Every finding on record at Complete Care at Nazareth LLC

Based on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 2 of 3 residents (R2 and R1) reviewed.On 5/12/26, the facility substituted Brussels sprouts for carrots at the evening meal, without the approval of CD G (Clinical Dietician.) Brussels sprouts were served whole to resident R2 and R1, despite having mechanical soft diets.R2 had a choking episode and was sent to the emergency room (ER) for evaluation.R1 had a choking episode and was sent to the ER for evaluation. R1 expired at the hospital.The facility's failure to ensure appropriate meal substitution, prepare food to the proper consistency for ordered diet, and recognize that inappropriate consistency was served created a finding of immediate jeopardy that began on 5/12/26. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 5/28/26 at 12:48 PM. The immediacy was removed and corrected on 5/13/26; the deficient practice is being cited as past noncompliance. Evidenced by:The facility's Menu Substitution policy, undated, states in part: .If therapeutic or mechanically altered diets are offered, appropriate substitutions will be approved by the Registered Dietician based on the therapeutic diet policies or the diet manual used by the community.The facility's Therapeutic Diet Orders policy, dated 5/26, states in part: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Definitions: Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Food must be soft, moist, and easily mashed with a fork. Maximum size: 1/2 inch pieces.5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed.The International Dysphagia Diet Standardization Initiative (IDDSI) website's (https://www.iddsi.org/) IDDSI Framework and Detailed Level Definitions, dated July 2019, states, in part: 6 Soft and Bite-Sized Examples of Level 6 Soft and Bite Sized Food for Adults .Vegetables steamed or boiled with final cooked size no bigger than 1.5 cm (centimeters) by 1.5 cm. 5 Minced and Moist Examples of Level 5 Minced and Moist Food for Adults .Vegetables cooked, finely mashed or use a blender to finely chop it into a 4 mm (millimeter) lump size pieces.On 5/28/26 at 8:37 AM, Surveyor interviewed [NAME] I and asked about the evening meal on 5/12/26. [NAME] I stated we didn't have carrots. I put the Brussels sprouts in the steamer. I did puree some for those with pureed diet. For the mechanical soft, I served them whole. 1.) R2 was admitted to the facility on [DATE] and has diagnoses that include in part: vascular dementia (a decline in thinking and memory skills caused by restricted or blocked blood flow to the brain); and dysphagia (difficulty swallowing.)R2's Physician orders include: Regular Diet, mechanical soft texture, Regular (thin) consistency, no bread, soft fruits only for diet. Order date 5/15/25R2's care plan includes: R2 is at risk for malnutrition related to history of .dysphagia requiring mechanically altered textures. Diet: regular diet, mechanical soft, thin liquids. No bread, soft fruits only. R2's Progress notes include, in part:*5/12/26 5:32 PM CNA (Certified Nursing Assistant) observed resident choking in dining room and pushed resident to nursing station. Writer started the Heimlich maneuver and proceeded to give the resident the Heimlich and dialed 911, proceeded to give the Heimlich until EMS (Emergency Medical Services) arrived; resident sent out to ER via EMS.*5/12/26 7:43 PM Resident returned to facility via EMS transport, VSS (vital signs stable.) Chest x-ray negative. Resident was able to clear secretions on resident's own prior to arriving at hospital.R2's Emergency/Urgent Care note, dated 5/12/26 at 6:28 PM, states, in part: Chief Complaint patient presents with *Aspiration Pt (patient) arrives via EMS.Staff reported resident was choking. EMS state pt was blue when they arrived. Pt placed on 3 liters (oxygen) via nasal cannula. Pt was able to clear food secretions. XR (x-ray) chest.findings: .No pleural effusion (excess buildup of fluid in the space between the lungs and the chest wall) or pneumothorax (collapsed lung). Lungs are clear.R2's Speech Therapy Evaluation dated 5/13/26, states in part: Pt was on a mech (mechanical) soft diet prior to her choking incident, .R2's meal ticket, dated 5/12/26, evening meal, states in part: *Diet: Regular-mechanical soft*Dislikes: .SOFT FRUIT ONLY!!! MINCED AND MOIST FOODS ONLY*Scalloped potatoes and grd (ground) ham, soft topping*Parslied Carrots .On 5/28/26 at 12:59 PM, Surveyor interviewed CNA J and asked about R2's meal on 5/12/26. CNA J stated R2 had a bowl of whole Brussels sprouts. As soon as R2 started coughing, I felt something wasn't right. I ran R2 straight to the nurse station, since I wasn't 100% confident so I got her to someone who would do it right (the Heimlich.)On 5/27/26 at 3:29 PM, Surveyor interviewed LPN E and asked about the choking episode for R2. LPN E stated R2 was in the dining room and food was placed in front of R2. LPN E stated I stepped away to give a resident a medication. I was training a MT (Medication Technician) by the nurses' station. CNA J ran R2 down the hall to me saying R2 was choking. I started the Heimlich and asked the MT to call 911. The MT helped me to set R2 up in the chair. I was doing the Heimlich, R2 was sort of breathing a bit, then she started turning blue. We were on the phone with 911. I asked the CNA to get another nurse to help with paperwork. LPN C came up and started listening to lungs, then took over on the phone. R2 was breathing but it was distressed. The Heimlich wasn't doing much. R2 was spitting up; some of it was not discernible. CNA J said R2 hadn't been fed yet, but R2 picks up food from her tray, so she may have gotten one of the Brussels sprouts. Then another CNA came up from 1st floor and said that another resident was choking on the 1st floor. At that point R2 was breathing and LPN C was there, so I ran to the 1st floor. On 5/27/26 at 2:15 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked about the choking episode for R2. LPN C stated that a CNA came to the 1st floor from the 2nd floor and said that a resident was choking on the 2nd floor and the nurse needed assist. When I got to the 2nd floor, LPN E was on the phone with 911 and I went straight to the patient and asked LPN E about what assessments had been done. I did a complete assessment; oxygen level was in the 70s. R2 was wearing oxygen, I turned it up a little bit. R2 wasn't moving hardly any air due to how her lungs sounded. She was gasping for breath and anxious, so I started talking to her and encouraging her to cough. As R2 coughed, her oxygen level was going up and she started calming down as I talked with her. EMS arrived quickly; they applied oxygen, put R2 on the gurney and left with her. On 5/27/26 at 1:54 PM, Surveyor interviewed SLP F (Speech Language Pathologist) and asked about mechanical soft diets. SLP F stated It should have ground meat, things should be cut in small pieces. Vegetables should be able to mash. Surveyor asked if there is a difference between mechanical soft and minced and moist. SLP F stated that minced and moist, to my understanding, everything is chopped pretty fine and has a gravy or moisture to it. We don't follow IDDSI (International Dysphagia Diet Standardization Initiative). Mechanical soft means different things to different food services and to different speech therapists. Surveyor asked what level of IDDSI mechanical soft would be. SLP F stated between level 5 and 6. Surveyor asked if Brussels sprouts are an equivalent to carrots? SLP F stated no, though R2 did have mashed Brussels sprouts during one of our assessments and ate 100%. With a true mechanical soft diet, Brussels sprouts would not be offered. Dietary said that if they are quartered, they are ok. But I feel they are really hard to break down. Surveyor asked if Brussels sprouts are part of a mechanical soft/minced and moist diet. SLP F stated no, I would say not. Surveyor asked about R2. SLP F stated R2 was no longer on speech due to hospice, though I'd have preferred to continue with her treatment. R2 was on mechanical soft diet. Surveyor asked if Brussels sprouts would be safe on R2's diet. SLP F stated no. While mashed Brussels sprouts were served in a therapy session, I would not have chosen/recommended this for her meals. 2.) R1 was admitted to the facility on [DATE] and had diagnoses including: vascular dementia and dysphagia;R1's Physician Orders include in part: Heart healthy diet Mechanical soft texture, regular (thin) consistency. Resident to remain on a mechanical soft diet with Supervision for small bites and slower eating pace.Order date 2/24/26R1's Care plan includes:*R1 has a swallowing problem r/t (related to) dysphagia, aspiration risk.diet mechanical soft minced/moistR1's Speech Therapy Discharge summary, dated [DATE], states in part: *What diet is recommended for the patient to swallow solids safely? = Minced and moist*Solids=Mechanical soft/ground texturesR1's meal ticket, dated 5/12/26 evening meal, states in part:*Diet: Heart healthy-mechanical soft*Ground pork steak Soft/chopped CarrotsR1's Progress Notes, dated 5/12/26 at 5:50 PM, state: Resident in dining room eating with staff present at table with staff member sitting at table supervising. Several other nursing staff present when client started coughing and sneezing. CNA immediately went to resident saw that resident was in distress and turning cyanotic, and started the Heimlich maneuver, resident coughed up food objects and started breathing on own, resident took to her room put her on 2 lt (liters) of O2 (oxygen) Resident still in distress ore (sic) objects coughed up nurse assessed resident still having complications.On 5/27/26 at 2:50 PM, Surveyor interviewed MT D (Medication Technician) who stated, I was in the dining room making coffee for another resident. A CNA called out saying R1 needed help. I asked R1 if she was ok and R1 put her hands to her throat (universal sign of choking.) I asked a CNA to help me raise R1 into a better sitting position and I started to do thrusts. A piece of food came out of R1's mouth. I told someone to get the nurse. Surveyor asked what came out of R1's mouth. MT D stated, It was a Brussels sprout; it appeared to be a whole Brussels sprout. Surveyor asked what happened next. MT D stated while the CNA went to get the nurse, I took R1 to her room. R1 said there was more in there. I did a couple more thrusts and more came out; it appeared to be meat, it was brown. I put R1 on oxygen, and then LPN E came. LPN E told us to come along and take R1 to the other nurse. On 5/27/26 at 3:29 PM, Surveyors interviewed LPN E who stated, a CNA came to the unit while I was working with LPN C and R2. The CNA said there was a resident choking on level 1. LPN C stayed with R2, and I went to R1. When I got there, the CNAs were doing the Heimlich. I started the Heimlich, R1 was blue when I arrived. With the Heimlich, R1 started to breathe, but it sounded like there was phlegm in her throat. I told the CNAs to get oxygen and get R1 upstairs by LPN C. R1 was breathing and talking at that point. LPN E stated, during the Heimlich a piece of Brussels sprout came out; when we got upstairs, more came out. EMS was there and taking R2. Someone asked if EMS could take both residents, but someone said they wanted us to call hospice.not sure if it was LPN C or EMS that wanted hospice called. R1 was breathing and talking, but the breathing was scary. On 5/27/26 at 2:15 PM, Surveyor interviewed LPN C and asked about R1. LPN C stated I was on the 2nd floor assisting with R2. Someone said that I had a resident choking on 1st floor. LPN E went to help R1 while I finished with R2. The CNAs and MT had done the Heimlich, then brought R1 up to the 2nd floor by me. R1 was breathing and talking but was still having respiratory noises and I knew that something was still in there. I gave R1 a thrust, and a Brussels sprout came out and rolled across the floor. It was a whole Brussels sprout. I took R1 back to the 1st floor. I checked R1's vital signs, she was talking to me. R1's oxygen level was low, I put oxygen on her; I think 3 Liters, she was still making a noise, like you could hear that there was something in there. I called the POA, I called hospice and was on hold. I called the on-call physician and got orders to send R1 out. R1's Emergency/Urgent Care hospital note, dated 5/12/26, states in part: Chief Complaint Patient presents with Aspiration. Aspirated and choked on brussels sprouts and chicken. Lab Interpretation: XR (x-ray) chest. Findings: .low lung volumes (decreased lung capacity) with multifocal interstitial and airspace opacities suggesting aspiration (accidentally breathing food or liquid into the airway and lungs) and atelectasis (partial or complete collapse of a lung or a specific section of the lung) and possible superimposed pulmonary edema (acute development of fluid in the lungs). Superimposed infection would be difficult to exclude.R1 passed away while at the hospital.R1's Hospital Notes Report, dated 5/12/26, states: .per coroner office, medical examiner will go to funeral home to sign death certificate due to death being documented by coroner office as accident. Clinical impressions: choking, initial encounter.cardiopulmonary arrest. Disposition: expired. On 5/27/26 at 1:54 PM, Surveyor interviewed SLP F regarding R1. SLP F stated R1 was on a mechanical soft diet. Surveyor asked if Brussels sprouts would be safe on R1's diet. SLP F stated no. On 5/28/26 at 8:01 AM, Surveyor interviewed CD G (Clinical Dietician) and asked about a mechanical soft diet. CD G stated it varies based on different sources, it is not necessarily approved by the Dysphagia Association as they use IDDSI. CD G stated it is ground meat, finely chopped meat. No fibrous vegetables. If Brussels sprouts are served, they would need to be tender. Gravy on meats. Everything is moist and soft. Surveyor asked about minced and moist. CD G stated that is IDDSI and is modified a bit different. Things need to be certain sizes, need to stay moist, pass a fork test. This facility doesn't use IDDSI at all. Surveyor asked if there is a difference between mechanical soft and minced/moist. CD G stated yes; there are different ways to distinguish. Mechanical soft is more of an umbrella that combines minced and moist and soft and bite size; the level 5 and 6 of IDDSI. Surveyor asked if Brussels sprouts are part of a mechanical soft/minced and moist diet. CD G stated it depends on the resource. Generally it is not recommended as it is more fibrous. It could be if it is cooked very soft and fork tender and cut small. You'd need to cut out the stem and remove the more fibrous parts. Surveyor asked about meal substitutions. CD G stated the kitchen will let me know if we need to substitute an item due to being out of stock. In this instance, I was not contacted in advance. Surveyor asked if Brussels sprouts are an equivalent substitute for carrots. CD G stated it wouldn't have been my preferred. I would've made sure to remind to cook very soft, remove the fibrous part and cut it into very small pieces. Surveyor asked if a resident on mechanical soft/minced and moist diet should receive whole Brussels sprouts. CD G stated no. On 5/28/26 at 9:26 AM, Surveyor interviewed DON B and asked if whole Brussels sprouts are part of a mechanical soft/minced and moist diet. DON B stated no. Surveyor asked if R2 and R1 were served whole Brussels sprouts. DON B stated yes, that is my understanding. DON B stated that following the choking incidents the facility confirmed that a meal substitution had been done without proper approval, food had been served without modification to the appropriate consistency, and staff had failed to recognize that inappropriate food items were served to residents. The failure to get approval for an appropriate meal substitution, prepare food to the appropriate consistency, and recognize that inappropriate food items were served created a hazard which led to serious harm for R1 and R2, which created a finding of immediate jeopardy. The facility removed the jeopardy on 5/13/26 when it completed the following:Same Day - Immediate Corrective ActionsRN assessments initiated for all residents on mechanically altered diets, including vitals and respiratory checks, completed within 3 hoursOutcome: no other residents affected, all assessments were within normal limits and residents at their baselineImmediate staff education drafted and initiated by 930pm on the following:Identifying mechanically altered diet items andEmergency response to chokingAll staff were educated PRIOR to the start of their next working shift100% compliance achievedWithin 24 HoursSelf report to DQA submitted.Thorough investigation initiated by Nursing and Regional Management, including staff interviews.Sentinel Event call held with Executive Leadership, including Director of Risk Management, CEO, Medical Director, etc.Following Days (Ongoing Corrective Actions)Daily tray audits by dietary management and DON to ensure diet texture compliance.Outcome: all trays were in compliance with altered diet requirements, continuation of audits still in place and show 100% complianceDaily rounding by nursing and dietary management to reinforce education and ensure supervision per care plans.Outcome: continuation of rounding still in place and show 100% knowledge of mechanically soft diet items and compliance with following care plansAll dietary staff reeducated on:Mechanically altered diet preparationMeal substitution processAll dietary staff were educated PRIOR to the start of their next working shift100% compliance achievedPolicies updated to strengthen therapeutic diet order language.Post Return of Resident from HospitalResident monitored with vitals and respiratory assessments every shift for 72 hours.Outcome: no adverse effects identified, all assessments were within normal limits and resident at her baselineSpeech Therapy evaluation ordered and completed before next meal.Care plan updated according to new Speech therapy recommendations

Based on interview and record review, the facility failed to ensure professional standards were in place to describe the characteristics of food and drink. This has the potential to affect the 65 Residents of the facility.The facility is not following current standards of practice for nutrition by not following IDDSI (International Dysphagia Diet Standardisation Initiative).Evidenced by:Per the SOM Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature. Possible reference sources for standards of practice include: Current manuals or textbooks on nursing, social work, physical therapy, etc. Standards published by professional organizations such as the American Dietetic Association, American Medical Association, American Medical Directors Association, American Nurses Association, National Association of Activity Professionals, National Association of Social Work, etc. Current professional journal articles. Per the IDDSI website : The IDDSI Framework (the Standard) The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness. IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature). The clinician has the responsibility to make recommendations for foods or drinks for a particular patient based on their comprehensive clinical assessment. (https://www.iddsi.org/standards/framework )Per the National foundation of Swallowing Disorders, IDDSI is the global framework designed to standardize the terminology and descriptors for texture-modified foods and thickened liquids for individuals with swallowing difficulties, known as dysphagia. I was created to improve safety, reduce confusion and ensure consistent care across healthcare settings worldwide.) On 5/27/26 at 1: 54 PM, Surveyor interviewed SLP F (Speech Language Pathologist) who stated we don't follow IDDSI. On 5/28/26 at 8:01 AM, Surveyor interviewed CD G (Clinical Dietician) who stated this facility doesn't use IDDSI at all. On 5/28/26 at 1:01 PM, Surveyor interviewed DM H (District Manager) who stated we go off whatever the client (the facility) has in place and what they want to do. IDDSI is used by a sister facility, but it is not used here. Surveyor asked if the standard of practice should be followed. DM H stated based off the situation of the last few weeks, yes. This would be more specific and help everyone in the process. On 5/28/26 at 1:08 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about the facility not following IDDSI. NHA A stated I didn't know that it needed to be followed. I am not aware of CMS (Centers for Medicare and Medicaid Services) regulation saying that it has to be followed. Surveyor asked if the Standard of Practice should be followed. NHA A stated yes.Additional information was provided by NHA A on 5/28/26 which indicated the facility follows the 12th edition of simplified diet manual, However this resource is not the current edition. The 13th edition indicates revisions and additions to the twelfth edition of the simplified diet manual include: .Revision of the modified texture diets and addition of the International Dysphagia Diet Standardization Initiative . Cross Reference F689.

