Every finding on record at Carolina Rivers Nursing and Rehabilitation Center

Based on record review and staff interviews, the facility failed to prevent a resident from rolling off the bed during care which resulted in an abrasion of the posterior scalp and left ankle soft tissue swelling from a fall for 1 of 3 sampled residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Her diagnoses included hemiplegia following cerebral infarction (stroke) affecting left side. Resident #1 ' s care plan, initiated 1/3/24 had a care focus area of activities of daily living/ personal care with one of the interventions noted as totally dependent on two-person assistance for bed mobility initiated 5/27/24. Resident #1 ' s quarterly Minimum Data Set Assessment (MDS) dated [DATE] coded the resident as moderately cognitively impaired and dependent with toileting and rolling left and right in bed. Resident #1 ' s medication administration record (MAR) dated August 2024 revealed Resident #1 received acetaminophen oral suspension (325 milligram/10.15 milliliter) 20 milliliters on 8/25/24 at 4:45 PM for 4/10 pain, 8/26/24 at 10:41 AM for 2/10 pain, 8/28/24 at 9:28 PM for 5/10 pain, and on 8/30/24 at 10:14 PM for 3/10 pain level. Prior to the fall Resident #1 received acetaminophen on 8/7/24 at 12:22 AM for 3/10 pain and on 8/15/24 at 10:25 PM for 5/10 pain level. The MAR also revealed Resident #1 was on Eliquis (blood thinner) 2.5 milligram twice a day. An incident report dated 8/25/24 stated NA #1 called to Nurse #1 stating that Resident #1 had fallen out of bed while being changed. When Nurse #1 entered the room, Resident #1 was on her back on the floor between Resident #1 ' s bed and roommate's bed. Resident #1 ' s bed was at a height of 2 feet. Resident was alert and able to answer questions. Resident #1 was assessed by Nurse #1 for pain/injury. Resident reported no pain. Upon assessment Resident #1 showed no facial grimacing or verbal cue for pain. Resident #1 vital signs were obtained, and nursing staff assisted Resident #1 back to bed. Upon transfer back to the bed scant blood was observed on Resident #1 ' s bed pillow. Nurse #1 observed dime size opening to Resident ' s right posterior head and minimal bleeding noted. On call provider was notified and advised Resident #1 to be sent to the emergency department (ED) for further evaluation. An undated Interview statement written by Nursing Assistant #1 (NA #1) indicated alleged occurrence date: 8/25/24 and alleged occurrence time: 3:40 AM. The statement indicated NA #1 was doing her rounds and at around 3:40 AM she entered Resident #1 ' s room and Resident #1 told her she was soiled. NA #1 began performing incontinence care. Resident #1 was laying on her side facing away from NA #1 who was holding the Resident with her left hand and cleaning her with her right hand. Resident #1 tensed up which caused her to grab the side of the bed and her body to move forward and away from NA #1 and she rolled off the bed. NA #1 tried to stop the fall, but she was unable to. She immediately alerted Nurse #1 who came to assess Resident #1. Hospital discharge summary dated 8/25/24 indicated Resident #1 was seen at the emergency department (ED) on 8/25/24 for a fall after being rolled out of bed in a nursing home. The note indicated Resident #1 was complaining of right shoulder and left ankle pain. X-ray of the chest and right shoulder, computed tomography (CT) scan of the head and cervical spine completed at the ED showed no acute significant findings. X- ray of left ankle showed soft tissue swelling. Clinical impression on the discharge plan indicated acute pain of right shoulder, acute left ankle pain and fall. Resident #1 ' s ED discharge instructions dated 8/25/24 indicated Resident was seen at the ED on 8/25/24 for acute pain of right shoulder, acute left ankle pain, fall, and abrasion of scalp. The discharge instructions indicated give Tylenol/ ibuprofen every 6-8 hours for ankle pain, clean right posterior scalp abrasion with soap and water and follow up with primary care provider the next day. Facility Nurse Practitioner (NP) progress note dated 8/26/24 indicated Resident #1 was seen by the NP for assessment following return from ED consult for right shoulder/left ankle pain following fall. The note indicated Resident #1 was alert, at baseline medication (no new added medications) without signs of distress and denied pain at the time of the assessment. The note further indicated fall precautions reviewed, ED consult notes reviewed and fall precautions reiterated with Resident #1 and nursing staff. During an interview on 10/1/24 at 12:36 PM with Nurse #1, she revealed she was the primary nurse for Resident #1 when the resident fell off the bed on 8/25/24. She indicated she became aware of the fall after Nursing Assistant (NA #1) called for assistance from Resident #1's doorway. When she walked into the room, Resident #1 was on the floor between her bed and her roommate ' s bed. Resident #1 stated she was cold, her back hurt and asked to get off the floor. After they transferred Resident #1 back to bed, Nurse #1 noticed a trace amount of blood on the pillow and realized the Resident had hit her head. Nurse #1 notified the on-call physician who gave orders for Resident to be transferred to the ED for further evaluation. She called emergency services who came to transport Resident #1 to the hospital. During an observation on 10/1/24 at 2:00 PM, Resident #1 was observed in bed on a low wing mattress and her bed was noted to be in the lowest position. Resident #1 did not appear to be in any pain or distress. She denied pain when asked if she was in any pain and attempts to carry on conversation were unsuccessful. Attempts to interview NA # 1 were unsuccessful. During an interview on 10/1/24 at 12:54 PM with the Assistant Director of Nursing (ADON), he indicated Resident #1 fell while being provided incontinent care by NA #1. The ADON stated Resident #1 was care planned for two-person assistance and NA #1 should have ensured there were two people in the room to provide incontinence care. The ADON indicated Resident #1 had not had a change in activity level after the fall. An interview was conducted with the Director of Nursing (DON) and the facility Administrator on 10/1/24 at 2:20 PM. The DON stated NA #1 should have had assistance in the room to provide incontinence care for Resident #1. She also stated NA #1 should have looked at the care plan because Resident #1 was care planned for two-person assist.

Based on observation, staff interview, and medical record review, the facility failed to refer a resident with newly evident diagnoses of serious mental illnesses for Pre-Admission Screening and Annual Resident Review (PASRR) Level II screen for 1 of 4 sampled residents reviewed for PASRR (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses including unspecified other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, and depression. The comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] had Resident #33 coded as cognitively intact and was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #33s had the diagnosis of anxiety disorder added to his diagnosis list on 06/14/2023. A review of the North Carolina PASRR level I screen dated 04/12/2024 revealed no mental health diagnoses were selected for the screen Resident #33. The care plan dated 08/07/2024 for Resident #33 revealed focus of resident had anxiety/depression/insomnia and was at risk for feelings of sadness, emptiness, anxiety, uneasiness, depression related to: Loss of function, decline in condition, and loss of independence. An interview with the Social Worker (SW) was conducted on 08/14/2024 at 2:00 PM. The SW stated she had worked at the facility for over a year and was responsible for completing the screens for PASRRs. An audit for residents who may need PASRRs were completed, and it was found that Resident #33 had mental health diagnoses including psychoactive substance abuse with psychoactive substance-induced psychotic disorder, depression, and anxiety. The SW also stated she marked no, on the screen tool for mental health diagnosis and should have selected yes, and checked all mental health diagnoses. The SW also stated she was trying to catchup with her audits, and it was an oversite. An interview was conducted with the Director of Nursing (DON) on 08/14/2024 at 2:00 PM. The DON stated he was very familiar with the regulations related to PASRRs and he expected the regulations to be followed in reference to completing a PASRR screening for a newly identified mental illness diagnosis. He added the SW was responsible for referring residents with a new psychiatric diagnosis. An interview with the Administrator was conducted on 08/14/2024 at 2:10 PM. The Administrator stated when completing the screen for PASRRs, all the diagnoses should be included in the screen to get the accurate determination for proper placement of residents. The SW missed this due to an oversite and she was educated.

Based on record review, and staff interviews, the facility failed to ensure a Physicians order for an as needed (PRN) psychotropic medication, Ativan, was time limited in time duration for 1 of 5 resident reviewed for unnecessary medications (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included chronic obstructive pulmonary disease, and anxiety disorder. The quarterly MDS dated [DATE] revealed Resident #34 was cognitively intact and on an antianxiety medication two out of seven days of the look back period. A PRN physicians order for Ativan 0.5 milligrams (mg) for anxiety dated 06/20/2024 to 08/06/2024 did not have a stop date with a two-week period. The June Medication Administration Record (MAR) review revealed an order for Ativan 0.5 mg as needed 06/20/2024 and discontinue 08/06/2024. The medication was administered on 06/20/2024 and 06/24/2024. A review of the summary of Medication Regimen Review by the Pharmacy Consultant (PC) dated 07/02/2024 revealed PRN psych meds must have a stop date and rationale per Centers for Medicare and Medicaid Services (CMS) regulations. Some discrepancies found and notified Director of Nursing (DON). A review of the summary of Medication Regimen Review by PC dated 08/02/2024 revealed PRN Psych meds must have a stop date and rationale per CMS regulations. Some discrepancies found and notified DON. The July MAR review revealed an order for Ativan 0.5 mg as needed 06/20/2024 and discontinue 08/06/2024. The medication was administered on 07/12/2024 and 07/25/2024. The August MAR review revealed an order for Ativan 0.5 mg as needed 06/20/2024 and discontinue 08/06/2024. The medication was administered on 08/03/2024. The care plan dated 08/12/2024 had a focus of problematic way resident acts characterized by ineffective coping due to anxiety. An interview was conducted with the PC on 08/16/2024 at 9:53 AM. The PC stated she performed monthly medication reviews on Resident #34 and was aware of the Ativan 0.5 mg PRN order and had sent the facility the summaries from June and July to make them aware that the drug needed a 14 day stop date. An interview was conducted with the Director of Nursing (DON) on 08/16/2024 at 12:05 PM. The DON stated he was aware of Resident #34 having Ativan 0.5 mg PRN from 06/20/2024 to 08/06/2024. He explained it did not have a 14 day stop date and realized it should have had a stop date and the medication was discontinued on 08/06/2024. He also stated he did have summaries from the pharmacy consultants, and it was missed due to an oversite. They have an audit for all medications to avoid this from happening again. A telephone interview with Nurse Practitioner (NP) was conducted on 08/16/2024 at 12:28 PM. The NP stated she tried to give a 14 day stop date for all psychotropic medications. The order slipper through the cracks and in the future, she would create a template with all the residents PRN psychotropic medication orders to make sure their orders had 14 day stop dates. An interview with the Administrator was conducted on 08/16/2024 at 12:53 PM. The Administrator stated he was made aware that Resident #34 had a PRN medication without a stop date of 14 days. He stated he wanted his staff to follow the regulations and make sure if there is a PRN medication to have a stop dated within 14 days.

Based on record review, observation, and staff interview the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level 2 Pre-Admission Screening and Resident Review (PASRR) for 2 out of 20 residents (Residents #9 and Resident #13) reviewed for accuracy in assessments. The findings included: 1. Resident #9 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of unspecified psychosis and depression. A review of Resident #9's North Carolina PASRR application indicated that he had a mental health diagnosis of major depression. A review of Resident #9's medical records included a PASSR Level 2 Determination Notification letter dated 2/7/2024. A review of Resident #9's annual MDS dated [DATE] did not indicate he was currently considered by the state level 2 PASRR process to have a serious mental illness. An interview with the Administrator on 8/15/24 at 8:35 AM indicated that Resident #9's MDS assessments was coded incorrectly regarding the PASRR question on his annual MDS. He further indicated that the annual MDS should be reviewed for accuracy prior to transmitting it. An interview with the MDS Coordinator on 8/15/24 at 9:10 AM revealed the MDS was not coded correctly for both Resident #9 and Resident #13 regarding the level 2 PASRR. She further stated that her process was to check the miscellaneous tab in the electronic medical record for a PASSR letter, if the resident had not had one in a while she would check the demographics for a PASSR number and if she had any concerns or questions would speak with Social Services. 2. Resident #13 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of schizoaffective disorder, depression, and anxiety. A review of Resident #13's North Carolina PASRR application indicated that she had a mental health diagnosis of anxiety, depression, and schizoaffective disorder. A review of Resident #13's medical records included a PASRR Level 2 Determination Notification letter dated 11/18/2019. A review of Resident #13's annual MDS dated [DATE] did not indicate she was currently considered by the state level 2 PASRR process to have a serious mental illness. An interview with the Administrator on 8/15/24 at 8:35 AM indicated that both Resident #9 and Resident #13's MDS assessments were coded incorrectly regarding the PASRR question on their annual MDS. He further indicated that the annual MDS should be reviewed for accuracy prior to transmitting it. An interview with the MDS Coordinator on 8/15/24 at 9:10 AM revealed the MDS was not coded correctly for both Resident #9 and Resident #13 regarding the level 2 PASRR. She further stated that her process was to check the miscellaneous tab in the electronic medical record for a PASSR letter, if the resident had not had one in a while she would check the demographics for a PASSR number and if she had any concerns or questions would speak with Social Services.

