Every finding on record at Celina Manor

Based on interviews, medical record review and review of facility policy, the facility failed to monitor for potential adverse side effects for residents receiving psychotropic medications. This affected three (#47, #65, and #70) of five residents reviewed for unnecessary medications. The facility census was 72.Findings include: 1. Review of the medical record for Resident #65 revealed an admission on [DATE]. Diagnoses included Alzheimer's disease, depression, and anxiety.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had impaired cognition. Review of the plan of care dated 02/05/26 revealed Resident #65 was at risk for adverse effects/complications due to psychotropic medication related to Alzheimer's disease and anxiety. Interventions included monitoring behaviors every shift, monitoring resident for side effects of medication use and notifying physician of adverse side effects.Review of the physicians' orders for Resident #65 revealed on 02/14/26, there was an order for Zoloft oral tablet 50 milligrams (mg) give one tablet by mouth one time a day for depression. There was no documentation in Resident #65's medical record for routine monitoring of behaviors and side effects of the psychotropic medication. Interview on 03/26/26 at 11:01 A.M. with Physician Assistant (PA) #201 who was contracted by the facility for psychiatry services stated he speaks to the staff present on the in-person visits regarding any medication side effects. PA #201 verified he had access to residents' medical records and has not reviewed any documentation specifically for monitoring for adverse side effects for psychotropic medications. Interview on 03/26/26 at 11:47 A.M. with the Administrator and the Director of Nursing verified the facility does not document any adverse side effects of the psychoactive medication for Resident #65. 2. Review of the medical record for Resident #70 revealed an admission date of 09/02/25. Diagnoses included Alzheimer's disease with late onset, anxiety and severe dementia with agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had severely impaired cognition. During the review period, Resident #70 exhibited physical and verbal behaviors towards others on one to three days, had behaviors that were not directed at others occurring four to six days, and had rejection of care on one to three days and wandering behaviors occurring four to six days. Review of the physicians' orders for Resident #70 for the month of March 2026 revealed Resident #70 was receiving psychotropic medications. These included the following: an order dated 03/05/26 for Celexa oral tablet 20 milligrams (mg) give one tablet by mouth daily related to anxiety; an order dated 03/19/26 for hydroxyzine oral tablet 25 mg give one tablet by mouth as needed for agitation/anxiety three times a day for fourteen days; an order dated 02/28/26 for valproic acid oral solution 250 mg per five milliliter (ml) give 10 ml by mouth two times a day related to dementia with severe agitation; and an order dated 02/04/26 for trazodone oral tablet 50 mg give one tablet by mouth one time a day related to anxiety disorder. There was no documentation in Resident #70's medical record for routine monitoring of behaviors and side effects of the psychotropic medication. Interview on 03/26/26 at 11:01 A.M. with Physician Assistant (PA) #201 who was contracted by the facility for psychiatry services stated he speaks to the staff present on the in-person visits regarding any medication side effects. PA #201 verified he had access to residents' medical records and has not reviewed any documentation specifically for monitoring for adverse side effects for psychotropic medications. Interview on 03/26/26 at 11:47 A.M. with the Administrator and the Director of Nursing verified the facility does not document any adverse side effects of the psychoactive medication for Resident #70. 3. Medical record review for Resident #47 revealed an admission date of 01/06/26 with diagnoses including Alzheimer's disease and dementia with behaviors. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition. During the review period, Resident #47 exhibited verbal and physical behaviors on one to three days and behaviors not directed towards others and wandering four to six days. Resident #47 received medications from the pharmacological class of antidepressants and antianxiety. Review of the plan of care dated 01/06/26 revealed Resident #47 had impaired cognitive function and dementia. Interventions included administration of medication as ordered and monitor and document any changes in cognitive function, decision making ability and mental status. Resident #47 was also at risk for adverse side effects or complications related to psychotropic medication use. Interventions included monitoring resident's behaviors and recording every shift, monitoring side effects of medications and notifying physician. Review of the physician's orders for the month of March 2026 revealed Resident #47 was receiving psychotropic medications. These included the following: an order dated 02/18/26 for Ativan oral tablet 0.5 milligrams (mg) give one tablet by mouth three times a day for anxiety; an order dated 02/18/26 for buspirone 7.5 mg one tablet by mouth three times a day for dementia; an order dated 02/18/26 for mirtazapine oral tablet 15 mg one tablet daily for treatment of dementia; and an order dated 02/25/26 for sertraline 100 mg tablet, give one tablet daily for treatment of anxiety. There was no documentation in Resident #47's medical record for routine monitoring of behaviors and side effects of the psychotropic medication. Interview on 03/26/26 at 11:01 A.M. with Physician Assistant (PA) #201 who was contracted by the facility for psychiatry services stated he speaks to the staff present on the in-person visits regarding any medication side effects. PA #201 verified he had access to residents' medical records and has not reviewed any documentation specifically for monitoring for adverse side effects for psychotropic medications. Interview on 03/26/26 at 11:47 A.M. with the Administrator and the Director of Nursing verified the facility does not document any adverse side effects of the psychoactive medication for Resident #47.Review of the facility policy titled Psychotropic Drugs last revised on 03/2017 revealed a physician, nursing or other health care professional will document that the resident is being monitored for adverse consequences or complications of the drug therapy.

Based on observation, record review, staff interview, and policy review, the facility failed to administer medications to a resident utilizing the proper infection control procedure. This affected one (Resident #29) of five residents reviewed for infection control. The facility census was 72.Findings include:Review of the medical record for Resident #29 revealed an admission date of 02/28/14. Diagnoses included depression, traumatic brain injury, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had impaired cognition. Observation on 03/25/26 at 6:58 A.M. revealed Registered Nurse (RN) #281 was preparing Resident #29's medications. RN #282 pulled the medication card containing Amoxicillin-Pot Clavulanate (antibiotic) oral tablet 875-125 milligrams (mg) and pushed the pill out of the medication card directly into the RN's ungloved hand. RN #281 then used her fingers to place the medication into the medication cup. RN #281 followed this same process with Escitalopram Oxalate (antidepressant) oral tablet 20 mg, Furosemide (diuretic) tablet 20 mg, Sennosides (laxative) tablet 8.6 mg Lyrica Oral (nerve pain) capsule 75 mg and Vitamin D (supplement) 1,000 units and placed each pill into her ungloved hand and used her fingers to place them into the medication cup prior to administering them to Resident #29.Interview on 03/25/26 at 7:27 A.M. with RN #281 directly following the administration of medications to Resident #29 verified she placed each medication into her ungloved hands prior to administering the medications. RN #281 acknowledged the proper procedure was to push the pill from the card directly into the medication cup.Review of the facility policy titled Medication Administration- General guidelines revised 10/08/25 revealed medications are administered as prescribed in accordance with good nursing principals and practices and only by persons legally authorized to do so.This deficiency represents non-compliance investigated under Complaint Number 2681777.

Based on medical record review, staff interview, and policy review, the facility failed to issue a resident the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) after the facility initiated a discharge from Medicare part A services. This affected one (#32) of three residents reviewed for beneficiary notices. The facility census was 72.Findings include:Review of the medical record for Resident #32 revealed an admission date of 05/29/25. Diagnoses included aftercare following surgery on the circulatory system, diabetes mellitus, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was cognitively intact.Resident #32 received skilled services under Medicare part A from 05/29/25 through 07/18/25. Resident #32 had skilled days left on 07/18/25 and remained in the facility. There was no documentation to support the facility issued Resident #32 a NOMNC or SNF ABN. Interview on 03/26/26 at 10:41 A.M. with the Director of Nursing (DON) confirmed the facility initiated Resident #32's discharge from Medicare part A services because skilled services were ending. The DON confirmed the medical record did not have documentation to support the facility issued Resident #32 a NOMNC or SNF ABN prior to services ending 07/19/25. Review of the facility policy titled Skilled Nursing Facility (SNF)- Beneficiary Notice Requirements, revised November 2022, revealed the facility would issue the Notice of Medicare Provider Non-Coverage (Form CMS-10123) when there is a termination of all Medicare Part A or Part B therapy services for coverage reasons. The Notice of Medicare Provider Non-Coverage informs the beneficiary of his/her right to an expedited review of a service termination by the Quality Improvement Organization (QIO). The facility must issue the notice, no later than two days before the services are terminated, but far enough in advance that the beneficiary/representative can man an informed decision. The Advanced Beneficiary Notice (ABN) of Non-Coverage is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services if billed and denied.

Based on record review, resident and staff interviews, and policy review, the facility failed to address a resident's concern regarding staff in a timely manner. This affected one (#31) of four residents reviewed for dignity and respect.Findings include:Review of the medical record for Resident #31 revealed an admission date of 07/09/21.Diagnoses included anoxic brain damage, diabetes mellitus type two, and depression.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition.Interview on 03/24/26 at 12:08 P.M. with Resident #31 revealed he did have a concern a staff member had not treated him with dignity and respect. He shared Certified Nursing Assistant (CNA) #268 had told him he was too old to be wearing a diaper. Resident #31 denied he believed CNA #268 had not been verbally abusive but felt she had disrespected him by the comment. Resident #31 acknowledged he had not spoken to management regarding the issue and was agreeable of notification to the Director of Nursing (DON) of the concern.Interview on 03/24/26 at 12:42 P.M. with the DON acknowledged she had not been aware of a dignity concern by Resident #31 and stated she would follow up with him.Follow- up interview on 03/26/26 at 8:39 A.M. with the DON regarding the dignity and respect concern from Resident #31 revealed she had not spoken to Resident #31 herself, but instead had the Resident Services Coordinator (RSC) #201 interview him.Interview on 03/26/26 at 8:58 A.M. with RSC #201 revealed she had spoken to Resident #31 and he had voiced a general concern with CNA #268. RSC #201 explained Resident #31 had informed her he and CNA #268 have friendly back and forth banter and he sometimes feels she goes too far. RSC #201 verified she had not been informed of Resident #31's concern by the DON until that morning (03/26/26).Interview on 03/26/26 at 3:33 P.M. with the Administrator revealed it would be her expectation that staff would follow up with a resident's concern for dignity and respect within 24 hours.Review of the facility policy titled Resident Rights, revised 11/2016, revealed a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his pr her quality of life, recognizing each individual's individuality.

