs. 12/09/25 -- 164.6 lbs. 01/05/26-- 154.5 lbs.01/07/26 -- 154.8 lbs. Based on the weights obtained the resident had suffered a 5.95 % weight loss in 30 days based on his most recent weight. This was considered a severe weight loss. Resident #15 lost 12/15 percent in the last 90 days based on his most recent weight. This is also considered a severe weight loss. Further review of the weight record found the resident suffered the largest losses between 12/09/25 and 01/05/26 and 10/27/25 and 11/12/25. A comparison of the activities of daily living (ADL) flow sheet for the task of eating found between 10/27/25 and 11/12/25 Resident #15 was coded as being dependent for eating only 56 % of the time. From 12/09/25 to 01/05/26 resident #15 was coded as being dependent only 48 % percent of the time. A further comparison of Resident #15's ADL assistance coding and the percentage of his meals consumed found the following: The review period from 09/21/25 through 01/07/25 revealed when the resident was provided feeding assistance and was marked as being totally dependent for feeding the resident consumed 76- 100 % of his meals 75% of the time. When the resident was marked as being independent with his meals (meaning he received no assistance from staff) he consumed 0- 25 % of his meal 69 % of time. During an interview with Corporate Registered Nurse (CRN) #220 at 10:10 am on 01/13/25 the above findings were discussed. She stated the resident was in the hospital with an adrenal crisis and returned to the facility on [DATE]. CRN #220 said, We have changed his medication for hyperthyroidism twice. We were attributing his weight loss to that. She confirmed she did not know he was not being provided the assistance he required for meals. She provided the surveyor with the two (2) medication orders. Resident #15 started 10 mg of methimazole on 10/08/25 and this was decreased on 12/17/25 to 5 mg. An additional record review of the registered dietician notes and assessments found that she had entered a note and/or an assessment on 11 occasions since the resident's readmission to the facility on [DATE]. A review of this documentation found the dietician did not note anything attributing the weight loss to Resident #15's diagnosis of Hyperthyroidism. She never mentioned the medication changes or that he was on medication to treat hyperthyroidism. She mentioned his antidepressant in every assessment but failed to mention the methimazole which the facility attributed his weight loss to.

Based on record review and staff interviews, the facility failed to ensure accurate and complete medical records for the five (5) of 33 residents. Resident #73, 1:1 documentation incorrect, Resident #149's post-event form was missing, and a fall assessment time was incorrect. Resident #6's feeding and water flush entries were mixed up. Resident #12's weights recorded incorrectly, and Resident #8's readmission assessment missed the identification of wounds. This was found true for five (5) of 33 residents' medical records being reviewed during the long-term care survey process. Resident identifiers: #73, #149, #6, #12, and #8. Facility census: 138.a) Resident #73 Record Review: On 01/07/26, review of Resident #743's activity participation records showed no documentation of 1:1 visits. Further review on 01/07/26 revealed the resident's care plan indicates 1:1 visits are to occur five (5) times per week. Staff Interview: On 01/07/26 at 3:11 PM, the Activity Director stated, We only mark the 1:1 tab if the resident requires a 1:1 sitter. I didn't think to have staff mark it for the scheduled 1:1 visits. I will educate staff and get this done now. This confirms that 1:1 visits were not being documented correctly, despite being provided according to the care plan. b) Resident #149 Record Review: On 01/07/26, review revealed the following:A post-fall assessment dated [DATE] incorrectly recorded the date and time of the fall as 01/06/25 at 14:00; the actual time of the fall was 07:20 AM. Further review indicated Resident #149's code status is DNR (Do Not Resuscitate). However, the medical record did not contain the POST form, and none was available at the nurses' station. Staff Interview: Corporate RN #220 stated, The nurse who completed the admission did have an orange verification paper for the DNR order, but it has been misplaced. RN #220 confirmed that the POST form was not present in the medical record during the surveyor's review and that the post-fall evaluation did not reflect the correct time of the fall c) Resident #6 This resident receives her nutrition through a PEG (Percutaneous Endoscopic Gastrostomy) feeding tube, due to a stroke affecting her right side and a diagnosis of dysphagia. A review of the medical record documents the following orders pertaining to PEG feeding: Enteral Feed order every night shift. Change flush syringe and container daily. Verbal order. Order date 12/12/25. Enteral Feed order every shift HOB (Head of Bed) elevated at least 30 degrees while administering enteral feedings. HOB remains at 30 degrees for at least 1 hour post bolus enteral feeding and post medication administration. Verbal order. Order date 12/12/25. Entered Feed order every shift. Monitor for signs/symptoms or tube feed intolerance QS (every shift), abdominal distention, increase pain, shortness of breath, formula visual in saliva, diarrhea, emesis. Verbal order 12/12/25 Enteral Feed order one time a day down at 7 AM or when total volume of 1155 ml has infused (provides 1732 kcals per 24 hours). Verbal order 10/31/25 Enteral Feed order one time a day Jevity 1.5 @ 105 ml/hour x 11 hours via enteral pump, up at 8:00 PM. Verbal order 10/31/25 Enteral Feed order one time a day. Take water flush down at 7 AM or when total volume of 660 ml has infused. Verbal order 01/05.26 Enteral Feed order one time a day. Water flushes @ 60 ml/hour x 11 hours while TF is infusing to provide 660 ml per 24 hours, start at 8 PM. Verbal order 01/05/26 Enteral Feed order two times a day Flush PEG tube with 30 ml water before and after enteral feeding. Verbal order 12/12/25. Enteral Feed order two times a day Verify enteral tube placement before feeding and flushes by checking for gastric contents. Notify physician if gastric contents are not visualized. Verbal order 12/12/25. A review of the Medication Administration Report (MAR) for 01/01/26, under the order for Enteral Feed Order one time a day down at 7 AM or when total volume has infused, the number infused was reported as 660 ml. A total of 1155 ml should have been infused. On the same date under the order Enteral Feed Order one time a day down at 7 AM or when a total volume of 1155 has infused (provides 1732 kcals per 24 hours), a total of 1155 ml was documented. A review of the MAR for December, 2025 documented under the order Enteral Feed Tube Order one time a day at 7 AM or when total volume has infused, values of: 660 ml on 12/17/25 660 ml on 12/26/25 and 660 ml on 12/31/25 During an Interview with Corporate RN # 220 on 01/13/26 at approximately 10:00 AM, surveyor asked about discrepancies on 12/17/25, 12/26/25, 12/31/25 and 01/01/26 values, surveyor asked shouldn't the feeding tube amount should been 1155 ml? Surveyor pointed out the values recorded as 650 ml. RN #220 said she thought the orders were confusing to staff, and stated staff were putting in water flush amount instead of feeding amount. RN #220 stated she has gone into the medical record to define this better so that staff will not confuse the entries anymore. d) Resident #12 During the initial record review of this resident, the medical record documented resident weight on 01/05/26 was 151 pounds. On 12/31/25, the medical record documented the resident weighed 260 pounds, which is a loss of 109 pounds in less than a week. This was reviewed with Corporate RN #220, on 01/07/26 at 10:20 AM. She said let me go fix that, and then said she would go look at the post dialysis note from 01/05/26 to see what the recorded weight was on that documentation, and make the appropriate correction. e) Resident #8 A review of Resident #8's medical record found he was discharged from the facility to an acute care hospital on [DATE]. The record further indicated that he returned to the facility on [DATE]. According to the nursing admission assessment which was completed on 12/29/25 upon his readmission to the facility Resident #8 had no skin issues. However, a skin/wound note dated 12/29/25 found the following, readmission skin assessment performed by wound team and UM (Unit Manager). The following was noted - O2 (oxygen) via nasal cannula set at 2L (liters), scattered bruising and scabs, skin tear on left forearm, IAD (Incontinence Associated Dermatitis) to groin scrotum, DTI (Deep Tissue Injury) to bilateral heels, DTI to sacrococcygeal, orders received, care plan updated. Dr. (last name of Physician) and resident aware. An interview with Corporate Registered Nurse (CRN) #220 at 11:00 am on 01/13/26 confirmed Resident #8's readmission assessment was not accurate. She confirmed he had three (3) DTI's upon readmission and several bruises and scabbed areas as well as a skin tear. She agreed those should have been captured on the nursing assessment upon readmission.

Based on observation, record review, and staff interview, the facility failed to ensure oxygen was administered according to physician orders. This deficient practice was identified as a random opportunity for discovery. Resident Identifiers: #149 and #8. Facility census: 138. Findings included: a) Resident #8 An observation of Resident #8 on 01/05/26 at 3:22 PM found Resident #8 in his bed. His oxygen concentrator was on and running at two (2) liters per minute. The tubing for the residents oxygen was observed rolled up in a neat circle laying on the residents bed. It was not connected to the concentrator nor was the nasal cannula in Resident #8's nose. Registered Nurse (RN) #26 was asked to look at the oxygen and confirmed it was not connected to the concentrator or the resident. She stated that she would get him some new tubing and nasal cannula and get it hooked up appropriately. b) Resident #149 On 01/06/26 at approximately 11:09 a.m., the surveyor observed Resident #149 receiving oxygen at a rate of 4 liters per minute via nasal cannula. Record review completed on 01/06/2026 revealed a physician order indicating the resident was to receive oxygen at 2 liters per minute. An interview conducted on 01/06/26 with the Infection Prevention (IP) Nurse confirmed the physician order for Resident #149 was 2 liters per minute and acknowledged the oxygen was set incorrectly at 4 liters per minute at the time of observation.

Based on record review and staff interview, the facility failed to offer the pneumococcal vaccination to Resident #4. This was true for one (1) of five residents reviewed under the care area of infection control. Resident Identifier: #4. Facility Census: 138. Findings Include: a) Resident #4 On 01/05/26 at 2:30 PM, a record review was completed for Resident #4. The review found Resident #4 was eligible for a pneumococcal 20 vaccination in 09/2025. However, the resident was not offered the pneumococcal vaccination. On 01/06/26, at 1:30 PM, Corporate Nurse #220 confirmed the vaccination was not offered to the resident.

Based on observation, record review, and staff interview, the facility failed to ensure medications were labeled properly. A multi-dose vial of insulin had two (2) different dates to indicate when the vial had been opened and two (2) different dates to indicate when the vial would expire. This was a random opportunity for discovery. Resident Identifier: #90. Facility Census: 138. Findings included: a) Resident #90 On 01/12/2026 at 10:23 AM, the F even medication cart was inspected. Registered Nurse (RN) #29 was in attendance. A multi-dose vial of Humulin Regular insulin for Resident #90 was noted to have two (2) dates to indicate when the vial had been first accessed and two (2) dates to indicate when the vial would expire. On the box were written the opening date of 12/10/25 and expiration date of 01/07/26. An opening date of 01/04/26 and expiration date of 02/02/26 were also written on the box. These dates were also written on the vial itself. The box had been filled by the pharmacy on 11/22/25. According to the Humulin Regular insulin package insert, available on the Food and Drug Administration (FDA) Website, vials must be used within 31 days of opening or be discarded. RN #29 confirmed the two (2) different opening dates and two (2) different expiration dates written on Resident #90's Humulin Regular multi-dose insulin box and vial. She also confirmed the medication had expired according to the earlier date on the vial. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. This was a random opportunity for discovery. Resident identifier: #21. Facility census: 138. Findings included: a) Resident #21 The facility's policy titled Medication Administration, with no effective date or revision date given, stated narcotics would be signed out when given. On 01/12/26 at 10:26 AM, inspection was made of the F odd medication cart. Registered Nurse (RN) #29 was in attendance. The Individual Resident's Controlled Substance Administration Records were reviewed for several residents. The amount of medication remaining according to the administration record was compared to the actual amount of medication contained in the locked drawer. For Resident #21, the Individual Resident's Controlled Substance Administration Record showed 32 tablets of Tramadol were left. However, there were only 31 Tramadol tablets for Resident #21 left in the locked drawer. This was confirmed by RN #29, who was unable to explain the discrepancy. The Tramadol had last been signed out on the Controlled Substance Administration Record on 01/12/26 at 4:22 AM. Review of Resident #21's Medication Administration Record (MAR) showed the resident received Tramadol four (4) times a day for pain, at 4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure appropriate information was communicated to the receiving healthcare institution when a resident was transferred to the hospital in order to ensure a safe and effective transition of care. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of hospitalization. Resident Identifier: #8. Facility census: 138.Findings included:a) Resident #8 The facility's policy titled Transfer and Discharge Policy, with no implementation or revision dates given, stated a transfer form would be completed and sent with a resident being transferred to the hospital. The transfer form would contain the following information: - Patient status, including baseline and current mental, behavioral and functional status- Recent vital signs - Current diagnoses, allergies and reasons for transfer- Contact information for the practitioner responsible for the resident's care at the facility- Patient representative information, including contact information - Current medications and treatments- Relevant laboratory or radiological findings - Immunization status- Special instructions or precautions for care - Special resident risks - Other information necessary to ensure a safe and effective transition of care Review of Resident #8's medical records showed the resident was transferred to the hospital on [DATE] due to unresponsiveness and low blood pressure. Further review of the resident's medical records showed no completed transfer form to communicate to the hospital the information necessary to safely and effectively assume care of the resident. On 01/13/2026 at 10:53 AM, Corporate Nurse #220 stated she was unable to locate documentation of the information conveyed to the hospital when the resident was transferred. She stated a transfer form should have been completed and sent to the hospital with the resident. No further information was provided throughout the completion of the survey process

Based on record review, observation and staff interview the facility failed to ensure Resident #9 who was fed by enteral means received the enteral feeding in accordance with the physician's orders. This was true for one (1) of two (2) residents reviewed for the care area of Tube Feeding during the long term care survey process. Resident Identifier: #9. Facility Census: 138. Findings Include: a) Resident #9 A review of Resident #9's medical record on 01/07/26 found the following physician orders: -- Enteral feed order in the morning turn off tube feeding at 8:00 am if the total volume of 1400 ml has infused, clear pump and document total. The start date of this order was 09/26/25 and was the current order at the time of this review. -- Enteral Feed order one time a day Jevity 1.5 at 70/ml/hr. via enteral pump start time 12:00 pm and run until 1400 Ml has been infused. May turn off at 8:00 am if 1400 Ml has infused. This order also had a start date of 09/26/25 and was the current order at the time of this review. -- Enteral feed order in the morning for nutrition Turn off tube feeding at 8:00 am. If the total volume of 1400 ml has been infused. Clear pump and document total. This order had a start date 09/27/25 and was the current order at the time of this review. An observation of Resident #9 on 01/07/26 at approximately 9:00 am found the resident resting in bed. His feed pump had been turned off, and the pump was not on. An additional observation of Resident #9 at 12:45 pm on 01/07/26 found the nurse had started his feeding which was due to be started at 12:00 pm. The enteral pump was on and running. The rate of feeding was programmed in the pump as 70 ml per hour as ordered. An observation of the pump found that at 12:45 PM only 45 minutes after the feeding was scheduled to start the total amount fed read 1105 ml. Corporate Registered Nurse (CRN) #220 was asked to look at the pump. She confirmed the amount fed said 1105 ml. She agreed the pump was not cleared after the resident's last feeding as directed in the order. When asked why it only read 1105 ml if the resident was to receive 1400 ml on the previous day she was unable to answer. She indicated she would have to talk to the nurses involved and see what happened. She agreed there was no way to determine when the feeding would be complete if the pump was not cleared after each feeding.

Based on resident interview, staff interview, record review, and observations the facility failed to ensure one resident received timely, consistent, and effective pain management in accordance with physician orders, and resident assessments, This practice was found true for one (1) of two (2) resident's reviewed for pain. Resident identifier: #149. Facility Census: 138.a) Resident #149On 01/06/2026 at 9:39 AM, Resident #149 reported uncontrolled pain and stated: They don't give me my pain medication. I hurt.The resident reported having cancer and stated he may have three (3) to four (4) months left to live. The resident expressed a desire to read his Bible and get closer to the Lord, but stated his pain prevented him from doing so. He reported that when pain medication was administered, it helped and made the pain tolerable, but stated there were days he did not receive any pain medication. The resident stated he usually activated his call light 30 minutes before his pain medication was due. Resident #149 said staff respond but do not return.At the time of interview, the resident confirmed he was in pain and rated it 7/10.The resident stated his last pain medication was morphine at approximately 8:00 PM the previous evening, although it was ordered every 12 hours.During the surveyor's interview with Resident #149, LPN #148 entered the resident's room to obtain vital signs and stated the resident was on neurological checks due to a fall. The nurse did not assess the resident's pain, did not discuss pain control, and did not administer or address overdue pain medication during the encounter.Review of the Nursing admission Evaluation showed Resident #149 was admitted on [DATE] at 3:14 PM. The nursing admission assessment revealed a pain score of 9/10 on the verbal pain scale.Further record review revealed the resident did not receive pain medication until 01/01/26 at 5:15 AM. This was more than nine (9) hours after admission, despite documented severe pain.Physician Orders for Resident #149 included:Morphine 30 milligram (mg), one (1) tablet by mouth every 12 hours for intractable pain.Oxycodone 15 mg, one tablet by mouth every four (4) hours as needed for pain.Medication Administration Record Review revealed the following dates/times Resident #149 received pain medication:Oxycodone 15 mg:01/01/26: 5:16 AM, 2:45 PM, 10:30 PM01/02/26: 8:23 AM, 10:10 PM01/03/26: None01/04/26: None01/05/26: 4:46 AM, 9:26 AM, 2:55 PM, 7:30 PM, 11:40 PMMorphine 30 mg:01/05/26: 8:43 PM01/06/26: 10:16 AMThe medication administration record (MAR) demonstrated missed and delayed pain medication administration, including multiple days without PRN pain medicationDuring an interview, with LPN #148 on 01/06/26 at 10:00 AM, the LPN confirmed the scheduled morphine dose was late. The nurse stated he would need to contact the physician for a one-time order to administer the morphine.

Based on observation and staff interview, the facility failed to ensure safe infection control practices were followed to prevent the spread of diseases and infections. This was a random opportunity for discovery and has the potential to affect more than a limited number of residents. Facility Census: 139. a) Ice Chest On 9/08/25 at 3:30 PM an observation of the ice chest on F wing of the facility found the scoop for the Ice was stored in the chest with the clean Ice. An immediate interview with Registered Nurse #300 confirmed the scoop was not stored properly to prevent the spread of infection.

Based on observation, staff interview, the facility failed to ensure that baking pans were stored in a sanitary manner by stacking them while still wet (wet nesting). This practice had the potential to contaminate food-contact surfaces and cause foodborne illness. This failed practice had the potential to affect more than a minimal number of residents residing in the facility. Facility census: 139.Findings include: On 09/08/2025 at 10:29 AM, during a kitchen observation with the Dietary Manager, two (2) baking pans were observed stacked while wet. Wet nesting creates an environment that can support bacterial growth and contaminate food prepared in the pans.On 09/08/2025 at 10:42 AM, the Dietary Manager confirmed the pans should have been completely dried prior to storage and stacking. The pans were removed and rewashed at that time.

Based on record review and staff interview, the facility failed to ensure enteral (tube) feeding was provided in accordance with professional standards of practice. Documentation of the amount of enteral feeding infused was not accurately recorded. This deficient practice had the potential to affect (2) of (2) residents reviewed for the care area of tube feeding. Resident identifiers: #1 and #8. Facility census: 139. Findings included:a) Resident #8 Review of Resident #8's physician's orders showed the following order written on 01/31/25, Enteral Feed Order one time a day, Jevity 1.5 @ [at] 80 ml/hr [milliliters per hour] x [times] 10 hours via pump, up at 9 PM down at 9 AM or when total volume infused 800 ML to provide 1200 calories. to provide 1400 ml total volume, 2100 kcals [calories]. The administration times were 9:00 AM and 9:00 PM. The following order was also written on 01/31/25, Enteral Feed Order one time a day at 9:00 PM, confirm rate programmed at 80 m/hour, confirm total volume programmed in at 800 ml, and clear volume fed in the last 24 hours back to 0. The following order was also written on 01/31/25, Enteral Feed Order every night shift. When pump beeps that total volume has been delivered, turn pump off and document total volume fed on pump in last 24 hours. Review of Resident's Medication Administration Records (MARs) for June 2025 and September 2025 showed the following amounts of total enteral feed were documented: - On 06/03/25, n/a was documented. - On 06/07/25, 1600 ml was documented. - On 06/11/25, 984 ml was documented. - On 06/13/25, 1600 ml was documented. - On 06/16/25, 900 ml was documented. - On 06/17/25, 1600 ML was documented. - On 06/21/25, 550 ml was documented. - On 06/22/25, 550 ml was documented. - On 06/23/25, 1600 ml was documented. - On 07/01/25, 881 ml was documented. - On 07/12/25, 0 ml was documented. - On 07/14/25, 1480 ml was documented. - On 07/19/25, 1600 ml was documented. - On 07/20/25, 1600 ml was documented. - On 07/21/25, 1180 ml was documented. - On 07/25/25, 1600 ml was documented. - On 07/26/25, 1046 ml was documented. - On 07/27/25, 1876 ml was documented. - On 08/02/25, 825 ml was documented. - On 08/03/25, 2828 ml was documented. - On 08/11/25, 0 ml was documented. - On 08/12/25, 100 ml was documented. - On 08/13/25, 1180 ml was documented. - On 08/14/25, 1881 ml was documented. - On 08/16/25, 813 ml was documented. - On 08/18/25, 1588 ml was documented. - On 08/23/25, 825 ml was documented. - On 08/24/25, 430 ml was documented. - On 08/27/25, 1267 ml was documented. - On 09/04/25, 1200 ml was documented. - On 09/06/25, 0 ml was documented. - On 09/07/25, 100 ml was documented. - On 09/08/25, 748 ML was documented. - On 09/09/25, 0 ml was documented. - On 09/10/25, 300 ml was documented. On 09/10/25 at 4:15 PM, the Regional Director of Clinical Operations confirmed Resident #8's documented enteral feeding amounts on the aforementioned dates did not correlate with what she was ordered to receive daily. She stated she could not explain the discrepancies between the amount of enteral feeding ordered and the amount of enteral feeding recorded on the MARs. b) Resident #1 Review of Resident #1's physician's orders showed the following order written on 08/21/25, Enteral Feed Order two times a day, Jevity 1.5 @ [at] 70 ml/hr [milliliters per hour] x [times] 20 hours via pump to provide 1400 ml total volume, 2100 kcals [calories]. The administration times were 9:00 AM and 9:00 PM. The following order was also written on 08/21/25, Enteral Feed Order one time a day at 9:00 AM, confirm rate programmed at 70 m/hour, confirm total volume programmed in at 1400 ml, and clear total volume fed in last 24 hours back to 0. The following order was also written on 08/21/25, Enteral Feed Order every night shift. When pump beeps that total volume has been delivered, turn pump off and document total volume fed on pump in last 24 hours. Review of Resident's Medication Administration Records (MARs) for August 2025 and September 2025 showed the following amounts of total enteral feed were documented: - On 08/21/25, 800 ml was documented. - On 08/22/25, 1680 ml was documented. - On 08/23/25, 1680 ml was documented. - On 08/24/25, 1000 ml was documented. - On 08/25/25, 700 ml was documented. - On 08/26/25, the notation ok was made but no amount was documented. - On 08/27/25, 1400 ml was documented. - On 08/28/25, no amount was documented. - On 08/29/25, 1025 ml was documented. - On 08/30/25, 714 ml was documented. - On 08/31/25, 822 ml was documented. - On 09/01/25, 2100 ml was documented. - On 09/02/25, 1400 ml was documented. - On 09/03/25, 1088 ml was documented. - On 09/04/25, 850 ml was documented. On 09/05/25, the order was changed to the following, Enteral Feed Order every shift for Nutrition Enteral nutrition via pump of Jevity 1.5 at a rate of 70 mls per hour for a total of 2100 kcal intake. Start time 1 pm and run until 1400 mls has been infused. May turn off at 9 am if total of 1400 ml has infused. Review of Resident's Medication Administration Records (MARs) for August 2025 and September 2025 showed the following amounts of total enteral feed were documented: - On 09/05/25 200 ml was documented for night shift. - On 09/06/25 0 ml was documented for day shift and 1400 ml was documented for night shift. - On 09/07/25 1400 ml was documented for day shift and 1397 ml was documented for night shift. - On 09/08/25 1400 ml was documented for day shift and 1397 ml was documented for night shift. - On 09/09/25 0 ml was documented for day shift and 1120 ml was documented for night shift. The order was discontinued on 09/10/25. On 09/11/2025 at 9:12 AM, the Regional Director of Clinical Operations confirmed Resident #1's enteral feeding amounts had not been documented accurately on the MARs. She stated she could not explain the discrepancies between the amount of enteral feeding ordered and the amount of enteral feeding recorded on the MARs.

Based on resident interview, record review, and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of dialysis for one (1) of one (1) residents reviewed for the care area of dialysis. Resident Identifier: #135. Facility census: 139. Findings included: a) Resident #135 During an interview on 09/08/25 at 4:14 PM, Resident #135 stated he was receiving dialysis treatments. Review of Resident #135's physician's orders showed the resident had been receiving dialysis treatments since admission on [DATE]. Resident #135's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/27/25 indicated the resident was not receiving dialysis treatments. On 09/09/2025 at 1:10 PM MDS Nurse #182 confirmed Resident #135's MDS with ARD 08/27/25 was incorrect and should have indicated the resident was receiving dialysis treatments. No further information was provided through the completion of the survey process.

Based on record review and staff interview the facility failed to identify and report a situation of potential neglect. This was a random opportunity for discovery found during the long term care survey process. This was true for Resident #145. Resident Identifier: #145. Facility Census: 139. a) Resident #145 Resident #145 was selected as a closed record review for the care area of hospitalization during the long term care survey process. A record review completed during the investigation of this care area found the resident was sent to the emergency room (ER) on 07/18/25. The transfer form completed by the facility indicated the resident was sent to the local hospitals ER at 1:10 pm on 07/18/25. The reason for the transfer was listed as, unresponsive. Further review of the medical record found an Emergency Department Record from the local hospital in the scanned documents in the medical record. A review of the document found it was faxed to the facility on [DATE] at 8:30 am. This document had been scanned into the electronic medical record prior to the beginning of this survey. A review of this document found the following, -- Resident Arrived at the ER at 1:38 PM.-- . [AGE] year old female presents to ER via EMS with complaints of Unresponsive -- . [AGE] year old female from nursing facility arrives as a sepsis with hypotension., tachycardia, altered mental status, there was differentiating stories from the nursing facility a CNA reportedly said she had been this way since 7:00 am. EMS had nurses told her it was just since about 10:00 am. An interview with the Director of Nursing (DON) at approximately 12:00 pm on 09/09/25 confirmed she had not read the report which indicated the resident had been unresponsive since 7:00 am or 10:00 am. She indicated she knew this was not the truth. She was able to show with the Medication Administration Record (MAR) that resident had drank some of her mighty shake at 10:43 am on this day. She agreed that they had not looked into this being true and no investigation was done because she knew it was not true because she was here that day and had seen the resident. An interview later in the afternoon on 09/09/25 with the Nursing Home Administrator (NHA) and Regional Director of Clinical Operations (RDCO) confirmed this was not reported. The NHA stated, we knew this was not the case so we did not report it or investigate it. We talked about her decline in the morning meeting an knew she was not doing well.' They both agreed this was not reported as neglect.

Based on record review, staff interview and policy review the facility failed to implement their Abuse Prohibition policy in regards tot he reporting of neglect. This was a random opportunity for discovery and was true for Resident #145. Resident Identifier: #145. Facility Census: 139. a) Policy Review A review of the facility's policy titled, Abuse, Neglect, and Misappropriation found the following pertaining to the identification and reporting of abuse: IV Identification of Incidents and allegations 1. The accurate and timely identification of any even which would place our residents at risk is a primary concern of the facility. 2. The following procedures will assist the staff in the identification of incidents and direct them to the appropriate steps of intervention. a. Each occurance of resident incident, bruise, abrasion or injury of unknown source, or report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and investigated timely. b. The supervisor or designee will notify the Director of Nursing and Executive director of the incident or allegation immediately. Required notification of agencies, physician, and resident representative will be completed as required. c. The executive director or designee with direct the investigation VII. Reporting of Incidents and Facility Response 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported to the Executive Director immediately. 2. The executive Director/designee will report appropriate incidents to OHFLAC, APS, the regional ombudsman and other local authorities including but not limited to local law enforcement if appropriate and required by state law b) Resident #145 Resident #145 was selected as a closed record review for the care area of hospitalization during the long term care survey process. A record review completed during the investigation of this care area found the resident was sent to the emergency room (ER) on 07/18/25. The transfer form completed by the facility indicated the resident was sent to the local hospitals ER at 1:10 pm on 07/18/25. The reason for the transfer was listed as, unresponsive. Further review of the medical record found an Emergency Department Record from the local hospital in the scanned documents in the medical record. A review of the document found it was faxed to the facility on [DATE] at 8:30 am. This document had been scanned into the electronic medical record prior to the beginning of this survey. A review of this document found the following, -- Resident Arrived at the ER at 1:38 PM.-- . [AGE] year old female presents to ER via EMS with complaints of Unresponsive -- . [AGE] year old female from nursing facility arrives as a sepsis with hypotension., tachycardia, altered mental status, there was differentiating stories from the nursing facility a CNA reportedly said she had been this way since 7:00 am. EMS had nurses told her it was just since about 10:00 am. An interview with the Director of Nursing (DON) at approximately 12:00 pm on 09/09/25 confirmed she had not read the report which indicated the resident had been unresponsive since 7:00 am or 10:00 am. She indicated she knew this was not the truth. She was able to show with the Medication Administration Record (MAR) that resident had drank some of her mighty shake at 10:43 am on this day. She agreed that they had not looked into this being true and no investigation was done because she knew it was not true because she was here that day and had seen the resident. An interview later in the afternoon on 09/09/25 with the Nursing Home Administrator (NHA) and Regional Director of Clinical Operations (RDCO) confirmed this was not reported. The NHA stated, We knew this was not the case so we did not report it or investigate it. We talked about her decline in the morning meeting an knew she was not doing well.' They both agreed this was not reported as neglect.