Based on records reviews and staff interviews, the facility failed to have Advance Directives (AD) in the residents' records for 7 of 7 sampled residents. (Resident #49, Resident #95, Resident #21, Resident #47, Resident #58, Resident #84, Resident #6). Findings included: 1- Resident #49 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] indicated Resident#49's cognition was severely impaired. Review of the computerized clinical record for Resident #49 revealed no advanced directive noted in the resident's medical record. A review of Resident#49's admission's Receipt of information Acknowledgments dated 04/12/2023 revealed no note that the resident wanted to formulate an advance directive or refused. During phone interview with Social Worker (SW) on 05/09/23 at 10:42 AM, she acknowledged there was no note indicating Resident#49's representative wanted to formulate an advance directive or refused to formulate one. During an interview with Admission Coordinator (AC) on 05/09/23 at 1:42 PM, she indicated that there was no note indicating Resident#49's representative wanted to formulate an advance directive or refused to formulate one. She indicated that the SW was responsible for ensuring that the advance directives were reviewed and documented in the resident's record if they refused to formulate one. During the interview with Director of Nursing (DON) on 05/09/2023 at 01:04 PM, she stated that the Admission's Coordinator (AC)or SW was responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. She added that the expectation was that the advanced directive should have been completed and scanned in Resident #49's computerized clinical record or a note indicating the resident's refusal to formulate an advance directive. During the interview with the Administrator on 05/09/2023 at 1:30 PM, He stated the advanced directives should have been completed and scanned in Resident #49's clinical record or a note indicating refusal. 2- Resident #95 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] indicated Resident#95's cognition was intact. Review of the computerized clinical record for Resident #95 revealed no advanced directive noted in the resident's medical record. A review of Resident#95's admission's Receipt of information Acknowledgments dated 04/12/2023 revealed no note that the resident wanted to formulate an advance directive or refused. During phone interview with Social Worker (SW) on 05/09/23 at 10:42 AM, she acknowledged there was no note indicating Resident#95's representative wanted to formulate an advance directive or refused to formulate one. During an interview with Admission Coordinator (AC) on 05/09/23 at 1:42 PM, she indicated that there was no note indicating Resident#95's representative wanted to formulate an advance directive or refused to formulate one. She indicated that the SW was responsible for ensuring that the advance directives were reviewed and documented in the resident's record if they refused to formulate one. During the interview with Director of Nursing (DON) on 05/09/2023 at 01:04 PM, she stated that the Admission's Coordinator (AC)or SW was responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. She added that the expectation was that the advanced directive should have been completed and scanned in Resident #95's computerized clinical record or a note indicating the resident's refusal to formulate an advance directive. During the interview with the Administrator on 05/09/2023 at 1:30 PM, He stated the advanced directives should have been completed and scanned in Resident #95's clinical record or a note indicating refusal. 36573 3- Resident #21 was admitted to the facility on [DATE]. A review of Resident #21's admission's advanced directive/advance care planning summary dated 11/10/2020 revealed no note that the resident wanted to formulate an advance directive or refused advanced directives. It was left blank. Minimum Data Set (MDS) dated [DATE] indicated Resident #21's cognition was intact. Review of the computerized clinical record for Resident #21 revealed no advanced directives noted in the resident's medical record. During an interview with Resident #21 on 05/08/2023, she stated she did not remember discussing advanced directives on admissions or since her stay at the facility. During an interview with the Admission Coordinator on 05/09/2023 at 10:56 AM, she indicated that there was no note indicating Resident #21 wanted to formulate an advance directive or refused to formulate one. She indicated that the Social Worker was responsible for ensuring that the advance directives were reviewed and documented in the resident's record if they refused to formulate one. During telephone interview with the Social Worker on 05/09/2023 at 11:09 AM, she acknowledged there was no note indicating Resident #21 wanted to formulate an advance directive or a note of refusal. During the interview with Director of Nursing and the Administrator on 05/09/2023 at 11:39 AM, they stated that the Admission's Coordinator and/or Social Worker were responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. They also added advanced directives should have been completed and scanned in Resident #21's computerized clinical record or a note indicating the resident's refusal to formulate an advance directive. 4- Resident #47 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] indicated Resident #47 was moderately cognitively impaired. Record review of Resident #47's electronic medical record revealed there was no documentation of Resident #47's advanced directives. During a telephone interview with Resident #47 Responsible Party (RP) on 05/09/2023 at 08:40 AM, the RP refused to answer any questions regarding Resident #47. During an interview with the Admission Coordinator on 05/09/2023 at 10:56 AM, she indicated that there was no note indicating Resident #47 or the Responsible Party wanted to formulate an advance directive or refused to formulate one. She indicated that the Social Worker was responsible for ensuring that the advance directives were reviewed and documented in the resident's record if they refused to formulate one. During telephone interview with the Social Worker on 05/09/2023 at 11:09 AM, she acknowledged she had not written any notes indicating Resident #47 or the Responsible Party wanted to formulate an advance directive or refused to formulate one. During the interview with Director of Nursing and the Administrator on 05/09/2023 at 11:39 AM, they stated that the Admission's Coordinator and/or Social Worker were responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. They also added advanced directives should have been completed and scanned in Resident #47's computerized clinical record or a note indicating the resident's refusal to formulate an advance directive. 5- Resident #58 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] indicated Resident #58's cognition was severely impaired. Record review of Resident #58's electronic file revealed no documentation that the resident wanted to formulate an advance directive or refusal. During an interview with Admission Coordinator on 05/09/2023 at 10:56 AM, she indicated that there was no note indicating Resident #58 or the Responsible Party wanted to formulate an advance directive or refused to formulate one. She indicated that the Social Worker was responsible for ensuring that the advance directives were reviewed and documented in the resident's record if they refused to formulate one. During a telephone interview with Social Worker on 05/09/2023 at 11:09 AM, she acknowledged she had not written any notes indicating Resident #58 or the Responsible Party wanted to formulate an advance directive or refused to formulate one. During the interview with Director of Nursing and the Administrator on 05/09/2023 at 11:39 AM, they stated that the Admission's Coordinator and/or Social Worker were responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. They also added advanced directives should have been completed and scanned in Resident #58's computerized clinical record or a note indicating the resident's refusal to formulate an advance directive. 6- Resident #84 was admitted to the facility on [DATE]. Minimum Data Set (MDS) dated [DATE] indicated Resident #84's cognition was intact. Review of the computerized clinical record for Resident #84 revealed no advanced directives noted in the resident's medical record. During an interview with Resident #84 on 05/09/2023 at 8:20 AM, Resident #84 stated he did not remember discussing advanced directives on admission to the facility. During an interview with Admission Coordinator on 05/09/2023 at 10:56 AM, she indicated that there was no note indicating Resident #84 wanted to formulate an advance directive or refused to formulate one. She indicated that the Social Worker was responsible for ensuring that the advance directives were reviewed and documented in the resident's record if they refused to formulate one. During telephone interview with Social Worker on 05/09/2023 at 11:09 AM, she acknowledged there was no note indicating Resident #84 wanted to formulate an advance directive or refused to formulate one. During the interview with Director of Nursing and the Administrator on 05/09/2023 at 11:39 AM, they stated that the Admission's Coordinator and/or Social Worker were responsible for reviewing the advance directive forms with the residents or responsible party during the admission to the facility. They also added advanced directives should have been completed and scanned in Resident #84's computerized clinical record or a note indicating the resident's refusal to formulate an advance directive 44377 7 - Resident #6 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure. Her quarterly Minimum Data Set (MDS) indicated she was cognitively intact. Record review did not indicate advanced directives for Resident #6. During an interview on 5/9/23 at 11:00 AM, the Admission Coordinator revealed information about advanced directives was discussed in the admission packet. She did not have an additional form used to communicate preferences regarding care. During an interview on 5/11/23 at 1:00 PM, the Administrator revealed advanced directive were discussed with the admission packet. If a resident said they had an advanced directive in place, the facility would ask them to bring it in. The admission coordinator discussed advanced directives but did not have written documentation of preferences in place.

Based on staff interviews, and record reviews, the facility failed to submit an initial allegation report and an investigation report to the state survey Agency for 1 of 3 sampled residents (Resident #148) reviewed for abuse. Findings included: Review of the facility policy revised on 10/15/22 titled Abuse, Neglect, or Misappropriation of Resident Property Policy, revealed under subheading Reporting/Response. The Administrator will ensure all allegation that involves abuse or results in serious bodily injury, state agency, adult protective services are notified immediately but no later than 2 hours after the allegation is received, and determination of alleged abuse is made. For all allegations that do not involve abuse or result in serious bodily injury, the Administrator will ensure that the state agencies are notified no later than 24 hours. Resident#148 was admitted to the facility on [DATE] with diagnoses that included hypertension, migraine, and a history of falling. The resident was discharged home on 08/19/2022. The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #148 was cognitively intact. MDS did not indicate the resident had any behavioral symptoms Review of Resident#148's investigation dated 06/23/2022 revealed the resident alleged Nurse#1 fondled her breast during admission exam and called police. The investigation revealed the resident indicated to the police that abuse did not occur, and the nurse was doing her job by completing the admission assessment. After Resident #148 was discharged on [DATE], She filed a second report for sexual battery to the incident that happened 06/23/2022 on 10/24/2022. The summary of investigation revealed review of electronic health records, interview with staff, Resident #148 medical history, and Resident#1's admission to police that the abuse did not occur, the facility and police did not substantiate the abuse. Further review of the investigation revealed that the facility did not submit the initial report and the investigation report to the State Agency. Resident # 148 was no longer residing in the facility and did not answer the phone call. During the interview with the Director of Nursing (DON) on 05/10/23 at 11:15 AM, she explained a police officer came to the facility sometime in June 2022 and said he was investigating a complaint from Resident #148 about a nurse fondling the resident's breast during the admission's assessment. DON also indicated after resident was discharged on [DATE], she filed on 10/24/2022 a second report for sexual battery referring to the incident that happened in June 2022. DON stated the police officer's investigation concluded on June 06/23/2022 the nurse was doing her job and the abuse did not occur. DON indicated the police were unable to substantiate the allegation. DON reported the facility did not submit the investigation report to the State Agency after the investigation in June 2022 and August 2022 because they felt the allegation was resolved. The DON explained that the initial report and the investigation report should have been sent to the State Agency within 2-5 days after the conclusion of the investigation per facility policy. During the interview with the Administrator on 05/10/23 at 10:35 AM, he stated he was new at the facility, and he was not present at the facility during the time the alleged allegation of abuse occurred in June 2022. He explained when an allegation of abuse was made by Resident#148, the facility should have followed the protocol of submitting the initial and the investigation report to the State Agency.

Based on observations, record review and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities which gave the facility a medication error rate of 7.14%. This affected 2 of 4 residents observed during medication administration (Resident #31 and Resident #35). The findings included: 1. Resident #31's May 2023 Physician Orders were reviewed, and she was prescribed Oyster Shell Calcium / Vitamin D 500-200 1 tablet twice a day. A medication administration was observed on 05/10/23 at 9:05 a.m. with Med Tech (MT) #1. MT #1 was observed dispensing Calcium 500mg 1 tab into a medication cup and then administered it to Resident #31. The electronic Medication Administration Record (eMAR) was reviewed on 05/20/23 at 10:10 a.m. and Oyster Shell Calcium / Vitamin D 500-200 1 tablet was documented as having been administered on 05/10/23 by MT #1. MT #1 was interviewed on 05/10/23 at 10:50 a.m. MT #1 stated she gave Resident #31 the medication she always gave her and thought she had given her the correct medication. 2. Resident #35's May 2023 Physician Orders were reviewed, and he was prescribed Senna-Docusate Sodium 8.6-50 2 tablets twice a day. A medication administration was observed on 05/10/23 at 9:30 a.m. with Nurse #1. Nurse #1 was observed dispensing Senna 8.6 2 tabs into a medication cup and then administered it to Resident #35. The eMar was reviewed on 05/20/23 at 10:25 a.m. and Senna-Docusate Sodium 8.6-50 2 tablets was documented as having been administered on 05/10/23 by Nurse #1. Nurse #1 was interviewed on 05/10/23 at 10:42 a.m. Nurse #1 explained it had been human error as the reason for her administering the incorrect medication to Resident #35. During an interview with the Administrator on 05/11 23 at 2:14 p.m., the Administrator stated it was his expectation that nurses and med techs follow the doctor's orders for medication administration. He explained he did not know the reason for the medication errors and stated the nursing staff were being in-serviced in this regard. During an interview with the Director of Nursing (DON) on 05/11/23 at 2:33 p.m., the DON stated it was her expectation nursing staff follow the physician orders for medication administration and if they are unable to do so they are to contact the doctor.

Based on staff interviews, observation, and record review, the facility failed to implement fall interventions per the care plan for one of two (Resident #5) residents reviewed for accidents. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated 2/25/22 focused on falls included a goal that resident would not sustain serious injury from falls. Interventions included keep her bed in lowest position, a fall mat on floor when in bed, her call light within reach, and Resident #5 would use a scoop mattress on her bed. Resident #5's significant change Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment and had an acute change in mental status and worsened behavioral status. Resident #5 required extensive assistance with bed mobility and was total dependence for transfers. The MDS indicated she had not had any falls since the prior quarterly MDS. On 7/6/22 at 11:15 AM, an observation was made of Resident #5 in bed in a high position without a fall mat at bedside. Staff was not present or observed providing care. During an interview on 7/6/22 at 3:45 PM, the nurse aid (NA) #1 working with Resident #5 indicated that Resident #5's fall intervention included a scoop mattress, transfers with a mechanical lift, and fall mat. NA #1 indicated that Resident #5 was no longer trying to get out of bed and possibly did not need the fall mat anymore. She confirmed the bed should be in low position. During an interview on 7/6/22 at 3:50 PM, the Quality Assurance (QA) nursing indicated that Resident #5 no longer needed the fall mat, and it should have been removed from the Care Plan. She revealed she was responsible for removing interventions from the Care Plan. She confirmed the bed should be in low position. During an interview on 7/7/22 at 1:20 PM, the Director of Nursing (DON) revealed that the fall mat was discontinued last week and should have been removed from the Care Plan. She revealed the bed should be in low position and possibly staff had left it high after providing care. During an interview on 7/7/22 at 1:25 PM, the Administrator revealed the intervention should have been removed from the Care Plan.

Based on record reviewed and staff and resident interviews, the facility failed to resolved grievances that were reported in resident council meetings for 4 of 6 months reviewed (July 2021, September 2021, October 2021, and November 2021). Findings included: Record review of Resident Council Meeting minutes for the months of July 2021, September 2021, October 2021, and November 2021 all revealed concerns about call light times. There was no attached resolution of these grievances. During an interview on 1/11/21 at 9:30 AM, Resident #2 revealed he and his roommate attend resident council meeting every month. He further indicated that staff does not address concerns brought up in the meetings. During an interview on 1/12/21 at 10:40 AM, the activities director revealed they do not provide written resolutions to concerns brought up by the Resident Council group but will follow up with individual concerns. During an interview on 1/14/21 at 1:15 PM, the Administrator revealed individuals' concerns were addressed in writing but not concerns from the group.

Based on record review and staff interviews, the facility failed to ensure physician's orders for [CONDITION(S)] medications to be administered as needed (PRN) were time limited in duration for 1 of 3 residents (Resident #59) reviewed for unnecessary medications. The findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses that included mood disorder, dementia with behavioral disturbance. A Care Plan focused on [CONDITION(S)] drugs use dated 10/20/21 included a goal for improvement of mood and behavior with interventions to administer medications per physician's orders, notify the physician of significant changes to Resident #59's mood or behavior, and psychological services as needed. Review of Resident #59 physician's orders revealed an order dated 11/15/21 for [MEDICATION(S)] 5 milligrams (mg) intramuscular every 6 hours PRN for agitation. The end date indicated was indefinite. Further review of Resident #59 physician's orders revealed an order dated 11/16/21 entered by the psychology service's physician's assistant (PA) for [MEDICATION(S)] 5 mg intramuscular every 12 hours PRN for breakthrough agitation and aggression. The end date indicated was indefinite. Further review of Resident #59's physician's orders revealed an order dated 11/16/21 entered by the psychology service's PA for [MEDICATION(S)] (an antipsychotic medication) 50 mg tablet every 6 hours as needed for breakthrough agitation or [CONDITION(S)]. The end date indicated was indefinite. Resident #59's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment. He required extensive assistance with most activities of daily living. The MDS indicated he received an antipsychotic medication daily with physical and verbal behaviors occurring in 1 to 3 of 7 days reviewed. Two physician communication forms dated 11/30/21 and 12/31/21 provided recommendations from the pharmacist to limit duration of [MEDICATION(S)] and [MEDICATION(S)] to fourteen days. The communication forms did not indicate a response from the physician. During an interview on 1/14/22 at 9:00 AM, the pharmacist revealed she had made recommendations to indicate a stop date for fourteen days for Resident #59's [CONDITION(S)] medications. During an interview on 1/14/22 at 9:40 AM, the psychology services PA revealed Resident #59 refused medications at times and the PRN orders were to address behaviors. She indicates she was aware of the order needing a stop date and must have missed it. She further revealed she had received the pharmacist's recommendations and they were working to get stop dates on appropriate medications. During an interview on 1/14/21 at 12:10 PM, the Administrator revealed she was aware that PRN [CONDITION(S)] medications needed to be limited in duration and the facility was currently working to resolve the issue.

Based on record review and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of level II Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents (Resident # 71) identified as PASRR Level II. Findings included: Resident #71 was admitted to the facility on [DATE] and most recently readmitted on [DATE] after hospitalization with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review indicated Resident #71 had a Preadmission Screening and Resident Review (PASRR) Level II Determination Notification dated 1/29/21. The annual MDS assessment dated [DATE] was answered No to question A1500 which asked if Resident #71 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. An interview was conducted on 1/11/22 at 3:00 PM with the Administrator regarding PASRR II documentation for Resident #71. The Administrator provided a copy of the Level II PASRR Review for Resident #71. An interview was conducted on 1/12/22 at 1:15 PM with the Minimum Data Set Nurse 1 (MDS Nurse #1) and Minimum Data Set Nurse 2 (MDS Nurse #2) regarding PASRR II documentation. MDS Nurse #1 stated the PASRR II documentation was available but not to them; therefore, it did not get coded in Resident #71 ' s annual MDS assessment. An interview was conducted on 1/14/22 at 11:20 AM with the Administrator. The Administrator explained she had been notified by the MDS Nurses that the PASRR II was not coded on Resident #71 ' s annual assessment dated [DATE] and the coding was being corrected. The Administrator stated all PASRR II residents should be coded on their annual MDS assessments.