Based on medical record review, staff interview, and policy review, the facility failed to complete a discharge recapitulation of stay or discharge summary upon resident discharge to another healthcare setting. This affected one (#75) of one resident reviewed for planned discharge. The facility census was 72. Findings include:Review of the medical record for Resident #75 revealed an admission date of 10/28/25. Diagnoses included pneumonia, pulmonary fibrosis, emphysema, and chronic obstructive pulmonary disease (COPD).The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact. Review of the Social Service Weekly Baseline and Discharge Planning tool dated 12/22/25 revealed Resident #75 would be transferring to an Assisted Living on 12/26/25. The tool did not contain any other documentation.The medical record for Resident #75 revealed no documentation to support the facility completed a discharge recapitulation of stay or discharge summary.Interview on 03/26/26 at 3:15 P.M. with Director of Nursing (DON) confirmed Resident #75 had a planned discharge to an Assisted Living facility and the medical record for Resident #75 did not have documentation to support the facility completed a discharge recapitulation of stay or discharge summary. Review of the facility policy titled Admission, Transfer, Discharge and Room Change, dated 2025, revealed it was the responsibility of the DON to ensure that resident discharges are made only upon the physician written order unless the resident is leaving against medical advice (AMA) and that transfers and discharges are documented in the resident's clinical record. Written notification would also be provided to be the resident (whether facility or resident initiated) which would include the following information: reason for transfer or discharge, effective date of transfer or discharge, reason the resident was transferred or discharged , stated of the resident's appeal rights, and the name, address, and telephone number for Ombudsman's office.

Based on record review, staff interviews, observations, and policy review, the facility failed to ensure a resident who was at risk for falls and had a history of falls had their fall care plan interventions in place. This affected one (#5) of two residents reviewed for falls. The facility census was 72.Findings include:Review of the medical record for Resident #5 revealed an admission date of 09/12/25. Diagnoses included chronic obstructive pulmonary disease (COPD), lymphedema, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had impaired cognition and required moderate assistance from staff with toileting hygiene, bed mobility, and transfers.The care plan, last revised on 01/21/26, revealed Resident #5 was at risk for falls related to impaired mobility, weakness, a history of falls, confusion, edema, and COPD. Interventions to provide a safe environment with even floors, free from spills and a small pad sensor to the chair and a larger sensor pad to the bed.Observation on 03/25/26 at 9:25 A.M. revealed Resident #5 was in her recliner chair in the reclined position; her eyes were closed. There did not appear to be a sensor plugged in close to the recliner.Interview and observation on 03/25/26 at 9:37 A.M. with Certified Nursing Assistant (CNAs) #269 and CNA #248 in Resident #5's room confirmed there was a sensor on the bed, however there was no sensor on Resident #5's chair. CNA #269 and CNA #248 stated they were unaware Resident #5 needed a chair alarm in her recliner. CNAs #269 and #248 said Resident #5 needed the bed sensor pad because the resident would get up unattended through the night.Observation and interview on 03/25/26 at 9:49 A.M. with with Licensed Practical Nurse (LPN) #235 in Resident #5's room revealed Resident #5 was awake in her recliner. LPN #235 asked Resident #5 to stand with her walker allowing LPN #5 to verify there was no chair sensor. Following the observation, LPN #235 accessed Resident #5's care plan and verified Resident #5's care plan did list a chair and bed sensor as an intervention for falls. Review of the facility policy titled Fall Reduction, revised 04/2016, revealed based on outcome of the fall assessment, a fall risk reduction plan would be added to the plan of care.

Based on record review, dialysis staff interview, staff interview, and review of facility policy, the facility failed to implement pre-admission physician orders for peritoneal dialysis (PD) (treatment for kidney failure that cleans the blood using the body's abdominal lining (peritoneum) as a natural filter) and provide ongoing monitoring of the resident receiving PD. This affected one (#77) of one resident reviewed for dialysis. The facility census was 72.Findings include:Review of the medical record for Resident #77 revealed an admission date of 11/15/25. Diagnoses included chronic kidney disease (CKD) stage five. Resident #77 was hospitalized on [DATE] and did not return to the facility. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 received dialysis services.Review of the written pre-admission physician order for PD for three daily exchanges at 6:00 A.M., 2:00 P.M. and 10:00 P.M. There was also an order to monitor for signs and symptoms of peritonitis such as fever, abdominal pain and cloudy effluent (waste fluid from peritoneal dialysis consisting of dialysate, excess body water and toxins). The orders was signed 11/14/25.Review of the facilities physician orders for Resident #77 revealed there were no orders to monitor for signs and symptoms of peritonitis.The care plan, dated 11/17/25 revealed Resident #77 required PD related to CKD stage five. Interventions to monitor labs and report to the doctor as needed, monitor and report to physician signs and symptoms of bleeding, bacteremia, septic shock, report significant changes in pulse, respirations and blood pressure immediately.Review of the paper peritoneal flowsheet documentation revealed there were columns to document the time of the peritoneal dialysis and condition/other comments (call nurse immediately for cloudy fluid, abdominal pain fever). The first date completed on this document was 11/15/26 at 2:00 P.M. with a note the PD nurse had completed the exchange. The second documentation was on 11/15/26 at 10:00 P.M. and contained no documentation in the condition/comment section. Further daily documentation on 11/16/25, 11/17/25, and 11/18/25 revealed no correlating condition/comments for each time PD was completed, instead there was one entry for the entire day. There was no documentation PD was completed on 11/18/26 at 6:00 A.M.Review of the dialysis flowsheet for the PD cycler machine (a table-top device used to treat kidney failure, typically used overnight) revealed the start date was 11/19/25. There was no description of the effluent on 11/19/25, 11/20/25, 11/21/25 or 11/22/25.Interview on 03/30/26 at 9:02 A.M. with PD Nurse #355 from Company #1 revealed the facility staff would need to monitor the effluent for cloudiness and/or if the resident developed abdominal pain and fever during the procedure and report these things immediately to her staff. If they did occur, PD Nurse #355 verified the facility staff had been trained on the Peritoneal Dialysis Cycler the facility had used for Resident #77.Interview on 03/30/26 at 1:17 P.M. with the Director of Nursing (DON) verified the paper charting did not allow for an area to provide description of the effluent or signs and symptoms of abdominal pain and or fever for each time PD was performed. The DON confirmed there was no documentation for PD on 11/18/25 at 6:00 A.M. and there was no order to monitor for signs and symptoms of peritonitis as physician ordered. The DON confirmed there was no physician order in the electronic charting for the use of the Peritoneal Dialysis Cycler . The DON explained the cycler was brought in by Resident #77's caregiver and Company #1 was aware she was using it because they provide the daily orders for the amount of dialysate to use with the cycler.Review of the facility policy titled Dialysis Care revised 04/04/18 revealed the facility would provide an ongoing assessment of the resident's condition and monitoring for complications before, during and after treatments including: monitoring resident condition during the treatment, monitoring for complications, implementing appropriate interventions and using appropriate infection control practices.This deficiency represents non-compliance investigated under Complaint Number 2681777.

Based on record review, staff interview, and policy review, the facility failed to ensure required Quality Assurance and Performance Improvement (QAPI) committee members attended the quarterly meetings as required. This had the potential to affect all 72 residents residing in the facility.Findings include:Review of the facility's QAPI attendance sign in sheets for the third quarter (07/01/25 to 09/30/25) and fourth quarter (10/01/25 to 12/31/25) of 2025 revealed no documentation to support the Infection Control Nurse attended the quarterly meeting.Interview on 03/30/26 at 1:20 P.M. with the Administrator confirmed the Infection Prevention nurse did not attend the quarterly QAPI meetings for the third and fourth quarter of 2025. Review of the facility's policy titled QAPI policy and procedure, dated February 2018, revealed an essential element of the QAPI program was the thoughtful and candid review of the company's provision of care to its residents by the QAPI committee. The full committee would meet quarterly and include the Administrator, Medical Director, Pharmacy Consultant, Social Service Designee, Director of Nursing, Activity Coordinator, Food Service Supervisor, Infection Control Nurse, Environmental Service Supervisor, Restorative Nurse, and Business Office Manager.

Based on record review, observation, staff interview, and policy review, the facility failed to store prescribed medications appropriately and securely. This affected Resident #36 and had the potential to affect four residents (#29, #38, #58, and #266) who the facility identified to be confused and independently ambulatory. The facility census was 66. Findings include: 1. Medical record review for Resident #36 revealed an admission on 12/01/17. Diagnoses included schizophrenia, psoriasis, anxiety, and psychotic disorder with delusions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. Observation on 05/08/23 at 9:19 A.M. of Resident #36's dresser in room revealed a tube of Nystatin-Triamcinolone Cream (a skin treatment) was unsecured with prescription label on it for Resident #36. Interview on 05/08/23 at 9:25 A.M. with Registered Nurse (RN) #102 verified the tube was for Resident #36 and the tube should not have been left in the room unattended. RN #102 stated the treatment was done on the previous shift and left in the room by mistake. 2. Observation on 05/09/23 at 8:41 A.M. of an unlocked and unsupervised treatment cart located outside of the restorative nursing office. The treatment cart contained povidone iodine swab sticks and povidone bottles with warning label to contact poison control if accidental ingestion, tubes of miconazole nitrate house stock tube if swallowed get medical help and contact poison control and a bottle of peroxide with label stating chemical danger causes skin irritation and serious eye damage and shortness of breath with ingestion. Contact poison control if ingested. Interview with Register Nurse (RN) #161 on 05/09/23 at 8:45 A.M. verified the treatment cart was unlocked and not under direct supervision of a licensed nurse. RN #161 proceeded to walk away from the unlocked treatment cart stating the wound nurse was in the facility using it. Review of the facility's list of residents who were confused and independently ambulatory revealed Residents #58, #29, #38, and #266) were confused and independently ambulatory around the facility. Review of the facility policy titled Medication Storage in the Facility, dated 03/1996, stated medications and biologicals are stored safely and securely following manufactures recommendations. Medication/treatment carts are to be locked or attended by persons with authorized access.