Based on record review and staff interview the facility failed to ensure Resident #151's physician orders reflected her wishes concerning the end of life care. This was true for one (1) of five (5) residents reviewed for the care area of advance directives during the long term care survey process. Resident identifier: #151. Facility census: 139. a) Resident #151 A review of Resident #151's medical record on [DATE] found a Physician Orders for Scope of Treatment (POST) form which was completed by the resident on [DATE] and signed by the Nurse Practitioner on [DATE]. On this form Resident #151 indicated she did not want Cardiopulmonary Resuscitation (CPR) should her heart stop. She also indicated she would want full intervention prior to her heart stopping. Further review of the medical record found a physician's order dated [DATE] which read CPR. This order directed nursing staff to perform CPR on the resident should her heart stop. This order did not align with the resident's directive contained on the post form. An interview with the Regional Director of Clinical Operations (RDCO) #207 at 12:45 PM on [DATE] confirmed the order in the resident's electronic medical record needed to be updated to reflect the residents wishes regarding CPR.

Based on record review, observation and staff interview the facility failed to ensure Resident #16's care plan in regards to falls was implemented. This was true for one (1) of five (5) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier; #16. Facility Census: 139. a) Resident #16 A review of Resident #16's medical record found the following care plan: Focus Statement (First Name of Resident #16) has had falls and is at risk for further falls secondary to dementia with severe impaired cognitive function, unsteadiness on feet, muscle weakness, episodes of incontinence, difficulty hearing, episodes of pain. (Resident #16) has hypertension, panic disorder, anxiety, osteoarthritis, anemia, depression, hx of CVA. She has use of medications that carry side effects that increase risk for falling. Resident has poor safety awareness. Date Initiated: 09/15/23.Goal associated with this Focus Statement: (First Name of Resident #16) will not sustain major injury related to falls through review date Date Initiated: 09/15/2023 Revision on: 05/20/2025 Target Date: 11/20/25 Interventions included: Dycem under cushion of wheelchair Date Initiated: 06/24/25 Laminated sign in room to remind resident to use call light Date Initiated: 07/03/2025 Revision on: 07/08/2025An observation of Resident #16 with the Director of Nursing (DON) at 10:05 am on 09/10/25 found the resident resting in bed. Her wheelchair was sitting to the right of her bed. There was no Dycem in her wheelchair and no cushion. Also, there was not a laminated sign reminding the resident to use her call light. The DON agreed the interventions were not in place.

Based on record review, observation, and staff interview the facility failed to ensure the resident environment was as free from accident hazards as possible. This was true for Resident #1 and was a random opportunity for discovery. Nurse Aide (NA) #20 and NA #21 had completed Resident#1's shower. They returned her to the hall and without surveyor intervention NA #20 and NA #21 would have used the total mechanical lift as a transport device to transport Resident #1 from the hallway to her bed which was by the window in her room. The surveyor intervened and prevented this from happening due to the risk of serious harm and/or death associated with using the lift as a transport device. The State Agency (SA) determined this practice placed Resident #1 in an immediate jeopardy (IJ) situation. The facility was notified of the IJ at 6:49AM on 05/19/25. The facility's plan of correction (POC) was accepted by the SA on 05/19/25 at 8:53 AM. After the facility implemented their plan of correction the SA abated the IJ at 10:35 am on 05/20/25. The implementation of the POC was confirmed by reviewing training documentation, observations and staff interviews to ensure the deficient practice had been corrected to the point of removing the immediacy. Resident Identifier: #1. Facility Census: 144. Findings Include: a) Resident #1 At 4:45 AM on 05/19/25 as the surveyor began walking down C-wing it was noted Resident #1 was on the shower bed in the hallway outside of the door to her room. Nurse Aide (NA)#20 was hooking the loops of the lift pad, which was under Resident #1 to the total mechanical lift; he then lifted the resident into the air. It should be noted that NA #21 was standing by and was available to assist. NA #20 however was the one hooking the lift pad to the lift and using the controls of the lift to lift the resident off the shower bed. Once NA #20 had lifted the resident slightly off the shower bed, the surveyor asked NA #20 what he was doing and if he intended to wheel the resident into her room while in the lift. He stated, Yes Ma'am that's how I always do it. I can't get the lift and the shower bed into the room at the same time. Is that Okay? At this time the surveyor intervened and asked him to not do that. He lowered the resident back to the shower bed and Licensed Practical Nurse (LPN) # 22 was asked if she could help NA #20 and #21 to safely transfer Resident #1 to the bed. LPN #22 then accompanied NA #20 and NA #21 into the resident's room. Upon entering the room, the surveyor noted Resident #1's bed was by the window. Her roommate who resided in the bed by the door was in bed. Her roommate's bed was against the back wall of the room. To the open side of the roommate's bed was a fall mat and an over the bedtable. Both of which had to be passed by to get Resident #1 to her side of the room. In the room was also a rock and go wheelchair which belonged to the roommate and Resident #1's wheelchair. NA #20 moved the roommate's chair out into the hallway. They then pushed the shower bed and lift into the resident's room. The shower bed did fit beside the resident's bed. They then lifted the resident into the air again. At this time the three (3) Staff members realized they were unable to move the shower bed out of the way due to the lift's legs being under the shower bed. At this time LPN #22 told NA#20 and NA #21 to transfer Resident #1 into her wheelchair and then remove the shower bed from the room. Then to transfer Resident #1 from her wheelchair to her bed. This transfer was eventually completed at 5:00 AM. A review of the Invacare Reliant 450 (the lift being used at the time of this transfer) lift manual found the following: WARNING!-Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. WARNING!-The Invacare patient lift is NOT a transport device. Itis intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). The Invacare patient lift is NOT intended as a transport device. If the bathroom facilities are NOT near the bed or if the patient lift cannot be easily maneuvered toward the commode, the patient MUST be transferred to a wheelchair and transported to the bathroom facilities before using the patient lift again to position the patient on a standard commode. A review of the warning label which was affixed to the lift found the following, .This Invacare patient lift is NOT a transport device. DO NOT roll casterbase over uneven surfaces that may cause the patient lift to tip over. b) Facility's Plan of Correction Beckley Abatement Plan 5/19/25 Mechanical Lift Transfer 1. Patient #1 was assessed by the nurse and the Licensed Treatment nurse with no injuries noted on 5/19/25. On 5/19/25, Staff C.N.A. #20 was re-educated and competency re-evaluated by the staff development nurse on the proper lift transfer process and the requirement to not use the mechanical lift as a transport device. 2. An audit was completed by the Center Directors of Nursing with no other patients being transported by a mechanical lift device as a transport device at the time of discovery. 3. All Center Hands on Nursing Staff will be re-educated by the Staff Development Nurse/ Designee on the proper lift transfer process upon their next working shift. 4. Center Unit Managers/designee will audit daily, both shifts (7a-7p; 7p-7a), for three weeks, then three times per week for 3 weeks, to ensure staff are appropriately using the mechanical lifts and not using a mechanical lift as a transport device. All concerns will immediately be reported to the Center Executive Director by the Unit Manager/designee. 5. Results of audits will be presented in Quality Assessment and Performance Improvement meeting Monthly for follow-up to ensure compliance.

Based on record review and staff interview, the facility failed to ensure Resident #61 was free from restraints, which includes freedom from physical restraints to restrict movement. This is true for one (1) of one (1) residents reviewed during the survey. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur and because Resident #61 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. A reasonable person would suffer psychosocial harm from being tied to a chair and being unable to move against their will therefore this will be cited as actual harm at past non compliance. Resident Identifier: #61. Facility Census: 195. Findings Include: a) Resident #61 On 04/15/23 at 10:00 AM, a record review was completed for Resident #61. The record review found a documented incident which occurred on 04/04/24 at 8:30 PM. An allegation of the resident being tied to a scoot chair with a sheet was made by an anonymous source. The resident was admitted to the facility on [DATE]. The resident was transferred on 04/16/24 to another skilled nursing facility per family request. The resident had the following diagnoses: --unspecified dementia, severe, with mood disturbance --unspecified severe protein-calorie malnutrition --coronary artery disease --muscle weakness --dysphagia, oropharyngeal phase --unspecified lack of coordination --other abnormalities of gait and mobility --generalized anxiety disorder --chronic kidney disease, stage 2, mild --stiffness of right knee, not elsewhere classified --stiffness of left knee, not elsewhere classified --stiffness of right shoulder, not elsewhere classified --stiffness of left shoulder, not elsewhere classified --stiffness of the right hip, not elsewhere classified --stiffness of the left hip, not elsewhere classified --unspecified dementia, severe with anxiety --depression, unspecified --history of falling --anemia, unspecified --allergic rhinitis, unspecified --gastro-esophageal reflux disease without esphagitis --neuralgia and neuritis, unspecified --bipolar disorder, unspecified --repeated fall --urinary tract infection, site not specified The Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed on 04/16/24 at 9:30 AM. The Brief Interview of Mental Status (BIMS), found under section C, a score of -0- (zero), which indicates severe cognitive impairment. The resident is non-verbal and rarely speaks. The resident does not have capacity and has a resident representative in place. On 04/15/24 at 10:30 AM, a review of the facility reportables was completed. The review found a reportable dated 04/05/24 at 10:36 AM by Social Services Director (SSD) #105. The incident took place on 04/04/24 at approximately 8:30 PM. The allegation was the resident was tied to her scoot chair with a sheet at Nurses' station 1 which was reported by an anonymous source. The reportable was faxed to all appropriate state agencies and the (Name of the Sheriff's Department). The investigation started immediately on 04/05/24. A written statement was obtained from Nurse Aide (NA) #223 on 04/05/24. The written statement states, I did tie the sheet around (Name of Resident). She was very anxious and wouldn't stay in her chair. I tried to lay her down prior but she kept trying to get out of bed. I immediately got her back up in chair and brought her to the nurses station. She was still trying to get up and down and move from chair to chair. I assumed it would be best protect her while I had to attend to another resident who was yelling help. As soon as I came back up the hall, I took her back down and layed her back down. She only had the sheet on for 10 min at most. I was not aware it was abuse. I was honestly trying to protect her from hurting herself. Incident happened approximately 11:30 PM. (Typed as written.) The NA #223 was placed on unpaid suspension as of 04/05/24 to the completion of the investigation. The disciplinary form was signed by NA #223 and Registered Nurse (RN) #90 with the date of 04/05/24. Multiple witness statements were obtained by other staff members regarding the incident from 04/08/24 through 04/10/24. All the other staff members denied knowledge of the incident or denied observing the incident. The five (5) day follow up investigation was submitted by SSD #105 on 04/11/24 at 2:10 PM stating, Allegation resident was tied to her chair with a sheet was substantiated CNA (certified nursing assistant) stated she did tie the resident to the chair while she took care of another resident to keep resident from falling. (Typed as written.) On 04/16/24 at approximately 3:00 PM, the Administrator provided a copy of the Abuse Abatement Plan dated 04/05/24. The Abatement Plan states the following: Plan of Correction: Resident's Head to toe assessment completed 04/05/24 Resident's Pain assessment complete. 04/05/24 Resident's MD (medical doctor) and RP (resident representative) notification of incident. 04/05/24 Resident placed on q (every) shift charting x (times) 72 hours starting 04/05/24 Resident Social services referral. 04/05/24 Care plan reviewed- 04/11/24 All agencies and police notified of incident. 04/05/24 Employee placed on suspension pending investigation. 04/05/24 Identification of Others: All competent residents on G hall interviewed regarding abuse. Head to toes skin sweeps conducted on residents residing on G hall who are unable to be interviewed. Skin sweeps of like residents on E and F hall completed for residents with a BIM of 0-7 (zero to seven). No additional residents identified 04/05/24 Education: Educate all staff (nursing, rehab (rehabilitation), EVS (environmental services), laundry,maintenance, dietary, laundry, administrative) on abuse prevention policies. 04/05/24 and ongoing. Education will be provided to all new employees upon hire and annually on the abuse policy 04/05/24 and ongoing. System Change: Education will be provided to all new employees upon hire and annually on the abuse policy 04/05/24 and ongoing. Facility Leadership team to conduct daily ambassador rounds and interviews to assure residents with potential for abuse are identified, investigation initiated and reported to the state timely per guidelines. Monitoring: Nursing supervisor and/or Social worker will complete 10 random observations/interviews [NAME] x 5 d (days), then weekly for 3 (three) weeks and then monthly x 3 (three). Audits will be reviewed weekly during adhoc ( ) at QAPI. (The entire Abatement plan was typed as written.) A further review of Resident #61's record did indicate a head to toe assessment and a pain assessment were completed on 04/05/24. However, due to the resident being non-verbal, the facility was unable to confirm what happened during the incident. The completed assessments by nursing staff documented no indication the resident had any physical injuries and the resident did not have any signs or symptoms to indicate pain. On 04/16/24 at 6:00 PM, a review of the skin sweeps dated 04/05/24 was completed. The review found the following residents did have a skin assessment completed on 04/05/24: --#5 --#13 --#18 --#30 --#41 --#45 --#56 --#57 --#81 --#97 --#106 --#114 --#117 --#135 --#142 --#148 --#152 --#167 A review of the staff education was completed on 04/16/24 at approximately 10:00 AM. All staff signatures were obtained and included one (1) new employee. The staff signatures were verified via the staff roster. On 04/16/24 at 2:30 PM, a review of the daily observations and/or interviews were completed on 04/05/24, 04/06/24, 04/07/24, 04/08/24, 04/09/24, 04/10/24, 04/15/24 and 04/16/24. The initial observations and/or interviews were conducted on the G unit. All additional observations and/or interviews were completed on all units A-F as well as the G unit. An interview was conducted on 04/16/24 at approximately 3:00 PM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #61 did happen as reported. The Administrator, also stated, NA #223 has not entered the building since the incident and will be terminated per the corporate policy.

Based on record review and staff interview, the facility failed to ensure Resident #61 was free from abuse which includes freedom from physical restraints to restrict movement. This is true for one (1) of one (1) residents reviewed during the survey. This will be cited as past non compliance because the facility identified what had happened and took immediate steps to correct the failure to ensure it does not reoccur. All components of the of plan of correction were completed prior to this survey beginning. This did occur and because Resident #61 did not have the cognitive ability to indicate how this affected her the reasonable person standard was applied. A reasonable person would suffer psychosocial harm from being tied to a chair and being unable to move against their will therefore this will be cited as actual harm at past non compliance. Resident Identifier: #61. Facility Census: 195. Findings Include: a) Resident #61 On 04/15/23 at 10:00 AM, a record review was completed for Resident #61. The record review found a documented incident which occurred on 04/04/24 at 8:30 PM. An allegation of the resident being tied to a scoot chair with a sheet was made by an anonymous source. The resident was admitted to the facility on [DATE]. The resident was transferred on 04/16/24 to another skilled nursing facility per family request. The resident had the following diagnoses: --unspecified dementia, severe, with mood disturbance --unspecified severe protein-calorie malnutrition --coronary artery disease --muscle weakness --dysphagia, oropharyngeal phase --unspecified lack of coordination --other abnormalities of gait and mobility --generalized anxiety disorder --chronic kidney disease, stage 2, mild --stiffness of right knee, not elsewhere classified --stiffness of left knee, not elsewhere classified --stiffness of right shoulder, not elsewhere classified --stiffness of left shoulder, not elsewhere classified --stiffness of the right hip, not elsewhere classified --stiffness of the left hip, not elsewhere classified --unspecified dementia, severe with anxiety --depression, unspecified --history of falling --anemia, unspecified --allergic rhinitis, unspecified --gastro-esophageal reflux disease without esphagitis --neuralgia and neuritis, unspecified --bipolar disorder, unspecified --repeated fall --urinary tract infection, site not specified The Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed on 04/16/24 at 9:30 AM. The Brief Interview of Mental Status (BIMS), found under section C, a score of -0- (zero), which indicates severe cognitive impairment. The resident is non-verbal and rarely speaks. The resident does not have capacity and has a resident representative in place. On 04/15/24 at 10:30 AM, a review of the facility reportables was completed. The review found a reportable dated 04/05/24 at 10:36 AM by Social Services Director (SSD) #105. The incident took place on 04/04/24 at approximately 8:30 PM. The allegation was the resident was tied to her scoot chair with a sheet at Nurses' station 1 which was reported by an anonymous source. The reportable was faxed to all appropriate state agencies and the (Name of the Sheriff's Department). The investigation started immediately on 04/05/24. A written statement was obtained from Nurse Aide (NA) #223 on 04/05/24. The written statement states, I did tie the sheet around (Name of Resident). She was very anxious and wouldn't stay in her chair. I tried to lay her down prior but she kept trying to get out of bed. I immediately got her back up in chair and brought her to the nurses station. She was still trying to get up and down and move from chair to chair. I assumed it would be best protect her while I had to attend to another resident who was yelling help. As soon as I came back up the hall, I took her back down and laid her back down. She only had the sheet on for 10 min at most. I was not aware it was abuse. I was honestly trying to protect her from hurting herself. Incident happened approximately 11:30 PM. (Typed as written.) The NA #223 was placed on unpaid suspension as of 04/05/24 to the completion of the investigation. The disciplinary form was signed by NA #223 and Registered Nurse (RN) #90 with the date of 04/05/24. Multiple witness statements were obtained by other staff members regarding the incident from 04/08/24 through 04/10/24. All the other staff members denied knowledge of the incident or denied observing the incident. The five (5) day follow up investigation was submitted by SSD #105 on 04/11/24 at 2:10 PM stating, Allegation resident was tied to her chair with a sheet was substantiated CNA (certified nursing assistant) stated she did tie the resident to the chair while she took care of another resident to keep resident from falling. (Typed as written.) On 04/16/24 at approximately 3:00 PM, the Administrator provided a copy of the Abuse Abatement Plan dated 04/05/24. The Abatement Plan states the following: Plan of Correction: Resident's Head to toe assessment completed 04/05/24 Resident's Pain assessment complete. 04/05/24 Resident's MD (medical doctor) and RP (resident representative) notification of incident. 04/05/24 Resident placed on q (every) shift charting x (times) 72 hours starting 04/05/24 Resident Social services referral. 04/05/24 Care plan reviewed- 04/11/24 All agencies and police notified of incident. 04/05/24 Employee placed on suspension pending investigation. 04/05/24 Identification of Others: All competent residents on G hall interviewed regarding abuse. Head to toes skin sweeps conducted on residents residing on G hall who are unable to be interviewed. Skin sweeps of like residents on E and F hall completed for residents with a BIM of 0-7 (zero to seven). No additional residents identified 04/05/24 Education: Educate all staff (nursing, rehab (rehabilitation), EVS (environmental services), laundry,maintenance, dietary, laundry, administrative) on abuse prevention policies. 04/05/24 and ongoing. Education will be provided to all new employees upon hire and annually on the abuse policy 04/05/24 and ongoing. System Change: Education will be provided to all new employees upon hire and annually on the abuse policy 04/05/24 and ongoing. Facility Leadership team to conduct daily ambassador rounds and interviews to assure residents with potential for abuse are identified, investigation initiated and reported to the state timely per guidelines. Monitoring: Nursing supervisor and/or Social worker will complete 10 random observations/interviews [NAME] x 5 d (days), then weekly for 3 (three) weeks and then monthly x 3 (three). Audits will be reviewed weekly during adhoc ( ) at QAPI. (The entire Abatement plan was typed as written.) A further review of Resident #61's record did indicate a head to toe assessment and a pain assessment were completed on 04/05/24. However, due to the resident being non-verbal, the facility was unable to confirm what happened during the incident. The completed assessments by nursing staff documented no indication the resident had any physical injuries and the resident did not have any signs or symptoms to indicate pain. On 04/16/24 at 6:00 PM, a review of the skin sweeps dated 04/05/24 was completed. The review found the following residents did have a skin assessment completed on 04/05/24: --#5 --#13 --#18 --#30 --#41 --#45 --#56 --#57 --#81 --#97 --#106 --#114 --#117 --#135 --#142 --#148 --#152 --#167 A review of the staff education was completed on 04/16/24 at approximately 10:00 AM. All staff signatures were obtained and included one (1) new employee. The staff signatures were verified via the staff roster. On 04/16/24 at 2:30 PM, a review of the daily observations and/or interviews were completed on 04/05/24, 04/06/24, 04/07/24, 04/08/24, 04/09/24, 04/10/24, 04/15/24 and 04/16/24. The initial observations and/or interviews were conducted on the G unit. All additional observations and/or interviews were completed on all units A-F as well as the G unit. An interview was conducted on 04/16/24 at approximately 3:00 PM with the Administrator and the Director of Nursing (DON). Both the Administrator and the DON confirmed the incident which involved Resident #61 did happen as reported. The Administrator, also stated, NA #223 has not entered the building since the incident and will be terminated per the corporate policy.