Based on interview and record review, the facility did not ensure comprehensive care plans were revised in accordance with the resident's current status and care needs for 1 of 3 residents (R4) reviewed for care planning timing and revision.The facility did not update R4's care plan to prevent future occurrences after he had a resident to resident incident where he grabbed the wrist of another resident (R3).Evidenced by:Facility policy, titled Comprehensive Care Plans, dated 2023, includes: . It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs. Trigger specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Alternative interventions will be documented as needed.R3 admitted to the facility on [DATE] with the following diagnoses: Anxiety disorder and depression.R4 admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia with psychotic disturbances, irritability and anger, cognitive communication deficit.R4's Comprehensive Care Plan, includes: Initiated 8/12/24, Focus-R4 has delusional thoughts at times. Goal- no harm to self or others due to delusional thoughts. Will be free of signs and symptoms of delirium. Interventions- Redirect and provide gentle reality orientation as required. Initiated 10/28/25, The resident has a mood problem related to admission. Goal- The resident will have improved mood state, happier, calmer appearance, no signs and symptoms of depression, anxiety, or sadness. Interventions- The resident needs time to talk. Encourage the resident to express feelings.Facility Self Report, dated 4/4/26, includes, in part: Investigative Summary- On Saturday, 4/4/26, an altercation transpired between R3 and R4. The event occurred at approximately 6:10 PM in the. dining room. According to staff, R3 was seated at the dining table with other residents awaiting their dinner meal when he began extending his middle finger in the air. At this time, R4 was walking around the dining room, and it appeared that this was perceived as a derogatory gesture towards him. In response, he grabbed R3's wrist, which was later understood to be an effort to get R3 to stop. Staff present immediately intervened and it was reported the entire event lasted 5 seconds. The two individuals were separated and R4 elected to return to his room. Nursing assessed both individuals and there was no evidence of injury. The evening continued with no further interactions between the two individuals. Staff remained present in the dining room and continued to monitor. CNA XXX witness statement- At dinner time around 5:40 PM R3 and R4 was in the dining room with the others. Residents were getting agitated as dinner has not arrived yet. R3 flicked off. as R4 was walking past and saw it. R4 went at R3 grabbing his wrist trying to punch him.On 5/27/26 at 10:30 AM, DON B (Director of Nursing) indicated staff are aware of R4's and R3's resident to resident interaction and staff make sure R4's proximity to others is not near. DON B indicated R4 is a higher risk for a resident to resident since he has already been involved in one incident with R3. DON B indicated the facility uses agency staff who may not be aware of R4's and R3's history and would not be able to identify that R4 is high risk of having a resident-to-resident incident. DON B indicated the facility should have updated R4's care plan with focus, goals, and interventions related to preventing another resident-to-resident interaction, but they focused too much on R3's care plan. DON B indicated the facility could include R4's triggers for aggressive behaviors include perceived insults and obscene gestures.On 5/27/26 at 12:06 PM, Surveyor observed R4 to be walking in the dining room approaching other residents. R4 handed another resident a packaged cinnamon roll but then took it back. R4 took an empty cup away from one resident and tossed it in the garbage. Surveyor also observed R4 to be standing and fixing the radio antenna in the dining room that was near R3 who was at this was raising his fist and shaking it in the air. Staff were present during the interaction, but had their backs turned away from R3 and R4.(It is important to note R4 is independent with ambulating and is entering into other residents' spaces. It is also important to note staff were not visualizing R4 at all times while in dining room amongst other residents, including R3.)On 5/27/26 at 3:23 PM, NHA A (Nursing Home Administrator) indicated the IDT (Interdisciplinary Team) reviewed R4's care plan and thought it was appropriate at the time. NHA A indicated R4 is at a higher risk for a resident-to-resident incident due to the fact that he has already been involved in one. NHA A indicated the facility uses agency staff who may not be aware R4 had a resident to resident in his history and would not be able to identify R4 as being at a higher risk for this. NHA A indicated there were no changes made to R4's care plan after the incident to prevent future occurrences and so unfamiliar staff are able to identify R4 is at a higher risk for resident-to-resident interactions.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 64 Residents residing in the facility. The facility may have allowed staff to return to work too soon after reporting gastrointestinal/respiratory symptoms. Employee surveillance list is incomplete. It has vague symptoms (i.e.: sick, sick-stomach, not feeling well.), did not accurately report onset date and has no end dates for symptoms, and has no last day worked. R46 had a sign posted on her door that she was under isolation for contact precautions, however a staff member entered R46's room without following the contact precaution protocol or wearing the appropriate Personal Protective Equipment (PPE). Evidenced by: The facility policy titled Employee Work Restrictions-Infectious Diseases revised 1/2026 states in part: .Policy Explanation and Compliance Guidelines: 5. Employees who are restricted from work shall remain away from work until no longer contagious or cleared by a medical professional as needed. The facility policy titled Infection Prevention and Control Program revised 1/2026 states in part: .3. Surveillance: a. A system of surveillance is utilized for controlling infections and communicable diseases for all staff. b. The Infection Preventionist serves as the leader in surveillance activities. Example 1: The facility provided Surveyor with the facility staff line list. According to the line list, 14 staff members had GI symptoms including vomiting and/or diarrhea. January 2026 line list showed 2 staff members with GI symptoms -neither had start date, end date, or last day worked. February 2026 line list showed 7 staff members with GI symptoms-none had end dates. 5 staff members had no last day worked. March 2026 line list showed 1 staff member with GI symptoms-had no end date. 5 staff members with no last day worked. 2 staff members with no return date. On 4/2/26 at 1:10 PM, Surveyor interviewed IP/ADON C (Infection Preventionist/Assistant Director of Nursing). Surveyor asked If a staff member calls in with GI symptoms how do you determine when they can come back to work. IP/ADON C states she would find out when GI symptoms ended. Once no further GI symptoms, it would be 48 hours after that, kitchen staff has to stay out for 72 hours. Surveyor asked IP/ADON C, how do you determine if there is an outbreak with staff? IP/ADON C stated that she would look to see where the sick staff worked, did they work together on the same day, or same hall, did they eat lunch together, etc. Surveyor asked IP/ADON C How do you know if this is an outbreak if you don't have their last day of work? Well, I could talk with the HR director and see if she has that information. Surveyor asked IP/ADON C with all the missing information on your line list how are you evaluating when people are returning to work. IP/ADON C stated we just started using this new spreadsheet, between HR and I. When I called the staff, I got an end date and determined the RTW (return to work) date. I just didn't always write it down. Surveyor asked IP/ADON Would you expect that you could not determine a RTW date using this spreadsheet if there is no end date listed? IP/ADON C stated yes. On 4/2/26 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked would you expect that a spreadsheet for staff infection surveillance to be filled out completely in order to track infections. DON B stated absolutely. Example 2: Facility policy, titled, Infection Prevention and Control Program dated 1/2025, with last review date of 1/2026, states, in part: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: . 4. Standard Precautions: . b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. 16. Staff Education: b. All staff shall demonstrate competence in relevant infection control practices. Facility policy, titled, Hand Hygiene dated 1/2025, with last review date of 1/2026, states, in part: Policy: All staff perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: . 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table. Between resident contacts. After handling contaminated objects. After handling items potentially contaminated with blood, body fluids, secretions or excretions. For conditions involving a resident, or the resident's environment, who is isolated for Clostridioides difficile or other infection diarrhea, handwashing with soap and water is required. R46 was admitted to the facility on [DATE]. R46's Nursing Progress Notes include the following: On 3/29/26 at 4:54 AM: CNA (Certified Nursing Assistant) called writer to check on pt (patient) at 0430 (4:30 AM) d/t (due to) pt with emesis. pt had 3 coffee ground emesis and then during cares pt had mucous, bloody discharge from rectum. pt refused VS (vital signs), but writer able to get temp- 97.6. writer updated [Hospice Name] and currently awaiting a nurse visit. pt given PRN (as needed) Zofran per Hospice triage RN. pt was cleaned up and was Hoyered into Broda chair. will continue to monitor . updated Nurse Manager. On 3/29/26 at 2:18 PM: Hospice nurse came for a visit. Hospice nurse stated to continue administering Zofran for nausea if not effective or resident continuous to have emesis and rectal bleeding to call and update Hospice. On 3/29/26 at 2:20 PM: Resident is on a change of condition for coffee ground emesis/ bloody mucous discharge from rectal. VSS (vital signs stable), no emesis noted on this shift. Resident had scant bloody mucous discharge from rectal. On 3/30/26 at 2:17 PM: remains on coc (change of condition) for recent emesis episode. No emesis events today. Resident able to keep nutrition, some food down. No BM (bowel movement) today. VSS. On contact precautions per policy. On 3/30/26 at 8:19 PM: resident remains on coc of recent emesis, coffee ground emesis episode. No new emesis events today. VSS, resident did appear hot and clammy however room is uncomfortably warm. Temp normal. changed into short sleeve and set up fan. resident much more comfortable. remains on contact prophylactically. R46's Physician Orders include, in part: Contact isolation for loose stool/emesis. Full PPE (personal protective equipment). all services brought to room. Start Date: 3/30/26. End Date: 4/2/26. R46's Care Plan: Focus: The resident has an alteration in gastrointestinal status r/t (related to) coffee ground emesis/mucus release from rectum, Date Initiated: 3/29/26 Revision on: 3/29/26 Goal: The resident will remain free from discomfort, complications or s/sx (signs/symptoms) related to gastrointestinal alterations through review date. Date Initiated: 3/29/26 Target Date: 5/05/26 Interventions: VITAL SIGNS, Notify MD of significant abnormalities ie: (rapid pulse, shallow, rapid or labored respirations, low blood pressure. Date Initiated: 3/29/26 Revision on: 3/29/26 . Give medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 3/29/26. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 3/29/26. On 4/1/26 at 8:38 AM, Surveyor observed that R46 had a Contact Precaution sign on her door that indicated everyone must hand hygiene when entering and leaving the room and wear gloves and gown when entering the room. Surveyor observed CNA D (Certified Nursing Assistant) enter R46's room without wearing a gown, gloves, or performing hand hygiene. Surveyor observed CNA D pick up a used tissue from the floor of R46's room, place it in the garbage can inside R46's room, and come back out into the hallway without performing any hand hygiene. Surveyor interviewed CNA D and asked what kind of PPE should be worn in R46's room. CNA D stated she was told in report that R46 was off contact precautions today. Surveyor asked CNA D if she should have worn gloves and performed hand hygiene after picking up a soiled tissue with her bare hands. CNA D indicated that yes that she probably should have. On 4/2/26 at 8:39 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) and asked about R46's contact precautions. LPN E stated that R46 had been on contact precautions for having emesis and some bloody mucous stool. Surveyor asked LPN E, if PPE should be worn in R46's room. LPN E stated yes, PPE should be worn in R46's every time you enter the room. On 4/2/26 at 9:55 AM, Surveyor interviewed LPN F and asked what PPE should be worn with a resident on contact precautions. LPN F stated that gloves and gowns should be worn before going into the room, every time the room is entered. On 4/2/26 at 9:57 AM, Surveyor interviewed CNA G and asked what is done for a resident who is on contact precautions. CNA G stated that there is a cart outside those rooms with PPE and they are to gown up and wear gloves every time before going into the room. On 4/2/26 at 9:59 AM, Surveyor interviewed CNA H and asked about R46's contact precautions. CNA H stated that R46 had been on contact precautions for some vomiting and diarrhea. CNA H indicated that they should always wear PPE, including gown and gloves, before going into her room. On 4/2/26 at 10:05 AM, Surveyor interviewed ADON C (Associate Director of Nursing) and asked her about R46's contact precautions. ADON C stated that R46 was on contact precautions because she had an emesis and some loose stools. Surveyor asked ADON C what is required in caring for someone on contact precautions. ADON C stated that staff should wear gowns and gloves when doing cares. Surveyor asked ADON C to clarify if staff should be wearing PPE with a resident on contact precautions every time they enter the room or only if they are doing cares? ADON C replied every time they go in the room. ADON C stated that it was her expectation that, at a minimum, staff would be wearing a gown and gloves and perform hand hygiene before exiting the room of a resident on contact precautions. ADON C indicated that she talks about hand hygiene with all new staff at orientation and that she recently performed hand washing audits, at which time she discussed with staff that they should be washing with soap and water whenever a resident has GI (gastrointestinal) symptoms. On 4/2/26 at 10:12 AM, Surveyor interviewed DON B (Director of Nursing) and asked her about R46's contact precautions. DON B stated that whenever a resident has an emesis, they are put on precautionary contact precautions for 72 hours. DON B indicated that R46 had an order to be on contact precautions that ended this morning at 5:59 AM. Surveyor shared with DON B her observation of CNA D entering R46's room yesterday without wearing any PPE and picking up a soiled Kleenex and not performing any hand hygiene. Surveyor asked DON B if it was her expectation that staff wear the appropriate PPE when entering the room of a resident on contact precautions and perform appropriate hand hygiene. DON B stated yes, that was her expectation, and that all staff should follow the contact precaution signage when they enter the room for any reason.

Based on observation and interview, the facility did not ensure that garbage and refuse was disposed of properly. This has the potential to affect all 64 residents.Surveyor observed the dumpers area to have garbage/refuse around the dumpster.Evidenced by:On 3/30/26 at 8:46 AM, Surveyor and CK J (Cook) observed the following outside on the ground, near and under the facility's main garbage dumpsters:*2 empty egg crates*Empty tissue boxes*Plastic forks, spoons, and knives*Cardboard boxes*Various sauce/condiment packets*An empty plastic bag of coffee*Empty used garbage bags (appeared to have been tied and discolored)*Surgical masksAt this time, CK J stated that the area was Gross.On 4/2/26 at 10:49 AM, DM K (Dietary Manager) stated the task of cleaning the dumpster area is completed regularly but would ensure consistent proper disposal and cleaning is carried out.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 64 residents.The sanitizing solution in the kitchen's three compartment sink did not meet manufacturer parts per million (PPM) requirements.Food items were found to be improperly dated or not dated.Findings include:Example 1The facility's main kitchen uses a three compartment sink to wash larger pots, pans and utensils. One of these compartments uses a sanitizing agent to complete the dishwashing process. Sanitizer dispenses from a machine through a hose into the sink basin.On 4/1/26 at 11:53 AM, Surveyor observed the three-compartment sink in the kitchen to have a large pile of dishes (small pots, pans and utensils) at the end. These appeared to be clean with no discernable traces of debris or food. Surveyor used a thermometer to test the temperature of the water that contained the sanitizing solution, which read 115 degrees Fahrenheit. On the wall above the sink, Surveyor observed signs prepared by the sanitization manufacturer that stated the sanitization of the three-compartment sink was to be tested with a test strip submerged for 10 seconds at a temperature of 65 to 75 degrees Fahrenheit with manufacturer recommendations of reaching150 and 400 PPM (Parts Per Million. Surveyor then put sanitizer in a cup and waited for the sanitizing solution temperature to cool. At 12:28 PM, Surveyor, along with CDM L (Certified Dietary Manager), who is assisting from another facility, tested the solution at a temperature of 77 degrees Fahrenheit. The manufacturer recommended test strips were used to test the solution and did not change color, indicating the solution's PPM was 0. CDM L observed and agreed the test strip did not change color.On 4/2/26 at 10:49 AM, DM K (Dietary Manager) stated to Surveyor that she had been testing the PPM of the sanitizing sink last night and was unable to get it to reach the necessary sanitization level, so she had temporarily put the sink out of commission and contacted the manufacturer for additional assistance. Example 2On 3/30/26 at 8:58 AM, Surveyor observed the following in the facility's main kitchen refrigerator:*5-6oz vanilla nutritional shakes, thawed with no thaw date*2-4oz chocolate nutritional shakes, thawed with no thaw date*2 grilled cheese sandwiches wrapped in aluminum foil with no datesSurveyor also observed, at 10:15 AM in the second-floor medication room refrigerator, 8-4oz nutritional juices with no thaw dates.It should be noted that the nutritional juices and shakes the facility uses are stored frozen and indicate on the packaging that they must be used or discarded within 14 days of being thawed.On 4/2/26 at 10:49 AM, Surveyor interviewed DM K who stated that shakes or nutritional juices that are not dated and are thawed need to be discarded as there is no way of knowing when they were pulled from the freezer.