Based on medical record review, staff interview, and policy review, the facility failed to promptly notify the physician of an abnormal urinalysis result which indicated the resident had a urinary tract infection (UTI). This affected one (Resident #316) of two residents reviewed for laboratory values. The facility census was 66. Findings include: Medical record review for Resident #316 revealed an admission on 04/28/23. Diagnoses included fracture of metatarsal bone in left foot, hemiplegia, and hemiparesis affecting left side. Review of the plan of care revealed Resident #36 had incontinence of bladder related to weakness. Interventions include encourage fluids, monitor for decline in urine output or signs and symptoms of urinary tract infections (UTI), monitor lab results as ordered and report any abnormal laboratory results to physician. Review of the physician orders for Resident #316 revealed an order dated 05/02/23 for urinalysis with reflex culture and sensitivity. Review of the laboratory results dated [DATE] and reported to the facility on [DATE] for Resident #316 revealed a urine culture result indicating a UTI from the bacteria proteus vulgaris. There was nothing in the medical record to indicate the physician was notified of the urine culture result indicating a UTI. Interview on 05/09/23 at 1:19 P.M. with Licensed Practical Nurse (LPN) #140 stated she was unable to locate any communication or documentation that the physician was notified of the abnormal results indicating Resident #316 had a UTI. Subsequent interview on 05/09/23 at 4:10 P.M. with LPN #140 verified the physician was not notified on 05/06/23 and LPN #140 notified the physician that day (three days later on 05/09/23) and an antibiotic (Bactrim double strength tablet 800/160 milligrams (mg) one tablet by mouth for five days) was ordered for the treatment of a UTI for Resident #316. Interview on 05/10/23 at 2:10 P.M. with the Director of Nursing (DON) stated the laboratory company usually sends a fax to the facility and the physician was notified. The DON was unable to determine why the physician was not notified as he should have been on 05/06/23 further stating the facility was unable to locate the fax from the laboratory. Review of the facility policy titled Notification of Changes Policy, dated 11/02/16, revealed the facility must inform the resident, physician and the resident representative when an change occurs resulting in an altered treatment plan.

Based on medical record review, resident and staff interviews, and policy review, the facility failed to develop a comprehensive plan of care for Resident #59. This affected one (#59) of three resident reviewed for plan of cares. The facility census was 66. Findings include: Medical record review for Resident #59 revealed an admission on 12/12/22. Diagnoses included wedge compression fracture of thoracic vertebra, hypertension, hypokalemia, fracture of thoracic vertebra 11-12, blindness, dehydration, fall, and tachycardia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. Review of the hospital discharge documentation dated 12/11/22 revealed Resident #59 had difficulty swallowing foods and weight loss of 15 pounds since 11/04/22. Review of the facility's speech therapy note dated 12/14/22 revealed Resident #59 was on a regular diet. Resident #59 reported being on a pureed diet at home and was requesting a dietary downgrade. Resident #59 reported oral surgery on 10/20/22 to remove an infected tooth. Therapy assessment noted severed mandibular range of motion deficits. Speech therapist notified the physician's assistant and an order to follow up with the oral surgeon was ordered. Review of the nursing progress notes dated 12/14/22 revealed Resident #59 was not able to open her mouth fully since her tooth extraction in October 2022. The physician assistant was notified and new orders to follow up with oral surgeon. Review of the plan of care for Resident #59 revealed it was silent for the inability to open her mouth adequately to consume a regular diet related to decreased mandibular range of motion. Interview on 05/07/23 11:00 A.M. with Resident #59 stated she went to a dentist in October 2022 and had a infected tooth pulled and the jaw just stopped working after that. Resident #59 stated she was no longer able to open her mouth to eat solid food due to inability to chew it. Interview with 05/08/23 at 4:20 P.M. with Corporate Registered Nurse (RN) #98 verified Resident #59's care plan did not include the inability of the resident to open her jaw due to severe mandibular range of motion resulting in an altered diet. RN #98 verified this should have been included in the care plan. Review of the facility policy titled Resident assessment dated [DATE] revealed a comprehensive plan of care must be developed within seven days after the completion of the comprehensive MDS.

Based on medical record review, observation, review of facility policy, and staff interview, the facility failed to ensure staff followed physician ordered enhanced barrier precautions (EBP) for high resident care activities. This affected two (Residents #28 and #36) of six residents reviewed for infection control. The facility census was 66. Findings include: 1. Review of Resident #28's medical record revealed an admitted [DATE]. Diagnoses included end stage renal disease, chronic kidney disease, hemiplegia, presence of vascular graft, and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was totally dependent on staff for toilet use and transfer. Resident #28 received dialysis services. Further review of the medical record revealed Resident #28 received peritoneal dialysis through a dialysis catheter at the facility. Review of the physician orders dated 08/24/22 revealed an order indicating Resident #28 required the use of EBP to to an indwelling medical device. Observation on 05/09/23 at 11:57 A.M. revealed State tested Nursing Assistant (STNA) #114 and STNA #103 entering Resident #28's room with a Hoyer (mechanical) lift. STNA #114 and STNA #103 proceeded to transfer Resident #28 from a recliner into his bed and repositioned him in bed. Neither STNA #114 or STNA #103 donned any gloves or gown while transferring and caring for Resident #28. A bin with gowns was present at Resident #28's room entrance and a receptacle for used gowns was present inside Resident #28's room. Interview on 05/09/23 at 12:01 P.M. with STNA #114 confirmed STNA #103 and #114 had not donned gloves and gown while transferring and caring for Resident #28. STNA #114 confirmed a sign posted on the door read to use EBP for high resident care activities and that transferring was on a list that was considered a high contact resident care activity. 39702 2. Medical record review for Resident #36 revealed an admission on 12/01/17. Diagnoses included schizophrenia, quadriplegia, bladder dysfunction, and psychotic disorder with delusions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. Resident #36 required extensive assistance with two staff members for toileting and total assistance from staff for transfers. Resident #36 had a suprapubic urinary catheter. Review of the plan of care for Resident #36 reviewed has a suprapubic catheter due to neuromuscular dysfunction of the bladder secondary to spinal stenosis from quadriplegia. Interventions included catheter care every shift, change catheter per physician's order, and monitor for signs/symptoms of urinary tract infection. Review of the physician orders for Resident #36 revealed an order for the use of EBP due to a multi-drug resistant organism (MDRO) and an indwelling medical device. Observation on 05/09/23 09:48 AM with State tested Nursing Aide (STNA) #120 revealed the STNA provided morning care (including bathing, incontinent care, and catheter care) for Resident #36. STNA #120 failed to don a gown while providing care and services for Resident #36. A bin with gowns was present at the entrance of Resident #36's room entrance and a receptacle for used gowns was present inside Resident #36's room. Interview on 05/09/23 at 12:10 P.M. with STNA #120 confirmed that she had not donned a gown while providing morning care for Resident #36. STNA #120 confirmed a sign was posted on the door read to use EBP for high resident care activities and that transferring. bathing, and incontinent care was on a list that was considered a high contact resident care activity. STNA #120 stated she did not see the sign on the door and just missed it. Review of the facility's policy titled Enhance Barrier Precautions dated August 2022 revealed it is the intent of the facility to use EBP in addition to standard precautions for residents to prevent transmission of MDROs in their care community. All personnel must wear gloves when high-contact resident care activities are being performed. All personnel should wear gowns when high-contact resident care activities are being performed. Shared resident care equipment should be clean and disinfected. High contact resident care activities listed were dressing, bathing/showering, transferring, providing hygiene, changing linens, changing attends or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing.

Based on record review, review of facility policy, and staff interview, the facility failed to respond to the pharmacy's medication regimen review recommendations in a timely manner. This affected one (Resident #53) of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of the medical record for Resident #53 revealed an admitted [DATE]. Diagnoses included dementia, Parkinson's disease, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had impaired cognition. Review of the Summary of Monthly Recommendations dated 12/22/22 revealed Resident #53 was receiving the following medication with psychotropic properties: Depakote Delayed Release (DR) 125 milligram (mg) by mouth twice daily. Please review the resident's medication regimen and indicate your professional opinion on further use of the medication listed (check all that apply): 1) A dose reduction will be attempted. See new order below. 2) Medication regimen at this time appears appropriate and consistent with diagnosis. Resident is at optimal dose and is stable. No need for weaning at this point. 3) Discontinuation likely will be harmful to resident and/or others or it will disrupt their provision of care. 4) Resident's target symptoms returned/worsened after the most recent attempt of gradual dose reduction (GDR). 5) Target symptoms continue to persist in this resident. Reduction is clinically contraindicated as a result. There was no response from the physician in the medical record or on the Summary of Monthly Recommendations form. Interview on 05/09/23 at 2:32 P.M. with the Director of Nursing (DON) verified the physician did not address Resident #53's pharmacy recommendations timely. The DON verified the physician has not responded to Resident #53's pharmacy recommendation made on 12/22/22. Subsequent interview on 05/09/23 at 4:10 P.M. with the DON verified the pharmacy recommendation should have been addressed within 30 days. Review of the facility policy titled Medications Regiment Review and Recommendation, dated 03/20/18, revealed when a recommendation is made: Non-emergent recommendations are to addressed within the next 30 days.

Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure a resident that required assistance from staff with dressing was provided adequate care and services with changing her clothes routinely. This affected one (#316) of two residents reviewed for activities of daily living. The facility identified 65 residents who required assistance from staff with dressing. The facility census was 66. Findings include: Medical record review for Resident #316 revealed an admission on 04/28/23. Diagnoses included fracture of metatarsal bone in left foot, respiratory failure, hemiplegia, and hemiparesis affecting left side, osteoarthritis, left knee pain, and osteoarthritis. Review of the plan of care revealed Resident #316 had an activity of daily self-care performance deficit related to recent hospitalization , need for assistance, and multiple fractures. Interventions include physical and occupational evaluation and treatment as per physician orders. Review of the State tested Nursing Assistants (STNA) documentation dated 05/04/23 through 05/20/23 revealed no documentation was completed for the dressing activities of daily living for Resident #316 Observation and interview on 05/07/23 at 1:35 P.M. revealed Resident #316 was sitting in bed with a light purple blouse on. The light purple blouse had multiple stains on the upper chest area and food crumbs. Resident #316 stated she ate her lunch in bed and spilt her coffee and the crumbs were from lunch also. Resident #316 stated she had been wearing the shirt since Friday and needed to change it. Subsequent observation and interview on 05/08/23 at 11:45 A.M. revealed Resident #316 was wearing the same light purple blouse with stains on it. There were additional stains on the bottom front of the shirt. Resident #316 stated she slept in her shirt because no one asked her to change it. She had pajamas available to wear, but she was not changed by staff last evening (05/07/23). Interview on 05/09/23 at 2:13 P.M. with State tested Nursing Assistant (STNA) #97 stated she worked on 05/07/23 from 2:00 P.M. to 6:00 P.M. after being moved from another unit and again on 05/08/23 from 7:00 A.M. to 7:00 P.M. STNA #97 stated Resident #316 complained that her shirt was not changed since Friday, and she wanted to have it changed today. STNA #97 verified Resident #313 was wearing the same light purple shirt on three consecutive days, 05/07/23, 05/08/23, and 05/09/23. STNA #97 stated she gave Resident #316 a shower on 05/08/23. Review of the facility policy titled Quality of Care, dated 04/29/16 revealed a resident that is unable to carryout activities of daily living receives the necessary services to maintain good nutrition, grooming personal and oral hygiene.

Based on medical record review, resident interview, staff interview, review of pharmacy recommendations and review of facility policy, the facility failed to ensure respiratory medications were available from the pharmacy. This affected one (Resident #36) of one resident reviewed. The facility identified four residents who received rescue respiratory medications. The census was 85. Findings include: Review of the medical record for Resident #36 revealed an admission date of [DATE] with a re-entry dated of 06/13/18. [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #36 was cognitively intact with the need for oxygen. Review of the plan of care dated 12/20/18 revealed the resident had Asthma and [MEDICAL CONDITION] and could become short of breath if laying flat. Intervention included to give aerosol or [MEDICATION NAME][MEDICATION NAME] as ordered. Monitor and document any side effects and effectiveness Review of the physician's order dated 07/05/19 revealed [MEDICATION NAME] ([MEDICATION NAME]) 200 microgram (mcg) to give one inhalation every four hours as needed (PRN) and resident may keep at bedside. an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the pharmacy delivery route packing slip dated 12/17/19 at 12:06 P.M. revealed the facility received Resident #36's [MEDICATION NAME] Aerosol 160 mcg- 4.5 mcg. Interview with Resident #36 on 12/18/19 at 9:27 [NAME]M. revealed he had issue about not being allowed to keep his rescue inhaler in his room. He stated he preferred to keep his rescue inhaler in the room due to he didn't want to have to wait for the nurse to get if for him. Follow up interview with Resident #36 on 12/19/19 at 10:25 [NAME]M. revealed he still did not have his rescue inhaler at his bedside. He stated he had asked staff to keep it and they told him he was not allowed. Observation on 12/19/19 at 10:30 [NAME]M. of the medication cart for C-Hall with Licensed Practical Nurse (LPN) #208 revealed Resident #36 did not have [MEDICATION NAME] 200 mcg inhaler in the cart Interview during the observation with LPN #208 revealed she looked at the order for [MEDICATION NAME] 200 mcg which indicated may be kept at bedside, but it was documented as other. She explained this medication probably was never received by the pharmacy due to the order was put in wrong. LPN #208 revealed it should have indicated pharmacy in this area Interview with the Director of Nursing (DON) on 12/19/19 at 10:45 [NAME]M. revealed pharmacy had not sent Resident #36's [MEDICATION NAME] rescue inhaler due to it did not indicate pharmacy on the order in point click care. Interview with Registered Nurse (RN) #307 on 12/19/19 at 2:00 P.M. verified she did not know why the [MEDICATION NAME] was not given on 12/13/19 at HS and 12/16/17 and 12/17/19 at rising. Review of the facility policy Pharmaceutical Service dated 1020/03 revealed the manor must provide routine and emergency drugs and biologicals to it's residents by providing pharmaceutical services including procedure that assure the accurate acquiring, receiving and dispensing of all drugs to meet the needs of each resident.

Based on medical record review, observation, staff interview and facility policy review the facility failed to ensure staff witnessed residents take their medications. This affected one (Resident #58) of one resident observed during a random observation. The facility identified 17 Residents (#5, #10, #19, #20, #32, #33, #56, #57, #58, #60, #62, #69, #73, #75, #78, #80, and #81 who resided on the B Hall. The facility further failed to ensure the glucose control solution was dated once opened to ensure potency and accuracy. This had the potential to affect three Residents (#2, #4 and #44) residing in the [NAME] hall who had blood glucose monitoring. The facility census was 85. Findings include: 1. Review of the medical record of Resident #58 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment dated [DATE] revealed Resident #58 was cognitively intact. Observation on 12/19/19 at 10:15 [NAME]M. revealed Resident #58 seated in a wheelchair at a table in the dining room of B hall. Nine various medication tablets were lying on the table in a small pile. Resident #58 was holding a four-ounce plastic cup that contained a clear liquid. Resident #58 took two large tablets and this surveyor asked him to stop until a staff member was present. The surveyor asked an unidentified State tested Nursing Assistant (STNA) to enter a nearby room and ask Corporate Registered Nurse (CRN) #900 to come and assist. CRN #900 arrived at the table and verified the remaining seven medications and observed Resident #58 ingest the remaining seven tablets. CRN #900 encouraged him to drink all of the water. Review of the Medication Administration Record [REDACTED]. Interview on 12/19/19 at 10:20 [NAME]M. with RN #302 revealed she had thought it was acceptable to allow Resident #58 to ingest his medications unsupervised as he was alert and oriented. She further identified the liquid in the four-ounce plastic cup to contain [MEDICATION NAME]. Review of the facility policy titled Medication Storage in the Facility dated 09/2017 revealed medications are stored safely and securely and accessible only to licensed nursing personnel authorized to administer medications. 2. Observation on 12/19/19 at 9:30 [NAME]M. with Licensed Piratical Nurse (LPN) #202 revealed an opened and undated box containing two vials of glucose control solution. Each of the vials had the words discard three months after opening on them. Interview at the time of the observation with LPN #202 verified the vials of glucose control solution was opened and undated.

Based on closed medical record review, staff interview and facility policy review the facility failed to ensure residents received discharge notices timely. This affected one (Resident #84) of one reviewed for hospitalization . The facility census was 85. Findings include: Review of the closed medical record of Resident #84 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the progress notes dated 10/17/19 revealed Resident #84 went to a scheduled doctors appointment with his daughter. He was sent to the emergency department and was admitted to the hospital related to multiple blood clots in both legs. The medical record was silent for any discharge notice being sent to the resident and/or family. Interview on 12/19/19 at 4:05 P.M. with the Director of Nursing verified no transfer notice had been sent to Resident #84 or his family. Review of the facility policy titled Admission, Transfer and Discharge Rights dated 02/2018 revealed a notice of transfer or discharge will be given to the resident and sent certified mail to the resident's sponsor, family or guardian, if known.

Based on closed record review, staff interview and facility policy review the facility failed to provide one resident, #84, with a bed hold notice upon discharge to the hospital. The facility census was 85. Findings include: Review of the closed medical record of Resident #84 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the progress notes dated 10/17/19 revealed Resident #84 went to a scheduled doctors appointment with his daughter. He was sent to the emergency department and was admitted to the hospital related to multiple blood clots in both legs. The record was silent for any bed hold notice having been sent to the resident and/or family. Interview on 12/19/19 at 4:05 P.M. with Office Manager #700 provided verified no transfer notice was sent to Resident #84 or his family. Review of the facility document titled Bed Holds and Leave of Absence dated 03/2017 revealed the Medicaid program will pay for the costs of holding your bed at the facility. so long as the number of bed hold days has not been exceeded.

Based on observation, resident interview and staff interview the facility failed to maintain a homelike environment when they stored [MEDICAL TREATMENT] solution in resident rooms. This affected one, (Resident #31) during a random observation. The facility identified three Residents (#31, #54 and #58) as having [MEDICAL TREATMENT] solution stored in residents rooms. The facility census was 85. Findings include: Interview on 12/16/19 at 10:19 [NAME]M. with Resident #31 revealed the facility stored the [MEDICAL TREATMENT] solution in her room. Resident #31 stated she was slightly claustrophobic and all of the boxes made her anxious. She added there was no place in her room for visitors to sit. Observation on 12/16/19 at 10:40 [NAME]M. of Resident #31's room revealed a wooden pallet, on the floor to the left of the doorway, with approximately 40 boxes labeled [MEDICAL TREATMENT] solution in various strengths. On the extra bed, which had been pushed against the wall, were more boxes. Interview at the time of the observation with Housekeeper #603 revealed visitors had commented on all of the boxes stored in the room. Interview on 12/17/19 at 3:39 P.M. with the Administrator revealed Resident #31 had indicated on 12/15/19 her desire to have the [MEDICAL TREATMENT] solution not stored in her room, yet no plan had been activated to date to correct the issue. The Administrator stated the facility had no policy regarding maintaining a homelike environment.

