Every finding on record at Charleston Healthcare Center

Based on record review and staff interview, the facility failed to ensure the resident's orders and care plan matched for a resident ordered Nothing By Mouth (NPO) by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #56. Facility Census: 145. Findings included:Resident #56 a) On 03/31/2026 at 3:13 PM, Resident #56's medical chart was reviewed. The resident's care plan stated, NPO diet order. and Administer medications per physician orders and flush before/after medication administration per order. The residents diet order stated, NPO diet NPO texture, NPO consistency. A medication order for Norvasc Tablet was stated, Norvasc Tablet (amLODIPine Besylate) Give 5 mg by mouth one time a day for HTN. On 04/01/2026 at 1:40 PM, the Administrator confirmed the order for Nothing by Mouth (NPO), the medication ordered by mouth and the care plan for NPO. The Administrator stated, We will get that taken care of.

Based on record review and staff interview, the facility failed to update the comprehensive care plan in a timely manner following a significant change in the resident's mental capacity. This was found to be true for one (1) of three (3) residents reviewed during the long term care survey process. Resident identifier: #19. Facility census: 145.Findings included: a) Resident #19 Resident #19 had a change in her capacity to make own medical decisions on 03/02/26. Upon initial review of the resident's medical record on day one of the long-term care survey process (03/31/26), the resident's comprehensive care plan stated the resident had capacity to make her own medical decisions. Surveyor requested a copy of the care plan late afternoon on 04/01/26. Upon the surveyor's arrival at the facility the next morning, the care plan was provided. A review of the care plan documented that it had been updated on 04/01/26 to show the resident no longer has capacity. The surveyor reviewed the care plan documentation change with the Director of Nursing (DON) on 04/02/26 at 10:50 AM, showing the DON the change was made only after the surveyor requested the care plan. The DON stated, I guess there is not much I can say to defend us on this one.

Based on record review and staff interview, the facility failed to ensure an updated Preadmission Screening and Resident Review (PASRR) was completed for a resident with a bipolar diagnosis identified after admission. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #153. Facility census: 145. Findings included: Resident #153 a) On 04/01/26 at 9:26 AM, Resident #153's medical chart was reviewed. A diagnosis of Bipolar II Disorder was listed after the resident's admission to the facility in 08/2024. The diagnosis of Bipolar II Disorder was added on 04/04/2025 to the resident's diagnosis list in the medical chart. The resident's most recent Preadmission Screening and Resident Review (PASRR) dated 11/21/2024 did not have Bipolar Disorder listed or checked under Section 30 of the PASARR. On 04/01/26 at 3:30 PM, the PASSAR and diagnosis list with bipolar diagnosis date were reviewed with the Director of Nursing (DON). The DON confirmed the Bipolar II Disorder diagnosis was not listed or marked on the most recent PASARR.

Based upon record review and staff interview, the facility failed to notify the resident's representative in writing of the reason for transfer/discharge and provide a copy of the bed hold notice. This was found to be true for one (1) of four (4) resident reviewed during the long term care survey process. Resident identifier: #19. Facility census: 145. Findings included: a) Resident #19 Record review revealed Resident #19 had three (3) acute transfers in the last 120 days. These included: 01/29/26 - 02/03/26, 02/22/26 - 03/01/26, and 03/04/26 - 03/10/26. During the first two acute transfers, the resident had the capacity to make their own medical decisions. The resident was provided a notice of transfer and bed hold notice. The resident lost her capacity to make her own medical decisions on 03/02/26. On 03/04/26, the resident sustained a fall at the facility and was transferred to the hospital. The resident was provided a transfer notice and bed hold notice. However, since the resident's capacity had changed two days earlier and the resident no longer had the capacity to make medical decisions, the resident's designated representative or Power of Attorney should have been informed. This was reviewed with the Director of Nursing on 04/02/26 at approximately 10:40 AM.

Based on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was within reach. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #129 and #146. Facility Census: 145.Findings included: The facility's policy and procedure for Resident Rights stated, c. To have a method to communicate needs to staff. i. Call light or bell access will be within reach of the resident as one method to communicate needs to staff. a) Resident #129 - On 03/31/2026 at 11:10 AM, during the initial interview process, Resident #129's call light was observed on the floor. The resident was lying in bed. Nurse Aide #138 confirmed the call light was out of reach and on the floor and stated, I'll fix it and let their CNA know. Resident #129's care plan stated, Place call bell within reach, remind resident to call for assistance.b) Resident #146 On 03/31/2026 at 11:15 AM, during the initial interview process, Resident #146 reported his only problem was he wanted to get back in bed and that he had been sitting here a long time. The resident was observed sitting in his wheelchair beside the bed with his call light under his wheelchair. The resident was unable to reach his call light to obtain assistance. Nursing Aide #138 confirmed the call light was out of reach and stated, I'll take care of it and let their CNA know. Resident #146's care plan stated, Place call light within reach. Remind resident to call for assistance if cognitively intact.

Based upon Observation, staff interviews and policy, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections by not dating IV lines for Resident #108 and #60. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Resident identifiers #108, #60. Census: 145.Findings included: a) During the resident interview process performed on 03/31/26 at approximately 1:30 PM it was observed that Resident #108's IV line was not dated and was in use. The Director of Nursing and Unit manager confirmed that there was no date on the IV line. Secondary observation on 03/31/2026 at approximately 2:00PM, Resident #60 had medication running and the IV line was not labeled with date and time when two surveyors went into the room, before they (surveyors) were able to get a staff member to confirm , the nurse took down the set because the medication had finished. Interview with DON at 2:00 PM revaled the DON said I'll go look at it and get it fixed Policy named Changing IV administration Set dated 02-2009 Revision 02-2019; states that IV tubing must be changed every 24 hours. It also states Label IV tubing indicating the date and time and initials.

Based on observation and staff interview, the facility failed to provide a clean and sanitary area for storage of equipment and maintain a clean area for all kitchen equipment. This failed practice had the potential to affect all residents receiving nourishment from the facility kitchen. This was a random opportunity for discovery. Facility Census: 142.Findings Include: a) Kitchen On 11/13/25 at 10:00 AM, a 50-gallon trash can with the lid was noted with a dry white substance as well as food debris on the lid of the trash can. The trash can was sitting at the entrance of the dining room. At this time, Dietary Aide #163 was sitting in the dining room. Dietary Aide #163 was notified of the trash can being dirty. Dietary Aide #163 stated, I'll get it taken care of. At this time, the Dietary Aide #163 was asked, Is this where we enter the kitchen? The Dietary Aide stated, yes, I'll get the Manager. A tour of the kitchen began at approximately 8:50 AM. An observation in the storage area found 10-one (1) gallon-sized bottles of hand sanitizers on the bottom shelf in the storage area. The bottles of hand sanitizers had a brown dried substance all over each bottle. The Dietary Manager #164 stated, we have had those since COVID, I should have gotten rid of them. Observations in the storage area, found two (2) hotel pans and two (2) hotel pan lids on the bottom shelf with a dried white subtance on each. Two (2) 50-gallon trash cans found between the storage area and the dish room, had lids with dried food debris on top. The Dietary Manager #164 stated, we will get those cleaned. While continuing the tour of the kitchen, gnats were observed flying around the area. The drain in the floor of the dish room, was visibly wet with food debris seen. All major equipment, including the stove, oven, fryer, tilt skillet, and steam table were observed with a dried, greasy film on all areas of the equipment. The ice machine door was opened to find a dust-like substance around the inside of the lid. The drain in the floor by the tilt skillet had a wet, slimy substance which was easily observed. The floors were dirty and between the fryer and tilt skillet, the floor had a dried, black substance on it. The Dietary Manager #164 stated, we have a monthly cleaning schedule for the major equipment . but if something is found to be visibly dirty, I expect the staff to clean it up. The Dietary Manager #164 confirmed all issues found within the kitchen and the dirty trash can lid in the dining room. On 11/13/25 at approximately 11:00 AM, the Administrator and Director of Nursing (DON) were notified of the issues found in the kitchen. The Administrator stated, we don't have a specific cleaning schedule, we clean some things, after each meal, daily, weekly and monthly. The Administrator confirmed all equipment and flooring should be clean in the kitchen.

The facility failed to ensure residents maintain acceptable levels of hydration and nutrition. Resident #141, Resident #17, Resident #103, and Resident #40 did not have fresh ice water at bedside. In addition Resident #153 the facility failed to prevent avoidable weight loss. This was true for five (5) of sampled residents reviewed during a complaint survey. Resident Identifiers: #141, #17, #103, #40 and #153. Facility Census: 143. A) Access to Fresh Water An interview on the morning of 10/15/25 with the Director of Nursing and the Nursing Home Administrator it was discovered nursing provides three (3) ice water passes per day. The times of the passes are at 6:00 am, 2:00 pm and 10:00 pm. They also indicated activities do two (2) drink passes during the course of the day as well. An observation with the (DON) beginning at 3:30 pm and concluding at 4:05 PM on 10/15/25 found Resident #141, Resident #17, Resident #103, and Resident #40 did not have ice water pitchers at their bed side. The DON confirmed, night shift usually changes out the pitchers at either the 10:00 PM or 6:00 am ice water pass and then day shift will usually just refill them with ice water at the 2:00 pm ice pass. She agreed the aforementioned residents needed to have ice water at bedside and did not have any. b) Resident #153 On 10/14/25 at 1:30 PM, a record review was completed for Resident #153. The review found the resident had not been provided feeding assistance as a dependent resident for meals. The documentation of assistance given during meals from 07/2025 through 09/2025 was reviewed. The following meals were not documented as dependent: --07/15/25 at breakfast, lunch --07/16/25 at dinner --0717/25 all meals --07/18/25 all meals --07/19/25 all meals --07/21/25 all meals --07/22/25 breakfast, lunch --07/23/25 all meals --07/24/25 all meals --07/25/25 all meals --07/27/25 all meals --07/28/25 all meals --07/29/25 all meals --07/30/25 all meals --07/31/25 all meals --08/01/25 all meals --08/02/25 all meals --08/03/25 all meals --08/04/25 breakfast, dinner --08/05/25 all meals --08/06/25 all meals --08/07/25 all meals --08/08/25 all meals --08/09/25 breakfast, lunch --08/10/25 all meals --08/11/25 all meals --08/12/25 all meals --08/13/25 all meals --08/14/25 all meals --08/15/25 all meals --08/16/25 all meals --08/17/25 all meals --08/18/25 all meals --08/19/25 all meals --08/20/25 all meals --08/22/25 all meals --08/23/25 all meals --08/24/25 breakfast, lunch --08/25/25 all meals --08/26/25 all meals --08/27/25 all meals --08/30/25 breakfast --09/01/25 all meals --09/04/25 dinner The resident was noted with weight loss from the admission date of 07/14/25 through discharge on [DATE]. The weight loss was noted as 26.2 pounds. This is -15.78% of weight loss in 53 days. On 10/15/25 at approximately 1:30 PM, the Director of Nursing (DON) confirmed the meals were not documented as dependent; and, the resident was noted as dependent for meals.

Based on observation and staff interview the facility failed to ensure the resident environment was as free from accident hazards as possible. Resident #58's bed was observed with a six (6) inch gap between the footboard and the end of the mattress in addition Resident #98 was noted to be lying in bed and an aerosol spray can of Clorox Fabric Sanitizer was on the resident's overbed table. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Resident Identifier: #58 and #98. Facility Census: 143. Findings Include: A) Resident #58 During an observation on the morning of 10/15/25 Resident #58's bed was observed to have a gap at the foot board which was wide enough to pose a risk for entrapment. The facility's Registered Nurse of Clinical Operations (RNCO) confirmed there was a gap at the foot of the bed between the foot board and the mattress. The RNCO looked in Resident #58's room and no gap filler was located. The surveyor requested the Director of Plan Maintenance measure the gap between the foot board and the mattress. The gap was found to be six (6) inches wide. The Director of Plan Maintenance stated, They usually put in a gap filler when they extend the beds out for taller residents. He was asked when Resident #58's bed was extended, he stated, I don't know but I will get a gap filler right now for it. B) Resident #98 On 10/15/25 at 3:20 PM, Resident #98 was noted to be lying in bed. An aerosol spray can of Chlorox Fabric Sanitizer was on the resident's overbed table. The overbed table did not appear to be in reach of the resident. Registered Nurse (RN) #14 was immediately notified. She stated the facility does not use Chlorox Fabric Sanitizer product and stated the family must have brought it in. RN #14 acknowledged the product could be assessed by other residents entering the room, and she removed the spray can. The safety data sheet, available on-line on the Chlorox Website, stated as follows: May cause irritation of respiratory tract. Causes serious eye irritation. Causes skin irritation. Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea. Resident #98's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 08/29/25 showed the resident's Brief Interview for Mental Status (BIMS) score could not be determined because the resident was rarely understood. The resident did not have capacity to make medical decisions. On 10/16/25 at 9:42, the Director of Nursing (DON) stated there was no written documentation the resident's family had been notified of products that could not be brought into the facility.

Based on observation, record review and staff interview, the facility faild to ensure pressure ulcer assessment and treatment in a timely manner. The facility also failed to ensure pressure ulcer prevention measures were put into place. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for the care area of pressure ulcers. Resident Identifiers: #152, #40, and #. Facility census: 143. Findings included: A) Resident #40 Review of Resident #40's comprehensive care plan showed the following focus, Preventative: [Resident] is at risk for pressure ulcers/injuries related to decreased mobility (dementia/TBI [traumatic brain injury], incontinence of B&B [bowel and bladder] function, HDL [hyperlipidemia], HTN [hypertension]. History of scratching self. [Resident] will hit and bang on walls, his chair, over the bed table and has the potential for bruising. The focus was initiated and revised on 01/16/23. An intervention initiated on 01/16/23 and revised on 03/06/23 was to Encourage and assist with floating heels as resident will allow/tolerate. Floating heels involves elevating a patient's heels off a surface, such as a bed with a pillow, to prevent pressure injuries. Resident #40 had diagnoses of traumatic brain injury, contracture of the left ankle, functional quadriplegia, and hemiplegia affecting left nondominant side. Review of Resident #40's most recent Braden assessment for pressure ulcer risk completed on 08/19/25 showed the resident was at a low risk for pressure ulcer development. On 10/15/25 at 3:26 PM, Resident #40 was noted to be lying in bed. His heels were not floated. On 10/15/25 at 3:43, Unit Manager Registered Nurse (UM RN) confirmed Resident #40's heels were not floated. She stated the resident spent a lot of time out of bed in a chair. On 10/16/25 at 8:49 AM, Resident #40 was again noted to be lying in bed. His heels were not floated. When questioned about why the resident's feet were not floated, Nursing Assistant (NA) #111 used a pillow on the resident's bedside table to float his feet. NA #111 stated the resident usually moved his right foot off of the pillow but he was unable to move his left foot. Resident #40 appeared to tolerate having his feet floated. B) Resident #152 Review of Resident #152's medical records showed the resident was admitted to the facility on [DATE]. The nursing admission evaluation completed by the Licensed Practical Nurse (LPN) on 01/19/25 noted a blackened area to the resident's left toe. The first assessment of the left toe skin condition was performed on 01/20/25. The wound was described as unstageable pressure ulcer, measuring 1.5 centimeters (cm) x 1.4 cm x 0 cm. Skin prep to the left great toe pressure injury twice a day was ordered on 01/20/25. On 10/16/25 at 9:45 AM, the Director of Nursing (DON) was interviewed regarding Resident #152's pressure ulcer not being assessed and having treatments ordered upon admission. The DON stated the LPN performing the resident admission should obtain pressure ulcer treatment orders. The DON stated that LPNs do not stage pressure ulcers so this should be performed by a Registered Nurse shortly after admission. C) Resident #153 On 10/15/25 at approximately 1:40 PM, a review was completed regarding the skin integrity interventions in place for Resident #153. The resident was noted with a deep tissure injury (DTI) to the right heel on 08/18/25. The skin integrity interventions were not put in place until 08/18/25 after the DTI was found. The following interventions were added: --Heels floated as resident allows --Turn and reposition schedule On 10/15/25 at approximately 3:00 PM, the DON confirmed the interventions were not added to the care plan until 08/18/25. The DON confirmed the DTI to the right heel was in-house acquired.

Based on record review and staff interview the facility failed to ensure Resident #152's recommendations from a hospital stay were followed up on with the attending physician. The discharge summary indicated the resident should have a BMP (Basic Metabolic Panel) and CBC (complete blood count) in one week from the date of discharge. This labs were not obtained nor was there evidence this was addressed with the attending physician to see if they wanted the lab work to be obtained or not. This was true for one (1) of residents reviewed during the complaint survey. Resident Identifier: #152. Facility Census: 143. Findings Included: a) Resident #152 A review of Resident #152's medical record found the resident was readmitted from the hospital on [DATE]. A review of the hospital discharge summary associated with this readmission found the following, Pending Labs and studies: BMP CBC in one (1) week. In the afternoon on 10/15/25 the Interim Director of Nursing (DON) was asked to provide the results of the BMP and CBC the hospital recommended be obtained in one (1) week. After reviewing the electronic medical record (EMR) she stated, I know why we did not get that. It was on the discharge summary and not the discharged instructions. She further stated, the nurses are trained to look at the discharge instructions and not the summary. The DON was then asked if the physician had addressed the recommendation for a BMP and CBC, she confirmed they had not.