Based on policy review, staff interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision and assistance to prevent accidents. A structure fire resulted in the activation of the facility fire alarm system. The facility staff did not begin evacuation after seeing smoke and hearing the fire alarm system. Two (2) residents were using illegal substances inside the facility. These substances include opiates that were not prescribed. The residents required Narcan due to overdose. Fire A total of 18 minutes elapsed from the time the fire alarm activated on the A-Wing, and the time the facility began to evacuate. The facility did not begin to evacuate until told to do so by emergency responders. The facility's failure to follow their Fire Safety plan and begin immediate evacuation upon discovery of a minor or major fire placed all residents currently residing in the facility at risk for serious bodily harm and/or death. These failures were determined to place all residents in an immediate jeopardy (IJ) situation. Fentanyl Residents #300 and #301 were using illegal drugs at the facility exposing other residents to potential hazards. The facility failed to take steps to protect other residents from the illegal drugs. This failure placed all residents currently residing at the facility at an immediate risk for serious harm and or death. Resident identifiers: #86, #87, #88, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #121, #122, #122. #300 and #301. Facility census: 191 Findings included: a) Fire Safety Plan Review of the facility's Fire Safety plan revealed the following directives: -Upon discovery of a minor or major fire, Call Code Red or Fire to available staff members for assistance. -Immediately remove endangered residents or staff from affected area and adjacent rooms. -If resident is bedridden, evacuate the resident in his/her bed as necessary. -Take residents/employees to safe area in the adjacent smoke compartment. b) Staff Interviews An interview was completed with Nurse Aide (NA) #62 on 02/26/24 at 1:20 PM. NA #62 reported she was assigned to work on the D-Wing but was on the C-Wing helping another NA with a resident when the fire alarm went off. Head counts were done on the C-Wing and the D-Wing and residents were placed in rooms and resident doors were shut. NA #52 stated maybe 15-20 minutes went by before the decision was made by the Sheriff to evacuate the A-Wing. NA #52 reported she assisted with the evacuation of the A-Wing. An interview was completed on 02/26/24 at 1:30 PM with NA #137. NA #137 was assigned to work on the E-Wing and at first thought it was just a drill when the fire alarm went off. As she walked over to the A-Hall to see what was happening, firemen were saying A-Wing needed to be evacuated and NA #62 went to get more help. After residents were safely evacuated in the dining room the NA went back to her assigned wing. An interview was completed with NA #116 on 02/26/24 at 1:45 PM. NA #116 was assigned to work on the C-Wing and recalled the fire doors closed at around 10:02. At first, staff thought it was just a fire drill because they had just had a fire drill on the nightshift. LPN #21 reported that it as a Code Red on the A- Wing. NA #116 stated she remained on the C-Wing and assisted in getting residents up in their chairs in case there was a need to evacuate the entire building. NA #116 stated she was told there were two (2) NAs and a nurse on the A-Wing who witnessed smoke coming out of the vent and the alarm reportedly sounded around the same time. An interview was completed on 02/26/24 at 1:58 PM with NA #53. NA #53 was assigned to work on the A-Wing. She reported that as soon as the fire alarm sounded sheltering residents in place began. Staff on the floor got a complete head count and started shutting resident doors. NA #53 believed it might have been the firemen who instructed the staff to evacuate the A-Wing. She recalled hearing, We need to evacuate but there was no specific plan that she was aware of. She stated she would have liked to have more training to know what her responsibilities would be if she heard the word evacuate. She reported residents, chairs and beds were taken to the dining room. An interview was completed with the ADON on 02/26/24 at 2:17 PM. The ADON reported she arrived at the facility at the same time the first emergency vehicle pulled into the facility's parking lot. Other emergency response vehicles began pulling into the parking lot as she was walking into the facility. The ADON reports she spoke to MDS LPN Nurse who reported the fire panel showed there was a problem on the A-Wing. She reported she believed it was the firemen who said, we're evacuating A-Wing. The ADON reported the fireman also made the decision to evacuate the first four (4) rooms on the B-Wing as a precaution as well. An interview was completed on 02/26/24 at 2:33 PM with NA #146. NA reported she was assigned to work on the A-Wing. When the fire alarm first sounded the NA was in a male resident's room providing care. After finishing in that room, she made her way to the hallway where the nurse was trying to comfort Resident #101 who always gets upset when the fire alarm goes off because she had a child perish in a fire. Another NA walked by and stated, It might be real referring to the fire alarm. NA #146 reported it was the Sheriff who made the decision to evacuate residents off the A-Wing. c) Resident Interview During an interview on 02/26/24 at 3:30 PM, Resident #107 stated she heard the alarm go off and there was either a deputy or a firefighter that came sometime later and started to evacuate us at the end of the A-hall around the building to the dining room. d) Interview with Assistant Fire Marshall During an interview, on 02/26/24 at 12:55 PM, the Assistant Fire Marshall shared his insights on how the facility failed to move residents upon the sight of smoke. Expressed concern that the facility did not evacuate their building properly per their Fire Safety Plan. He noted if it had been a real fire it had potential to be a complete disaster. e) Review of Facility Video on 02/26/24 at 3:15 PM Review of the facility's video of the A-Wing on 02/24/24 revealed the fire alarm activated at 9:49 AM. MDS LPN #54 could be seen calling 911 at 9:50 AM. MDS LPN #54 could be seen looking at the fire panel and pointing to the A-Wing. At 10:04 AM, an employee from the Sheriff's office arrived. At 10:07 AM the facility began evacuating residents from the A-Hall. A total of 18 minutes elapsed from the time the fire alarm activated, and the time the facility began to evacuate residents. f) Interview with the Nurse in Charge During an Interview with MDS LPN #58, on 02/26/24 at 4:24 PM, she stated she was the nurse on the B-Wing and had just finished medication pass and sat down at the Nurses Station. When she saw smoke, she thought it was from where a resident had taken a shower and that perhaps the heater had gotten hot. She saw smoke on A-Wing and called, Code Red A Wing and repeated this three (3) times. This was about 9:51 AM - 9:52 AM. She stated that Maintenance turned off something and there was no more smoke. She stated that they did not evacuate any residents but did shut the doors to resident rooms. When the Sheriff and EMS arrived, they ordered the residents to be evacuated. When asked how they determined who they evacuated first (triage) she stated that they just started evacuating residents. She stated that there were eight (8) residents in beds. The facility was notified of the Immediate Jeopardy (IJ) at 6:28PM on 02/26/24. The State Office approved the facility's POC at 9:25 PM on 02/26/24. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 12:24 PM on 02/27/24. The IJ started on 02/24/24 at 9:49 AM and ended on 02/27/24 at 12:24 PM. The facility's approved abatement POC consisted of the following: 1. All residents were interviewed for potential post event trauma by the Director of Nursing and designees on 2/26/24. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier on 2/26/24. 2. All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator on next worked shift beginning 2/26/24. 3. The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery. 4. Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes. Fentanyl Facility policy Review of the facility policy entitled, Resident Substance Abuse in facility, found: A facility may admit a resident who has a history or diagnosis of substance abuse. However, residents may not possess, use or provide illicit drugs or abuse drugs in any manner, and may not have drug-related paraphernalia in their possession while a resident in the facility. Being under the influence of illicit or illegal drugs or alcohol places the resident at risk for overdose, falls and respiratory depression and places other residents at risk for injury by a resident under the influence of illicit or illegal drugs or alcohol. The facility will safeguard the resident under the influence of illicit or illegal drugs to the extent possible, as well as provide a safe environment for other residents, staff, and visitors. This may include up to discharge of the substance abusing resident. Management of Acute Episodes a. In the event a resident is found to be under the influence of abused substances: i. Wear proper PPE including gloves and mask when assessing a suspected drug overdose resident or when administering Naloxone to protect against unanticipated exposure to dangerous drugs. Clear the room of unnecessary personnel, visitors, or other residents to reduce risk of exposure to the illicit/illegal drug or as a safety precaution for erratic behavior . b) For residents receiving Naloxone i. Provide increased observation until the resident is transported or until the resident is no longer exhibiting signs and symptoms of being under the influence . III Observation of other Residents a. Observe other residents for signs and symptoms of illicit drug use . Resident #300 Record review found Resident #300 was admitted to the facility on [DATE]. He was discharged from the facility on 01/12/24. On 12/28/23, the facility physician determined the resident had capacity to make medical decisions. The resident's care plan noted the resident wished to be discharged to home once his clinical and therapy goals were achieved. The resident was care planned on 01/02/24 for a substance use disorder related to opioid dependence and a history of methamphetamine abuse. The goal associated with this focus was, Will not use illegal drugs in facility. This care plan was initiated on 01/02/24, four (4) days after his admission. Interventions included: - Administer medications per medical provider's orders. - Observe for side effects and effectiveness. - Report abnormal findings to medical provider and resident. - Educate resident on following the prescribed treatment regime and leave of absence policy. - Encourage resident to express feelings regarding addiction. - Evaluate resident for stumbling, nodding off even when standing or in mid conversation, incoherent speech, slurred speech, rambling, sleepy, erratic behavior, hyperactive, threatening, hostile, blood shot eyes, pinpoint pupils, pale face, sweaty unruly appearance, fumbling, nervous, jerky movements. On 12/23/23, the facility physician prescribed an opioid medication, Oxycodone HCI 15 milligrams every 4 hours for pain. The following progress notes were found in the medical record: A note dated 12/28/23 at 6:35 PM revealed the resident was alert and oriented and signed out for visit and to go to get some supplies from store. The note stated the resident was educated to be back to facility by midnight. There was no documentation as to how the resident was going to get to the store to get supplies. The next progress note written at 8:04 PM on 12/28/23 noted the resident's medication could not be given because he was out of the facility. There was no documentation regarding what time the resident returned to the facility or his condition upon return. A note dated 01/02/24 at 12:50 PM revealed staff observed the resident snorting a white substance off his dresser in Room #E12a. BP (blood pressure) was 126/100 HR (heart rate) 72. Pupils were pinpoint. The medical director was notified and there was a new order to hold the12:00 PM dose of oxycodone. The registered nurse (RN) supervisor and administration were aware of the situation. (Room #E12 was occupied by Resident #301 which will be discussed under his medical record review below) The medical director ordered a urine drug screen. The results of this drug screen dated 01/02/24 found the Resident tested positive for THC (Tetrahydrocannabinol) and opiates. On 01/05/24 at 1:51 PM a medical record note revealed the resident signed out to leave the facility for a short time. The next note written on 01/5/24 at 5:53 PM revealed the resident was out of the facility. There were no notes indicating when the resident returned to the facility or his condition when he returned. On 01/06/2024 at 3:15 AM a note revealed a facility nurse was notified by a nurse aide that the resident was on the floor next to his bed. The note reflected that when the nurse entered the room the resident was sitting on the floor with his head against the dresser, not responding to verbal stimuli. The nurse was able to wake the resident up, but he was not answering questions appropriately, was nodding out, and there was a noted drop in his blood pressure, The note reflected the nurse contacted someone from a program who the resident was affiliated with. A worker from that program attempted to ask the resident questions. The resident was unable to answer. There was an order for the resident to be sent out to ER (emergency room ) for evaluation. The nurse called 911 and as emergency medical services (EMS) were in route, the resident was nodding out and his blood pressure dropped to 77/43. An order was given to administer Narcan (Naloxone). The resident became more alert and able to answer questions. His blood pressure returned to normal. The resident transferred via EMS (emergency medical squad) to (Name of a local hospital) for evaluation. A note dated 01/06/24 at 6:29 AM revealed the resident returned to the facility at 6:30 AM via ambulance on stretcher. DX (diagnoses) fentanyl overdose. He was given clonidine 0.1mg for blood pressure. On 01/08/24 at 9:09 AM a note revealed the resident left the facility at this time via public transit. Resident stated he was going to an appointment. There was no indication an appointment was scheduled by the facility. There was no documentation as to where the resident was going. On 01/8/2024 at 1:59 PM (five (5) hours later) Nurses Note revealed the resident returned to facility at this time via public transit. (There was no indication the resident was assessed for his condition after his return.) An interdisciplinary team meeting note dated 01/09/24 at 3:45 PM revealed, Resident has used illegal, non-prescribed, controlled substances on at least two known occasions in the facility since admission on 12/22/23. Resident observed vaping a marijuana vape device and snorting a white powder on 01/02/24, physician was notified, and drug screen ordered, which was positive for THC. Drug abuse support offered and refused, he resigned the facility non-smoking and non-drug use policy and expressed clear understanding that he was not permitted to smoke, bring illegal substances in facility. On 01/06/24 he was sent out to the ER after the Licensed Nurse administered Narcan for a fentanyl overdose. He stated he obtained the drug from a friend outside of the facility. Police were notified and State Troopers came in and spoke to (Name of Resident.) (Resident) has been leaving the facility unattended, signing himself out. Therapy has issued a NOMNC (Medicare non-coverage) as he has reached his potential and the last day of treatment will be Thursday, 1/11/24. (Name of Resident) BIMs (Brief interview for mental status) is 15 and he has capacity. On 02/27/24 at 2:03 AM, the Administrator and the DON were interviewed. The DON stated the resident had capacity and there was no abuse or neglect suspected to report. He was free to leave the facility for outings. Both employees were asked about the risk to other residents and the roommate of this resident during his drug usage. They were asked how the facility ensured other residents and staff were not at risk when a white powder was found in Room #E12A on 01/02/24 noted to be used by Resident #300. The DON said they had no reports of any other residents approaching the two (2) residents involved in illegal drug usage at the facility. The DON confirmed this resident did have a roommate at the time of both incidents. The administrator stated the facility called the police after Resident #300 received Narcan on 01/06/24 but were told there was nothing they could do. The DON confirmed the police were not called after the 01/02/24 incident. According to the DON, the State Police came and searched the room but found no drugs and said the Resident had capacity. The administrator said the police were asked for a report, but nothing was ever provided. In addition, they were asked if the resident was assessed after all his trips out of the facility. Both were asked to provide evidence of their investigation after the 01/02/24 incident of the white powder being found on the dresser and the IDT team noted the resident was using a marijuana vape pipe on 01/02/24. They were asked was the incident on 01/06/24, when the resident received Narcan and was sent to the hospital, investigated. Both staff confirmed the resident was diagnosed with a Fentanyl overdose on 01/06/24. They were asked where the resident got the Fentanyl. Both employees confirmed the Resident was not prescribed Fentanyl at the facility. The administrator and the DON said they believed Resident #301 was supplying the illegal drugs. During an interview, at 2:27 PM on 02/27/24, with Licensed Practical Nurse (LPN) #60, the author of the 01/02/24 note, (Staff observed resident snorting a white substance from dresser in E12a. BP (blood pressure) 126/100 HR (heart rate) 72. Pupils pinpoint. (Name of medical director) notified and new order to hold oxycodone 12 pm dose. RN supervisor and administration is aware of situation.) was asked about her role during the incident. LPN #60 said the staff person who observed the incident was a nurse aide (NA) who no longer works at the facility. LPN #60 said, I don't even remember her name. I wrote the note and reported this to my supervisor, that was my role in the situation. My supervisor said he was calling the administrator and the DON. I believe the administrator did come in to talk with the resident. I did not get any statement from the NA. On the afternoon of 02/27/24 around 3:30 PM, the DON provided an occurrence report that contained the same information as the progress note written on 01/06/24. A typed note on a separate piece of paper with this occurrence number noted the following: Resident #300 and Resident #301 were both placed on one-on-one observation in their respective rooms. The nurse phoned 911 to request an officer respond to the facility to have both residents' rooms searched for drugs. The officer stated he could only search if the Residents consented to the search. Each Resident consented to have their room and belongings searched. Officer (name) conducted the search. No drugs or paraphernalia were found. Both residents admitted to smoking, it. Neither resident would state what was contained in the aluminum foil they smoked. Resident #301 said a friend of his brought it in for him. Officer (Name) stated he would complete the report, but that it would be an informational report. The DON said the residents were placed on one (1) on one (1) supervision on 01/06/24 from when the police were called until the police arrived at the building. The DON said the resident was offered counseling but refused. The DON was unable to provide any further information regarding this incident and no information was provided noting how the other residents at the facility were protected from the illegal drug usage of Resident #300. c) Resident #301 Record review found this Resident was admitted to the facility on [DATE] and was discharged on [DATE]. The resident was found to have capacity on 12/28/24. On 12/29/23 the resident was prescribed Percocet 7.50325 milligrams, 1 tablet every 6 hours for pain. On 12/27/23 the Resident was prescribed Oxycodone 5 milligrams every 6 hours for pain. The Resident was care planned on12/27/23 with a revision date of 01/17/24. The care plan was for: Utilizing nicotine products and having used illegal drugs in facility since admission and has been observed vaping in his room. The goal associated with this problem was: Resident will utilize nicotine products in a safe manner. Interventions included completing a smoking evaluation on 12/27/23 and complete smoking evaluation - 12/27/23 Provide safe smoking devices, if required, such as smoke blankets, smoke aprons and cigarette extenders - 12/27/23. On 01/09/23 an intervention was added to observe for altered mental status and other signs that may indicate drug impairment. On 01/02/24 at 10:44 AM the resident was re-educated resident on facility smoking policy that was signed upon admission to facility. The resident was educated resident that this was a non-smoking facility and that a vaping fell under that. Risks and benefits discussed with the resident. Resident stated that his son brought the vape to him. Educated resident that his son should not bring anymore vapes to him. Resident has capacity and he stated that he understood. Resident denied wanting nicotine patch at this time. (This resident's nursing notes did not include any information about Resident #300 being in Resident #301's room snorting a white substance off his dresser. Resident #300's progress note on 01/02/24 noted he was observed snorting a white substance off dresser in Room #E12a. Resident #301 was residing in Room #E12A on 01/02/24. On 01/03/24 a nursing note written at 12:45 PM, revealed the resident left the facility via taxi service. This nurse educated the resident on the importance of staying in the facility to participate in therapy and receive treatment. Resident verbalized understanding. 01/03/24 at 5:28 PM a nursing note revealed the resident returned to the facility at this time. There were no notes to indicate the Resident was assessed upon his return. A late entry note dated 01/05/24 at 9:00 PM revealed the resident was found on the toilet in bathroom of Room #E12, lethargic, diaphoretic, and disoriented. The resident's vitals were taken, the resident was unable to answer questions appropriately, notified (name of on-call physician services,) ordered Narcan for patient. Narcan was given per order, resident answering questions appropriately, vitals within normal limits. There were no notes indicating the resident was ever assessed again after the Narcan was administered. An interdisciplinary team note dated at 2:50 PM on 01/09/24 was a follow up to illicit drug use in the facility on 01/01/24 and 01/05/24. The administrator, DON and vice president of risk management were all involved in the meeting. According to this note the resident was observed vaping marijuana on 01/01/24 and was provided with the opportunity for substance abuse support and declined. The resident re-signed the facility policies on smoking and illegal drug use and stated understanding. On 01/05/24 nursing staff found him unresponsive, contacted the physician, and administered Narcan. He responded and was able to disclose that he had used fentanyl that he got from another individual. Police were involved and came to the facility; State Troopers were the response team and addressed the resident. The resident allowed nursing staff to search the room and they removed drug residue and paraphernalia. Yesterday he walked out of the facility and headed to the local gas station after refusing to sign himself out. Earlier today while he was in his room a staff member observed him release what appeared to be a puff of smoke. When questioned about the incident he first denied smoking, then stated he had smoked/vaped on a vape pen he got at gas station but threw the pen away, and then when asked again to hand over the device he handed it to this author. It was concealed in his glove. The medical record revealed a meeting held with the resident to discuss the two (2) instances of illegal drug use in facility since his admission on 12/27/24. Explained that it was not allowed and that police would be involved if it happened again. Also, addressed today's vaping episode. The resident stated understanding. Therapy had issued Notice of Medicare Non-Coverage (NOMNC) because he had reached his maximum potential in therapy and (Name of Resident) will be discharging either Thursday afternoon or Friday morning. During the meeting he gave permission, and we contacted his son (Name of son) by phone. The facility staff explained to the resident that they were concerned about the safety of other residents and staff and that if there was another incident of drug use or any indication of activity that the police would be notified. The resident stated understanding. The resident was again offered referral for substance use support and he declined stating that he did not need it. On 02/27/24 at 2:03 AM, the Administrator and the DON were interviewed. The DON stated the resident had capacity and there was no abuse or neglect suspected. He was free to leave the facility for outings. Both employees were asked about the risk to other residents and the roommate of this resident during his drug usage. The DON confirmed this resident did have a roommate at the time of the incident. Staff were asked how the facility ensured other residents or even staff were not at risk when a white powder was found in Room #E12A on 01/02/24. They were asked who cleaned the room after the white powder was found and how was the room cleaned. They were also asked if anyone investigate or confirm what the white powder was. The DON stated Resident #301 was involved in the incident in his room on 01/02/24 with Resident #300 even though his progress note stated he had a vape pen. She said both residents were using a marijuana vape pen . Resident #301 received Narcan on 01/05/23 but the DON said since this resident had a positive reaction to the Narcan, he was not sent to the hospital. No drug testing was ordered for Resident #301 to determine what substances he had used that resulted in the use of Narcan. The DON confirmed Resident #301 admitted to using Fentanyl himself. The DON confirmed the police were not called until 01/06/24 after the incident with Resident #300. The DON said the staff felt Resident #301 was getting the drugs for himself and Resident #300. That was why the police were asked to search both Resident rooms on 01/06/24. On the afternoon of 02/27/24 around 3:30 PM, the DON provided an occurrence report noting the following: (Name of Resident #301) was found on the toilet in his bathroom unresponsive. Narcan was given per order. The DON provided the same statement for this resident's occurrence as provided for the occurrence report with Resident #300. Resident #300 and Resident #301 were both placed on one (1) on one (1) observation in their respective rooms. The nurse phoned 911 to request an officer respond to the facility to have both residents' rooms searched for drugs. The officer stated he could only search if the residents consented to the search. Each Resident consented to have their room and belongings searched. Officer (name) conducted the search. No drugs or paraphernalia were found. Both residents admitted to smoking, IT. Neither resident would state what was contained in the aluminum foil they smoked. Resident #301 said a friend of his brought IT in for him. Officer (Name) stated he would complete a report, but that it would be an informational report. The DON was unable to provide any documentation, other than calling the State Police and filling out an occurrence report to show how the other residents were protected during Resident #301's drug usage. No information was provided to conclude an investigation was conducted to determine the source of the white powder on the dresser in this resident's room seen on 01/02/24. No information was provided to include how the room was cleaned or if the condition of the resident's roommate was assessed or if any other residents were assessed for possible drug usage or exposure to the drugs used by Resident's #301. According to the Centers for Disease Control (CDC) Fentanyl even in small doses can be deadly. It is among the most common drugs involved in overdose. Fentanyl can be absorbed into the body via inhalation, oral exposure or ingestion, or skin contact. When coming into contact with Fentanyl, the CDC recommends wearing nitrile gloves; respiratory protection if powdered illicit drugs are visible or suspected; avoid performing tasks or operations that may cause illicit drugs to become airborne; do not touch eyes, nose or mouth after touching any surface that may become contaminated; wash hands with soap and water, do not use hand sanitizer or bleach. The facility was notified of the Immediate Jeopardy (IJ) at 4:47 PM on 02/27/24. The State Agency (SA) approved the facility's Plan of Correction (POC) at 6:45 PM on 02/27/24. The IJ was abated at 12:18 PM on 02/28/24. The facility's approved abatement POC consisted of the following: 1. All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings. 2. All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on 2/27/24 on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs. Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary. If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor. Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility. The facility will request a toxicology report prior to the resident returning to facility. Facility will notify local law enforcement and initiate an internal investigation. Resident will be educated on substance abuse and staff will attempt to provide substance abuse counseling. Center will update CP and educate the resident if found to be a repeat offender will be subjec[TRUNCATED]

Based on policy review, staff interview, and record review, the facility failed to protect from neglect after a fire on 02/24/24 and after illegal drug activity was identified. Both situations created immediate jeopardy for more than a limited number of residents. Fire Local media reported a structure fire at the facility on 02/24/24. The facility also reported the fire by fax to the State Agency (SA) on 02/25/24. A total of 18 minutes elapsed from the time the fire alarm activated on the A-Wing, and the time the facility began to evacuate residents. The facility failed to identify the need to evacuate residents in a timely manner. They only began the evacuation of the residents after they were told to do so by emergency responders. The delay in evacuation and the failure to implement their fire plan placed all residents currently residing on the A- Hall at immediate risk for serious harm and/or death. The state agency determined this was an Immediate Jeopardy situation. Fentanyl The State Agency received a complaint alleging illegal drug activity involving residents at the facility. Record review at the facility revealed Resident #300 and Resident #301 were observed using illicit/illegal drugs at the facility in January 2024. Resident #300 was administered Narcan on 01/06/24. Resident #301 was administered Narcan on 01/05/24. Resident #300 was diagnosed by a local hospital with a Fentanyl overdose. According to facility documentation Resident #301 admitted to using Fentanyl. Fentanyl was not prescribed by the facility for either resident. Both residents were observed to be using a marijuana vaping device prior to the episode where Narcan was used. A mystery white powder was also observed on the dresser of Resident #300 on 01/02/24. No interventions were put in place to assess and protect other facility residents from possible exposure to drugs and risk of harm, including the roommates of Resident #300 and #301. These failures placed all residents currently residing in the facility at immediate risk of serious harm and/or death. Resident identifiers: #86, #87, #88, #88, #89, #91, #92, #93, #94, #95, #96, #97, #98, #99, #100, #101, #102, #103, #104, #105, #107, #108, #109, #110, #114, #116, #117, #118, #119, #120, #121, #122, #122, #300 and #301. Facility census: 191 Findings included: a) Fire Staff Interviews An interview was completed with certified nurse aide (CNA) #62 on 02/26/24 at 1:20 PM. CAN #62 reported she was assigned to work on the D-Wing but was on the C-Wing helping another CNA with a resident when the fire alarm went off. Head counts were done on the C-Wing and the D-Wing and residents were placed in rooms and resident doors were shut. CNA #52 stated maybe 15-20 minutes went by before the decision was made by the Sheriff to evacuate the A-Wing. CNA #52 reported she assisted with the evacuation of the A-Wing. An interview was completed on 02/26/24 at 1:30 PM with CNA #137. CNA #137 was assigned to work on the E-Wing and at first thought it was just a drill when the fire alarm went off. As she walked over to the A-Hall to see what was happening, firemen were saying A-Wing needed to be evacuated and CNA #62 went to get more help. After residents were safely evacuated in the dining room the CNA went back to her assigned wing. An interview was completed with CNA #116 on 02/26/24 at 1:45 PM. CNA #116 was assigned to work on the C-Wing and recalled the fire doors closed at around 10:02. At first, staff thought it was just a fire drill because they had just had a fire drill on the nightshift. LPN #21 reported that it as a Code Red on the A-Wing. CNA #116 stated she remained on the C-Wing and assisted in getting residents up in their chairs in case there was a need to evacuate the entire building. CNA #116 stated she was told there were two (2) CNAs and a nurse on the A-Wing who witnessed smoke coming out of the vent and the alarm reportedly sounded around the same time. An interview was completed, on 02/26/24 at 1:58 PM, with CNA #53. CNA #53 was assigned to work on the A-Wing. She reported that as soon as the fire alarm sounded sheltering residents in place began. Staff on the floor got a complete head count and started shutting resident doors. CNA #53 believed it might have been the firemen who instructed the staff to evacuate the A-Wing. She recalled hearing, We need to evacuate but there was no specific plan that she was aware of. She stated she would have liked to have more training to know what her responsibilities would be if she heard the word evacuate. She reported residents, chairs and beds were taken to the dining room. An interview was completed with the ADON on 02/26/24 at 2:17 PM. The ADON reported she arrived at the facility at the same time the first emergency vehicle pulled into the facility's parking lot. Other emergency response vehicles began pulling into the parking lot as she was walking into the facility. The ADON reports she spoke to Minimum Data Set (MDS) Licensed Practical Nurse (LPN) Nurse who reported the fire panel showed there was a problem on the A-Wing. She reported she believed it was the firemen who said, we're evacuating A-Wing. The ADON reported the fireman also made the decision to evacuate the first four (4) rooms on the B-Wing as a precaution as well. An interview was completed on 02/26/24 at 2:33 PM with CNA #146. CNA reported she was assigned to work on the A-Wing. When the fire alarm first sounded the CNA was in a male resident's room providing care. After finishing in that room, she made her way to the hallway where the nurse was trying to comfort Resident #101 who always gets upset when the fire alarm goes off because she had a child perish in a fire. Another CNA walked by and stated, It might be real referring to the fire alarm. CNA #146 reported it was the Sheriff who made the decision to evacuate residents off the A-Wing. Resident Interview During an interview on 02/26/24 at 3:30 PM, Resident #107 stated she heard the alarm go off and there was either a deputy or a firefighter that came sometime later and started to evacuate us at the end of the A-hall around the building to the dining room. Interview with Assistant Fire Marshal During an interview, on 02/26/24 at 12:55 PM, the Assistant Fire Marshall shared his insights on how the facility failed to move residents upon the sight of smoke. The Assistant Fire Marshal expressed concern that the facility did not evacuate their building properly per their Fire Safety Plan. He noted if it had been a real fire, it had potential to be a complete disaster. Review of Facility Video on 02/26/24 at 3:15 PM Review of the facility's video of the A-Wing on 02/24/24 revealed the fire alarm activated at 9:49 AM. MDS LPN #54 could be seen calling 911 at 9:50 AM. MDS LPN #54 could be seen looking at the fire panel and pointing to the A-Wing. At 10:04 AM, an employee from the Sheriff's office arrived. At 10:07 AM the facility began evacuating residents from the A-Hall. A total of 18 minutes elapsed from the time the fire alarm activated, and the time the facility began to evacuate residents. Interview with the nursing in charge During an Interview with MDS LPN #58, on 02/26/24 at 4:24 PM, she stated she was the nurse on the B-Wing and had just finished medication pass and sat down at the Nurses Station. When she saw smoke, she thought it was from where a resident had taken a shower and that perhaps the heater had gotten hot. She saw smoke on A-Wing and called, Code Red A Wing and repeated this three (3) times. This was about 9:51 AM - 9:52 AM. She stated that Maintenance turned off something and there was no more smoke. She stated that they did not evacuate any residents but did shut the doors to resident rooms. When the Sheriff and EMS arrived, they ordered the residents to be evacuated. When asked how they determined who they evacuated first (triage) she stated that they just started evacuating residents. She stated there were eight (8). The facility was notified of the Immediate Jeopardy (IJ) at 6:28 PM on 02/26/24. The The State Agency (SA) approved the facility's POC at 9:25 PM on 02/26/24. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 12:24 PM on 02/27/24. The IJ began on 02/24/24 at 9:49 AM when the fire alarm sounded, and the problem was identified as being on the A - Wing of the facility. The facility's approved abatement POC consisted of the following: 1. All residents were interviewed for potential post event trauma by the Director of Nursing and designees on 2/26/24. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier on 2/26/24. 2. All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator on next worked shift beginning 2/26/24. 3. The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery. 4. Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes. The facility's failure to follow their Fire Safety plan and begin IMMEDIATE evacuation upon discovery of a minor or major fire placed these residents at risk for serious bodily harm and/or death. Fire Safety Plan Review of the facility's Fire Safety plan revealed the following directives: -Upon discovery of a minor or major fire, Call Code Red or Fire to available staff members for assistance. -Immediately remove endangered residents or staff from affected area and adjacent rooms. -If resident is bedridden, evacuate the resident in his/her bed necessary. -Take residents/employees to safe area in the adjacent smoke compartment. Abuse, Neglect & Misappropriation Policy Review of the facility's Abuse, Neglect, and Misappropriation Policy revealed the following details: Neglect -Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. WV-Code 9-6-1 defines neglect as the unreasonable failure by a caregiver to provide the care necessary to assure the physical safety or health of an incapacitated adult; or the unlawful expenditure or willful dissipation of the funds or other assets owned or paid to, or for the benefit of, an incapacitated adult or resident. Fentanyl Facility policy Review of the facility policy entitled, Resident Substance Abuse in facility, found: A facility may admit a resident who has a history or diagnosis of substance abuse. However, residents may not possess, use or provide illicit drugs or abuse drugs in any manner, and may not have drug-related paraphernalia in their possession while a resident in the facility. Being under the influence of illicit or illegal drugs or alcohol places the resident at risk for overdose, falls and respiratory depression and places other residents at risk for injury by a resident under the influence of illicit or illegal drugs or alcohol. The facility will safeguard the resident under the influence of illicit or illegal drugs to the extent possible, as well as provide a safe environment for other residents, staff, and visitors. This may include up to discharge of the substance abusing resident. Management of Acute Episodes In the event a resident is found to be under the influence of abused substances: Wear proper PPE including gloves and mask when assessing a suspected drug overdose resident or when administering Naloxone to protect against unanticipated exposure to dangerous drugs. Clear the room of unnecessary personnel, visitors, or other residents to reduce risk of exposure to the illicit/illegal drug or as a safety precaution for erratic behavior . For residents receiving Naloxone Provide increased observation until the resident is transported or until the resident is no longer exhibiting signs and symptoms of being under the influence . Observation of other Residents Observe other residents for signs and symptoms of illicit drug use . Resident #300 Record review found Resident #300 was admitted to the facility on [DATE]. He was discharged from the facility on 01/12/24. On 12/28/23, the facility physician determined the resident had capacity to make medical decisions. The resident's care plan noted the resident wished to be discharged to home once his clinical and therapy goals were achieved. The resident was care planned on 01/02/24 for a substance use disorder related to opioid dependence and a history of methamphetamine abuse. The goal associated with this focus was, Will not use illegal drugs in facility. This care plan was initiated on 01/02/24, four (4) days after his admission. Interventions included: - Administer medications per medical provider's orders. - Observe for side effects and effectiveness. - Report abnormal findings to medical provider and resident. - Educate resident on following the prescribed treatment regime and leave of absence policy. - Encourage resident to express feelings regarding addiction. - Evaluate resident for stumbling, nodding off even when standing or in mid conversation, incoherent speech, slurred speech, rambling, sleepy, erratic behavior, hyperactive, threatening, hostile, blood shot eyes, pinpoint pupils, pale face, sweaty unruly appearance, fumbling, nervous, jerky movements. On 12/23/23, the facility physician prescribed an opioid medication, Oxycodone HCI 15 milligrams every 4 hours for pain. The following progress notes were found in the medical record: A note dated 12/28/23 at 6:35 PM revealed the resident was alert and oriented and signed out for visit and to go to get some supplies from store. The note stated the resident was educated to be back to facility by midnight. There was no documentation as to how the resident was going to get to the store to get supplies. The next progress note written at 8:04 PM on 12/28/23 noted the resident's medication could not be given because he was out of the facility. There was no documentation regarding what time the resident returned to the facility or his condition upon return. A note dated 01/02/24 at 12:50 PM revealed staff observed the resident snorting a white substance off his dresser in Room #E12a. BP (blood pressure) was 126/100 HR (heart rate) 72. Pupils were pinpoint. The medical director was notified and there was a new order to hold the12:00 PM dose of oxycodone. The registered nurse (RN) supervisor and administration were aware of the situation. (Room #E12 was occupied by Resident #301 which will be discussed under his medical record review below) The medical director ordered a urine drug screen. The results of this drug screen dated 01/02/24 found the Resident tested positive for THC (Tetrahydrocannabinol) and opiates. On 01/05/24 at 1:51 PM a medical record note revealed the resident signed out to leave the facility for a short time. The next note written on 01/5/24 at 5:53 PM revealed the resident was out of the facility. There were no notes indicating when the resident returned to the facility or his condition when he returned. On 01/06/2024 at 3:15 AM a note revealed a facility nurse was notified by a nurse aide that the resident was on the floor next to his bed. The note reflected that when the nurse entered the room the resident was sitting on the floor with his head against the dresser, not responding to verbal stimuli. The nurse was able to wake the resident up, but he was not answering questions appropriately, was nodding out, and there was a noted drop in his blood pressure, The note reflected the nurse contacted someone from a program who the resident was affiliated with. A worker from that program attempted to ask the resident questions. The resident was unable to answer. There was an order for the resident to be sent out to ER (emergency room ) for evaluation. The nurse called 911 and as emergency medical services (EMS) were in route, the resident was nodding out and his blood pressure dropped to 77/43. An order was given to administer Narcan (Naloxone). The resident became more alert and able to answer questions. His blood pressure returned to normal. The resident transferred via EMS (emergency medical squad) to (Name of a local hospital) for evaluation. A note dated 01/06/24 at 6:29 AM revealed the resident returned to the facility at 6:30 AM via ambulance on stretcher. DX (diagnoses) fentanyl overdose. He was given clonidine 0.1mg for blood pressure. On 01/08/24 at 9:09 AM a note revealed the resident left the facility at this time via public transit. Resident stated he was going to an appointment. There was no indication an appointment was scheduled by the facility. There was no documentation as to where the resident was going. On 01/8/2024 at 1:59 PM (five (5) hours later) Nurses Note revealed the resident returned to facility at this time via public transit. (There was no indication the resident was assessed for his condition after his return.) An interdisciplinary team meeting note dated 01/09/24 at 3:45 PM revealed, Resident has used illegal, non-prescribed, controlled substances on at least two known occasions in the facility since admission on 12/22/23. Resident observed vaping a marijuana vape device and snorting a white powder on 01/02/24, physician was notified, and drug screen ordered, which was positive for THC. Drug abuse support offered and refused, he resigned the facility non-smoking and non-drug use policy and expressed clear understanding that he was not permitted to smoke, bring illegal substances in facility. On 01/06/24 he was sent out to the ER after the Licensed Nurse administered Narcan for a fentanyl overdose. He stated he obtained the drug from a friend outside of the facility. Police were notified and State Troopers came in and spoke to (Name of Resident.) (Resident) has been leaving the facility unattended, signing himself out. Therapy has issued a NOMNC (Medicare non-coverage) as he has reached his potential and the last day of treatment will be Thursday, 1/11/24. (Name of Resident) BIMs (Brief interview for mental status) is 15 and he has capacity. On 02/27/24 at 2:03 AM, the Administrator and the DON were interviewed. The DON stated the resident had capacity and there was no abuse or neglect suspected to report. He was free to leave the facility for outings. Both employees were asked about the risk to other residents and the roommate of this resident during his drug usage. They were asked how the facility ensured other residents and staff were not at risk when a white powder was found in Room #E12A on 01/02/24 noted to be used by Resident #300. The DON said they had no reports of any other residents approaching the two (2) residents involved in illegal drug usage at the facility. The DON confirmed this resident did have a roommate at the time of both incidents. The administrator stated the facility called the police after Resident #300 received Narcan on 01/06/24 but were told there was nothing they could do. The DON confirmed the police were not called after the 01/02/24 incident. According to the DON, the State Police came and searched the room but found no drugs and said the Resident had capacity. The administrator said the police were asked for a report, but nothing was ever provided. In addition, they were asked if the resident was assessed after all his trips out of the facility. Both were asked to provide evidence of their investigation after the 01/02/24 incident of the white powder being found on the dresser and the IDT team noted the resident was using a marijuana vape pipe on 01/02/24. They were asked was the incident on 01/06/24, when the resident received Narcan and was sent to the hospital, investigated. Both staff confirmed the resident was diagnosed with a Fentanyl overdose on 01/06/24. They were asked where the resident got the Fentanyl. Both employees confirmed the Resident was not prescribed Fentanyl at the facility. The administrator and the DON said they believed Resident #301 was supplying the illegal drugs. During an interview, at 2:27 PM on 02/27/24, with Licensed Practical Nurse (LPN) #60, the author of the 01/02/24 note, (Staff observed resident snorting a white substance from dresser in E12a. BP (blood pressure) 126/100 HR (heart rate) 72. Pupils pinpoint. (Name of medical director) notified and new order to hold oxycodone 12 pm dose. RN supervisor and administration is aware of situation.) was asked about her role during the incident. LPN #60 said the staff person who observed the incident was a nurse aide (NA) who no longer works at the facility. LPN #60 said, I don't even remember her name. I wrote the note and reported this to my supervisor, that was my role in the situation. My supervisor said he was calling the administrator and the DON. I believe the administrator did come in to talk with the resident. I did not get any statement from the NA. On the afternoon of 02/27/24 around 3:30 PM, the DON provided an occurrence report that contained the same information as the progress note written on 01/06/24. A typed note on a separate piece of paper with this occurrence number noted the following: Resident #300 and Resident #301 were both placed on one-on-one observation in their respective rooms. The nurse phoned 911 to request an officer respond to the facility to have both residents' rooms searched for drugs. The officer stated he could only search if the Residents consented to the search. Each Resident consented to have their room and belongings searched. Officer (name) conducted the search. No drugs or paraphernalia were found. Both residents admitted to smoking, it. Neither resident would state what was contained in the aluminum foil they smoked. Resident #301 said a friend of his brought it in for him. Officer (Name) stated he would complete the report, but that it would be an informational report. The DON said the residents were placed on one (1) on one (1) supervision on 01/06/24 from when the police were called until the police arrived at the building. The DON said the resident was offered counseling but refused. The DON was unable to provide any further information regarding this incident and no information was provided noting how the other residents at the facility were protected from the illegal drug usage of Resident #300. c) Resident #301 Record review found this Resident was admitted to the facility on [DATE] and was discharged on [DATE]. The resident was found to have capacity on 12/28/24. On 12/29/23 the resident was prescribed Percocet 7.50325 milligrams, 1 tablet every 6 hours for pain. On 12/27/23 the Resident was prescribed Oxycodone 5 milligrams every 6 hours for pain. The Resident was care planned on12/27/23 with a revision date of 01/17/24. The care plan was for: Utilizing nicotine products and having used illegal drugs in facility since admission and has been observed vaping in his room. The goal associated with this problem was: Resident will utilize nicotine products in a safe manner. Interventions included completing a smoking evaluation on 12/27/23 and complete smoking evaluation - 12/27/23 Provide safe smoking devices, if required, such as smoke blankets, smoke aprons and cigarette extenders - 12/27/23. On 01/09/23 an intervention was added to observe for altered mental status and other signs that may indicate drug impairment. On 01/02/24 at 10:44 AM the resident was re-educated resident on facility smoking policy that was signed upon admission to facility. The resident was educated resident that this was a non-smoking facility and that a vaping fell under that. Risks and benefits discussed with the resident. Resident stated that his son brought the vape to him. Educated resident that his son should not bring anymore vapes to him. Resident has capacity and he stated that he understood. Resident denied wanting nicotine patch at this time. (This resident's nursing notes did not include any information about Resident #300 being in Resident #301's room snorting a white substance off his dresser. Resident #300's progress note on 01/02/24 noted he was observed snorting a white substance off dresser in Room #E12a. Resident #301 was residing in Room #E12A on 01/02/24. On 01/03/24 a nursing note written at 12:45 PM, revealed the resident left the facility via taxi service. This nurse educated the resident on the importance of staying in the facility to participate in therapy and receive treatment. Resident verbalized understanding. 01/03/24 at 5:28 PM a nursing note revealed the resident returned to the facility at this time. There were no notes to indicate the Resident was assessed upon his return. A late entry note dated 01/05/24 at 9:00 PM revealed the resident was found on the toilet in bathroom of Room #E12, lethargic, diaphoretic, and disoriented. The resident's vitals were taken, the resident was unable to answer questions appropriately, notified (name of on-call physician services,) ordered Narcan for patient. Narcan was given per order, resident answering questions appropriately, vitals within normal limits. There were no notes indicating the resident was ever assessed again after the Narcan was administered. An interdisciplinary team note dated at 2:50 PM on 01/09/24 was a follow up to illicit drug use in the facility on 01/01/24 and 01/05/24. The administrator, DON and vice president of risk management were all involved in the meeting. According to this note the resident was observed vaping marijuana on 01/01/24 and was provided with the opportunity for substance abuse support and declined. The resident re-signed the facility policies on smoking and illegal drug use and stated understanding. On 01/05/24 nursing staff found him unresponsive, contacted the physician, and administered Narcan. He responded and was able to disclose that he had used fentanyl that he got from another individual. Police were involved and came to the facility; State Troopers were the response team and addressed the resident. The resident allowed nursing staff to search the room and they removed drug residue and paraphernalia. On 02/27/24 at 2:03 AM, the Administrator and the DON were interviewed. The DON stated the resident had capacity and there was no abuse or neglect suspected. He was free to leave the facility for outings. Both employees were asked about the risk to other residents and the roommate of this resident during his drug usage. The DON confirmed this resident did have a roommate at the time of the incident. Staff were asked how the facility ensured other residents or even staff were not at risk when a white powder was found in Room #E12A on 01/02/24. They were asked who cleaned the room after the white powder was found and how was the room cleaned. They were also asked if anyone investigate or confirm what the white powder was. The DON stated Resident #301 was involved in the incident in his room on 01/02/24 with Resident #300 even though his progress note stated he had a vape pen. She said both residents were using a marijuana vape pen . Resident #301 received Narcan on 01/05/23 but the DON said since this resident had a positive reaction to the Narcan, he was not sent to the hospital. No drug testing was ordered for Resident #301 to determine what substances he had used that resulted in the use of Narcan. The DON confirmed Resident #301 admitted to using Fentanyl himself. The DON confirmed the police were not called until 01/06/24 after the incident with Resident #300. The DON said the staff felt Resident #301 was getting the drugs for himself and Resident #300. That was why the police were asked to search both Resident rooms on 01/06/24. On the afternoon of 02/27/24 around 3:30 PM, the DON provided an occurrence report noting the following: (Name of Resident #301) was found on the toilet in his bathroom unresponsive. Narcan was given per order. The DON provided the same statement for this resident's occurrence as provided for the occurrence report with Resident #300. Resident #300 and Resident #301 were both placed on one (1) on one (1) observation in their respective rooms. The nurse phoned 911 to request an officer respond to the facility to have both residents' rooms searched for drugs. The officer stated he could only search if the residents consented to the search. Each Resident consented to have their room and belongings searched. Officer (name) conducted the search. No drugs or paraphernalia were found. Both residents admitted to smoking, IT. Neither resident would state what was contained in the aluminum foil they smoked. Resident #301 said a friend of his brought IT in for him. Officer (Name) stated he would complete a report, but that it would be an informational report. The DON was unable to provide any documentation, other than calling the State Police and filling out an occurrence report to show how the other residents were protected during Resident #301's drug usage. No information was provided to conclude an investigation was conducted to determine the source of the white powder on the dresser in this resident's room seen on 01/02/24. No information was provided to include how the room was cleaned or if the condition of the resident's roommate was assessed or if any other residents were assessed for possible drug usage or exposure to the drugs used by Resident's #301. According to the Centers for Disease Control (CDC) Fentanyl even in small doses can be deadly. It is among the most common drugs involved in overdose. Fentanyl can be absorbed into the body via inhalation, oral exposure or ingestion, or skin contact. When coming into contact with Fentanyl, the CDC recommends wearing nitrile gloves; respiratory protection if powdered illicit drugs are visible or suspected; avoid performing tasks or operations that may cause illicit drugs to become airborne; do not touch eyes, nose or mouth after touching any surface that may become contaminated; wash hands with soap and water, do not use hand sanitizer or bleach The facility was notified of the Immediate Jeopardy (IJ) at 4:47 PM on 02/27/24. The State Agency (SA) approved the facility's Plan of Correction (POC) at 6:45 PM on 02/27/24. The IJ was abated at 12:18 PM on 02/28/24. The facility's approved abatement POC consisted of the following: 1. All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings. 2. All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on 02/27/24 on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs. Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary. If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor. Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility. The facility will request a toxicology report prior to the resident returning to facility. Facility will notify local law enforcement and initiate an internal investigation. Resident will be educated on substance [NAME][TRUNCATED]