Based on record review and staff interviews, the facility failed to ensure the physician received the Pharmacy Consultant's recommendations to include a stop date for [CONDITION(S)] medications for 1 of 3 residents reviewed for unnecessary [CONDITION(S)] medications (Resident #59). The findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses that included mood disorder, dementia with behavioral disturbance. Review of Resident #59's physician orders revealed an order dated 11/15/21 for [MEDICATION(S)] 5 milligrams (mg) intramuscular every 6 hours PRN for agitation. The end date indicated was indefinite. Review of Resident #59's physician orders revealed an order dated 11/16/21 entered by the psychology service Physician Assistant (PA) for [MEDICATION(S)] 5 mg intramuscular every 12 hours PRN for breakthrough agitation and aggression. The end date indicated was indefinite. Review of Resident #59's physician orders revealed an order dated 11/16/21 entered by the psychology service's PA for [MEDICATION(S)] (an antipsychotic medication) 50 mg tablet every 6 hours as needed for breakthrough agitation or [CONDITION(S)]. The end date indicated was indefinite. Resident #59's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment. He required extensive assistance with most activities of daily living. The MDS indicated he received an antipsychotic medication daily with physical and verbal behaviors occurring in 1 to 3 of 7 days reviewed. A Consultant Pharmacist's Medication Regimen Review (MRR) dated 11/30/21 provided recommendations to provide a stop date for the PRN [MEDICATION(S)] and [MEDICATION(S)]. The follow-through column was blank. A Physician Communication Form dated 12/31/21 signed by the consultant Pharmacist provided recommendations to limit the PRN antipsychotic to 14 days and to discontinue the duplicate [MEDICATION(S)] order. The bottom of the form provided check boxes and a signature line which were blank. During an interview on 1/14/22 at 9:00 AM, the Pharmacist Consultant revealed she had made recommendations to indicate a stop date for fourteen days for Resident #59's [CONDITION(S)] medications in November and December 2021. She revealed she emailed her recommendations on a Physician Communication Form to the Director or Nursing (DON) and she distributes them. The recommendations sheets were uploaded into the electronic medical record when they had a response and signature by the physician. During an interview on 1/14/22 at 9:40 AM, the psychology services PA revealed she had not received the pharmacist's recommendations until that morning. She indicated the recommendations were normally emailed to the DON by pharmacy then placed in her mailbox. She had not had any for several months. During an interview on 1/14/21 at 12:10 PM, the Administrator revealed that the pharmacy recommendations were sent to the PA that morning and they were working to address the issue. She stated she did not know what happened to the recommendations as the DON had been out for several weeks.

Based on record review and staff interviews, the facility failed to provide written notification to the resident representative of the reason for discharge to the hospital and failed to provide a copy of the notice to the Ombudsman for 2 of 5 sampled residents (Resident #35 and Resident #73) reviewed for hospitalization . The findings included: 1. Resident #35 was initially admitted to the facility on [DATE] with the last readmission on 1/7/22. The most recent comprehensive Minimum Data Set (MDS) dated [DATE] indicated Resident #35 was cognitively impaired Review of Resident #35's medical record revealed hospital stays from 10/27/21 through 10/31/21 and 1/2/22 through 1/7/22. During an interview on 1/14/22 at 10:44 AM, facility Administrator stated she was not aware that a letter was supposed to be sent to the resident representative regarding the reason a resident was being discharged to the hospital. The administrator communicated the resident representative was usually notified of transfer by telephone call and documented in resident's record. She indicated the Social Worker was supposed to send a log of admissions and discharges to the Ombudsman monthly. An interview was conducted with Social Worker (SW) on 1/14/22 at 1:44 PM. The SW indicated she was not aware she was supposed to send the Ombudsman a copy of notification of a resident discharge to hospital. A follow up interview was conducted with facility Administrator on 1/14/22 at 1:56 PM. The Administrator stated she thought they were doing what they were supposed to do regarding notification of resident discharge to hospital. She stated that they called resident representative but did not provide a written notification to resident representative. Social worker was supposed to send monthly notifications of discharges to ombudsman but had not sent it in. Administrator stated going forward she would ensure a written notification of reason for discharge to hospital was provided to resident representative and a copy of notice was provided to the Ombudsman. 2. Resident #73 was admitted to the facility on [DATE]. The most recent comprehensive Minimum Data Set (MDS) dated [DATE] indicated Resident #73 was cognitively intact. Review of Resident #73's medical record revealed hospital stays from 11/27/21 through 11/29/21, 12/1/21 through 12/7/21, and 12/10/21 through 12/11/21. During an interview on 1/14/22 at 10:44 AM, facility Administrator stated she was not aware that a letter was supposed to be sent to the resident representative regarding the reason a resident was being discharged to the hospital. The administrator communicated the resident representative was usually notified of transfer by telephone call and documented in resident's record. She indicated the Social Worker was supposed to send a log of admissions and discharges to the Ombudsman monthly. An interview was conducted with Social Worker (SW) on 1/14/22 at 1:44 PM. The SW indicated she was not aware she was supposed to send the Ombudsman a copy of notification of a resident discharge to hospital. A follow up interview was conducted with facility Administrator on 1/14/22 at 1:56 PM. The Administrator stated she thought they were doing what they were supposed to do regarding notification of resident discharge to hospital. She stated that they called resident representative but did not provide a written notification to resident representative. Social worker was supposed to send monthly notifications of discharges to ombudsman but had not sent it in. Administrator stated going forward she would ensure a written notification of reason for discharge to hospital was provided to resident representative and a copy of notice was provided to the Ombudsman.

Based on record review, staff and resident council group interviews, the facility failed to resolve grievances that were reported in the monthly resident council meetings for 6 of 13 months reviewed (October (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019). Findings included: During residents' council meeting on 9/25/2019 at 2:00 PM, it was reported by the residents in the meeting that the grievances were not acted on promptly by the facility and there were no explanations given as to the reason the grievances were not resolved. The assistant resident council president explained that during each meeting the issues from the prior month were discussed by the council members to see if the issues were still a concern. The assistant resident council president reported the Activities Director (AD) documented the issues and discussed the ongoing concerns during each meeting. Several of the members indicated the AD explained during the meetings that the issues were passed along to the appropriate staff to ensure resolution of the issues. The members stated the issues that were not being resolved and on ongoing were the following: Call lights were not being answered timely sometimes when they need to be changed after they were incontinent. Night time snacks were still not being provided and their bed linens were not being changed regularly. Review of the monthly resident council meeting minutes from (MONTH) (YEAR) until (MONTH) 2019 were reviewed. The minutes revealed no response for the following grievances: Review of the resident council minutes dated (MONTH) 23, (YEAR) indicated the residents reported night snacks were not being passed by staff and the residents asked when a task requires 2 Nurse Assistants (NA) that if one of the Nurse Assistant (NA) is new, that the other Nurse Assistant (NA)be experienced. Further review of the council minutes revealed no response for the residents' concerns. Review of the resident council minutes dated (MONTH) 13, (YEAR) revealed that the residents were not getting their linens changed on their shower days or when they are soiled. Further review of the council minutes revealed no response for the residents' concerns. Review of the resident council minutes dated (MONTH) 13, (YEAR) indicated the residents voiced concerns of staff coming in late for their shift, therefore residents were waiting long periods of time before getting assistance. Further review of the council minutes revealed no response for the residents' concerns. Review of the resident council minutes dated (MONTH) 29, 2019 indicated the residents reported continued issues from the last council meetings. The residents were not getting changed timely and call lights were not getting answered timely. Further review of the council minutes revealed no response for the residents' concerns. Review of the resident council minutes dated (MONTH) 29, 2019 indicated the bed linens were not being changed and nourishments were not getting passed out. Further review of the council minutes revealed no response for the residents' concerns. Review of the resident council minutes dated (MONTH) 10, 2019 indicated the residents reported nourishments were not getting passed. Linens on the 100, 200 and 300 halls were not getting changed at least twice a week and call lights on all halls were not getting answered timely. Further review of the council minutes revealed no response for the residents' concerns. An interview was conducted with the Activity Director (AD) on 9/26/2019 at 11:44 AM. The AD indicated the grievances from the Resident Council meetings for the last year were forwarded to the specific departments for resolution. The AD reported she was aware that the department heads were not responding back to the resident council grievances. AD reported she always made the Administrator aware of the department heads not responding back to resident council minutes. An interview was conducted with the Administrator on 9/27/2017 at 9:59 AM. The Administrator revealed the Resident Council grievances were not addressed under another Administrator who no longer was employed at the facility. She reported they were unable to locate the Resident council grievance responses from the last year. The Administrator stated the facility grievance resolution system was under review. She stated the expectation was all grievances would be investigated when reported and the actions of the investigations be documented and reported to ensure resolution.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 7 of 29 resident assessments reviewed (Residents #64, #97, #89, #91, #92, #36 and #71 ). Findings included: 1. Resident # 64 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's medical record contained a Preadmission Screening Resident Review (which is an evaluation for mental illness or intellectual disability for all persons who live in or seek entry to a Medicaid-certified nursing facility) Level II Determination Notification that was dated 6/25/2019 with the end date of 9/23/2019. The Admission Minimum (MDS) data set [DATE] indicated a No to question A1500 which asked if Resident # 64 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. During the interview on 9/26/2019 at 1:29 PM, Minimum Data set (MDS) nurse reviewed the discharge MDS and confirmed it was inaccurate. The MDS nurse explained it was coded in error as Resident # 64 had been approved for a level II PASRR on 6/25/2019 and determined to have a serious mental illness. During an interview on 9/26/2019 at 1:35 pm with the Director of Nursing (DON) she acknowledged Resident # 64's Admission MDS was inaccurately coded. She stated that it is her expectation that the MDS should be coded accurately. Interview with the Administrator on 09/26/19 at 4 :15 PM revealed her expectation is that all MDS documentation be coded correctly. 2. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #97's discharge Minimum Data Set ((MDS) dated [DATE] indicated Resident #97 was discharged to an acute hospital. Review of the nurse note dated 6/28/2019 indicated Resident # 97 was discharged home with home health services not to an acute hospital. During the interview on 9/26/2019 at 1:29 PM, Minimum Data Set (MDS) nurse reviewed Resident #97's discharge MDS and confirmed it was inaccurately coded that the resident was discharged to acute hospital. The MDS nurse explained it was coded in error as Resident # 97 was discharged home not to acute hospital. During an interview on 9/26/2019 at 1:35 pm with the Director of Nursing (DON) she acknowledged Resident #97 discharge MDS was inaccurately coded. She indicated that discharge to the community should have been coded on Resident #97's MDS dated [DATE] not acute hospital. During further interview with DON, she stated that it is her expectation that the MDS should be coded accurately. Interview with the Administrator on 09/26/19 at 4 :15 PM revealed her expectation is that all MDS documentation be coded correctly. 3. Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated on 09/03/19 revealed that the resident was coded as receiving an anticoagulant medication for 7 of 7 days during the assessment period. Review of Medication Administration for (MONTH) 2019 indicated that the resident was prescribed Aspirin 325 mg daily and [MEDICATION NAME] 75 mg daily and the Resident Assessment Instrument (RAI) indicated do not code this medication in section N under anticoagulant. An interview was conducted with the MDS Coordinator on 09/27/19 at 12:20 PM. She stated that she thought all anticoagulants had to be coded in Section N on the MDS to include Aspirin and [MEDICATION NAME]. The MDS Coordinator further stated that it is her expectation all residents MDS assessments be coded correctly. An interview was conducted with Administrator on 09/27/19 at 3:30 PM. She stated that it is her expectation that all MDS documentation be coded correctly. 4. Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated on 09/04/19 revealed that the resident was coded as receiving an anticoagulant for 7 of 7 days during the assessment period. Review of Medication Administration Record [REDACTED]. An interview was conducted with the MDS Coordinator on 09/27/19 at 12:20 PM. She stated that she thought all anticoagulants had to be coded in Section N on the MDS to include [MEDICATION NAME] Bisulfate. The MDS Coordinator further stated that it is her expectation all residents MDS assessments be coded correctly. An interview was conducted with Administrator on 09/27/19 at 3:30 PM. She stated that it is her expectation that all MDS documentation be coded correctly. 5. Resident #92 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].>[MEDICAL CONDITION] disease. The admission MDS dated on 09/14/19 revealed the resident was coded as receiving an anticoagulant for 7 of 7 days during the assessment period. Review of the Medication Administration for (MONTH) 2019 indicated that the resident was prescribed Aspirin 325 mg daily and the Resident Assessment Instrument (RAI) indicated do not code this medication in section N under anticoagulant. An interview was conducted with the MDS Coordinator on 09/27/19 at 12:20 PM. She stated that she thought all anticoagulants had to be coded in Section N on the MDS to include Aspirin. The MDS Coordinator further stated that it is her expectation all residents MDS assessments be coded correctly. An interview was conducted with the Administrator on 09/27/19 at 3:30 PM. She stated that it is her expectation that all MDS documentation be coded correctly. 6. Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #36's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #36 was cognitively intact had received injections, insulin and anticoagulant medications for 7 days of the assessment period. A review of Resident #36's Care Plan, last updated 07/25/19, revealed insulin injections and anticoagulant medications had not been planned. A review of Resident #36's physician orders [REDACTED]. During an interview with the MDS Nurse on 09/27/19 at 11:50 a.m., the MDS Nurse stated he must have been looking at another resident's medication list and had accidently transcribed insulin injections and anticoagulant medications into Resident #36's MDS assessment. During an interview with the Director of Nursing (DON) on 09/26/19 at 1:35 p.m., the DON stated it was her expectation the MDS assessments be correctly coded. During an interview with the Administrator on 09/26/19 at 4:15 p.m., the Administrator stated it was her expectation the MDS assessments be correctly coded. 7. Resident #71 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #71's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #71 was severely cognitively impaired and had received anticoagulant medication for 7 days of the assessment period. A review of Resident #71's Care Plan, last updated 09/09/19, revealed anticoagulant medications had not been planned. A review of Resident #71's Physician order [REDACTED]. The Resident Assessment Instructions (RAI) indicated not to code the medication aspirin in section N of the MDS assessment. During an interview with the MDS Nurse on 09/27/19 at 11:50 a.m., the MDS Nurse stated he had been in training as a new MDS nurse at the facility and had misunderstood his corporate trainer. The MDS Nurse stated he had thought if the physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) on 09/26/19 at 1:35 p.m., the DON stated it was her expectation the MDS assessments be correctly coded. During an interview with the Administrator on 09/26/19 at 4:15 p.m., the Administrator stated it was her expectation the MDS assessments be correctly coded.