Based on observations, medical record review, review of facility Legionella risk assessment, review of facility's policies, review of form A 0010 and staff interviews, the facility failed to provide appropriate monitoring to reduce the risk of Legionella exposure as required for long term health care facility's. In addition the facility failed to follow appropriate infection control policy and procedure related to handling residents who are on contact isolation for communicable diseases. This had the potential to effect all 77 of 77 residents residing in the facility. Findings include 1.) Review of the facility risk assessment dated [DATE], documented the facility should have a water management program for the hot and cold water distribution to reduce the risk of Legionella growth and spread. Review of Form A-0010 documented on 05/15/18 and 08/04/18, all areas assessed as a risk were not being monitored as required per the facility's Appendix B Legionella management plan for control and prevention. There were some temperatures completed these months but without weekly documentation as described in the facilities policy. There was also quarterly chlorine testing but it was only documented for the hot and cold water heaters. Interview on 10/17/18 at 9:35 A.M., with Environmental Service Supervisor #510 verified he was not doing the monitoring as it was required per the facilities risk assessment and policy. He verified he was only monitoring the entry point to the building and at the end point in the building. He stated this is what it said at the bottom of his monitoring sheet. he also revealed quarterly chlorine testing was completed but only at the cold and hot water heaters. He further verified he was not aware he should have been conducting monitoring at all the point on Appendix B as required per the facility assessment and policy but will be starting to monitor them from now on. Review of the facility policy titled Legionella policy-environmental date 02/17/16, documented the facility will implement control measure to reduce the potential growth and spreading of Legionella. Further review documented Appendix B Legionella management plan for control and prevention will identify the control measures that included quarterly testing for chlorine levels at the cold distribution for central shower/circulation tub and the hot distribution chlorine levels kitchen of the kitchen appliances and central shower/circulation tub. Further review also indication weekly water temperatures will be completed for water heaters, mixing valves, sinks and showers in residents rooms, central shower/circulation tub and kitchen appliances. All the other areas will be visually monitored for evidence of debris and or biofilm which cause contamination. The policy identifies to document this on form A-0010. 2) Observation on 10/16/18 at 11:40 A.M., of meal trays being delivered to resident rooms revealed State tested Nurse Assistant (STNA) #315 was to deliver a meal tray to Resident #77. STNA #315 obtained the lunch tray from the B hall kitchenette and walked to the residents room. The STNA knocked on the resident's door, walked in the room, and place the meal tray on the bedside table of Resident #77. With ungloved hands, STNA #315 moved the bedside table, leaned towards the resident, and touched Resident #77 on the shoulder several times in attempt to wake the resident. Continued observation revealed Resident #77 requested to eat the meal at a later time. STNA #315 picked up the meal tray and exited the residents room without washing hands or placing the meal tray in a bag. The STNA then carried the meal tray through B hall dining room to the kitchenette and handed the tray to the dietary manager, with the meal tray passing over the food serving area which contained the food being used for resident afternoon meals. Review of the medical record for Resident #77 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of a laboratory result dated 09/30/18 revealed Resident #77 had positive test results for [MEDICAL CONDITION]. Review of the physician orders revealed the resident was being treated for [REDACTED]. Interview on 10/16/18 at 11:45 A.M., with STNA #315 revealed the STNA was aware staff were to utilize contact precautions when providing care for Resident #77. STNA #315 verified he/she did not don gloves or any other personal protective equipment prior to making contact with Resident #77. The STNA further verified he/she did not bag the meal tray or wash hands prior to leaving the residents room. STNA #315 revealed he/she did not know the proper procedure for handling a meal tray that was removed from an isolation room. Review of a policy titled, Transmission Based Precautions General Principles undated, revealed trays to residents on transmission based precautions are delivered last. Nursing personnel will wear appropriate protective apparel when taking tray service in to the room. The meal tray is to be bagged prior to leaving the residents room. Bagged trays are to return to the kitchen and washed last. The policy further revealed employees should wear gloves when handling dirty dishes.