Based on record review, and staff interview the facility failed to ensure Resident # 196 who was discharged from the facility with the expectation of returning to the facility was readmitted to the first available bed. Resident #196 was sent to a local psychiatric hospital on 09/06/23. When he was stabilized and ready to be discharged back to the facility the facility denied his readmission stating they could not handle his behavioral problems. This failed practice resulted in actual harm to Resident #196 who suffered increased frustration, irritability, and depression related to not being allowed to return to the facility and having to remain a patient at the psychiatric hospital for a prolonged period of time. This was true for one (1) of three (3) discharged residents reviewed during a complaint survey. Resident Identifiers: #196. Facility Census: 191. Findings Include: a) Resident #196 A review of Resident #196's medical record found the resident was admitted to the facility on [DATE]. The resident was admitted to the facility with a diagnosis of Urinary Tract Infection with hydronephrosis and stent placement. A review of Resident #196's progress notes found the following notes pertaining to his behaviors and discharge plans: -- Note dated 08/30/23 at 9:14 am read as follows, Attempted PT (Physical therapy) evaluation this date. Patient was very verbally aggressive and threatening to this therapist. Attempted to gentle redirection to calm resident. Pt (patient) continued to verbally berate and verbally threaten to hit staff with cane. Will attempt assessment at a later date when patient is less agitated and combative. -- Note dated 08/30/23 at 9:45 am read as follows, Attempted OT (occupational therapy) evaluation. Patient was quite agitated and argumentative, frequently interrupting and being verbally aggressive. Eval (evaluation) deferred at this time. Recommend rescreening as patients temperament and consent allows. -- Note Dated 08/30/23 at 5:09 pm this social service note read as follows, . Plans are for Long Term Care. -- Note Dated 08/30/23 at 6:16 pm read as follows, Resident refused to let me get VS (Vital Signs). Resident cursed at me and told me to leave him alone. -- Note Dated 09/02/23 at 1:20 pm read as follows. Resident is aggressive with staff when attempting to provide care or administer medication. Resident curses at staff consistently. -- Note dated 09/04/23 at 3:44 pm read as follows, Resident being verbally abusive to roommate. Roommate removed from room to decrease stimuli. Cursing staff and refusing AM are throughout the day. Multiple attempts made to calm resident were unsuccessful. Call light and bed control left within reach when exiting the room. -- Note date 09/05/23 at 10:50 am read as follows, MDS (minimum data set) 5 day completed by nursing. No skin Issues at this time other than dry skin; treatment order in place. IV antibiotics completed. Refusing therapy at this time. Wanderguard in place. Resident often refuses care and becomes aggressive verbally towards staff. Care plan reviewed and updated. -- Note dated 09/05/23 at 1:48 pm read as follows, Resident being verbally abusive to staff/residents. Attempts to redirect resident have been unsuccessful. Resident became very agitated and raised fist stating he would hit anyone that came near him. Provider notified. New order to send to ER or psych consult. -- Note Dated 09/05/23 at 5:50 pm read as follows, Resident returned from (name of local hospital) ER. No new orders. All parties made aware. -- Note Date 09/06/23 at 10:35 am read as follows, .Issues/concerns none none aggression and agitation -- Note dated 09/06/23 at 1:26 pm read as follows, Resident being confused and agitated with staff and roommate FNP (Family Nurse Practitioner) ordered to call (Name of Psychiatrist) for direct admit to (name of local hospital) Psych for Psych Consult. Resident sent to (name of local hospital) by (name of ambulance company) Sister made aware. Further review of the medical record found an MDS with an ARD (assessment reference date) of 09/06/23 which indicated Resident #196 was discharged on this date and his return to the facility was anticipated. Review of the facility's incident log found no recorded incidents for this resident. A review of Resident #196's care plan included the following focus statements goals and interventions: Focus Statement: Plans are for Long Term Care. The goal associated with this focus was: I will not have adjustment issues with not returning to my previous living status. I will participate in my care decisions for my long term care stay. Interventions included: Invite and encourage to attend activities of interest. Monitor for signs and symptoms of anxiety, distress withdrawal or depression relating to not returning to their previous home environment. The center will provide activity calendar for me to choose my participation. The focus statement, goals, and interventions were all initiated on 08/30/23. Focus Statement: The resident has a behavior problems (SIC) with episodes of verbal /physical aggression at times. Goal: resident will have fewer episodes of behaviors through review date. Interventions included: Administer medications as ordered. Observe and document signs and symptoms of effectiveness and side effects. Educate resident/resident representative to medication effectiveness and side effects. Approach, speak in a calm manner. Behavioral health consult as needed. Encourage resident to express feelings. Encourage resident to participate in activities of choice. Monitor behavioral episodes and attempt to determine underlying causes. Notify medical provider of increase episodes of behaviors. This focus statement, goal, and interventions were all initiated on 09/06/23 which was the day Resident #196 was discharged from the facility to the psychiatric unit. An interview with Counselor #1 (an employee of the psychiatric hospital Resident #196 was taken too) at 12:13 pm on 11/27/23, revealed Resident #196 was still a patient at their facility. Counselor #1 indicated Resident #196 has been at the hospital for a total of 82 days at the time of this interview. She stated, the nursing home first told them if they (the hospital) could get him medicaid approved they would readmit him. She agreed the process to get medicaid for him was lengthy, but during the entire time the facility never led them to believe they were not going to readmit him once the medicaid was approved. She stated, once the medicaid issue was resolved they then told the hospital they could not readmit him at any of their buildings because of his behaviors. She stated, we have tried to get them to come and see him face to face and reevaluate their decision but they continue to refuse to readmit him. She indicated he was ready to return to the nursing home around 09/20/23. It was around this time the facility advised her he would have to be medicaid eligible to return. Counselor #1 stated, it was around the first of November before his medicaid was approved and it was around this time the facility refused to readmit him because of behaviors. She said, we then had to start the whole process over. She indicated they did find him placement at another local facility but they are currently waiting on a bed to be available for him to discharge there. Counselor #1 stated it has been very frustrating for the resident because he does not understand what is happening and he has been told one thing and then that changes and then he is told something else and that changes. She indicated this whole situation has caused him to have a decline. On 11/28/23 at 9:46 am, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was interviewed concerning Resident #196. When asked why Resident #196 was not readmitted to the facility they indicated he was aggressive and was trying to hit people with his cane. When asked if he ever physically hit a resident the NHA stated, No its all been directed at staff. The NHA further stated, His family did not want to pay bed hold so we did not hold his bed. At 11:00 am at 11/28/23, The NHA and the DON stated, the reason they did not take him back was because the hospital notes indicated he was still having behaviors the facility provided the referral information they received from the hospital to the surveyor. Review of this information found, on 09/20/23 the facility's network liaison received a referral for Resident #196. The facility provided a copy of the email which at the bottom had the following typed as written: Notes: Readmission. Anticipate Denial. This email indicated the resident would be ready to return to the facility on [DATE]. Accompanying the referral was a part of Resident #196's hospital records. A review of the records sent to the facility found the following information: -- Psychiatry Progress note dated 09/17/23: . No behavioral issues. -- Psychiatry Progress note dated 09/18/23: .We are attempting to see if we can convince (Name of Facility) to reconsider their decision and give him a second chance and take him back but at this point they do not seem to responding well to that. Staff are trying to explore other options for placement. He reportedly is private pay for the nursing home and has resources to be able to afford a single room and that might decrease some of his friction with other patients. Patient is in a room with another resident here and has not given any problems with the other resident or has not gotten any upset about the same while here. -- Psychiatry Progress note date 09/19/23: .Still tends to be very passive aggressive and negativistic his [SIC] not been physically aggressive or violent however he tends to be very fixed in the way things need to be for him Staff are continuing to work on getting him placed but it looks very challenging to be able to find a place visual [SIC] to accept him and were his behaviors could be handled . In an additional interview in the afternoon of 11/28/23 the NHA referred to the paperwork from the hospital and cited concerns with the residents listed diagnosis of Dementia behavioral or psychological symptom with psychotic disturbance which was classified as chronic, and Schizoaffective disorder type bipolar which is classified as acute. He also stated they are concerned with the comment made by the physician which indicated finding placement for the resident at a facility that could manage his behavior problems. He asserted these were the reasons they did not take him back. He indicated at the time the referral came over they did not have a bed for him. He stated, how long am I supposed to keep following up if the hospital doesn't send us another referral. The facility was asked to provide a list of new admissions from 09/20/23 through 11/27/23. Review of the list found the facility had admitted 45 new male residents since 09/21/23 through 11/27/23. b) Hospital Record Review The hospital record for #196 was requested and reviewed. The following was found during this review all notes typed as written: -- Progress note dated 09/09/23: .Staff indicates (Name of Nursing Facility)that had him before has indicated they will not be able to take him back because of his behavior however he seems to be better and so we will have to check with them to reevaluate him and see if they would change their decision. -- Progress note dated 09/10/23: .When speaking about he was swinging around a cane at others prior to admission, patient interrupted. 'that cane story is bull shift. I never hit anyone with my cane.' Patient is cooperative with care . -- Progress note date 09/11/23: .The staff will try to communicate with the administration at the (Name of Nursing Facility)to see if they still insists that they do not want to take him back then they will start the process of trying to find another alternate facility. -- Progress note dated 09/15/23 : .He does need some assistance with ambulation but because of his previous abuse of his cane in trying to hit other with it is has been not allowed here at the nursing home at the present time. Is becoming challenging in trying to find an appropriate placement for him he is settled here has not been agitated or aggressive however we do not know how he be when he returns back to nursing facility. -- Progress note dated 09/18/23: .We are attempting to see if we can convince (Name of Nursing Facility) to reconsider their decision and give him another chance and take him back but at this point they do not seem to be responding well on that . -- Progress note dated 09/19/23: .Staff are continuing to work on getting him placed but it looks very challenging to be able to find a place visual accept him and were his behavior could be handled . -- Progress note dated 09/21/23: .He is stable and ready for discharge. -- Progress note dated 09/22/23: .(Name of Nursing Facility) will not allow him to return unless he has medicaid insurance . -- Progress note dated 09/23/23: . Awaiting bed at (Name of Nursing Facility). -- Progress note dated 09/24/23: .Awaiting bed at (Name of Nursing Facility). -- Progress note date 09/25/23: . Staff are attempting to get him back into (Name of Nursing Facility) . -- Progress note dated 09/26/23: . Staff indicates that they are still waiting for his [NAME] Virginia Medicaid to come through so that a nursing home placement can be arranged for him. -- Progress note dated 09/27/23: .Patient appears to be getting to the point where he can be managed back at the nursing homes. However he is still waiting for his long term [NAME] Virginia Medicaid to come through so that he will be eligible to be place at a nursing home. (Name of Nursing Facility) has already agreed to take him back from what staff letting me know. -- Progress note dated 09/28/23: . Patient tends to get irritated and frustrated when he is told about the problems were are having trying to get him out of here and in an appropriate facility. -- Progress note dated 10/04/23: .It is our understanding that once the paired (payer) source is sorted out the (Name of Nursing Facility) where he was a resident before has agreed to take him and so we are going to wait and see how that goes there is no other lesser level of option available until the administrative payment source can be worked out. -- Progress note dated 10/05/23: .The administration at (Name of Nursing Facility) have indicated that once the administrative process is finished and he has a medical card they do plan to take him as long as they have a bed for him so will keep in touch and keep them informed as we go along. -- Progress note dated 10/12/23: Counselor here tells me that the representative from 1 of the nursing facility's had come to talk with him yesterday and they have indicated that once his medicaid come through they should be able to find a bed for him at 1 of their facilities and that does appear to be encouraging news. Patient was made aware of the same and he was pleased to here that. -- Progress note dated 10/13/23: .Counselor indicates that once his medicaid comes through the (Name of Nursing Facility) has indicated that they will be able to take him back. -- Progress note dated 10/16/23: .(Name of Nursing Facility) where he was before has indicated that once the Medicaid comes through they should be able to take him back and at this time he seems to be at that level that he can be handled there without any problem. -- Progress note dated 10/17/23: . Counselor indicates that they are still waiting for his [NAME] Virginia Medicaid to come through and the nursing home where he came from has already agreed to accept him back as soon as the medicaid comes through he should be able to return back to the (Name of Nursing Facility). -- Progress note dated 10/19/23: .Had a episode where he got pretty agitated and upset yesterday and had to be settled down appears it be getting frustrated over the prolonged stay in the current facility we are doing everything we can to get him back into the nursing home that he came from however he is getting impatient and also after us explaining to him over and over several times he does not remember it on a day to day basis . -- Progress noted dated 10/20/23: It is our understanding that he has already been accepted at the (Name of Nursing Facility) and has a bed as soon as he gets his [NAME] Virginia medicaid approved. Patient is expressing frustration at not understanding what he is being told on a day to day basis and why he is still here after all this time. -- Progress note dated 10/26/23: .The counselor is exploring all that and once he is cleared to go we will be sending him over to the (Name of Nursing Facility) where they have already accepted him. -- Progress note dated 10/27/23: .Staff indicates his level 2 is supposed to be completed today and if everything goes okay and a bed becomes available he should be able to go to the nursing home early in the coming week. Reportedly the facility (Name of Nursing Facility) have indicated that they do not have a bed open for him at the present time so may have to send him to 1 of another of their facilities and see how things go patient should have no problems adjusting where he goes. He is ambulating on his own and is using the toilet etc. With out any trouble therefore there is no need for him to have the cane which was an issue when he was at (Name of Nursing Facility). -- Progress note dated 10/30/23: .Patients level 2 has been completed the nursing home is trying to find a bed for him and as soon as we hear that they have a definite placement available we should be ready to discharge him. -- Progress note dated 11/01/23: . Patient has completed the administrative process with the help of the staff and is ready to go back to the nursing home however after giving us the impression for a prolonged period of time that the (Name of Nursing Facility) were going to take him back they have now informed us that there cooperate office has decided that because of his previous behavior none of their facilities will be able to take him back and so now he will have to be referred to (name of another nursing home corporate chain) and they will have to find a placement bed for him. Obviously this sets us back and frustrates the patient but at this point we do not know what else anybody can do. -- Progress note dated 11/06/23: .Staff indicates that they even made a request for (Name of Nursing Facility) to send somebody to do a face to face evaluation on him and see how much he has settled down and how much he has changed for the better but they refused to do so and just indicated that none of their facilities will be willing to take him back because of his previous behavior. -- Progress note dated 11/09/23: .In the last several weeks as he has settled down he also has been getting a little frustrated and depressed because of his prolonged stay here and him not understanding what is going on and where he is going to go .

Based on record review, and staff interviews the facility failed to ensure two (2) of Resident #193 and Resident #194 received care and services in accordance with professional standards of practice, to ensure their highest practicable level of well-being. Resident #193 sustained physical harm when the facility failed to ensure a resident was properly assessed for care needed after an incident involving her foot. In addition, the facility failed to ensure Resident #194's orthopedic surgeon was contacted before providing treatment to a surgical wound created by the surgeon. Resident identifiers: #193. Census: 192. Findings included: a) Resident #193 At approximately 10:45 AM on 9/18/2023, surveyor began reviewing records for an incident involving Resident #193 on 6/14/2023. An incident report was filled outdated 06/14/23 that indicated an injury occurred to Resident #193 while the resident was being transported back from the therapy gym. According to the incident report, Resident #193 stated she was being transported back from the therapy gym by Employee #208 (therapy staff) without footrests on her wheelchair when their foot dropped and went under the wheel on the wheelchair. The resident then said felt her knee pop. The incident report revealed Employee #208 instructed the resident to remain in place while the employee went and retrieved the footrest for the wheelchair At approximately 4:05 PM, on 09/18/23 the Director of Nurses (Don) and the Administrator presented surveyor with a file on an investigation completed pertaining to the incident involving Resident #193. Upon review of the file, it was discovered that an order for an x-ray was entered for the resident on 6/14/2023, but was never signed, nor completed. The file also revealed statements that were taken by the facility and interviews that were conducted with staff that were involved in the incident and provided care to the resident after the incident occurred. Statement by Employee #1 (Licensed Practical Nurse) reflected she was notified by Employee #208 (Therapy Staff) of the incident. The Licensed Practical Nurse's statement read as follows, Resident #193 reported to the employee that they let my foot drop and it got caught and it felt like my knee popped. Employee #1 reports that the resident was asked to rate their pain on a scale of 0-10, to which the resident rated their pain a 10. Employee #1 (Licensed Practical Nurse) stated that PRN (as needed) meds for pain were given, the resident was resting, the incident report was completed, and an x-ray was ordered. Employee #1 (Licensed Practical Nurse) stated that Resident #193 ' s left knee was swollen on initial assessment on 6/14/23 and swollen and tender on 6/15/23. On 09/19/23 at 9:57 AM during an interview with the DoN, regarding orders for an x-ray for Resident #193 left foot following the injury of his/her foot, the DoN confirmed the order was not physically signed by the doctor. The DoN said she would run a report to confirm/deny whether the order was signed off on electronically. On 09/19/23 at 10:12 AM the DoN presented a report with all signed orders for the month of June 2023. The report indicated that the order for the x-ray was not signed off on by the attending physician. The Surveyor asked the DoN for clarification on whether contact had been made with the x-ray company or whether an orthopedic consult had been made. On 09/19/23 at 10:55 AM the DoN confirmed that contact had not been made with anyone as it pertained to an x-ray for the left leg of Resident #193. The DoN also confirmed an orthopedic consult was not made and wouldn't ' t have done much good anyway due to the possibility of it taking weeks before the resident could be seen. During an interview with Employee #208 (therapy staff) on 09/19/23 at 12:18 PM the employee stated they were getting ready to clock out and Resident #193 would have been in the gym by themselves, while they were waiting on the PRN (as needed) COTA (certified occupational therapy assistant) to arrive. Employee #208 (therapy staff) said they offered to take Resident #193 back to her room so she would not be left unattended. Employee #208 (therapy staff) stated during transport, Resident #193 dropped her legs and the therapy staff immediately stopped the chair. Employee #208 (therapy staff) stated that Resident #193 reported she felt a pop in her leg when her foot dropped. Employee #208 stated she told Resident #193 to stay where she was while she (therapy staff #208) went to retrieve the footrests for the wheelchair. Employee #208 (therapy staff) stated that footrests were applied to wheelchair and Resident #193 was taken to her room. Employee #208 (therapy staff) said she notified the nurse of what had happened. Employee #208 states that the resident denied any pain after the incident. Employee #208 states she told the resident to hold their feet up during transport so she would be able to see them if they dropped and she could stop the chair. On 12:59 PM on 09/19/23 during an interview with the DoN regarding orders for an x-ray for Resident #193 the DoN said orders were entered on 6/14/2023 for an x-ray on the resident's left leg following the incident involving their wheelchair but were not signed by the attending physician. Upon review, DON confirmed the orders were not signed by a physician and stated that to the best of my knowledge the former unit manager that was present on the day of the incident must not have followed up on the order for the x-ray. DoN stated this would be what led to the x-ray not being completed until Resident #193 was sent out to the hospital for shortness of breath on 6/16/2023. At 2:31 PM on 09/19/23 during an interview with Employee #69 (nurse aide) it was revealed that this employee cared for Resident #193 immediately following the incident. Employee #69 (nurse aide) stated Resident #193 told her about the incident when she returned to her room. Employee #69 (nurse aide) said that Resident #193 said her foot dropped while being transported back from the therapy gym. Employee #69 stated the resident sat outside of her room for a while after the incident and requested to get in bed soon after, due to pain in their left leg. Employee #69 (nurse aide) reported that Resident #193 was a total lift and complained of increased pain when being transferred from wheelchair to bed via Hoyer lift. Employee #69 (nurse aide) reported that after transporting the resident to her bed she noticed Resident #193 ' s left leg was red from the shin down and she complained of it being very tender when touched. At 2:41 PM on 09/19/23 an interview was conducted with Employee #140 (nurse aide) who cared for Resident #193 on 6/15/23, the day after the incident. Employee #140 (nurse aide) stated the resident was normally up, socializing, and drinking plenty of fluids throughout the day. Employee #140 (nurse aide) stated on 6/15/23 Resident #193 refused to eat breakfast and lunch, and slept most, if not all, of the day, and did not want anything to drink that day. Employee #140 (nurse aide) stated Resident #193 refused a shower that day and acted like she just wanted to be left alone. Employee #140 (nurse aide) stated this behavior was very unusual. Employee #140 (nurse aide) stated the only interactions she had that day with Resident #193, was during incontinence care, which caused the resident pain due to moving her left leg. Employee #140 (nurse aide) stated Resident #193 was very vocal about the pain and discomfort they experienced during incontinence care. When asked if they were aware of the incident involving Resident #193 ' s left leg the day prior, or if an x-ray for the resident was mentioned, Employee #140 (nurse aide) stated they were not told an injury occurred and that an x-ray was never mentioned. Employee #140 stated that they were not made aware of any incident or injury to Resident #193 until after fact when they were asked to make a written statement regarding the incident on 6/22/2023. This was after the resident was sent out to the hospital for shortness of breath. On 09/20/23 at approximately 9:00 am, medical records were obtained from (name of local hospital) pertaining to the Emergency Department visit and admission for Resident #193. Upon review of official documents from the hospital, it was determined that Resident #193 complained of pain in their left leg due to an incident that took place at the nursing home two (2) days prior. Hospital record review revealed the resident stated she was being pushed in her wheelchair without footrests and her leg got trapped under the wheel and she heard a pop. Resident #193 stated in the hospital record that the nursing home was planning on performing an x-ray, but had not done so. Due to complaints of pain and the nature of the incident the hospital performed imaging tests that showed Resident #193 had sustained a comminuted fracture of the distal left femoral metaphysis, with approximately 5 mm (millimeter) posterior lateral displacement of distal bone fragment.