Based on record review and staff interviews, the facility failed to implement a care plan for a resident with a Level II Preadmission Screening and Resident Review (PASRR), failed to incorporate PASRR recommendations into a care plan for 1 of 1(Resident # 64)residents reviewed for PASRR care plan. Facility also failed to make a referral for re-evaluation after a change in mental health status for 4 of 4 residents (Resident #64, #2, #74, #91 and #23) reviewed for Pre-Admission Screening and Resident Review. Findings included: 1. Resident # 64 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognition was intact and he had no behavioral symptoms indicated. MDS also indicated the resident was taking antipsychotic medication. The resident's medical record contained a Preadmission Screening Resident Review (PASARR) Level II Determination Notification that was dated 6/25/2019 with the end date of 9/23/2019. The notification indicated the resident placement was appropriate for 90 days. Under specialized services determination the notification indicated the following: - Follow- up psychiatrist services by a psychiatrist and continue substance use treatment. Review of Resident # 64 care plan dated 8/14/2019 and medical record revealed no care plan was in place for follow-up with psychiatrist services and the resident had not received psychiatrist services as recommended by PASRR level II determination. The Minimum Data Set (MDS) nurse was responsible for updating the care plan and Director of Nursing (DON) was responsible for monitoring the care plan. An observation of the resident on 9/25/2019 at 10:00 AM revealed the resident sleeping in his bed with his eyes closed. No concerns or behavioral problems were noted. An interview was conducted with the Minimum Data Set (MDS) Nurse #1 on 9/26/2019 at 10:15 AM and she reported she did not complete the Admission MDS assessment dated [DATE] for Resident # 64. MDS Nurse #1 added the nurse who was responsible for completing the MDS was on sick leave. MDS Nurse # 1 added that in the future they will be more specific in documenting the specialized recommendations from a PASSR level II determination. An interview was conducted with Nurse # 4 on 9/26/2019 at 10:20 AM. She reported the resident had no behavioral problems since his admission to the facility. She reported the resident continues to take his antipsychotic medications with no problems. The Social Worker (SW) was interviewed on 9/26/2019 at 10:28 AM. The SW reported Resident # 64 was a Level II PASRR and she did not refer the resident for psychiatrist services sooner because she was out on sick leave. SW reported she was on leave for about a month and the Admissions coordinator was responsible for setting up an appointment for the resident with the psychiatrist. SW added she was going to set up an appointment immediately. She also stated that the resident was stable and had not experienced any behavioral symptoms or any decline due to not receiving psychiatrist services and substance use treatment for [REDACTED]. The Administrator (AD) was interviewed on 9/26/2019 at 4:44 PM. The AD explained she was not aware that Resident #64 had not been seen by a psychiatrist as determined by PASRRR level II since his admission. AD reported the Admissions coordinator was responsible for fulfilling the SW responsibilities while the SW was on leave but it looks like she missed setting up an appointment for the resident with the psychiatrist. The AD further reported a new process will be initiated to track all residents with Level II PASRR and had specialized services. She added her expectation will be to have the SW set up psychiatrist appointments with PASRR level II residents as soon as they get admitted to the facility. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of face sheet list with [DIAGNOSES REDACTED]. The additional mental health [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognition is severely impaired. The staff assessment noted her feeling tired or having little and poor appetite or overeating on 2 to 6 days. She had delusions and on 1 to 3 days verbal behavior. The Resident was administered antipsychotic and antidepressant medication on 7 of 7 days. Her active [DIAGNOSES REDACTED]. Review of the care plan dated on 08/21/19 revealed that the resident was care planned for [MEDICAL CONDITION] drug use. Review of the PASARR Level I Determination Notification dated on 03/10/16 revealed that the resident did not have any mental health [DIAGNOSES REDACTED]. An interview was conducted with the Social Worker on 09/27/19 at 3:00 PM. She stated that she was not aware that the resident was diagnosed with [REDACTED]. She further stated that she was not aware that another PASARR screening needed to be completed. An interview was conducted with the Administrator on 09/27/19 at 3:43 PM. She stated that there had been a lot of turnover and transition in the staff at the facility. She further stated that it was her expectation that when a resident is diagnosed with [REDACTED]. 3. Resident #74 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of face sheet list with [DIAGNOSES REDACTED]. The additional mental health [DIAGNOSES REDACTED]. Review of the PASARR Level II Determination Notification letter was dated 12/07/09 revealed that the PASARR expiration date was 12/07/10. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident's cognition was moderately impaired. No mood or behaviors were documented on the MDS. The Resident was administered antipsychotic and antidepressant medication on 7 of 7 days. Her active [DIAGNOSES REDACTED]. Review of the care plan dated on 09/01/19 revealed that the resident was care planned for [MEDICAL CONDITION] drug use with [DIAGNOSES REDACTED]. An interview was conducted with the Social Worker on 09/27/19 at 3:00 PM. She stated that she was not aware that the resident was diagnosed with [REDACTED]. She further stated that she was not aware that another PASARR screening needed to be completed. An interview was conducted with the Administrator on 09/27/19 at 3:43 PM. She stated that there had been a lot of turnover and transition in the staff at the facility. She further stated that it was her expectation that when a resident is diagnosed with [REDACTED]. 4. Resident #91 was admitted to the facility on [DATE] with no mental health diagnoses. Review of face sheet list with [DIAGNOSES REDACTED]. The additional mental health [DIAGNOSES REDACTED]. Review of the PASARR Level I Determination Notification dated on 09/28/18 revealed that the resident did not have any mental health diagnoses. The annual Minimum Data Set (MDS) dated on 09/04/19 revealed that the resident's cognition was intact. No mood or behaviors were documented on the MDS. The Resident was administered antipsychotic and antidepressant medication on 7 of 7 days. Her active [DIAGNOSES REDACTED]. Review of the care plan dated on 09/20/19 revealed that the resident was care planned for [MEDICAL CONDITION] drug use with [DIAGNOSES REDACTED]. An interview was conducted with the Social Worker on 09/27/19 at 3:00 PM. She stated that she was not aware that the resident was diagnosed with [REDACTED]. She further stated that she was not aware that another PASARR screening needed to be completed. An interview was conducted with the Administrator on 09/27/19 at 3:43 PM. She stated that there had been a lot of turnover and transition in the staff at the facility. She further stated that it was her expectation that when a resident is diagnosed with [REDACTED]. 5. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the North [NAME]ina Department of Health and Human Services, Division of Medical Assistance, Preadmission Screening and Annual Resident Review (PASRR) application, dated 02/22/13, revealed Resident #23's mental health [DIAGNOSES REDACTED]. Resident #23 had been given the determination of a PASRR Level 1 with no expiration date. A review of Resident #5's annual Minimum Data Set (MDS), dated [DATE], revealed Resident #5 was severely cognitively impaired and had not been considered by the State Level II PASRR process to have a serious mental illness. The MDS indicated Resident #5 had [DIAGNOSES REDACTED]. A review of Resident #5's Care Plan, last revised 08/13/19, revealed Resident #5 had been planned for the use of [MEDICAL CONDITION] medications. During an interview with the Social Worker (SW) on 09/27/19 at 9:44 a.m., the SW stated she had been doing the PASRR tasks for the past 3 to 4 years and had just found out she had been doing it incorrectly secondary to a misunderstanding of the PASRR process. During an interview with the Administrator on 09/27/19 at 4:15 p.m., the Administrator stated it was her expectation PASRRs are completed as per the federal regulations.

Based on observations, record reviews and staff interviews, the facility failed to assess the ability of a resident to administer oral medications that were observed beside the resident's bedside for 1 of 1 sampled resident. (Resident # 13) The findings included: Review of the undated facility's policy indicated the facility shall permit residents who are competent and physically able to self- administer their medications if the self administration is orderd by the physician or othe authorized prescriber and documented in the residents medical record. Resident #13 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Annual MDS (Minimum Data Set) dated 5/11/2018 revealed that resident #13 was intact with his cognition. Resident #13 had adequate hearing, clear speech, able to understand and make herself understood. Resident #13 required supervision with bed mobility and independent with transfer an eating. Review of the care plan updated on 5/11/2018 revealed that resident #13 was not care planned to self-administer oral medications. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. An observation on 8/14/18 around 10:33am revealed that resident #13 had all his AM (morning) medications on the bed side table. Nurse # 1 was not in the room with Resident # 13. Review of the medical record (all active orders) for month of (MONTH) (YEAR) revealed that resident #13 did not have an order to self-administer oral medications or to keep at the bedside. Review of medical record (assessments) for the month of (MONTH) (YEAR) revealed that there was no self-administration assessment for oral medication completed for Resident #13. During the interview on 8/14/2018 at 10:35 am with Resident #13 he stated that he normally takes all his morning medications given by the nurse. He added he likes to take his time when taking his medication. Interview on 8/14/18 at 10:40am with Nurse # 1 revealed that she left the medications on Resident # 13's bedside table knowing that the resident was going to take them. She added that it was not her usual practice to leave the medications on the resident's bedside before the resident takes them. Nurse # 1 also revealed that residents that self-administer medications at the facility would need a doctor's order and an assessment completed. An interview on 8/15/18 at 11:47am with the Director of Nursing (DON) revealed that residents who desire to self-administer medications would need a doctor's order and an assessment completed. She added Resident # 13 did not have an assessment completed to self- administer medication. DON also stated she did not expect Nurse # 1 to have left the medication on the bedside table for the resident to take without supervision. An interview on 8/15/18 at 11: 50am with the Administrator revealed that her expectation was for Nurse # 1 not to have left the medications on the bedside table without supervising the resident to make sure all the medication were taken. She added regarding self-administration of medication would be that staff speak with the residents who desired to self-administer medications, obtain a physician's orders [REDACTED].

Based on record review and staff interviews the facility failed to submit information for Preadmission Screening and Resident Review (PASRR) for a level II re-evaluation for 1 of 1 sampled resident (Resident #29). The findings included: Resident #29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #29's Annual Minimum Data Set (MDS) dated on 01/02/18 indicated that the resident cognition was intact. The resident was coded as feeling tired or have little energy for 2-6 days. The resident was coded as having had received antipsychotic medication for 7 of the 7 days during the assessment period. Review of Resident #29's care plan which was revised on 08/12/18 indicated the resident was care planned for use of [MEDICAL CONDITION] drugs due to [DIAGNOSES REDACTED]. Record review revealed that the following [DIAGNOSES REDACTED]. An interview was conducted with the Social Worker on 08/16/18 at 3:24 PM and she stated that she was not aware when a resident received a new [DIAGNOSES REDACTED]. An interview was conducted with the Administrator on 08/16/18 at 3:34 PM revealed that it was her expectation that when a resident receives a [DIAGNOSES REDACTED].

Based on record review, policy review and staff interviews, the facility failed to offer the influenza immunization during the (MONTH) (YEAR) through (MONTH) (YEAR) influenza season for 1 of 5 residents reviewed for immunizations (Resident #61). The findings included: A review of the facility's Immunization Policy, last revised 10/18/17, indicated before offering the influenza immunization, residents or residents' legal representatives will be provided education regarding the benefits and potential side effects of the influenza immunization with documentation in the medical record. The policy indicated residents will be offered the influenza vaccination from early (MONTH) to March. A review of Resident #61's medical record indicated Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #61's annual Minimum Data Set (MDS), dated [DATE], indicated Resident #61 was severely cognitively impaired. The MDS indicated the influenza vaccine had not been administered and it had been offered and declined. A review of Resident #61's Immunization Record did not indicate the influenza vaccine had been offered and declined. During an interview with the Administrator on 08/14/18 at 5:30 p.m., the Administrator stated she could find no documentation Resident #61 had been offered the influenza vaccination for the (YEAR)-18 influenza season and stated Resident #61 had not been administered the influenza vaccination for the (YEAR)-18 influenza season. During an interview with the MDS Coordinator on 08/16/18 at 11:35 a.m., the MDS Coordinator stated she had coded Resident #61 on the 07/20/18 annual MDS as having had the influenza vaccine offered and declined after she had reviewed Resident #61's Immunization Record. The MDS Coordinator stated she had assumed Resident #61 had refused based on past refusals from 2012 and 2013. During an interview with the Administrator on 08/16/18 at 11:45 a.m., the Administrator stated it was her expectation for facility staff to mail the Influenza Vaccine Information Sheets (VIS) to the residents' Responsible Party (RP) prior to the beginning of the influenza season. The Administrator stated staff would then call the residents' RP to ask if they had received the Influenza VIS and ask if they had any questions regarding the influenza vaccination. The Administrator stated they would then obtain consent for or declination of the influenza vaccination and document it in the medical record.

Based on observation, staff interviews and record review, the facility failed to follow physician orders [REDACTED].#13). Findings include: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #13's admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #13 was severely cognitively impaired and required supervision when eating. The MDS indicated Resident #13 was receiving Speech Therapy services. A review of Resident #13's Care Plan, last updated 02/02/17, indicated Resident #13 was to receive nectar thick liquids related to her cognitive impairment. A review of Resident #13's physician's orders [REDACTED].#13 was to continue nectar thick liquids. During a medication administration observation on 04/26/17 at 8:30 a.m., Resident #13 was observed to swallow her oral medication with a cup of thin liquid (water) provided to her by Nurse #1. During an interview with Nurse #1 on 04/26/17 at 11:20 a.m., Nurse #1 stated she had known Resident #13 had been on thickened liquids but had become nervous during the observation and had forgotten to administer Resident #13's medication with nectar thick liquids. During an interview with the Director of Nursing (DON) on 04/26/17 at 11:40 a.m., the DON stated it was her expectation the nursing staff follow physician orders.