Based on observation, staff and resident interview, and record review, the facility did not ensure meals were served at regular times and in accordance with residents' preferences. This practice had the potential to affect all 64 residents residing in the facility.The facility consistently served meals later than posted mealtimes and residents' preferences.Findings include:The facility policy, titled Frequency of Meals, dated 2/2025 with last revision date of 2/2026, states in part: Policy: The facility will ensure that each resident receives at least three meals daily without extensive time lapses between meals. Policy Explanation and Compliance Guidelines: 1. The facility has scheduled three regular meal times, comparable to normal mealtimes in the community, per day.The facility Schedule of Meal Times, Locations provided to the survey team by the facility states:1st Floor Dining Room Meal Times:Breakfast: 7:50 AMLunch: 11:50 AMDinner: 5:45 PM2nd Floor Dining Room Meal Times:Breakfast: 7:40 AMLunch: 11:40 AMDinner: 5:35 PM3rd Floor Dining Room Meal Times:Breakfast: 7:30 AMLunch: 11:30 AMDinner: 5:25 PM On 3/30/26, Surveyor observed lunch in the 2nd floor dining room, which was to start at 11:40 AM. Surveyor observed that lunch service did not begin until 12:23 PM.On 3/30/26, Surveyor observed meal trays being delivered in the 1st floor hallways for lunch at 12:54 PM.On 3/30/26, Surveyor observed lunch in the 1st floor dining room, which was to start at 11:50 AM. Surveyor observed that lunch service did not begin until 12:55 PM.On 3/30/26 at 12:55 PM, Surveyor interviewed R2 in the dining room, who commented that lunch was really late today.On 3/30/26 at 12:56 PM, Surveyor interviewed R3 in the dining room, who stated that meals are always late.On 3/31/26 at 10:00 AM, during resident council meeting, R2, R3, and R19 all indicated that meals are a big problem at the facility and that the facility is aware, but nothing is getting done about it. R3 stated that dinner is usually served well after 6:00 PM, and that meals are served more often late than on time. R19 stated that the meals are always late, and by the time the food is actually served to them it is cold.On 4/1/26, Surveyor observed meal trays being delivered in the 1st floor hallways for breakfast at 8:42 AM.On 4/2/26 at 2:12 PM, Surveyor discussed the late meal service with NHA A (Nursing Home Administrator). NHA A agreed the lateness of meals this week had been excessive, and stated he had never seen them served that late before.

Based on observation, interview, and record review, the facility did not ensure that each resident receives food that is palatable. This has the potential to effect 2 of 18 sampled residents (R25 & R5) and 2 of 2 supplemental residents (R32 & R55) reviewed for food palatability. R25, R5, R32, and R55 voiced concerns with their food being not palatable.Surveyor conducted a test tray, and the pork chop was not palatable. Evidenced by: Facility policy titled: Dining Subject: Preparation: states in part: . C. Foods shall be prepared by methods that conserve nutritive value, flavor and appearance and should be served at the proper temperature.Example 1R5 most recent Minimum Data Set (MDS) indicates a Brief Interview for Mental Status (BIMS) of 14/15 indicating R5 is cognitively intact. On 04/01/2026 at12:38 PM Surveyor asked how lunch was. R5 reported it was terrible. The pork chop was hard; you can't even eat it.Example 2R25 was admitted to the facility on [DATE]. R25 most recent Minimum Data Set (MDS) indicates a Brief Interview for Mental Status (BIMS) of 15/15 indicating R5 is cognitively intact. On 4/1/26 at 12:45 PM Surveyor observed that R25 was eating a peanut butter and jelly sandwich. Her full meal was on a plate in front of her. I can't eat that, it is terrible. The pork chop is so touch I can't even cut through it. Example 3R32's latest Minimum Data Set (MDS) indicates his Brief interview of Mental Status (BIMS) is 11/15, indicating a moderate level of impairment. It also indicates he understands others and is understood by others. On 4/1/26 at 12:49 PM, R32 his lunch table. Surveyor asked how his lunch was as the plate was pushed up on the table. He just pushed his plate further away and just shook his head. He had pork chops and green beans, R32 said he was supposed to get extra gravy, and he didn't get it so he for sure would not be able to eat the pork chop because it was too hard. Example 4R55's latest Minimum Data Set (MDS) indicates his Brief Interview of Mental Status (BIMS) is 9/15, indicating moderate impairment. It should be noted that R55 was able to ask and answer questions with good understanding on this day.On 4/1/26 at 12:52 PM Surveyor observed resident at lunch table. Asked R55 how his meal was today. R55 took his fork and said, I'll show you. He then stabbed his fork into his pork chop and R55 stated that he couldn't eat it. Example 5:On 4/1/26 at 12:53 PM, Surveyor received a test tray from the kitchen. The pork chop, the featured item on the menu, was very hard and dry. Surveyor found it difficult to chew and was unable to swallow it. On 4/2/26 at 10:56 AM, DM K (Dietary Manager) stated that the issues with the pork chop may have been because it was prepared, then frozen, and then re-cooked.

Number of residents sampled:18Number of residents cited:4Based on observation, interview and record review, the facility did not ensure that the menu was followed for 2 of 18 sampled residents (R34, R24) and 2 of 2 supplemental (R54 &R32). R54's diet instructions indicate R54 is to receive gravy to all ground meat. Surveyor observed R54's breakfast ground meat with no gravy. Surveyor observed that R34 received oatmeal instead of cold cereal at breakfast. R34's Meal ticket indicated R34 received cold cereal. Surveyor observed that R24 received oatmeal at breakfast. R24's Meal ticket indicated oatmeal is a dislike of R24. R24's Meal ticket indicated R24 received cold cereal. Surveyor observed that R32 did not receive extra gravy/sauce or fruit per his dietary preferences for his noon meal. Evidenced by: The facility policy entitled Meal Identification, undated, states, in part: . Policy: An electronic meal identification and food preference slip is used to properly identify each individual's needs and desires for food. Procedure: 1. The food service manager visits a newly admitted individual to obtain food and beverage preferences, dislikes and food allergies/intolerances before an electronic meal identification and preference card (meal ID card) is written. 3. The electronic Meal ID includes the name of the individual, room number, diet order, beverage preferences, food dislikes and any other specific diet information. Food allergies should be written in red or printed boldly to call attention to them. 4. Meal ID are used during meal service to ensure the correct diet is being served and food preferences are honored. 5. Meal ID are placed on corresponding meals to ensure delivery to the correct individual. 7. The food service manager/RD (Registered Dietician) is responsible for keeping ID up to date. Example 1: R54 admitted to the facility 6/16/2021 and has diagnoses that include abnormal weight loss and type 2 diabetes mellitus (chronic condition causing high blood sugar due to insulin resistance or insufficient insulin production). R54's Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/25, shows that R54 has a Brief Interview of Mental Status (BIMS) score of 3 indicating R54 has severe cognitive impairment. R54's Physician Orders, dated 4/01/26, states, in part: . Dietary Diet: Consistent Carb Diet (CCD) diet Mechanical Soft texture, regular (Thin) consistency, gravy to all ground meat, NO BREAD, NO RICE, Mashed potatoes as replacement for all starches. R54's Meal ID ticket, dated 4/01/26, states, in part: . Dislikes: oatmeal, biscuits and gravy NO RICE MASHED POTATOES AND GRAVY INSTEAD, GRAVY ON ALL MEATS, Oatmeal, CHILI, BISCUITS/GRAVY, Mandarin oranges. Instructions: . gravy to all ground meat. Served: Cold cereal, scrambled egg (liquid eggs), choice of juice, cold cereal, cheese omelet, ground bacon, toast. On 4/1/26 at 8:48 AM, Surveyor observed R54's breakfast to include ground meat with no gravy. Note: Per R54's diet instruction R54 is to receive gravy to all ground meat. R54 did not receive gravy on his ground meat. On 4/1/26 at 8:52 AM, Surveyor interviewed CNA H (Certified Nursing Assistant) and asked if R54's MEAL ID ticket states gravy on all ground meat. CNA H indicated yes. Surveyor asked if R54 's ground meat has gravy on it. CNA H indicated no. Surveyor asked if the ground meat should have gravy on it and CNA H indicated yes, it should. Example 2: R34 admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease with late onset (progressive memory loss, cognitive decline, and behavioral changes caused by amyloid plaques and [NAME] tangles (the two hallmark brain abnormalities in Alzheimer's that disrupt neuron communication and cause cell death) and dysphagia (difficulty swallowing). R34's Physician Orders, dated 4/1/26, states, in part: . Dietary Diet: Regular diet Mechanical Soft Texture, Thickened Liquid Nectar consistency. R34's Meal ID Ticket, dated 4/1/26, states, in part: .Served: cold cereal. On 4/1/26 at 9:04 AM, Surveyor observed R34's breakfast to consist of an omelet, ground sausage, oatmeal. Note: Oatmeal is not what R34's ID Meal ticket indicates she received. Example 3: R24 admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus (chronic condition causing high blood sugar due to insulin resistance or insufficient insulin production) and dysphagia (difficulty swallowing). R24's Physician Orders, dated 4/1/26, states, in part: . Dietary Diet: Consistent Carb Diet (CCD) diet Regular/non modified texture, Regular (Thin) consistency, larger portions for all meals. R24's Meal ID Ticket, dated 4/1/26, states, in part: .Dislikes: cabbage, oatmeal. Served: Orange juice, cold cereal, cheese omelet. On 4/1/26, at 8:53 AM, Surveyor observed R24's breakfast to include oatmeal. Of note: R24's Meal ID ticket shows oatmeal as a dislike on R24's Meal ID Ticket. On 4/1/26 at 8:53 AM, Surveyor asked R24 if she likes oatmeal. R24 stated, I don't like oatmeal. Surveyor asked R24 if she would rather have cold cereal and R24 indicated yes. On 4/1/26 at 9:03 AM, Surveyor interviewed CNA H and asked, does R24's Meal ID ticket indicates oatmeal as a dislike? CNA H indicated yes. Surveyor asked CNA H if R24 had oatmeal on her breakfast tray. CNA H indicated yes. CNA H indicated this happens all the time with the kitchen. The kitchen staff always mix up the cold cereal and the oatmeal; the kitchen staff get so busy. Surveyor asked CNA H if a resident does not like a certain food and the Meal ID Ticket indicates the dislike, should the resident receive that food item. CNA H indicated no. On 4/1/26 at 1:29 PM, Surveyor interviewed DM K (Dietary Manager). Surveyor asked if R54 has on his meal ticket to receive gravy with all ground meat, would she expect all ground meat to have gravy on. DM K looked at R54's meal ticket with Surveyor and indicated that gravy on all ground meat is indicated as instructions to R54's diet. DM K indicated yes, R54 should receive gravy to all ground meat. Surveyor informed DM K R54 did not receive gravy on breakfast's ground meat. Surveyor asked DM K if a resident has a food item listed as a dislike if a resident should receive the disliked food. DM K indicated she cannot change the diet order. The dietary staff sends the disliked food out to the residents. The residents do not have to eat it. The residents can ask for something else. Surveyor asked if substitutions should be offered to residents for disliked foods. DM K indicated yes residents should have substitutions to choose from. DM K indicated the system does not pull forward food substitutions that the residents can choose from, so she sends the dislikes out to follow the residents' orders. Surveyor asked DM K if it is the expectation that the residents receive what the Meal Id ticket indicates. DM K indicated yes. Surveyor informed DM K R24 received oatmeal at breakfast and R24's ticket indicated she was to receive cold cereal. R24's Meal ID ticket indicated R24 does not like oatmeal. Surveyor informed DM K that R34 also received oatmeal instead of cold cereal. DM K indicated she would have the Meal ID Tickets updated and have the RD follow up with the residents. Example 4: R32's meal ticket has instructions to provide extra gravy/sauce. Also states that he dislikes vegetables, offer fruit. The facility failed to provide extra gravy/sauce or fruit to R32 resulting in him not being able to eat his noon meal on 04/01/26. R32 was admitted to the facility on [DATE]. His diagnoses include hemiplegia/hemiparesis (neurological conditions caused one-sided body weakness due to brain or spinal cord injury). Type II Diabetes Mellitus (body can't effectively use insulin or produce enough insulin leading to high blood sugar levels,) R32's latest Minimum Data Set (MDS) indicates his Brief interview of Mental Status (BIMS), is 11/15 , indicating a moderate level of impairment. It also indicates he understands others and is understood by others. R32's physician orders, dated 04/01/26, states in part: . Consistent Carb Diet (CCD) Regular/non modified texture, Regular thin consistency. R32's meal ID ticket, dated 04/01/26, states in part: . Instructions: EXTRA GRAVY/SAUCE. DISLIKES VEGETABLES, OFFER FRUIT. On 4/1/26 at 12:49 PM, Surveyor observed R32 with his lunch meal. There was no extra gravy for his pork chop, and he had vegetables on his plate. No fruit was provided. R32 stated that he could not eat this meal without the gravy and he doesn't like vegetables. He pushed it away, was upset. Surveyor asked if he would like an alternative, and R32 just shook his head and swatted his hand towards the plate. On 4/01/26 at 3:51 PM, Surveyor asked DON B (Director of Nursing) if it is her expectation that diet staff follow diet orders, menus, and Meal Id tickets? DON B indicated yes. Surveyor asked if foods listed as dislikes on the meal tickets, should residents receive those disliked food items. DON B indicated no. Surveyor informed DON B of the concern with food preferences and the Meal Id tickets. The dietary staff are serving disliked foods to residents. The food listed as served to residents is not what residents are receiving.

Based on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 (R61) out of 14 residents reviewed during the medication administration task.Surveyor observed R61 receiving her roommate's metoprolol. R61 does not have an order for metoprolol.Evidenced by:The facility policy entitled Medication Administration, dated 1/2025, states, in part: . Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right route d. Right route e. Right time f. Right documentation.12. Compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time. The policy entitled Medication Errors, dated 1/2025, states, in part: . Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors.Definitions: . Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety.Policy Explanation and Compliance Guidelines:1. The facility shall ensure medications will be administered as follows: a. According to physician's orders.b. Per manufacturer's specifications regarding preparation, and administration of the drug or biological.c. In accordance with accepted standards and principles which apply to professionals providing services.7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration; b. Right resident and right documentation. R61 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue) and hemiplegia (severe or total paralysis affecting one side of the body) and hemiparesis (partial weakness or reduced motor function on one side of the body, often causing difficulty with walking, balance, and fine motor tasks).R61's Quarterly Minimum Data Set (MDS) Assessment shows R61 has a Brief Interview of Mental Status (BIMS) Score of 00 indicating R61 has severe cognitive impairment.R61's March Medication Administration Record (MAR) shows the following medications ordered for AM:-Aspirin 81 milligrams (mg)-Furosemide 20 mg-Miralax 17 grams powder-Vitamin D3 2000 units-metformin 500 mg-Senna-Docusate 8.6-50 mg-Acetaminophen 1000 mg R61's Physician Orders, dated 4/01/26, does not include an order for Metoprolol.On 3/31/26 at 8:28 AM, Surveyor observed LPN M (Licensed Practical Nurse) administer Metoprolol succinate extended release 50 mg tablet to R61.On 3/31/26 at 9:15 AM, Surveyor reconciled R61's medication administration to find R61 did not have an order for Metoprolol. Surveyor did note R61's roommate did have an order for Metoprolol. On 3/31/26 at 9:24 AM, Surveyor approached DON B (Director of Nursing) and informed DON B that LPN M administered metoprolol to R61 during the observation of medication administration. Surveyor does not see an order for Metoprolol when reconciling R61's medications. DON B looked at R61's MAR and verified R61 does not receive Metoprolol. DON B reviewed R61's roommate's medication administration record and indicated R61's roommate does have an order for the Metoprolol. DON B indicated that by looking at both R61 and her roommates MARs, LPN M administered R61 her roommates Metoprolol. DON B indicated this was a significant medication error. DON B indicated she would expect nurses to perform the five rights during medication administration. DON B indicated she would start education with LPN M and notify R61's physician of the medication error. DON B indicated the staff will monitor R61 throughout the day.