Based on medical record review, review of a medical transportation run report, staff and physician interview, and policy review, the facility failed to seek timely medical evaluation/treatment when two (#1 and #3) Resident's experienced a significant change in condition. This resulted in actual harm when Resident #1 had unrelieved nausea with the development of abdominal pain with a delay in medical evaluation/treatment. Resident #1 subsequently required hospitalization and surgical intervention for a perforated bowel. This affected two (#1 and #3) out of three residents reviewed for change of condition. Facility census was 80. Findings include: 1. Review of Resident #1's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] identified the resident as being cognitively intact as indicated by a brief interview for mental status (BIMS) score of 15. It identified the resident as requiring extensive assist of one person with bed mobility; extensive assist of two person with transfers; limited assist of one person with walk in room; limited assist with one person with walk in corridor; extensive assist of one person with locomotion on unit; extensive assist of one person with dressing; supervision assist of one person with eating; extensive assist of one person with toilet use; and extensive assist of one person with personal hygiene. It identified the resident as being frequently incontinent of urine and always continent of bowel. Review of the physicians orders revealed an order for [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED].M. and was effective, on [DATE] at 12:27 P.M. and was effective, on [DATE] at 4:34 P.M. and was effective, on [DATE] at 7:07 P.M. and was ineffective. Additionally, the resident was administered the one-time dose of [MEDICATION NAME] 4 mg for nausea on [DATE] at 10:47 P.M. Review of the nurses note from [DATE] until [DATE] revealed on [DATE] at 10:30 P.M. the nurse sent a tiger text to the physician that indicated the resident has not been feeling well this evening. She had an emesis after taking [MEDICATION NAME] as needed at 7:07 P.M. and she is still not feeling well. Her stomach is very upset. She did not have a temperature. The physician was asked if there was anything else we can give the resident to help her feel better. The physician responded back on [DATE] at 10:32 P.M. to repeat extra dose of [MEDICATION NAME] 4 mg now please. On [DATE] at 12:45 A.M. the nurse sent a tiger text that indicated the resident continues to vomit, gave the extra dose of [MEDICATION NAME] and she kept that down. She's now saying her stomach is still upset and hurts really bad; tried drinking sips of water and sprite and she vomits it right back up-temperature 99.9 degrees Fahrenheit (F) orally. There was no response from the physician after the tiger text was sent. Further review of nurses notes revealed a note on [DATE] at 5:10 A.M. which revealed the resident's temperature was 97.8 degrees F, respirations were 16, and oxygen saturation was 92 percent (%) on room air. It revealed her breath sounds were diminished bilaterally with auscultation; her abdomen was soft with active bowel sounds in all four quadrants and the resident had a soft bowel movement this shift. It revealed the resident states she wants no more pills because she thinks they make her worse. The State tested Nursing Assistants (STNA's) stated the resident had five emesis this shift, the emesis were bright yellow in color and had a stringy consistency. The STNA informed to let the nurse see emesis. The resident stated she has some discomfort in her stomach area. The STNA stated the resident cannot drink water or Shasta lemon lime as this upsets her stomach. She cannot eat saltine crackers. Resident #1 states she felt sick to her stomach one day last week with stomach discomfort. No reply from the physician regarding condition status around midnight. According to nurses notes, on [DATE] at 6:22 A.M. the nurse sent a tiger text: to the physician that the resident has active bowel sounds in all four quadrants with a bowel movement yesterday. On [DATE] at 6:27 A.M. a tiger text was sent to the physician that revealed the resident continues to complain of pain, and states thinks [MEDICATION NAME] made it worse. The physician responded back on [DATE] at 6:29 A.M. that revealed, sorry, he missed the earlier note. Please send to the emergency room for evaluation. On [DATE] at 8:00 A.M. a nurse note revealed attempted to reach the residents daughter as resident wished to wait to see if family transport was a possibility. There was no return phone call as of this time. Will call for transport. Resident states, I still don't feel too good at all. My stomach is hurting so bad. Review of the note on [DATE] at 9:18 A.M. revealed the resident is in route with Medical Transport Services (MTS) #1. Report was called to the emergency room (ER) nurse at the hospital and the resident's power of attorney would meet the resident at the hospital. There was no attempt to contact the physician of the resident's change in condition after the tiger text was sent on [DATE] at 12:45 A.M. when the physician never responded until 6:29 A.M. Review of the MTS #1 run report revealed on [DATE] they were called for Resident #1. It revealed the priority was immediate and the nature of the call was for severe pain. It revealed the call was received at 8:14 A.M., they were dispatched at 8:15 A.M., they were in route at 8:17 A.M., they were at the scene at 9:00 A.M., they were at the patient's side at 9:01 A.M., and at the destination at 9:31 A.M. It identified the chief complaint being abdominal pain. It revealed the resident had abdominal pain in the left lower quadrant and the right lower quadrant. The treatment summary indicated at 9:01 A.M. the residents states 10 out of 10 pain in the lower abdominal regions. At 9:15 A.M. it revealed the resident's blood pressure was ,[DATE], pulse 124, respirations were 18 and oxygen saturation was 96% on room air. Review of the narrative revealed the transport was called to the nursing facility for resident recently diagnosed with [REDACTED]. The resident just finished her run of antibiotics and is now showing signs that the medications have not worked. The resident has been vomiting all last night and the nurse administered multiple doses of [MEDICATION NAME] to help with her nausea, with no relief. Review of the Hospital #2's ER notes dated [DATE] at 10:47 A.M. revealed Resident #1 presents with nausea, vomiting and abdominal pain. The results of the computed tomography scan (CT) of the abdomen identified the resident as having a large amount of intra-abdominal free air concerning for bowel perforation. Mild thickening of the sigmoid colon, with suggestion of a bowel wall pneumatosis involving the sigmoid colon. A small amount of free fluid within the abdomen and pelvis, with more loculated collection within pelvis measuring 8.2-centimeter (cm) by 3.3 cm; this may represent early abscess. It revealed the resident had extensive [DIAGNOSES REDACTED]. Review of the Hospital #2's history and physical dated [DATE] revealed Resident #1 was transferred from Hospital #2 to Hospital #3 without a surgical evaluation because the resident could need more intensive care. The report further documented Resident #1 has free air under the diaphragm. Possible source is her sigmoid color per her non-contrast CT scan. It revealed the resident reports nausea and vomiting last night and generalized abdominal pain that started this morning. Further review of Hospital #3's history and physical revealed the resident was admitted for evaluation and treatment as Resident #1 had generalized abdominal pain and had a perforated abdominal bowel. Further review revealed Resident #1 had a Hartmann Procedure (bowel resection surgery) while at Hospital #3. Interview with Licensed Practical Nurse (LPN) #500 on [DATE] at 3:00 P.M. revealed she stayed over until 2:00 A.M. on [DATE]. She voiced she received report from second shift nurse who reported the resident was vomiting and [MEDICATION NAME] was given. She voiced she messaged the physician to update him, and there were orders to repeat the [MEDICATION NAME]. She voiced she gave the resident the [MEDICATION NAME] and she kept that down. She voiced she only had the resident from 10:00 P.M. until 2:00 A.M. and during this time the resident was complaining of not feeling well and felt like she had the stomach bug that she has had for about a week. LPN #500 voiced she vomited once for her and she checked her temperature and it was 99.9 degrees F. She voiced she tried to give the resident Tylenol, however, the resident didn't take it because she didn't think she could keep it down. LPN #500 voiced she again messaged the physician on [DATE] around 12:30 A.M. to update him on Resident #1 and she never heard back from the resident at the time that she had left. LPN #500 voiced she had informed the in-coming nurse, Registered Nurse (RN) #152 that she had messaged the physician, however, did not hear anything back yet. Phone interview with RN #152 on [DATE] at 3:27 P.M. revealed she came on at 2:00 A.M. on [DATE] and was told Resident #1 had a temperature of 99.9 degrees F, and that the physician had been notified. RN #152 voiced at the end of her shift the aides had reported that Resident #1 had vomited five times, however, they did not specify whether this was five times during the time she was there from 2:00 A.M. until 6:00 A.M. or during the entire shift. She voiced when she looked at the emesis in the toilet, it appeared as yellow. She voiced the resident had told her that she didn't think the [MEDICATION NAME] had helped and that her stomach was hurting. RN #152 confirmed she did not call the physician during any time during her shift to update him on the residents' status. Interview with State tested Nurse Aide (STNA) #181 on [DATE] at 8:34 A.M. revealed she worked 6:00 A.M. to 2:00 P.M. on [DATE]. She voiced Resident #1 just kept saying, help me and that she didn't feel good. STNA #181 voiced she went and told the nurse, LPN #218. She voiced the resident just wanted me to help her, because she didn't feel good. STNA #181 voiced her eyes were sunken in like she had been up all night. STNA #181 voiced she was told in report that the resident didn't feel good. Phone interview with LPN #218 on [DATE] at 9:44 A.M. revealed on [DATE] around 8:00 A.M. she had seen Resident #1 and she was holding a basin and reported that she feels the stomach medicine made it worse. LPN #218 voiced the resident was complaining of constant stomach pain, and she asked her to classify her pain. LPN #218 voiced the resident said, I just feel like something crawled in my belly and died . She voiced she had logged on to the electronic medical record and seen the physicians tiger text to send the resident out. She voiced she called the residents daughter and they said to set up transport for her. LPN #218 voiced she talked to the resident to ask her if she wanted nine-one-one (911) called or if she wanted to wait for transport and she voiced the resident was okay to wait 45 minutes to an hour. She voiced she called MTS #1 out of Greenville, Ohio for transport. She voiced she had got on and read the nurses notes and read that the resident was unable to hold anything down the previous night and it seemed to be an on-going thing. She voiced she received report from the third shift nurse who had said the aides had reported that Resident #1 had vomited liquid emesis, however, the aides flushed it and didn't let her see it. Phone interview with Physician #600 on [DATE] at 10:39 A.M. revealed the tiger text that came in on [DATE] at 12:45 A.M., about Resident #1, unfortunately this text came through in the middle of the night and when it does the text dings once on his phone and he did not awaken to it. Physician #600 voiced he would have expected the nurses to call him after the text was sent and he never responded. Physician #600 voiced if staff would have notified him on [DATE] at 12:45 A.M. of Resident #1, he would have probably told them to send Resident #1 to the ER because that was the first time she had started with pain; prior to that it was just the resident being nauseous. He voiced once the pain became an issue, that changed the situation with what was going on. Physician #600 voiced he felt bad that it went that many hours without that communication. Interview with the Director of Nursing (DON) on [DATE] at 11:05 A.M. confirmed she would have expected the staff to call the physician on [DATE] after a tiger text was sent regarding Resident #1's condition at 12:45 A.M. and there was no physician response. Interview with STNA #133 on [DATE] at 2:00 P.M. revealed she worked day shift on [DATE]. She voiced typically the resident is gotten up by third shift and is typically up before they get there. She voiced Resident #1 was not up and she was not dressed. She voiced the resident was in her recliner which was unusual for her. STNA #133 voiced the third shift aides said she had complained of her stomach being upset. STNA #133 voiced Resident #1 kept saying I don't know what to do and would say her stomach was upset. STNA #133 voiced she looked sick. STNA #133 voiced the resident just kept saying her stomach was upset. 2. Review of Resident #3's closed medical record revealed an admission date of [DATE] and a discharge date of [DATE] with [DIAGNOSES REDACTED]. during surgery. The ends of the lowest part of the small intestine is brought through this opening to form a stoma, usually on the lower right side of the abdomen), pneumonia, vascular disorder of intestine, acute kidney failure, [MEDICAL CONDITION] stage 3, hypertension (high blood pressure), type two diabetes mellitus, shortness of breath, and heart failure. Review of the Medicare 14-day MDS dated [DATE] identified the resident as having moderate cognitive impairment as indicated by a BIMS of 12. Review of the nurses notes from [DATE] until [DATE] revealed a tiger text on [DATE] at 2:09 P.M. that revealed the resident is not feeling well, and states she is having indigestion; refused breakfast and lunch. The resident is dry heaving with some mucous phlegm. She has an [MEDICAL CONDITION], but not much coming out which is not normal for resident, but possibly from decreased oral intakes, with bowel sounds active. The residents husband is concerned that the [MEDICAL CONDITION] may be obstructed. On [DATE] at 2:26 P.M. revealed the resident now just had a large emesis black/brown in color and smells like blood. The message asked if the facility could send to the resident to the ER for evaluation. The physician did not respond to this message and there was no phone call made regarding the resident change in condition. On [DATE] at 2:53 P.M. there was a tiger text to the physician that revealed the resident's husband was at the facility and wanted resident to go to the ER for evaluation and the resident was sent to ER. On [DATE] at 9:22 A.M. revealed nurses note that indicated the hospital ER nurse called and informed them the resident was being transferred for a possible [MEDICAL CONDITION] (when bleeding occurs in any part of the gastrointestinal tract), urinary tract infection and elevated potassium level. Additionally, interview with Physician #600 on [DATE] at 10:39 A.M. that when Resident #3 was having a large emesis of black/brown in color and smells of blood, and a text was sent, however, he did not respond he would have expected the staff to call him regarding this. Review of the facility policy titled Notification of Changes Policy dated [DATE] revealed the policy is the man will inform the resident, the attending physician and the resident's representative or interested family member of changes which affect the resident. It revealed the facility will inform the resident immediately, the attending physician and the resident's representative or interested family member when there is a. An accident involving the resident, which may or may not result in injury; b. A significant change in the resident's physical, mental or psychosocial status; c. A need to alter treatment significantly; d. A decision to transfer or discharge the resident from the facility. The review of the policy revealed there was no information as to when a tiger text versus a phone call to the physician was appropriate. This deficiency substantiates Complaint Number OH 005.