Based on observation, record review, staff interviews, interview with Department of Social Services, Physician interviews and interview with the police Detective, the facility failed to ensure 1 of 4 residents reviewed for abuse was free from a combination of injuries determined to be life-threatening, not self-inflicted nor the result of a fall. Resident #1 was admitted to the emergency room with bruising on her face, neck and arm, had a petechial rash on her face, swelling in her face and neck, blood in her ears and was showing signs of neck pain. Immediate jeopardy began on [DATE] when the resident was found to have a purple face, blue lips, bleeding out of both ears and a bruise on her face and under her eyes. Immediate Jeopardy was removed on [DATE] at 7:35 PM. The facility remained out of compliance at a lower scope and severity of (D) isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. The findings included: Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her cumulative [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], indicated the resident had long and short term memory problems and decision making ability was severely cognitively impaired. The MDS indicated the resident was rarely or never understood, required total assistance for bed mobility, had contractures in both lower extremities and could not ambulate. Per the MDS, the staff assessment of the resident's mood did not indicate the presence of any symptoms of depression, mood disorder or behaviors. Resident#1's Plan of Care, most recently updated on [DATE], indicated the resident had feelings of depression and ineffective coping characterized by tearfulness, anxiety and repetitive motor agitation. Documentation in Resident #1's record was reviewed for the events on [DATE]. An entry dated [DATE] at 12:15 AM, indicated the resident was in bed with her eyes closed, that she was incontinent and required staff turning and repositioning. The entry stated there were no acute changes or signs of distress. The note was signed by LPN#1. The next entry was dated [DATE] at 6:51 AM and read, "CNA (Nursing Assistant) informed me that resident was bleeding out of her ears. Resident had blood coming out of her ears and her face was slightly purple." The note also stated the Resident's oxygen saturation level (O2 sat) was 92%. After the resident was given oxygen the O2 sat was 97%, the blood pressure was ,[DATE] and heart rate was 98. The note indicated the Director of Nursing (DON) was informed, a voicemail message had been left for the attending physician and the nurse was unable to contact the responsible party (RP). The note was signed by Licensed Practical Nurse (LPN)#1. A physician's telephone order, dated [DATE] at 11:48 AM stated Resident #1 was to be sent to the hospital emergency room for evaluation. At 12:05 PM on [DATE] the progress note read, "Resident being assessed throughout the shift. No Bleeding noted thus far, but a rashy area to upper face and dark circles to Bilat (both) eyes noted. Resident continues on 2L (2 liters) O2 via NC (nasal cannula). Resident grimacing more than usual. MD (physician) made aware. No answer at RP's number. DON made aware." This note was signed by LPN#2. A progress note dated [DATE] at 12:15 PM read, "Resident being assessed throughout the shift. No bleeding noted thus far, but a rashy area to upper face and dark circles to Bilat eyes noted. Upon starting shift no black circle noted. Area around eyes appeared to slowly darken throughout the shift. Resident continues on 2L O2 via NC. Resident grimacing more than usual. MD made aware. No answer at RP's number. DON made aware." The note was signed by LPN#2 Review of an ambulance transportation "Patient Care Report" included, "Chief Complaint: Abdominal Pain. Primary Symptom: Pain. Patient found in bed in nursing home, pt (patient) was observed to be guarding her abdomen and had two black eyes, nurse stated she did not know how she got the black eyes and that they were not black yesterday." The transport note indicated on [DATE] at 12:28 PM they departed from the nursing home and arrived at the hospital at 12:31 PM. The hospital Emergency Department exam report dated [DATE] included, "Patient with petecchiae to face and ecchymosis around eyes, blood from ears. There are bruises along the patient's throat that are suspicious for finger prints. I am concerned about elder abuse and attempted strangulation. Will notify DSS (Department of Social Services) and plan to admit patient for her safety until this situation can be investigated. Pt (patient) is nonverbal but when I ask her if anyone hurt her, her eyes began to tear up." The report was signed by Hospital Physician #1. The Radiology report (dated [DATE]) revealed the Computerized Tomography (CT) scan was negative for a cranial fracture, there was no mass or hematoma and no other significant findings. During an interview on [DATE] at 9:51 AM, Hospital Physician #1 discussed her findings regarding her examination of Resident #1 on the afternoon of [DATE]. Hospital Physician #1 said that in addition to the bruising around her eyes and on her neck, Resident #1 also had a bruise on her upper arm when she came into the emergency department (ED). Hospital Physician #1 said, "We had to call the nursing home three times to get the list of medications." and added that Resident #1 wasn't on any medications that would have caused the petechiae or bruising. Hospital Physician #1 said, "Very few things will cause that petechial rash. It is forensically distinctive,- pathognomonic (specifically characteristic of a disease or condition; denoting a sign or symptom on which a [DIAGNOSES REDACTED]." The physician further stated, "The petechial rash is indicative of strangulation or a crushing force. I could not find anything else that would have caused it with this patient." The documentation from Resident #1's admitting hospital physician (Hospital Physician #2) dated [DATE] included, "Her face appears atraumatic except for large periorbital, infraorbital ecchymosis (bruising under and around the eyes).Patient has a petechial rash from the upper lip up to the forehead." The document also indicated there was a little bit of petechial rash "on the left side of the neck." Hospital Physician #2's assessment included, "Petechial rash. Is it a case of elderly abuse? We spoke with the nursing home staff and they truly do not have any idea of what happened. Patient is not ambulatory. She is totally bedridden so there was no history of a fall. This has to be investigated and DSS will be called." Hospital Physician #2 was interviewed on [DATE] at 10:44 AM and said, "This patient has so many unexplained injuries. These were life-threatening injuries." When asked about possible causes for the bleeding from the ears, Hospital Physician #2 stated that bleeding from the ears was usually associated with a skull fracture or very forceful coughing. She further stated that petechiae is often found with strangulation or forceful vomiting and that the nursing home had said there was no vomiting. Hospital Physician #2 said that tests showed no cranial fracture but there was swelling of the soft tissue in her face and neck, bruising, and subconjuctival hemorrhaging. Hospital Physician #2 said, "I don't know of anything that could cause all of that other than strangulation when you rule out a fall, vomiting or forceful cough." Physician #2 indicated that during communication with the facility she had only asked questions and had not shared any concerns with facility staff. Hospital Physician #2 indicated Resident #1 was still in the hospital. On [DATE] at 5:05 PM, the Department of Social Services (DSS) Social Worker stated the hospital had called their hotline and left a message after hours on Friday, [DATE], with allegations of abuse and strangulation. The Social Worker also said this resident "didn't have much family contact." On [DATE] at 11:47 AM, the Police Detective stated she was notified by the hospital on Monday [DATE], about the allegation of strangulation. The facility provided their investigation and written statements from the facility staff taken on [DATE] through [DATE]. After review of each written statement, the facility staff were interviewed during the survey. On [DATE] Nursing Assistant (NA) #1 wrote, "(Resident #1) had no falls on ,[DATE] that I'm aware of in the last 2 wks (weeks)." An interview was conducted with NA #1 on [DATE] at 10:42 AM. NA#1 indicated she was working the 11 PM to 7 AM shift, had provided care for Resident #1, and was the person who discovered Resident #1 with bleeding ears. NA#1 stated that the resident required total care and when agitated, would pull off her nightgown and incontinent brief. NA #1 stated during that night the resident had been agitated and ripping her brief. At approximately 6:40 AM, NA #1 looked in to check on the resident and found her with the gown pulled up over her face. NA#1 said Resident #1 was facing the door, laying on her right side and her sheet was on the floor. NA#1 saw blood on sheet, and spots of blood, close together on the pillow in front of her face. "I had no idea where the blood was coming from, so I went to look." NA #1 turned the resident on her back, "and the blood poured out of her (left) ear" so she turned her on her back and went to look for the nurse. NA#1 reported that neither of the nurses were available but the NA from the 100 hall was doing care and she motioned for her to come with her to Resident #1's room. NA#1 and NA#2 went back to the room and when NA#2 saw the resident she left to go get LPN#1. NA#1 stated that when she started to clean Resident #1 up and turned her over blood came out of the other ear. NA#1 said, "The nurse sometimes has to give her medication to get her to calm. But not that night, she was up all night long, restless." NA#1 said that she had not reported the resident's restlessness to the nurse. Nursing Assistant (NA) #2's undated statement included, "I got done caring for my residence(sic) and as I was making my way to the back nurses station I bumped into (NA#1) who said (Resident #1) was bleeding. As I enter the room I noticed that her face was blue and that their (sic) was blood in her ears." NA#2's statement included that the resident was scratching her face. NA#2 left to find nurse #1 who told her to get the resident's vital signs. NA#2 was interviewed during the survey, on [DATE] at 5:20 PM and said, "I was through with my rounds and saw (NA#2) was coming out of her room and she said (Resident #1) was bleeding and she didn't know why or where. So I followed into the room and her (Resident #1's) face was blue and we noticed her bleeding." NA#2 said, "I left to go find a nurse and she told me to get her vitals." On [DATE] LPN#1 wrote, "Between the times of 6:,[DATE]:45ish am, CNA came an told me that (Resident #1) had blood coming out of her ear and was slightly purple in her face. I ran to the room with my vital sign equipment. Her pulse was high and her O2 was in the low 90s after getting oxygen put on her at 2L resident's vitals were re-taken and after were good within normal limits." LPN#1 was interviewed during the survey, on [DATE] at 11:14 AM, and said she had given the resident her scheduled medications ([MEDICATION NAME] and [MEDICATION NAME]) around 6AM and had not noticed any agitation at that time or earlier in the night. LPN#1 stated that the resident had not had problems during the night and no one had reported any fall or agitation with regard to Resident #1. When asked how she had learned of the resident's condition that morning LPN#1 said, "(NA#2) reported it to me. She said (Resident #1) was slightly purple in her face and she had blood coming out of her ear. I think it was her left ear. I got vital signs right away. She had blood coming out of her ear and she was purple in her face like she wasn't getting enough oxygen." When asked about the amount of blood coming from the resident's ears LPN#1 replied, "I would say it was like a nose bleed. It wasn't gushing but was actively flowing." LPN#1 stated that she called LPN#2 and #3. She indicated LPN #2 went to get the oxygen and the resident's oxygen saturation level "started to come up and color started to come back and the bleeding had stopped." LPN#1 stated there were no other residents in the hallways and when asked what she thought had occurred she stated, "I have no idea." LPN#2 said, "I called the DON and I told her everything that was going on, - the blood, purple and O2 and that her vital signs were okay. I called the doctor and left a message. The next nurse came on and I told her everything." When asked about what might cause bleeding from both ears, LPN#1 said, "I don't know." On [DATE] LPN#2's statement included that LPN#1 had called for assistance and when she entered the resident's room the NAs were changing the bed. "The ring of blood I saw was approximately four inches in diameter. (LPN#1) stated that resident was bleeding from her ears. Resident's lips were bluish tinged so I told (LPN#1) I would get oxygen." The statement indicated that LPN#2 told LPN#1 to call Resident #1's attending physician. LPN#2 was interviewed on [DATE] at 3:50 PM. LPN#2 said, "I did see blood, probably the size of a grapefruit, maybe ,[DATE] inches on the sheet or pillowcase. The resident's lips were a little blue tinged so I went to get some oxygen." LPN#2 stated she herself did not do an assessment of Resident#1 and that LPN#1 applied the oxygen and took vital signs. When asked about what might cause bleeding from both ears LPN#2 said, "When (LPN#1) told me she couldn't get the doctor- that he didn't answer, I told her to call the DON." When asked if she told LPN #1 to call the hospital to contact the physician outside regular office hours, LPN#2 indicated she only told her to call the doctor and added "I can't tell you that I did tell her or that I didn't tell her on any prior occasion." LPN #3 provided a written statement for the facility on [DATE]. The statement included that when LPN#3 arrived at the 200 hall nursing station, LPN#1 told her that everything was okay. LPN#3 went into Resident #1's room and saw blood in her ear and on the pillowcase. LPN#3 was interviewed during the survey on [DATE] at 4:15 PM. LPN#3 said that on the morning of [DATE] she had been giving report when someone paged for all nurses to go to the 200 hall. "She (LPN#1) didn't call any kind of a code or anything so we just walked there." LPN#3 said that when she arrived at the nursing station, "(LPN#2) said 'That's okay, we got it.'" LPN#3 stated she went to Resident #1's room and saw blood in the resident's right ear. LPN## stated she did not do an asssessment of the resident but did ask the NAs in the room what happened, "and they all said they didn't know." LPN#3 said she observed fresh blood, "about the size of a donut" on the linen and the resident was grimacing. She said, "I didn't know what to think" and added"I would have called the doctor and then called the DON and if the doctor didn't call back then I would have called the DON again." On [DATE] the DON wrote that on [DATE] at approximately 6:50 AM, "I received a call from (LPN#1). She stated that (Resident #1) had some blood coming out of her ears and she didn't know what to do. I said you need to call the doctor and make sure to call the R.P. (Responsible Party) as well. She stated okay. I got to the facility (approximately) 8:30 on [DATE] and I had not heard anything else regarding resident status until ,[DATE] nurse (LPN#4) stated that she had sent the resident to the ER for rash on face and dark circles forming under eyes." The DON was interviewed during the survey on [DATE] at 5:35 PM and said, "I got a phone call from (LPN#1) at about 6:,[DATE]:50. She said (Resident #1) had blood from her ear and she didn't know what to do. I told her she needed to call the doctor