Based on observation, staff interview, resident interview, and record review, the facility failed to ensure residents received care in accordance with professional standards of care. For Resident #258, the facility failed to weigh the resident as per policy and physician orders. The facility failed to ensure the resident received the appropriate oxygen treatment to including the route and rate of the oxygen to be delivered. The facility also failed to ensure the resident received medications and treatments for [CONDITION(S)] (CHF.) Resident #145's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #313 did not receive restorative services as ordered. For Resident #132 the facility failed to rinse the resident's mouth after the administration of an inhaler as directed by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice for Resident #258 caused actual harm due to failure to treat [CONDITION(S)] (CHF.) After surveyor intervention, the physician recognized the resident had not been evaluated for the continued need of [MEDICATION(S)] (a diuretic.) The Resident had a weight gain of 36.2 pounds in 27 days. The failure to treat and assess Resident #258's CHF lead to the development of bilateral pneumonia which decreased the resident's ability to complete activities of daily living and ability to breath comfortably. Resident identifiers: #258, #145, #313, #132 and #138. Facility census: 156. Findings included: a) Resident #258 Observation on 10/04/21 at 12:00 PM, found the resident was noted to be using eight (8) liters of supplemental oxygen via oxygen mask. Resident was gasping for breath with visible distress. He was attempting to eat. He would raise his mask, take a bite but quickly became tired and only consumed 25% of lunch. The Resident told the therapist, who was assisting with eating, he was tired. Resident #258 was admitted to the facility on [DATE] at 12:20 AM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #258's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/04/21 at 12:35 PM, Registered Nurse (RN) #205 confirmed Resident #258's supplemental oxygen was set for eight (8) liters of supplemental oxygen delivered by an oxygen mask and his order was for two (2) liters of oxygen to be delivered by a nasal cannula. RN#205 was asked how he got an oxygen mask and he stated, I don't know. He verified there was no nasal cannula in the room. Nursing progress noted by Employee #176, Licensed Practical Nurse (LPN) on10/4/2021 at 1:30 pm read: Increase Oxygen to 3LPM (liters per minute) via NC (nasal cannula) per FNP (Family Nurse Practitioner). Resident is aware. On 10/7/2021 at 8:50 AM a progress note written by RN #205 read: Resident sitting on edge of bed at this time. Resident alert and oriented x3. Respirations are non-labored upon visual examination. Resident has no c/o (complaints of) shortness of breath or difficulty breathing currently. Upon auscultation of lung sounds, the resident had clear upper lobes with diminished lung sound on the left base of his lung. Resident's oxygen saturation at this time is 94% of 2 L/min via n/c. Resident stated, I am feeling great this morning. Thank you for asking. (The physician ordered 3 L/min on 10/04/21 not 2 L/min.) Review of Resident #258's medical records found a History and Physical (H&P) completed at a local hospital on 09/05/21. This report reads(Resident's Name) presented to the emergency room (ER) with complaints of increased shortness of breath, orthopnea and increased [CONDITION(S)]. Patient was admitted to (Hospital's Name) most recently from 08/26/21 through 08/31/21 for exacerbation of [CONDITION(S)] (CHF) and was sent home with an increase of [MEDICATION(S)] 40 milligrams (MG) twice daily (BID). He states that he started feeling poorly soon after getting home and has progressively continued to worsen. The patient will be admitted to inpatient with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He presents with bilateral 2+ pitting [CONDITION(S)] to bilateral legs from the knees down Review of discharge summary for Resident #258 from local hospital written on 09/15/21. This report orders for an increase of his [MEDICATION(S)] to 80 mg bid (twice a day) for three days and repeat his Basic Metabolic Panel (BMP) and his [MEDICATION(S)] to be adjusted accordingly. Patient is on three (3) liters per minute at this time and will be adjusted at the facility as needed . Upon admission to the nursing home the Resident was ordered [MEDICATION(S)] 80 mg BID. The resident received [MEDICATION(S)] 80 mg BID for only 3 days. The [MEDICATION(S)] was never evaluated after the Resident received the medication for 3 days. Review of Resident #258's care plan found the following: Focus: Risk for [CONDITION(S)] (swelling), high blood pressure or shortness of breath related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Goals: Patient will not require hospitalization due to exacerbation of CHF through next review. Interventions: Administer medications as ordered. Encourage and assist the patient to elevate legs when sitting. Monitor weights and vital signs as ordered Observe and document/report to physician as needed any signs/symptoms of CHF: dependent [CONDITION(S)] (swelling) of legs and feet, periorbital (around eyes) [CONDITION(S)], shortness of breath upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles, and wheezes on auscultation (listening with stethoscope) of the lungs. Orthopnea (shortness of breath when lying flat), weakness and/or fatigue, increased heart rate, lethargy, or disorientation. Resident #258 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #258's weights found the resident was weighed on 09/16/21 and weighed 242 pounds (LBS). No weights noted until after this surveyors intervention on 10/06/21 and again on 10/12/21. The resident was not weighted on 10/06/21 when the surveyor ask for a weight. Weight was obtained on 10/12/21 at 11:27 am and recorded as 278.2 lbs. Observation on 10/12/21 at 2:00 pm, found Resident #258 was ambulating down the hallway with Employee #229, Occupational Therapy Assistant (OTA.) The resident was short of breath. The OTA had him sit in a chair and she immediately obtained his oxygen saturation and heart rate. The oxygen saturation was 85% on 2 l/m oxygen via nasal cannula and heart rate was elevated at 91. (Again the Resident was not receiving oxygen 3 L/M as ordered by the physician on 10/04/21.) Progress Note written by RN#205 on 10/12/2021 at 2:28 PM read: Resident had episode of shortness of breath upon exertion with therapy. The resident was assessed at this time. O2 sat currently at 91% on 2L/Min via Nc. Resident stated, I just got a little short of breath when I was working with that girl. I feel ok now. Resident is currently in no visual distress. FNP (family nurse practioner) notified of findings and received order for chest x-ray today and lab work (Complete Blood Count (CBC), Basic Metabolic Panel (CMP) and a brain natriuretic peptide (BNP) test is a type of blood test. Doctors use the BNP family of tests as an indicator of how well the heart is pumping blood around the body. Many doctors find it useful in helping to diagnose or monitor heart failure) tomorrow. The resident is aware of new orders. On 10/13/21 a progress note by Resident #258's attending physician read: (typed as written) (age of resident and sex) seen for a routine visit. Lying in bed awake and alert. Only c/o SOB (shortness of breath) on exertion. Was on [MEDICATION(S)] 40 mg bid at home. Had an increase of [MEDICATION(S)] for 3 days and never restarted 40 mg. Will restart and check BMP in 1 week. Chest X-ray shows bilateral PNA (pneumonia), Will start on [MEDICATION(S)]. He states no other issues other than SOB on exertion. The physician noted the Resident has 2 + pitting [CONDITION(S)] BLE (bilateral lower extremities.) Nursing progress note written by RN #129 on 10/13/2021 at 3:30 PM read: New orders for [MEDICATION(S)] 40mg x 1 dose today and then [MEDICATION(S)] 40 mg BID. Start [MEDICATION(S)] 500mg everyday x 7 days. Repeat BMP in 1 week. All parties made aware. Facility's weight and height policy reviewed and found: Patients are weighed upon admission and/or re-admission, then weekly for four (4) weeks and monthly thereafter and recorded in Point Click care (PCC). Purpose: To obtain baseline weight and identify significant weight change. To determine possible causes of significant weight change. Interview on 10/12/21 at 11:10 am, with the RN #205, found the weight entered on Resident #258's weekly weights were not obtained until 10/12/21 after two (2) episodes of intervention (10/06/21 and 10/12/21) by this surveyor. He confirmed the resident's weekly weights were not obtained on 09/23/21, 09/30/21and 10/07/21. RN #205 confirmed the facility had issues regarding the use of oxygen and following the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] After surveyor intervention, the physician recognized the resident had not been evaluated for the continued need of [MEDICATION(S)] (a diuretic.) The Resident had a weight gain of 36.2 pounds in 27 days. The failure to treat and assess Resident #258's CHF lead to the development of bilateral pneumonia which decreased the resident's ability to complete activities of daily living and ability to breath comfortably. b) Resident #145 On 10/04/21 at 12:35 AM, Resident #145 was noted to be using oxygen 8 1/2 liters via [CONDITION(S)] collar. Review of Resident #145's medical record showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/04/21 at 12:41 PM, Licensed Practical Nurse (LPN) #27 confirmed Resident #145's oxygen was set on 8 1/2 liters but he was ordered five (5) liters. He stated he would reset the oxygen flow rate to five (5) liters, the rate prescribed by the physician. Further review of Resident #145's medical record showed an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of emergency items at Resident #145's bedside was made on 10/05/21 at 12:26 PM with assistance of LPN #27. Resident #145 did not have an obturator or syringe at the bedside. LPN #27 stated he would obtain these items and place them at Resident #145's bedside. No further information was provided through the completion of the survey. c) Resident #313 Review of Resident #313's medical records revealed the following orders for the Restorative Nursing Program (RNP): - 05/21/21: RNP for AROM (active range of motion) to perform straight leg raises, knee flexion, hip abduction/adduction and hip flexion 10 repetitions for 3 sets. x 4 weeks. This was discontinued on 06/08/21. - 05/21/21: RNP for PROM (passive range of motion) to both lower extremities. 5 repetitions for 30 seconds each repetition QD (every day) x 6 days/week x 4 weeks. This was discontinued on 06/08/21. - 06/18/21: RNP to assist with AROM exercises to perform straight leg, knee flexion, hip abduction/adduction and hip flexion BLE (bilateral lower extremities) x10 reps x 3 sets x 6days/wk (week) x 4wks (weeks), to be completed 7/21/2021. - 06/18/21: RNP to perform PROM to BLE x15min/day x6 days/wk x4 wks, to be completed 7/21/2021. RNP is a nursing intervention to maintain or improve residents' functional abilities and prevent declines in abilities to perform activities of daily living. Review of Resident #313's Documentation Survey Report in the medical records showed the resident's RNP therapy was started on 05/25/21. In May 2021, the resident received RNP therapy on 05/25/21, 05/26/21, 05/27/21, 05/29/21, 05/30/21, and 05/31/21. According to the Documentation Survey Report, in June 2021, the resident did not receive any additional RNP therapy before it was discontinued on 06/08/21. On 06/05/21, the Documentation Survey Report documented NA, possibly for not applicable. The other dates the resident should have received RNP were blank. The resident's nursing progress notes contain no explanations for why the resident did not receive RNP therapy these days. When Resident #313's RNP was reordered on 06/18/21, the Documentation Survey Report documented NA for 06/18/21. The other dates the resident should have received RNP in June 2021 were blank. The resident's nursing progress notes contained no explanation for why the resident did not receive RNP therapy these days. In July 2021, the Documentation Survey Report documented the resident received RNP on 07/03/21 and 07/09/21. On 07/12/21, the Documentation Survey Report documented NA. The other dates the resident should have received RNP were blank. The resident's nursing progress notes contained no explanation for why the resident did not receive RNP therapy these days. During an interview on 10/12/21 at 12:20 PM, the Administrator confirmed Resident #313's Documentation Survey Report did not document six (6) days of RNP a week as ordered by the physician. No additional information was provided through the completion of the survey. d) Resident #132 During Medication pass observation on 10/05/21 8:10 a.m., Registered Nurse (RN) #49 administered Anoro inhaler to Resident #132 and did not prompt or offer resident to rinse mouth after inhalation was completed, as ordered by the provider. RN #49 stated, It's not a steroid so he didn't need to rinse. Medication order stated to rinse mouth after use. Record review showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Rinse mouth after use. Start Date 04/28/2021. On 10/12/21 at 1:53 p.m. during an interview, the Administrator agreed the RN should have followed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . e) Resident #138 On 10/04/21 at 1:03 PM, suprapubic urinary catheter care was provided by Nurse Aide (NA) #98. A drain sponge was not applied per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . NA #98 stated I don't even know where they are. On 10/04/21 at 1:33 PM, the Administrator was notified. No further information was obtained during the Long-Term Care Process Survey.

Based on record review, staff interview, policy review and resident interview the facility failed to assess and treat Resident #170's pain which has been a primary factor in her refusing to go to [MEDICAL TREATMENT]. Her refusals of [MEDICAL TREATMENT] has the potential to cause serious harm and/or death. The resident has already suffered actual harm by the facility's failure to treat her pain on multiple occasions. The resident since [DATE] has refused to go to six (6) out of eight (8) [MEDICAL TREATMENT] treatments ([DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). Resident #170 only recieved one full treatment since the placement of the wound vac on [DATE]. She did go to [MEDICAL TREATMENT] on [DATE], but her treatment had to be stopped after seventy-nine (79) minutes because of the residents complaints of pain. The clinical diretor of the local dialyis center during and interview on [DATE] at 1:35 p.m. stated the resident was complaining of pain related to her wound vac on [DATE] and that is why her treatment had to be stopped. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner was notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] the facility did not address this. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. The failures to assess and treat the residents pain which has caused her to refuse [MEDICAL TREATMENT] has resulted in Resident #170 being at immediate risk for serious harm and/or death. This has resulted in the determination of an immediate jeopardy. The nursing home administrator (NHA) and the Director of Nursing (DON) were notified of the immediate jeopardy at ¿¿¿¿1:45 p.m. on [DATE]. The facility provided a plan of correction to the State agency at 5:33 p.m. on [DATE], which the State agency reviewed and accepted at 5:35 p.m. on [DATE]. The State agency then observed for implementation of the plan of correction and abated the immediacy at 11:05 p.m. on [DATE]. This immediate jeopardy began on [DATE], when the facility first failed to provide appropriate assessment of pain and pain management techniques by not notifying Resident #170's attending physician and/or nurse practitioner when she refused to go to [MEDICAL TREATMENT] treatments due to the pain caused by the [DEVICE]. After the immediacy was removed, a deficient practice remained for the following and the scope and severity was decreased to an K . Additionally, for Resident #170, the facility failed to correlate care between the facility and the [MEDICAL TREATMENT] center and failed to administer the Renavela as directed by the nephrologist. For Resident #225, the facility failed to provide effective pain management by failing to assess his level of pain prior to and timely reassess after the administration of an as needed (PRN) pain medication. These issues were found for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT] and for one (1) of five (5) reviewed for the care area of unnecessary medications. Resident identifier: #170 and #225. Facility census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on [DATE] found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The medical record, reviewed on [DATE] at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of the nurses' progress notes found Resident #170 was admitted to the facility on [DATE] at 5:35 p.m. Further review of the nursing progress notes found a note written by Employee #282, LPN, on [DATE] at 4:55 p.m. which read, Worsening [MEDICAL CONDITION] to bilateral lower extremities and resident missed [MEDICAL TREATMENT] yesterday. The resident has orders for the following advance directives: CPR (cardiopulmonary resuscitation). Resident admitted to this facility on [DATE]. Skin warm and dry. Respirations even and non-labored. Denies cough or shortness of breath. Resident is becoming short of breath when lying flat or turning in bed. Oxygen saturation is 96% (percent) on room air. Observed 3+ (plus) [MEDICAL CONDITION] to bilateral lower extremities. Notified the NP earlier today with no new orders received. As day has progressed, [MEDICAL CONDITION] has worsened and is now non-pitting. Resident states she was due [MEDICAL TREATMENT] yesterday and was not sent. A progress note written on [DATE] at 11:21 p.m. by Employee #199, registered nurse (RN) read, Per (Name of Hospital) was admitted to hospital for [MEDICAL TREATMENT], [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #170 was re-admitted to the facility on [DATE] after receiving treatment for [REDACTED].#273). Physician orders [REDACTED].#273) read: --Wound care per previous orders. --Daily weight, report increase in [MEDICAL CONDITION] or shortness of breath to physician (#273) --Follow-up at facility by attending physician (#273) --[MEDICAL TREATMENT] as previous (Tuesday, Thursday and Saturday) --Transferring physician (#273) and admit to facility under my service. --admitting [DIAGNOSES REDACTED]. --Code status: Full Code --[MEDICATION NAME] coated Aspirin 81 mg by mouth daily. --[MEDICATION NAME] 50mg by mouth at bedtime --[MEDICATION NAME] 50 mcg topically every three (3) days. --[MEDICATION NAME] 17 grams by mouth every day. --[MEDICATION NAME] 12.5 mg by mouth twice daily, (Hold if systolic blood pressure is 100 or below). --[MEDICATION NAME] 10mg by mouth daily --[MEDICATION NAME] 40 mg by mouth daily --[MEDICATION NAME] 7.5 mg by mouth at bedtime --[MEDICATION NAME] 3,200 mg by mouth three times daily with meals. --[MEDICATION NAME] 200mg by mouth three times daily --[MEDICATION NAME] 50 mcg by mouth daily --Dosage of [MEDICATION NAME] will be advised after looking at the [MEDICATION NAME] time/international ratio (PT/INR) tomorrow ([DATE]) --[MEDICATION NAME] 0.25 mg by mouth daily -- Fluid restrictions --[MEDICATION NAME] 325 mg by mouth three times daily --[MEDICATION NAME] ,[DATE] mg by mouth every 6 hours prn Review of the readmission orders [REDACTED]. No orders for fluid restrictions could be found. Additionally, a review of the MAR for ,[DATE] and ,[DATE] found the medication [MEDICATION NAME] was administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m. This medication should have been, administered at meal times which would have been 7:30 a.m., 12:00 p.m. and 5:30 p.m. Review of the Physician Desk Reference (PDR) read, [MEDICATION NAME]® (sevelamer [MEDICATION NAME]) is indicated for the control of serum phosphorus in patients with [MEDICAL CONDITION] (CKD) on [MEDICAL TREATMENT]. [MEDICATION NAME] (sevelamer) is a [MEDICATION NAME] binder. Sevelamer helps prevent [DIAGNOSES REDACTED] (low levels of calcium in the body) caused by elevated phosphorus. This medication should be taken with meals. During an interview on [DATE] at approximately 3:15 p.m. with local [MEDICAL TREATMENT] center's medical director (nephrologist) it was confirmed the [MEDICATION NAME] should be given with meals otherwise the medication is useless. Further review of the record found a, new patient history and physical completed on [DATE] by Physician #272 read, Patient Was admitted from (Name of hospital #1) with a [DIAGNOSES REDACTED]. Patient was admitted to my services but resident requests to be changed to (Name of physician #273) as he is her regular doctor. Continue current pain regimen. Staff to monitor for pain per facility policy. [MEDICATION NAME] ,[DATE]mg by mouth every six (6) hours prn for pain. Consultation report written on [DATE] by Physician #275, vascular and wound care specialist read, Non-ambulatory. Sacral ulcer- 4 centimeters (cm) in length and 3 cm in width. Stage III- IV. The right heel is fully healed. + Coagulant ([MEDICATION NAME]). Plan- Needs to change dressing to a [DEVICE] to the sacral ulcer. Review of the Treatment Administration Record (TAR) for the month ,[DATE] found the following, Cleanse Stage IV pressure ulcer to sacrum with IHWC (In House Wound Cleanser), pat dry, apply wound vac (vacuum) @ (at) 125 mm(millimeters)/hg (of mercury) every 3 (three) days and prn (as needed) . This had a start date of [DATE]. Review of Resident #170's [MEDICAL TREATMENT] record from [DATE] to [DATE] found the following: --From [DATE] to [DATE]- Resident #170 was ordered a 240 minute [MEDICAL TREATMENT] treatment three times a week. The following occasions are the actual days and times Resident #170 received [MEDICAL TREATMENT]. --[DATE]- 190 minutes of treatment. --[DATE]- 208 minutes of treatment --[DATE]-239 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE] through [DATE]- Resident hospitalized --[DATE]- 206 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-219 minutes of treatment --[DATE]- 244 minutes of treatment --[DATE]- 196 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-0 minutes of treatment --[DATE]-237 minutes of treatment --[DATE]- 233 minutes of treatment --[DATE]- 137 minutes of treatment --[DATE]- 200 minutes of treatment --[DATE]- 89 minutes of treatment --[DATE]- 242 minutes of treatment --[DATE] through [DATE]- Resident was hospitalized --[DATE]- 149 minutes of treatment --[DATE]- 253 minutes of treatment --[DATE]- 241 minutes of treatment --[DATE]- 145 minutes of treatment --[DATE]- 173 minutes of treatment --[DATE]- 255 minutes of treatment --[DATE]- 175 minutes of treatment --[DATE]- 93 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE]- 212 minutes of treatment --[DATE]- 179 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 237 minutes of treatment --From [DATE] through [DATE] Resident #170 was ordered a 210 minute [MEDICAL TREATMENT] treatment three times a week. The following are the actual dates and times she received [MEDICAL TREATMENT]. --[DATE]- 215 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE] through [DATE]- Resident hospitalized . -- [DATE] 0 minutes of treatment ( A nurses noted dated [DATE] that the resident stated to the nurse, she was due [MEDICAL TREATMENT] yesterday and was not sent. Resident #170 later that day was sent to the hospital and was admitted for [MEDICAL TREATMENT], [MEDICAL CONDITION], and [MEDICAL CONDITION]) --[DATE] through [DATE]- Resident hospitalized --[DATE]- 217 minutes of treatment --[DATE]- 214 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 211 minutes of treatment --[DATE]-100 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 79 minutes of treatment -- [DATE] - 0 minutes of treatment. --[DATE]- 0 minutes of treatment In summary from [DATE] through [DATE] resident had the opportunity to go to the [MEDICAL TREATMENT] center for her [MEDICAL TREATMENT] treatment 39 times this is not counting the times the resident was in the hospital because on those dates she was receiving [MEDICAL TREATMENT] at the hospital and could not go in center to get [MEDICAL TREATMENT] even if she wanted to. Of those 39 opportunities resident #170 missed only 7 treatments in their entirety. Of note, one of those treatments was on [DATE] which the resident stated she was not sent by the facility too the [MEDICAL TREATMENT] treatment. She did not refuse this treatment. Upon placement of the resident wound vac on [DATE] through present Resident #170 had the opportunity to go in center for a [MEDICAL TREATMENT] treatment a total of eight (8) times. Of those eight (8) opportunities the resident missed six (6) of those treatments in their entirety. During an Interview with the Chief Medical Officer (CMO) #271 at 10:20 a.m. on [DATE], he stated that Resident #170 had a long history of refusing [MEDICAL TREATMENT]. Also, during an interview with the Medical Director #272 at 12:13 p.m. on [DATE] it was also mentioned Resident #170 had a long history of refusing [MEDICAL TREATMENT]. These statements were not supported by the local [MEDICAL TREATMENT] centers records which showed Resident #170 only missed six (6) out of 38 possible treatments from [DATE] through [DATE]. However, after the wound vac placement she missed six (6) of the eight (8) possible treatments from [DATE] through [DATE] because of what she stated to be pain caused by the wound vac. Review of Resident #170's [MEDICAL TREATMENT] records from [DATE] thru [DATE], Missed HD treatment report and staff interviews, found that beginning on [DATE] through [DATE] Resident #170 either missed or had her [MEDICAL TREATMENT] treatments cut short for the following reasons: --On [DATE], a nursing progress note indicated, Resident refused [MEDICAL TREATMENT]. States she does not feel good. --[DATE], a nursing progress note indicated, Patient went to [MEDICAL TREATMENT] today. Explained the importance of her completing her [MEDICAL TREATMENT] treatment completely for her heath. Patient agreed to go and would try to complete treatment today. --[DATE], nursing progress note indicated, Resident c/o (complains of) wound vac hurting her. Wing nurse notified and resident stated she was medicated. (Name of MD #275) notified and decreased intensity to 50 mmHg per order for two hours and resident continued to c/o the wound vac bothering her and request it be taken off. (Name of MD #275) notified and gave order to hold vac and gave dressing orders until Sunday if he comes and if not, he will evaluate when next in facility. Resident aware. No [MEDICAL TREATMENT] scheduled on this date but information pertinent due to the resident complaining of pain related to her wound vac. --[DATE], nursing progress note indicated, Resident refused to go to [MEDICAL TREATMENT]. States her back is hurting. --[DATE], nursing progress note indicated, Resident agreed to resume wound vac to sacrum. Applied wound vac with no s/s (signs or symptoms) of pain or complications will continue to monitor. -- [DATE], nursing progress note indicated, . Goes to [MEDICAL TREATMENT] Tues., Thurs., and Sat; however resident refused this morning d/t wound vac for sacral ulcer. Often refuses to go to [MEDICAL TREATMENT] . -- [DATE], nursing progress note indicated, Patient refused to go to [MEDICAL TREATMENT] after 3 attempts by the nurse to get her to go. Attempted to explain the importance of completing her [MEDICAL TREATMENT] treatment but she continuously refuses. --No nursing notes for [DATE]. However the [MEDICAL TREATMENT] Communication record indicated the resident was experiencing pain and was crying until her treatment was stopped per her request. She only completed 79 minutes of her 240 minute treatment. --No nursing progress notes for [DATE] pertaining to Resident #170's [MEDICAL TREATMENT] treatment, however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on this date. --No nursing progress notes for [DATE] however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on this date. In an interview with Resident #170 on [DATE] at 9:35 a.m., the resident stated she did not go to [MEDICAL TREATMENT] today due to her wound vac hurting. She further explained she has chronic pain, but since the wound vac was placed she has experienced more pain and discomfort. She further indicated that since the placement of the wound vac she has had to miss several of her [MEDICAL TREATMENT] treatments due to pain. Resident #170 missed a total of six (6) of her last eight (8) [MEDICAL TREATMENT] treatments since the placement of the wound vac on [DATE]. Of the two (2) treatment she did attend she only completed one full treatment. On [DATE] the residents [MEDICAL TREATMENT] treatment was cut 131 minutes short. There is no evidence in Resident #170's medical record that her attending physician was notified of her missed [MEDICAL TREATMENT] treatments and/or her increased pain associated with the use of her wound vac. A review of Resident #170's controlled medication sheets for her ordered as needed [MEDICATION NAME] found the following, -- [DATE] the resident refused to go to [MEDICAL TREATMENT] due to pain. She was scheduled to leave for [MEDICAL TREATMENT] at 5:30 a.m. however she only received two (2) doses of [MEDICATION NAME] on this date one (1) at 12:00 p.m. and one (1) at 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] which she was scheduled to be picked up for at 5:30 a.m. because of back pain. She did not receive her as needed pain medication until 6:00 a.m. she also received additional doses at 1:30 p.m. and 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] due to pain from her wound vac. The resident ' s pick up time was scheduled for [MEDICAL TREATMENT] pick up at 5:30 a.m. She did not receive her as needed pain medication until 6:00 a.m., 12:00 p.m., and 9:00 p.m. -- [DATE] the patient had refused to go to [MEDICAL TREATMENT] after three attempts she did not receive pain medication until 10:30 a.m. and 5:30 p.m. Please note the nursing note did not mention why the resident refused [MEDICAL TREATMENT] however, interviews with the resident confirmed she had been refusing [MEDICAL TREATMENT] due to pain from the wound vac. --[DATE] Resident #170 returned from [MEDICAL TREATMENT] after only receiving a 79 minutes treatment when she was scheduled to receive a 240 minute treatment. The [MEDICAL TREATMENT] center wrote on the communication form that Resident #170 ' s treatment had to be stopped because she was crying in pain. She arrived back to the facility at approximately 9:00 a.m. and she received pain medication at 4:30 a.m. and 5:30 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] she did not receive pain medication until 9:00 a.m. and 9:00 p.m. even though her scheduled pick up time for [MEDICAL TREATMENT] was 5:30 a.m. -- [DATE] Resident #170 again refused to go to [MEDICAL TREATMENT] she had receive pain medication at 4:40 a.m. on this date. -- [DATE], [DATE] and [DATE] the location of the residents and/or complaints of pain were not noted in the medical record. She did however, refuse [MEDICAL TREATMENT] on these dates. An interview with Resident #170 on [DATE] at 9:35 a.m. revealed she had been refusing to go to [MEDICAL TREATMENT] because of pain associated with her wound vac. She indicated she had told the staff about it and this was the reason she could not do her [MEDICAL TREATMENT]. The resident was also interviewed prior to this conversation by a different surveyor on [DATE] at 1:10 p.m. During this interview Resident #170 also stated that she had not been going to [MEDICAL TREATMENT] because of the pain she was experiencing from her wound vac. On [DATE] Resident #170's [MEDICAL TREATMENT] treatment ended after 79 minutes due to complaints of pain as noted by the [MEDICAL TREATMENT] clinic. At 1:35 p.m. on [DATE] the clinical director of the local [MEDICAL TREATMENT] center was interviewed. She was asked if the facility needed to set up a new chair time (scheduled time for [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center) when Resident #170 was admitted to thier facility she replied, No we do not give up thier chair time when they are in the hospital. She stated, she would have had the same cahir time and no arrangements were needed. When asked why Resident #170's treatment was cut short on [DATE] she stated, Because of pain related to her wound vac. She indicated Resident #170 had at times refused [MEDICAL TREATMENT] prior to the placement of the wound vac, but since its placement these have increased drastically. Further review of the Resident #170's controlled substance utilization record found the following dates and times when Resident #170 was administered her prescribed as needed pain medication with no assessment of where the pain was located, the intensity of the pain prior to administration, and no follow up assessment to determine if the pain medication was effective in relieving the resident pain: --[DATE] at 10:00 a.m. and 6:00 p.m. --[DATE] at 12:00 a.m., 1:00 a.m., and 9:10 p.m. --[DATE] at 4:30 a.m. and 9:00 p.m. --[DATE] at 10:00 p.m. --[DATE] at 9:00 a.m. and 9:00 p.m. --[DATE] at 9:00 a.m. (Not noted on MAR) and 9:00 p.m. --[DATE] at 5:00 a.m. (Marked not given, Wasted on Narcotic sheet), 12:00 p.m. and 9:15 p.m. (Not recorded on MAR). --[DATE] at 7:00 a.m. and 6:00 p.m. --[DATE] at 12:00 a.m. (Not recorded on MAR, 2:00 p.m. (Not recorded on MAR, and 10:00 p.m. (Not recorded on MAR). --[DATE] at 6:20 a.m. and 10:00 p.m. --[DATE] at 12:00 p.m. and 9:30 p.m. --[DATE] at 1:25 p.m. (Not recorded on MAR) and 8:00 p.m. --[DATE] at 5:30 a.m., 11:30 a.m. (Not recorded on MAR) and 6:00 p.m.( Not recorded on MAR) --[DATE] at 12:00 p.m., and 9:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 a.m., 4:30 p.m. and 11:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 p.m. --[DATE] at 11:00 a.m. and 5:00 p.m. --[DATE] at 6:00 a.m., 1:30 p.m., and 9:00 p.m. --[DATE] at 6:30 a.m., 2:30 p.m. (Not recorded on MAR) and 10:30 p.m. --[DATE] at 9:30 a.m. (Not recorded on MAR) and 9:00 p.m. --[DATE] at 6:00 a.m. (Not recorded on MAR). 12:00 p.m. and 9:00 p.m. --[DATE] at 5:00 a.m. (Not recorded on MAR), and 10:30 p.m.( Not recorded on MAR) --[DATE] at 10:30 a.m. and 5:30 p.m. --[DATE] at 5:30 a.m., 5:00 p.m. (Not recorded on MAR)., and 11:00 p.m.( Not recorded on MAR) --[DATE] at 4:30 a.m., and 5:30 p.m. ( Not recorded on MAR) --[DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. --[DATE] at 9:00 a.m., 2:25 p.m. and 9:00 p.m. --[DATE] at 9:00 a.m. (Not recorded on MAR), and 9:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 a.m., 3:00 p.m. and 10:30 p.m. (Not recorded on MAR) --[DATE] at 4:40 a.m. Review of the facility's pain management policy on [DATE] at 9:15 p.m. read: Pain documentation- All residents will be asked/observed for the presence of pain a minimum of daily. This is documented on the Medication Administration Record (MAR) and/or Point of Care (POC). Use of medications will be documented on the resident MAR/POC. Documentation will include: Date/time of resident's pain. Pain rating prior to intervention(s) utilizing the appropriate pain scale. Non-pharmlogical interventions utilized, as indicated. Pain rating after intervention utilizing the appropriate pain scale. Monitoring for side effects. Nurse signature/initials Any resident with persistent pain control issues will have their medical record presented to the physician for review for additional recommendations. In an interview on [DATE] at approximately 10:05 a.m., with the Director of Nursing (DON) she was infomed of Resident #170's multiple documented occasions from [DATE] through [DATE], the resident refused [MEDICAL TREATMENT] treatments, and the resident interview in which she stated she was refusing [MEDICAL TREATMENT] due to caused by the wound vac. The lack of notification of the attending physician and/or nurse practitioner was also brought to her attention at this time. Additionally, the DON was informed the [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] which had not yet been addressed by the facility. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. No further information provided prior to the determination of an IJ. Review of Resident #170's [MEDICAL TREATMENT] Communication Records found a recommendation from the [MEDICAL TREATMENT] center on [DATE] which read, Discontinue [MEDICATION NAME] per (Name of local [MEDICAL TREATMENT] clinic's medical director). Again on [DATE] the [MEDICAL TREATMENT] clinical sent another recommendation which read, Discontinue [MEDICATION NAME] per (name of local [MEDICAL TREATMENT] clinic's medical director). Review of Resident #170's MAR's for the months of ,[DATE] and ,[DATE] found the resident has received [MEDICATION NAME] daily since [DATE]. The record contained no evidence this recommendation from the [MEDICAL TREATMENT] clinic had been communicated to the attending physician. There was no evidence to suggest this recommendation had been acted upon. Corporate Nurse Registered Nurse (CNRN) #277 provided a computer print-out of what she stated was pre and post administration pain assessments for Resident #170's as needed pain medication at approximately 2:05 p.m. on [DATE]. Upon review of the computer print-out it was noted the times on the computer print-out did not correlate with the actual times the medication was administered. She was asked why the times did not match and she stated, she would have to get back with the surveyor as to why the times did not match. At the time exit on [DATE] she had provided no additional information or explanation. A Review of the Local [MEDICAL TREATMENT] Clinic's plan and goals for Resident #170's which was located in Resident #170's HD book/chart found the following: --Plan for the month of [DATE] (Printed on [DATE]) Continue high protein diet with supplements. --[MEDICATION NAME]- Protein in the blood helps to fight infections and aid in healing; Goal 3.0. --Potassium (K+) - This mineral is needed for normal heart and muscle action. Too much can make your heart stop. Goal 5.0 --Hemoglobin (HGB) - Contains iron and carries oxygen from the lungs to the body. Goal 10.0. --Phosphorus- The right amount helps keep my bones strong and the heart healthy. Goal 3.4 --Calcium, Total- A mineral needed for healthy bones and muscles. Goal 8.3. --Intact [MEDICAL CONDITION] hormone (iPTH) - Balances calcium and phosphorus in the blood. High phosphorus can cause high iPTH and lead to bone and heart damage. Review of local [MEDICAL TREATMENT] clinic's laboratory results for Resident #170 completed on [DATE], for a Complete Metabolic Panel (CMP), Complete Blood Count) and [MEDICAL CONDITION] Function Panel (TFP) results send on [DATE] at 2:48 p.m. and copy was provided to the NHA so Resident #170's attending physician could review the lab results. The following results were abnormal: --Hemoglobin- 9.0- Low (Normal- ,[DATE]) --Ferritin- 1076 - High-(Normal- 10- 291) --Iron - 25 Low-(Normal- ,[DATE]) --BUN- 161- High-before [MEDICAL TREATMENT] and 46 High after [MEDICAL TREATMENT] (Normal- ,[DATE]) --Creatinine- 4.7 High- (Normal- 0.6- 1.3) --Potassium - 6.0 High-(Normal 3XXX,[DATE].1) --[MEDICATION NAME]- 14 Low - (Normal ,[DATE]) --[MEDICATION NAME]- 3.0 Low-(Normal 3XXX,[DATE].2) --Phosphorus 8.8 High (Normal 2.6- 4.5) --PTH-intact Plasma - <7 Low (normal ,[DATE]) After notification of the immediate jeopardy on [DATE], the facility obtained a CMP, CBC, [MEDICAL CONDITION] stimulating hormone (TSH) and a urinalysis and culture and sensitivity of urine. --Hemoglobin- 7.7- Low (Normal- ,[DATE]) --BUN- 135- High- (Normal- ,[DATE]) --Creatinine- 4.0 High- (Normal- 0.6- 1.3) --Potassium - 6.0 High-(Normal 3XXX,[DATE].1) --[MEDICATION NAME]- 2.1- Low-(Normal 3XXX,[DATE].2) --TSH- 7.40 High- (Normal 0.358- 3.74) b) Facility ' s Immediate Plan of Correction --Resident #107 was immediately assessed by the Nurse Practitioner for any health concerns related to pain and refusal of [MEDICAL TREATMENT]. -- Stat labs were ordered, CMP, CBC, TSH, and UA/CS and will be compared with most recent lab from [MEDICAL TREATMENT] upon receipt. --Resident was immediately weighed with a result of 157.5# at 14:22. Resident weighed 162.5 on [DATE]. This is a 5# loss. --Dr. Raheem, attending physician was notified on, [DATE] at 11:15am, regarding resident pain and refusing to attend [MEDICAL TREATMENT] after a discussion with State surveyor. -- All findings will be reviewed with the attending physician for further instruction/orders. --The facility will immediate re-assess all residents that participate in [MEDICAL TREATMENT] for unresolved pain that interferes with compliance to participate in treatment. --The nurse practitioner will assess all [MEDICAL TREATMENT] residents for any concerns related to general health. --Physician will be immediately notified of recommendation to discontinue [MEDICATION NAME]. --All communications from [MEDICAL TREATMENT] will be reviewed for missed recommendations related to treatment to ensure that recommendations have been addressed. --All residents will be re-assessed/evaluated for pain once [MEDICAL TREATMENT] residents have been reviewed to ensure that pain is controlled. --Any concerns identified, related to pain, will be presented to the physician for review/adjustment of pain medication regimen. --The facility will immediately begin re-education on the pain process of identification, assessing, prevention, treatment, and documentation, --The facility will immediately begin education with the Nursing staff on End Stage [MEDICAL CONDITION]/[MEDICAL TREATMENT]. b) Resident #225 Medical record review on [DATE] at 1:30 p.m., found this [AGE] year-old resident had [DIAGNOSES REDACTED]. disorder, depression, mood disorder, post-traumatic stress disorder, and [MEDICAL CONDITION] other than [MEDICAL CONDITIONS] of the right knee. He currently receives hospices services for the [DIAGNOSES REDACTED]. Daily medications included: --[MEDICATION NAME] (an antianxiety medication) 11 milligram (mg) 3 times daily; --[MEDICATION NAME] (antipsychotic medication) 25 mg daily at bedtime; and --[MEDICATION NAME] (an antidepressant medication) 15 mg daily at bedtime. --Additionally, he had a pain medication, [MEDICATION NAME]-[MEDICATION NAME] 7XXX,[DATE] milligrams (mg), 1 every 6 hours as needed (prn) for pain. Review of the medication administration record (MAR) found nursing staff administered the [MEDICATION NAME] 20 times thus far in September. Of that total, nursing staff did not assess the effectiveness of the pain medication on seven (7) occasions; did not assess the severity of the pain or show evidence of trying non-pharmacological methods prior to administering the pain medication on seven (7) occasions; and did not note the location of the resident's pain on those seven (7) occasions. The dates and times as described above, were as follows: --[DATE] at 9:00 a.m. (No documentation of pain effectiveness) --[DATE] at 10:00 p.m. (No documentation of pain effectiveness) --[DATE] at 1:35 p.m. (No documentation of pain effectiveness) --[DATE] at 8:00 p.m. (Nursing documented at 3:19 a.m. that the resident had no pain at this time.) --[DATE] at 8:00 p.m. (Nursing documented at 11:10 p.m. that the resident had no pain at this time.) --[DATE] at 8:00 p.m. (Nursing documented at 11:20 p.m. that the resident had no pain at this time.) --[DATE] at 9:00 p.m. (Nursing documented at 12:14 a.m. on [DATE] that the resident had no pain at this time. During an interview at 5:45 p.m. on [DATE], the director of nursing (DON) reviewed the resident ' s MAR, the nurses ' progr