Based on observation, interview, and record review, the facility did not ensure adequate interventions were in place for safety to prevent accidents from occurring for 1 of 5 residents (R37) reviewed for falls. R37 has had three falls sliding out of her Broda chair. The care planned intervention was to remove the Hoyer sling and not leave it under her in the Broda chair. Surveyor made several observations with the Hoyer sling left under R37 in her Broda chair. The facility did not ensure care planned interventions were followed to prevent R37 from further falls. Evidenced by: The facility's policy titled Facility Fall Protocol and Risk Assessment, dated 1/2025 with last revision date of 1/2026, states, in part: Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1. The risk assessment will be completed by the nurse or designee upon admission, quarterly, or when a significant change is identified. 3. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. Updates to At Risk for Falls care plan will be reviewed quarterly and with any new fall incidents. 5. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. 6. All staff will follow fall facility protocol. 7. IDT (Interdisciplinary Team) will review each fall incident for root cause of fall and determine appropriate interventions to be implemented and update At Risk for Falls care plan with each incident. 8. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. The facility's policy titled Comprehensive Care Plan, dated 2/2025 with last revision date of 2/2026, states, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident. Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: . f. Resident specific interventions that reflect the resident's needs and preferences.6. With any changes to the care plan the Unit Manager and DON (Director of Nursing) will update the care plan at time of implementation. 7. Unit Manager will educate all nursing staff on unit regarding any new interventions. 10. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. R37 admitted to the facility on [DATE] on hospice services following a fall at home resulting in a fractured hip. R37's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/26 indicates Brief Interview of Mental Status (BIMS) score of 00 out of 15, indicating R37 has severe cognitive impairment. R37's Fall Risk Assessments Include:12/16/25 score of 8 low risk for falls3/17/25 score of 6 low risk for falls3/19/26 score of 6 low risk for falls R37's comprehensive care plan includes, in part:-Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) closed left hip fracture and dementia. Date Initiated: 11/6/25. Revision on: 11/7/25.-Intervention: Broda chair primary mode of transportation, staff to propel to desired locations. Date Initiated: 12/2025.-Intervention: Transfer: Hoyer lift transfer assist of (2) staff. Date Initiated: 2/9/26. Revision on: 2/9/26. -Focus: The resident is at risk for falls r/t dementia, history of falls with left hip fracture. 3/19: -witnessed fall w/o (without) injury. Date Initiated: 11/6/25. Revision on: 3/20/26.-Interventions: Follow facility fall protocol. Date Initiated: 11/16/25.-Intervention: Staff to ensure Broda chair is in reclined position when resident in WC (wheelchair) unattended. Date Initiated: 3/18/26.-Intervention: Staff to remove Hoyer sling when resident is up in Broda. Date Initiated: 3/20/26. R37's Fall Documentation includes the following:On 12/16/25 at 7:30 PM: CNA (Certified Nursing Assistant) observed resident slide out of chair on to the floor in resident's bedroom while walking past. Resident did not hit her head. Laceration noted to be reopened on left leg near the knee. Root cause of fall resident slides out of Broda. On 3/17/26 at 3:00 PM: One of floor's Resident (sic) was wheeling self and saw [Resident Name] on the floor. She alerted Staff someone is on the floor. Staff ran to check who it was and saw [Resident Name] sitting on her bedroom floor with legs crossed next to her Broda chair at 1500 (3:00 PM). Prior to resident's fall hospice staff gave her a shower and left her on [sic] Broda chair in bedroom. On 3/18/26 an IDT (Interdisciplinary Team) Note indicated: IDT note concerning unwitnessed) fall without injury on 3/17/26. The resident was located in her room at time of incident sitting on her buttock next to her Broda chair.This fall has been discussed, and the IDT feels [Resident Name] would benefit from reclining her Broda chair back when she is left unattended. On 3/19/26 at 7:58 PM: Writer called to resident's room by CNA staff. Upon arrival, resident was noted sitting on the floor in front of her Broda chair. CNAs report resident slowly slid out of the chair while they were providing care to the roommate. They witnessed the descent and confirmed there was no impact or hitting her head. On 3/20/26 an IDT Note indicated: IDT note concerning witnessed fall without injury on 3/19/26. The resident was located in her room at time of incident with staff present. [Resident Name] was sitting upright in her Broda while staff were getting her roommate ready for bed, [Resident Name] slid forward and slid out of floor to her buttock. Nursing assessed the resident and noted no injuries occurred. Neuros at baseline and no pain noted. Immediate intervention was assisting resident off the floor via facility protocol. This fall has been discussed, and the IDT feels resident would benefit from staff to remove Hoyer sling when resident is up in Broda. On 3/30/26 at 12:05 PM, Surveyor observed R37 at the table in the dining room eating lunch. Surveyor observed that R37 had a Hoyer sling under her in the Broda chair. Surveyor observed that R37 appeared restless and was repeatedly sitting forward and backward and was slouching down in her chair. On 4/1/26 at 8:41 AM, Surveyor observed R37 at the table in the dining room waiting for breakfast to be served. Surveyor observed that R37 had a Hoyer sling under her in the Broda chair. On 4/1/26 at 12:35 PM, Surveyor observed R37 at the table in the dining room waiting for lunch to be served. Surveyor observed that R37 had a Hoyer sling under her in the Broda chair. On 4/2/26 at 8:24 AM, Surveyor observed R37 at the table in the dining room waiting for breakfast to be served. Surveyor observed that R37 had a Hoyer sling under her in the Broda chair. On 4/2/26 at 8:31 AM, Surveyor interviewed CNA I (Certified Nursing Assistant) and asked her what fall interventions were in place for R37. CNA I indicated that she wasn't sure, as she was an agency CNA and this was her first morning working with R37. Surveyor asked CNA I where she could find R37's fall interventions. CNA I stated that she was given a PCC (Point Click Care) login, but that she hadn't looked at R37's care plan yet. On 4/2/26 at 8:32 AM, Surveyor interviewed CNA H and asked her what fall interventions were in place for R37. CNA H stated that she did not know what R37's fall interventions were. Surveyor asked CNA H where she could find R37's fall interventions. CNA H stated she would ask the nurse or nurse manager or find them in PCC. On 4/2/26 at 8:35 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) and asked her what fall interventions were in place for R37. LPN E stated that she was working when R37 fell recently, and that she remembered that hospice gave her a shower and left her in her Broda chair in her room without telling any staff. LPN E indicated that it was another resident that was passing by R37's room and saw her on the floor and came and brought it to her attention. LPN E stated that they put in an intervention that if hospice gives her a shower, they are to let staff know that she is up or in bed, and they try not to leave her in the Broda chair by herself. LPN E stated that if R37 is up in her Broda chair they will keep her near the nurse's station or engaged in activities. Surveyor asked LPN E how she is made aware of changes to a resident's care plan. LPN E stated that the Nurse Manager usually updates the care plan and will let the staff know of changes. On 4/2/26 at 8:53 AM, Surveyor interviewed DON B (Director of Nursing) about R37's falls. DON B indicated that after every fall they complete a post fall assessment and risk management which the IDT team will review. DON B stated that a root cause is identified after each fall, and that fall interventions are reviewed with each fall. DON B indicated that R37 has had three falls, two within the last month. DON B stated that the recent falls were from her Broda chair, and that she was found on the floor in front of the Broda chair. DON B stated that per staff, hospice had given R37 a shower and placed her in her room, and then when they assessed R37 the Broda was fully upright so it was determined that the Broda should be reclined slightly when she is in her chair. DON B indicated that two days later staff was in the room attending to R37's roommate when they witnessed R37 slowly slide out of the Broda chair onto the floor. DON B stated that the intervention for that fall was to remove the Hoyer sling after transfers and to make sure it is out from underneath her. Surveyor asked DON B how updates to the care plan were communicated to the frontline staff. DON B indicated that the Unit Managers or herself update the care plans, and the interventions are included on the CNA Kardex, which are printed and kept in a binder at the nurse's station. DON B stated that they let the frontline staff know there is a new intervention, and they highlight the intervention in the binder. Surveyor asked DON B how agency staff are made of how to care for the residents. DON B stated that she makes sure agency staff know how to access and bring the Kardex up in PCC. Surveyor shared her multiple observations of R37 in the dining room with her Hoyer sling under her in the Broda chair, as well as interviews with staff not being aware of R37's current care planned interventions. Surveyor asked DON B if she would expect that R37's care plan interventions be followed. DON B stated yes, always, and that falls were something that she was currently educating staff on. The facility failed to ensure that fall interventions were being followed for R37, thereby failing to keep R37 safe from future falls.

Based on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 1 of 5 medication rooms.During the medication storage observation task, there were five medications found to be with expired dates.Evidenced by:The facility policy entitled Medication Storage, dated 1/2026, states, in part: . Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations.Policy Explanation and Compliance Guidelines: .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. On 4/2/26 at 9:02 AM, during the Medication Storage Task, Surveyor observed in the Main Medication Stock Room:-6 Mylanta Antacid Liquid 12 fluid ounce bottles with expired dates. -4 bottles with expiration dates of 11/25 -1 bottle with an expiration date of 11/24 -1 bottle with an expiration date of 5/25- 3 bottles of 60 Melatonin 1 milligram tablets with an expiration date of 8/25- 1 bottle of 100 Aspirin 325 milligram tablets with an expiration date of 1/26-3 bottles of 100 multivitamin tablets - 2 bottles with an expiration date of 2/26 - 1 bottle with an expiration date of 11/25- 1 bottle of 100 vitamin b12 100 microgram tablets with an expiration date of 2/26On 4/2/26 at 9:21 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) and asked if the six bottles of Mylanta have expired dates. LPN E indicated yes. Surveyor asked if the expired bottles should be in the medication rotation. LPN E indicated no. LPN E indicated she will dispose of them in the Drug Buster. Surveyor asked LPN E if the three bottles of Melatonin, one bottle of Aspirin, three bottles of Multivitamin and the one bottle of vitamin B12 have expired dates. LPN E looked at each bottle and verified they were all expired. LPN E indicated the expired bottles should not be in the stock medication room. LPN E indicated she would remove and destroy the expired bottles.On 4/2/26 at 10:40 AM, Surveyor asked DON B (Director of Nursing) if expired medications should be in the stock medication rotation. DON B indicated no. DON B indicated it is the facility expectation for staff to check the expiration date when taking the medication from the stockroom and placing the medication in the medication carts.

Based on interview and record review the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 4 residents (R5) reviewed for equipment. R5 requested a referral for a new wheelchair for use out of the building. The facility did not follow up with the outside vendor in a timely manner. Evidenced by: The facility's Social Worker Job Description, undated, states, in part: .The Social Worker will also assist residents and their representatives in locating and accessing financial, legal, and other community resources. Accurately and completely document social service actions and interactions in each resident's medical record . Surveyor requested facility policy for requisition of wheelchairs. No policy provided. R5 admitted to the facility on [DATE] and has diagnoses that include, in part: Parkinsonism (a group of movement disorders characterized by symptoms including tremor, rigidity, slow movements, and postural instability/inability to maintain body balance), abnormalities of gait and mobility, low back pain, weakness, and depression (a mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels). R5's MDS (Minimum Data Set), with target date of 3/7/25, indicates a BIMS (Brief Interview of Mental Status) score of 15, indicating that R5 is cognitively intact. It also indicates that R5 uses a wheelchair for mobility. R5's Social Service Note, dated 1/23/25, states: WVOS H (Wheelchair Vendor Operations Supervisor) called. Vendor received the order from doctor's office, but also stated that she has the original order that I sent in November. She stated that vendor did not open the order in November because they were not able to fill the order. This is because R5 resides in a skilled level of care facility and already has a wheelchair, so it is not a necessity that they could bill Medicare for. On 4/1/25 at 1:07 PM, Surveyor interviewed R5 and asked about R5's wheelchair. R5 stated the wheelchair doesn't fold so it can't be taken anywhere. R5 stated that when going out of the facility, R5 uses a borrowed poor one. R5 clarified by stating that R5 is crammed into the chair; the seat is too small and the foot pedals are too close. R5 stated there has been work on getting a new chair since August 2024, but no new chair is yet in place. R5 stated there was approval from Occupational Therapy, but apparently that is not enough, as R5 is still waiting. R5 stated it is frustrating. On 4/1/25 at 1:29 PM, Surveyor interviewed OT D (Occupational Therapist) and DOR E (Director of Rehab) and asked about process for getting a new wheelchair. OT D stated a letter of recommendation is written with justification for the chair along with measurements. The recommendation is sent from DOR E to SSD F (Social Services Director) for processing. Generally, chairs are ordered a few days before a resident discharges from the facility and arrive prior to the discharge. Surveyor asked if R5 was looking for a new chair. DOR E stated yes, RR G (Resident Representative) was asking about a new chair and trying to assist R5 with the process, but was running into road blocks. DOR E stated there was some lack of communication between RR G and SSD F. Surveyor asked if a letter of recommendation was written for a new chair. OT D stated yes, two or three letters had been written and forwarded to SSD E. Surveyor asked if there was follow up communication after the letters of recommendation had been submitted. OT D stated that OT D had spoken with SSD F on a couple occasions and was told that SSD F had spoken to the vendor, but was waiting for further information. DOR E stated that the status of the chair would be talked about at Medicare meetings and SSD F would state that SSD F was still waiting on response from the vendor. On 4/1/25 at 2:27 PM, Surveyor interviewed WV C (Wheelchair Vendor) and asked about a referral for R5. WV C stated there was a referral on 1/23/25. Surveyor asked if there had been any referrals prior to 1/23/25. WV C stated no. Surveyor asked if a referral was made into another office of their company, would WV C be aware. WC V stated yes, all referrals are documented in the same system, no matter which office. On 4/2/25 at 9:03 AM, Surveyor interviewed SSD F and asked about the process for getting a new wheelchair. SSD F stated a referral letter from therapy is written, an order is obtained, and the paperwork is submitted to a DME (Durable Medical Equipment) vendor. Surveyor asked how soon after the referral is the paperwork sent to the vendor. SSD F stated right away. Surveyor asked if residents living in a SNF (skilled nursing facility) qualify for a new chair. SSD F stated it depends; if the resident has their own, functional equipment, they may not qualify, but sometimes they will. Surveyor asked if R5 was looking for a new chair. SSD F stated yes, the chair that he has doesn't fold properly to fit into RR G's car; RR G saw a chair on the internet and asked us to send in a referral. The referral was sent to a local vendor and was denied due to not being in network. SSD F stated that SSD F then contacted R5's managed care organization for assistance and was advised to send a referral to another vendor. SSD F shared a fax cover letter to the new vendor with a fax date of 11/8/24 and refax of 11/9/24. Surveyor asked why the cover letter stated it had been refaxed. SSD F stated the vendor had not received it. SSD F stated that SSD F spoke with WVOS H on 1/23/25 and WVOS H had indicated that an order had come from a physician's office and would not be filled due to resident living in SNF. Surveyor asked if there was any correspondence with vendor between 11/9/24 and 1/23/25. SSD F stated I believe I may have left messages. Surveyor asked for any documentation of communication attempts with vendor. SSD F stated there was no documentation. Surveyor asked if R5 or RR G were updated on the status of the chair. SSD F stated that SSD F told R5 in passing. Surveyor asked if there was documentation of R5 being updated. SSD F stated no. On 4/2/25 at 10:04 AM, Surveyor interviewed WVOS H and asked about a referral for a wheelchair for R5. WVOS H stated that a referral was made on 1/23/25. Surveyor asked if there had been a referral prior to 1/23/25. WVOS H stated that sometimes referrals are received, and the vendor is not able to fill the order, so the referral is not opened in the vendor's system. If the order is not opened in the system, the SNF would be notified that the order could not be filled. WVOS H stated that all received faxes are kept for a year whether they are opened or not and that all received faxes from October 2024 through December 2024 had been reviewed and that no referral for R5 was found. On 4/2/25 at 1:21 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if a resident/resident representative asked for a wheelchair referral to be sent to a vendor, should it be sent. NHA A stated yes. Surveyor asked how soon a referral written by therapy should be sent to the vendor. NHA A stated right away. Surveyor asked if a referral is sent and there is no response from vendor, would the facility be expected to follow up with vendor about the status. NHA A stated yes, that would be reasonable. Surveyor asked if a fax letter was dated 11/9/24, would follow up be expected prior to 1/23/25. NHA A stated yes. Surveyor asked if there should be documentation of the referral and follow up. NHA A stated yes. R5 requested a referral for a new wheelchair for use out of the building. The facility did not follow up with the outside vendor in a timely manner.