Based on record review and staff interview, the facility failed to provide activities of daily living (ADLs) for a dependent resident, #153. The ADLs included feeding assistance as well as showers or baths. This was true for one (1) of 18 residents reviewed during the survey process. Resident Identifier: #153. Facility Census: 143. Findings Include:a1) Resident #153On 10/14/25 at 1:30 PM, a record review was completed for Resident #153. The review found the resident had not been provided feeding assistance as a dependent resident for meals. The documentation of assistance given during meals from 07/2025 through 09/2025 was reviewed. The following meals were not documented as dependent:--07/15/25 at breakfast, lunch--07/16/25 at dinner--0717/25 all meals--07/18/25 all meals--07/19/25 all meals--07/21/25 all meals--07/22/25 breakfast, lunch--07/23/25 all meals--07/24/25 all meals--07/25/25 all meals--07/27/25 all meals--07/28/25 all meals--07/29/25 all meals--07/30/25 all meals--07/31/25 all meals--08/01/25 all meals--08/02/25 all meals--08/03/25 all meals--08/04/25 breakfast, dinner--08/05/25 all meals--08/06/25 all meals--08/07/25 all meals--08/08/25 all meals--08/09/25 breakfast, lunch--08/10/25 all meals--08/11/25 all meals--08/12/25 all meals--08/13/25 all meals--08/14/25 all meals--08/15/25 all meals--08/16/25 all meals--08/17/25 all meals--08/18/25 all meals--08/19/25 all meals--08/20/25 all meals--08/22/25 all meals--08/23/25 all meals--08/24/25 breakfast, lunch--08/25/25 all meals--08/26/25 all meals--08/27/25 all meals--08/30/25 breakfast--09/01/25 all meals--09/04/25 dinnerThe resident was noted with weight loss from the admission date of 07/14/25 through 09/05/25. The weight loss was noted as 26.2 pounds.On 10/15/25 at approximately 1:30 PM, the Director of Nursing (DON) confirmed the meals were not documented as dependent; and, the resident was noted as dependent for meals.a2) Resident #153On 10/15/25 at approximately 2:15 PM, a record review was completed for Resident #153. The resident was noted as totally dependent for showers and baths. The review found the resident did not receive a shower or a bed bath between the dates of 07/26/25 through 08/06/25. This is ten days. Also, the resident did not receive a shower or a bed bath between the dates of 08/13/25 through 08/20/25. This is seven (7) days.On 10/15/25 at 3:00 PM, the DON confirmed the resident was dependent for showers and baths; and, on two (2) different occasions the resident did not receive a shower or bath.

Based on record review and staff interview, the facility failed to implement the care plan regarding the amount of feeding assistance needed as well as develop and implement impaired skin integrity interventions for Resident #153. This was true for one (1) of 18 residents reviewed during the survey process. Facility Census: 143.Findings Include:a1) Resident #153On 10/14/25 at 1:30 AM, a record review was completeid for Resident #153. The review found the care plan had not been implemented regarding feeding assistance. The resident was noted as totally dependent of staff x 1 (one) for eating. The documentation of assistance given during meals from 07/2025 through 09/2025 was reviewed. The following meals were not documented as dependent:--07/15/25 at breakfast, lunch--07/16/25 at dinner--0717/25 all meals--07/18/25 all meals--07/19/25 all meals--07/21/25 all meals--07/22/25 breakfast, lunch--07/23/25 all meals--07/24/25 all meals--07/25/25 all meals--07/27/25 all meals--07/28/25 all meals--07/29/25 all meals--07/30/25 all meals--07/31/25 all meals--08/01/25 all meals--08/02/25 all meals--08/03/25 all meals--08/04/25 breakfast, dinner--08/05/25 all meals--08/06/25 all meals--08/07/25 all meals--08/08/25 all meals--08/09/25 breakfast, lunch--08/10/25 all meals--08/11/25 all meals--08/12/25 all meals--08/13/25 all meals--08/14/25 all meals--08/15/25 all meals--08/16/25 all meals--08/17/25 all meals--08/18/25 all meals--08/19/25 all meals--08/20/25 all meals--08/22/25 all meals--08/23/25 all meals--08/24/25 breakfast, lunch--08/25/25 all meals--08/26/25 all meals--08/27/25 all meals--08/30/25 breakfast--09/01/25 all meals--09/04/25 dinnerOn 10/15/25 at approximately 1:30 PM, the Director of Nursing (DON) confirmed the meals were not documented as dependent and the care plan was not implemented.a2) Resident #153On 10/15/25 at approximately 1:40 PM, a review was completed regarding the skin integrity interventions in place for Resident #153. The resident was noted with a deep tissure injury (DTI) to the right heel on 08/18/25. The skin integrity interventions were not put in place until 08/18/25 after the DTI was found. The following interventions were added:--Heels floated as resident allows--Turn and reposition scheduleOn 10/15/25 at approximately 3:00 PM, the DON confirmed the interventions were not added to the care plan until 08/18/25. The DON confirmed the care plan had not been developed and implemented regarding the skin integrity interventions.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. For one (1) of three (3) residents reviewed for the care area of pressure ulcers, the wound nurse practitioner's note documented the wrong treatment being used. Resident Identifier: #152. Facility census: 143.Findings included:a) Resident #152Review of Resident #152's physician's orders showed an order written on 01/20/25 for skin prep to left great toe pressure injury. The order continued through the resident's discharge from the facility.The resident's medical records documented an allergy to betadine. Wound Nurse Practitioner (NP) #173 assessed the wound weekly and made treatment recommendations. On 01/23/25, 02/04/25, and 02/10/25, NP #173 indicated the resident's left great toe pressure ulcer was being treated with betadine. Beginning 02/19/25, NP #173 correctly indicated the pressure ulcer was being treated with skin prep. On 10/16/25 at 9:45 AM, the Director of Nursing (DON) confirmed NP #173's weekly treatment recommendations on 01/23/25, 02/04/25, and 02/10/25 incorrectly indicated Resident #152's pressure ulcers were being treated with betadine, to which the resident had an allergy.

Based on record review and resident and staff interviews, the facility failed to make orthopedic appointments as directed, provide transportation to appointments, obtain documentation from appointments, and follow directions from those appointments to prevent contractures in Resident #88's left arm and hand following a fall at the facility. The State Agency (SA) determined physical harm was caused to Resident #88 when the resident developed contractures in her upper left arm and hand following a fall at the facility. The failure to schedule a follow up appointment with Resident #88's orthopedic doctor in a timely manner, provide transportation, obtain the documentation sent from the appointments, and follow the recommendations from the appointments, resulted in the resident developing contractures in her left arm and hand. This will be cited at past non-compliance due to the facility identifying and correcting the issue on 08/04/23. The facility also failed to administer anticonvulsant and narcotic pain medications, as ordered by the physician to Resident #105, # 51, #79, #494, #93, #75, #64, #23, #101, #3, #60, #48, #495, #52, #91. This will also be cited as past noncompliance. Resident identifiers: #88, #105, #51, #79, #494, #93, #75, #64, #23, #101, #3, #60, #48, #495, #52, #91. Facility census: 145. Findings include: a) Resident #88 At approximately 1:57 PM on 10/28/2024, an interview was conducted with Resident #88. During the interview, the resident was asked about the range of motion in her left arm, due to a fall suffered in the facility on 05/24/2023. During the interview, Resident #88 stated she had fallen out of bed while a Nurse Aide (NA) was providing care to her. She states she broke her upper arm because of the fall. Resident #88 proceeded to state I have a hard time using my hand now. It ' s hard to use it to eat. At this time, Resident #88 took her left hand out from under her blanket and held it up. Resident #88's left hand was observed to be contracted. At approximately 3:00 PM on 10/29/2024, a review of the Facility reported incidents related to this fall were reviewed. During this review, it was determined the facility did not schedule the follow up appointment for the resident as advised, did not provide transportation to the appointments as needed, and did not ensure all documentation was obtained from the doctor's office, resulting in the resident not getting the treatment she needed, resulting in the development of contractures of her left arm and hand. When the resident went to the orthopedic appoinment on 06/29/24 the facility did not receive follow up information regarding the range of motion exercices recommended by the orthopedist. The facilities narrative of their investigation reads as follows: On May 24, (Resident #88's name) sustained a fracture of her left humerus because of a fall. (Resident #88's name) returned to the facility the same day with orders to follow up with ortho in 1-2 weeks. The appointment was not made until 06/09/23 for 06/29/23. The facility obtained documentation from that consult with the follow up appointment date only. No consult report was returned to the facility following this appointment. (Resident #88's name) should have had the next follow up appointment with orthopedics on 07/13/23. The facility did not ensure that this appointment was completed for (Resident #88's name) due to failing to ensure transportation was arranged. On 8/2/23, occupational therapy identified that (Resident #88's name) had contractures noted to left upper extremity and hand. (Resident #88's name) Had an immobilizer ordered but after investigation it was determined that she frequently was non-compliant with allowing the application of the immobilizer. It was further discovered that the initial orthopedics appointment recommendation was made for range of motion exercises. The facility failed to ensure that this consult documentation was received after the appointment on 06/29/24. As a resultand Resident #88 had not been receiving this range of motion. As a result of the investigation, the facility substantiated neglect as the facility failed to ensure needed follow up for Resident #88. At approximately 12:00 PM on 10/30/2024, an interview was conducted with the Administrator and Director of Nursing (DON). During the interview, the Administrator and DON acknowledged the facility failed to ensure a follow up for Resident #88 after the fall. The administrator and DON then supplied the plan the facility put into place to correct the issue. Education was conducted with the person in charge of scheduling appointments (Medical Records Coordinator) for residents, to ensure they were made in a timely manner and they returned with all of the follow up documentation. Education was also completed with the nursing staff. Furthermore, the DON revealed she has implemented a process to ensure all appointments are completed and documentation has returned with the resident. The policy is as follows: 1. Appointments are placed on the communications tab. 2. Nursing checks appointments and reviews them daily in stand up for the day. 3. Nursing reviews appointments in stand-down to ensure our notes and return notes are completed with any follow up. 4. Any appointment that has not returned before stand-down goes onto the next day follow-up sheet. 39043 c) On 06/15/24, the facility reported an incident to the Office of Health Facility Licensure and Certification (OHFLAC) that occurred on 06/14/24 and was discovered on 06/15/24. Licensed Practical Nurse (LPN) #195 had failed to administer bedtime medications for Residents #105, #51, #79, #494, #93, #75, #64, #23, #101, #3, #60, #48, #495, #52, and #91. This was past non-compliance that began on 06/14/24 and ended 06/29/24. The incident was investigated by the facility. The five (5) day follow-up report submitted to OHFLAC verified the allegation of failure to administer medications. The medications that were identified as not given were anticonvulsants and narcotics. The physicain was contacted and did not order the missed dose to be given. Pain assessments were also done and residents did not appear to have been affected by the missed dose. The written statement by LPN #55 on 06/15/24 stated as follows: On 06/14/24 7p-7a shift I worked with [LPN #195]. She was assigned to B Hall cart. [LPN #55] was unable to log into the computer (PCC) around 5:30 am on 6/15/24. She asked to use my username and password to give her morning meds. I refused and gave her the phone number for IT help in resetting her password. [LPN #55] never reset her password and I realized she did not start morning med pass yet. I asked if she needed help and she gave me her med cart keys and I realized our residents wouldn't have morning meds. Upon starting B Hall med pass I noticed pill packets for 6/14/24 times 2100 and 2200 [9:00 PM and 10:00 PM] unopened on multiple residents. I called the on-call nurse [Registered Nurse #97] and explained the situation. I completed all 6:00 rx [prescription] med pass and reported the situation to the oncoming nurse as well. (Typed as written.) The verbal statement by LPN #195 taken by the Director of Nursing on 06/16/24 stated as follows: I do not know what happened. I thought I gave all of the medications. It was a busy night but uneventful. The physician was notified regarding the omitted medications. The medications were to be given at the next scheduled dose. Change in condition forms with assessments were completed for all residents with omitted medications. All these residents were assessed for adverse consequences, which included vital signs and assessment for pain levels and behaviors. Frequent assessments for these residents continued through 06/18/24. No resident was found to have experienced harm. All medications, including controlled substances, were accounted for. Interviewable residents were interviewed and reported no pain or other adverse consequences. LPN #195's employment was terminated. All other nurses received education on medication administration. The education was completed for all nurses on 06/29/24. The education followed the facility's policy and standard procedure titled Medication Administration, with no implementation given. The education included, but was not limited to, observing the five (5) rights of giving medication, to administer medications within the time frame of one hour before and up to one hour after the time ordered, and documentation of medication within accepted standards of nursing practice. On 10/30/24 at 1:00 PM, the DON was interviewed regarding the matter. She stated the day shift nurse found the evening pill packets in the cart and realized the meds had not been given. LPN #195 was interviewed and stated she thought she had given all the medications. The DON stated LPN #195 had signed out all the omitted medications on the Medication Administration Record (MAR). She stated LPN #195's employment was terminated and she had not worked any shifts at the facility after this incident. The DON stated she was performing daily MAR audits before this incident and the audits continued after this incident. The MAR audits are ongoing. The following nurses were interviewed on 10/30/24 and were able to correctly state five (5) rights of medication administration as well as the time frame for medication administration and the correct documentation for medication administration. - LPN #153 at 12:30 PM - LPN #95 at 12:35 PM - LPN #84 at 1:28 PM - LPN #54 at 1:41 PM Resident #105 was interviewed on 10/30/24 at 1:33 PM and had no complaints about medication administration. Resident #23 was interviewed on 10/30/24 at 1:38 PM and no complaints about medication administration. No further information was provided through the completion of the survey.

Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. These were random opportunities that had the potential to affect more than a limited number of residents. Resident identifiers: #132 and #130. Facility census: 145. Findings included: a) On 10/30/24 at 10:02 AM an inspection of the laundry room was made with the Assistant Executive Director accompanying the survey. In the dirty area of the laundry room, where dirty laundry was brought and sorted, five (5) mop heads were noted to hanging on hooks. Laundry room worker #176 stated the mop heads were clean. She stated they could not go into the dryer so they had been hung there to dry after washing. She stated she realized clean items should not be drying in the dirty laundry area, but that she did not have anywhere else to hang them. 45173 b) Resident #132 On 10/30/24 at 8:55 AM, an observation of Licensed Practical Nurse (LPN) #153 was made during medication administration for Resident #132. LPN #153 dropped four (4) pills on the medication cart with no barrier in place. The medication dropped was Eliquis (blood thinner), Losartan Potassium (high blood pressure, and two (2) Lasix (diuretic) pills. At this time, LPN #153 went to the medication room to retrieve the new medication. On 10/30/24 at 9:05 AM, LPN #153 returned to the medication cart and dropped one (1) of the Lasix pills on the barrier; however, LPN #153 picked the pill up with a bare hand and placed the pill in the medication cup. After Surveyor intervention, LPN #153 stated, I didn't realize I did that .I'll get some new medication to replace these. On 10/30/24 at 9:08 AM, Unit Manager (UM) #148 was notified. UM #148 stated, okay .thank you for letting me know. On 10/30/24 at approximately 2:30 PM, the Director of Nursing (DON) was notified. The DON stated, I'm sure she was nervous .but she shouldn't have picked up the pill with her bare hand. 49650 c) Resident #130 During a tour of the facility on 10/28/24 at 11:35 AM it was identified that Resident #130's breathing treatment with mouth piece was observed to be still connected to oxygen and laying on the bedside chair without a protective barrier for infection control. During an interview with Registered Nurse RN #158 on 10/28/24 at 11:40 PM, RN #158 stated that the respiratory therapist had just been in there and turned off the treatment. Stated that the therapist should have placed the mouth piece back inside the bag.

Based on record review and staff interview the facility failed to ensure residents had care plans developed for as of area of concern. Resident #68 had suffered fluid volume depletion and did not have a care plan focus area for dehydration. Resident identifier: #68. Facility census: 145. Findings included: a) Resident # 68 During the initial interview on 10/28/24 at 12:47 PM, Resident #68 stated, I don't drink the water here. I drink coffee with each meal and I eat Ice chips. They don't always bring me my ice chips. They are getting a little better since I had that intravenous (IV) to get fluids. Further record review of Resident #68's diagnoses revealed that Resident #68 was diagnosed with a Urinary Tract Infection (UTI) on 09/06/24 that was resolved on 10/05/24. The Hydration risk evaluation dated 10/09/24 did not indicate that Resident #68 had a history of UTI, which would put her at a higher risk for dehydration. Further record review of Resident #68's diagnosis revealed a diagnosis of depression. The Hydration risk evaluation dated 10/09/24 does not indicate that Resident #68 had depression, which would put her at a higher risk for dehydration. A record review on 10/29/24 at 11:15 AM of Resident #68's progress notes, revealed a nurses note dated 10/01/2024 reads as follows: Received new order to infuse 2 liters of normal saline (NS). Fluid volume depletion. All parties aware Further record review revealed that there is no care plan in place for dehydration or for at risk of dehydration. During an interview on 10/29/24 at 2:10 PM, The Director of Nursing (DON) confirmed that risk for dehydration was not on Resident #68's care plan. 49650

Based on observations and staff interviews the facility failed to make sure call light was accessible to Resident #120. This was a random opportunity for discovery during the Long-Term Care survey. Facility census: 145. Resident identifier: #120 Findings included: a) Resident #120 During the initial facility tour on 10/28/24 around 11:45 AM the surveyor observed Resident #120 lying in bed with head elevated, the call light was not within reach of Resident #120. The call light was hanging between the headboard and the mattress. As the surveyor exited the room, the staff entered the room. Further observation on 10/28/24 around 12:15 PM of Resident #120 laying in the bed after staff left the room revealed the call light was still hanging on the headboard not within reach to Resident #20. An interview with Unit Manager Registered Nurse (UMRN)# 50 on 10/28/24 at approximately 12:20 PM confirmed the call light was not within reach for Resident #120. On 10/29/24 at approximately 9:00 AM the Administrator provided a copy of the facility policy. On page two (2) procedure one (1) Section C stated the following: To have a method to communicate needs to staff 1. Call light or bell access will be within reach of the resident as one method to communicate needs to staff.

Based on record review and staff interview, the facility failed to complete a thorough investigation of a reported incident and identify an allegation of neglect. The facility did not follow physician's orders for Resident #122. This was true for 1(one) of 4 (four) residents reviewed for abuse and neglect. Resident identifier #122. Facility Census 145. Findings included: a) A review of the incident report, investigation and five day-follow-up that occurred on 06/16/24 for Resident #122 revealed the following: Resident # 122 was found in her room with chopped up fruit in her bed by a nurse aide. The resident's brother later reported to the nurse that he had Resident #122 laughing and spitting up chunks of fruit. There was a spoon and empty fruit cup on the floor beside her bed on 06/16/24. There were (3) three witness statements collected. Witness statements were collected from the nurse aide and Licensed Practical Nurse (LPN) #52 and the assistant cook. The Assistant [NAME] reported that a nurse called and asked for scrambled eggs for Resident #122 on 06/17/24 and she made them without checking the resident's diet card. The facility did not substantiate the allegation per five-day follow-up. No further documentation was provided. b) A review of Resident #122's records on 10/30/24 at 12:05 PM revealed the following: Diagnoses: Hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphasia requiring feeding tube, apraxia following cerebral infarction. Physician's orders: Start date 1/08/24- Nothing By Mouth (NPO) diet, NPO texture, NPO Consistency for diet type Start date 6/17/24, Puree texture, thin liquids consistency, pleasure tray diet type Nurses Notes- 6/16/2024 6:00 pm: Physician order not followed related to diet. All parties aware. Nurses Note 6/17/2024 12:17 pm: New order obtained per speech therapy, upgrade diet pureed texture, thin liquids for pleasure feeding. All parties aware. c) During an interview on 10/30/24 at 1:30 PM, the Director of Nursing (DON) stated, The investigation was pertaining to the fruit. We did not substantiate it because we feel her brother brought in the fruit. No staff said that they brought in the fruit. She did not get the eggs. (name) the nurse called down and got eggs for another resident. The statement from the kitchen came into play because we just called the kitchen and said 'Did anyone call down and get extra food and they said (name) did for (Resident #122). The kitchen had the person mixed up. (name) is not working today. If you need her number, I can get it for you. There was no evidence of the information provided by the DON in the investigation provided by the facility. When the surveyor reviewed the investigation provided by the facility it appeared that the resident had received eggs and the resident's physician orders stated she was NPO.