Based on record review, staff interview, policy review and resident interview, the facility failed to assess and treat Resident #170's pain in accordance with professional standards which has been a primary factor in her refusing to go to [MEDICAL TREATMENT]. Her refusals of [MEDICAL TREATMENT] has the potential to cause serious harm and/or death. The resident has already suffered actual harm by the facility's failure to treat her pain on multiple occasions. The resident since [DATE] has refused to go to six (6) out of eight (8) [MEDICAL TREATMENT] treatments ([DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). Resident #170 only recieved one full treatment since the placement of the wound vac on [DATE]. She did go to [MEDICAL TREATMENT] on [DATE], but her treatment had to be stopped after seventy-nine (79) minutes because of the residents complaints of pain. The clinical diretor of the local dialyis center during and interview on [DATE] at 1:35 p.m. stated the resident was complaining of pain related to her wound vac on [DATE] and that is why her treatment had to be stopped. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner was notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] the facility did not address this. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. The failures to assess and treat the residents pain which has caused her to refuse [MEDICAL TREATMENT] has resulted in Resident #170 being at immediate risk for serious harm and/or death. This has resulted in the determination of an immediate jeopardy. The nursing home administrator (NHA) and the Director of Nursing (DON) were notified of the immediate jeopardy at ¿¿¿¿1:45 p.m. on [DATE]. The facility provided a plan of correction to the State agency at 5:33 p.m. on [DATE], which the State agency reviewed and accepted at 5:35 p.m. on [DATE]. The State agency then observed for implementation of the plan of correction and abated the immediacy at 11:05 p.m. on [DATE]. This immediate jeopardy began on [DATE], when the facility first failed to provide appropriate assessment of pain and pain management techniques by not notifying Resident #170's attending physician and/or nurse practitioner when she refused to go to [MEDICAL TREATMENT] treatments due to the pain caused by the [DEVICE]. After the immediacy was removed, a deficient practice remained for the following and the scope and severity was decreased to an K . Additionally, for Resident #170, the facility failed to correlate care between the facility and the [MEDICAL TREATMENT] center and failed to administer the Renavela as directed by the nephrologist. For Resident #225, the facility failed to provide effective pain management by failing to assess his level of pain prior to and timely reassess after the administration of an as needed (PRN) pain medication. These issues were found for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT] and for one (1) of five (5) reviewed for the care area of unnecessary medications. Resident identifier: #170 and #225. Facility census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on [DATE] found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The medical record, reviewed on [DATE] at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of the nurses' progress notes found Resident #170 was admitted to the facility on [DATE] at 5:35 p.m. Further review of the nursing progress notes found a note written by Employee #282, LPN, on [DATE] at 4:55 p.m. which read, Worsening [MEDICAL CONDITION] to bilateral lower extremities and resident missed [MEDICAL TREATMENT] yesterday. The resident has orders for the following advance directives: CPR (cardiopulmonary resuscitation). Resident admitted to this facility on [DATE]. Skin warm and dry. Respirations even and non-labored. Denies cough or shortness of breath. Resident is becoming short of breath when lying flat or turning in bed. Oxygen saturation is 96% (percent) on room air. Observed 3+ (plus) [MEDICAL CONDITION] to bilateral lower extremities. Notified the NP earlier today with no new orders received. As day has progressed, [MEDICAL CONDITION] has worsened and is now non-pitting. Resident states she was due [MEDICAL TREATMENT] yesterday and was not sent. A progress note written on [DATE] at 11:21 p.m. by Employee #199, registered nurse (RN) read, Per (Name of Hospital) was admitted to hospital for [MEDICAL TREATMENT], [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #170 was re-admitted to the facility on [DATE] after receiving treatment for [REDACTED].#273). Physician orders [REDACTED].#273) read: --Wound care per previous orders. --Daily weight, report increase in [MEDICAL CONDITION] or shortness of breath to physician (#273) --Follow-up at facility by attending physician (#273) --[MEDICAL TREATMENT] as previous (Tuesday, Thursday and Saturday) --Transferring physician (#273) and admit to facility under my service. --admitting [DIAGNOSES REDACTED]. --Code status: Full Code --[MEDICATION NAME] coated Aspirin 81 mg by mouth daily. --[MEDICATION NAME] 50mg by mouth at bedtime --[MEDICATION NAME] 50 mcg topically every three (3) days. --[MEDICATION NAME] 17 grams by mouth every day. --[MEDICATION NAME] 12.5 mg by mouth twice daily, (Hold if systolic blood pressure is 100 or below). --[MEDICATION NAME] 10mg by mouth daily --[MEDICATION NAME] 40 mg by mouth daily --[MEDICATION NAME] 7.5 mg by mouth at bedtime --[MEDICATION NAME] 3,200 mg by mouth three times daily with meals. --[MEDICATION NAME] 200mg by mouth three times daily --[MEDICATION NAME] 50 mcg by mouth daily --Dosage of [MEDICATION NAME] will be advised after looking at the [MEDICATION NAME] time/international ratio (PT/INR) tomorrow ([DATE]) --[MEDICATION NAME] 0.25 mg by mouth daily -- Fluid restrictions --[MEDICATION NAME] 325 mg by mouth three times daily --[MEDICATION NAME] ,[DATE] mg by mouth every 6 hours prn Review of the readmission orders [REDACTED]. No orders for fluid restrictions could be found. Additionally, a review of the MAR for ,[DATE] and ,[DATE] found the medication [MEDICATION NAME] was administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m. This medication should have been, administered at meal times which would have been 7:30 a.m., 12:00 p.m. and 5:30 p.m. Review of the Physician Desk Reference (PDR) read, [MEDICATION NAME]® (sevelamer [MEDICATION NAME]) is indicated for the control of serum phosphorus in patients with [MEDICAL CONDITION] (CKD) on [MEDICAL TREATMENT]. [MEDICATION NAME] (sevelamer) is a [MEDICATION NAME] binder. Sevelamer helps prevent [DIAGNOSES REDACTED] (low levels of calcium in the body) caused by elevated phosphorus. This medication should be taken with meals. During an interview on [DATE] at approximately 3:15 p.m. with local [MEDICAL TREATMENT] center's medical director (nephrologist) it was confirmed the [MEDICATION NAME] should be given with meals otherwise the medication is useless. Further review of the record found a, new patient history and physical completed on [DATE] by Physician #272 read, Patient Was admitted from (Name of hospital #1) with a [DIAGNOSES REDACTED]. Patient was admitted to my services but resident requests to be changed to (Name of physician #273) as he is her regular doctor. Continue current pain regimen. Staff to monitor for pain per facility policy. [MEDICATION NAME] ,[DATE]mg by mouth every six (6) hours prn for pain. Consultation report written on [DATE] by Physician #275, vascular and wound care specialist read, Non-ambulatory. Sacral ulcer- 4 centimeters (cm) in length and 3 cm in width. Stage III- IV. The right heel is fully healed. + Coagulant ([MEDICATION NAME]). Plan- Needs to change dressing to a [DEVICE] to the sacral ulcer. Review of the Treatment Administration Record (TAR) for the month ,[DATE] found the following, Cleanse Stage IV pressure ulcer to sacrum with IHWC (In House Wound Cleanser), pat dry, apply wound vac (vacuum) @ (at) 125 mm(millimeters)/hg (of mercury) every 3 (three) days and prn (as needed) . This had a start date of [DATE]. Review of Resident #170's [MEDICAL TREATMENT] record from [DATE] to [DATE] found the following: --From [DATE] to [DATE]- Resident #170 was ordered a 240 minute [MEDICAL TREATMENT] treatment three times a week. The following occasions are the actual days and times Resident #170 received [MEDICAL TREATMENT]. --[DATE]- 190 minutes of treatment. --[DATE]- 208 minutes of treatment --[DATE]-239 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE] through [DATE]- Resident hospitalized --[DATE]- 206 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-219 minutes of treatment --[DATE]- 244 minutes of treatment --[DATE]- 196 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]-0 minutes of treatment --[DATE]-237 minutes of treatment --[DATE]- 233 minutes of treatment --[DATE]- 137 minutes of treatment --[DATE]- 200 minutes of treatment --[DATE]- 89 minutes of treatment --[DATE]- 242 minutes of treatment --[DATE] through [DATE]- Resident was hospitalized --[DATE]- 149 minutes of treatment --[DATE]- 253 minutes of treatment --[DATE]- 241 minutes of treatment --[DATE]- 145 minutes of treatment --[DATE]- 173 minutes of treatment --[DATE]- 255 minutes of treatment --[DATE]- 175 minutes of treatment --[DATE]- 93 minutes of treatment --[DATE]- 236 minutes of treatment --[DATE]- 212 minutes of treatment --[DATE]- 179 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 237 minutes of treatment --From [DATE] through [DATE] Resident #170 was ordered a 210 minute [MEDICAL TREATMENT] treatment three times a week. The following are the actual dates and times she received [MEDICAL TREATMENT]. --[DATE]- 215 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE] through [DATE]- Resident hospitalized . -- [DATE] 0 minutes of treatment ( A nurses noted dated [DATE] that the resident stated to the nurse, she was due [MEDICAL TREATMENT] yesterday and was not sent. Resident #170 later that day was sent to the hospital and was admitted for [MEDICAL TREATMENT], [MEDICAL CONDITION], and [MEDICAL CONDITION]) --[DATE] through [DATE]- Resident hospitalized --[DATE]- 217 minutes of treatment --[DATE]- 214 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 211 minutes of treatment --[DATE]-100 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 210 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 0 minutes of treatment --[DATE]- 79 minutes of treatment -- [DATE] - 0 minutes of treatment. --[DATE]- 0 minutes of treatment In summary from [DATE] through [DATE] resident had the opportunity to go to the [MEDICAL TREATMENT] center for her [MEDICAL TREATMENT] treatment 39 times this is not counting the times the resident was in the hospital because on those dates she was receiving [MEDICAL TREATMENT] at the hospital and could not go in center to get [MEDICAL TREATMENT] even if she wanted to. Of those 39 opportunities resident #170 missed only 7 treatments in their entirety. Of note, one of those treatments was on [DATE] which the resident stated she was not sent by the facility too the [MEDICAL TREATMENT] treatment. She did not refuse this treatment. Upon placement of the resident wound vac on [DATE] through present Resident #170 had the opportunity to go in center for a [MEDICAL TREATMENT] treatment a total of eight (8) times. Of those eight (8) opportunities the resident missed six (6) of those treatments in their entirety. During an Interview with the Chief Medical Officer (CMO) #271 at 10:20 a.m. on [DATE], he stated that Resident #170 had a long history of refusing [MEDICAL TREATMENT]. Also, during an interview with the Medical Director #272 at 12:13 p.m. on [DATE] it was also mentioned Resident #170 had a long history of refusing [MEDICAL TREATMENT]. These statements were not supported by the local [MEDICAL TREATMENT] centers records which showed Resident #170 only missed six (6) out of 38 possible treatments from [DATE] through [DATE]. However, after the wound vac placement she missed six (6) of the eight (8) possible treatments from [DATE] through [DATE] because of what she stated to be pain caused by the wound vac. Review of Resident #170's [MEDICAL TREATMENT] records from [DATE] thru [DATE], Missed HD treatment report and staff interviews, found that beginning on [DATE] through [DATE] Resident #170 either missed or had her [MEDICAL TREATMENT] treatments cut short for the following reasons: --On [DATE], a nursing progress note indicated, Resident refused [MEDICAL TREATMENT]. States she does not feel good. --[DATE], a nursing progress note indicated, Patient went to [MEDICAL TREATMENT] today. Explained the importance of her completing her [MEDICAL TREATMENT] treatment completely for her heath. Patient agreed to go and would try to complete treatment today. --[DATE], nursing progress note indicated, Resident c/o (complains of) wound vac hurting her. Wing nurse notified and resident stated she was medicated. (Name of MD #275) notified and decreased intensity to 50 mmHg per order for two hours and resident continued to c/o the wound vac bothering her and request it be taken off. (Name of MD #275) notified and gave order to hold vac and gave dressing orders until Sunday if he comes and if not, he will evaluate when next in facility. Resident aware. No [MEDICAL TREATMENT] scheduled on this date but information pertinent due to the resident complaining of pain related to her wound vac. --[DATE], nursing progress note indicated, Resident refused to go to [MEDICAL TREATMENT]. States her back is hurting. --[DATE], nursing progress note indicated, Resident agreed to resume wound vac to sacrum. Applied wound vac with no s/s (signs or symptoms) of pain or complications will continue to monitor. -- [DATE], nursing progress note indicated, . Goes to [MEDICAL TREATMENT] Tues., Thurs., and Sat; however resident refused this morning d/t wound vac for sacral ulcer. Often refuses to go to [MEDICAL TREATMENT] . -- [DATE], nursing progress note indicated, Patient refused to go to [MEDICAL TREATMENT] after 3 attempts by the nurse to get her to go. Attempted to explain the importance of completing her [MEDICAL TREATMENT] treatment but she continuously refuses. --No nursing notes for [DATE]. However the [MEDICAL TREATMENT] Communication record indicated the resident was experiencing pain and was crying until her treatment was stopped per her request. She only completed 79 minutes of her 240 minute treatment. --No nursing progress notes for [DATE] pertaining to Resident #170's [MEDICAL TREATMENT] treatment, however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on this date. --No nursing progress notes for [DATE] however the Missed HD Treatment Report indicated the resident did not go to [MEDICAL TREATMENT] on this date. In an interview with Resident #170 on [DATE] at 9:35 a.m., the resident stated she did not go to [MEDICAL TREATMENT] today due to her wound vac hurting. She further explained she has chronic pain, but since the wound vac was placed she has experienced more pain and discomfort. She further indicated that since the placement of the wound vac she has had to miss several of her [MEDICAL TREATMENT] treatments due to pain. Resident #170 missed a total of six (6) of her last eight (8) [MEDICAL TREATMENT] treatments since the placement of the wound vac on [DATE]. Of the two (2) treatment she did attend she only completed one full treatment. On [DATE] the residents [MEDICAL TREATMENT] treatment was cut 131 minutes short. There is no evidence in Resident #170's medical record that her attending physician was notified of her missed [MEDICAL TREATMENT] treatments and/or her increased pain associated with the use of her wound vac. A review of Resident #170's controlled medication sheets for her ordered as needed [MEDICATION NAME] found the following, -- [DATE] the resident refused to go to [MEDICAL TREATMENT] due to pain. She was scheduled to leave for [MEDICAL TREATMENT] at 5:30 a.m. however she only received two (2) doses of [MEDICATION NAME] on this date one (1) at 12:00 p.m. and one (1) at 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] which she was scheduled to be picked up for at 5:30 a.m. because of back pain. She did not receive her as needed pain medication until 6:00 a.m. she also received additional doses at 1:30 p.m. and 9:00 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] due to pain from her wound vac. The resident ' s pick up time was scheduled for [MEDICAL TREATMENT] pick up at 5:30 a.m. She did not receive her as needed pain medication until 6:00 a.m., 12:00 p.m., and 9:00 p.m. -- [DATE] the patient had refused to go to [MEDICAL TREATMENT] after three attempts she did not receive pain medication until 10:30 a.m. and 5:30 p.m. Please note the nursing note did not mention why the resident refused [MEDICAL TREATMENT] however, interviews with the resident confirmed she had been refusing [MEDICAL TREATMENT] due to pain from the wound vac. --[DATE] Resident #170 returned from [MEDICAL TREATMENT] after only receiving a 79 minutes treatment when she was scheduled to receive a 240 minute treatment. The [MEDICAL TREATMENT] center wrote on the communication form that Resident #170 ' s treatment had to be stopped because she was crying in pain. She arrived back to the facility at approximately 9:00 a.m. and she received pain medication at 4:30 a.m. and 5:30 p.m. -- [DATE] Resident #170 refused to go to [MEDICAL TREATMENT] she did not receive pain medication until 9:00 a.m. and 9:00 p.m. even though her scheduled pick up time for [MEDICAL TREATMENT] was 5:30 a.m. -- [DATE] Resident #170 again refused to go to [MEDICAL TREATMENT] she had receive pain medication at 4:40 a.m. on this date. -- [DATE], [DATE] and [DATE] the location of the residents and/or complaints of pain were not noted in the medical record. She did however, refuse [MEDICAL TREATMENT] on these dates. An interview with Resident #170 on [DATE] at 9:35 a.m. revealed she had been refusing to go to [MEDICAL TREATMENT] because of pain associated with her wound vac. She indicated she had told the staff about it and this was the reason she could not do her [MEDICAL TREATMENT]. The resident was also interviewed prior to this conversation by a different surveyor on [DATE] at 1:10 p.m. During this interview Resident #170 also stated that she had not been going to [MEDICAL TREATMENT] because of the pain she was experiencing from her wound vac. On [DATE] Resident #170's [MEDICAL TREATMENT] treatment ended after 79 minutes due to complaints of pain as noted by the [MEDICAL TREATMENT] clinic. At 1:35 p.m. on [DATE] the clinical director of the local [MEDICAL TREATMENT] center was interviewed. She was asked if the facility needed to set up a new chair time (scheduled time for [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center) when Resident #170 was admitted to thier facility she replied, No we do not give up thier chair time when they are in the hospital. She stated, she would have had the same cahir time and no arrangements were needed. When asked why Resident #170's treatment was cut short on [DATE] she stated, Because of pain related to her wound vac. She indicated Resident #170 had at times refused [MEDICAL TREATMENT] prior to the placement of the wound vac, but since its placement these have increased drastically. Further review of the Resident #170's controlled substance utilization record found the following dates and times when Resident #170 was administered her prescribed as needed pain medication with no assessment of where the pain was located, the intensity of the pain prior to administration, and no follow up assessment to determine if the pain medication was effective in relieving the resident pain: --[DATE] at 10:00 a.m. and 6:00 p.m. --[DATE] at 12:00 a.m., 1:00 a.m., and 9:10 p.m. --[DATE] at 4:30 a.m. and 9:00 p.m. --[DATE] at 10:00 p.m. --[DATE] at 9:00 a.m. and 9:00 p.m. --[DATE] at 9:00 a.m. (Not noted on MAR) and 9:00 p.m. --[DATE] at 5:00 a.m. (Marked not given, Wasted on Narcotic sheet), 12:00 p.m. and 9:15 p.m. (Not recorded on MAR). --[DATE] at 7:00 a.m. and 6:00 p.m. --[DATE] at 12:00 a.m. (Not recorded on MAR, 2:00 p.m. (Not recorded on MAR, and 10:00 p.m. (Not recorded on MAR). --[DATE] at 6:20 a.m. and 10:00 p.m. --[DATE] at 12:00 p.m. and 9:30 p.m. --[DATE] at 1:25 p.m. (Not recorded on MAR) and 8:00 p.m. --[DATE] at 5:30 a.m., 11:30 a.m. (Not recorded on MAR) and 6:00 p.m.( Not recorded on MAR) --[DATE] at 12:00 p.m., and 9:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 a.m., 4:30 p.m. and 11:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 p.m. --[DATE] at 11:00 a.m. and 5:00 p.m. --[DATE] at 6:00 a.m., 1:30 p.m., and 9:00 p.m. --[DATE] at 6:30 a.m., 2:30 p.m. (Not recorded on MAR) and 10:30 p.m. --[DATE] at 9:30 a.m. (Not recorded on MAR) and 9:00 p.m. --[DATE] at 6:00 a.m. (Not recorded on MAR). 12:00 p.m. and 9:00 p.m. --[DATE] at 5:00 a.m. (Not recorded on MAR), and 10:30 p.m.( Not recorded on MAR) --[DATE] at 10:30 a.m. and 5:30 p.m. --[DATE] at 5:30 a.m., 5:00 p.m. (Not recorded on MAR)., and 11:00 p.m.( Not recorded on MAR) --[DATE] at 4:30 a.m., and 5:30 p.m. ( Not recorded on MAR) --[DATE] at 5:00 a.m., 2:00 p.m., and 9:00 p.m. --[DATE] at 9:00 a.m., 2:25 p.m. and 9:00 p.m. --[DATE] at 9:00 a.m. (Not recorded on MAR), and 9:00 p.m. (Not recorded on MAR) --[DATE] at 9:00 a.m., 3:00 p.m. and 10:30 p.m. (Not recorded on MAR) --[DATE] at 4:40 a.m. Review of the facility's pain management policy on [DATE] at 9:15 p.m. read: Pain documentation- All residents will be asked/observed for the presence of pain a minimum of daily. This is documented on the Medication Administration Record (MAR) and/or Point of Care (POC). Use of medications will be documented on the resident MAR/POC. Documentation will include: Date/time of resident's pain. Pain rating prior to intervention(s) utilizing the appropriate pain scale. Non-pharmlogical interventions utilized, as indicated. Pain rating after intervention utilizing the appropriate pain scale. Monitoring for side effects. Nurse signature/initials Any resident with persistent pain control issues will have their medical record presented to the physician for review for additional recommendations. In an interview on [DATE] at approximately 10:05 a.m., with the Director of Nursing (DON) she was infomed of Resident #170's multiple documented occasions from [DATE] through [DATE], the resident refused [MEDICAL TREATMENT] treatments, and the resident interview in which she stated she was refusing [MEDICAL TREATMENT] due to caused by the wound vac. The lack of notification of the attending physician and/or nurse practitioner was also brought to her attention at this time. Additionally, the DON was informed the [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] which had not yet been addressed by the facility. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. No further information provided prior to the determination of an IJ. Review of Resident #170's [MEDICAL TREATMENT] Communication Records found a recommendation from the [MEDICAL TREATMENT] center on [DATE] which read, Discontinue [MEDICATION NAME] per (Name of local [MEDICAL TREATMENT] clinic's medical director). Again on [DATE] the [MEDICAL TREATMENT] clinical sent another recommendation which read, Discontinue [MEDICATION NAME] per (name of local [MEDICAL TREATMENT] clinic's medical director). Review of Resident #170's MAR's for the months of ,[DATE] and ,[DATE] found the resident has received [MEDICATION NAME] daily since [DATE]. The record contained no evidence this recommendation from the [MEDICAL TREATMENT] clinic had been communicated to the attending physician. There was no evidence to suggest this recommendation had been acted upon. Corporate Nurse Registered Nurse (CNRN) #277 provided a computer print-out of what she stated was pre and post administration pain assessments for Resident #170's as needed pain medication at approximately 2:05 p.m. on [DATE]. Upon review of the computer print-out it was noted the times on the computer print-out did not correlate with the actual times the medication was administered. She was asked why the times did not match and she stated, she would have to get back with the surveyor as to why the times did not match. At the time exit on [DATE] she had provided no additional information or explanation. A Review of the Local [MEDICAL TREATMENT] Clinic's plan and goals for Resident #170's which was located in Resident #170's HD book/chart found the following: --Plan for the month of [DATE] (Printed on [DATE]) Continue high protein diet with supplements. --[MEDICATION NAME]- Protein in the blood helps to fight infections and aid in healing; Goal 3.0. --Potassium (K+) - This mineral is needed for normal heart and muscle action. Too much can make your heart stop. Goal 5.0 --Hemoglobin (HGB) - Contains iron and carries oxygen from the lungs to the body. Goal 10.0. --Phosphorus- The right amount helps keep my bones strong and the heart healthy. Goal 3.4 --Calcium, Total- A mineral needed for healthy bones and muscles. Goal 8.3. --Intact [MEDICAL CONDITION] hormone (iPTH) - Balances calcium and phosphorus in the blood. High phosphorus can cause high iPTH and lead to bone and heart damage. Review of local [MEDICAL TREATMENT] clinic's laboratory results for Resident #170 completed on [DATE], for a Complete Metabolic Panel (CMP), Complete Blood Count) and [MEDICAL CONDITION] Function Panel (TFP) results send on [DATE] at 2:48 p.m. and copy was provided to the NHA so Resident #170's attending physician could review the lab results. The following results were abnormal: --Hemoglobin- 9.0- Low (Normal- ,[DATE]) --Ferritin- 1076 - High-(Normal- 10- 291) --Iron - 25 Low-(Normal- ,[DATE]) --BUN- 161- High-before [MEDICAL TREATMENT] and 46 High after [MEDICAL TREATMENT] (Normal- ,[DATE]) --Creatinine- 4.7 High- (Normal- 0.6- 1.3) --Potassium - 6.0 High-(Normal 3XXX,[DATE].1) --[MEDICATION NAME]- 14 Low - (Normal ,[DATE]) --[MEDICATION NAME]- 3.0 Low-(Normal 3XXX,[DATE].2) --Phosphorus 8.8 High (Normal 2.6- 4.5) --PTH-intact Plasma - <7 Low (normal ,[DATE]) After notification of the immediate jeopardy on [DATE], the facility obtained a CMP, CBC, [MEDICAL CONDITION] stimulating hormone (TSH) and a urinalysis and culture and sensitivity of urine. --Hemoglobin- 7.7- Low (Normal- ,[DATE]) --BUN- 135- High- (Normal- ,[DATE]) --Creatinine- 4.0 High- (Normal- 0.6- 1.3) --Potassium - 6.0 High-(Normal 3XXX,[DATE].1) --[MEDICATION NAME]- 2.1- Low-(Normal 3XXX,[DATE].2) --TSH- 7.40 High- (Normal 0.358- 3.74) b) Facility ' s Immediate Plan of Correction --Resident #107 was immediately assessed by the Nurse Practitioner for any health concerns related to pain and refusal of [MEDICAL TREATMENT]. -- Stat labs were ordered, CMP, CBC, TSH, and UA/CS and will be compared with most recent lab from [MEDICAL TREATMENT] upon receipt. --Resident was immediately weighed with a result of 157.5# at 14:22. Resident weighed 162.5 on [DATE]. This is a 5# loss. --Dr. Raheem, attending physician was notified on, [DATE] at 11:15am, regarding resident pain and refusing to attend [MEDICAL TREATMENT] after a discussion with State surveyor. -- All findings will be reviewed with the attending physician for further instruction/orders. --The facility will immediate re-assess all residents that participate in [MEDICAL TREATMENT] for unresolved pain that interferes with compliance to participate in treatment. --The nurse practitioner will assess all [MEDICAL TREATMENT] residents for any concerns related to general health. --Physician will be immediately notified of recommendation to discontinue [MEDICATION NAME]. --All communications from [MEDICAL TREATMENT] will be reviewed for missed recommendations related to treatment to ensure that recommendations have been addressed. --All residents will be re-assessed/evaluated for pain once [MEDICAL TREATMENT] residents have been reviewed to ensure that pain is controlled. --Any concerns identified, related to pain, will be presented to the physician for review/adjustment of pain medication regimen. --The facility will immediately begin re-education on the pain process of identification, assessing, prevention, treatment, and documentation, --The facility will immediately begin education with the Nursing staff on End Stage [MEDICAL CONDITION]/[MEDICAL TREATMENT].