and report it." The DON stated that she did not inquire further about the blood from the resident's ears and said, "I thought it was a skin tear or scratch or something. I didn't think it was anything emergent but I did tell her to call the doctor." The DON added, "I should have been more inquisitive." The DON said she spoke to the day shift nurse (LPN#4) and learned that the bleeding from the ears had stopped but the DON did not go to the room to assess the resident herself. The DON stated that a lot of blood from a resident's ears could be a sign of a head injury and said, "I would have expected her (LPN#1) to send her to the hospital when they saw the amount of blood I have since learned of." The DON said if the nurse did not hear back from the physician that the resident should have been sent to the hospital for evaluation. The DON said she learned that LPN#1 had called the physician's office and left a message on the answering machine. Upon request the DON reviewed the physician numbers posted at the nursing station and said the off-hours paging number for that doctor was not posted at the desk. The DON also indicated that none of the Registered Nurses in the building on that Friday morning of [DATE], had assessed Resident #1. LPN#4's undated statement indicated she was told by the off-going nurse that Resident #1 had been bleeding from her ears. "The nurse mentioned to another that it was a lot. She attempted to get in touch with the resident's doctor but never talked to him." LPN#4's statement also included, "All the while in the back of my mind I'm thinking her doctor was paged at some point and he should be calling soon." The statement indicated LPN#4 had checked the resident at approximately 8:30 AM and there was no active bleeding from the ears and no other symptoms but about an hour later the resident had developed a rash around her eyes and there was some discoloration on her face. "I then called the MD's (physician's) office to see why they hadn't called and to tell them about the rash. I spoke with the MD's nurse and told her about the bleeding from the previous shift as well. She stated she would let him know and call back. Not even an hour later resident began to have dark circles under her eyes like blood had pooled there. I called the MD's office back to let them know and found out from the nurse that the MD said that he never received any pages or calls from anyone about the matter. I was instructed to send the resident out to the hospital for evaluation. Resident was alert with eyes open when she left. I was asked by MD's office if resident has sustained any falls but I was unaware of any recent falls." LPN#4 was interviewed during the survey on [DATE] at 10:08 AM. She stated when she examined Resident #1 she didn't see any blood but there was a light purple discoloration on the right side of her face and the discoloration was on her forehead too. "I was waiting for the doctor to call back and I continued with my med-pass." LPN#4 stated that about one and a half hours later she checked the resident and the oxygen was still on at 2L per minute. She said the treatment nurse went in to change a dressing and identified the rash on the resident's face as petechiae. LPN#4 said she called the attending physician's nurse and then about an hour and a half later she noted the dark circles forming under her eyes and called the physician's office again. The resident went out to the hospital at approximately noon. LPN#4 said, "I thought she had fallen when her eyes started to turn black but night shift said she had not fallen and she was in bed all day for us and I know she didn't have a fall. I was thinking closed head injury or that she had fallen." She added, "I called the DON to tell her I was sending (Resident #1) out." During an interview on [DATE] at 6:38 PM, the Administrator was asked about when she was informed by staff about Resident #1's condition. The Administrator said, "I was informed at the time (Resident #1) was going out (to the hospital). I was told she had rash on her face that developed throughout the morning and she was starting to get some discoloration under her eyes. I was also told about the blood out of one of her ears " The Administrator also said, "My first question was if she had a recent fall or struck her head. When I was told about the rash and discoloration I thought there was an acute condition going on after ruling out a fall." She said, "My initial thought (on [DATE]) was not that someone harmed her but what was going on clinically. I never thought that someone hurt her." She added, "I had no reason to initiate investigation of injury of unknown origin." When asked if a Registered Nurse (RN) had assessed Resident #1 on [DATE], the Administrator said, "Not to my knowledge." When asked if she would expect an RN to assess if one was available, the Administrator said, "No I would have expected the nurse to send her out. If the nurse came in and found her blue with blood coming out of her ears I would have expected her to send her out." The Administrator indicated she was informed about the allegation of abuse on Monday, [DATE] and initiated an investigation at that time. During an interview on [DATE] at 5:15 PM, the Administrator said, "I would have expected (LPN#1) to do a full assessment. I would have expected her to call 911. I would have expected (the DON) to have more discussion regarding that assessment." When asked her expectations of staff regarding injuries of unknown origin, the Administrator said, "I don ' t expect my staff to recognize an injury of unknown origin. I expect them to tell me about any suspicions about an injury so myself and (the DON) can make a determination." During an interview on [DATE] at 9:11 AM, Resident #1's attending physician in the facility stated, "I was informed that the day nurse had been waiting for a call back from me but I didn't know anything about an earlier call about the bleeding from both ears earlier." The physician stated the resident was not on any medications that would cause bleeding from the ears or petechiae. The physician said, "I would expect the nurse to send her to the hospital to see why she was bleeding from the ears." He added, "This (bleeding from the ears) was definitely an emergency." The Administrator was notified of the Immediate Jeopardy for F309 on [DATE] at 7:41 PM. The facility provided the following credible allegation of compliance on [DATE] at 5:00 PM. CREDIBLE ALLEGATION OF COMPLIANCE F223-ABUSE Resident #1 was observed on [DATE] at approximately 6:30am by NA with flushed skin and blood coming from resident ears. NA notified nurse of resident flushed skin and blood coming from resident #1 ears on [DATE]. Nurse assessed resident #1 at approximately 6:45 am on [DATE] with O2 sats range at 92% and skin color slightly purple. Nurse applied O2 and sats went to 97%, blood pressure ,[DATE] and heart rate 98. Resident #1 was reassessed on [DATE] at approximately 7:00 am by the third shift and first shift nurse with no active bleeding noted. First shift nurse continued to assess resident #1 on [DATE] at 8:30 am with no active bleeding observed. First shift nurse reassessed resident #1 on [DATE] around 9:30 am and observed a rash on resident face and light discoloration to resident face. On [DATE] the MD office nurse was made aware by first shift nurse of bleeding from resident #1 ears at 6:30am, rash on face, and light discoloration to resident face. Resident #1 was assessed by first shift nurse again at approximately 10:30 am an observed darkening under resident's eyes. On [DATE] first shift nurse contacted MD office nurse again and notified of darkening under resident's eyes. Order received from MD office nurse on [DATE] approximately 11:00 am to send resident to ER. Hall nurse assigned to resident #1 during the acute change was suspended and drug tested by the Administrator on [DATE]. NA assigned to resident #1 during the acute change in condition was suspended and drug tested by the Administrator on [DATE]. On [DATE] APS worker reported to facility that hospital made allegation that resident #1 had been strangled. Resident #1 was already in the hospital during the time of the allegation. Hospital reported allegation of strangulation to the local law enforcement which came to the facility to investigate on [DATE]. 24 hour report for allegation of abuse/suspicion of crime was completed and faxed to the NC Health Care Personnel Registry (NC HCPR) [DATE] by the Administrator. The investigation of the injury of unknown origin and abuse was initiated by the Administrator on [DATE] and completed on [DATE]. The 5 day report was completed and faxed to the NC HCPR on [DATE]. The facility Admission's Coordinator initiated abuse interviews for all alert and oriented residents. There were 29 alert and oriented residents interviewed with questions regarding: Do they feel safe in the facility? Has anyone come into their room, visitor or another resident that made them feel uncomfortable? Has anyone physically or verbally harmed them? on [DATE]. No concerns voiced by residents interviewed. All other residents who are unable to communicate or who are disoriented were assessed by DON, QI (Quality Improvement) nurse, MDS nurses, and staff facilitator for any bodily signs of abuse on [DATE]. No bodily signs of abuse or injury of unknown origin. No concerns were noted. The procedure for all allegations of abuse and injury of unknown origin is as follows: Any employee accused of abuse will be immediately removed from resident care area to an office. The resident will be assessed by a license nurse and will document in the medical record. Corrective measures will be initiated immediately to protect the resident. Statements will be obtained from identified employee, if any, and any possible witnesses. Employee will be suspended immediately per policy pending outcome of investigation. The Administrator and/or DON will complete and send to RVP for prior approval and then fax the 24 hour report to the NCHCPR. Notification of law enforcement if applicable. Resident interviews will be conducted by the Admissions Coordinator with alert and oriented residents and physical assessments will be conducted for non-alert and oriented residents by license nurse. At the completion of the investigation the Administrator and/or the DON will submit a 5 day report to the NCHCPR. The Administrator is responsible to direct the investigation process and to ensure that the appropriate agencies, to include the NCHCPR, are notified per policy. An Action Checklist was initiated on [DATE] for Licensed nursing staff and placed at each nurse's station for licensed nurses to complete for all allegations of abuse and injury of unknown origin. The Action Checklist includes: ? Remove involved employee, if known, from resident care area to an office: instruct employee to wait in office until your return ? Notify Administrator and/or DON immediately of incident ? Assess resident: document notification in chart ? Notify attending MD; document notification in chart ? Implement MD orders as indicated ? Notify resident's representative as indicated; document notification in chart ? Obtain employee "witness" statement of incident ? Drug test employee per personnel policy as applicable or as instructed by Administrator or DON ? Punch employee out and send home immediately pending outcome of investigation ? Implement corrective measures to protect resident (i.e., alarm bracelet, padding of equipment, 1:1 monitoring, etc.) ? Completion of Resident QI Reporting form (electronic QI incident record) ? Continue to monitor resident as appropriate All license nurses will be in-serviced on the Action Checklist that has been placed at all nurses' station, initiated [DATE] by the Staff facilitator. No license nurse will be allowed to work until receiving the Action checklist in-service. ? The staff nurse is responsible to assess, document, provide appropriate interventions and notify Attending Physician and Responsible Party of any acute changes in condition noted. On [DATE] the after-hours MD notification number was posted at each nurse's station by the DON. If the staff nurse is unable to reach the attending physician, the on-call MD must be called. If unable to contact the attending or the on-call MD, the nurse must call the Medical Director. The staff nurse will implement appropriate interventions based on the needs of the resident and notify Attending Physician and Responsible Party. Staff will notify the DON or on-call nurse of any acute changes. DON, QI nurse, Staff facilitator and MDS nurses were in-serviced by the Administrator on [DATE] concerning when they are on-call and they receive a call concerning a change in condition of a resident that they are to ask more questions, if needed, to get a clear picture of what is occurring with the resident and to insure that the nurse has notified the MD of the acute change. A QI tool, Acute Change Call Log, will be used daily by the On-Call nurse and the Administrator will review weekly. The DON will determine if the acute change in condition reported by the hall nurse fits the definition of an injury of unknown origin- "Injury of any type that occurs where the cause or contributing factor is not known or determined" . If the acute change in condition fits the definition of an injury of unknown origin then the abuse/injury of unknown origin procedure will be followed to include: Any employee accused of abuse will be immediately removed from resident care area to an office. The resident will be assessed by a license nurse and will document in the medical record. Corrective measures will be initiated immediately to protect the resident. Statements will be obtained from identified employee, if any, and any possible witnesses. Employee will be suspended immediately per policy pending outcome of investigation. The Administrator and/or DON will complete and send to RVP (Responsible Vice President) for prior approval and then fax the 24 hour report to the NCHCPR. Notification of law enforcement if applicable. Resident interviews will be conducted by the Admissions Coordinator with alert and oriented residents and physical assessments will be conducted for non-alert and oriented residents by license nurse. At the completion of the investigation the Administrator and/or the DON will submit a 5 day report to the NCHCPR. The Administrator is responsible to direct the investigation process and to ensure that the appropriate agencies, to include the NCHCPR, are notified per policy. The Staff Facilitator initiated in servicing for all staff on [DATE] to include dietary, laundry, housekeeping, AR book keeper, payroll, medical records, maintenance, activities, therapy, admission coordinator, NAs, and license nurses on abuse. The abuse inservice included that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origins are reported as soon as possible to the Administrator, any employee who witnesses abuse or suspects abuse, must report immediately report the alleged abuse to his/her supervisor, who will then report the incident to the Administrator and/or DON, failure to report any concern related to abuse will result in disciplinary action and possible termination of employment, facility will provide supervision to staff to identify behaviors to include, but not limited to, using derogatory language, rough handling, or not communicating with residents while giving care, and employees accused of being directly involved in allegations of abuse or neglect while be suspended immediately from employment pending the outcome of the investigation. There is 1 employee on vacation that has not received the in-service that will be mailed a certified letter on [DATE]. All staff, to include housekeeping, laundry, dietary, maintenance, AR book keeper, receptionist, payroll, medical records, activitie