Based on record review, resident interview, and staff interview the facility failed to honor Resident #68's choices in their preference to only have female caregivers. This failed practice was found true for (1) one of (9) nine residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier: #68. Facility Census: 145. Findings include: a) Resident #68 During an interview on 10/29/24 at 1:00 PM, Resident #68 stated, I don't like it when the guys come in to take care of me, I won't let them. Record review on 10/29/24 at 2:15 PM, for Resident #68 revealed a care plan that reads as follows: Residents prefers female caregivers. A record review on 10/29/24 at 4:30 PM of the Daily Assignment sheets for EB2 indicated that Resident #68 had a male Nursing Assistant (NA) assigned to her on 10/08/24, 10/09/24, 10/15/24, and 10/23/24. During an interview on 10/29/24 at 4:40 PM, the Director of Nursing (DON) stated, She usually doesn't like male caregivers, but she will tolerate (NA #44 named). We do the assignments by seniority. So he typically gets the assignment that is left, which is usually that assignment. During an interview on 10/30/24 at 11:15 AM, Resident #68 stated, (NA #44 named, is assigned to me a lot. I tell him you are not taking care of me.

Based on record review and staff interview the facility failed to put interventions in place to prevent avoidable pressure ulcers. In addition, the facility failed to identify and treat pressure ulcers once developed. This resulted in actual harm for Resident #338. Resident Identifier: #338. Facility Census 142. Findings included: a) Resident #338 Record review revealed Resident #338 was transported from the facility to the [CONDITION(S)] center on [DATE]. The [CONDITION(S)] center sent the resident to the hospital. Medical record review found a form titled, Weekly Licensed Nurse Skin Evaluation dated, [DATE] which read as follows: A. Skin/Check Evaluation 1. If any of the following questions are checked 'yes' indicate on the body outline. 1a. Any reddened areas that remain after 30 minutes of pressure reduction? 1) Yes 2) No 1aa. If yes indicate location/description: ---This was blank--- 2a. Any rashes? 1) Yes 2) No 2aa. If yes indicate location/description ---This was blank--- 3a. Any bruises? 1) Yes 2) No 3aa. If yes indicate location/description ---This was blank--- 4a. Any opened [CONDITION(S)], cuts, lacerations. or skin tears? 1) Yes 2) No 4aa. If yes indicate location/description. ---This was blank--- 5a. Any blisters? 1) Yes 2) No 5aa. If yes indicate location/description. ---This was blank--- 6a. Any existing ulcers (previously identified)? 1) Yes 2) No 6aa. Any new ulcers? 1) Yes 2) No 6aaa. If yes indicate location/description. ---This was blank--- 7a. Excessively dry or flaky skin? 1) Yes 2) No 7aa. If yes indicate location/description. ---This was blank--- 8a. Nursing Note: Weekly skin assessment completed. No new skin issues noted. Noted lesion to right heel and noted redness to buttocks is not new. Treatments already in place. Signed by Registered Nurse # 122. Dated [DATE]. A review of the medical record found treatment orders as follows: *Cleanse bilateral buttock with skin cleansing lotion. pat dry, Apply Chamosyn every shift and night. *Cleanse groin with skin cleansing lotion, pat dry, apply antifungal powder every shift and night. *Apply [MEDICATION(S)] Cream to lesion on right heel every shift. A nursing note written by Licensed Practical Nurse # 270 (former employee) on [DATE] at 3:47 AM: Resident has BIL (bilateral) laceration type wounds to inner thigh resulting from resident digging herself with her fingernails. ABD pads placed for protective measures, but resident refuses any creams to be applied. Resident has been digging places on her buttock with her fingernails as well. Resident refuses to let staff cut her fingernails. Review of the medical record found no evidence indicating the attending physician was notified of the resident's behaviors and noncompliance with treatment. There was no further evidence found in the medical record regarding Resident # 338's skin condition. A review of the admission assessment forms completed by the hospital at the time time of arrival on [DATE] found the following pressure ulcers: Wound #1 Thigh left, right circumferential Type of wound: Pressure Ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury (DTI) Wound length: 24 cm (centimeters) Wound width: 8 cm Color Purple Wound #2 Thigh Left Anterior Type of wound: Pressure ulcer Present on admission: [DATE] Pressure Ulcer stage: III Wound length: 4cm Wound width: 0.5 cm Wound #3 Buttock left Type of wound: Pressure ulcer Present on admission: [DATE] Pressure ulcer stage: II Wound length: 6 cm Wound width: 5cm Wound #4 Coccyx Type of wound: Pressure Ulcer Present on admission: [DATE] Pressure Ulcer stage: II Wound length: 2,5 cm Wound width: 1 cm Wound #5 Buttock Right Type of wound: Pressure Ulcer Present on admission: [DATE] Pressure ulcer stage: II Wound length: 7.8 Wound width: 5 cm Wound #6 Thigh right posterior upper Type of wound: Pressure Ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury Wound length: 4 cm Wound width: 8cm Color: purple Wound #7 Thigh right middle posterior Type of wound: Blister, Pressure Ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury Wound length: 4 cm Wound width: 9 cm Wound #8 Right ankle posterior Type of wound: Pressure ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury Wound length: 1.5 cm Wound width: 0.5 Wound #9 Right ankle lateral Type of wound: Pressure Ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury Wound length: 2 cm Wound width: 0.5 cm Wound #10 Right heel Type of wound: Pressure ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury Wound Length: 3 cm Wound width: 3 cm Wound #11 Left heel Type of wound: Pressure ulcer Present on admission: [DATE] Pressure ulcer stage: Deep Tissue Injury Wound length: 3 cm Wound width: 3 cm During an interview on [DATE] at 11:00 AM, Registered Nurse (RN) # 75 stated this happened before the facility developed a wound care team. She went on to say that the facility knew they had a problem at that time with inaccurate documentation on the weekly skin assessments. RN #75 and the Administrator had no further comments. Resident # 338 was admitted to the local hospital on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 338 expired on [DATE] from [CONDITION(S)].

Based on record review, staff and resident interview, and observation, the facility failed to consistently provide pain management, attempt non-pharmacological interventions, document the location of the pain, and the severity of pain in accordance with the physicians' orders for Resident #3. This failure resulted in actual harm for Resident #3. For Resident #99, the facility failed to rate the resident's pain before administering an as needed (PRN) pain medication. In addition, the facility administered pain medication when the resident indicated there was no pain. For Resident #340 the facility failed to document non-pharmacological interventions attempted, failed to document the location of pain, and failed to document the administration of narcotics signed out on two (2) occasions. These findings were a random opportunity for discovery. Resident identifiers: #3, #99, #340. Facility census: 142. Findings included: a) Resident #3 Observation During initial tour of the long-term care facility on 08/02/21 at 11:28 AM, Resident #3 stated she is always in pain and said, I got one (pain medication) coming now should be time for it. At that time the Resident rated her pain level at a seven (7) on a one (1) to ten (10) pain scale with 10 being the most severe. The Resident was noted to be rubbing her left leg during interview, grimacing with slightly reddened face, and crying. Resident stated she had an old leg fracture on the left side and that caused her leg and hip pain constantly, sometimes keeping her awake at night. Resident stated she gets pain medication every 6 hours and she used to get them every 4 hours, but they changed it and she can't get anyone to talk to her about why. The Resident stated again, I am always in pain. Resident stated, Sorry to be 'weepy, but that's what I do when I hurt. The Resident rubbed her lower stomach and stated, I also have a terrible problem with my bowels and being constipated, it's a constant battle and so uncomfortable. At 11:30 AM on 08/02/21, the surveyor informed Licensed Practical Nurse (LPN) #239, in the B hallway outside the residents room, the resident was having pain. LPN #239 stated That resident (Resident #3) is on Hall A med cart, I don't have her I have Hall B Med Cart. Her meds are given from Hall A med cart. Surveyor located medication cart for hall A occupied by LPN #44, and informed LPN #44 Resident #3 was crying in pain and requested a pain pill. LPN #44 stated, Yea she does that, I will be giving it soon, she is scheduled to have it at noon. Record Review Record review of Resident's active orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents Medication Administration Record (MAR) for May of 2021 indicated the scheduled pain medication, ([MEDICATION(S)] Tablet 7.5-325 mg ([MEDICATION(S)]-acetaminophen) to be given every six hours), doses were omitted on the following dates: May 2021 - 5/05/21 - 6:00 PM dose omitted. 5/13/21 - 6:00 AM dose omitted. 5/14/21 - 6:00 AM dose omitted. 5/24/21 - 6:00 PM dose omitted. Review of Residents Medication Administration Record (MAR) for May 2021 indicated the scheduled pain assessment was not adequately performed for the entire month of May. The pain assessment was to be completed every day and every evening shift, with question of Is Resident currently experiencing pain? 1 = yes, 2 = no. A check mark and staff initials were entered in the box for each shift (7a-7p, 7p-7a) daily, with only an X in the box where the numeric indication if Resident reported pain (1 yes, 2 no pain) should be noted. Review of Residents Medication Administration Record (MAR) for June of 2021 indicated the scheduled pain medication, ([MEDICATION(S)] Tablet 7.5-325 mg ([MEDICATION(S)]-acetaminophen) to be given every six hours), sixteen (16) doses were omitted on the following dates: June 2021 - 6/05/21 - 6:00 PM dose omitted. 6/07/21 - 6:00 PM dose omitted. 6/09/21 - 6:00 PM dose omitted. 6/10/21 - 6:00 AM dose omitted. 6/13/21 - 12:00 PM and 6:00 PM doses omitted. 6/23/21 - 6:00 PM dose omitted. 6/24/21 - 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM doses omitted. 6/25/21 - 12:00 PM, and 6:00 PM doses omitted. 6/27/21 - 6:00 PM dose omitted. 6/29/21 - 12:00 AM and 6:00 AM doses omitted. Review of Residents Medication Administration Record (MAR) for June 2021 indicated the scheduled pain assessment was not adequately performed for the entire of June. The pain assessment was to be completed every day and every evening shift, with question of Is Resident currently experiencing pain? 1 = yes, 2 = no. answered. A check mark and staff initials were entered in the box for each shift (7a-7p, 7p-7a) on June 1st - June 6th with only an X in the box where the numeric indication if Resident reported pain (1)/no pain (2) was to be noted. No Pain assessment was completed on June 23rd, 2021, for either shift. On June 24th and 25th, 2021 no pain assessment was completed for dayshift (7a - 7p shift). Review of Residents Medication Administration Record (MAR) for July of 2021 indicated the scheduled pain medication, [MEDICATION(S)] Tablet 7.5-325 mg ([MEDICATION(S)]-acetaminophen) that was scheduled to be given every six (6) hours for pain was omitted from administration for a total of fourteen (14) occurrences on the following dates: July 2021 - 7/02/21 - 12:00 PM, and 6:00 PM doses omitted. 7/04/21 - 6:00 AM dose omitted. 7/05/21 - 12:00 PM and 6:00 PM dose omitted. 7/08/21 - 12:00 PM and 6:00 PM dose omitted. 7/10/21 - 12:00 PM and 6:00 PM doses omitted. 7/11/21 - 6:00 PM dose omitted. 7/25/21 - 12:00 PM and 6:00 PM doses omitted. 7/29/21 - 12:00 PM and 6:00 PM doses omitted. Review of Residents Medication Administration Record (MAR) for July 2021 indicated the scheduled pain assessment was not adequately performed for six (6) occurrences in July. The pain assessment was to be completed every day and every evening shift, with question of Is Resident currently experiencing pain? 1 = yes, 2 = no. answered. No Pain assessment was completed during dayshift (7a - 7p shift) for the following dates: 7/02/21, 7/05/21, 7/08/21, 7/10/21, 7/25/21, 7/29/21. The facility's policy Pain Management, implemented 11/27/17, Revised 5/3/21, listed the following behavioral signs and symptoms for recognition that may suggest the presence of pain: bracing, guarding, or rubbing, facial expressions such as grimacing, frowning, fear, and sleeping poorly, and crying. The policy stated non-pharmacological interventions include adjusting room temperature, smoothing linens, turning, and repositioning patient, cognitive behavioral interventions, of which none were documented within the resident's medical record as attempted or provided on 08/02/21 before or after staff were notified by of Resident's pain by Surveyor. Review of Residents Medication Administration Record (MAR) for August 1st through August 3rd, 2021, indicated the scheduled pain medication, [MEDICATION(S)] Tablet 7.5-325 mg ([MEDICATION(S)]-acetaminophen was to be given every six hours and was omitted from administration on the following date: 08/02/21 - 6:00 PM dose omitted. Review of the facility's policy, Mediation Administration, effective 06/21/17, stated, Return to the mediation cart and document medication administration with initials on the Medication Administration Record (MAR) immediately after administering mediation to each resident. Review of most current Physician Determination of Capacity dated 9/25/20 indicated Resident #3 demonstrated capacity to make decisions. Record review revealed Resident's last reported BIMS score of 12 on quarterly MDS in progress dated July 24th, 2021. Review of radiology report dated 11/9/2020 concluded a S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings were unchanged from 9/18/2020. Record Review indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Emergency Department Physician's note provided by the facility to indicate Resident may be drug seeking (as evidenced by the Resident's sisters' information given to ED at that time) dated 01/08/2018 contained the following statement from the Emergency Department Physician: The patient presented to the ER with complaints of worsening back pain. The patient does have a history of low back pain and follows with her pain management specialist, (Doctor Last Name). The patient is currently on [MEDICATION(S)] 7.5 and has been taking as prescribed. The patient presented here via EMS and the patient's sister called to the ER multiple times stating that the patient has been taking her [MEDICATION(S)] for more frequently than prescribed. I however, looked at the patient's mediation that she brought with her, and she had the appropriate amount of [MEDICATION(S)] left in her prescription. I do not believe that the patient is overmedicating. The patient is awake and alert. She is talking to me appropriately. Review of the Emergency Department Physician note, provided by the facility to indicate Resident may be drug seeking (as evidenced by information given to ED by the Resident's family at that time) dated 03/27/2018 contained the following: Increase in discharged pain medication home from the Emergency Department Physician: Discharge Medications Home: [MEDICATION(S)] 10mg-325mg oral tablet, one tab every six (6) hours as needed. Resident was initially taking 7.5/325 mg dose of [MEDICATION(S)] on previous visit to ED on 01/08/20. This note does not represent the resident is, drug seeking, as the Residents pain medication was increased. During the Pain MDS 3.0 rev 4-16 assessment conducted on 08/04/21, J0500 Pain effect on function was answered by Resident as follows: -A. Ask the Resident, Over the past few days, has pain made it hard for you to sleep at night? Resident Response: Yes -B. Ask Resident, Over the past 5 days, have you limited your day-to-day activities because of pain? Resident Response: Yes During the Pain MDS 3.0 rev 4-16 assessment conducted on 7/23/21, J0500 Pain effect on function was answered by Resident as follows: -A. Ask the Resident, Over the past few days, has pain made it hard for you to sleep at night? Resident Response: Yes -B. Ask Resident, Over the past 5 days, have you limited your day-to-day activities because of pain? Resident Response: Yes Record reviewed indicated the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Pain in the Right Leg - onset date 5/18/18 Presence of Bilateral Artificial Knee Joint - onset 5/18/18 Other chronic pain - onset 5/18/18 Periprosthetic fracture around internal Prosthetic left knee joint subsequent encounter - onset 2/01/21. Unspecified Fracture of the left Femur subsequent encounter for closed Fracture with routine healing onset - 9/24/20. Staff Interview On 8/04/21 at 2:55 PM, Licensed Practical Nurse (LPN) #12 was asked to clarify the process of giving medications to Resident #3 since the Resident was located on Hall B and she had Hall A med cart. LPN #12 replied, I just remember, to flip the screen to Hall B and go check. I usually save that Resident to last. It could be easy to forget her (Resident #3) I guess since the rest of med pass is on hall A. During an interview at 3:00 PM on 08/04/21, the Licensed Practice Nurse (LPN) #239 was asked if she ever administers mediations from Hall A med Cart to Resident #3 on Hall B, and if so how did she remember to verify all medications had been given? LPN #239 stated, Yes, sometimes I have Med Cart for Hall A, and we have a report sheet (LPN #239 pointed to clip board laying on Med Cart) that tells us our assignments so we should never forget her (Resident #3) or forgot to give her meds and should sign them off as soon as they are given. On 8/4/21 at 11:30 AM the Administrator stated, The unit managers run an audit every morning before stand up meeting to check for any discrepancies or missed does on the MAR (Medication Administration Record) they should be catching this. We are doing an enteral audit; I notified the pharmacist sometime last week I thought we had some issues. The Administrator provided the Pharmacist phone number for use by Surveyor. Please note, the Administrator was not able to provide an exact date and time the pharmacist was notified. During an Interview on 8/5/21 at 08:30 AM, the Director of Nursing (DON) stated, If anything I feel like these holes in the MAR are just med errors, I am sure it's a documentation issue and they (staff) forgot to sign off the meds given. We know having that one Resident from a different hall on the A Hall cart is a problem, we are working on it. The failure to provide pain medication and assess pain level as prescribed resulted in actual harm to Resident #3. b) Resident #99. Medical record review revealed Resident #99's Physician order: [MEDICATION(S)] Tablet 5-325 MG ([MEDICATION(S)]-Acetaminophen) *Controlled Drug* Give 1 tablet by mouth every four (4) hours as needed (PRN) for pain. A continued review of the Medication Administration Record (MAR) revealed, Resident #99 was administered as needed controlled pain medication without being assessed for pain. On five (5) occasions the resident received PRN pain medication when the pain was rated as (0), indicating no pain: --05/31/21 at 3:00 AM pain level X- [MEDICATION(S)] given with the Code E= Effective. --05/31/21 at 8:19 AM pain level X- [MEDICATION(S)] given with the Code E= Effective. --06/01/21 at 1:35 AM pain level X- [MEDICATION(S)] given with the Code E= Effective. --06/03/21 at 7:00 PM pain level X- [MEDICATION(S)] given with the Code E= Effective. --06/04/21 at 1:18 AM pain level X- [MEDICATION(S)] given with the Code E= Effective. --06/04/21 at 8:35 AM pain level X- [MEDICATION(S)] given with the Code E= Effective. --07/10/21 at 9:00 AM pain level 0 - [MEDICATION(S)] given with the Code E= Effective. --07/14/21 at 8:00 AM pain level 0 - [MEDICATION(S)] given with the Code E= Effective. --07/22/21 at 2:22 PM pain level 0 - [MEDICATION(S)] given with the Code E= Effective. --08/04/21 at 12:31 AM pain level 0 - [MEDICATION(S)] given with the Code E= Effective. --08/04/21 at 5:26 AM pain level 0 - [MEDICATION(S)] given with the Code E= Effective. On 08/04/21 at 12:45 PM, the DON stated the expectation to administer a PRN Controlled [MEDICATION(S)], should have been evaluated for pain and not have been given if the pain level is 0. On 08/05/21 at 08:52 AM during an Interview with DON, she stated, I feel these are medication errors and they should have been investigated. c) Resident #340 Medical record review for Resident #340 found she was admitted to the facility on [DATE] at 10:20 pm. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission minimum data set (MDS) with assessment reference date of 12/20/20 reveals a Brief Mini-Mental Interview Status (BIMS) of 15, which indicates she is cognitively intact. Resident #340's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record (MAR) and nurse's progress notes found: no non-pharmaceutical interventions, location and type of pain was not documented and on four (4) occasions the pain medication was ineffective with no indication the physician was notified and/or no other interventions attempted. The following dates and times the [MEDICATION(S)] was ineffective: --12/15/20 at 3:37 pm --12/16/20 at 12:23 am --12/21/20 at 1:09 am --12/25/20 at 8:36 am The following dates and times the location of the pain and non-pharmaceutical interventions were not documented: --12/15/20 at 3:37 pm --12/16/20 at 12:23 am, 7:47 pm. --12/17/20 at 8:30 pm --12/18/20 at 3:10 am and 8:21 pm --12/19/20 at 7:20 pm --12/20/20 at 8:19 am and 8:30 pm --12/21/20 at 1:09 am, 6:48 am and 7:36 pm --12/23/20 at 5:32 am and 9:16 am --12/24/20 at 5:55 am and 8:11 pm --12/25/20 at 8:36 am and 4:39 pm --12/26/20 at 2:41 am and 8:58 pm --12/27/20 at 8:27 pm --12/29/20 at 5:05 am and 8:32 pm --12/30/20 at 5:20 am --12/31/20 at 3:02 am, 12:23 pm and 7:30 pm Further review of the Controlled Drug Receipt/Record/Disposition Form and the MAR found the following doses of [MEDICATION(S)] were signed out on the Controlled Drug Receipt/Record/Disposition Form but was not documented as administered on the MAR: --12/22/20 at 4:19 am and 11:00 pm. During a review of the Narcotic sheets and the MAR with the Director of Nursing (DON) on 08/05/2021 at 11:30 am., she confirmed the nursing staff failed to document non-pharmacological interventions attempted and failed to document the location of pain and additionally on the two (2) above episodes the medication was signed out on the narcotic record but was not documented on the MAR as administered.

Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure [MEDICATION NAME] (PT) and International Normalized Ratio (INR) testing was obtained per the physician order for [REDACTED]. This finding was determined to constitute immediate jeopardy to Resident #79. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) and preparation of a written statement, the Administrator was notified of the Immediate Jeopardy on 03/06/19 at 4:15 PM. The facility provided an acceptable Plan of Correction on 03/06/19 at 6:46 PM. The Plan of Correction was accepted, and implementation was verified. The immediate jeopardy was abated at 6:49 PM on 03/06/19. Resident identifier: #79. Facility census: 134. Based on medical record review, staff interview, and policy review, after removal of the immediate jeopardy, deficient practice remained at a scope and severity of [NAME] for six (6) of 42 residents reviewed during the long-term care survey process. The facility failed to ensure laboratory testing and weights were performed according to the physician's orders for Resident #123. The facility failed to ensure measurement of Resident #223's peripherally inserted central catheter (PICC) as ordered by the physician. The facility failed to obtain blood pressure and heart rate monitoring prior to medication administration as ordered by the physician and also to administer enteral tube feedings and flushes as ordered by the physician for Resident #275. The facility failed to follow the order to notify the physician when Resident #18's blood glucose levels were above 400. The facility failed to ensure neurological assessments were performed appropriately after unwitnessed falls for Resident #114. The facility failed to ensure insulin administration and blood glucose monitoring according to the physician's orders for Resident #232. Resident identifiers: #123, #223, #275, #18, #114, #232. Facility census: 134. Findings included: a) Resident #79 On 02/13/19, Resident #79 was started on the anticoagulant [MEDICATION NAME] ([MEDICATION NAME]) 5 mg by mouth every day. The goal of [MEDICATION NAME] therapy is to decrease the clotting tendency of blood, not to prevent clotting completely. Therefore, the effect of [MEDICATION NAME] must be monitored carefully with blood testing. On the basis of the results of the blood test, the daily dose of [MEDICATION NAME] will be adjusted to keep your clotting time within a target range. The blood test used to measure the time it takes for blood to clot is referred to as a [MEDICATION NAME] time test, or [MEDICATION NAME] (PT). The PT is reported as the International Normalized Ratio (INR). Resident #79 had previously been on the anticoagulant apixaban (Eliquis) for a past medical history of [REDACTED]. Resident #79 had developed a spontaneous hematoma, or localized bleeding, of the chest wall. During an interview of 03/06/19 at 2:37 PM, Assistant Director of Nursing (ADoN) #73 stated the attending physician had changed Resident #79's anticoagulant from Eliquis to [MEDICATION NAME] to allow for monitoring of the resident's anticoagulation status. On 02/14/19, Resident #79's attending physician ordered PT/INR testing every Monday to begin on 02/18/19. During review of Resident #79's medical records, no record of PT/INR testing on Monday, 02/18/19, Monday 02/25/19, or Monday 03/04/19 could be located. During an interview on 03/06/19 at 1:50 PM, ADoN #73 confirmed Resident #79 did not have PT/INR testing as ordered on Monday, 02/18/19, Monday 02/25/19, or Monday 03/04/19. ADoN #73 stated there was a breakdown in the system and the order for PT/INR had not been entered into the laboratory book. She stated the attending physician had been notified and a stat PT/INR had been ordered for Resident #79. During a follow-up interview on 03/06/19 at 2:37 PM, ADoN #73 stated the order had been entered as a diagnostic order rather than a laboratory order, which caused the laboratory order to be missed. At 03/06/19 at 3:35 PM, the ADoN provided the stat PT/INR results. She stated the attending physician had reviewed the results and determined Resident #79's [MEDICATION NAME] dosage did not need adjusted. INR was 1.93. per(NAME) Doctor said to continue weekly PT INR. [MEDICATION NAME] does not need to be adjusted. The survey team determined the facility's failure to perform PT/INR testing as ordered placed Resident #79 at immediate risk for serious harm and/or death. The State Agency was contacted and agreed that these failures posted an immediate jeopardy (IJ). The Administrator was notified of the Immediate Jeopardy on 03/06/19 at 4:15 PM. The facility provided an acceptable Plan of Correction on 03/06/19 at 6:46 PM. The plan of correction stated as follows: OHFLAC (Office of Health Facility Licensure and Certification) surveyors identified a failure to follow the policy [MEDICATION NAME] Therapy & Monitoring. At the time it was identified that Resident #79 did not have a follow up PT/ INR lab, the facility obtained a lab and it was within normal limits. Residents #72, #19, #24, #115, #40, #48, and #75 are currently receiving [MEDICATION NAME]. Upon completion of an audit, all above residents were noted to have current lab orders and results for monitoring of PT/ INR. Once the issue was noted, the physician was notified, and the lab studies were obtained on the afternoon of 3/6/19 at approximately 1:00 pm. Resident # 79 PT/INR was within therapeutic range and was reviewed with physician. Currently all PT/ INR results for residents receiving [MEDICATION NAME] are current. All resident's prescribed [MEDICATION NAME] Therapy were assessed by nursing staff, none were noted to have any outward signs or symptoms of bleeding (excessive bruising, tarry stool, nosebleeds, hematuria). No residents displayed abnormal vital signs or abnormal oxygen saturation readings. Follow up lab studies for Resident #79 PT/ INR were written and entered into the Lab Book. An immediate staff re- education was completed for all licensed nursing staff relating to the [MEDICATION NAME] Therapy & Monitoring policy. A performance improvement plan was initiated and reviewed by the QAPI committee on 3/6/19. The abatement plan was accepted, and implementation was verified. The immediate jeopardy was abated at 6:49 PM on 03/06/19. b) Resident #123 On 01/02/2019, Resident #123's attending physician wrote an order for [REDACTED]. Review of Resident #123's medical records did not reveal results for laboratory testing performed on 01/03/19. During an interview on 03/07/19 at 1:00 PM, the Director of Nursing (DoN) confirmed Resident #123 did not have laboratory testing on 01/03/19 as ordered by the physician. The first laboratory testing obtained for Resident #123 pursuant to this order was on 01/11/19. Resident #123 also had an order written [REDACTED]. A weight was obtained on Wednesday, 12/26/18. A weight was not obtained on Friday, 12/28/18. Weights were obtained on Monday, 12/31/18 and Tuesday, 01/01/19. A weight was not obtained on Wednesday, 01/02/19. A weight was obtained on Friday, 01/04/19. A weight was not obtained on Monday, 01/07/19. A weight was obtained on Wednesday, 01/09/19. A weight was not obtained on Friday, 01/11/19. A weight was obtained on Monday, 01/14/19. During an interview on 03/07/19 at 2:34 PM, the Administrator was notified that weights were not performed on Resident #123 three times a day as ordered by the physician. The Administrator had no further information regarding the matter. No additional information was provided through the completion of the survey. c) Resident #223 Resident #223 was admitted on [DATE] with a peripherally inserted central catheter (PICC) in her arm to receive intravenous antibiotics. On 02/27/19, Resident #223's attending physician wrote an order to Measure external catheter length on admission, with each dressing change and prn. Notify physician if external catheter length has changed since the last measurement. A PICC is a long catheter tube inserted into a vein. The tip of catheter is positioned in a large vein that carries blood into the heart. Measuring the external length of catheter, or the catheter tubing outside of the vein in the arm, is important to determine if the PICC has been inadvertently pulled out of the vein. Review of Resident #223's medical records did not reveal an external PICC catheter length measurement on 02/27/19. Resident #223 inadvertently pulled out her PICC, and the catheter was reinserted in the emergency roiagnom on [DATE]. On 03/05/19, the attending physician again wrote an order to Measure external catheter length on admission, with each dressing change and prn. Notify physician if external catheter length has changed since the last measurement. Resident #223's medical records did not reveal an external PICC catheter length measurement on 03/05/19. On 03/07/19 at 10:25 PM, a general progress note written by a registered nurse stated, Changed PICC line dressing using sterile technique, arm circ (circumference) 37 cm, exposed line 2 cm, resident tolerated well. During an interview on 03/11/19 at 2:36 PM, Assistant Director of Nursing (ADoN) #110 provided a Catheter Information sheet that stated the catheter inserted 03/04/19 was threaded into the vein approximately 40 cm. However, the form did not state how much of the catheter length was external. During an interview on 03/11/19 at 3:57 PM, the Corporate Registered Nurse was informed that external PICC catheter measurements could not be located in Resident #223's medical records as ordered by the physician on 02/27/19 or 03/05/19. Although the progress note on 03/07/19 reported an exposed catheter length of 2 cm, there was no initial external catheter length measurement to compare this with to determine if the PICC had been dislodged from the vein. d) Resident #114 A review of Resident #114's medical record revealed the resident had sustained 16 falls between 01/09/19 and 02/23/19. The resident could not walk independently . A review of the facility's policy on falls revised 10/18 reflected the facility would initiate neurological checks per policy if a fall was unwitnessed. The following incident reports described unwitnessed falls: --01/09/19 8:30 PM Staff noted resident on floor lying on fall safe mat beside bed when entering room. The neurological assessment dated [DATE] reflected neurological checks were not completed on 01/09/19 at 9:45 PM, 10:15 PM, and 10:45 PM. Neurological checks were not completed on 01/10/19 at 8:45 PM, 12:45 am, 4:45 AM, 8:45 AM, 12:45 PM. Neurological checks were not completed at 1:15 AM, 2:15 AM, 3:15 AM, 4:15 AM, 8:15 AM, 12:15 PM on 01/10/19. The resident experienced another fall on 01/10/19 at 4:04 PM. --01/10/19 at 4:04 PM Resident found on knees next to bed. Vitals obtained and within normal limits. No bruising or open areas observed. Denies pain. Assisted back to bed. POA (power of attorney)) and physician notified. Stated he (Resident #235) rolled off the bed and landed on his knees. Resident assisted back to bed. Bed alarm activated. Vitals obtained. Neuro checks initiated. POA and physician notified. Bed was in lowest position. Fall mats on bilateral floor. Bed alarm was on bed but no turned on. There were no neurological assessments completed after this fall. The neurological assessment flow sheet completed for the fall on 01/09/19 at 8:30 PM showed that a new neuro sheet was started on 01/10/19 at 14:45 PM. No evidence of a new neurological sheet was located. --01/20/19 at 9:10 AM Called to resident room by CNA (nurse aide), she was walking by resident room, saw resident lying face down in the floor by room mates bed. Resident trying to get up, stating 'help me get up and back in the bed.' Assisted CNAs, resident helped up to feet unsteady states he is 'dizzy', placed in w/c. There were no neurological assessments completed after this unwitnessed fall. In addition there was no evidence that the alarm to the bed/chair was sounding when the resident was found. --02/05/19 at 11:55 PM Resident alarm was ringing and resident was in floor on mat. Denies pain at this time. resident cursing stated 'I fell .' There were no neurological assessments completed after this unwitnessed fall. --02/07/19 at 3:30 PM LPN (licensed practical nurse) found resident on floor on buttock near right side of bed coming from restroom with pants down with w/c (wheelchair) behind him. Neurological assessments were not located and there was no documentation regarding whether or not the alarm was sounding. The neurological assessment flow sheet reflected that neurological checks would be completed after unwitnessed falls as follows: --Q (every) 15 minutes x 4 --Q 30 minutes x 6 --Q hour x 4 --Q 4 hours x 5 --Q 8 hours x 6 During an interview, on 03/11/19 at 4:56 PM, the Director of Nursing (DoN) said she would attempt to locate additional information regarding the missing neurological assessments. At the close of the survey on 03/12/19 at 12:30 PM no additional information was provided. e) Resident #275 Review of Resident #275's medical records found an order for [REDACTED]. Hold for a systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 65. Review of the Medication Administration Record (MAR) for 02/22/19 through 03/07/19 found: 02/23/19 at 9 am blood pressure 98/53 and 9 pm blood pressure 98/53; both times the [MEDICATION NAME] was administered and should have been held according to the physician established parameters. On 03/07/19 at 9 am heart reate was 63 and [MEDICATION NAME] was administered and should have been held according to the physician established parameters. Additionally, blood pressure and heart rate was not obtained prior to the administration of [MEDICATION NAME] from 02/25/19 through 03/05/19 as directed by the physician order. Additionally, Resident #275 was ordered bolus feeds of [MEDICATION NAME]. 240 cc via PEG tube if she eats less than 50% of meals. Flush feeding tube with 100 milliliters (ML) of water before and after bolus feedings. Review of meal intake from 02/23/19 through 03/25/19: found: --02/23/19 - Only one (1) meal documented. --02/24/19 - Only two (2) meal documented. --02/25/19 - Only one (1) meal documented. Review of the Medication Administration Record (MAR) for 02/23/19 through 02/25/19 found Resident #275 did not receive any bolus feedings via feeding tube on 02/23/18, 02/24/19 and 02/25/19. No documentation of flushes could be found. On 03/07/19 at 2:15 pm, Resident #275's orders and MARs was reviewed with the Director of Nursing (DON). She verified the [MEDICATION NAME] was given when should have been held on the above dates and she verified the blood pressure and heart rate was not obtained from 02/25/19 through 03/05/19 . She also verified no documentation the resident received the bolus tube feedings and flushes for 02/23/19 through 02/25/19. No further information provided. f) Resident #18 Review of Resident #18's medical records found an order for [REDACTED]. Notify the physician if the bllod sugar is greater than 300. order started on 02/01/2019. Review of the MAR for Febuary 2019 found the blood sugar over 300 on 02/07/19 at 6 pm blood sugar 316 and on 02/15/19 blood sugar was 330. No documentation could be found to indicate the doctor was notified. On 03/07/19 at 1:15 pm, Resident #275's orders and MARs was reviewed with the DON. She verified the physician should have been notified. She also verified there was no documentation the physician was notified. g) Resident #232 A review of Resident #232's medical record at 11:42 a.m. on 03/07/19 found the following physician order dated 02/22/19 which read as follows, [MEDICATION NAME] Solution Cartridge 100 unit/ml inject per sliding scale: If 150 - 200 give 2 units, 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units below 60 start hypoglycemic protocol Above 400 call MD (medical doctor). Subcutaneous before meals and at bedtime for DM. Review of the medication administration record (MAR) for 02/2019 found Resident #232's blood sugar was above 400 on two (2) separate occasions: On 02/23/19 at 9:00 p.m. Resident #232's blood sugar was 517. The MAR had a 9 documented which directs the reader to see the nurses notes. A review of the nurses notes for this date found the following, . MD notified. new order for 4 extra units of [MEDICATION NAME] to equal 14 units. On 02/27/19 at 11:00 a.m. Resident #232's blood sugar was 458. The MAR had a 9 documented which directs the reader to see the nurses notes. A review of the nurses notes for this date found the following, .Dr. Notified he said to cover with 10 units and repeat BS (blood sugar) in 2 hours due to resident having cappuccino this AM. Further review of the MAR found no documentation that Resident #232 received 14 units of insulin on 02/23/19. The 4 extra units was documented as administered but the 10 required by the sliding scale was not documented as administered. Also on 02/27/19 there was no documentation on the MAR to indicate Resident #232 received the 10 units of insulin ordered by the physician. Also the medical record contained no documentation to prove the residents blood sugar was repeated in 2 hours as ordered by the physician on 02/27/19. An interview with the Assistant Director of Nursing (ADON) at 1:00 p.m. on 03/11/19 confirmed the above findings. She indicated she did not see the repeat blood sugar documented in the medical record. She also confirmed the insulin was not documented on the MAR.