Based on medical record review, observations, staff interview, physician interview, interview with an Invacare representative, review of the facility's mechanical lift (Hoyer) policy, and review of the Hoyer lift manufacturer's guide for the Invacare lift, the facility failed to ensure a resident requiring transfers with a Hoyer lift was transferred safely. This resulted in Immediate Jeopardy when Resident #6 experienced actual harm during an avoidable fall from a Hoyer lift resulting in a wedge fracture of his lumbar (L) 1 vertebrae and contusion/abrasions to the right ankle. Resident #6 was placed at risk for further serious harm as the staff continued with the same Hoyer lifting techniques following the incident. This affected one (#6) of 11 residents reviewed who required a Hoyer lift for transfers. The facility identified 21 residents requiring the use of a Hoyer lift for transfers. The facility census was 97. On 05/25/16 at 4:50 P.M., the administrator, Director of Nursing (DON), Restorative Nurse #110 and Activity Director (AD) #111 were notified Immediate Jeopardy began on 05/07/16 at 1:05 P.M. when Resident #6 suffered harm when State tested Nursing Assistant (STNA) #105 and STNA #107 were providing Resident #6 with a Hoyer lift transfer from his bed to his adaptive wheelchair. The STNA's positioned the left Hoyer leg between the back wheel and the front wheel of the adaptive wheelchair and one STNA began to pull on the back of Resident #6's Hoyer sling so the resident could be positioned into the seat of the wheelchair. This pulling motion shifted the center of gravity of the Hoyer lift from side to side and the lift tipped to the left. Resident #6 fell to the floor landing on his buttocks and his back came to rest against the foot pedals on his wheelchair. Resident #6 was sent to the emergency room via Emergency Medical Squad (EMS) where he was diagnosed with [REDACTED]. STNA #109 reported a separate incident occurring on 05/21/16 when Resident #6 was being weighed in the Hoyer lift scale and then transferred to his adaptive wheelchair. STNA #109 reported when Resident #6 was being lowered into the wheelchair, the Hoyer lift began to tip but the resident was able to be lowered into the wheelchair. Resident #6 was at risk for further serious harm as the staff continued to provide Hoyer transfers using the same techniques following the L1 wedge fracture on 05/07/16. The Immediate Jeopardy was removed on 05/26/16 when the facility completed all staff in-service training regarding appropriate Hoyer lift techniques and implemented the following corrective actions: · On 05/25/16 at 5:00 P.M., the DON and Restorative Nurse #110 completed audits of the 21 residents who require a Hoyer lift to ensure there were no other injuries involving a transfer and to determine the safest method for transferring. · On 05/25/16 at 5:10 P.M., the Administrator, DON, Restorative Nurse #110, Registered Nurse (RN) #115, Licensed Practical Nurse (LPN) #116, and RN #117 began contacting all staff to complete re-education related to facility practices involving mechanical lifts. · On 05/25/16 at 5:10 P.M., the Administrator, Human Resources (HR) Coordinator #120 and Food Service Supervisor (FSS) #121 provided in-service training to all non-nursing staff instructing them that only trained nursing personnel are permitted to use the Hoyer lift. The in-service training was completed on 05/26/16 at 2:00 P.M. · On 05/25/16 at 5:10 P.M. the DON, Restorative Nurse #119, Case Manager #122, Staff Development Coordinator #123 and Minimum Data Set (MDS) nurse #125 began in-service training with nursing staff regarding appropriate Hoyer lift transfers including competency and return demonstrations. The in-service training was completed on 05/26/16 at 2:00 P.M. · On 05/26/16 between 9:10 A.M. and 10:00 A.M., interviews with STNA #115, STNA #116 and LPN #117 revealed they were provided education and responded appropriately regarding safe Hoyer lift techniques and transfers. · On 05/26/16, review of the medical records for 11 additional residents (#2, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) requiring Hoyer lifts for transfers revealed no other incidents involving inappropriate transfers. · On-going mechanical lift competencies/return demonstration will be conducted by the DON or designee of five employees a week for four weeks. Variances will be corrected immediately and findings will be reported immediately. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #6's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #6's quarterly MDS assessment dated [DATE] revealed the resident has severe cognitive impairment. Further review of the MDS revealed Resident #6 requires extensive assist for bed mobility, and requires total dependence of two or more person's physical assist for transfers. Review of the most recent plan of care revealed Resident #6 is at risk for falls related to [DIAGNOSES REDACTED], pain, difficulty following commands, decreased physical function, impaired vision, leans with poor trunk control, limitations in range of motion to left hand and lower extremities bilaterally, psychoactive medications, history of fall, resistance with care, agitated behaviors, requires mechanical lifting, and has a history of pneumonia. The care plan listed interventions including the use of an adaptive wheelchair when up with pressure reducing cushion, and Hoyer lift for all transfers. Review of Resident #6's nursing notes revealed on 05/07/16 at 1:05 P.M. Restorative Nurse #119 was called to the resident's room. Upon entering Resident #6's room, the resident was observed sitting on the floor facing the closet with his back against the foot pedals on his wheelchair, still hooked to the Hoyer lift in the Hoyer pad. The Hoyer lift had tipped over. The nurse was able to unhook Resident #6 from the Hoyer lift and the resident was assisted to lie down on the ground and was pulled away from the closet. Then, per four extensive assist, the staff Hoyer lifted Resident #6 into bed with the Hoyer pad and lift. Resident #6 complained of pain to the lower back, and no reddened areas were observed. An abrasion was noted to Resident #6's left lateral aspect of his foot with bruising started. Resident #6 yelled out in pain from his back. The physician was notified and a new order was received to send the resident to the emergency room (ER) for evaluation and treatment. On 05/07/16 at 2:00 P.M., the emergency squad was notified and at 2:05 P.M. the squad was at the facility to transport Resident #6 to the hospital. Resident #6 arrived back at the facility at 6:00 P.M. with new orders for Norco (narcotic pain medication) 5/325 milligrams (mg) for pain. and with instructions that Resident #6 is not to bend or lift. At 6:20 P.M. the ER contacted the nursing facility and reported the resident did not have a fracture to the left foot/ankle but does have a contusion and abrasions. The notes further documented Resident #6 sustained a fracture to his L1 vertebrae and was given Morphine Sulfate (narcotic pain medication) via injection at 3:03 P.M. Further review of Resident #6 ' s medical record revealed there was no documentation regarding any further Hoyer lift incidents, including the 05/21/16 Hoyer lift incident reported by STNA #109. Interview with Restorative Nurse #110 on 05/25/16 at 12:00 P.M. revealed an investigation was completed of Resident #6's fall with the Hoyer lift. The nurse stated the lift, tipped over, the nursing assistants were quite upset about the accident. They were using two assist with the Hoyer lift and it tipped. She further stated she was unaware of how the Hoyer tipped. The lift they were using was the Invacare - 400 pound Hoyer lift and the resident did not exceed the maximum weight for the lift. The interview further revealed the legs of the lift were opened which provided the appropriate wide base. The nurse further stated she completed competencies on nursing staff for Hoyer lift transfers following the incident. The facility also completed a monthly lift maintenance audit on 05/09/16 to all Hoyer lifts with no concerns noted. Interview with STNA #105 on 05/25/16 at 12:15 P.M. revealed she and another aide were completing the transfer for Resident #6 on 05/07/16 when the Hoyer tipped over. STNA #105 stated they were transferring Resident #6 from the bed to the wheelchair and the Hoyer lift legs were opened. As they began the transfer from the bed to the chair, the nursing assistant positioned the lift coming from the side of Resident #6's adaptive wheelchair, and the other nursing assistant began to pull the sling to position the resident in his wheelchair and the lift tipped over. STNA #105 stated Resident #6 was not flailing or resisting care during the Hoyer lift. STNA #105 stated Resident #6 landed on his bottom facing the door of the closet. Interview with STNA #107 on 05/25/16 at 1:30 P.M. revealed she was assisting STNA #105 with transferring Resident #6 on 05/07/16 when the Hoyer tipped over. STNA #107 stated they were transferring Resident #6 from bed to his adaptive wheelchair. STNA #107 stated the appropriate lift pad was in place. She stated the legs of the Hoyer lift were open and she began to positron the Hoyer lift coming from the side of the adaptive wheelchair. The resident was over his chair and the other aide began to pull the resident back to position him in the wheelchair which is when the lift tipped over with the resident still in the Hoyer lift. STNA #107 stated the right leg of the lift was in the air and Resident #6 landed on his bottom and his back hit the foot pedals of the lift. STNA #107 stated it happened so fast. Interview with STNA #109 on 05/25/16 at 2:00 P.M. revealed on 05/21/16 she was assisting STNA #105 and STNA #107 with weighing Resident #6 using the Hoyer lift scale. STNA #109 stated she was operating the Hoyer lift when she felt it tip a little. STNA #109 stated the Hoyer lift legs came up a little bit and the resident was already over his wheelchair so he was lowered into the wheelchair. STNA #109 stated they were coming in with the Hoyer at the adaptive wheelchair sideways during the incident. On 05/25/16 at 2:30 P.M, the DON, Administrator, Restorative Nurse #110, and STNA #108 provided a demonstration using the Hoyer lift and Resident #6's adaptive wheelchair, without the resident in the Hoyer lift or the wheelchair. The demonstration revealed during transfers the nursing assistants had the Hoyer lift legs open; however, the legs of the lift do not straddle the entire wheelchair from the front of the wheelchair, so the Hoyer was being angled between the front wheel and the back wheel of the adaptive wheelchair. The administrator demonstrated and confirmed the Hoyer lift tipped to the side when the lightest of force or pulling on the lift was shifted from side to side. Interview with STNA #108 and STNA #107 on 05/25/16 between 3:15 P.M. and 3:20 P.M. verified Resident #6's Hoyer lift legs did not straddle the resident's entire adaptive wheelchair from a front approach; therefore, the legs of the lift are brought in from the side. This allows the Hoyer legs to maneuver between the front and back wheels of the wheelchair. STNA #108 and #107 stated Resident #6's Hoyer transfer is completed with two staff members and the one aide pulls on the sling to position Resident #6 in his wheelchair which causes the weight of the lift to shift which in turn causes the lift to tip. Interview with the facility's Medical Director on 05/26/16 at 9:00 A.M. revealed he was not aware of Resident #6's fall during a Hoyer transfer. Interview with Invacare Representative (IR) #120 on 05/26/16 on 2:40 P.M. revealed the preferred method of transferring a resident into a wheelchair is to position the Hoyer lift in front of the wheelchair before lowering the resident to ensure safety. The interview with IR #120 further revealed if a leg of the Hoyer lift was caught on something, not allowing the casters to move, this would have caused the Hoyer to tip when the weight of the Hoyer shifted side to side. Review of the facility's form titled, Skill Checklist-Transferring a Resident from Bed to Chair-Invacare/Liko Lifts, dated 12/07 revealed there were no instructions for transferring a resident from the side of a wheelchair. Review of the Manufacturer's Guidelines for the Hoyer Lift, an undated manual, revealed no documentation or instructions on performing a Hoyer lift from the side of a wheelchair; however, all pictures within the manual regarding transfers depict Hoyer lifts positioning occurring from the front of wheelchairs. Furthermore, there was no documentation instructing staff to pull the Hoyer sling or shifting the weight of the Hoyer lift from side to side. Review of the facility's policy titled, Mechanical Lifts, with a revision date of 10/07 instructed staff to inspect the lift for proper operating condition and cleanliness, choose the appropriate sling for the lift, place wider seat part under resident 's thighs so lower ledge of sling and seat is under knees, place narrow part of the sling just above small of back. The policy instructed staff to move the lift with open end of horse shoe base under side of bed or toward resident being raised from a chair or floor, to keep the base legs spread at all times, if possible. This reduces the risk of the lift tipping. Attach the strap loops to the bar hooks per manufacturer's recommendation. Further review of the policy revealed, to position wheelchair, shower chair, chair or bed and lock the breaks. When resident has been lifted, grasp steering handles and move resident to the desired location. Lift brakes unlocked during the positioning. This deficiency substantiates Complaint Number OH 566.