Based on observation, record review, staff interviews and physician interviews, the facility failed to identify the need for medical intervention and failed to immediately initiate emergency medical services for 1 of 4 residents (Resident #1) reviewed for an acute change of condition. Immediate jeopardy began on 09/12/2014 when the resident was found to have a purple face, blue lips, bleeding out of both ears, a bruise on her face, and staff delayed calling for transport to the hospital for approximately five hours after the change in condition was recognized. The Administrator was notified of the Immediate Jeopardy on 9/18/14 at 7:41 PM. Immediate Jeopardy was removed on 09/19/2014 at 7:35 PM. The facility remained out of compliance at a lower scope and severity of (D), isolated with potential for more than minimal harm that is not immediate jeopardy, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. The findings included: A review of the facility's protocol for "NOTIFICATION OF CHANGES" dated 1/2009, included, "The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: * An accident which results in injury and has the potential for requiring physician intervention * A significant change in the resident's physical, mental, or psychosocial status" The Notification of Change protocol had an attached section entitled, "ACUTE EPISODE" dated 8/2012. The Acute Episode protocol read as follows: "It is the policy of the facility to be alert to any change in resident condition and to respond in an appropriate manner to ensure satisfactory intervention treatment for [REDACTED]." dated 8/2012 which read, "It is the policy of the facility to notify the physician when a significant change in a resident's condition occurs with documentation contained within the medical record." Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her cumulative [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], indicated the resident had long and short term memory problems and decision making ability was severely cognitively impaired. The MDS indicated the resident was rarely or never understood, required total assistance for bed mobility, had contractures in both lower extremities and could not ambulate. Per the MDS, the staff assessment of the resident's mood did not indicate the presence of any symptoms of depression, mood disorder or behaviors. Resident#1's Plan of Care, most recently updated on 7/21/2014, indicated the resident had feelings of depression and ineffective coping characterized by tearfulness, anxiety and repetitive motor agitation. Documentation in Resident #1's record was reviewed for the events on 09/12/2014. An entry dated 09/12/2014 at 12:15 AM, indicated the resident was in bed with her eyes closed, that she was incontinent and required staff turning and repositioning. The entry stated there were no acute changes or signs of distress. The note was signed by Licensed Practical Nurse (LPN)#1. The next entry was dated 09/12/2014 at 6:51 AM and read, "CNA (Nursing Assistant) informed me that resident was bleeding out of her ears. Resident had blood coming out of her ears and her face was slightly purple." The note also stated the Resident's oxygen saturation level (O2 sat) was 92%. After the resident was given oxygen the O2 sat was 97%, the blood pressure was 134/58 and heart rate was 98. The note indicated the Director of Nursing (DON) was informed, a voicemail message had been left for the attending physician and the nurse was unable to contact the responsible party (RP). The note was signed by LPN#1. A physician's telephone order, dated 9/12/2014 at 11:48 AM stated Resident #1 was to be sent to the hospital emergency room for evaluation. At 12:05 PM on 09/12/2014 the progress note read, "Resident being assessed throughout the shift. No bleeding noted thus far, but a rashy area to upper face and dark circles to Bilat (both) eyes noted. Resident continues on 2L (2 liters) O2 via NC (nasal cannula). Resident grimacing more than usual. MD (physician) made aware. No answer at RP's number. DON made aware." This note was signed by LPN#2. A progress note dated 09/12/2014 at 12:15 PM read, "Resident being assessed throughout the shift. No bleeding noted thus far, but a rashy area to upper face and dark circles to Bilat eyes noted. Upon starting shift no black circle noted. Area around eyes appeared to slowly darken throughout the shift. Resident continues on 2L O2 via NC. Resident grimacing more than usual. MD made aware. No answer at RP's number. DON made aware." The note was signed by LPN#2. Review of an ambulance transportation "Patient Care Report" included, "Chief Complaint: Abdominal Pain. Primary Symptom: Pain. Patient found in bed in nursing home, pt (patient) was observed to be guarding her abdomen and had two black eyes, nurse stated she did not know how she got the black eyes and that they were not black yesterday" The transport note indicated on 09/12/2014 at 12:28 PM they departed from the nursing home and arrived at the hospital at 12:31 PM. The hospital Emergency Department exam report dated 09/12/2014 included, "Patient with petecchiae to face and ecchymosis around eyes, blood from ears. There are bruises along the patient's throat that are suspicious for finger prints. I am concerned about elder abuse and attempted strangulation. Will notify DSS (Department of Social Services) and plan to admit patient for her safety until this situation can be investigated. Pt (patient) is nonverbal but when I ask her if anyone hurt her, her eyes began to tear up." The report was signed by Hospital Physician #1. The Radiology report (dated 09/12/2014) revealed the Computerized Tomography (CT) scan was negative for a fracture, there was no mass or hematoma and no other significant findings. During an interview on 09/19/2014 at 9:51 AM, Hospital Physician #1 discussed her findings regarding her examination of Resident #1 on the afternoon of 09/12/2014. Hospital Physician #1 said that in addition to the bruising around her eyes and on her neck, Resident #1 also had a bruise on her upper arm when she came into the emergency department (ED). Hospital Physician #1 said, "We had to call the nursing home three times to get the list of medications" and added that Resident #1 wasn't on any medications that would have caused the petechiae or bruising. Hospital Physician #1 said, "Very few things will cause that petechial rash. It is forensically distinctive,- pathognomonic (specifically characteristic of a disease or condition; denoting a sign or symptom on which a [DIAGNOSES REDACTED]." The physician further stated, "The petechial rash is indicative of strangulation or a crushing force. I could not find anything else that would have caused it with this patient." The documentation from Resident #1's admitting hospital physician (Hospital Physician #2) dated 09/12/2014 included, "Her face appears atraumatic except for large periorbital, infraorbital ecchymosis (bruising under and around the eyes). Patient has a petechial rash from the upper lip up to the forehead." The document also indicated there was a little bit of petechial rash "on the left side of the neck." Hospital Physician #2's assessment included, "Petechial rash. Is it a case of elderly abuse? We spoke with the nursing home staff and they truly do not have any idea of what happened. Patient is not ambulatory. She is totally bedridden so there was no history of a fall. This has to be investigated and DSS will be called." Hospital Physician #2 was interviewed on 09/18/2014 at 10:44 AM and said, "This patient has so many unexplained injuries. These were life-threatening injuries." When asked about possible causes for the bleeding from the ears, Hospital Physician #2 stated that bleeding from the ears was usually associated with a skull fracture or very forceful coughing. She further stated that petechiae is often found with strangulation or forceful vomiting and that the nursing home had said there was no vomiting. Hospital Physician #2 said that tests showed no cranial fracture but there was swelling of the soft tissue in her face and neck, bruising, and subconjunctival hemorrhaging. Hospital Physician #2 said, "I don't know of anything that could cause all of that other than strangulation when you rule out a fall, vomiting or forceful cough." Hospital Physician #2 indicated Resident #1 was still in the hospital. The facility provided their investigation and written statements from the facility staff taken on 09/15/2014 through 09/17/2014. After review of each written statement, the facility staff were interviewed during the survey. On 09/16/2014 Nursing Assistant (NA) #1 wrote, "(Resident #1) had no falls on 11-7 that I'm aware of in the last 2 wks (weeks)." An interview was conducted with NA #1 on 09/18/2014 at 10:42 AM. NA#1 indicated she was working the 11 PM to 7 AM shift, had provided care for Resident #1, and was the person who discovered Resident #1 with bleeding ears. NA#1 stated that the resident required total care and when agitated, would pull off her nightgown and incontinent brief. NA #1 stated during that night the resident had been agitated and ripping her brief. At approximately 6:40 AM, NA #1 looked in to check on the resident and found her with the gown pulled up over her face. NA#1 said Resident #1 was facing the door, laying on her right side and her sheet was on the floor. NA#1 saw blood on sheet, and spots of blood, close together on the pillow in front of her face. "I had no idea where the blood was coming from, so I went to look." NA #1 turned the resident on her back, "and the blood poured out of her (left) ear" so she turned her on her back and went to look for the nurse. NA#1 reported that neither of the nurses were available but the NA from the 100 hall was doing care and she motioned for her to come with her to Resident #1's room. NA#1 and NA#2 went back to the room and when NA#2 saw the resident she left to go get LPN#1. NA#1 stated that when she started to clean Resident #1 up and turned her over blood came out of the other ear. NA#1 said, "The nurse sometimes has to give her medication to get her to calm. But not that night, she was up all night long, restless." NA#1 said that she had not reported the resident's restlessness to the nurse. Nursing Assistant (NA) #2's undated statement included, "I got done caring for my residence (sic) and as I was making my way to the back nurses station I bumped into (NA#1) who said (Resident #1) was bleeding. As I enter the room I noticed that her face was blue and that their(sic) was blood in her ears." NA#2's statement included that the resident was scratching her face. NA#2 left to find nurse #1 who told her to get the resident's vital signs. NA#2 was interviewed during the survey, on 9/18/2014 at 5:20 PM and said, "I was through with my rounds and saw (NA#2) was coming out of her room and she said (Resident #1) was bleeding and she didn't know why or where. So I followed into the room and her (Resident #1's) face was blue and we noticed her bleeding." NA#2 said, "I left to go find a nurse and she told me to get her vitals." On 09/15/2014 LPN#1 wrote, "Between the times of 6:30-6:45ish am, CNA came and told me that (Resident #1) had blood coming out of her ear and was slightly purple in her face. I ran to the room with my vital sign equipment. Her pulse was high and her O2 was in the low 90s after getting oxygen put on her at 2L resident's vitals were re-taken and after were good within normal limits." LPN#1 was interviewed during the survey on 09/18/2014 at 11:14 AM, and said she had given the resident her scheduled medications ([MEDICATION NAME] and [MEDICATION NAME]) around 6AM and had not noticed any agitation at that time or earlier in the night. LPN#1 stated that the resident had not had problems during the night and no one had reported any fall or agitation with regard to Resident #1. When asked how she had learned of the resident's condition that morning LPN#1 said, "(NA#2) reported it to me. She said (Resident #1) was slightly purple in her face and she had blood coming out of her ear. I think it was her left ear. I got vital signs right away. She had blood coming out of her ear and she was purple in her face like she wasn't getting enough oxygen." When asked about the amount of blood coming from the resident's ears LPN#1 replied, "I would say it was like a nose bleed. It wasn't gushing but was actively flowing." LPN#1 stated that she called LPN#2 and #3. She indicated LPN #2 went to get the oxygen and the resident's oxygen saturation level "started to come up and color started to come back and the bleeding had stopped." LPN#1 stated there were no other residents in the hallways and when asked what she thought had occurred she stated, "I have no idea." LPN#2 said, "I called the DON and I told her everything that was going on, - the blood, purple and O2 and that her vital signs were okay. I called the doctor and left a message. The next nurse came on and I told her everything." When asked about what might cause bleeding from both ears, LPN#1 said, "I don't know." On 09/15/2014 LPN#2's written statement included that LPN#1 had called for assistance and when she entered the resident's room the NAs were changing the bed. "The ring of blood I saw was approximately four inches in diameter. (LPN#1 stated that resident was bleeding from her ears. Resident's lips were bluish tinged so I told (LPN#1) I would get oxygen." The statement indicated that LPN#2 told LPN#1 to call Resident #1's attending physician. LPN#2 was interviewed during the survey on 9/19/14 at 3:50 PM. LPN#2 said "I did see blood, probably the size of a grapefruit, maybe 3-4 inches on the sheet or pillowcase. The resident's lips were a little blue tinged so I went to get some oxygen." LPN#2 stated she herself did not do an assessment of Resident#1 and that LPN#1 applied the oxygen and took vital signs. When asked about what might cause bleeding from both ears LPN#2 said, "When (LPN#1) told me she couldn't get the doctor- that he didn't answer, I told her to call the DON." When asked if she told LPN #1 to call the hospital to contact the physician outside office hours, LPN#2 indicated she only told her to call the doctor and added "I can't tell you that I did tell her or that I didn't tell her on any prior occasion." LPN #3 provided a written statement for the facility on 09/17/2014. The statement included that when LPN#3 arrived at the 200 hall nursing station, LPN#1 told her that everything was okay. LPN#3 went into Resident #1's room and saw blood in her ear and on the pillowcase. LPN#3 was interviewed during the survey on 09/19/2014 at 4:15 PM. LPN#3 said that on the morning of 09/12/2014 she had been giving report when someone paged for all nurses to go to the 200 hall. "She (LPN#1) didn't call any kind of a code or anything so we just walked there." LPN#3 said that when she arrived at the nursing station, "(LPN#2) said 'That's okay, we got it.'" LPN#3 stated she went to Resident #1's room and saw blood in the resident's right ear. LPN## stated she did not do an asssessment of the resident but did ask the NAs in the room what happened, "and they all said they didn't know." LPN#3 said she observed fresh blood, "about the size of a donut" on the linen and the resident was grimacing. She said, "I didn't know what to think" and added"I would have called the doctor and then called the DON and if the doctor didn't call back then I would have called the DON again." On 09/15/2014 the DON wrote that on 09/12/2014 at approximately 6:50 AM, "I received a call from (LPN#1). She stated that (Resident #1) had some blood coming out of her ears and she didn't know what to do. I said you need to call the doctor and make sure to call the R.P. (Responsible Party) as well. She stated okay. I got to the facility (approximately) 8:30 on 9/12/14 and I had not heard anything else regarding resident status until 7-3 nurse (LPN#4) stated that she had sent the resident to the ER for rash on face and dark circles forming under eyes." The DON was interviewed during the survey on 09/18/2014 at 5:35 PM, and said, "I got a phone call from (LPN#1) at about 6:45-6:50. She said (Resident #1) had blood from her ear and she didn't know what to do. I told her she needed to call the doctor and report it. " The DON stated that she did not inquire further about the blood from the resident's ears and said, "I thought it was a skin tear or scratch or something. I didn't think it was anything emergent but I did tell her to call the doctor." The DON added, "I should have been more inquisitive." The DON said she spoke to the day shift nurse (LPN#4) and learned that the bleeding from the ears had stopped but the DON did not go to the room to assess the resident herself. The DON stated that a lot of blood from a resident's ears could be a sign of a head injury and said, "I would have expected her (LPN#1) to send her to the hospital when they saw the amount of blood I have since learned of." The DON said if the nurse did not hear back from the physician that the resident should have been sent to the hospital for evaluation. The DON said she learned that LPN#1 had called the physician's office and left a message on the answering machine. Upon request the DON reviewed the physician numbers posted at the nursing station and said the off-hours paging number for that doctor was not posted at the desk. The DON also indicated that none of the Registered Nurses in the building on that Friday morning of 09/12/2014, had assessed Resident #1. LPN#4's undated statement indicated she was told by the off-going 11-7 nurse that Resident #1 had been bleeding from her ears. "The nurse mentioned to another that it was a lot. She attempted to get in touch with the resident's doctor but never talked to him." LPN#4's statement also included, "All the while in the back of my mind I'm thinking her doctor was paged at some point and he should be calling soon." The statement indicated LPN#4 had checked the resident at approximately 8:30 AM and there was no active bleeding from the ears and no other symptoms but about an hour later the resident had developed a rash around her eyes and there was some discoloration on her face. " I then called the MD's (physician's) office to see why they hadn't called and to tell them about the rash. I spoke with the MD's nurse and told her about the bleeding from the previous shift as well. She stated she would let him know and call back. Not even an hour later resident began to have dark circles under her eyes like blood had pooled there. I called the MD's office back to let them know and found out from the nurse that the MD said that he never received any pages or calls from anyone about the matter. I was instructed to send the resident out to the hospital for evaluation. Resident was alert with eyes open when she left. I was asked by MD's office if resident has sustained any falls but I was unaware of any recent falls." LPN#4 was interviewed during the survey on 09/18/2014 at 10:08 AM. She stated when she examined Resident #1 she didn't see any blood but there was a light purple discoloration on the right side of her face and the discoloration was on her forehead too. "I was waiting for the doctor to call back and I continued with my med-pass." LPN#4 stated that about one and a half hours later she checked the resident and the oxygen was still on at 2L per minute. She said the treatment nurse went in to change a dressing and identified the rash on the resident's face as petechiae. LPN#4 said she called the attending physician's nurse and then about an hour and a half later she noted the dark circles forming under her eyes and called the physician's office again. The resident went out to the hospital at approximately noon. LPN#4 said, "I thought she had fallen when her eyes started to turn black but night shift said she had not fallen and she was in bed all day for us and I know she didn't have a fall. I was thinking closed head injury or that she had fallen." She added, "I called the DON to tell her I was sending (Resident #1) out." During an interview on 09/19/2014 at 5:15 PM, the Administrator said, "I would have expected (LPN#1) to do a full assessment. I would have expected her to call 911. I would have expected (the DON) to have more discussion regarding that assessment." During an interview on 09/25/2014 at 9:11 AM, Resident #1's attending physician in the facility stated, "I was informed that the day nurse had been waiting for a call back from me but I didn't know anything about an earlier call about the bleeding from both ears earlier." The physician stated the resident was not on any medications that would cause bleeding from the ears or petechiae. The physician said, "I would expect the nurse to send her to the hospital to see why she was bleeding from the ears." He added, "This (bleeding from the ears) was definitely an emergency. They have to make sure someone with experience is there to take charge." The Administrator was notified of the Immediate Jeopardy for F309 on 9/18/14 at 7:41 PM. The facility provided the following credible allegation of compliance on 9/19/14 at 5:00 PM. CREDIBLE ALLEGATION OF COMPLIANCE F309-Asssessment ? Resident #1 was observed on 9/12/14 at approximately 6:30am by NA (NA) with flushed skin and blood coming from resident ears. NA notified nurse of resident flushed skin and blood coming from resident #1 ears on 9/12/14. Nurse assessed resident #1 at approximately 6:45 am on 9/12/14 with O2 sats range at 92% and skin color slightly purple. Nurse applied O2 and sats went to 97%, blood pressure 134/58 and heart rate 98. Resident #1 was reassessed on 9/12/14 at approximately 7:00 am by the third shift and first shift nurse with no active bleeding noted. First shift nurse continued to assess resident #1 on 9/12/14 at 8:30 am with no active bleeding observed. First shift nurse reassessed resident #1 on 9/12/14 around 9:30 am and observed a rash on resident face and light discoloration to resident face. On 9/12/14 9:30am the MD (physician) office nurse was made aware by first shift nurse of bleeding from resident #1 ears at 6:30am, rash on face, and light discoloration to resident face. Resident #1 was assessed by first shift nurse again at approximately 10:30 am an observed darkening under resident's eyes. On 9/12/14 first shift nurse contacted MD office nurse again and notified of darkening under resident's eyes. Order received from MD office nurse on 9/12/14 approximately at 11:48am MD order was written to send resident to ER. Hall nurse assigned to resident #1 during the acute change was drug tested and suspended by the Administrator on 9/15/14. NA assigned to resident #1 during the acute change in condition was suspended and drug tested by the Administrator on 9/16/14. An inservice was initiated on 9/12/14 and an additional inservice was initiated on 9/16/14 with both in-services completed at 100% by 9/18/14 with all other licensed nurses by the Staff Facilitator (Staff Educator) regarding assessing acute changes in condition, sending resident out if unable to contact MD, examples of acute changes to include abnormal bleeding, notification to physician by telephone when an acute change in condition to include cognitive status, behavior, immune system response, normal body system functioning, changes in cognitive status, changes in behavior, changes in oral intake to include fluids, changes in immune system, changes in normal body functioning, Panic laboratory values, resident's condition warrants based upon nurse's assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. Notification of the physician of these types of changes in a resident's condition by fax is not acceptable. If it warrants send the resident to the ER (emergency room ). Handouts given to staff for reference. No nurse will be allowed to work without first receiving the in-services. ? Acute Change is defined as anything outside the norm for a resident to include but not limited to abnormal bleeding, skin color changes, changes in behaviors, change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. ? 100% of all current residents were physically observed for acute changes in condition to include changes in skin color and bleeding on 9/15/14 by DON, SDC (Staff Development Coordinator) nurse, QI (Quality Improvement) nurse, MDS nurses (2) and facility consultant. Four concerns were noted during this audit and corrected by the treatment nurse on 9/15/14 and 9/16/14 with interventions placed, MD and RP notification, and documentation in the progress notes. Three months of nurse's notes were reviewed to ensure all documented acute changes in condition to include changes in skin color and bleeding have been addressed with appropriate interventions placed, Attending Physician notification and Responsible Party notification of the acute change on 9/15/14 by DON, SDC nurse, QI nurse, MDS nurses (2) and facility consultant. Two concerns were noted during this audit with reassessment of the resident by the treatment nurse on 9/16/14, no concerns observed during the reassessment, and documentation in the progress note. ? An inservice was initiated with all NAs, Housekeeping, Dietary, therapy staff and any agency/contracted staff on 9/16/14 on all shifts by the Staff Facilitator regarding observation and reporting changes in resident's condition promptly to the staff nurse or supervisor, not leaving the resident during an emergency situation, and completion of The Early Warning Tool "Stop and Watch" tool by N.A's, licensed nurses, housekeeping, dietary, Therapy staff and any agency/contracted staff on any acute change in condition noted to include seems different than usual, talks or communicates less than usual, overall needs more help than usual, participated in activities less than usual, ate less than usual (not because of dislike of food), Drank less than usual, weight change, agitated or nervous more than usual, tired, weak, confused, or drowsy, change in skin color or condition, and help with walking, transferring, toileting more than usual and given to hall nurse. No staff will be allowed to work until they have received in-service. All newly hired N.A's, Housekeeping, Dietary, Therapy Staff and any newly assigned agency staff will be in-serviced in orientation regarding acute changes in condition. An inservice was initiated with 100% of license nurses to include agency nurses initiated on 9/12/14, on assessment of acute changes in condition, sending resident out if unable to notify MD, notification to physician by telephone to include second shift, third shift and weekends; when an acute changes in condition occur, including abnormal bleeding, changes in cognitive status, behavior, oral changes to include fluids, immune system response, normal body system functioning, Panic laboratory values, resident's condition warrants based upon nurse's assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. Notification of the physician of these types of changes in a resident's condition by fax is not acceptable. In-service was initiated 9/18/14 by Staff Facilitator on notifying the DON of all acute changes in condition. All newly hired licensed nurses and newly assigned agency staff will be in-serviced in orientation on notification to the physician of acute changes in resident condition, and notifying DON of all acute changes in condition. ? The staff nurse will follow up on completed Early Warning Tools by assessing the resident, reporting to Attending Physician and Responsible Party, appropriate interventions initiated and documentation is in progress notes. The Early Warning Tool will be placed in the DON mailbox for review to ensure that the resident was assessed, reporting to Attending Physician and Responsible Party was completed, appropriate interventions initiated and documentation is in progress notes. The staff nurse is responsible to assess, document, provide appropriate interventions and notify Attending Physician and Responsible Party of any acute changes in condition noted. The staff nurse will implement appropriate interventions based on the needs of the resident and notify Attending Physician and Responsible Party. When a LPN is on duty and the resident has had an acute change in condition but the resident is not sent to the hospital, the LPN must notify the RN and the RN must re-assess the resident to insure the acute change in condition does not warrant hospitalization . All staff nurses will document all acute changes in condition on the 24 hour report/communication board daily. The staff nurses will communicate all acute changes utilizing the communication board during shift report. Staff will notify the DON or on-call nurse of any acute changes. DON, QI nurse, Staff facilitator and MDS nurses were in-serviced by the Administrator on 9/16/14 concerning when they are on-call and they receive a call concerning a change in condition of a resident that they are to ask more questions, if needed, to get a clear picture of what is occurring with the resident Staff Facilitator will include in newly hired Nurses orientation and newly assigned agency staff, nursing scenarios to include acute changes, such as: S/SX (signs and symptoms) UTIs (urinary tract infections), S/SX hyper/[DIAGNOSES REDACTED], difficulty breathing, decreased ability to perform ADLs, change in bowel/urinary patterns, unusual bleeding from the ears to insure nurse is competent in identifying acute changes in condition, notifying the MD and contacting the DON. Staff Facilitator will provide additional training on recognizing and assessing for acute changes in condition for any nurse that is deemed incompetent prior to taking an assignment. This will occur with all new hires, LPN's and RN's. On 09/19/2014 at 7:10 PM the credible allegation was validated and Immediate Jeopardy was abated at 7:35 PM when interviews with nursing staff revealed awareness of emergent changes in condition. Staff verified training had been received, that changes in condition were to be documented in the medical record, an RN was to be involved in the assessment, the physician should be notified and the resident transferred for acute care as indicated. Interviews revealed that if the attending or on-call physician could not be reached, the facility's Medical Director should be called. The number for paging the physicians after regular business hours was posted at the nursing station.