Part I Based on record review, staff interview, and family interview, the facility failed to ensure the resident environment was as free of accident hazards as possible for one (1) of nine (9) sample residents,and failed to provide adequate supervision during meal times. A resident with a known swallowing problem received the incorrect diet and was not provided with adequate supervision to prevent choking. Resident #142 was on a mechanical soft diet with ground meat, was not to receive bread, and her foods (fruits and vegetables) were to be cut in small pieces. She was served a whole hot dog on a bun resulting in her becoming choked requiring hospitalization . This practice resulted in actual harm for the resident. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, "Resident was noted to be choking. Heimlich maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . . . ." She was transferred to the hospital by ambulance at 7:20 p.m. A review of the physician orders [REDACTED].#142 was to receive a mechanical soft diet (ground meat) with no bread and her food (such as fruits and vegetables) was to be cut into small pieces. Further review of the medical record revealed the resident was transferred to the hospital on [DATE]. According to her hospital records, she was admitted due to "aspiration." During her hospitalization she received TPN (total pretrial nutrition). She returned to the facility on [DATE] with physician's orders [REDACTED]. There were no restrictions in this order indicating she was to have "no bread" or to "cut food up into small pieces," which were interventions in place prior to her hospitalization . These instructions were included on the dietary card which was on the tray when the resident was served her meals. The care plan in effect prior to the resident's hospitalization was reviewed. This care plan did not identify any issues with swallowing problems. The instructions included in her orders were not specified in the care plan for the staff providing care. The care plan did not reflect she was not to have bread or that her food was to be cut in small pieces or that she had any swallowing issues that needed to be monitored. The Speech Pathologist (Employee #171) was interviewed 04/22/14 at 10:00 a.m. She stated this resident should not have had bread and her food should have been cut into bite sized pieces. She also said she should have had ground meats. She said the resident was on the Red Napkin program because she had decreased intake. The red napkin also meant she required supervision. Employee #171 said she had seen the resident in the past and recommended "no bread" and her food to be cut in small pieces. This was included in her physician orders. The instructions were written on the resident's dietary card as a dislike to remind the kitchen not to give her bread. This was not because she did not like bread, but she should not have it due to swallowing problems. She stated these precautions should have been continued when the resident came back from the hospital. Employee #171 said she was treating the resident for swallowing, but did not realize the precautions previously put in place were not continued. It was still written on the tray card that accompanied the resident's meal each day. She confirmed anytime someone went to the hospital and had restrictions put in place by Speech Therapy, those should be continued when the resident returned. Speech therapy would evaluate the resident when he/she returned and if there were changes, new recommendations would be written. During an interview with the dietitian (Employee #229) on 04/22/14 at 10:15 a.m., she said speech therapy had made a recommendation for Resident #142 to have "no bread" due to the resident's unsafe swallowing. This instruction was written on the resident's dietary card and listed as a "dislike," but was not really a dislike. It was just written as a dislike to remind the kitchen not to give it to her. She confirmed that all of the residents in the facility, who had a bread restriction due to unsafe swallowing, had bread written in the dislikes so they would not receive it. She said none of these were truly dislikes, it was for swallowing issues. She stated the kitchen staff knew if the ticket had the resident disliked bread, the resident should not be given bread. In an interview with the dietary manager (Employee #228) on 04/22/14 at 10:20 a.m., she said Resident #142 should not have had a whole hot dog or a bun. She said the diet recorded in the kitchen stated the resident was to have a mechanical soft diet (ground meat) with no bread. She said the no bread restriction was carried over from before she went to the hospital because they carry these restrictions forward unless they are changed or discontinued. On 04/22/14 at 9:45 a.m., a registered nurse, Employee #22 (Assistant Director of Nursing), was asked how the the facility ensured restrictions and precautions, that had been in place prior to a resident's hospitalization , were continued when the resident returned. She said after so many days the computer discontinued these interventions and the resident was addressed as a new admission. She said the nurses have to look at the prior record for things like restrictions, that were previously part of their care, to see if those should be continued. She was specifically questioned about Resident #142's swallowing issues and the order for "no bread and cut the food into small pieces." She stated those restrictions should have been included when the nurse wrote the orders upon the resident's return from the hospital, or at least discussed with the physician. She verified there was no evidence this was reviewed when the resident returned from the hospital. A telephone interview was conducted with Resident #142's son on 04/22/14 at 2:00 p.m. He said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. The son stated he was standing at the door and the "girl" handed him his mother's tray. He verified the nursing assistant did not open it or look at it, she just gave it to them with the lid still covering the food. He stated when they saw the food on the tray he said to his mother, "Are you sure you are allowed to have that?" He said he was concerned about her having a whole hot dog because the facility had called him the night before and told him Speech Therapy was going to evaluate her because she was having swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. The hospital had fed her through her veins with an IV (intravenously with TPN - total parenteral nutrition). He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth and he tried to get her to spit it out. She choked and he yelled for help. A telephone interview was conducted with a nursing assistant (Employee #161) 04/22/14 at 7:30 p.m. She confirmed she had been the nursing assistant responsible for Resident #142 on the evening of 03/26/14. She stated she took the tray off the cart and gave it to the son who was visiting his mother. She verified she did not remove the lid and look at the resident's tray. She could not confirm whether the resident received the correct diet, because she did not see it, she just gave the tray to the family. The Director of Nursing was interviewed on 04/23/14 at 2:00 p.m. She stated she was present the night of the choking incident involving Resident #142. She said she was still in the facility that evening and heard the page over the loud speaker for a nurse to come immediately to the resident's room. She stated when she went to the room, staff were performing the Heimlich maneuver on Resident #142. She said she immediately went to the resident's tray and found one-third (1/3) of a whole hot dog on the tray. She stated the resident's tray card was laying on her tray. It indicated the resident was to receive a mechanical soft diet with no bread. She immediately identified the resident was served the incorrect diet. She had a whole hot dog, that was not ground, and it was on a bun. She said, prior to leaving the facility, she made sure there were no other residents who had received the wrong diet. The director of nursing stated the nursing assistants were supposed to look at the trays as they were served to make sure the resident received the correct diet. The residents' diet cards were placed on their trays as a way to double check. Part II Based on observation and staff interview, the facility failed to ensure the environment was as safe and free of accident hazards as possible.. Potentially hazardous items were in residents' rooms on the "A" unit. This had the potential to affect more than an isolated number of residents. Facility census: 141. Findings include: a) Room 210 During an observation on 04/22/14 at 11:55 a.m., a container of Clorox disinfecting wipes were observed on the floor just inside the door of Room 210. Review of the label on the Clorox disinfecting wipes found the wipes were for cleaning surfaces. The precautionary statements included, "Hazardous to Humans." A warning on the label also stated "Not for cleaning or sanitizing skin. Do not use as diaper wipe or personal cleansing." There was also a warning that stated "Keep out of reach of Children." On 04/22/14 at 12:00 p.m., Employee #36, a nurse aide, confirmed these wipes were in the room and should not be. They were immediately removed from the room. b) Room A-SPC During a tour of the environment on the "A" unit, on 04/22/14 at 4:00 p.m., there were potentially harmful items on a bedside table in Room A-SPC. These items included eye drops (artificial tears), Max Vision vitamins, Dyna-Hex surgical cleanse, Aspercreme, and a disinfectant spray with a label that stated "Keep out of reach of Children." The nurse (Employee #41), who was present at the time of these observations, immediately removed the items. She confirmed these items were not to be in the room and accessible to residents. She also verified there was only one (1) resident occupying the room, and she was in the hospital at that time. .

Based on record review, staff interview, and family interview, the facility failed to implement procedures to ensure residents were free of neglect. The facility failed to provide care and services to ensure residents received the correct diet to prevent choking. The facility did not ensure restrictions regarding swallowing were implemented for Resident #142. The resident did not receive a mechanical soft diet as ordered by the physician, but was served a whole hot dog (not ground) on a bun. As a result of being served the incorrect diet, the resident experienced actual harm when she choked and was sent to the hospital. Subsequently, the facility's investigation of the occurrence failed to identify the resident did not receive a mechanical soft diet as ordered. As a result the facility did not implement measures to prevent this from reoccurring for this resident or other residents. Staff gave inconsistent responses regarding what swallowing restrictions were in place upon her return from the hospital. This was true for one (1) of nine (9) sampled residents and had the potential to affect more than an isolated number of residents who received a mechanically altered diet. Fifty-two (52) residents were receiving mechanically altered diets at the time of the survey. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, "Resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . . . ." She was transferred to the hospital by ambulance at 7:20 p.m. A review of the physician's orders [REDACTED].#142 was to receive a mechanical soft diet with no bread, and her food was to be cut into small pieces. Further review of the resident's medical record found that on 03/02/14, the resident experienced vomiting and had a decreased level of consciousness. She was transferred to the hospital, where, according to the hospital records, she was admitted due to "aspiration (entry of foreign material into the airway)." During her hospitalization , she received total [MEDICATION NAME] nutrition (TPN - which is nutrition provided intravenously (IV)). She returned to the facility on [DATE] with physician's orders [REDACTED]. Her readmission orders [REDACTED]" which were interventions put in place prior to her hospitalization on [DATE]. These restrictions were, however, included on the resident's dietary card that was on the tray with her meals. She was also to receive a speech therapy evaluation. Review of the resident's plan of care in effect prior to the resident's hospitalization on [DATE], and the care plan revised when she returned on 03/24/14, found the plans did not identify any issues with swallowing problems or any special precautions to be taken for this resident. There were no instructions provided for the amount of supervision needed. Prior to her discharge to the hospital on [DATE], the resident had a recommendation from the Speech Therapist for "No Bread" and for her food to be cut into bite sizes pieces in addition to the mechanical soft diet. It was unclear if this restriction was to be continued when she returned from the hospital because theses interventions were not included in the resident's care plan in effect prior to her admission to the hospital with aspiration. The care plan was not individualized to identify this resident's specific problem, but stated "provide diet as ordered." In an interview with the Speech Pathologist (Employee #171), on 04/22/14 at 10:00 a.m., she stated this resident should not have had bread and her food (fruits and vegetables) should have been cut into bite size pieces. She also said the resident should have had ground meats and not a whole hot dog. According to the Speech Pathologist, the resident was on the Red Napkin program because she had decreased intake. The Red Napkin also meant the resident required supervision. Employee #171 said she had seen the resident in the past and recommended no bread and for the resident's food to be cut in small pieces. She commented this was included on the resident's physician's orders [REDACTED]. This was not because the resident did not like bread, but she should not have it due to her swallowing problems. The Speech Pathologist stated this precaution should have been continued when the resident came back from the hospital. Employee #171 said she was treating the resident for swallowing problems, but did not realize the precautions previously put in place were not continued. This information was still written on her tray card that came with her meal each day. She confirmed anytime a resident went to the hospital and had restrictions put in place by the Speech Therapist, the restrictions should continue when the resident returned. During an interview with the dietitian (Employee #229), on 04/22/14 at 10:15 a.m., she indicated speech therapy had made recommendations for Resident #142 to have "no bread." She said this recommendation was made due to the resident's unsafe swallowing. "No bread" was written on the resident's dietary card and listed as a "dislike," but was not really a dislike. It was just written as a dislike to remind the kitchen not to give bread to the resident. She said all of the residents in the facility who had a bread restriction due to unsafe swallowing, had bread written in the "dislikes" so they would not receive it. She said none of these were truly dislikes, it was for swallowing issues. She stated the kitchen knew if the ticket said the resident disliked bread, the resident should not receive it. During an interview with the dietary manager (Employee #228), on 04/22/14 at 10:20 a.m., she said Resident #142 should not have had a hot dog or a bun. She said the diet recorded in the kitchen stated the resident was to have a mechanical soft diet with no bread. She said the no bread restriction was carried over from before she went to the hospital because they carried these restrictions forward, unless they were changed or discontinued. Her diet was still mechanical soft and the meats should be ground mechanically. In an interview with a registered nurse, Employee #22 (Assistant Director of Nursing), 04/22/14 at 9:45 a.m., an inquiry was made about the procedure for the facility after a resident returned from the hospital. She was asked how the facility ensured the restrictions and precautions previously in place were continued upon the resident's return. She said after so many days, the computer discontinued all of these interventions and the resident was addressed as a new admission. She said the nurses had to look at the prior record for things like restrictions, that were previously part of the resident's care, to see whether the restrictions should be continued. She was specifically questioned about Resident #142's swallowing issues regarding the order for no bread and to cut the food into small pieces. She stated those restrictions should have been included when the nurse wrote the orders upon the resident's return from the hospital, or at least discussed with the physician. She verified there was no evidence this was reviewed when the resident returned from the hospital. In a telephone interview with Resident #142's son, on 04/22/14 at 2:00 p.m., he said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. He stated he was standing at the door and the "girl" handed him his mother's tray. He verified the nursing assistant did not look at what was on the tray, she just gave it to him with the lid still covering the plate. He stated when they saw the food on the tray, he said to his mother "Are you sure you are allowed to have that?" He said he was concerned about her having an entire hot dog because the facility had called him the night before and told him Speech Therapy was going to analyze her because she was having swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. In the hospital, they were feeding her through her veins with an IV. He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth and tried to get her to spit it out and then she choked and he yelled for help. A telephone interview was conducted with a nursing assistant (Employee #161) 04/22/14 at 7:30 p.m. She confirmed she had been the nursing assistant responsible for Resident #142 on the evening of 03/26/14. She stated she took the tray off the cart and gave it to the resident's son. She verified she did not remove the lid and look at the resident's tray. She could not confirm whether it was the correct diet because she did not see it, she just gave it to the family. On 04/23/14 at 2:00 p.m., in an interview, the Director of Nursing (Employee #73) stated she was present the night of the choking incident involving Resident #142. She said she was still in the facility that evening and heard the page over the loud speaker for a nurse to come immediately to the resident's room. She stated when she arrived, staff were performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to the resident's tray and noted there was one third (1/3) of an entire hot dog on the tray. She stated the resident's tray card was lying on her tray and indicated she was to get a mechanical soft diet with no bread. She immediately identified the resident had been served the incorrect diet of an entire hot dog that was not ground on a bun. She said prior to her leaving that day, she made sure there were no other residents who had received the wrong diet. The director of nursing stated the nursing assistants were supposed to look at the trays when they served them to make sure the residents received the correct diet. The staff were to check the tray with the diet card that was placed on their tray as a way to double check. When Employee #73 was asked whether an issue was identified or any plan of action was implemented to ensure this did not reoccur, she stated she had not implemented a plan to evaluate how this happened and to prevent reoccurrence. The person identified to investigate incidents in the facility to determine if abuse or neglect occurred was a Registered Nurse (Employee #199). She was interviewed on 04/23/14 at 2:30 p.m. regarding this incident. She was asked if the incident was identified as neglect. She stated "no" it was not. Employee #199 said she did not identify the resident got anything she was not supposed to get that would result in her to choking. When asked if this would have been determined as "neglect" if she had identified the resident received the incorrect diet, she said "yes because that would have been failure to provide a service."

Based on record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents was provided food in a form to meet her individual needs. The resident had a physician's orders [REDACTED]. This diet called for ground meat. The resident received a whole hot dog instead of ground meat. The resident choked on the hot dog, requiring a transfer to the hospital. Resident identifier: #142. Facility census: 141. Findings include: a) Resident # 142 A nursing note dated 03/26/14 indicated this resident's son and a nursing assistant called for a nurse. The note stated "The resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. The resident's family stated that the resident had choked on her hot dog stating she put the whole thing in her mouth." The resident was transferred to the hospital at 7:20 p.m. on 03/26/14. Resident # 142's physician's orders [REDACTED]. This diet called for ground meat. The Director of Nursing was interviewed on 04/23/14 at 2:00 p.m. She stated she was present the night of the choking incident involving Resident #142. She said she was still there that evening and heard the page over the loud speaker for a nurse to come immediately to this resident's room. She stated when she got to the room, staff was performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to her tray and observed one third (1/3) of a whole hot dog on her tray. She stated the resident's tray card was on her tray and indicated she was to get a mechanical soft diet with no bread. She said she immediately identified the resident was served the incorrect diet. She was served a whole hot dog (not ground meat) on a bun. A phone interview was conducted with Resident # 142's son on 04/22/14 at 2:00 p.m.. He said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. The son stated he was standing at the door and the "girl" handed him his mothers' tray. He verified the nursing assistant did not open it or look at it, she just gave it to him with the lid still covering it. He stated when they saw the food on the tray he said to his mother "Are you sure you are allowed to have that?" He said he was concerned she had a whole hot dog because the facility had called him the night before and told him Speech Therapy was going to evaluate her because due to swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. He said they were feeding her through her veins with and IV (intravenously with TPN -total [MEDICATION NAME] nutrition). He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth, and tried to get her to spit it out. She choked and he yelled for help. The resident was transferred to the hospital.