Based on observation, interview, and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect all 65 residents residing at the facility. Residents (R) voiced concern with hot foods being served cold and cold foods being served warm. (R46, R11, R5, R31, R4, R58, and R55) 2 of 2 test trays were observed to not be served at desirable temperatures. Evidenced by: The facility policy Food Temperatures, dated 2023, states in part: .1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F . Example 1: R46 was admitted to the facility on [DATE]. On 1/7/25 at 9:58AM, R46 indicated hot food is often served cold in the dining room. R46 indicated they discuss food concerns at the monthly resident council meeting. Example 2: R11 was admitted to the facility on [DATE]. On 1/6/25 at 3:17PM, R11 indicated the food was supposed to get better under new management in the kitchen. R11 indicated R11 still has concerns with the meals. R11 indicated he eats in his room and that food is not always palatable, hot foods are served cold, and the portions are small. Example 3: On 1/7/25 at 8:28AM, Surveyor received the last tray that was being served in dining room on the first floor. Scrambled eggs temped at 98.9 F, bacon 85.4 F, oatmeal 105.8 F, and the toast was hard. All food tasted cold and was not palatable. Example 4: On 1/7/25 at 11:59AM, Surveyor received the last room tray that was being served on the third floor. Spaghetti with meat temped at 125 F, garlic bread 108 F, and mixed vegetables 109 F. The milk temped at 45.5 F and juice 42.8. The hot food was cold and the milk and juice warm and not palatable. On 1/8/25 at 3:11PM, Food and Service Director D and District Manager E Indicated they would expect hot foods to be served hot and cold foods to be served cold. Both indicated understanding with the concerns voiced by residents and test tray temperatures. The facility failed to ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. 38725 Example 5: On 1/6/25 at 11:02 AM, Surveyor interviewed R58. Surveyor asked R58 how the food is at the facility, R58 said not good. Surveyor asked R58 if his hot foods are hot and cold foods are cold. R58 stated hot foods are lukewarm and cold foods are warm. Surveyor asked R58 if there was anything else about the food he wanted to share. R58 replied all the meat is mysterious. Example 6: On 1/6/25 at 2:50 PM, Surveyor interviewed R31. Surveyor asked R31 how the food is at the facility, R31 said it's ok. Surveyor asked R31 what would make it better? R31 said if the vegetables weren't cold. 49436 Example 7: R5 admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis in left and right hand (a chronic inflammatory disorder usually affecting small joints in the hands) and acquired absence of right and left leg above knee (amputation of both legs above the knee). On 1/7/25 at 9:58 AM, Surveyor interviewed R5 regarding food temperatures at mealtimes. R5 indicated he eats his meals in the dining room and the resident lounge. R5 states the hot foods are served cold. R5 states there is a small microwave in the other room (not in the dining room) the facility can use to warm up the food, but it takes forever for the staff to warm up the food. 50285 Example 8: R55 was admitted to the facility on [DATE]. Her most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11/24, indicates her cognition is intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. On 1/6/25 at 10:14 AM, Surveyor interviewed R55 who indicated that most of the time the food that is served is not hot. R55 stated especially the french fries are always cold, and that every day the food that is served is lukewarm at best. On 1/6/25 at 12:04 PM, Surveyor observed dining service on the 300 unit, and noted that french fries were being served for lunch. Surveyor approached R55 and asked her about the french fries on her plate. R55 indicated they were not warm at all and that they looked undercooked. R55 then held up a french fry from her plate and stated, See they are soft and limp. They should not really even call them french fries because they are not. Example 9: R4 admitted to the facility on [DATE]. His most recent MDS with an ARD of 11/5/24 indicates his cognition is intact with a BIMS score of 15 out of 15. On 1/6/25 at 11:59 AM, Surveyor observed dining service on the 300 unit and noted that R4 declined what was being served for lunch and requested soup. Staff brought R4 a bowl of soup at 12:04 PM. Surveyor heard R4 comment to his tablemates that the soup was a little bit warm. On 1/6/25 at 2:52 PM, Surveyor interviewed R4 who stated that breakfast is okay but after that the food is downhill. R4 stated that the meals were not very good and that the food is never hot. R4 indicated that breakfast is sometimes lukewarm. R4 stated that all the staff know that the food is cold and sometimes they have to heat it up in the microwave, but usually he tries to eat it as fast as he can and go back to his room.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 65 residents who reside in the facility. FSD D (Food Service Director) was taking temperatures of lunch on 1/6/25. Surveyor observed FSD D wearing gloves touching items in FSD D pocket, thermometer, alcohol wipes, hot pad, lids on pans, and then directly touch chicken with same pair of gloves. Surveyor observed FSD D then go to dishwashing room and touch items, use cell phone, and touch steam table with same pair of gloves on. Surveyor observed no changing of gloves or hand washing. Evidenced by The facility policy, General Food Preparation and Handling, dated 2023, states, in part; .Food items will be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep free of harmful organisms and substances .h. Bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. Employees should wash their hands prior to putting gloves on and after removing gloves . On 1/6/25 at 10:18AM, Surveyor observed FSD D (Food Service Director) temping food that was being served for lunch. Surveyor observed FSD D wearing gloves. FSD D was observed touching items in FSD D's pocket, including a thermometer, alcohol wipes, a hot pad, 2 lids on pans, and then directly touch chicken multiple times with the same pair of gloves on. Surveyor observed FSD D then go to dishwashing room and touch items, use cell phone, and touch steam table with the same pair of gloves on. Surveyor observed no changing of gloves or hand washing. On 1/8/25 at 3:11PM, Food and Service Director D and District Manager E indicated they would expect staff to change gloves and wash hands before and after directly touching food items. The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on interview and record review the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, this affected 2 of 2 residents reviewed for med errors, 1 sampled resident (R38) and 1 supplemental resident (R50). R38 had the wrong pain medication administered on 8/15/24 and 8/16/24. R38's narcotic count was not accurate on 9/26/24. RN G (Registered Nurse) used a contaminated pill cutter to cut an unscored tablet for R50. This is evidenced by: The Facilities Policy and Procedure entitled Medication Administration dated 10/2024 documents in part: .9. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation .16. Administer medication as ordered in accordance with manufacturer specifications .c. Crush medications as ordered. Do not crush medications with do not crush instructions . The Facilities Policy and Procedure entitled Medication Errors dated 2/22/24 documents in part: .Medication error means the observed or identified preparation of administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specification (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services .Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. b. Per manufacturer's specifications regarding the preparation, and administration of the drug or biological. c. In accordance with accepted standards and principles which apply to professionals providing services .4. The facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: i. Incorrect dose, route of administration, dosage form, time of administration .b. Medication administered not in accordance with the manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological. Examples include, but not limited to: .ii. Crushing do not crush medications .7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration b. Right resident and right documentation . R38 is a long-term resident of the facility. R38 has the following diagnoses: polyosteoarthritis (arthritis that affects 5 or more joints), pain in right shoulder, pain in right elbow, osteoarthritis (chronic disease that causes breakdown of cartilage and other tissues in the joints), gout (form of arthritis), and low back pain. RN G (Registered Nurse) used a contaminated pill cutter to cut an unscored tablet for R50. Example 1 R38's August Physician Orders document: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) Give 1 tablet by mouth four times a day for pain R38's Telephone Orders for 8/14/24 document: 1) Oxycontin ER 10 mg tablet po (by mouth) BID (twice per day) Dx (diagnosis): pain 2) Oxycodone 5 mg every 6 hours PRN (as needed) Dx: pain 3) D/C (discontinue) Hydrocodone 4) Monitor every shift for increased sedation r/t (related to) Oxycontin, update R38's MAR (Medication Administration Record) documents: -Oxycodone HCl Tablet 10 mg Give 1 tablet by mouth two times a day for pain. Start date 8/14/24. End date 8/16/24. This medication is signed out twice (AM and PM) on 8/15/24 and once (AM) on 8/16/24. -Oxycontin Oral Tablet ER 12 Hour -Abuse-Deterrent 10 mg (Oxycodone HCl) Give 10 mg by mouth two times a day for pain. Start date 8/16/24. -Oxycodone HCl Oral Tablet 5 mg (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain. Start date 8/14/24. R38's Controlled Drug Record Count Sheet documents: -Oxycodone HCl (IR) 5mg tablet issued 8/14/24, 10 tablets dispensed -8/16/24 at 0830 (8:30 AM) 2 tablets were signed out The medication errors on 8/15/24 and 8/16/24 were due to the incorrect order being transcribed twice a day for scheduled pain medication. R38's September Physician Orders document: -Oxycontin ER 12 Hour Abuse-Deterrent 10 mg Give 10 mg by mouth two times a day for pain -Oxycodone HCl Oral Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain R38's Controlled Drug Record Count Sheet documents: -Oxycodone HCl (IR) 5mg tablet issued 8/23/24, 8 tablets dispensed -9/26/24 count on this form goes from 5 tablets to 3 tablets The facility identified that the count on R38's controlled drug record was wrong and identified that someone had taken 2 tablets from R38's card instead of another residents' card. Therefore, R38's care was inaccurate with 2 few tablets and the other resident's card was also inaccurate with 2 many tablets. On 1/9/25 at 10:06 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R38 had any medication errors August 2024-present, DON B stated there are no medication errors for R38. On 1/9/25 at 3:29 PM, Surveyor interviewed DON B. Surveyor asked DON B if on 8/15-8/16/24 if the medications Oxycodone and Oxycontin could have been inverted (used in place of the other), DON B replied yes. Surveyor asked DON B if she could explain how the error occurred on 9/26/24, DON B explained that the wrong card of medication was taken for another resident and that is why R38's count was incorrect. Surveyor asked DON B if there should be medication error reports for these issues, DON B said yes. 49436 Example 2 R50 admitted to the facility on [DATE]. R50's physician orders dated 1/9/25 include Vitamin D3 oral capsule 25 mcg, give 1 capsule by mouth in the morning. On 1/8/25 at 8:06 AM, Surveyor observed RN G (Registered Nurse) prepare R50's medications. During this observation, RN G removed a Vitamin D 50 mcg tablet from the medication bottle. Surveyor observed the Vitamin D 50 mcg tablet was not a scored tablet. RN G opened the pill cutter to cut the Vitamin D 50 mcg tablet in half. Surveyor observed the pill cutter contained white chunks and powder from previously cut medications. Surveyor also observed the cutting blade contained white powder. RN G placed the Vitamin D 50 mcg tablet into the pill cutter and cut the pill in half. RN G placed the cut Vitamin D into a medication cup to administer to R50. Surveyor stopped RN G and interviewed RN G regarding the preparation of R50's medications. RN G indicated the pill cutter was contaminated with unknown medication residue and she should have cleaned the pill cutter prior to cutting R50's Vitamin D. Surveyor interviewed RN G regarding which medications are allowed to be cut in half. RN G indicated only medications that are scored should be cut in half. RN G indicated she should not cut the Vitamin D tablet in half since it was not a scored tablet. On 1/9/25 at 9:07 AM, Surveyor interviewed DON B (Director of Nursing) regarding medication administration. DON B indicated the pill cutter should be clean prior to cutting a medication. DON B also indicated an unscored tablet should not be cut.

Based on observation, interview and record review the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections RN F touched items within resident room with dirty gloves. R319 was admitted with a pressure injury (PI) and previous wound infection. During observation of wound care, the facility failed to utilize standard infection control practices. This is evidenced by: The facility policy Clean Dressing Change dated 10/2024, states, in part: .17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. 18. Return resident to a comfortable position . Example 1 On 1/7/25 at 10:53 AM, Surveyor observed RN F (Registered Nurse) perform wound care for R51. Surveyor observed RN F complete R51's dressing change. RN F removed the old dressing and RN F proceeded to discard the used wound care supplies and with same gloves, RN F touched the bed side table and bed controller. RN F then stated she should take the gloves off. RN F removed gloves and then performed hand hygiene. Surveyor observed RN F complete wound care. Surveyor observed RN F, with gloved hands, apply R51's dressing. Surveyor interviewed RN F regarding touching the bed side table and bed controller with dirty gloves. RN F indicated she should have removed her gloves and performed hand hygiene prior to touching anything. On 1/9/25 at 9:05 AM, Surveyor interviewed DON B (Director of Nursing) regarding wound care. DON B indicated RN F should have performed hand hygiene before touching the bed side table and bed controller. 50285 Example 2 R319 was admitted to the facility on [DATE] with diagnoses that include pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus without complications, need for assistance with personal care, cognitive communication deficit, unspecified abnormalities of gait and mobility, and depression unspecified. R319's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/24, documented R319 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Section M of the MDS indicates that R319 had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be visible on some parts of the wound bed, may include undermining or tunneling) PI on admission. R319's discharge paperwork from the hospital dated 12/10/24 indicates in part: (R319) who is being admitted today with sacral wound infection . she developed a sacral wound and has been following at wound care clinic . today she was at the wound care clinic and there was suspicion for abscess so she was sent back to ED (Emergency Department) . CT (computed tomograghy) showed abscess and General Surgery debrided it at the bedside . previous culture shows MRSA (methicillin-resistant Staphylococcus aureus, a bacterial infection that does not get better with usual antibiotics) and Morganella (an opportunistic pathogen that mainly causes post-operative wound infections) with some resistance . Patient Active Problem List includes pressure injury of buttock, unstageable and Skin ulcer of sacrum, unspecified ulcer stage. R319's admission Weekly Skin Charting on 10/20/24 indicates that R319 had a pre-existing open area to left buttock. R319's admission Skin Assessment on 12/20/24 indicates a wound Stage 4 to left gluteus with measurements of 1.96 cm (centimeters) by 1.44 cm. R319's physician orders include an order to treat the left gluteus wound: Cleanse wound with saline, protect periwound with skin prep, apply Hydrofera Blue or Derma Blue (cut to size) to wound bed, cover wound with Bordered Gauze, change daily, change PRN (as needed) for soiling and/or saturation, as needed. R319's Care Plan includes in part: . Focus: (R319) has actual impairment to skin integrity of the left gluteus , stage 4 at risk for further skin breakdown . Intervention: pressure reducing cushions, to protect the skin while up IN CHAIR. pressure reducing mattress to protect the skin while IN BED . Intervention: Assist me with my general hygiene and comfort measures . Intervention: Consult Dietary for my nutritional needs, Encourage good nutrition and hydration in order to promote healthier skin . Intervention: Encourage/assist me to elevate heels, Encourage/assist me with reposition as needed . Intervention: Follow facility protocols for treatment of injury . Intervention: My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment, Report any skin redness/impaired integrity areas to my nurse . Intervention: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . Intervention: Use barrier cream to prevent skin impairment issues, as needed, Wound doctor to follow wound progression . On 1/7/25 at 10:15 AM, Surveyor observed wound care for R319. RN F (Registered Nurse) gathered the supplies to perform wound care, entered R319's room and performed hand hygiene. RN F donned appropriate PPE (personal protective equipment) including gown and gloves. RN F placed an unused garbage bag at the end of R319's bedside table. RN F stated she planned to tape the garbage bag to the end of the bedside table but forgot the tape. RN F assisted R319 to bed and completed the wound care according to physician orders, performing hand hygiene and glove changes as appropriate. RN F then began to clean up, but the loose garbage bag fell on the floor with the old, soiled dressing falling out onto the floor, as well as used gloves and paper towels. RN F picked up the trash and placed it back in the garbage bag. As RN F was walking toward R319's door, the soiled trash fell on to the floor again. RN F picked up the trash and placed it back in the garbage bag a second time. RN F placed trash bag into a larger trash receptacle inside R319's door. RN F then stated that she had forgotten to give R319 back her call light. Surveyor observed RN F go back to R319's bedside and gave her the call light and put bedside table back near R319's bed, still wearing the soiled gloves she had used to pick up the trash off the floor. RN F then removed soiled gloves and washed hands before leaving R319's room. Surveyor asked RN F when it was appropriate to change gloves during wound care. RN F answered any time touching a dirty area and going to a clean area. Surveyor asked RN F if she had changed gloves after picking up the trash and soiled dressing and before she touched the resident's belongings such as call light and bedside table. RN F stated she couldn't remember but that she probably forgot because she had been so nervous. Surveyor asked RN F if touching dirty paper towels, dirty gloves, and soiled bandage would be a potential for infection. RN F stated yes, that would be possible. On 1/9/25 at 7:32 AM, Surveyor interviewed DON B (Director of Nursing) about infection control practices. Surveyor asked DON B when it is appropriate to change gloves and perform hand hygiene during wound care. DON B stated gloves should be changed and hand hygiene should be performed anytime the nurse goes from dirty to clean and hand hygiene should be performed before putting on gloves and after removing them. Surveyor asked DON B if the nurse should remove soiled gloves and perform hand hygiene after picking up soiled bandages, paper towels, and gloves and before touching the resident's belongings. DON B stated yes, the soiled gloves should be removed and hand hygiene performed before touching resident's belongings.

Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 2 of 3 residents (R34 and R51) reviewed for pressure injuries. R34 did not have wound care treatments documented as completed in October and December. R51's pressure injury was left open to air for approximately 2 hours. This is evidenced by: The facility policy and procedure entitled Documentation of Wound Treatments dated 9/19/24, documents the following in part: .3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact) . Example 1 R34 is a long-term resident of the facility who is receiving Hospice services. R34's goal for her pressure injury is to be as comfortable as possible and be free from infection. R34 has the following diagnoses: myotonic muscular dystrophy (genetic disorder that causes progressive muscle weakness), protein-calorie malnutrition, palliative care (end of life care), neoplasm of endocrine glands (tumor), neoplasm of spinal cord, weakness, benign neoplasm of spinal meninges, underweight, and cord compression. R34's October Physician Orders include: -Wound care to ischial tuberosity: - cleanse SNS (sterile normal saline), - skin prep to peri wound, - Apply Manuka honey/Alginate to wound bed (cut to size), - cover with foam dressing daily and PRN (as needed) until healed then DC (discontinue) every day shift for wound care. Start date 8/30/24. End date 10/4/24. -Wound care to ischial tuberosity: - cleanse SNS (sterile normal saline), - skin prep to peri wound, - Apply Medi-honey GEL to wound bed, - cover with bordered foam dressing daily and PRN until healed then DC every day shift for wound care. Start date 10/4/24. End date 11/8/24. R34's October TAR (Treatment Administration Record): Ischial tuberosity had a blank box in TAR on 10/4/24, 10/11/24, 10/19/24, 10/24/24, and 10/28/24. R34's December Physician Orders include: -Cleanse wound with cleanser, protect periwound with Skin Prep, Apply Manuka honey/Alginate to wound bed, Cover wound with Foam, change daily, Change PRN for soiling and/or saturation, every day shift for wound care. Start date 11/8/24. R34's December TAR: Blank box in TAR on 12/6/24 and 12/27/24. It is important to note that despite the TAR not being signed out for the above dates, R34's wounds did not cause more pain or become infected. On 1/9/25 at 1:34 PM, Surveyor interviewed LPN C (Licensed Practical Nurse). Surveyor asked LPN C if there is a blank in the TAR what does that indicate, LPN C said someone didn't click it off, if they would have clicked it and put refused or whatever it would show their initials and a number code, if blank someone probably didn't do it. Surveyor asked LPN C should treatments be signed out and completed as ordered, LPN C stated yes, the order should be done, if not signed out it wouldn't have been done, physician orders should be carried out as ordered and signed off. On 1/9/25 at 3:28 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there is a blank in the TAR what does that indicate, DON B said they forgot to sign it out. Surveyor asked DON B if the blank could indicate that the treatment was not completed, DON B stated it could. Surveyor asked DON B if she expects all treatments to be done as ordered, DON B stated yes. 49436 Example 2 R51 admitted to the facility on [DATE]. R51's physician orders for January 2025 include left inner gluteal cleft: cleanse with wound cleanser, pat dry, apply Santyl to wound bed, zinc to peri-wound, cover with foam dressing change daily and as needed. On 1/7/25 at 10:53 AM, Surveyor observed R51 in bed with no dressing on her gluteal pressure injury. Surveyor interviewed RN F (Registered Nurse) regarding R51's pressure injury being open to air with no dressing in place. RN F indicated R51 had a shower earlier and the dressing had not replaced after R51's shower. RN F indicated a wound should not remain uncovered for more than 30 minutes. RN F indicated prolonged exposure to air can hinder wound healing. On 1/7/25 at 11:30 AM, Surveyor interviewed CNA H (Certified Nursing Assistant) regarding R51's shower. CNA H indicated R51's shower was done before 9:00 AM. On 1/9/25 at 9:05 AM, Surveyor interviewed DON B (Director of Nursing) regarding wound care. DON B indicated a wound should not be left uncovered and the dressing should have been applied after R51's shower without delay.