Based on medical record review, staff interview, physician interview, review of facility policy and review of information from a Cleveland Clinic website, the facility failed to timely address a resident's ongoing diarrhea and positive results for a stool infection or ,[MEDICAL CONDITION]. difficle ([MEDICAL CONDITION]). This resulted in actual harm when Resident #155 experienced ongoing diarrhea, tested positive for [MEDICAL CONDITION] and required hospitalization for severe low potassium, low magnesium and intravenous (IV) re-hydration due to the facility's failure to follow-up with the physician regarding the resident's ongoing symptoms. This affected one (#155) of three residents reviewed for bowel related infections. The facility identified three residents in the past year with bowel related infections. Findings include: Review of Resident #155's medical record revealed the resident was admitted to the facility on [DATE] and later discharged on [DATE]. [DIAGNOSES REDACTED]. An admission care plan for incontinence of bowel and bladder dated 01/19/12 was reviewed. According to the care plan, staff was to notify the medical doctor of changes in bowel or bladder habits. Resident #155's nurses' notes dated 01/30/12 indicated the physician was in and the resident had complaints of pain in the stomach and loose stool. New orders were written by the physician. A physician order [REDACTED]. On 01/31/12, a nurses' note revealed the nurse was notified that the resident's stool culture was positive for [MEDICAL CONDITION]. On 01/31/12 a physician order [REDACTED]. The nurse also documented she was awaiting return from the physician's office regarding any further treatments. There were no further orders pertaining to the positive [MEDICAL CONDITION] results. Continued review of nurses' notes revealed on 02/01/12 at 8:00 P.M., the resident had complaints of some abdominal cramping with notation that C- Diff was present in the bowel movement (BM). On 02/02/12, the day shift nurse documented C- Diff in the BM and loose stools. On 02/03/12 to 02/06/12, the nurses' notes documented concerns pertaining to the bowels: diarrhea/ loose stools, and bowel incontinence. On 02/07/12, bowel sounds were hyperactive. On 02/10/12 at 12:00 P.M., nurses' notes documented the resident continued with diarrhea related to C- Diff. On 02/11/12 at 12:00 P.M., nurses' notes documented the resident continued to have excessive amounts of loose BM with C- Diff present. The nurse noted she would speak with the physician on Monday. On 02/12/12 at 1:30 P.M., the physician was notified of Resident #155's condition and orders were received to send the resident to the emergency room (ER) for evaluation. On 02/12/12 at 5:40 A.M., nurses' notes documented the resident was admitted for low potassium. Review of Resident #155's bowel tracking information from 01/31/12 to 02/12/12 revealed the following bowel movements (BM's): on 01/31/12, one medium/formed BM and one large/loose BM; on 02/01/12, one small/loose BM and two large/loose BM's; on 02/02/12, one small/loose BM and one medium/loose BM; on 02/03/12, one small/putty like BM, two small/loose BM's and one medium/loose BM; on 02/04/12, two small/loose BM's and one large/loose BM; on 02/05/12, one small/loose BM, one medium/loose BM and one large/loose BM; on 02/06/12, two small/loose BM's, one small/formed BM, one large/formed BM and two large/loose BM's; on 02/07/12, one small/loose BM and two large/loose BM's; on 02/08/12, two medium/loose BM's and one large/loose BM; on 02/09/12, two medium/loose BM's; on 02/10/12, one medium/formed BM and two large/loose BM's; on 02/11/12, three large/loose BM's and on 02/12/12, one large/loose BM. Review of Resident #155's history and physical (H&P) dated 02/12/12 documented the resident has been on several different antibiotics in the recent past. The H&P documented the last three weeks, the resident has been having ongoing diarrhea, about 10 to 12 bowel movements a day for the last several weeks. The patient was evaluated for [MEDICAL CONDITION] from a prior work-up at the nursing home and that further work-up revealed severe hypokalemia (low potassium) for which the resident was admitted to the hospital for progressive care for further management. The H&P documented the plan to supplement potassium and magnesium and to hydrate the patient along with other treatments. Upon admission to the hospital, Resident #155's potassium level was critically low at 2.2 (normal range is 3.5 to 5.1). A repeat potassium level continued to show a critically low level at 2.3 and the resident's magnesium level was low at 1.3 (normal range is 1.7 to 2.5). Resident #155's transfer order dated 02/20/12, from the hospital to the nursing home, documented the primary admitting [DIAGNOSES REDACTED]. According to the transfer orders, Resident #155 was to continue an oral medication used to treat [MEDICAL CONDITION] ([MEDICATION NAME] 250 mg orally every six hours for four days). Further review of Resident #155's hospital documentation revealed a CT scan of the abdomen and pelvis on 02/13/12 showed mild pericolonic inflammation reaction in the sigmoid and rectal portions of the colon probably from [MEDICAL CONDITIONS] with sigmoid divertuculosis and cholelithiasis. Review of the hospital discharge summary dated 02/20/12 noted the resident's final [DIAGNOSES REDACTED]. On 11/27/12 at 9:50 A.M., interview with Licensed Practical Nurse (LPN) #6 and Corporate Registered Nurse (RN) #9 confirmed Resident #155 tested positive for [MEDICAL CONDITION] on 01/31/12. LPN #6 stated that according to the nurses' notes on 01/31/12, the physician was notified and the facility was awaiting a response; however, there was no further documentation that the physician had responded regarding starting a treatment. LPN #6 and Corporate RN #9 confirmed the resident later needed to be admitted to the hospital on [DATE] for severe low potassium, low magnesium and for IV re- hydration as a result of continued loose stools. They state that when the nurses did not hear back from the physician, they should of attempted to call again and then due to the progressive diarrhea if the attending physician did not respond, the nurses could of went through the medical director to initiate a treatment plan for Resident #155's symptomatic [MEDICAL CONDITION]. On 11/27/12 at 1:39 P.M., interview with Resident #155's attending physician (Physician #8) verified the resident had tested positive for [MEDICAL CONDITION] on 01/31/12 and that according to the medical record at the facility, there had been no treatment implemented to correct the [MEDICAL CONDITION] or diarrhea. Physician #8 verified that on 02/12/12, the resident had further declined due to the ongoing diarrhea and required hospitalization for severe low potassium, low magnesium and to be IV hydrated. Physician #8 verified treatment for [REDACTED]. He thought the resident had been treated for [REDACTED]. The physician further stated in this circumstance Resident #155 was symptomatic (having diarrhea, loose stools and hyperactive bowel sounds) and tested positive for [MEDICAL CONDITION] which would result in a treatment plan for the [MEDICAL CONDITION]. Physician #8 further stated the discharge summary indicated Resident #155 had [MEDICAL CONDITIONS] with treatment failure as an outpatient because he thought at that time the resident had been receiving treatment for [REDACTED]. On 11/27/12 at 2:00 P.M., interview with the Director of Nursing (DON) and Corporate RN #9 verified there was no treatment implemented for Resident #155's [MEDICAL CONDITION]/diarrhea from 01/31/12 until 02/12/12, when the resident was sent to the emergency room for an evaluation regarding the prolonged diarrhea. They stated the resident was found to have severe low potassium, low magnesium and to required IV rehydration due to the prolonged diarrhea. They verified the lack of follow-up on 01/31/12 when the nurse documented she was awaiting the physician's return call regarding a treatment. They also verified the lack of follow-up and notifying the physician regarding the ongoing diarrhea. They stated if the attending physician did not return a call then the nurse would be expected to go through the medical director for a situation like this. The interview confirmed the facility has a policy and procedure regarding physician notification; however, it's not specific regarding the steps to take if the attending physician does not respond in a timely manner. On 11/27/12 at 2:06 P.M., interview with LPN #7 verified she cared for Resident #155 during her stay and during the time when she had [MEDICAL CONDITION]. LPN #7 stated the resident had C- Diff with ongoing diarrhea for around two weeks and that she remembers hearing the attending physician had been notified but not aware of a response from that physician. LPN #7 also verified there was no documentation in the record following the note on 01/31/12 that there had been any communication with the physician until 02/12/12, when the resident required hospitalization . LPN #7 stated that if the physician does not call back to the facility the nurse would be responsible to contact the attending physician again and if the attempts were unsuccessful, the nurse should go through the medical director in order to properly treat the resident. Review of the facility's policy entitled "Notification of Changes" revised 01/2012, indicated the Manor must inform the attending physician when there is a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly. Information from the Cleveland Clinic (www.clevelandclinicmeded.com) was reviewed regarding [MEDICAL CONDITION] treatment. According to the information, the most important aspect of management of [MEDICAL CONDITION] is rapid recognition of the disease and discontinuation of the inciting agent. Medical therapy for [MEDICAL CONDITION] is necessary in moderate to severe disease and surgery may be necessary for severe disease. Adequate hydration and electrolyte [MEDICATION NAME] should accompany medical and surgical therapy.