Based on medical record review, review of hospital records, staff interview, and review of facility records, policies, and procedures, the facility failed to provide ongoing assessment / monitoring for and failed to obtain timely medical intervention for one (1) of eleven (11) sampled residents who simultaneously received [MEDICATION NAME] (an anticoagulant) and Bactrim DS (an antibiotic that potentiates anticoagulant effects) from 10/11/10 through 10/15/10. Resident #29 was found on the floor in her room (an un-witnessed fall) on the morning of 10/14/10. The day shift nurse on 10/14/10 recorded the fall in the nursing notes, noting no injury was apparent at the time. No further entries were made in the resident's nursing notes until 3:20 p.m. on 10/15/10, when the evening shift nurse noted the presence of bruising with hematoma to the resident's left temple and noted the resident appeared to have difficulty opening her left eye. The evening shift nurse contacted the attending physician, who stated that he had not previously been informed of the resident's fall and ordered that she be sent to the hospital emergency room for evaluation, as she was on a blood thinner. The resident was transported to Hospital #1's ER, where she was noted to have critical lab values related to her anticoagulation therapy and subarachnoid bleeding. The resident was later transferred to Hospital #2, where she was admitted to its neurology intensive care unit. According to the Hospital #2 discharge summary, Resident #29's subarachnoid hemorrhaging was "secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." Nursing assistants on the early afternoon of 10/14/10 and the morning of 10/15/10 reported to the licensed nursing staff that Resident #29 had a bruise to her left temple, but no on-going neurologic assessments were completed by the licensed nursing staff after the initial assessment occurred shortly after the fall on the morning of 10/14/10, the physician was not notified of the fall or subsequent bruising to the resident's temple until the afternoon of 10/15/10, and no one at the facility recognized and/or was monitoring the resident for increased anticoagulant effects associated with administering Bactrim DS with [MEDICATION NAME]. Resident identifier: #29. Facility census: 150. Findings include: a) Resident #29 Record review revealed this [AGE] year old female was admitted to the facility in 2002. Her active [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] ([MEDICATION NAME]) 6.5 mg and 7 mg alternating every other day, according to the physician's monthly recapitulation of orders for October 2010. Review of a lab report, dated 10/07/10, for [MEDICATION NAME] time (PT) and international normalized ratio (INR), both of which were used to evaluate blood clotting time, found the PT to be high at 28.5 (normal range is 11.9 - 25.4) and the INR to be within normal limits (WNL) at 2.7 (normal range is 2.0 - 3.0). The physician was notified and ordered the same dosage of [MEDICATION NAME] with a recheck of labs in four (4) weeks. Previously, on 09/07/10, Resident #29 ' s PT was elevated at 25.9 and her INR was WNL at 2.1, and no change in medication was ordered. Review of the nursing notes found an entry, dated 10/10/10 at 6:15 p.m., stating the physician was notified that the resident had an increased temperature of 101.9 degrees Fahrenheit (F). The physician ordered Tylenol 500 mg and a urinalysis (UA) and complete blood count (CBC) stat. The results were called to the physician on 10/10/10 at 11:00 p.m., and the physician ordered Bactrim DS was ordered twice daily for seven (7) days. Her temperature at this time was 98.7 degrees F. Review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/10 at 1530 (3:30 p.m.), the nurse's notes indicated the resident's legal representative was notified of the resident having a urinary tract infection, of her increased temperature on 10/10/10, and of the new order for Bactrim DS. The resident's temperature at this time was noted at 97.0 degrees F. On 10/13/10 at 1:00 a.m., the nursing notes indicated the resident's was not having any signs or symptoms of adverse reactions associated with the use of the antibiotic. She remained afebrile, denied pain / discomfort, and was resting in bed with eyes closed. The next nursing note, written by a licensed practical nurse (LPN - Employee #137) and dated 10/14/10 at 7:20 a.m., stated, "Res(ident) found in floor @ bottom of bed. Res states she is OK, no visible injuries.... Res states she was going to the bathroom and fell , bed alarm was not on. Assessment completed, (symbol for 'no') c/o (complaint of) pain or discomfort. Will continue to monitor." In this same note, the nurse recorded her vital signs as follows: blood pressure (B/P) - 138/78; pulse - 78; respirations - 18; temperature - 98.8 degrees F; O2 sat was 93% on room air. Oxygen was reapplied, and her O2 sat was 95%. The next nursing note, written by a registered nurse (RN - Employee #166) and dated 10/15/10 at 3:20 p.m., stated, "Staff report pt (patient) had fall on 10/14/10. Noted bruising /c (with) hematoma to (L) (left) temporal area. Appeared to have difficulty opening (L) eye. Resident alert & speech clear. Pupils equal & reactive. B/P this am (morning) 136/64, O2 sat 90%, (pulse) 86, (respirations) 18. Dr. (name) notified & made aware of current status. Dr. (name) stated he was unaware of fall. New order received to send resident to (Hospital #1) ER for evaluation. Resident is currently on blood thinner. POA (power of attorney) was notified." The next nursing note, dated 10/15/10, at 4:15 p.m. stated, "TC from (Hospital #1) ER. Resident being sent to (Hospital #2); has a subarachnoid bleed." -- 2. Review of Hospital #1's records found Resident #29 had critical lab values of PT greater than 100 (normal range is 20.5 - 30.0, with critical values greater than 39), INR of 11.9 (normal range is 2.5 - 3.5, with critical values greater than 4.0), and PTT (partial [MEDICAL CONDITION] time) of 83 (normal range is 27 - 32) on 10/15/10 at 1526 (3:26 p.m.). The resident's red blood cells were low at 3.61 (normal range is 4.5 - 6.3), hemoglobin was low at 11.6 (normal range is 12.1 - 15), hematocrit was low at 33.9 (normal range is 35.8 - 46). The results of a CT scan of Resident #29's brain without contrast, dated 10/15/10, noted: "Findings: There is punctate hemorrhage of the left frontal lobe. There is no extra axial component. There is a large, left frontal scalp hematoma. Sulcal and ventricular prominence correlation with atrophy. There is no midline shift. There is no calvarial fracture." Under the heading CT Brain Impression was: "1. Acute left frontal lobe parenchymal hemorrhage. 2. Generalized cerebral atrophy. 3. Large, left, frontal scalp hematoma." The resident received 8 units of fresh frozen plasma and 30 mg of Vitamin K and was transferred to Hospital #2's neurology intensive care unit for a neurosurgical consultation on 10/15/10; she was subsequently admitted there at 2352 (11:52 p.m.), according to Hospital #2's discharge summary. -- 3. The discharge summary from Hospital #2, dated 10/20/10, under the heading Admission History and Physical stated: "This was a transfer from (Hospital #1). The patient initially is a resident at Heartland of Beckley. The patient apparently fell down. The patient was not taken to the hospital at that time. After a day (sic) refer to consultation with the family. The patient was sent to (Hospital #1). At Hospital #1, the patient was found to have (sic) subarachnoid hemorrhages. The patient was subsequently transferred to the Neuro ICU here at (Hospital #2) for neurological evaluation. On presentation to (Hospital #1), patient ' s blood pressure was 170/74. The patient's INR was noted to be 11.9. The patient did receive a course of Bactrim previously while at Heartland of Beckley." Under the heading Hospital Course was stated, "... I believe patient's subarachnoid hemorrhage is secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." -- 4. Review of the resident's resident assessment protocol (RAP) for falls with an effective date and time of 06/29/10 at 11:09 a.m. stated, " ... resident was walking back from bathroom and slid and fell (sic) improper footware (sic) pt educated on use of proper footware (sic) improper footware (sic) removed (sic) assessed for injury (sic) none noted (sic) neuro checks started (sic) md and poa aware." An off-cycle falls RAP, with an effective date of 10/14/10 at 08:34 a.m., was completed by one (1) of the assistant directors of nursing (ADON - Employee #192) and signed on 10/16/10. It stated, "Fall care plan reviewed and remains in place. No new recommendations made during IDT (interdisciplinary team) review." - The Care Plan Focus for "At risk for falls due to Cognitive (sic) impairment, pain, unsteady gait, walks without assistance, low oxygen saturations from not wearing oxygen, [MEDICAL CONDITION]", which was initiated on 04/11/07, contained the goal of "No injury requiring transfer to hospital." The following interventions to achieve this goal were initiated on 04/11/07: "Monitor for and report development of pain, bruises, change in mental status, ADL function, appetite or neurological status for at least 72 hours after a fall. Administer medications as ordered and monitor for effectiveness. Minimize environmental clutter. Have commonly used articles within easy reach. Encourage to transfer and change positions slowly. Reinforce need to call for assistance. Encourage and assist as needed to wear proper and non slip footwear. Encourage to use assistive devices: walker." On 10/04/07, the IDT added: "Give medication as ordered." On 12/31/08, the IDT added: "Educate staff to not leave resident unattended." On 06/25/09, the IDT added: "Educate resident on the use of call light and asking for assistance." On 09/24/09, the IDT added: "Sensor pad to bed at all times." On 10/18/09, the IDT added, "Anti-rollbacks to W/C (wheelchair)." On 03/19/10, the IDT added: "non (sic) skid shoes as tolerate (sic)." (Note that several of the "newer" interventions were very similar to interventions that had been in place since 04/11/07.) - The Care Plan Focus for "Anticoagulant therapy to treat [MEDICAL CONDITION]: At risk for adverse effects", which was initiated on 04/11/07, contained the goal of "Resident will have no adverse effects from anticoagulant use such as (sic) not limited to bruising, bleeding, blood in stool / emesis, etc." Interventions to achieve this goal included: "Monitor lab values and report results to physician. Monitor for and reports (sic) adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Provide education to family / resident about safety precautions. Administer medications per physician orders. Monitor for S/S (signs / symptoms) of [MEDICAL CONDITION] such as pain (sic) redness in ext (extremities)." The last revision to this care plan was made on 10/27/09, beyond updating to the goal ' s target date. -- 5. The LPN who received the order from the physician on 10/10/10 at 11:00 p.m. (Employee #53) was interviewed at 9:57 a.m. on 10/27/10. Employee #53 said when she called the physician she did not tell him specifically what medications the resident was already receiving. She said the pharmacy usually calls before sending a medication if there would have been any problems with drug-to-drug interactions. - The nursing assistant (NA) who showered Resident #29 on day shift on 10/14/10 (Employee #31) was interviewed at 10:20 a.m. on 10/27/10. Employee #31 reported that, after lunch on 10/14/10, she noted a knot on the resident's head and bruising to the resident's hand, and the resident told her she fell . She said when she was on the way to the shower with the resident, she told the medication nurse (Employee #82, an LPN). He looked at the resident's head, administered a medication to the resident, and the resident was given a shower. Employee #31 said the resident was taken back to her room. She did note that the resident appeared to be having increased congestion. A review of Employee #31's statement taken by the director of care delivery (Employee #192) on 10/16/10 found the following: "States she took over care of resident on 10/14 AM (morning) when other CNA (certified nursing assistant) was pulled to another unit. State she saw a large raised area with a bruise stating to form on resident's (L) temple area. States this was around noon, during resident ' s shower. States she brought it to the attention of the nurse '(Employee #82 ' s first name)'. States resident's behavior was normal & speech was normal." Review of the Shower / Skin Observation Report for 10/14/10, completed by Employee #31 and signed by Employee #82, did not show any bruising or abnormalities for the resident. - The LPN who assessed Resident #29 after she was found on the floor at 7:20 a.m. on 10/14/10 (Employee #137) was interviewed at 10:25 a.m. on 10/27/10. She reported having been told of the fall by a NA (Employee #93) at the start of the shift. She said the resident was sitting in the floor upright with her legs out in front of her. The bed alarm was not on and was not sounding. She said she did a head-to-toe assessment of the resident and found no bruising or signs of injury. She indicated she checked the resident's head, back, and legs, as she was afraid the resident might have broken a hip. She also said she thought she started a neurological evaluation flow sheet but was told it could not be found. A review of Employee #137's statement taken by Employee #192 on 10/14/10 at 0830 (8:30 a.m.) found the following: "Nurse stated that resident had a fall around 0730 and that she found no apparent injuries. Stated resident denied any pain or discomfort. States she notified Dr. (name) and MPOA (medical power of attorney) of the fall and completed an incident report. State she initiated neuro checks because the fall was not witnessed. No noted abnormalities at that time." Elsewhere in witness statement for was written: "Staff member became ill shortly after the incident and was taken to the hospital by EMS. Unable to locate neuro check sheet." - The resident's October 2010 MAR indicated [REDACTED]. Review of the MAR for 10/14/10 found Employee #82 only gave the resident [MEDICATION NAME] 100 mg at 2:00 p.m. on that date, as he was reassigned to that area when Employee #137 was sent out to the emergency room . He stated, "(Employee #31) said the resident had a bruise on her head. I looked at it. I went out and looked at the book for acute documentation. I did not know if it was documented. I don't recall saying anything to (Employee #134) who I reported off to (at 3:00 p.m.)." A review of Employee #82's statement taken by Employee #192 on 10/16/10 found the following: "Stated he took over med cart for nurse that left due to illness, along with (Employee#134), LPN. States he did note a bruise to the L temple area of the resident, but (sic) had been told it was already there from a fall. States he did not know when the fall occurred." - An interview was conducted, on 10/27/10 at 11:30 p.m., with the LPN who received report from Employee #82 at 3:00 p.m. on 10/14/10 (Employee #134). Employee #134 said she worked from 7:30 to 4:00 p.m. on 10/14/10 as a treatment nurse. The October 2010 treatment record was reviewed with her at this time. She said she checked the resident's sensor pad and oxygen on 10/14/10, but she did not remember at what time. She thought it was before breakfast (before 8:30 a.m.). She reported that she helped Employee #82, after Employee #137 was sent out to the emergency room , with medications and doing treatments. She did not know anything about the resident's fall on 10/14/10. - A review of a statement taken from Resident #29 by Employee #192 on 10/15/10 revealed the following: "Resident sitting up on side of bed. Bruising noted to (L) temple / forehead area. Resident alert and answering appropriately to my questions. When asked if she had any pain, she answered, 'my head'. When asked if she remembered fall she stated, 'I'm not sure'. When asked where her head hurt she stated 'Inside and out'. Resident sent to (Hospital #1) within 30 minutes of my conversation with her." - A review of a statement taken from Employee #72 (a nursing assistant) by Employee #192 on 10/15/10 revealed the following: "CNA states that she noted a bruise to the (L) temple area of the resident around 0830 (8:30 a.m.) on the morning of 10/15/10 when she took her breakfast tray to her. States that the nurse was aware of the bruise at that time." - A review of a statement written on 10/18/10 by Employee #166 (a registered nurse assigned to Resident #29 on the morning of 10/15/10) revealed the following: "I had a wing and part of another wing (we were short nurses). I received report from night shift (name). No mention of a fall or injury to the resident was made during report. I gave her morning meds first. I noticed bruising to the left side of her temple area. I took her VS (vital signs) and they were normal. I had to wake her to take her meds. She was 'groggy' but sat up and took her pills for me. I questioned some other staff and they stated she had a fall the morning before. I assumed her bruising was from the fall. When I reviewed the chart there was no documentation of any injury. I recognized the resident was on [MEDICATION NAME]. I went to assess her neurologically and found her to be WNL but C/O pain to (L) eye. I notified Dr. (name) of fall (sic) 10/14 & injury noted @ this time. Dr. (name) stated he was not notified and asked that resident be sent to ER." -- 6. Review of the pharmacy manual's policy titled "Adverse Drug Reaction" from Omnicare, Inc (last revised 01/10/06), which was provided by the facility ' s administrator at approximately 9:00 a.m. on 10/27/10, found: "ROCEDURE: The pharmacy will identify potential ADRs (adverse drug recations) by reviewing any drug therapy that appeared to cause: - Discontinuation of therapy - Patient hospitalization - Treatment with another drug used for allergic reactions - Significant patient illness - Threat to life or death. "The pharmacist will document the potential adverse drug reaction on the Adverse Drug Reaction Log ... noting severity level. "The pharmacy operating system is set to identify First Data Bank (FDB) levels 1, 2, and 3 drug interactions for the dispensing pharmacist at the time of order entry. "The dispensing pharmacist evaluates the potential seriousness and immediacy of the drug interaction in the individual using their professional judgment and the information provided by FDB. Factors such as the person's age, comorbidities, and concurrent drug therapies area taken into consideration ..." "[MEDICATION NAME] Interactions: "a) Determine if the drug interaction potential is serious and predict the timing of the interaction as advised by FBD. "b) Recommend an alternate medication if possible ... or determine if a [MEDICATION NAME] dosage adjustment is indicated. Determine the appropriate INR monitoring frequency if needed. Call the facility and document the intervention ...." -- 7. Review of the facility's policy titled "Neurological: Neurological Evaluation" (dated 3/2010) found: "PURPOSE: A neurological evaluation is used to establish a baseline neurological status upon which subsequent evaluation may be compared and changes in neurological status may be determined. "USE: - Following a witnessed fall (when a patient has hit his/her head) - Following an un-witnessed fall (when a head injury may be suspected) - Following a patient event which results in a known or suspected head injury (i.e.: hemorrhagic stroke) ... "PROCEDURE: "1. Initiate and document a baseline neurological evaluation as indicated on the Neurological Evaluation Flow Sheet. "2. Notify physician of specific patient event, initial findings, and baseline neurological evaluation. "3. Obtain orders for subsequent neurological evaluations, diagnostic studies or other medical care. "4. After the completion of initial neurological evaluation with vital signs, continue evaluations every 30-minutes x 4, then every 1-hour x 4, then every 8-hours x 9 (for the next 72 hours). "NOTE: More frequent neurological evaluations may be necessary if clinically indicated or as ordered per physician. "5. Subsequent neurological evaluation should be compared to baseline and previous neurological evaluations. "6. Evaluate level of consciousness and document 'Y = Yes or N = No' responses to the following: - Alert - Lethargic - Semi-comatose - Comatose "7. Evaluate level of orientation and document 'Y = Yes or N = No' responses to the following: - Oriented to person - Oriented to place - Oriented to situation "8. Evaluate pupils. (It may be necessary to darken room or ask patient to close eyes for 30 seconds prior to evaluation.) Upon opening eyes, use a penlight or flashlight to evaluate Pupil Size and Pupil reaction for both the left and right eyes. Document using the following responses: - E = equal pupil size - U = unequal pupil size - R = reacts to light - NR = no reaction to light "9. Evaluate motor movement by providing patient with simple motor commands. Document 'Y = Yes or N = No' responses to the following: - Moves right upper limb - Moves left upper limb - Moves right lower limb - Moves left lower limb - Facial symmetry "10. Evaluate communication / language by providing simple communication commands. Document 'Y = Yes or N = No' responses to the following: - [MEDICAL CONDITION] - Receptive [MEDICAL CONDITION] - Speech slurred - Communication changes "11. Evaluate for unusual / new observations. Document observation responses using the following: - W = Weakness - T = Tremors - D = Dizziness - H = Headache - V = Vision changes - N = Numbness - O = Other "12. Evaluate vital signs. Record baseline vital signs and compare subsequent vital signs to baseline and previous evaluations. Document the following information: - Blood pressure - Pulse - Pulse Ox % (Oxygen Saturation) - Temperature - Respiration rate - Respiration pattern -- N = Normal / Regular / Unlabored -- AB = Abnormal (i.e.: Labored, Kussmaul's , Cheyne-Stokes or Apnea) "NOTE: Pay close attention to respiratory patterns. Notify physician regarding any 'Abnormal' findings or any changes in respiration rate or pattern. "NOTE: Notify physician of any neurological evaluation findings which are a change from baseline or previous evaluations. Document physician notification in Progress Notes. "13. Notify the family / caregiver of patient condition an devaluation findings. "14. Communicate event, interactions, and plan of actions using center specific systems (i.e. shift to shift reports, 24-Hour Reports, Eagle Room team meeting and alert charting)" - Random confidential nursing staff interviews found that evidence of ongoing neurological evaluations of Resident #29 could not be found. Although Employee #137 (who first assessed her after she was found on the floor on the morning of 10/14/10) reported she completed an initial neurological exam, evidence of that initial assessment could not be found. This lack of on-going neurologic assessments was confirmed during an interview at exit with the facility administrator at 4:30 p.m. on 11/02/10. -- 8. The facility's "Practice Models Charting Alert" (dated 08/11/06) stated: "Purpose: To provide a guideline for the clinical documentation process that may be needed following a change in patient condition or status "Guidelines: The alert charging process includes documentation of a patient's condition that warrants alert charging, the decisions and actions of staff related to the patient's condition and the patient's response to interventions implemented - Situation for alert charting typically include new admission monitoring needs, acute change of patient condition or situations that are expected to resolve or stabilize within. Some examples may include, but are not limited to: -- Change of condition, e.g. flu symptoms -- Accidents -- New admission or re-admissions -- Signs and symptoms of infection -- Skin alterations, e.g., skin tear, bruise, rash - The Alert Charting process includes, but is not limited: -- Documentation of patient evaluation findings, physician notifications and responses, family notification and any new orders or instructions received in the interdisciplinary progress notes or nursing notes -- Initiation of an Acute Care Plan including the patient ' s problem or need, goal, and interventions planned to manage the patient ' s condition -- Addition of patient name and information to the Alert Charting Log -- Update to the Change in Status Report, 24-hour Report -- Inclusion of information in shift-to shift report -- Notification of nurse supervisor, IDT members and other staff as needed -- Review of patient status during Eagle Room meetings - Documentation for alert charting occurs each shift for a minimum of 72 hours - Licensed nurses reference the Alert Charting Log at the start of each shift to identify patients requiring continued follow-up and alert documentation - Documentation related to the alert charting process may include, but is not limited to: -- Patient evaluation pertinent to the condition identified as the acute event -- Vital signs -- Presence or absence of pain -- Complaints and/ or behavior problems -- Changes in activities of daily living -- Patient response or outcomes - Remove patients form Alert Charting Log and discontinue Acute Care Plan when patient status has stabilized or the condition or symptom has resolved." There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. Review of the "Change In Status Worksheet / 24 Hour Report" for 10/10/10 through 10/14/10 revealed no mention of Resident #29's condition and/or status except for on 10/10/10, when a nurse wrote: "Give Tylenol 500 mg PO now D/T (due to) increased temp. U/A and CBC stat." - The "Change In Status Worksheet, 24-Hour Report Practice Model" (dated 08/11/06) stated: "Purpose: To provide an interdisciplinary communication tool that may be used to identify patient with a change in condition requiring intervention and follow-up. "Guideline: "- Complete form per directions and use narrative section for additional information as needed "- Information includes but is not limited to: -- Admissions -- Unplanned discharges -- Change in condition, e.g. improvement or deterioration in physical, mental and psychological status -- Unstable condition -- Incidents / accidents -- New / discontinued medication orders -- Abnormal lab results -- Pain level > or = 4 -- Patient / family concerns -- Notification of physician, family / responsible party, administrator and/or ADNS -- Documentation completed: Nursing admission evaluation, off-cycle RAP, progress RAP, progress notes -- Nurse's initials "- Interdisciplinary team members may enter any identified change of condition requiring clinical follow-up "- Use report to communicate concerns at morning and after Eagle Room meetings "- Use report during shift change to communicate patient information and needed follow up "- Review report to confirm follow-up, notification and documentation of patient needs are complete" - There was no evidence this practice model was implemented for Resident #29 following her fall on the morning of 10/14/10. -- 10. Review of the pharmacy manual's "Policy #4.1 Prescriber Authorization and Communication of Orders" (dated 12/01/07) found: "PROCEDURE: " ... 3. Verbal Orders: "3.1 The facility's licensed nurses should contact the resident's physician where there is a change in condition that may require a new medication or a renewal of an existing order. "3.1.1. Before contacting the physician / prescriber, the Facility's licensed nurses should assemble the necessary clinical information. This information may include, but is not limited to: vital signs, recent laboratory or diagnostic study results, recent medication orders, residents' response to medication, and possible adverse drug reactions." No one at the facility recognized the possible adverse drug reaction associated with simultaneously administering Bactrim DS with [MEDICATION NAME]. .

Based on closed record review, review of witness statement collected by the facility during an internal investigation, and staff interview, the facility failed to perform assessments and monitor changes in a resident's condition, and failed to notify the physician of changes in condition in a timely manner. According to closed record review, one (1) resident changes demonstrated potential alteration in circulatory function to her right lower extremity that were first identified and reported to a licensed nurse by a nursing assistant on 12/18/09. There was no evidence of ongoing nursing assessments and monitoring of the residents right lower extremity nor evidence of attempts to notify the physician of the potential impaired circulatory function prior to 12/21/2009. On 12/21/09, a nursing assistant again reported to a licensed nurse the resident's right lower leg was purple and cool to touch. The resident was subsequently transferred to the hospital, where she underwent a below-the-knee amputation. This was evident for one (1) of ten (10) sampled residents. Resident identifier: #158. Facility census: 157. Findings include: a) Resident #158 1. The closed record of Resident #158 was reviewed as part of a complaint investigation beginning on 09/01/10. Review of the nursing notes revealed an entry by a licensed practical nurse (LPN - Employee #205) dated 12/21/09 at 6:30 a.m., stating, "In to assess resident. CNA notified nurse of RLE (right lower extremity) coloring being 'purple'. RLE noted to have faint pulse, noted to be cool to touch & purple (arrow pointing up) to mid shin area. Dr. (name) beeped." The physician ordered the resident to be transferred to a local hospital emergency room for evaluation, and she was admitted to the hospital later that same day for "(R) (right) leg ischemia & UTI (urinary tract infection)", according to a subsequent entry in the nursing notes. Review of the resident's hospital history and physical examination History of Present Illness": "... It has been reported that family noticed that her right leg was purplish, bluish and cold for the past six days. She was subsequently referred to the emergency room for evaluation. In the emergency room she was noted to have (sic) acute ischemic right leg. She has already been evaluated by Dr. (name). Right above knee amputation has been recommended and the patient is not a candidate for revascularization secondary to irreversible ischemia to the right leg. ..." The resident's right leg was amputated during this hospitalization , and the resident did not return to the facility. Review of the nursing notes entered in Resident #158's medical record during a two-week period prior to 12/21/09 found no mention of the condition of the resident's right lower extremity to suggest the nursing staff was aware of any acute changes affecting circulation to that limb. Further review of Resident #158's closed record found a note recorded on the reverse side of the December 2009 food intake record by Employee #163 on 12/18/09 on the 3:00 p.m. to 11:00 p.m. shift, stating, "Residents (sic) Rt (right) leg is purple from knee to toes." - 2. On 12/30/09, the facility conducted an internal investigation into the circumstances leading up to Resident #158's hospitalization . Review of a witness statement, collected during a telephone interview with Employee #163 by the former administrative director of nursing services (ADNS) on 12/30/09, revealed: "Noted during shower on 12-18-09 that resident (sic) foot was purple in color and cold. Throughout the weekend noted that RLE continued to be discolored and cold to touch. (Name of Employee #184, an LPN supervisor) was made aware on 12-18-09. On 12-19-09 (name of Employee #9), LPN, was aware, and (name of former ADNS) also made aware." Review of a witness statement, collected during a telephone interview with Employee #2 (a CNA) by the former ADNS on 12/30/09, revealed: "On 12/18/09 I assisted (name of Employee #163), CNA, to turn & reposition resident. Residents (sic) RLE was noted to be purple from toe to ankle and cold to touch from knee down. (Name of Employee #149), LPN Supervisor made aware." Review of a witness statement, collected during a telephone interview with Employee #149 by the former ADNS on 12/30/09, revealed Employee #149's responses to the following questions: "(1) Do you recall being notified of (Resident #158)'s leg being discolored? I remember on the morning of the 19th, the CNA's came and told me they were discolored and then I told (name of former ADNS). (2) Did you notify the MD? No." Review of a witness statement, collected during a telephone interview with Employee #168 by the former ADNS on 12/30/09, revealed Employee #168's responses to the following questions: "(1) Do you recall being notified of (Resident #158)'s leg being discolored? I worked even rooms on F Wing and (Employee #149) worked odd. (2) Did anyone ask you to come look at (Resident #158)'s leg? No." Review of Employee #205's witness statement, dated 12/30/09, revealed: "6:15 a.m. on 12/21/09 (Employee #99) reported to me that residents (sic) leg was discolored. This LPN & I checked her vital signs, and these were all within normal range. 0630 Dr. (name) was beeped. RLE no pedal pulses (sic) faint inner ankle (DP) {dorsalis pedis} pulse. Leg was dark and cold. Dr. (name) phoned back & orders obtained to send out for eval(uation)." Review of a witness statement from the former ADNS, dated 12/30/09, revealed: "On 12/19/09 was called to residents (sic) room by (Employee #163), CNA. CNA stated 'Look at her foot.' And pointed to right foot. I asked her what was wrong with it. (Employee #163 said it had been discolored but looked much better now. Both feet where (sic) elevated on pillow, pulses were present. RLE was not discolored. I asked (Employee #163) if she had informed nurse and she stated 'Yes.' I asked (Employee #149) was she aware of residents (sic) leg, and she stated 'Yes.' I was called again to room on Dec. 21 @ 7:30 AM, residents (sic) R (right) leg was cold, purple, no pedal pulse palpable, (sic) resident was then sent out for eval." - 3. During interview with the interim ADNS on 09/01/10 at 11:30 a.m. she said, when asked, that she would have expected physician notification on 12/18/09 when the nursing assistant noticed the discolored foot. During interview with the administrator 09/01/10 at 1:20 p.m., she said she found nothing regarding physician notification of the right foot problem prior to 12/21/09. She said the 12/18/09 24-hour shift report noted the physician had been called that day regarding drowsiness or change in level of consciousness for this resident, and the physician decreased the resident's [MEDICATION NAME], ordered a CBC (complete blood count), and prescribed an antibiotic. When asked if anything was mentioned in the report about the foot, she replied in the negative. During interview with the administrator and interim ADNS on 09/01/10 at 2:30 p.m., the administrator said the physician was called 12/18/09 about a change in level of consciousness but not about the foot. When asked if this discoloration of the right foot was a new symptom, the interim ADNS replied in the affirmative. When the administrator and the interim ADNS were asked if they found any assessments in the medical record about the pedal pulse, color, or temperature of the right lower extremity after the nursing assistant reported on 12/18/09 that the right foot was purple and prior to the morning of 12/21/09, they replied in the negative. During interview with the administrator, a corporate human resource director (Employee #218), and the interim ADNS on 09/01/10 at 4:15 p.m., they agreed, after further record review, they could find no evidence of physician notification of the discolored foot prior to the morning of 12/21/09 and no evidence of nursing documentation of assessment and monitoring of the right lower extremity prior to the morning of 12/21/09. .