Based on observation, interview, and record review, the facility failed to ensure they provided adequate supervision and assistance to prevent accidents for 1 (R11) of 4 residents reviewed for accidents and supervision. R11's care plan indicates R11 needs supervision for all meals. Surveyor observed R11 eating meal in his room alone. R11 indicated it was difficult to eat the meal. Evidence by The facility policy, Activities of Daily Living, dated 8/24, states, in part; .2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . R11 was admitted to the facility on [DATE] with a diagnoses including parkinsonism (collection of movement symptoms- slow movements, stiffness, walking/balance issues, and/or tremors), dysphagia (difficulty swallowing), osteoporosis (bones become weak and brittle), tremor, and mild cognitive impairment. R11's most recent MDS (Minimum Data Set) dated 12/20/24, states that R11 has a BIMS (Brief Interview of Mental Status) of 15 indicating R11 is cognitively intact. R11 is own person. R11's care plan states, in part; .At nutrition risk r/t (related to) Parkinson's, mild cognitive impairment, weakness, tremors I would prefer finger foods as they are easiest for me to eat .I do not want items I have trouble eating such as spaghetti .date initiated 4/20/23 .revision 12/19/24 .The resident has a swallowing problem r/t coughing or choking during meals .Resident to eat only with supervision .initiated: 9/30/24 . On 1/7/25 at 12:10PM, Surveyor observed R11 eating in his room alone. R11 was eating spaghetti and having difficulty scooping up the noodles. Surveyor asked R11 how lunch was going. R11 stated difficult, and that R11's food was delivered cold. On 1/8/25 at 10:41AM, RN I (Registered Nurse) indicated R11 needs supervision for all meals. On 1/8/25 at 11:03AM, ST J (Speech Therapist) indicated R11 should have supervision for meals. ST J indicated it is her expectation if a resident care plan states they should have supervision for meals the facility must follow care plan. On 1/9/25 at 9:14AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated they would expect staff to follow resident care plan for supervision and preferred food items. NHA A and DON B indicated understanding with concern for R11. The facility failed to ensure they provided adequate supervision and supports per resident care plan.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 4 of 5 residents (R1, R2, R3, and R5) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care (APOAHC). R1 eloped from the facility on [DATE] and fell outside the facility, resulting in a fracture of his jaw. The facility did not have adequate supervision to ensure they were aware of R1's whereabouts and did not have security measures and monitoring in place to ensure R1 could not access various locations in the building, allowing him to exit the rear of the facility. Door alarms did not function correctly, allowing R1 to exit his wing into the elevator, go down 2 floors, propel himself in his wheelchair the length of the building on the ground floor, then through the kitchen, through the maintenance area, and walk up a flight of stairs to exit through the employee entrance. R1 then walked through the parking lot, down the sidewalk, and attempted to enter an adjacent church just off the facility grounds and fell , breaking his jaw. The facility's failure to provide adequate supervision to R1 and ensure all the alarmed doors were armed created a finding of Immediate Jeopardy which began on [DATE]. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 2:10 PM. The Immediate Jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and as evidenced by: R3 and R5 reside on the first floor which does not have a Wanderguard alarm system. R3 and R5 were at risk for elopement and had a Wanderguard. There was no alarm system to prevent R3 and R5 from exiting the building on the first floor. R2's Wanderguard tab was expired and still on R2's person. Findings include: The facility's policy titled Elopements and Wandering Residents states the following: *This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. *The facility is equipped with door locks/alarms to help avoid elopements. *Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. *The facility shall utilize and establish a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. *Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care team. *The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. *Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. *Adequate supervision will be provided to help prevent accidents or elopements. *Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. *The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. R1 was admitted to the facility on [DATE] and has diagnoses that include dementia with psychotic disturbance and agitation. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 is severely cognitively impaired. A [DATE] elopement risk assessment indicates R1 is at risk for wandering. R1's care plan states, Focus .is potential elopement risk/wanderer related to diagnoses of dementia, history of sundowning, independently mobile .Interventions: .resident's behavior is de-escalated by 1:1, talk about Alabama sports, initiated [DATE]. The facility documented the following progress notes for R1: *[DATE] at 4:44 PM: .increase in behaviors of exit seeking 1530 (3:30 PM) until 1600 (4:00 PM). Unsuccessful using distraction: drinks, snacks, stuffed dog in resident's room, use of wheelchair, folding towels, walking with staff in hallways, conversing with other residents. Staff kept eyes on resident while gathering residents to dining room for dinner meal. At 1610 (4:10 PM) writer inquired staff of resident's whereabouts, resident not seen on primary floor. Writer in search of resident, noted to be in front of facility building, with dirt on hands. Denied falling or hitting head, vitals, and neuros (neurological checks to check for head/brain injury) completed all within normal limits .resident stated, I don't remember I might have slipped or tripped or whatnot. Of note, the facility did not have a report or investigation of R1's elopement from the facility on [DATE]. Although administration was aware of the incident, it is not known or documented as to whether the alarm system was working at that time. No documentation was provided to surveyors. The facility documented the following progress notes for R1: *[DATE] at 3:42 AM: Reported to writer in report that resident had been at nurse station with previous nurse for supervision. When previous nurse left floor, resident began pacing, attempting to leave on the elevator, going into other residents' rooms, yelling down hallways. *[DATE] at 1:11 PM: Continues pacing hallway wanting to leave to get to his wife. Resident first stated he needed to get to the grocery store on Main Street, that his wife was waiting for him there. Resident was seen in dining room after he had taken the screen off a window and was attempting to climb out the window to get to his house four blocks down the road. *[DATE] at 3:00 PM: Resident has been awake all AM shift. He has been walking all around the floor also went into the elevator and down to the ground floor. He also was running at top speed he came running around a corner by the nurses station and stumbled but writer caught him before he was able to fall. He was undirectable, agitated at times, very strong physically with staff when they tried to redirect him for safety sake. Again, insisting at times to go out the fire doors, to the car lot, or the farm. The facility documented and reported to the State Agency an incident which occurred on [DATE], stating, On Sunday [DATE], at approximately 11:00 PM R1 was discovered in the rear parking lot of the facility. CNA (Certified Nursing Assistant) was in the process of going outside to meet her husband who had brought her food for the night shift. As CNA went to exit the building, she observed an unattended wheelchair by the rear exit. She immediately exited the building and was met by her husband who noted that there was a man walking by the building. CNA continued her pursuit and found resident (R1) approximately 30 feet from the property at the entrance of the adjacent church. She noted he was standing upright and attempting to gain access to the church. Additional details of the event as documented in the report: *911 was called and EMS (Emergency Management Services) was contacted. *R1 was transferred to the local ED (Emergency Department) and returned the next morning ([DATE]) at 4:00 AM. *R1 was wearing a Wanderguard, but no alarm sounded on his second-floor unit when he exited. Facility documentation shows R1's Wanderguard was checked to be functioning correctly at 10:16 PM the night of [DATE]. *The maintenance director was contacted and reported to the facility around 1:00 AM ([DATE]) and found the Wanderguard system to be functioning properly. The ED (Emergency Department) found R1 to have a closed fracture of left condylar process of mandible (broken jaw close to left ear), 3 mm (millimeter) chin laceration that is 3 mm deep - not down to bone with 6 sutures placed, and a contusion of the left knee. The facility's plan after the event to prevent a similar event included: *Maintenance to check the entire wander system to ensure functioning properly and to audit the wander system weekly x 4 weeks to ensure functioning properly. *Any resident who is exit seeking and not able to redirect, Administrator, DON (Director of Nursing) or Unit Manager will be updated, and resident will be placed on 1:1 until DON or Administrator removes 1:1. *All staff education regarding double doors near the kitchen, doors at the equipment room, doors at locker room and near employee entrance near stairs will be kept closed at all times. Signs were placed on the doors. On [DATE] at 3:50 PM, Surveyor interviewed CNA C, who was the staff member to find R1 in the parking lot. CNA C stated that her husband saw R1 fall onto his face in front of the church prior to her arrival in the parking lot. According to CNA C, her husband stated that R1 had fallen onto his face and let out a gasp in pain. On [DATE] at 3:40 PM, Surveyor interviewed CNA F who stated that she was working on the second floor on [DATE] and had just walked past his (R1's) room while doing rounds around 10:30 PM. CNA F stated she went downstairs to take her 15-minute break and saw R1's wheelchair wedged in the doorway of the staff stairwell exit. CNA F stated she saw CNA C outside and the ambulance was already there. CNA F stated that she had not heard any alarms sounding at any point during her shift and had not been aware of an issue until she had seen R1's wheelchair wedged in the stairwell doorway on her way out of the building on her break. On [DATE] at 11:34 AM, Surveyor walked with MD D (Maintenance Director) the length of distance R1 traveled from his 2nd floor unit to the exterior of the building on the night of [DATE]. The path started on the second-floor elevator which had a Wanderguard sensor on it and went down 2 levels to the ground floor. From the ground floor elevator, R1 propelled himself in his wheelchair the entire length of the building, approximately 300 feet, which goes by the facility's front reception desk, went through the double-doors to the kitchen, through the kitchen, into a maintenance area, through the employee section of the building, then left his wheelchair in a doorway at the base of a stairwell that leads out the back of the building, where staff enter through a rear parking lot area. R1 walked up the stairs and out the of the building. R1 then walked approximately 100 feet through the rear parking lot to an adjacent church. MD D stated that the facility was sure this was his route as his wheelchair was found in the doorway at the base of the stairs that leads to the rear exit of the building. Of note, the rear exit door that R1 exited on [DATE] was found to be unlocked from the inside when surveyors walked the route on [DATE] at 11:34 AM. It should be noted that the doors to the kitchen, maintenance area, and staff area remain open at all times. The front desk near the ground floor elevator is not staffed in the evening hours. The rear exit where R1 exited is unlocked on the inside but requires a key code entry from the outside. Additionally, the audit sheet MD D uses to audit the doors in accordance with the facility's proposed plan shows that the doors being audited are main entrance, rear entrance (no Wanderguard), small elevator, large elevator, and 4 additional stairwell doors on the second floor. According to MD D, doors on the 1st floor were not checked. There is no Wanderguard or alarm system on the first floor or ground floor elevator. On [DATE] at 11:54 AM, MD D showed Surveyor the doors on the second floor that he had been auditing/checking since the event took place on [DATE]. MD D used a handheld device to check the Wanderguard system on the 2nd floor elevator and one of the stairwell exit doors at the back of a wing on the second floor, both tested in working condition. However, 2 Wanderguard sensors on stairwell doors on the second floor were not being monitored. These doors have keypads that require a certain code to open. If the door is pushed without entering a code, the door alarms. However, if the code is entered and door opened, the Wanderguard system would provide a secondary alarm in the event that a resident with a Wanderguard attempted to go through the door before it closed. The Wanderguard system on these doors is a different brand than the others MD D had just checked. MD D attempted to use the handheld device to check the Wanderguard system on the magnetic doors and nothing happened. MD D then stated that he had not been checking the Wanderguard alarms on these magnetic-release type doors as he was not sure how to do so. R1's Progress Notes dated [DATE] at 10:11 PM: Resident was agitated during supper tonight. He was using abusive language, hitting, and kicking towards staff, and continuously wandering the hallways trying to escape. Resident had been given food and 1:1 conversation for redirection. R1's Progress Notes dated [DATE] at 9:54 PM: Around 7:30 PM resident was wandering into other residents' rooms and agitating other residents. Staff had to redirect him, and staff did 1 on 1. On [DATE] at 4:27 PM, during interview with Surveyor, LPN E (Licensed Practical Nurse), who wrote the [DATE] progress note regarding R1 in another resident's room, stated R1 was supposed to be 1:1 with a CNA on [DATE]. The CNA must have started rounding and getting other residents ready for bed. LPN E stated she looked where R1 had been near the nurse's station with the CNA on 1:1 and did not see him. LPN E stated that she started looking for R1 and found him in another resident's room. LPN E stated that she made sure that R1 remained 1:1 the remainder of the night. R1's Progress Notes dated [DATE] at 2:40 PM: Resident extremely agitated, continuously wandering the hallway and trying to leave facility. Writer notified by activity staff resident was found on the ground in dining room. Resident resistive to staff helping off ground, taking vitals or assessing .Resident on 1:1 with staff to ensure safety at this time. The facility failed to ensure R1, who was at risk for elopement, had adequate supervision after a previous elopement on [DATE]. The facility did not document this event, it is unknown if the security features of the building were working at this time, and they were not regularly auditing these doors. R1 continued to exhibit exit-seeking behavior, attempting to exit a second story window on [DATE] and taking the elevator from the second floor to the ground floor on [DATE] before his eventual elopement later in the evening, which resulted in a fractured jaw. The facility did not put measures into place to ensure a similar event did not occur. R1 was to be placed on 1:1 when he was displaying exit-seeking behavior but he was not monitored on [DATE] when he was supposed to be on 1:1 due to his behaviors and was eventually found in another resident's room. Facility maintenance was not auditing their Wanderguard system on all doors on the second floor as was stated the facility would do and were not monitoring doors on the first or third floors where other residents reside. These failures created a reasonable likelihood for serious harm to occur, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility began implementing the following: *All other residents that had the potential for elopement and other safety concerns were assessed and care plans reviewed. *Maintenance to check the entire wander system to ensure proper functionality. This will include all 4 floors of the facility that contain wander system elements, as well as both the [NAME] and Wanderguard systems. *All residents that have a Wanderguard will have their Wanderguard bracelet checked to ensure proper functionality. This will include validation of activation dates and a replacement cycle equal to or less than 90 days. *All other residents who have the potential to leave out the doors were assessed. *Wander books were updated To ensure safety of residents, staff were educated prior to next working day on: Residents at Risk for Elopement Definition of 1:1 How to check Wanderguards Standing orders for Wanderguard's implementation Assigning staff to daily schedule in the event 1:1 is needed who will take 1:1 task. Educate staff with a clear understanding of what 1:1 means. Educate staff on how to input new standing orders for Wanderguards. *DON/designee audit conducted to ensure all standing orders for Wanderguards are clear accurate and match for when they need to be changed every 90 days. *Audit all Wanderguard bracelets to ensure an accurate date of change. *All staff will be provided with education prior to next working day regarding the double fire doors near the kitchen, the door at the equipment room, the door at the locker room and the door at the base of the employee entrance that these doors will be mandated always closed. *Signs were placed on the doors noting the need to keep them closed. *A secure key code lock will be placed on the equipment room door to ensure residents cannot access staff or unsecure outside exits. A staff person will be designated to monitor this door to prevent a resident from exiting until the key code lock is in place. *Maintenance will coordinate with a Wanderguard Vendor the possible installation of a Wanderguard sensor at the rear entrance and/or modification to the existing system *Maintenance will enhance the lighting in the rear employee parking area/service entrance. *The facility will complete an initial round of elopement drills on each shift. Facility reviewed the following policies: Elopement and Wandering residents Accidents and Supervision *Nursing will test the residents Wanderguard bracelets to ensure functionality weekly going forward. The facility will then audit all resident Wanderguard bracelet tests weekly to ensure compliance for 4 weeks. *The facility will audit the 4 doors identified in the path of egress to ensure closure status for 4 weeks. *Maintenance will test the wander guard sensors at all doors on all 4 floors to ensure proper functionality weekly going forward. The facility will then audit all tests weekly to ensure compliance for 4 weeks. *The facility will review during the daily clinical IDT all residents that demonstrated exit seeking behavior during the previous day to ensure appropriate elopement interventions are implemented and the care plan is reviewed/revised as necessary. R3 and R5 had new elopement risk assessments completed, and it was determined they are no longer at risk. *All new admissions will have an elopement risk assessment upon admission *All current residents will have a quarterly elopement assessment and as needed with change. *Audits will be reviewed at QAPI. *Facility Assessment will be updated to reflect staffing needs to ensure proper management of individuals with exit seeking behavior. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan and as evidenced by the following examples: Example 2: The facility employs a Wanderguard system that alarms when a resident with a Wanderguard (either on their person or wheelchair) passes through a doorway that has a compatible alarm system installed. The facility uses a model of Wanderguard tab that is good for 90 days once activated. At the end of 90 days, a new Wanderguard tab must be placed on the resident. The Wanderguards have an activation date printed on them, much like an expiration date, and the Wanderguard must be activated to start the 90-day clock. Residents in the facility that are deemed elopement risks have Wanderguards and orders for them to be changed every 90 days. R2 was admitted to the facility on [DATE] and has diagnoses that include dementia with psychotic disturbance. Her most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 2, indicating R2 is severely cognitively impaired. Her care plan indicates she is at risk to wander due to her dementia and has increased episodes of exit seeking in late afternoon/early evening. Her care plan states, Apply Wanderguard, monitor for placement/function, replace as needed ([DATE]). On [DATE] at 11:10 AM, R2's Wanderguard on her wheelchair was observed by Surveyor to say, in black handwriting, changed on [DATE]. RN G (Registered Nurse), who was with Surveyor, stated he would change the Wanderguard. Of note, R2's Wanderguard was beyond the recommended 90-day change date and there is no evidence that R2's Wanderguard was changed in July and if it had exceeded its life of 90 days of usage. Example 3: R3 was admitted to the facility on [DATE] and has diagnoses that include dementia. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 7, indicating R3 is severely cognitively impaired. His care plan states, Resident is an elopement risk/wanderer related to history of attempts to leave facility unattended. Goal: the resident will not leave facility unattended through the review date (target date [DATE].) The resident's safety will be maintained through the review date (target date [DATE]) .Interventions: Wanderguard to right wrist. R3's Treatment Administration Record (TAR) indicates the facility checks the placement and function of his Wanderguard three times per day. R3 resides on the first floor where there is no Wanderguard or alarm system on the elevator, nor are any doors on the first floor being audited or monitored. R3 was noted at the time of survey to be at risk for elopement according to R3's current plan of care. The facility was completing and the once-per-shift monitoring of their Wanderguard function and placement but there was no monitoring of the doors on the first floor and the first-floor elevator had no alarm at all, potentially allowing R3 to take the same route as R1 did on [DATE] without sounding any alarms. On [DATE] at 11:10 AM, Surveyor observed R3's Wanderguard on his right wrist and noted it read activate by [DATE] but did not have a date it was placed on resident. R3's TAR indicates this Wanderguard was to be replaced on [DATE] but it was not signed out as having been changed. No other documentation was provided indicating when it was replaced. Example 4: R5 was admitted to the facility on [DATE] and has diagnoses that include alcohol-induced dementia. His most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 1, indicating R5 is severely cognitively impaired. R5's care plan states he is an elopement risk/wanderer related to exit seeking. His care plan states, Wanderguard bracelet on right wrist . ([DATE]). R5's TAR indicates the facility checks the placement and function of his Wanderguard three times per day. R5 resides on the first floor where there is no Wanderguard or alarm system on the elevator, nor are any doors on the first floor being audited or monitored. At the time of the survey, R5 was noted to be at risk for elopement according to R5's current plan of care. The facility was completing the once-per-shift monitoring of their Wanderguard function and placement but there was no monitoring of the doors on the first floor and the first-floor elevator had no alarm at all, potentially allowing R5 to take the same route as R1 did on [DATE] without sounding any alarms. On [DATE] at 3:49 PM, NHA A (Nursing Home Administrator) stated that he had recently contacted the manufacturer of the alarms that the facility uses to find out how long they can function. NHA A stated the manufacturer recommended to not wear them beyond 90 days as they could not be guaranteed beyond that time, although they may still work. When Surveyor asked why R3 and R5 were residing on the 1st floor when there was no Wanderguard on the first-floor elevator, nor were the other stairwell doors being audited for functioning, NHA A stated R3 and R5 were probably not capable, at this point, of elopement. When asked if it was possible for R3 and R5 to take the same route R1 took on [DATE] given the first-floor elevator had no alarm and all other doors along that route were unlocked, NHA A stated yes and stated that the kitchen doors are now to remain shut at all times, even though they are not locked, they are heavy.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening, or to promote healing of PIs for 1 of 3 residents (R1) reviewed for PIs out of a sample of 17 residents. R1 was admitted to the facility without a pressure injury and was identified to be at risk for development of PIs. On [DATE] and [DATE], the facility identified that R1 had a reddened area on his sacrum and gluteal cleft. The facility did not notify R1's physician, obtain a treatment order, or monitor the reddened area. On [DATE], a Certified Nursing Assistant (CNA) discovered an open blood blister on R1's right buttock that was draining. The CNA reported this to LPN T (Licensed Practical Nurse). LPN T did not notify the RN (Registered Nurse) or R1's physician, obtain a treatment order, or monitor the open draining blood blister. Ten (10) days passed with the PI left unattended and without monitoring or treatment. On [DATE], an RN documented the approximate size of the PI as 3.0 x 3.0 x 0.2 cm with slough and odor. On [DATE], the facility notified NP D (Nurse Practitioner) of R1's PI; NP D put interventions in place. On [DATE], NP D requested DON B (Director of Nursing) take a photo of the PI and upload it to the electronic charting system for her to view; the facility did not take photos or upload photos to the electronic charting system until [DATE]. On [DATE], NP D ordered the visiting wound physician to assess R1. On [DATE], the visiting wound physician documented the PI as 7.0 x 4.0 x 4.0 centimeters in size, undermining 7 cm at 12 o'clock, heavy purulent drainage, and 100% thick adherent devitalized necrotic tissue. R1 developed a facility acquired PI, which worsened to a Stage IV PI which was infected with Methicillin-Resistant Staphylococcus Aureus (MRSA). R1 was hospitalized from ,d+[DATE] - [DATE]. On [DATE], R1 was admitted to inpatient hospice where he expired on [DATE]. R1 developed a new pressure injury that worsened and became infected with MRSA, a life-threatening Multidrug-Resistant Organism (MDRO). Staff failed to identify, measure, and assess R1's PI weekly, failed to contact a Physician/NP timely, and failed to implement aggressive preventative measures to prevent R1's PI from developing/deteriorating/worsening. This created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and RN Consultant S (Registered Nurse Consultant) of the immediate jeopardy on [DATE] at 11:34 AM. The immediate jeopardy was removed on [DATE] when the facility began education and corrected on [DATE]. As evidenced by: The facility's policy Pressure Injury Prevention Guidelines, dated ,d+[DATE], indicates in part the following: Purpose: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency of performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders. 7. Interventions will be documented in the care plan and communicated to all relevant staff. Repositioning Routine repositioning schedule: frequently, using both side-lying and back positions. Avoid positioning the resident on bony prominences/turning surfaces with existing pressure injuries, including stage 1. Pressure Relieving Devices Support surfaces do not eliminate the need for turning and repositioning. The standard mattress for all facility beds are pressure redistribution mattresses (i.e., high specification reactive foam). The NPIAP (National Pressure Injury Advisory Panel) classifies a pressure injury as follows: Suspected Deep Tissue Injury; (SDTI) Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may be associated with Stage 4 pressure ulcers. Advancing Excellence notes that Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: o Decrease in bowel and bladder function o More incontinence o Decrease in ability to move without help o Decrease in mental capacity o Increase in pain o Increased risk for infection o Less participation in activities (http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf Mayo Clinic's website describes the complications of pressure injuries, including: Sepsis. Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. Cellulitis can lead to life-threatening complications. Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con-20030848 R1 developed a new pressure injury that worsened and became infected with MRSA, a life-threatening MDRO. Staff failed to identify, measure, and assess R1's PI weekly, failed to contact a Physician/NP timely, and failed to implement preventative measures timely to prevent R1's PI from developing/deteriorating/worsening. This created a finding of immediate jeopardy that began on [DATE]. The facility recognized the deficient practice and took the following corrective steps to ensure that deficient practice does not reoccur on [DATE] when they completed the following: R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: failure to thrive, diabetes mellitus type 2, dysphagia, abnormalities of gait and mobility, obesity, signs, and symptoms involving the digestive system and abdomen, history of malignant neoplasm of large intestine, and osteoarthritis. R1 has an Activated Power of Attorney for Health Care (APOAHC). R1's Admission Braden Assessment score (a measure of pressure injury risk) is 14, indicating he is at risk for PI development. The assessment documents the following Details/Comments: Pt (Patient) has redness to coccyx. Area is blanchable. No open areas. Covered w/(with) sacral Mepilex for comfort/protection. R1's Admission Minimum Data Set (MDS) dated [DATE] indicates R1 is moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 8 and requires extensive assistance of 1 for bed mobility, walking on the unit, and extensive assist of 2 for transferring, dressing and hygiene. R1's MDS indicates he is at risk for PI development, and he was admitted with no PIs. Surveyor requested R1's Kardex twice. No Kardex was provided to Surveyor. R1's comprehensive care plan indicates the following: (Date Initiated [DATE]) R1 has potential impairment to skin integrity. (Date Initiated [DATE]) Buttock red/blanchable on admit. Goal: The resident will maintain or develop clean and intact skin by the review date. (Date Initiated [DATE]) I will not experience any additional skin breakdown or other complications thru next review date. ([DATE]) Encourage good nutrition and hydration in order to promote healthier skin. (Date Initiated [DATE]) R1 has a pressure reducing mattress (Panacea Foam Mattress - see below) to protect the skin while in bed. (Date Initiated [DATE]) R1 has cushion to protect the skin while up in chair (note, this is used in his wheelchair only.) (Date Initiated [DATE]) My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment. (Date Initiated [DATE]) Report any skin redness/impaired skin integrity areas to my nurse. (Date Initiated) Use barrier cream to prevent skin impairment issues, as needed. Note, the facility did not add any additional skin interventions until [DATE], [DATE] and [DATE] after the PI was discovered and acted upon; On [DATE] in R1's comprehensive care plan, the facility documented R1's PI as a Stage III ulcer on coccyx. R1 has been on a Panacea Foam Mattress since admission. The manufacturer guidelines indicate the following: WARNING THIS MATTRESS IS NOT INTENDED FOR STAGE III OR STAGE IV PRESSURE ULCERS. On [DATE] R1's Weekly Skin Review indicates: Skin intact On [DATE] R1's Weekly Skin Review indicates: Skin intact, Redness, buttock redness from lying on buttocks in bed and wheelchair. On [DATE] R1's Weekly Skin Review indicates: Skin intact On [DATE] R1's Weekly Skin Review indicates: Skin intact *On [DATE] R1's Weekly Skin Review indicates: (Skin Intact is not checked) Skin Dry Redness pre-existing: Sacrum and gluteal cleft area with mild redness. Tissue blanchable and intact. Application of barrier oint (ointment) after incontinence episodes in place. Position changes enc (encouraged). BLE (bilateral lower extremity) tissue dry and heels w (with) dry, flaky tissue. All other tissue intact . *On [DATE] R1's Weekly Skin Review indicates: (Skin Intact is not checked) Sacrum and gluteal cleft area with mild redness. Tissue blanchable and intact. Application of barrier ointment after incontinence episodes in place. Position changes enc. BLE tissue dry and heels w (with) dry, flaky tissue . On [DATE] NP C (Nurse Practitioner) conducted a Routine Nursing Home Visit with R1. NP C documents, in part, as follows: .R1 reports occasional discomfort in his low back especially with prolonged sitting, this is why he likes to be in bed Nursing Concerns: Needs a lot of motivation and encouragement to get up on chair during meals Mood/Behavior: With some yelling, screaming, confused, frequent refusals of cares, wife assists with this while visiting. Mobility: x,d+[DATE] (staff) to pivot transfer; ADL (Activities of Daily Living) assistance: complete care need; Pain: R1 reports low back pain with sitting, chronic *On [DATE] R1's Weekly Skin Review indicates: Resident (R1) had shower today. CNA alerted nurse (LPN T - Licensed Practical Nurse, an LPN at this time) to blood blister on right buttock that was draining. Blister appeared to be fully drained. A&D ointment applied around area. Of note, a blood blister is defined by NPIAP as a SDTI - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This is evidence of tissue injury and can progress to a PI. SDTI's need aggressive treatment to prevent further pressure and promote wound healing. Of note, the facility should have implemented aggressive PI interventions to prevent further deterioration of the PI. However, interventions were not implemented until [DATE]. On [DATE] at 1:11 PM, DON B (Director of Nursing) documented the following in R1's Progress Note: Per information from floor nurse, NP (NP D) updated on coccyx wound. New Tx (treatment) orders received. Air mattress to be ordered. Order to have RD (Registered Dietician) follow up with resident. NP indicated she is enroute to facility and will visit resident. NP also updated on range of blood sugars past several days of ,d+[DATE]. On [DATE] at 2:28 PM, R1's Progress Notes indicates the following: Wound observed, wound on coccyx area approx 3 x 3 x 0.2 (measurements in centimeters) depth irregular circumference, slough with epibole (rolled PI edges makes impossible for wound to heal without intervention) to wound edges, peri wound intact, moderate sero drainage (serum and blood drainage) noted with odor. Floor LPN (Licensed Practical Nurse) to update NP (Nurse Practitioner) and dietary. R1's POA (Power of Attorney) notified. On [DATE] the facility notified NP D (Nurse Practitioner) regarding the open area on R1's coccyx/buttock. It is important to note, facility's initial notification to the provider regarding R1's PI was on [DATE], 10 days after the open blister was discovered. NP D provided the following verbal orders via phone: Treatment Order: Clean coccyx would [sic] with normal saline, pat dry and cover with Mepalix [sic] every 3 days. Change PRN (as needed). every day shift every 3 day(s) for wound care, contact NP if wound worsens. Air mattress for bed. Have RD (Registered Dietician) follow up with resident. May follow recommendations of RD. On [DATE] at 4:46 PM, NP D electronically signed the following additional orders for R1: 1. Consult (name) visiting wound physician; indication: coccyx wound 2. Prostat liquid supplement, take 30 ml (milliliters) PO (by mouth) daily; Indication: wound healing. On [DATE] R1's Weekly Skin Review indicates: Coccyx-tx (treatment) order in place, cleanse with NS (normal saline) pat dry and apply Mepilex change every three days and PRN (as needed) if soiled. Consult with (name removed) visiting wound physician. Coccyx 3.0 cm (centimeters) x 3.0 cm open area On [DATE] at 9:40 AM, ADON E (Assistant Director of Nursing) documented the following Progress Note regarding R1: R1 was assessed during wound rounds with wound MD (Medical Doctor) today due to coccyx wound. Upon assessment, large amount of purulent drainage noted to be actively draining from another small open area near top of rectum. Open area 2 cm deep with 7 cm undermining to 12 o'clock. Peri anal are firm to touch about 2.5 cm surrounding anus. MD expressed concerns for peri-anal abscess and inability to properly assess in SNF (Skilled Nursing Facility) setting. POA, updated with MD's concerns and need of further eval in ED (emergency department). NP (NP D) also updated and order for vital signs stat; stable BP (blood pressure) ,d+[DATE], HR (Heart Rate) 62, RR (Respiratory Rate) 18, SpO2 98, T (Temperature) 96.8. POA (Power of Attorney) agrees to transport to ED (emergency department). On [DATE] visiting wound Physician W documented the following assessment: Wound Buttock Full Thickness Etiology: Infection Duration: >1 days Objective: Control infection, Healing Wound Size: 7.0 cm x 4.0 cm x 4.0 cm Surface Area: 28.00 cm Undermining: 7 cm. at 12 o'clock Exudate: Heavy Purulent Thick Adherent devitalized necrotic tissue: 100% Factors Complicating Wound Healing: Type 2 Diabetes Mellitus, Obesity, Anemia Coordination of Care: During today's visit, provided counseling specific to infected wound of the Buttock. Concern for significant infection with perirectal abscess and coccygeal pressure wound, appear to be communicating with each other on bedside assessment, freely expressed purulent drainage from wounds with significant induration along buttock concerning for deeper and larger abscess pocket. Given how tender and extensive this wound is, I believe he would be better served for surgical debridement and drainage under anesthesia. Discussed this with patient and his POA (Power of Attorney) and described procedure for debridement and drainage with possible counter incision along his buttock to facilitate further drainage of his abscess cavity . On [DATE] at 8:57 PM, R1 is admitted to the hospital. R1's hospital note indicates, in part, the following: R1 currently resides in a skilled nursing facility and is known to have a sacral decubitus ulcer who presented to the emergency department with worsening pain and drainage from the region. He underwent a CT (Computed Tomography) scan (type of x-ray) which showed a large perianal abscess likely associated with the known sacral decubitus ulcer. Given the size of the infection, I recommended incision and drainage as well as debridement in the operating room. Findings: Large sacral decubitus ulcer which connected with abscess cavities surrounding the anal canal. No evidence of connection with the anal canal or rectum. Counter incision made in the anterior midline and Penrose drains placed on either side of the anal canal We began a rectal exam. He was noted to have minimal sphincter tone, but no masses or lesions were noted. This was explored and connected to a large cavity underlying an eschar at the site of his known sacral decubitus ulcer. We removed the eschar and explored the abscess cavity. It was noted to extend circumferentially around the anal canal and connected anteriorly. We again confirmed no connection between the abscess cavity and the anal canal or the rectum. We sharply debrided the abscess cavity, which had copious purulent fluid and fibrinous exudate Following the procedures, I did speak with the patient's family about the findings of the case and the expected postoperative course. I did discuss possible diversion with a colostomy to aid with wound healing given the size of the wound and the proximity to the anal canal. Postoperative diagnosis is Circumferential perianal abscess associated with large sacral decubitus ulcer The hospital cultured R1's Perianal Abscess Fluid. The Result Note indicates: Many Methicillin-RESISTANT Staphylococcus aureus! Patient requires isolation. It is important to note, R1 has no history of MRSA (Methicillin-Resistant Staphylococcus Aureus). It is also important to note that R1's perianal abscess and PI are connected which indicates the PI is also infected with MRSA. R1 developed an avoidable Stage IV facility acquired PI that became infected with MRSA. R1 was hospitalized from ,d+[DATE] - [DATE]. On [DATE] R1 was admitted to in patient hospice where he expired on [DATE] (9 days later). On [DATE] at 10:57 AM, Surveyor spoke with NP D (Nurse Practitioner). NP D stated she conducts visits at the nursing home in conjunction with the residents' primary care provider. NP D stated she had just returned from maternity leave when she received a phone call on [DATE] from DON B (Director of Nursing). NP D stated, at that time she gave several orders related to wound care, adding an air mattress, dietary assessment, Prostat liquid, consult with wound physician. NP D stated the wound physician does rounds together with a nurse at the facility on Thursdays. NP D stated, ADON E (Assistant Director of Nursing) called her on [DATE] early in the morning. NP D stated she documented ADON E's call at 9:22 AM, but it was earlier than that. ADON E indicated tunneling between sites, the abscess is draining pus and the Physician referred R1 to be sent to the ED (emergency department). NP D stated she never saw R1's wounds herself. NP D indicated she had hoped to get to the facility on [DATE], however, she was unable to make it and requested photos be uploaded to PCC (Point Click Care - electronic health record) for her review. NP D stated on [DATE], R1 was seen by her colleague, NP C (Nurse Practitioner). Surveyor asked NP D to access R1's record in PCC and view the photos uploaded on [DATE]. NP D stated, I would agree with the Full Thickness. NP D stated, without debridement it's hard to say how many layers it's going through. It's at least a stage 3 or 4 and debridement is necessary to determine. NP D reviewed NP C notes from [DATE]. NP D confirmed there are no skin concerns noted in this visit notes. Surveyor asked NP D, was R1 at risk for skin breakdown. NP D stated, I classified him to be at risk and ordered interventions. Surveyor asked NP D, is R1's PI avoidable or unavoidable. NP D stated, in general PIs are avoidable and that's why we make interventions to avoid them. NP D stated R1's PI is avoidable. NP D stated, when the facility contacted her on [DATE], she did a chart review and could see he was a frail elderly gentleman. NP D stated, she could see R1 is at risk (of PIs) that's why she placed those previous measures (see above orders). Surveyor asked NP D, if a resident is at risk of PIs would you expect staff to put interventions in place. NP D stated, if a resident has issues like immobility, areas of redness or blanchable area, the facility calls for an air mattress, frequent turning, propping, and offloading, nutritional support, more frequent toileting, and peri cares. NP D indicated the facility should be looking for modifiable interventions, usually she gets a call and that's why kicks off these cares. Note, there is no evidence that any provider was notified regarding skin integrity issues or pressure injuries prior to the facility notifying NP D on [DATE]. Surveyor asked NP D, if a resident has blanchable redness to their coccyx upon admission what would you do. NP D stated, if this is brought to the attention of a Nurse Practitioner or any provider, we would assess the resident, implement preventative measures, review other risk factors, history of wounds, malnutrition, etc. NP D stated, on [DATE] she requested that DON B (Director of Nursing) take and upload photos of R1's wounds (PI and abscess) in PCC (Point Click Care electronic charting system). NP D stated, no photos were uploaded into PCC for her to review. On [DATE] at 2:37 PM, Surveyor asked NHA A (Nursing Home Administrator), did the facility provide any risks and benefits to R1 or his APOAHC. NHA A stated, No. On [DATE] at 7:45 AM, Surveyor asked CNA I if she is familiar with R1. CNA I stated, yes. Surveyor asked CNA I, did R1 have any skin interventions in place before the PI developed. CNA I stated, Not really, there's no communication or follow up about anything. CNA I stated R1 would scream help all day and all night. R1's APOAHC did everything for him. CNA I stated, she would transfer R1 into the recliner in the activity room in the morning. CNA I stated R1 would stop screaming and seemed to enjoy being up in the recliner. CNA I stated this would allow her to get other residents up and out of bed after she got R1 up out of bed. Surveyor asked CNA I, did R1 have a cushion in the recliner. CNA I stated, No. CNA I added, R1's APOAHC did not like him being up in the recliner or participating in activities and would yell at staff to take him back to his room and put him to bed. Surveyor asked CNA I, was R1 agreeable to repositioning. CNA I stated, R1 was set in his ways (clarified did not like to reposition). CNA I stated, R1 preferred to lay on his right side and would never lay on his left side. CNA I stated, R1's APOAHC took his wheelchair cushion home with her on [DATE]. CNA I stated, she reported this to PT/OT and they replaced the cushion. (Surveyor confirmed this with PT/OT). CNA I added, R1 made a point that everybody is going to do everything for him (all cares including anything he can do for himself.) On [DATE] at 2:00 PM, Surveyor interviewed CNA I and asked if she ever cared for R1. CNA I indicated she had. Surveyor asked CNA I if she ever observed pads inside of his brief, double briefing, or saturated briefs. CNA I indicated, yes and that R1 had 2 pads overlapping in his brief. CNA I put her two hands together to show how the pads were in the brief, showing the pads would have been put together to make one long pad. CNA I indicated when she would come on the AM shift he would be saturated. Surveyor asked what time CNA I comes in for the AM shift. CNA I indicated 6 AM - 2 PM. Surveyor asked how often she would find R1 saturated. CNA I indicated, pretty much every time I came in. Full bed changes were needed a few times a week and he would never want to get out of bed, so we had to roll him to do it. On [DATE] at 11:39 AM, Surveyor called Wound Physician W. Surveyor was unable to reach Wound Physician W or leave a message. On [DATE] at 12:02 PM, Surveyor spoke with ADON E (Assistant Director of Nursing) who is also the wound care nurse. ADON E stated R1 developed a facility acquired PI that became infected with MRSA before he was transferred to the hospital. ADON E stated she was off on ,d+[DATE] and ,d+[DATE]. ADON E stated RN L (Registered Nurse) looked at R1 one of those days she was not here. ADON E stated the first date anything was noted regarding the PI was [DATE]. ADON E stated, R1 always had pain to his bottom but nothing was noted. Surveyor asked ADON E, did anybody inform you regarding the Skin Assessments completed on [DATE], [DATE], or [DATE]. ADON E stated, no. Surveyor reviewed the Skin Assessments with ADON E. Surveyor asked ADON E, if a staff member discovers an open blood blister on a resident what would you expect them to do. ADON E stated, she would expect staff to contact the provider, POA (Power of Attorney), if applicable, notify ADON E or RN L. Surveyor asked ADON E, would you expect staff to notify you regarding redness that is blanchable. ADON E stated, yes. ADON E stated, she would then go assess the resident and look at contributing factors such as are they on their bottom too much, do they need an air mattress. Surveyor asked ADON E, how do you determine which residents need an air mattress. ADON E stated if a resident has a decreased ability to move themselves or redness. Surveyor asked ADON E, could R1 reposition himself. ADON E stated, I think he needed assistance. Surveyor asked ADON E, if you were notified on [DATE] or [DATE], what you have done in response to reports of redness. ADON E stated, she would have looked at R1's current interventions, put an air mattress in place, barrier cream, care plan for repositioning and notified the provider. Surveyor asked ADON E, should these interventions have been put in place for R1 on [DATE]. ADON E stated, yes. Surveyor asked ADON E, do staff document turning and repositioning. ADON E stated she will check. No additional information was provided. Surveyor asked ADON E, do staff document refusals of care plan interventions. ADON E stated, CNAs should report refusals to the nurse and the nurse should document. Surveyor asked for documentation of refusals. No additional information was provided. Surveyor asked ADON E if any risks and benefits were provided to R1 or his family. ADON E stated, no. On [DATE] at 12:54 PM, Surveyor spoke with FM U (Family Member), R1's family member. FM U stated, she would visit R1 multiple times weekly from 4:,d+[DATE]:00 PM - 6:,d+[DATE]:00 PM. FM U stated the facility never floated R1's heels when he was in bed. Surveyor asked FM U, how did R1 prefer to lay in bed. FM U stated, R1 preferred to lay on his right side or his back. FM U stated, staff would not reposition him while she was at the facility. FM U stated she expressed concern to SS Dir V (Social Service Director) regarding a decline in R1's condition after he was transferred to the second (2nd) floor (Memory Care). Surveyor asked FM U, what changes did you noticed in R1. FM U stated, 1. R1 seemed to be more uncomfortable, 2. He kept complaining of his backside, 3. R1 stopped going to activities, 4. His voice kept getting softer and softer. FM U stated, R1 looked so weak and frail. FM U stated, SS Dir V spoke with Nursing staff, and they were unable to confirm any decline in R1's condition. FM U stated after R1 was transferred to the hospital she saw a photo of his PI and abscess, and she could tell from the picture that it was infected (redness, drainage, slough). FM U stated, at the hospital the physician made a 6 incision from R1's anus to his tailbone. FM U stated, the physician at the hospital told her that R1's PI and abscess is not ever going to heal and is infected with MRSA. FM U stated, the physician offered a colostomy. FM U stated, R1 did not want surgery (for the colostomy). FM U stated, I was frustrated that they (facility) let it get to that point. FM U stated, Nobody deserves to be in that much pain. FM U added, I am furious with them (facility)! On [DATE] at 3:15 PM, Surveyor spoke with CNA X. Surveyor asked CNA X, did R1 have skin interventions in place. CNA X stated, None that I'm aware of, no. Surveyor asked CNA X, did R1 require assistance to turn and reposition. CNA X stated, Yes. CNA X stated, sometimes R1 would call for repositioning. Surveyor asked CNA X, would staff go in at set intervals to turn and reposition R1. CNA X stated, she is unsure. On [DATE] at approximately 3:25 PM, Surveyor spoke with CNA Y. Surveyor asked CNA Y, did R1 have any skin interventions in place. CNA Y stated, not that I'm aware of. CNA Y added, we were supposed to turn him, but he fought us. CNA Y stated, she cared for R1 a total of ,d+[DATE] times. On [DATE] at 5:30 AM, Surveyor spoke with CNA M. Surveyor asked CNA M, how did R1 prefer to lay while in bed. CNA M stated, he liked side to side and always liked his left side. Surveyor asked CNA M, would R1 refuse repositioning. CNA M stated, Sometimes, he didn't want to do it. CNA M stated, she would encourage R1 to reposition, but he would say, I'm not comfortable that way. CNA M stated, R1 complained of pain to his tailbone area and the CNAs would pad the back of his commode to make him more comfortable. (Note, the facility did not provide risks and benefits to R1 or to his APOAHC. Also note, the facility did not provide documentation of turning and repositioning or refusals.) CNA M stated, she was educated that residents need to be turned and repositioned every two (2) hours at least. On [DATE] at 6:15 AM, Surveyor spoke with CNA J. CNA J worked as an RA (Resident Assistant) at the facility before becoming a CNA. CNA J stated, she saw R1 three (3) times, but did not care for R1 directly. CNA J stated, while she was in training, she observed R1 say his heels and tailbone hurt when staff would move him. On [DATE] at 11:08 AM, Surveyor spoke with SS Dir V (Social Services Director). SS Dir V stated FM U spoke with her a couple times regarding how R1 was doing. SS Dir V stated, R1's goal since admission was to discharge home with family. SS Dir V stated, when we could see that wasn't going to work, we started working with R1 and family to look at options such as Assisted Living, CBRF (Community Based Residential Facility), and Memory Care. The facility was actively working with R1's APOAHC and FM U to find alternate placement. Surveyor asked SS Dir V, did R1 decline during his stay. SS Dir V stated, yes, that's why R1 was unable to return home as originally planned. Surveyor asked SS Dir V, did R1 have a decline in activities, etc. SS Dir V stated, no, not that she is aware. SS Dir V stated, staff did not identify any specific decline related to FM U's concern she voiced. SS Dir V stated, she is unsure of the date FM U voiced this concern, but it was followed up with nursing with no concerns noted. On [DATE] at 11:55 AM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, what should staff do if they discover a resident has a reddened blanchable area. DON B stated, Report it to t [TRUNCATED]