Based on observation, record review, and staff interview, the facility failed to ensure a resident admitted without pressure ulcers, but identified to be at risk, received the necessary care and services to prevent the development of pressure ulcers. This resulted in actual harm when Resident #225 developed two (2) in-house acquired suspected deep tissue injuries (SDTI) following her admission to the facility. This was found for one (1) of two (2) Stage 2 sample residents reviewed for pressure ulcers during the Quality Indicator Survey (QIS). Resident identifier: #225. Facility census: 133. Findings include: a) Resident #225 Review of the resident's medical record on 02/02/17 at 8:32 a.m. found this [AGE] year-old woman, admitted to the facility on [DATE], for therapy services following a left [MEDICAL CONDITION] and repair. Her admission goal was for discharge to home following therapy. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 01/13/17 found the resident assessed as at risk for the development of pressure ulcers. She had no pressure ulcers at the time of admission. The MDS also identified the resident required the extensive assist of two (2) persons for bed mobility, therefore requiring the assistance of staff for turning and repositioning. The weekly wound evaluation completed on 01/20/17, identified a newly developed suspected deep tissue injury (SDTI) measuring 2.5 centimeters (cm) by 2 cm on the resident's left heel. The description of the wound included, .appearance of dark brown/red in color with some bogginess near center of wound. The weekly wound evaluation completed on 01/23/17, identified a vertebrae (upper-mid spine) SDTI measuring 0.6 cm by 0.5 cm with the appearance described as intact non-blanching pink skin. Although the resident was assessed as being at risk for pressure ulcers, the care plan dated, 01/08/17, included no individualized measurable goals, or established interventions, to meet the immediate needs of the resident at the time of admission. A focus (problem) statement, goals, and interventions regarding pressure sores were not initiated until 01/20/17, after the resident developed a left heel SDTI. A focus (problem) statement, goals, and interventions were also initiated on 01/23/17 after the resident developed a second SDTI on her vertebrae. During an interview and review of the record on 02/02/17 at 8:51 a.m., Registered Nurse (RN)/Wound Nurse stated, Yes both of the SDTIs could have been prevented. She (Resident #225) is just here for skilled nursing and these SDTIs should not have occurred during this timeframe nor any time. Preventative measures are in place now after she developed the two (2) SDTI, one (1) to her heel and one (1) to her back and they are both in the healing process, but it looks like nothing was in place before they occurred. A wound/treatment observation on 02/02/17 at 9:57 a.m., revealed the SDTIs on the resident's vertebrae and left heel were in the healing stages. Physical Therapist (PT) #45 reported during an interview on 02/02/17 at 11:44 a.m., Resident #225 did not ambulate with therapy for two (2) days due to the big unopened pressure sore on her left heel because nursing staff did not want any pressure on her heel. Therapy did continue with other therapy exercises and ordered special shoes for the resident. After reviewing the care plan on 02/06/17 at 1:45 p.m., the Director of Nursing (DON) agreed the care plan did not contain a focus, goals, or interventions prior to the development of the in-house acquired SDTIs on 01/20/17 and 01/23/17. The DON commented that she would look at the interim/initial care plan completed on admission to gather further information. The DON reported on 02/06/17 at 2:00 p.m. the initial/interim care plan on admission to the facility did not contain any focus, goals or interventions related to the prevention of pressure ulcers. She stated, I tried, but there is nothing there. The lack of preventative measures/interventions in place at the time of admission resulted in the resident acquiring two (2) in-house acquired avoidable SDTIs causing harm to the resident. Once interventions were implemented, the wounds began to heal and no additional wounds were identified.

Based on review of facility documents, staff interview, review of police reports, policy review, and resident interview, the facility failed to report and conduct a thorough investigation following allegations of verbal abuse by a nursing assistant (NA) toward one (1) of four (4) sampled residents. Resident identifier: #29. Facility census: 122. Findings include: a) Resident #29 1) Review of facility documents found an NA, Employee #9, alleged he witnessed sexual abuse/assault between Resident #29 and a male blood relative on [DATE], at approximately 4:00 p.m. The documents contained a signed statement by a registered nurse, Employee #145, which stated Employee #9 reported the allegation to her on [DATE]. An interview was conducted with Employee #145, on [DATE] at 4:15 p.m. Employee #145 described the events of [DATE]. She stated Employee #9 reported the allegation to her just as the fire alarm went off. Employee #145 stated she reported the allegation after the fire drill was over. An interview with the maintenance director, Employee #87, on [DATE] at 3:15 p.m., verified a fire drill was conducted between the hours of 4:00 p.m. and 4:20 p.m. on [DATE]. He provided a record of the [DATE] fire drill. Review of a statement signed by the social worker, Employee #101, on [DATE], found Employee #145 reported the allegation to her at 4:45 p.m. on [DATE]. The statement noted Employee #101 entered the resident's room, at 4:30 p.m. on [DATE], to complete readmission paperwork and "everything seemed fine.". Employee #101 was interviewed on [DATE] at 11:40 a.m. She confirmed the allegation of sexual abuse/assault was reported to her after the fire drill. Review of the police report, obtained on [DATE], found Employee #9 alleged he witnessed a male blood relative commit an oral intrusion upon Resident #29, at 3:50 p.m. on [DATE], when he answered the call light to remove Resident #29 from the bedpan. The report stated Employee #9 cleaned the resident, left the room, and reported the incident. An interview with Employee #9, at 2:30 p.m. on [DATE], confirmed he left Resident #29 and the male blood relative alone in the private room after allegedly witnessing an act of oral sexual abuse/assault. He stated he had placed the resident on the bedpan after she asked for one "in her usual hateful way" and left the room. He stated he entered the room due to the call bell going off and witnessed the act of oral sexual assault. He stated he cleaned the resident up as she had a bowel movement and left the room. Review of facility policy entitled "Abuse, Neglect and Misappropriation of Patient Property Prevention, dated [DATE], page 10, in the section entitled "Protect" found the following: "...The center supports and protects patients, family members and staff from harm during an investigation of alleged abuse." Review of facility documents, review of police reports and staff interviews determined the resident was left alone with a male blood relative after a facility staff member alleged he witnessed an oral sexual abuse/assault. Police officers took no action against the male blood relative related to the allegation during their [DATE] investigation. 2) Resident #29 was interviewed on [DATE] at 3:45 p.m. She stated a man who worked there (gave a detailed physical description) told a "bald-faced lie" about her and (a male blood family member). The resident said, "It was very embarrassing." The resident also said, "He calls my phone and growls and cusses at me and called me a "[***] ". He called me last night and said "I'm watching you"." He calls from here because there is some kind of beeping noise and I can hear it on the phone. He walks past my room and "gives me the finger". I am scared of him. He could kill me and they would just say I died in my sleep." When asked if she had reported this staff member, the resident replied, "They won't do nothing, they let him in my room after he told that bald-faced lie. I throwed a fit and made them get him out of here. I don't want him in my room. They try to say I am not in my right mind." This resident was able to accurately respond to questions about the date, time, marriage date, birthday, what she had for lunch, who the president was, etc. The resident was trembling, sobbing, and extremely distraught during her statement concerning the incident. The administrator was interviewed on [DATE] at approximately 6:00 p.m. He was asked if Employee #9 had been assigned to care for Resident #29 following his allegation of witnessing an act of sexual abuse/assault on [DATE]. The administrator stated he had left strict instructions that Employee #9 was to receive another assignment. An interview with the DON revealed Employee #9 had indeed been assigned to care for Resident #29 on [DATE] but was reassigned after the resident became upset. The administrator was present during this interview. He was asked why Employee #9 was assigned to the resident after he had left "strict instructions" that he not be assigned to this resident. Facility records reflect that Employee #9 ceased providing care to Resident #29 on [DATE] at 3:47 p.m. An interview was conducted with the resident's daughter, Family Member #1, at 8:30 p.m. on [DATE]. She identified Employee #9 as the staff member who was harassing her mother. She stated Employee #9 was assigned to her mother the evening after he told that "disgusting lie," and her mother was extremely upset by having him in her room. She stated the telephone calls started after that. Family Member #1 stated her mother only gets calls when Employee #9 is working. She relayed she had visited her mother the evening before and left about 7:00 p.m. Her mother told her she had not been gone 5 (five) minutes when he called her, threatening her. Family Member #1 stated she had reported this to the DON but they had not done anything to stop him. Facility records reflect that the resident's daughter called the facility on [DATE] and reported that Employee #9 had walked by the resident's room and gave her the middle finger. The DON was interviewed at 10:40 a.m. on [DATE]. She stated she was aware of allegations of Employee #9 walking by the resident's room and giving her the finger, but stated this was impossible as you cannot see the hallway from the resident's bed. When asked about the threatening phone calls, the DON stated the daughter (Family Member #1) had called her about the telephone calls but did not allege they were made by an employee. The DON stated other residents have access to telephones and may have dialed Resident #29's room by mistake. Review of nursing notes found a note, dated [DATE] at 11:30 a.m., authored by the DON. The note included the following, "Received call from resident's daughter, (daughter's name), who stated that her mother had been receiving phone calls at night. Stated that phone caller would not talk, just make noises. Daughter stated she thought calls were from employees but had not (sic) evidence...". Facility records reflect that a concern was made on [DATE] about phone calls and addressed by the DON with Family Member #1. Facility records reflect no specific mention was made concerning Employee #9. Following the DON's contention that the resident could not have seen anyone in the hallway from her bed, a registered nurse, Employee #91, assisted in determining if the resident could view individuals in the hallway while in her bed. Employee #91 and this surveyor walked past the resident's room and this surveyor called and waved at the resident. The resident had an unobstructed view of the hallway. The facility was unable to provide evidence the allegation of verbal abuse involving Employee #9 "giving the finger" to Resident #29 on [DATE] was reported timely and thoroughly investigated in accordance with State law. Additionally, there was no evidence Resident #29 was protected from further potential abuse before, and while, an investigation was conducted. Employee #9 was suspended on [DATE] pending and internal investigation relative to the allegations made by Resident #29 and the resident's daughter to the surveyor concerning the verbal abuse. The [DATE] incident was reported to State agencies on [DATE]. .

Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified that the resident's international normalized ratio (INR - a system established by the World Health Organization for reporting the results of blood coagulation (clotting) tests) was critically high. The nurse noted an order to administer Vitamin K to promote blood clotting but did not administer it before allowing the resident to leave the facility, nor did the nurse communicate to the family or the orthopedist's office that the resident had a critically high INR which placed him at risk for uncontrolled bleeding. Upon leaving the orthopedist's office later that same day, the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made"do not resuscitate" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with: bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use" (created on [DATE]) G -"minimize skin breakdown risks" (created on [DATE]) I -"... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..." (created on [DATE]) - P -"Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising" (created on [DATE]) G -"Will have no adverse effects" (created on [DATE]) and"Will maintain lab values within therapeutic range (created on [DATE]) I -"Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and report adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care." (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P -"At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]" created on [DATE]) G - Minimize risk for falls" (created on [DATE]) I -"Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE])." None of the above interventions related to the resident's risk for falls identified the anticoagulant therapy as a factor affecting the extent of injuries that could be sustained as a result of falling. - 4. According to a document titled"Clinical Services FYI - Post Fall Evaluation" (FYI File - [DATE] - Number 34): " Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs during a patient's stay. In the event that a patient does fall, a comprehensive clinical evaluation by the nursing supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for a post-fall evaluation may include: " ... Medication a) Anticoagulant therapy ... Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. ..." " Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient hits their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but NOT MOVE (both words in bold - not caps - in the original document) the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. " The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptoms, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of changes in condition is completed using the SBAR (situation - background - assessment - recommendation) process." According to the directions on the neurological evaluation flow sheet:"Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. ..." Based on these directions, a resident should receive no less than seventeen (17) neuro checks completed at progressive intervals. - 5. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident"missed his chair" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. After the fall on [DATE], neuro checks were started at 5:05 p.m. These checks, which were to include assessments of the resident's level of consciousness, orientation, pupils, motor movement, communication, and vital signs, were not always complete and were not completed at the progressive intervals required by the directions on the neurological evaluation flow sheet as stated above: - On [DATE] at 5:05 p.m.; at 5:35 p.m.; at 6:05 p.m. (vital signs only); at 6:35 p.m. (vital signs only); at 7:35 p.m. (vital signs only); at 8:35 p.m. (vital signs only); at 9:35 p.m. (vital signs only); and at 10:35 p.m. (vital signs only). - On [DATE] at 6:30 a.m. and at 2:00 p.m. - On [DATE] at 2:00 a.m.; at 6:00 a.m.; and at 8:00 p.m. - On [DATE] at 4:30 p.m. and at 8:00 p.m. - On [DATE] at 8:00 a.m. None of the neuro checks recorded at these times contained abnormal findings. 6. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed):"resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning." The LPN also noted the type of incident as a"(f)all without injury (or minor injury)" . Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and"resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest." Contrary to the information outlined above in the document titled"Clinical Services FYI - Post Fall Evaluation" , Resident #141 - whom staff witnessed hitting his head during the fall - was not evaluated by emergency personnel and there was no evidence that a head injury was ruled out. There was also no evidence that the nurse informed the physician or the family that Resident #141 had hit his head during this fall. - The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written):"Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot." An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written):"Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue." At 6:00 p.m. on [DATE], another nurse wrote:"Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results." At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 7. After the fall on [DATE], neuro checks were started at 10:45 a.m. In spite of the fact that a nurse witnessed the resident hitting his head during this fall, these neuro checks were not always accurate or complete (with temperature readings being recorded in the spaces intended for pulse oximeter readings, and pulse oximeter readings being omitted on several occasions) and the times these checks were completed were not always recorded, making it impossible to determine whether they were completed at the progressive intervals required by the directions on the neurological evaluation flow sheet: - On [DATE] at 10:45 a.m.; at 11:15 a.m.; at 11:45 a.m.; at 12:15 p.m.; at 2:15 p.m.; and at 6:15 p.m. (A nursing note, at 9:00 p.m. on [DATE], stated Resident #141 was sent to the ER, and he did not return to the facility until the early morning of [DATE].) - On [DATE] (no time recorded); and at",[DATE]" (no specific time recorded) - On [DATE] at",[DATE]" (no specific time recorded); at",[DATE]" (no specific time recorded); and at",[DATE]" (no specific time recorded) - On [DATE] at",[DATE]" (no specific time recorded) Beginning with the first entry on the sheet for this fall at 10:45 a.m. on [DATE], the nurse recorded"(arrow pointing down) ROM" to indicate an abnormal finding (decrease in range of motion) with respect to the motor movement of the right upper limb. This same notation was made with respect to an assessment of the motor movement of the right upper limb at 11:15 a.m., 11:45 a.m., and 2:15 p.m. on [DATE]; at 6:15 p.m. on [DATE], the nurse recorded"(arrow pointing down) R" as an abnormal finding for motor movement of the right upper limb. (Note: The injured arm was his left upper limb, not his right upper limb.) Beginning with the first entry on the flow sheet for [DATE] (with no time recorded) and continuing through the entry at",[DATE]" on [DATE], the nurse completing the form noted a problem with motor movement of the left upper limb. No problems with motor movement of either upper or lower limbs were noted when the last two (2) entries were recorded on the form for [DATE] at",[DATE]" and [DATE] at",[DATE]" . No other abnormal findings were noted. - 8. An entry in the nursing notes, in the early morning of [DATE], stated:"Resident brought back to facility ... Resident also has large bruising area on buttocks D/T (due to) fall. ..." After entries identified the presence of a skin tear to the left arm on [DATE] and the presence of a large area of bruising on the buttocks on [DATE], no additional entries made in the record during the remainder of his stay in the facility contained either a nursing assessment (or a physical description) of his appearance after the fall. There was no further mention of the large bruise on his buttocks and no description of physical findings about his head, which hit the door frame during the fall. There was also evidence in the nursing notes or care plan that were reflective of staff's recognition that the resident's anticoagulant therapy was a potential concern with respect to injuries associated with the fall. - 9. Prior to the fall on [DATE], Resident #141 had been self-ambulating frequently when awake and was able to feed himself independently. After this fall, he required 100% feeding by staff, was frequently refusing to eat or drink. Additionally, nursing entries on [DATE], [DATE], and [DATE] all contained phrases like"resting in bed with eyes closed";"Resident resting quietly";"resting quietly no acute distress"; and"resting in bed." There was no documentation in his record to reflect that staff observed the resident ambulating after [DATE], and the resident now required staff assistance with eating; these reflected a significant change in Resident #141's self-performance of activities of daily living. The resident's PT on [DATE] was 23.0 with an INR of 2.1. This was reported to the physician, and the resident's dosage of [MEDICATION NAME] remained the same with an order for [REDACTED]. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 10. Review of the physician's progress notes found the following entries, which appear as recorded (out of chronologic order) and are quoted as written: - On [DATE] at 11:50 a.m. -"I saw the pt again today because (1) He fell a couple of nights ago & fractured L humerus (2) He continues to be restless since we have tapered off [MEDICATION NAME] (3) When I went into room - he was flushed and agitated. Temp 99.9 HR 70's irregular. Lungs with bibasilar crackles. Mouth looks a little dry. No LE (lower extremity) [MEDICAL CONDITION]. I spoke with his son - who also noted a 'wild' look in his Dad's eyes recently. We discussed fracture, need to change pain regimen and med strategies for his agitation. He is in agreement with the treatment (illegible) changes." - On [DATE] at 11:22 a.m. -"Pt is sedated this morning - missed breakfast. O2 sat 94%. Lungs - coarse BS (breath sounds). Abd (abdomen) soft. Labs were basically OK - Will (check) CXR (chest x-ray) - but probably not a good idea to go for ride to ortho. Nursing aware." (This entry may have been incorrectly dated; it corresponds with a late entry record by nursing for [DATE].) - On [DATE] at 4:50 p.m. -"New developments - (Resident #141) continued to poor PO intake and alertness although he did better at times. Not really SOB (short of breath). He continues not to leave arm immobilizer arm. Na (sodium) was 177 last night - he started IV fluids And it was down to 166. PT / INR was also elevated. So [MEDICATION NAME] on hold. His O2 Sat currently - 92% with HR (heart rate) 84. He gets a little restless at times. Lungs with fine basilar crackles. Mouth dry - but he actually looks better and more comfortable than last visit. Nursing comforting family - they agree with us trying to not linger and are discussing Code Status. Will go ahead and change antibiotic to [MEDICATION NAME] IV since we have IV access. Labs in AM (morning). Since stable at present - Will continue fluids - plan change to ? NS tomorrow." - A review of laboratory tests, completed on [DATE], revealed the following: Sodium - 167 (normal range 136 - 146) Chloride - 136 (normal range 98 - 110) Blood urea nitrogen (BUN) - 70 (normal range 8 - 21) Calcium - 11.4 (normal range 8.4 - 10.2) All of these values had the highlighted statement:"Significantly different from previous result" (previous results were dated [DATE]). The labs were repeated on [DATE] and were approximately the same. - 11. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written):"Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%." The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated:"Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]." The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated:"(Name of transport service) here to p/u (pick up) for ortho appt." There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 12. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 13. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141"underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm." The report read:"The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding." He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. The resident's laboratory values included the following: Lactic acid - 2.2 (normal range 0.5 - 2.0) Sodium - 159 (normal range 98 - 110) INR - 9.53 (normal range 2.5 - 3.5; over 4.9 is critically high) Hemoglobin - 7.9 (normal range 14.0 - 16.0) Hematocrit - 24.8 (normal range 41.0 - 53.0) He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. Per the history provided to the ER physician by the resident's son, the resident had had a functional decline and decreasing memory for the previous four (4) months. However, the son had noted a marked decrease in the resident's mental status in the previous week. According to the history, the son reported to the hospital physician that, only days ago, Resident #141 was walking and feeding himself. The son also informed the ER physician of the resident's recent falls and the resulting fracture to the left arm. - 14. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was"old" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was"probably" old and that a"large amount of acute bleeding" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). On the previous day ([DATE]), Employee #24 had been asked by this surveyor to explain how the resident got to the hospital. He stated then that he did not know, but he supposed that the resident"went bad in the ambulance" and they took him there. When asked if he knew the resident's current health status or why he did not return to the facility, Employee #24 denied any such knowledge and stated that it was the policy of the facility that, if a resident did not return, to not make any inquiries. Employee #24 appeared surprised when informed that there had been no comprehensive nursing assessments during this resident's significant decline from [DATE] until his transfer from the orthopedist's office to the hospital on [DATE] (which was arranged by his son). - 15. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, and would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was"old", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's"right" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 16. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: "Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. ..." There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: "Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain." There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: "Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility." The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed):"... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..." Under the heading "Assessment and Plan" was: "1.[MEDICAL CONDITION]ly of urinary origin. ..." - The facility's policy titled "Catheter Care: Indwelling Catheter" (dated ",[DATE]"), provided by the facility on [DATE], contained the following under the heading "Suggested Documentation": "- Care provided and reaction to procedure, size of catheter and balloon. "- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians." - Review of the resident's care plan, with a print date

Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified that the resident's international normalized ratio (INR - a system established by the World Health Organization for reporting the results of blood coagulation (clotting) tests) was critically high. The nurse noted an order to administer Vitamin K to promote blood clotting but did not administer it before allowing the resident to leave the facility, nor did the nurse communicate to the family or the orthopedist's office that the resident had a critically high INR which placed him at risk for uncontrolled bleeding. Upon leaving the orthopedist's office later that same day, the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made "do not resuscitate" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with: bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use" (created on [DATE]) G - "minimize skin breakdown risks" (created on [DATE]) I - "... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..." (created on [DATE]) - P - "Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising" (created on [DATE]) G - "Will have no adverse effects" (created on [DATE]) and "Will maintain lab values within therapeutic range (created on [DATE]) I - "Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and report adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care." (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P - "At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]" created on [DATE]) G - Minimize risk for falls" (created on [DATE]) I - "Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). " None of the above interventions related to the resident's risk for falls identified the anticoagulant therapy as a factor affecting the extent of injuries that could be sustained as a result of falling. - 4. According to a document titled "Clinical Services FYI - Post Fall Evaluation" (FYI File - [DATE] - Number 34): "Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs during a patient's stay. In the event that a patient does fall, a comprehensive clinical evaluation by the nursing supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for a post-fall evaluation may include: "... Medication a) Anticoagulant therapy ... Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. ... " "Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient hits their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but NOT MOVE (both words in bold - not caps - in the original document) the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. "The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptoms, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of changes in condition is completed using the SBAR (situation - background - assessment - recommendation) process. " According to the directions on the neurological evaluation flow sheet: "Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. ..." Based on these directions, a resident should receive no less than seventeen (17) neuro checks completed at progressive intervals. - 5. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident "missed his chair" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. After the fall on [DATE], neuro checks were started at 5:05 p.m. These checks, which were to include assessments of the resident's level of consciousness, orientation, pupils, motor movement, communication, and vital signs, were not always complete and were not completed at the progressive intervals required by the directions on the neurological evaluation flow sheet as stated above: - On [DATE] at 5:05 p.m.; at 5:35 p.m.; at 6:05 p.m. (vital signs only); at 6:35 p.m. (vital signs only); at 7:35 p.m. (vital signs only); at 8:35 p.m. (vital signs only); at 9:35 p.m. (vital signs only); and at 10:35 p.m. (vital signs only). - On [DATE] at 6:30 a.m. and at 2:00 p.m. - On [DATE] at 2:00 a.m.; at 6:00 a.m.; and at 8:00 p.m. - On [DATE] at 4:30 p.m. and at 8:00 p.m. - On [DATE] at 8:00 a.m. None of the neuro checks recorded at these times contained abnormal findings. 6. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed): "resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning." The LPN also noted the type of incident as a "(f)all without injury (or minor injury)". Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and "resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. " Contrary to the information outlined above in the document titled "Clinical Services FYI - Post Fall Evaluation", Resident #141 - whom staff witnessed hitting his head during the fall - was not evaluated by emergency personnel and there was no evidence that a head injury was ruled out. There was also no evidence that the nurse informed the physician or the family that Resident #141 had hit his head during this fall. - The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written): "Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot." An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written): "Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue." At 6:00 p.m. on [DATE], another nurse wrote: "Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. " At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 7. After the fall on [DATE], neuro checks were started at 10:45 a.m. In spite of the fact that a nurse witnessed the resident hitting his head during this fall, these neuro checks were not always accurate or complete (with temperature readings being recorded in the spaces intended for pulse oximeter readings, and pulse oximeter readings being omitted on several occasions) and the times these checks were completed were not always recorded, making it impossible to determine whether they were completed at the progressive intervals required by the directions on the neurological evaluation flow sheet: - On [DATE] at 10:45 a.m.; at 11:15 a.m.; at 11:45 a.m.; at 12:15 p.m.; at 2:15 p.m.; and at 6:15 p.m. (A nursing note, at 9:00 p.m. on [DATE], stated Resident #141 was sent to the ER, and he did not return to the facility until the early morning of [DATE].) - On [DATE] (no time recorded); and at ",[DATE]" (no specific time recorded) - On [DATE] at ",[DATE]" (no specific time recorded); at ",[DATE]" (no specific time recorded); and at ",[DATE]" (no specific time recorded) - On [DATE] at ",[DATE]" (no specific time recorded) Beginning with the first entry on the sheet for this fall at 10:45 a.m. on [DATE], the nurse recorded "(arrow pointing down) ROM" to indicate an abnormal finding (decrease in range of motion) with respect to the motor movement of the right upper limb. This same notation was made with respect to an assessment of the motor movement of the right upper limb at 11:15 a.m., 11:45 a.m., and 2:15 p.m. on [DATE]; at 6:15 p.m. on [DATE], the nurse recorded "(arrow pointing down) R" as an abnormal finding for motor movement of the right upper limb. (Note: The injured arm was his left upper limb, not his right upper limb.) Beginning with the first entry on the flow sheet for [DATE] (with no time recorded) and continuing through the entry at ",[DATE]" on [DATE], the nurse completing the form noted a problem with motor movement of the left upper limb. No problems with motor movement of either upper or lower limbs were noted when the last two (2) entries were recorded on the form for [DATE] at ",[DATE]" and [DATE] at ",[DATE]". No other abnormal findings were noted. - 8. An entry in the nursing notes, in the early morning of [DATE], stated: "Resident brought back to facility ... Resident also has large bruising area on buttocks D/T (due to) fall. ..." After entries identified the presence of a skin tear to the left arm on [DATE] and the presence of a large area of bruising on the buttocks on [DATE], no additional entries made in the record during the remainder of his stay in the facility contained either a nursing assessment (or a physical description) of his appearance after the fall. There was no further mention of the large bruise on his buttocks and no description of physical findings about his head, which hit the door frame during the fall. There was also evidence in the nursing notes or care plan that were reflective of staff's recognition that the resident's anticoagulant therapy was a potential concern with respect to injuries associated with the fall. - 9. Prior to the fall on [DATE], Resident #141 had been self-ambulating frequently when awake and was able to feed himself independently. After this fall, he required 100% feeding by staff, was frequently refusing to eat or drink. Additionally, nursing entries on [DATE], [DATE], and [DATE] all contained phrases like "resting in bed with eyes closed"; "Resident resting quietly"; "resting quietly no acute distress"; and "resting in bed." There was no documentation in his record to reflect that staff observed the resident ambulating after [DATE], and the resident now required staff assistance with eating; these reflected a significant change in Resident #141's self-performance of activities of daily living. The resident's PT on [DATE] was 23.0 with an INR of 2.1. This was reported to the physician, and the resident's dosage of [MEDICATION NAME] remained the same with an order for [REDACTED]. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 10. Review of the physician's progress notes found the following entries, which appear as recorded (out of chronologic order) and are quoted as written: - On [DATE] at 11:50 a.m. - "I saw the pt again today because (1) He fell a couple of nights ago & fractured L humerus (2) He continues to be restless since we have tapered off [MEDICATION NAME] (3) When I went into room - he was flushed and agitated. Temp 99.9 HR 70's irregular. Lungs with bibasilar crackles. Mouth looks a little dry. No LE (lower extremity) [MEDICAL CONDITION]. I spoke with his son - who also noted a 'wild' look in his Dad's eyes recently. We discussed fracture, need to change pain regimen and med strategies for his agitation. He is in agreement with the treatment (illegible) changes. " - On [DATE] at 11:22 a.m. - "Pt is sedated this morning - missed breakfast. O2 sat 94%. Lungs - coarse BS (breath sounds). Abd (abdomen) soft. Labs were basically OK - Will (check) CXR (chest x-ray) - but probably not a good idea to go for ride to ortho. Nursing aware." (This entry may have been incorrectly dated; it corresponds with a late entry record by nursing for [DATE].) - On [DATE] at 4:50 p.m. - "New developments - (Resident #141) continued to poor PO intake and alertness although he did better at times. Not really SOB (short of breath). He continues not to leave arm immobilizer arm. Na (sodium) was 177 last night - he started IV fluids And it was down to 166. PT / INR was also elevated. So [MEDICATION NAME] on hold. His O2 Sat currently - 92% with HR (heart rate) 84. He gets a little restless at times. Lungs with fine basilar crackles. Mouth dry - but he actually looks better and more comfortable than last visit. Nursing comforting family - they agree with us trying to not linger and are discussing Code Status. Will go ahead and change antibiotic to [MEDICATION NAME] IV since we have IV access. Labs in AM (morning). Since stable at present - Will continue fluids - plan change to ? NS tomorrow. " - A review of laboratory tests, completed on [DATE], revealed the following: Sodium - 167 (normal range 136 - 146) Chloride - 136 (normal range 98 - 110) Blood urea nitrogen (BUN) - 70 (normal range 8 - 21) Calcium - 11.4 (normal range 8.4 - 10.2) All of these values had the highlighted statement: "Significantly different from previous result" (previous results were dated [DATE]). The labs were repeated on [DATE] and were approximately the same. - 11. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written): "Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%." The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated: "Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. " The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated: "(Name of transport service) here to p/u (pick up) for ortho appt. " There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 12. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 13. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141 "underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm." The report read: "The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding." He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. The resident's laboratory values included the following: Lactic acid - 2.2 (normal range 0.5 - 2.0) Sodium - 159 (normal range 98 - 110) INR - 9.53 (normal range 2.5 - 3.5; over 4.9 is critically high) Hemoglobin - 7.9 (normal range 14.0 - 16.0) Hematocrit - 24.8 (normal range 41.0 - 53.0) He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. Per the history provided to the ER physician by the resident's son, the resident had had a functional decline and decreasing memory for the previous four (4) months. However, the son had noted a marked decrease in the resident's mental status in the previous week. According to the history, the son reported to the hospital physician that, only days ago, Resident #141 was walking and feeding himself. The son also informed the ER physician of the resident's recent falls and the resulting fracture to the left arm. - 14. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was "old" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was "probably" old and that a "large amount of acute bleeding" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). On the previous day ([DATE]), Employee #24 had been asked by this surveyor to explain how the resident got to the hospital. He stated then that he did not know, but he supposed that the resident "went bad in the ambulance" and they took him there. When asked if he knew the resident's current health status or why he did not return to the facility, Employee #24 denied any such knowledge and stated that it was the policy of the facility that, if a resident did not return, to not make any inquiries. Employee #24 appeared surprised when informed that there had been no comprehensive nursing assessments during this resident's significant decline from [DATE] until his transfer from the orthopedist's office to the hospital on [DATE] (which was arranged by his son). - 15. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, and would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was "old", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's "right" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 16. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: "Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. ..." There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: "Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain." There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: "Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility." The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed):"... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..." Under the heading "Assessment and Plan" was: "1.[MEDICAL CONDITION]ly of urinary origin. ..." - The facility's policy titled "Catheter Care: Indwelling Catheter" (dated ",[DATE]"), provided by the facility on [DATE], contained the following under the heading "Suggested Documentation": "- Care provided and reaction to procedure, size of catheter and balloon. "- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians." - Review of the resident's

Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified that the resident's international normalized ratio (INR - a system established by the World Health Organization for reporting the results of blood coagulation (clotting) tests) was critically high. The nurse noted an order to administer Vitamin K to promote blood clotting but did not administer it before allowing the resident to leave the facility, nor did the nurse communicate to the family or the orthopedist's office that the resident had a critically high INR which placed him at risk for uncontrolled bleeding. Upon leaving the orthopedist's office later that same day, the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was madedo not resuscitate by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with: bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use (created on [DATE]) G -minimize skin breakdown risks (created on [DATE]) I -. Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. (created on [DATE]) - P -Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising (created on [DATE]) G -Will have no adverse effects (created on [DATE]) andWill maintain lab values within therapeutic range (created on [DATE]) I -Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and report adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care. (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P -At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION] created on [DATE]) G - Minimize risk for falls (created on [DATE]) I -Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). None of the above interventions related to the resident's risk for falls identified the anticoagulant therapy as a factor affecting the extent of injuries that could be sustained as a result of falling. - 4. According to a document titledClinical Services FYI - Post Fall Evaluation (FYI File - [DATE] - Number 34): Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs during a patient's stay. In the event that a patient does fall, a comprehensive clinical evaluation by the nursing supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for a post-fall evaluation may include: . Medication a) Anticoagulant therapy . Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient hits their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but NOT MOVE (both words in bold - not caps - in the original document) the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptoms, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of changes in condition is completed using the SBAR (situation - background - assessment - recommendation) process. According to the directions on the neurological evaluation flow sheet:Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. Based on these directions, a resident should receive no less than seventeen (17) neuro checks completed at progressive intervals. - 5. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the residentmissed his chair and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. After the fall on [DATE], neuro checks were started at 5:05 p.m. These checks, which were to include assessments of the resident's level of consciousness, orientation, pupils, motor movement, communication, and vital signs, were not always complete and were not completed at the progressive intervals required by the directions on the neurological evaluation flow sheet as stated above: - On [DATE] at 5:05 p.m.; at 5:35 p.m.; at 6:05 p.m. (vital signs only); at 6:35 p.m. (vital signs only); at 7:35 p.m. (vital signs only); at 8:35 p.m. (vital signs only); at 9:35 p.m. (vital signs only); and at 10:35 p.m. (vital signs only). - On [DATE] at 6:30 a.m. and at 2:00 p.m. - On [DATE] at 2:00 a.m.; at 6:00 a.m.; and at 8:00 p.m. - On [DATE] at 4:30 p.m. and at 8:00 p.m. - On [DATE] at 8:00 a.m. None of the neuro checks recorded at these times contained abnormal findings. 6. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed):resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning. The LPN also noted the type of incident as a(f)all without injury (or minor injury) . Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, andresident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. Contrary to the information outlined above in the document titledClinical Services FYI - Post Fall Evaluation , Resident #141 - whom staff witnessed hitting his head during the fall - was not evaluated by emergency personnel and there was no evidence that a head injury was ruled out. There was also no evidence that the nurse informed the physician or the family that Resident #141 had hit his head during this fall. - The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written):Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. Tx (treatment) initiated to (L) elbow. Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot. An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written):Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue. At 6:00 p.m. on [DATE], another nurse wrote:Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 7. After the fall on [DATE], neuro checks were started at 10:45 a.m. In spite of the fact that a nurse witnessed the resident hitting his head during this fall, these neuro checks were not always accurate or complete (with temperature readings being recorded in the spaces intended for pulse oximeter readings, and pulse oximeter readings being omitted on several occasions) and the times these checks were completed were not always recorded, making it impossible to determine whether they were completed at the progressive intervals required by the directions on the neurological evaluation flow sheet: - On [DATE] at 10:45 a.m.; at 11:15 a.m.; at 11:45 a.m.; at 12:15 p.m.; at 2:15 p.m.; and at 6:15 p.m. (A nursing note, at 9:00 p.m. on [DATE], stated Resident #141 was sent to the ER, and he did not return to the facility until the early morning of [DATE].) - On [DATE] (no time recorded); and at,[DATE] (no specific time recorded) - On [DATE] at,[DATE] (no specific time recorded); at,[DATE] (no specific time recorded); and at,[DATE] (no specific time recorded) - On [DATE] at,[DATE] (no specific time recorded) Beginning with the first entry on the sheet for this fall at 10:45 a.m. on [DATE], the nurse recorded(arrow pointing down) ROM to indicate an abnormal finding (decrease in range of motion) with respect to the motor movement of the right upper limb. This same notation was made with respect to an assessment of the motor movement of the right upper limb at 11:15 a.m., 11:45 a.m., and 2:15 p.m. on [DATE]; at 6:15 p.m. on [DATE], the nurse recorded(arrow pointing down) R as an abnormal finding for motor movement of the right upper limb. (Note: The injured arm was his left upper limb, not his right upper limb.) Beginning with the first entry on the flow sheet for [DATE] (with no time recorded) and continuing through the entry at,[DATE] on [DATE], the nurse completing the form noted a problem with motor movement of the left upper limb. No problems with motor movement of either upper or lower limbs were noted when the last two (2) entries were recorded on the form for [DATE] at,[DATE] and [DATE] at,[DATE] . No other abnormal findings were noted. - 8. An entry in the nursing notes, in the early morning of [DATE], stated:Resident brought back to facility . Resident also has large bruising area on buttocks D/T (due to) fall. After entries identified the presence of a skin tear to the left arm on [DATE] and the presence of a large area of bruising on the buttocks on [DATE], no additional entries made in the record during the remainder of his stay in the facility contained either a nursing assessment (or a physical description) of his appearance after the fall. There was no further mention of the large bruise on his buttocks and no description of physical findings about his head, which hit the door frame during the fall. There was also evidence in the nursing notes or care plan that were reflective of staff's recognition that the resident's anticoagulant therapy was a potential concern with respect to injuries associated with the fall. - 9. Prior to the fall on [DATE], Resident #141 had been self-ambulating frequently when awake and was able to feed himself independently. After this fall, he required 100% feeding by staff, was frequently refusing to eat or drink. Additionally, nursing entries on [DATE], [DATE], and [DATE] all contained phrases likeresting in bed with eyes closed;Resident resting quietly;resting quietly no acute distress; andresting in bed. There was no documentation in his record to reflect that staff observed the resident ambulating after [DATE], and the resident now required staff assistance with eating; these reflected a significant change in Resident #141's self-performance of activities of daily living. The resident's PT on [DATE] was 23.0 with an INR of 2.1. This was reported to the physician, and the resident's dosage of [MEDICATION NAME] remained the same with an order for [REDACTED]. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 10. Review of the physician's progress notes found the following entries, which appear as recorded (out of chronologic order) and are quoted as written: - On [DATE] at 11:50 a.m. -I saw the pt again today because (1) He fell a couple of nights ago & fractured L humerus (2) He continues to be restless since we have tapered off [MEDICATION NAME] (3) When I went into room - he was flushed and agitated. Temp 99.9 HR 70's irregular. Lungs with bibasilar crackles. Mouth looks a little dry. No LE (lower extremity) [MEDICAL CONDITION]. I spoke with his son - who also noted a 'wild' look in his Dad's eyes recently. We discussed fracture, need to change pain regimen and med strategies for his agitation. He is in agreement with the treatment (illegible) changes. - On [DATE] at 11:22 a.m. -Pt is sedated this morning - missed breakfast. O2 sat 94%. Lungs - coarse BS (breath sounds). Abd (abdomen) soft. Labs were basically OK - Will (check) CXR (chest x-ray) - but probably not a good idea to go for ride to ortho. Nursing aware. (This entry may have been incorrectly dated; it corresponds with a late entry record by nursing for [DATE].) - On [DATE] at 4:50 p.m. -New developments - (Resident #141) continued to poor PO intake and alertness although he did better at times. Not really SOB (short of breath). He continues not to leave arm immobilizer arm. Na (sodium) was 177 last night - he started IV fluids And it was down to 166. PT / INR was also elevated. So [MEDICATION NAME] on hold. His O2 Sat currently - 92% with HR (heart rate) 84. He gets a little restless at times. Lungs with fine basilar crackles. Mouth dry - but he actually looks better and more comfortable than last visit. Nursing comforting family - they agree with us trying to not linger and are discussing Code Status. Will go ahead and change antibiotic to [MEDICATION NAME] IV since we have IV access. Labs in AM (morning). Since stable at present - Will continue fluids - plan change to ? NS tomorrow. - A review of laboratory tests, completed on [DATE], revealed the following: Sodium - 167 (normal range 136 - 146) Chloride - 136 (normal range 98 - 110) Blood urea nitrogen (BUN) - 70 (normal range 8 - 21) Calcium - 11.4 (normal range 8.4 - 10.2) All of these values had the highlighted statement:Significantly different from previous result (previous results were dated [DATE]). The labs were repeated on [DATE] and were approximately the same. - 11. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written):Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%. The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated:Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated:(Name of transport service) here to p/u (pick up) for ortho appt. There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 12. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 13. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm. The report read:The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding. He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. The resident's laboratory values included the following: Lactic acid - 2.2 (normal range 0.5 - 2.0) Sodium - 159 (normal range 98 - 110) INR - 9.53 (normal range 2.5 - 3.5; over 4.9 is critically high) Hemoglobin - 7.9 (normal range 14.0 - 16.0) Hematocrit - 24.8 (normal range 41.0 - 53.0) He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. Per the history provided to the ER physician by the resident's son, the resident had had a functional decline and decreasing memory for the previous four (4) months. However, the son had noted a marked decrease in the resident's mental status in the previous week. According to the history, the son reported to the hospital physician that, only days ago, Resident #141 was walking and feeding himself. The son also informed the ER physician of the resident's recent falls and the resulting fracture to the left arm. - 14. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma wasold and she did not relate it to the fall (even though the CT report indicated the subdural hematoma wasprobably old and that alarge amount of acute bleeding was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). On the previous day ([DATE]), Employee #24 had been asked by this surveyor to explain how the resident got to the hospital. He stated then that he did not know, but he supposed that the residentwent bad in the ambulance and they took him there. When asked if he knew the resident's current health status or why he did not return to the facility, Employee #24 denied any such knowledge and stated that it was the policy of the facility that, if a resident did not return, to not make any inquiries. Employee #24 appeared surprised when informed that there had been no comprehensive nursing assessments during this resident's significant decline from [DATE] until his transfer from the orthopedist's office to the hospital on [DATE] (which was arranged by his son). - 15. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, and would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma wasold, and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team'sright to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 16. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: Resting in bed with eyes closed. Easily aroused. Afebrile. Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain. There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility. The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed):. This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated. Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. Under t

Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure residents received the services and care necessary to promote their highest level of well being. The facility failed to provide services to promote comfort and relieve pain and failed to communicate the recommendations of a consulting physician to a resident's attending physician related to lab studies for three (3) of thirty-eight (38) Stage II sample residents. The failure to provide these services caused actual harm to Resident #228, with the potential for more than minimal harm for Residents #227 and #125. Resident #228 suffered a fall with injuries and was sent to the emergency room six (6) hours after her admission to this facility. Her wound was treated, and she was sent back to the nursing home with instructions from the emergency room physician for follow up care of her injuries and measures for pain relief. This resident verbalized that she was experiencing pain at 3:15 p.m. on 05/18/11. She said she would like to have ice on her eye but they told to they did not have any. Observation found she had a hematoma, a laceration, and facial swelling around her left eye, as well as a large area of bruising. There was no evidence that any pain assessments or any pain relief interventions had been initiated for this resident since her return from the emergency room at 6:30 a.m. on 05/18/11. Resident #227 was admitted to the facility with wounds on his coccyx and was going to the wound healing center every week for treatment. On his visit to the wound center on 05/26/11, the following recommendation was communicated in writing to the facility by the wound center's physician: "If he has not had a PT ([MEDICATION NAME] Time) / INR (International Normalized Ratio) recently, please check. Patient bled during assessment and cleaning." (These are blood test to assess the clotting tendency of the blood and are also used to detect bleeding disorders.) There was no evidence to reflect this recommendation from the wound center's physician was communicated to the resident's attending physician, and these test were not performed. According to the physician orders [REDACTED]. Resident #125 made the staff aware he had a sore toe. The facility failed to address this sore toe even after being made aware of it by the resident. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 This surveyor arrived at the facility and went to this resident's room at 12:00 p.m. on 05/18/11. Observation found the resident had dried blood on her laceration just above her left eye, bruising surrounding the eye, and facial swelling involving the area around the eye. She also had a hematoma on her forehead. She was very pleasant and was eating lunch at that time of this visit. When asked about her eye, she stated she fell while trying to pick up a bag of birdseed. It was later learned that this was the same thing she told the emergency room physician. This surveyor introduced herself and told the resident we could talk after she ate. - Review of the resident's nursing notes found this resident was admitted to the facility at 8:30 p.m. on 05/17/11. The next entry in her nursing notes was at 2:30 a.m. on 05/18/11; this note stated the resident was found face down in her room with blood on her right hand and the left side of her forehead. She was transferred to the emergency room at that time. At the emergency room , her injuries were assessed and her wound was cleaned and repaired. According to the nursing notes, she returned to the facility at 6:30 a.m. on 05/18/11. The resident returned with instructions from the emergency department for follow-up care. There was no evidence the staff assessed the resident's wound, pain or swelling upon her return or provided interventions as instructed by the emergency room physician. The return note, written on 05/18/11, stated (quoted as written), "The resident arrived (name) hospital at 0630 (6:30 a.m.) via ambulance. Resident left eye has a hematoma cut to left eye is bleeding. Resident is talking refused to put ice on her eye for swelling." This was the last entry in the nursing notes when this surveyor reviewed the resident's medical record at 1:30 p.m. on 05/18/11. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was evidence to reflect she received treatment for [REDACTED]. - The resident was interviewed multiple times for short periods on 05/18/11. At 3:15 p.m., she stated, "They have not give me any medicine since I have been here, and I need my medicine." When asked what medicines she took, she said, "I do not know, but I do know that my eye and my head hurts." She was picking at the area above her eye where there was dried blood, and she had dried blood under her fingernails. When asked her if her eye was hurting, she stated, "What do you think? Look at it." When asked about putting ice on the area, and she said, "They have not done anything to it." She stated "the man" told her he did not have any ice. When questioned further about this, she did not remember who "the man" was, and she stated, "They don't even come in here." This surveyor told her, that according to documentation in her medical record, she refused to allow ice to be placed on her eye this morning at 6:30 a.m. when she came back from the emergency room . She denied this and stated, "They told me they did not have any ice." When asked (at 3:40 p.m. on 05/18/11) if she would like some ice, she said, "Yes, if they have some. Maybe that would make it stop hurting." - At 3:45 p.m. on 05/18/11, the registered nurse (RN - Employee #104) was asked by the surveyor to assess the resident for pain at that time. The resident told the RN that her eye was really hurting. The RN asked her if she would like some ice on it, and she stated, "Yes, but they told me they did not have any." The RN obtained an ice pack. The resident was very receptive and placed the ice pack on her eye. The resident had been back from the emergency room for more than nine (9) hours by this time. There was no evidence to reflect staff had assessed this resident, followed the instructions for the care that were provided by the emergency room , or contacted the resident's attending physician for further instructions. The RN stated they would notify the physician and see if they could get her something for pain. She also stated that, perhaps, the resident was speaking of the ambulance driver when she said "they told her they did not have any ice". - Employee #104, when interviewed at 4:30 p.m. on 05/18/11, was questioned about the aftercare instructions provided by the hospital emergency department, which directed them to use Tylenol or [MEDICATION NAME] to control the resident's pain and apply an ice pack for swelling for twenty (20) minutes every one (1) to two (2) hours until the swelling goes down. Employee #104 stated they were not allowed to follow the orders given by the emergency room doctor - they had to call the resident's attending doctor at the facility to get these orders. When asked if anyone had called Resident #228's attending physician for further direction, Employee #104 stated, "Not yet." When asked if there was evidence that any one had completed a pain assessment or provided any interventions for this resident since she returned from the hospital this morning at 6:30 a.m., she reported that an assessment had not yet been completed. - (NOTE: The facility's investigation report for this incident gave times that various events occurred that were different from those documented in the resident's nursing notes. According to the investigation report, the resident was admitted to the facility at 8:30 p.m. on 05/17/11, and she was found face down in the floor at 1:30 a.m. on 05/18/11, after which she was sent to the emergency room . She then returned from the emergency room at 4:45 a.m. on 05/18/11. This deficiency used the event times as recorded in the resident's nursing notes.) -- b) Resident #227 Review of Resident #227's medical record found he was admitted to this facility on 05/06/11 with multiple chronic sacral decubitus ulcers. He was going to the wound healing center weekly, and the physician at the wound clinic changed his dressings and made recommendations for his wound care. During his visit to the wound center on 05/26/11, the wound center physician stated in a report sent back to the facility: "If he has not had a PT / INR recently, please check. Patient bled during assessment and cleaning." There was no evidence this recommendation from the wound center physician was communicated to the resident's attending physician at the facility. A nursing note, dated 06/06/11 at 5:00 p.m., stated (quoted as written): "Resident was up in w/c (wheelchair) and when we returned him to bed his decubitus to his S/C (sacral / coccygeal) area begin to bleed profusely and it was noticed that his roommate while attempting a little earlier to exit the room ran into and caused skin tear /c (with) profusely bleeding to 3rd and 4th toe of (R) (right) foot. Both feet are very cyanotic - Wound to foot cleaned & dressed. Bandages to S/C area saturated /c blood & removed for transport to hosp. Dr. (name) notified of status advised to transport to ER (emergency room ). ..." A physician's orders [REDACTED]." The nursing note, written at 9:30 p.m. on 06/06/11, stated the hospital was called, and they reported the resident was admitted to the intensive care unit. During an interview on 06/07/11 at 11:00 a.m., the director of nursing (DON - Employee #12) verified the facility had not completed the laboratory test (PT / INR) as recommended by the wound center physician to assess the resident's clotting time. There was no evidence this recommendation had ever been communicated to the attending physician at the facility. The resident's attending physician discussed this issue with the surveyor at 11:30 a.m. on 06/08/11. He confirmed these tests (PT / INR) were done after the resident was transferred to the hospital and the results were normal. -- c) Resident #125 During Stage I of the survey on 05/25/11 at 2:20 p.m., this resident stated he had pain with no relief. When asked to describe it, the resident said the toe beside his great toe on his right foot had a "sharp nail (toenail)". The resident stated the podiatrist was the person who trimmed his toenails, and he "left it like that." The resident stated it hurt to walk, so he had been avoiding walking due to the pain. When asked if he had informed facility staff of this problem, he said, "I let three (3) or four (4) people know." Review of the resident's medical record, during Stage II of the survey on 05/31/11, revealed no evidence the facility had assessed or addressed this resident's sore toe. An interview was conducted with Employee #58 (a licensed practical nurse - LPN) at 9:00 a.m. on 06/01/11. Upon inquiry, Employee #58 stated the resident was "very compliant with care" and allowed staff to care for his needs. When asked about the sore toe, Employee #58 stated she had not been made aware of the resident's sore toe. At 10:45 a.m. on 06/01/11, the resident's right toe was observed with Employee #58. During the observation, the resident stated this toe had been hurting "a lot". Employee #58 confirmed there was a sharp toenail on the toe beside his great toe on his right foot. At this time, the resident was asked again if he had let anyone know about this sore toe. The resident stated, "I let three (3) or four (4) of them know." On 06/02/11 at 10:30 a.m., an interview was conducted with the DON. Upon describing the resident's sore toe and statements he told nursing staff about the problem, the DON stated the resident was competent and she believed his statements (regarding telling staff about his sore toe) were credible. At the time of the survey, the facility had not assessed the resident's sore toe to determine the extent of the problem and/or to determine the appropriate care and services needed to address the problem. .