Based on observation, record review, staff interviews and physician interviews, the facility failed to notify the primary physician of an emergent condition involving a resident bleeding from both ears, for 1 of 4 residents (Resident #1) reviewed for an acute change of condition. Immediate jeopardy began on 09/12/2014 when the resident was found to have a purple face, blue lips, bleeding out of both ears, a bruise on her face, and staff delayed calling for transport to the hospital for approximately five hours after the change in condition was recognized. The Administrator was notified of the Immediate Jeopardy on 9/18/14 at 7:41 PM. Immediate Jeopardy was removed on 09/19/2014 at 7:35 PM. The facility remained out of compliance at a lower scope and severity of (D) isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, while the facility completes the staff training required. The facility was in the process of monitoring the implementation of their corrective action. The findings included: Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her cumulative [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], indicated the resident had long and short term memory problems and decision making ability was severely cognitively impaired. The MDS indicated the resident was rarely or never understood, required total assistance for bed mobility, had contractures in both lower extremities and could not ambulate. According to the MDS, the staff assessment of the resident's mood did not indicate the presence of any symptoms of depression, mood disorder or behaviors. Documentation in Resident #1's record was reviewed for the events on 09/12/2014. An entry dated 09/12/2014 at 12:15 AM, indicated the resident was in bed with her eyes closed, that she was incontinent and required staff turning and repositioning. The entry stated there were no acute changes or signs of distress. The note was signed by Licensed Practical Nurse (LPN) #1. The next entry was dated 09/12/2014 at 6:51 AM and read, "CNA (Nursing Assistant) informed me that resident was bleeding out of her ears. Resident had blood coming out of her ears and her face was slightly purple." The note also stated the Resident's oxygen saturation level (O2 sat) was 92%. After the resident was given oxygen the O2 sat was 97%, the blood pressure was 134/58 and heart rate was 98. The note indicated the Director of Nursing (DON) was informed, a voicemail message had been left for the attending physician and the nurse was unable to reach the responsible party (RP) by phone. The note was signed by LPN#1. A physician's telephone order, dated 9/12/2014 at 11:48 AM stated Resident #1 was to be sent to the hospital emergency room for evaluation. At 12:05 PM on 09/12/2014 the progress note read, "Resident being assessed throughout the shift. No bleeding noted thus far, but a rashy area to upper face and dark circles to Bilat (both) eyes noted. Resident continues on 2L (2 liters) O2 via NC (nasal cannula). Resident grimacing more than usual. MD (physician) made aware. No answer at RP's number. DON made aware." This note was signed by LPN#2. A progress note dated 09/12/2014 at 12:15 PM read, "Resident being assessed throughout the shift. No bleeding noted thus far, but a rashy area to upper face and dark circles to Bilat eyes noted. Upon starting shift no black circle noted. Area around eyes appeared to slowly darken throughout the shift. Resident continues on 2L O2 via NC. Resident grimacing more than usual. MD made aware. No answer at RP's number. DON made aware." The note was signed by LPN#2. The hospital Emergency Department exam report dated 09/12/2014 included, "Patient with petecchiae to face and ecchymosis around eyes, blood from ears. There are bruises along the patient's throat that are suspicious for finger prints. I am concerned about elder abuse and attempted strangulation. Will notify DSS (Department of Social Services) and plan to admit patient for her safety until this situation can be investigated. Pt (patient) is nonverbal but when I ask her if anyone hurt her, her eyes began to tear up." The report was signed by Hospital Physician #1. The Radiology report (dated 09/12/2014) revealed the Computerized Tomography (CT) scan was negative for a fracture, there was no mass or hematoma and no other significant findings. During an interview on 09/19/2014 at 9:51 AM, Hospital Physician #1 discussed her findings regarding her examination of Resident #1 on the afternoon of 09/12/2014. Hospital Physician #1 said that in addition to the bruising around her eyes and on her neck, Resident #1 also had a bruise on her upper arm when she came into the emergency department (ED). Hospital Physician #1 said Resident #1 wasn't on any medications that would have caused the petechiae or bruising. Hospital Physician #1 said, "Very few things will cause that petechial rash. It is forensically distinctive,- pathognomonic (specifically characteristic of a disease or condition; denoting a sign or symptom on which a [DIAGNOSES REDACTED]." The physician further stated, "The petechial rash is indicative of strangulation or a crushing force. I could not find anything else that would have caused it with this patient." The documentation from Resident #1's admitting hospital physician (Hospital Physician #2) dated 09/12/2014 included, "Her face appears atraumatic except for large periorbital, infraorbital ecchymosis (bruising under and around the eyes).Patient has a petechial rash from the upper lip up to the forehead." The document also indicated there was a little bit of petechial rash "on the left side of the neck." Hospital Physician #2's assessment included, "Petechial rash. Is it a case of elderly abuse? We spoke with the nursing home staff and they truly do not have any idea of what happened. Patient is not ambulatory. She is totally bedridden so there was no history of a fall. This has to be investigated and DSS will be called." Hospital Physician #2 was interviewed on 09/18/2014 at 10:44 AM and said, "This patient has so many unexplained injuries. These were life-threatening injuries." When asked about possible causes for the bleeding from the ears, Hospital Physician #2 stated that bleeding from the ears was usually associated with a skull fracture or very forceful coughing. She further stated that petechiae is often found with strangulation or forceful vomiting and that the nursing home had said there was no vomiting. Hospital Physician #2 said that tests showed no cranial fracture but there was swelling of the soft tissue in her face and neck, bruising, and subconjunctival hemorrhaging. Hospital Physician #2 said, " I don't know of anything that could cause all of that other than strangulation when you rule out a fall, vomiting or forceful cough." Hospital Physician #2 indicated Resident #1 was still in the hospital. The facility provided their investigation and written statements from the facility staff taken on 09/15/2014 through 09/17/2014. After review of each written statement, the facility staff were interviewed during the survey. On 09/16/2014 Nursing Assistant (NA) #1 wrote, "(Resident #1) had no falls on 11-7 that I'm aware of in the last 2 wks (weeks)." During the survey, an interview was conducted with NA #1 on 09/18/2014 at 10:42 AM. NA#1 indicated she was working the 11 PM to 7 AM shift, had provided care for Resident #1, and was the person who discovered Resident #1 with bleeding ears. At approximately 6:40 AM, NA #1 looked in to check on the resident and found her with the gown pulled up over her face. NA#1 said Resident #1 was facing the door, laying on her right side and her sheet was on the floor. NA#1 saw blood on sheet, and spots of blood, close together on the pillow in front of her face. I had no idea where the blood was coming from, so I went to look." NA #1 turned the resident on her back, "and the blood poured out of her (left) ear" so she turned her on her back and went to look for the nurse. NA#1 reported that neither of the nurses were available but the NA from the 100 hall was doing care and she motioned for her to come with her to Resident #1's room. NA#1 and NA#2 went back to the room and when NA#2 saw the resident she left to go get LPN#1. NA#1 stated that when she started to clean Resident #1 up and turned her over blood came out of the other ear. Nursing Assistant (NA) #2's undated statement included, "I got done caring for my residence(sic) and as I was making my way to the back nurses station I bumped into (NA#1) who said (Resident #1) was bleeding. As I enter the room I noticed that her face was blue and that their (sic) was blood in her ears." NA#2 was interviewed during the survey on 9/18/2014 at 5:20 PM, and said, "I was through with my rounds and saw (NA#2) was coming out of her room and she said (Resident #1) was bleeding and she didn't know why or where. So I followed into the room and her (Resident #1's) face was blue and we noticed her bleeding." NA#2 said, "I left to go find a nurse and she told me to get her vitals (vital signs)." On 09/15/2014 LPN#1 wrote, "Between the times of 6:30-6:45ish am, CNA came and told me that (Resident #1) had blood coming out of her ear and was slightly purple in her face. I ran to the room with my vital sign equipment. Her pulse was high and her O2 was in the low 90s after getting oxygen put on her at 2L resident's vitals were re-taken and after were good within normal limits." LPN#1 was interviewed during the survey on 09/18/2014 at 11:14 AM and said she had given the resident her scheduled medications ([MEDICATION NAME] and [MEDICATION NAME]) around 6AM and had not noticed any agitation at that time or earlier in the night. LPN#1 stated that the resident had not had problems during the night and no one had reported any fall or agitation with regard to Resident #1. When asked how she had learned of the resident's condition that morning LPN#1 said, "(NA#2) reported it to me. She said (Resident #1) was slightly purple in her face and she had blood coming out of her ear. I think it was her left ear. I got vital signs right away. She had blood coming out of her ear and she was purple in her face like she wasn't getting enough oxygen." When asked about the amount of blood coming from the resident's ears LPN#1 replied, "I would say it was like a nose bleed. It wasn't gushing but was actively flowing." LPN#1 stated that she called LPN#2 and #3. She indicated LPN #2 went to get the oxygen and the resident's oxygen saturation level "started to come up and color started to come back and the bleeding had stopped." LPN#2 said, "I called the DON and I told her everything that was going on, - the blood, purple and O2 and that her vital signs were okay. I called the doctor and left a message. The next nurse came on and I told her everything." When asked about what might cause bleeding from both ears, LPN#1 said, "I don't know." On 09/15/2014 LPN#2's statement included that LPN#1 had called for assistance and when she entered the resident's room the NAs were changing the bed. "The ring of blood I saw was approximately four inches in diameter. (LPN#1 stated that resident was bleeding from her ears. Resident's lips were bluish tinged so I told (LPN#1) I would get oxygen." The statement indicated that LPN#2 told LPN#1 to call Resident #1's attending physician. LPN#2 was interviewed during the survey on 9/19/14 at 3:50 PM. LPN#2 said, "I did see blood, probably the size of a grapefruit, maybe 3-4 inches on the sheet or pillowcase. The resident's lips were a little blue tinged so I went to get some oxygen." LPN#2 said, "When (LPN#1) told me she couldn't get the doctor- that he didn't answer, I told her to call the DON." When asked if she told LPN #1 to call the hospital to contact the physician outside of regular office hours, LPN#2 indicated she only told her to call the doctor and added, "I can't tell you that I did tell her or that I didn't tell her on any prior occasion." LPN #3 provided a written statement for the facility on 09/17/2014. The statement included that when LPN#3 arrived at the 200 hall nursing station, LPN#1 told her that everything was okay. LPN#3 went into Resident #1's room and saw blood in her ear and on the pillowcase. LPN#3 was interviewed during the survey on 09/19/2014 at 4:15 PM. LPN#3 said that on the morning of 09/12/2014 she had been giving report when someone paged for all nurses to go to the 200 hall. "She (LPN#1) didn't call any kind of a code or anything so we just walked there." LPN#3 said that when she arrived at the nursing station, "(LPN#2) said 'That's okay, we got it.'" LPN#3 stated she went to Resident #1's room and saw blood in the resident's right ear. LPN## stated she did not do an asssessment of the resident but did ask the NAs in the room what happened, "and they all said they didn't know." LPN#3 said she observed fresh blood, "about the size of a donut" on the linen and the resident was grimacing. She said, "I didn't know what to think" and added"I would have called the doctor and then called the DON and if the doctor didn't call back then I would have called the DON again." On 09/15/2014 the DON wrote that on 09/12/2014 at approximately 6:50 AM, "I received a call from (LPN#1). She stated that (Resident #1) had some blood coming out of her ears and she didn't know what to do. I said you need to call the doctor and make sure to call the R.P. (Responsible Party) as well. She stated okay. I got to the facility (approximately) 8:30 on 9/12/14 and I had not heard anything else regarding resident status until 7-3 nurse (LPN#4) stated that she had sent the resident to the ER for rash on face and dark circles forming under eyes." The DON was interviewed during the survey on 09/18/2014 at 5:35 PM, and said, "I got a phone call from (LPN#1) at about 6:45-6:50. She said (Resident #1) had blood from her ear and she didn't know what to do. I told her she needed to call the doctor and report it." The DON stated that she did not inquire further about the blood from the resident's ears and said, "I thought it was a skin tear or scratch or something. I didn't think it was anything emergent but I did tell her to call the doctor." The DON stated that a lot of blood from a resident's ears could be a sign of a head injury and said, "I would have expected her (LPN#1) to send her to the hospital when they saw the amount of blood I have since learned of." The DON said if the nurse did not hear back from the physician that the resident should have been sent to the hospital for evaluation. The DON said she learned that LPN#1 had called the physician's office and left a message on the answering machine. Upon request the DON reviewed the physician numbers posted at the nursing station and said the off-hours paging number for that doctor was not posted at the desk. LPN#4's undated statement indicated she was told by the off-going 11-7 nurse that Resident #1 had been bleeding from her ears. "The nurse mentioned to another that it was a lot. She attempted to get in touch with the resident's doctor but never talked to him." LPN#4's statement also included, "All the while in the back of my mind I'm thinking her doctor was paged at some point and he should be calling soon." The statement indicated LPN#4 had checked the resident at approximately 8:30 AM and there was no active bleeding from the ears and no other symptoms but about an hour later the resident had developed a rash around her eyes and there was some discoloration on her face. "I then called the MD's (physician's) office to see why they hadn't called and to tell them about the rash. I spoke with the MD's nurse and told her about the bleeding from the previous shift as well. She stated she would let him know and call back. Not even an hour later resident began to have dark circles under her eyes like blood had pooled there. I called the MD's office back to let them know and found out from the nurse that the MD said that he never received any pages or calls from anyone about the matter. I was instructed to send the resident out to the hospital for evaluation. Resident was alert with eyes open when she left. I was asked by MD's office if resident has sustained any falls but I was unaware of any recent falls." LPN#4 was interviewed during the survey on 09/18/2014 at 10:08 AM. She stated when she examined Resident #1 she didn't see any blood but there was a light purple discoloration on the right side of her face and the discoloration was on her forehead too. "I was waiting for the doctor to call back and I continued with my med-pass." LPN#4 stated that about one and a half hours later she checked the resident and the oxygen was still on at 2L per minute. She said the treatment nurse went in to change a dressing and identified the rash on the resident's face as petechiae. LPN#4 said she called the attending physician's nurse and then about an hour and a half later she noted the dark circles forming under her eyes and called the physician's office again. The resident went out to the hospital at approximately noon. LPN#4 said, "I thought she had fallen when her eyes started to turn black but night shift said she had not fallen and she was in bed all day for us and I know she didn't have a fall. I was thinking closed head injury or that she had fallen." She added, "I called the DON to tell her I was sending (Resident #1) out." During an interview on 09/19/2014 at 5:15 PM, the Administrator said, "The physician should have been notified immediately and the resident sent out." During an interview on 09/25/2014 at 9:11 AM, Resident #1's attending physician in the facility stated, "I was informed that the day nurse had been waiting for a call back from me but I didn't know anything about an earlier call about the bleeding from both ears earlier." The physician said, "I would expect the nurse to send her to the hospital to see why she was bleeding from the ears." He added, "This (bleeding from the ears) was definitely an emergency." The Administrator was notified of the Immediate Jeopardy for F309 on 9/18/14 at 7:41 PM. The facility provided the following credible allegation of compliance on 9/19/14 at 5:00 PM. CREDITABLE ALLEGATION OF COMPLIANCE F157-MD Notification ? Resident #1 was observed on 9/12/14 at approximately 6:30am by NA with flushed skin and blood coming from resident ears. NA notified nurse of resident flushed skin and blood coming from resident #1 ears on 9/12/14. Nurse assessed resident #1 at approximately 6:45 am on 9/12/14 with O2 sats range at 92% and skin color slightly purple. Nurse applied O2 and sats went to 97%, blood pressure 134/58 and heart rate 98. Resident #1 was reassessed on 9/12/14 at approximately 7:00 am by the third shift and first shift nurse with no active bleeding noted. First shift nurse continued to assess resident #1 on 9/12/14 at 8:30 am with no active bleeding observed. First shift nurse reassessed resident #1 on 9/12/14 around 9:30 am and observed a rash on resident face and light discoloration to resident face. On 9/12/14 9:30am the MD (physician) office nurse was made aware by first shift nurse of bleeding from resident #1 ears at 6:30am, rash on face, and light discoloration to resident face. Resident #1 was assessed by first shift nurse again at approximately 10:30 am an observed darkening under resident ' s eyes. On 9/12/14 first shift nurse contacted MD office nurse again and notified of darkening under resident ' s eyes. Order received from MD office nurse on 9/12/14 approximately at 11:48am MD order was written to send resident to ER. Hall nurse assigned to resident #1 during the acute change was drug tested and suspended by the Administrator on 9/15/14. NA assigned to resident #1 during the acute change in condition was suspended and drug tested by the Administrator on 9/16/14. An inservice was initiated on 9/12/14 and an additional inservice was initiated on 9/16/14 with both in-services completed at 100% by 9/18/14 with all other licensed nurses by the Staff Facilitator (Staff Educator) regarding assessing acute changes in condition, sending resident out if unable to contact MD, examples of acute changes to include abnormal bleeding, notification to physician by telephone when an acute change in condition to include cognitive status, behavior, immune system response, normal body system functioning, changes in cognitive status, changes in behavior, changes in oral intake to include fluids, changes in immune system, changes in normal body functioning, Panic laboratory values, resident ' s condition warrants based upon nurse ' s assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility ' s Medical Director. Notification of the physician of these types of changes in a resident ' s condition by fax is not acceptable. Handouts given to staff for reference. No nurse will be allowed to work without first receiving the in-services. ? Acute Change is defined as anything outside the norm for a resident to include but not limited to abnormal bleeding, skin color changes, changes in behaviors, change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. ? 100% of all current residents were physically observed for acute changes in condition to include changes in skin color and bleeding on 9/15/14 by DON Director of Nurses), Staff Facilitator , QI (Quality Improvement) nurse, MDS (Minimum Data Set) nurses (2) and facility consultant. Four concerns were noted during this audit and corrected by the treatment nurse on 9/15/14 and 9/16/14 with interventions placed, MD and RP (resident representative) notification, and documentation in the progress notes. Three months of nurse ' s notes were reviewed to ensure all documented acute changes in condition to include changes in skin color and bleeding have been addressed with appropriate interventions placed, Attending Physician notification and Responsible Party notification of the acute change on 9/15/14 by DON, Staff Facilitator nurse, QI nurse, MDS nurses (2) and facility consultant. Two concerns were noted during this audit with reassessment of the resident by the treatment nurse on 9/16/14, no concerns observed during the reassessment, and documentation in the progress note. ? An inservice was initiated with 100% of license nurses to include agency nurses initiated on 9/12/14, on assessment of acute changes in condition, sending resident out if unable to notify MD, notification to physician by telephone to include second shift, third shift and weekends; when an acute changes in condition occur, including abnormal bleeding, changes in cognitive status, behavior, oral changes to include fluids, immune system response, normal body system functioning, Panic laboratory values, resident ' s condition warrants based upon nurse ' s assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility ' s Medical Director. Notification of the physician of these types of changes in a resident ' s condition by fax is not acceptable. This in-service was 100% completed on 9/18/14 by Staff Facilitator. In-service on 9/18/14 was initiated by Staff Facilitator regarding Notifying the MD through the hospital after office hours and location of after-hours numbers. No license nurse will be allowed to work until receiving the in-service on MD after-hours notification. All newly hired licensed nurses and newly assigned agency staff will be in-serviced in orientation on notification to the physician of acute changes in resident condition and the after-hours notification of MD. ? The staff nurse is responsible to assess, document, provide appropriate interventions and notify Attending Physician and Responsible Party of any acute changes in condition noted. On 9/18/14 the after-hours MD notification number was posted at each nurse ' s station by the DON. If the staff nurse is unable to reach the attending physician, the on-call MD must be called. If unable to contact the attending or the on-call MD, the nurse must call the Medical Director. The staff nurse will implement appropriate interventions based on the needs of the resident and notify Attending Physician and Responsible Party. Staff will notify the DON or on-call nurse of any acute changes. DON, QI nurse, Staff facilitator and MDS nurses were in-serviced by the Administrator on 9/16/14 concerning when they are on-call and they receive a call concerning a change in condition of a resident that they are to ask more questions, if needed, to get a clear picture of what is occurring with the resident and to insure that the nurse has notified the MD of the acute change. On 09/19/2014 at 7:10 PM the credible allegation was validated and Immediate Jeopardy was abated at 7:35 PM when interviews with nursing staff revealed awareness of emergent changes in condition. Staff verified training had been received, that changes in condition were to be documented in the medical record, an RN was to be involved in the assessment, the physician should be notified and the resident transferred for acute care as indicated. Interviews revealed that if the attending or on-call physician could not be reached, the facility's Medical Director should be called. The number for paging the physicians after regular business hours was posted at the nursing station.