Based on observation, medical record, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents and to promote resident safety. The facility failed to assess the immediate safety needs for Resident #228, a newly admitted resident who was identified in her admission information as having dementia and a history of falls. Failure of the facility to assess the resident upon admission for safety needs and to implement measures to prevent falls resulted in the resident falling only six (6) hours after she arrived at the facility and sustaining a head injury. She was transferred to the emergency room and treated for [REDACTED]. Resident #76, who had a [DIAGNOSES REDACTED]. He was in a low bed, and according to his treatment record, he was to have mats on both sides of the bed. Two (2) mats were stacked on top of each other on one (1) side of the bed with the tile floor on the other side. Resident #48 was observed to have Theraband used in a manner that was presented an accident hazard to this cognitively impaired resident. This band, which had been tied to the wheelchair to secure her leg secured to the chair, presented a hazard when the resident attempted to stand up from the chair without assistance. Resident #5 was observed at meal time to have straws in beverages, which were contrary to his physician's orders [REDACTED]. This was an accident hazard for this resident. Failure of the facility to assess the residents for safety needs and implement measures to prevent accidents and injuries affected three (4) of thirty-eight (38) Stage II sample residents. Resident identifiers: #228, #76, #48, and #5. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 A complaint investigation was initiated at this facility at 12:00 p.m. on 05/18/11. Observation, at this time, found Resident #228 in her room. The resident was seated on a low bed with one (1) mat on the floor on the right side of her bed by the window. She was reaching over to feed herself from her meal tray, which was sitting at bedside on a small isolation cart with rollers. There was no a mat on the floor on the left side of her bed. She had dried blood on her laceration just above her left eye, bruising surrounding the eye, and facial swelling involving the area around the eye. She also had a hematoma on her forehead. She was very pleasant and was eating lunch at that time of this visit. When asked about her eye, she stated she fell while trying to pick up a bag of birdseed. - Review of Resident #228's medical record revealed this [AGE] year old female was admitted to the facility at 8:30 p.m. on 05/17/11. According to hospital records provided on admission, this resident had dementia and a history of falls. That she had frequent falls was also noted on her physician's admission orders [REDACTED] According to the medical record, this resident was admitted to the facility at 8:30 a.m. on 05/17/11. Her admission note recorded her vital signs, weight, and height and stated the dietary department and the pharmacy were notified of her admission and her medications were ordered. The physician's orders [REDACTED]. The note stated: "Will cont (continued) to monitor." There were no further entries in the resident's nursing notes, there were no assessments on file, and there was no evidence to reflect that any safety measures had been implemented. According to the nursing notes dated 05/18/11 at 2:30 a.m., Resident #228 was found face down in the floor in her room with blood on her right hand and on the left side of her forehead; she was subsequently transferred to the hospital for evaluation due to complaints of pain in her left leg. The resident was in this facility for a total of six (6) hours prior to falling and being transferred to the hospital. She subsequently returned to the facility at 6:00 a.m. on 05/18/11. The hospital emergency department notes, when reviewed, indicated the resident arrived at the hospital with signs of head trauma present. Her forehead was tender with a small abrasion. She had facial swelling present involving the area around the left eye. She had a small abrasion to the left cheek and a small abrasion to the left lower eyelid. Her left eyebrow area had a 1.0 cm laceration with controlled bleeding. The resident's wound was repaired with skin adhesive. There were not complications. She had a CAT (Computerized Axial Tomography) scan of the head. The resident was then transported back to the nursing home. The nursing notes upon her return to the facility, dated 05/18/11 at 4:45 a.m., stated: "Notified POA of residents return." The next note, written on 05/18/11, stated (quoted as written), "The resident arrived (name) hospital at 0630 (6:30 a.m.) via ambulance. Resident left eye has a hematoma cut to left eye is bleeding. Resident is talking refused to put ice on her eye for swelling." This was the last entry in the nursing notes when this surveyor reviewed the resident's medical record at 1:30 p.m. on 05/18/11. Based on record review and staff interviews, there was no evidence that direct care staff had been made aware of the resident's risk for falls when she arrived at the facility (in view of her previous history of falls), and there were no evidence to reflect safety measures were implemented by staff to address her immediate care and safety needs until a comprehensive assessment could be completed. Employee #93 (nursing assistant) was interviewed, at 1:00 p.m. on 05/18/11, about how he was made aware of the immediate needs of newly admitted residents. He stated they have a care plan sheet on which the care interventions were written for every resident. He went to the nurses' station and showed this surveyor the care plan sheet. Review of this sheet found no mention of Resident #228. Employee #93 stated they still had the name of the resident who used to be in that room on the sheet and they had not added Resident #228 to it yet. He said usually they added new people and her care needs should have been on here. During an interview with a registered nurse (RN - director of care delivery Employee #104) on 05/18/11 at 2:00 p.m., she was asked how the immediate care needs for newly admitted residents were communicated to the direct care staff. She verified that Resident #228 was not on the care plan sheet, that the sheet contained the name of the resident who previously occupied her bed, and that this had not been changed yet. At this time, eighteen (18) hours had passed since Resident #228's admission to the facility. Employee #104, when questioned how often the care plan sheet was updated, said it was printed each morning with changes. However, this resident had not been added to the form and she was admitted at 8:30 p.m. the prior evening. Employee #76 (nursing assistant) was interviewed the afternoon on 05/18/11; she was providing care to Resident #228 at that time. She was questioned about how she was made aware of the immediate care needs for newly admitted residents, including measures to promote the safety of residents at risk for falling. She stated this facility did not use alarms or side rails because it was "against the state law" and they just do the best they can. Employee #104 was observed, at 5:00 p.m. on 05/18/11, to be completing a care plan for this resident's immediate care needs. She verified there had been nothing written prior to this time, and she could not provide any evidence to show that staff members assigned to provide care to Resident #228 had been made aware of her risk for falls and/or the need for supervision, prior to her fall that resulted in her being sent back to the hospital. She verified that the safety interventions now in place for this resident (low bed and the bilateral landing strips on the floor beside the bed) were initiated after the fall that resulted in her emergency room visit. She also verified that there was no immediate or interim care plan or physician's orders [REDACTED]. When she was made aware that there was only one (1) landing strip beside the resident's bed, she obtained another one (1) for the resident's safety. -- b) Resident # 76 Observation, on 05/31/11 at 1:30 p.m., found Resident #76 in a low bed. He had a feeding tube, a below the knee amputation, and a tracheostomy. There were no side rails on his bed, and two (2) mats ("landing strips") were stacked on top of each other in the floor on the resident's left side of the bed by the window. The nurse administering his medications at that time (Employee #100) was questioned about the mats being on top of each other and asked if there should be one (1) mat on each side of the bed. She stated she did not know, because she was new to this unit. She stated they (the mats) were that way this morning, and this was how she had always seen them. The nurse administered the resident's medication and did not move the mats to provide safety to this resident, nor did she check his medical record to see how these mats were to be used. She stated at that time that she "would have to check on that." The medical record was reviewed, and the resident's medications were checked. At this time, it was noted that this resident's [DIAGNOSES REDACTED]. Employee #100 was questioned again about the mats at 2:30 p.m. on 05/31/11. It had been one (1) hour since the initial observation of these mats being found on only one (1) side of the resident's bed. The nurse said she forgot to check. She looked in the resident's record and stated, "You are right. They should be on both sides of the bed." She then went into the resident's room at that time and moved one (1) of the mats to the resident's right side of the bed, so he would have padding on the tile floor on both sides of the bed. -- c) Resident #148 During the initial tour in Stage I of the survey on 05/24/11 at 11:15 a.m., this resident was observed seated in a wheelchair in the hallway on C-Wing. The resident had a yellow Theraband (stretchy therapy band) tied to her wheelchair and attached to her right foot. The device was knotted in several places to make it short, and had a loop on the end in which to place the resident's foot. The device did not appear to be a product designed to be used in this manner, instead it appeared to be something "rigged" to suit a purpose. During the observation, the resident attempted to stand several times. Fortunately, she had squirmed around in her wheelchair enough that her foot had slipped out of the Theraband before she attempted to stand. However, the resident did not have the cognitive ability to purposefully remove her foot from the device so it would not cause a fall when she attempted to stand. Since the resident made attempts to stand, the Theraband (when attached to her foot) presented an accident hazard. At 11:40 a.m. on 05/24/11, an interview was conducted with a licensed practical nurse (LPN - Employee #8), who stated, "Therapy puts it on her foot to keep her from dropping her leg." Employee #8 looked at the resident's treatment records and stated there was nothing in those records regarding the use of this observed device. - The resident was reviewed during Stage II of the survey. At 10:45 a.m. on 06/08/11, an interview was conducted with Employee #110 (the rehabilitation services manager) and Employee #200 (a physical therapist). Employee #200 stated she had decided to use the device and had applied it to the resident and the wheelchair. Further interview revealed the resident had a total hip replacement. The surgery later had to be redone. Employee #200 stated, "After the surgery the whole leg was rotating, and she does not have cognitive ability to maintain hip precautions." For these reasons, Employee #200 stated she decided to use the Theraband in this fashion. When asked if this was a recommended use for a Theraband, Employee #200 stated, "I have seen other therapists do it at other places." At that time, Employee #200 was informed about the resident's attempts to stand on 05/24/11. Employee #200 stated she was not aware the resident was able to stand and was not aware of her attempts to do so. - Medical record review, on 06/08/11, revealed no assessment or care plan for any device to maintain hip precautions. Employees #110 and #200 were asked if there were any therapy notes and/or orders for this device. At 10:45 on 06/08/11, Employee #110 stated there were no progress notes, physician's orders [REDACTED]. - The facility had not used results of a comprehensive assessment to develop a care plan for this resident regarding her need to maintain hip precautions, and at the same time prevent avoidable accidents. The hazards and risks of using a device which restricts the movement of a foot, especially for a cognitively impaired resident, were not identified. There was the potential for an avoidable accident because the facility failed to identify this resident's individual risk of an accident. The Theraband, as used, was an accident hazard over which the facility had control. The facility failed to assess this resident's individual needs and risks regarding the use of the Theraband in this manner. -- d) Resident #5 After lunch on 05/26/11, the resident was observed lying in bed drinking her afternoon nutritional supplement. She was drinking from a straw inserted into a small carton of supplement. The head of her bed was elevated at only approximately 30 degrees. This posed a potential for increased risk of aspiration. Observation, on 05/31/11 at approximately 2:00 p.m., found the resident lying in bed holding a carton of supplement with a straw. The head of her bed was elevated at only approximately 30 degrees. On 06/01/11 at 11:30 a.m., the resident was observed lying in bed. A cup with a straw and a small carton of supplement with a straw were at her bedside. The resident was elevated at only approximately 20 degrees. Subsequent observations throughout the day on 06/01/11 and 06/02/11 found she had straws in her beverages and was not positioned in an upright position. A speech therapist had evaluated the resident on 02/15/11. The therapist had noted the resident needed to be in upright position. Review of the physician's orders [REDACTED]." .

Based on closed record review, review of the facility's self-reported injuries of unknown source and allegations of resident abuse / neglect, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injury for one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute fracture of the fibula with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Resident identifier: #147. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually understood what others said to her. According to the assessor, Resident #147 had partial loss of voluntary movement with limitations to range of motion in both her legs and her feet; tests for standing and sitting balance were not able to be attempted; she required the extensive physical assistance of one (1) person for bed mobility, bathing, dressing, and personal hygiene; she was totally dependent on two (2) or more persons for transferring, locomotion, and toilet use; she was to be transferred using a mechanical lift; and she was non-ambulatory. Her [DIAGNOSES REDACTED]., anxiety disorder and depression, and chronic obstructive pulmonary disease. The assessor did not identify, as active diagnoses, either osteoporosis or pathological bone fracture, and the assessor did not identify the resident as having any acute episode or flare-up of a recurrent or chronic problem, nor did the assessor indicate the resident had an end-stage disease. As other the ARD of 02/24/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - In Resident #147's most recent abbreviated quarterly assessment, with an ARD of 08/11/10, the assessor noted there had been no changes in her memory, cognitive functioning, or ability to communicate. She continued to have partial loss of voluntary movement with limitations to range of motion in both legs and feet; a test for standing balance was not able to be attempted, and a test for sitting balance revealed the need for partial physical support. According to the assessor, she was now totally dependent on one (1) person for bed mobility and toilet use; she was totally dependent on two (2) or more persons for transferring; she required the extensive physical assistance of one (1) person for locomotion, dressing, bathing, and personal hygiene; and she remained non-ambulatory. As other the ARD of 08/11/10, Resident #147 did not have any falls or fractures in the preceding one hundred-eighty (180) days. - Review of her most recent comprehensive care plan (with a print date of 08/18/10) revealed the following problem statement (with a created date of 11/28/07 and a revision date of 10/08/08): "ADL (activities of daily living) Self (sic) care deficit as evidenced by need of (sic) staff support to complete her self care activities related to physical limitations, trremors (sic), pain and dementia." Goals associated with this problem statement were: "Will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing. Will receive assistance necessary to meet ADL needs. Will participate in self-care tasks at the highest practicable level of functioning." Interventions to meet these goals included: "Tranfer (sic) with 2 person / Mechanical Lift (sic)." (This intervention was created / initiated on 01/18/10.) -- 2. A review of Resident #147's nursing notes revealed the following consecutive entries: - On 09/02/10 at 10:20 p.m. - "Resident c/o (complained of) pain to (L) (left) leg. MD aware. N.O. (new order) for Stat xray (sic) to left leg. MPOA (medical power of attorney representative) aware. Assessment completed to left leg. (Symbol for 'no') bruising, (symbol for 'no') scratches, (symbol for 'no') edema, (symbol for 'no') redness noted. Resident states 'I can't feel my legs'. Xray (sic) obtain (sic) per order. Resident didn't complain of discomfort during x-ray. Xray (sic) to be faxed to nurses (sic) station." The author, registered nurse (RN) supervisor Employee #134, struck through this entry and labeled it "error", although the author did not note the date / time when this correction was made. - On 09/03/10 at 1:00 a.m. - "C/O (complaint of) pain in left leg. PRN (as needed) analgesic x 1 per order /c (with) No (sic) relief." - 09/03/10 at 2:30 a.m. - "Xray (sic) results called to Dr. (name) /c new order noted to send to ER (sic) (emergency room ) for evaluation & ortho (orthopedic) consult d/t fx (fracture) of left fibula. ..." - 09/03/10 at 3:15 a.m. - "Left unit via gernie (sic) accompanied by two attendants from ems (emergency medical service) en route to (name of local hospital)." - After the resident's transfer to the hospital on [DATE], Employee #134 recorded the following series of late entries: - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 7:30 p.m. Resident complaint (sic) of pain to left leg. Assessment completed to left leg. (Symbol for 'no') bruising noted. (Symbol for 'no') redness. (Symbol for 'no') edema, or scratches noted to left leg. resident (sic) c/o pain in the knee area. Resident stated 'I can't feel my legs.' Call placed to MD. resident (sic) medicated for pain per order. Will continue to monitor." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 8:00 p.m. MD return (sic) call obtain (sic) order for stat xray (sic). POA (power of attorney) aware. (Name of mobile imaging company) aware." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 8:45 p.m. Xray's (sic) obtained, daughter /c resident at bedside. (Symbol for 'no') complaints of pain at this time. Will continue to monitor resident and await the report." - 09/09/10 (no time noted) - "late (sic) entry for 9/2/10 10:20 p.m. Resident resting in bed. (Symbol for 'no') discomfort noted. (Symbol for 'no') complaints of pain noted. Awaiting xray (sic) to be faxed to nurses (sic) station. (Symbol for 'no') edema, (symbol for 'no') bruising, (symbol for 'no') redness noted to left leg. Will continue to monitor." This was the last entry in the resident's nursing notes; she did not return to this facility after being transferred to the hospital on [DATE]. -- 3. The radiology report for Resident #147 from the mobile imaging company, with a "date of exam" of "2010-09-02" (09/02/10) contained the following impression: "Left tibia-fibula - Mildly displaced acute fracture of the proximal fibular shaft and fibular head demonstrated." There was no evidence to reflect this acute displaced fracture of the left fibula of this non-ambulatory resident, who was totally dependent on staff for bed mobility, transferring, and locomotion, was clinically unavoidable (e.g., the result of osteoporosis or a pathological bone fracture). -- 4. A review of the facility's self-reported allegations of resident abuse / neglect and injuries of unknown source, on 12/21/10 beginning at approximately 11:00 a.m., revealed the facility reported Resident #147's fracture as an injury of unknown source to the State survey and certification agency and other State agencies on 09/03/10 as follows: "Resident complained of 'not being able to feel' her leg. Obtained xray (sic) of left leg and results showed fracture. ..." The date of the incident was noted to be on 09/02/10 during the 3:00 p.m. to 11:00 p.m. shift (no specific time stated); the location of the incident was noted to be "Unknown". - Review of the facility's internal investigation into this fracture of unknown source revealed that, although a discreet causal event could not be isolated, three (3) nursing assistants (Employees #152, #141, and #170) transferred the resident on 09/02/10 without using a mechanical lift as identified in the resident's comprehensive assessment and care plan. - According to a handwritten witness statement by the former interim director of nursing (Employee #171), dated 09/08/10: "During the termination phase of the disciplinary process for (Employee #152, CNA (certified nursing assistant), regarding (Resident #147) (sic). The employee made the following verbal statements: "'About 4 pm (sic) (Resident #147) was sitting in w/c (wheelchair) in hallway crying. I asked her what was wrong and (Employee #141, another nursing assistant) said she always cries when she looses (sic) at Bingo. I ask (sic) her if she wanted to take a shower. I took her to the shower room in the wheelchair.' "'(Employee #170) had stayed until 7:00 PM (sic) to do showers; (Resident #147) was still crying. (Employee #170 and I stood (Resident #147) and pivoted her to the shower chair. I left and came back when shower was done; we dressed her, stood and pivoted her from the shower chair to the wheelchair. I took her back to her room, she usually is only out of bed for an hour. I was going to put her in bed; I did a face to face lift; she wasn't bearing weight but she started saying 'my leg, my leg, set me down. (sic) I set her down and called to (Employee #141) to help me. We transferred her to bed with (Employee #141) behind her, me in front; we stood her and pivoted. "We didn't use a gait belt; we didn't use a mechanical lift. "'I did not check the Patient information worksheet.' "'I know we are a no lift company.' "'I have used the lift in the past.' ..." -- 5. Upon request, the facility provided a copy of the policy titled "Mechanical Lift" (dated 03/10/10). According to this document, the purpose of the policy is "(t)o move immobile or obese patients for whom manual transfer poses potential for staff or patient injury". Review of the facility's employee handbook revealed, under the heading "Safety Rules" on page 38: "1. Report all accidents immediately, no matter how minor, to your supervisor. Your supervisor is required to make a thorough investigation and to complete an Accident Investigation Report. You are required to complete an Employee Incident Report for on-the-job accidents. "2. Utilize appropriate lifting techniques and body mechanics for all lifting, including patient / resident transfers. All lifting must be performed in accordance with location procedures. Utilize mechanical lifting equipment where appropriate. ..." -- 6. On the Patient Information Worksheet, Resident #147 was listed as requiring "2 person / Mechanical Lift". -- 7. In an interview on 12/22/10 at approximately 3:00 p.m., Employee #134 stated she did work on 09/02/10. She came back to work on 09/09/10 and recorded additional documentation in Resident #147's medical record, after she realized she had made an error regarding the time of the incident in her original note. Employee #134 stated a nurse aide did inform her that the resident complained of pain on the evening of 09/02/10. She assessed the resident's leg, and the resident did not appear to have any swelling, redness or tenderness to her leg during the assessment. She assisted the mobile imaging company during their x-ray of the resident's leg, and the resident did not appear to be in any pain at that time. -- 8. In an interview on 12/22/10 at approximately 3:30 p.m., Employee #141 stated his employment was terminated after this incident, but he was later asked to return to work. He reported he was not the aide assigned to Resident #146 on 09/02/10, but he did assist his co-worker (Employee #152) on that day. He verified they did not use a mechanical lift to transfer the resident from her wheelchair to her bed. He agreed he should have looked to see what type of assistance the resident needed for transferring before he assisted Employee #152, but he reiterated that he had his own assignments and had just agreed to help out a co-worker with a transfer on 09/02/10. -- 9. The assistant director of nursing (ADON - Employee #139) confirmed, during an interview on the afternoon of 12/22/10, the facility was a "no lift company". The ADON also confirmed that no incident / accident report was completed related to the events that took place on the evening of 09/02/10 involving Resident #147. -- 10. Although it could not be ascertained at what time the fracture occurred on 09/02/10, staff manually transferred Resident #147 on three (3) separate occasions on this date (from the wheelchair to the shower chair; from the shower chair back to the wheelchair on the evening; and from the wheelchair to the bed), contrary to the resident's comprehensive assessment, comprehensive care plan, and the Patient Information Sheet. The resident complained of leg pain during the second and third manual transfers, and the fracture was identified via x-ray in response to the resident's complaints of leg pain after the third manual transfer occurred. .