Based on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 5 residents (R119) reviewed for pain. R119 was admitted to the facility following an intertrochanteric femur fracture (hip fracture). The facility did not provide R119 with physician ordered [MEDICATION(S)] for over 15 1/2 hours. Subsequently, R119 was experiencing severe uncontrolled pain and the facility failed to consult with R119's Physician. In addition, the facility does not have a documented pain goal for R119. Evidenced by: The facility policy, Pain - Clinical Protocol, updated 3/8/22, indicates in part the following: Assessment and recognition: 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes reviewing known diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .b. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Treatment/Management: 2. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. 3. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; for example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. R119 was admitted to the facility 8/24/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R119's Admission MDS (Minimum Data Set) indicates a BIMS (Brief Interview for Mental Status) of 15, indicating she is cognitively intact. R119 is her own person. R119's CAA (Care Area Assessment) for Pain Section J0500A: Analysis of Findings: R119 has chronic pain and remains at pain risk. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Diseases and conditions that may cause pain: Skin/wound (surgical incision), Musculoskeletal, Arthritis, Hip fracture . Frequency and intensity of the pain: Blank Non-Verbal indicators of pain: Blank Pain effect on function: Disturbs sleep, adversely affects mood, Limits day-to-day activities Other Considerations: Immobility Will pain - Functional status be addressed in the care plan: Yes If care planning for this problem, what is the overall objective: Symptom relief or palliative measure (Note, for R119 this is symptom relief) R119's comprehensive care plan includes, in part, the following: Focus: R119 has chronic pain due to DJD ([CONDITION(S)] Joint Disease), [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], acute pain post nailing of left hip fx (fracture) Date Initiated: 8/24/22 Revision on: 8/25/22; Goal: Express feeling of comfort or pain relief; Interventions: Complete pain assessment on admission and per facility policy to determine the nature of the discomfort, my desired response and any previously successful strategies used; Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance to care. Offer non pharmalogical pain relief measurement: rest, relaxation, position changes; Report my pain to the nurse; Update MD/NP (Medical Doctor/Nurse Practitioner) for any new or unrelieved pain. Note, all interventions are dated 8/24/22. R119's Physician Orders, signed 8/24/22, include the following orders for pain control: [MEDICATION(S)] ([MEDICATION(S)] Sulfate IR) (Immediate Release) 15 mg (milligrams) immediate release tablet - Take 1 (one) tablet by mouth 3 (three) times daily. [MEDICATION(S)] ([MEDICATION(S)] Sulfate IR) (immediate release) 15 mg (milligrams) immediate release tablet - Take 1 (one) by mouth every 4 (four) hours as needed (moderate to severe pain). Quantity: 60 tablets Acetaminophen (Tylenol) 325 mg - Take 3 (three) tablets by mouth 3 (three) times daily [MEDICATION(S)] ([MEDICATION(S)]) 400 mg capsule - Take 3 (three) capsules by mouth 3 (three) times daily R119's hospital MAR (Medication Administration Record) indicates that R119 received [MEDICATION(S)] on 8/24/22 at 9:24 AM and 1:04 PM. It is important to note, 1:04 PM is the last dose of [MEDICATION(S)] R119 received before being discharged to the facility. It is also important to note, R119 was also receiving [MEDICATION(S)] PRN (as needed) at the hospital an average of 2-3 times per day prior to discharge. R119's received her first dose of [MEDICATION(S)] at the facility on 8/25/22 at 8:38 AM. R119 went from 8/24/22 at 1:04 PM to 8/25/22 at 8:38 AM (Over 15 1/2 hours) with no [MEDICATION(S)] administered. Of note, R119 received acetaminophen 975 mg and [MEDICATION(S)] 1,200 mg at the hospital at 1:04 PM prior to discharge. R119's MAR (Medication Administration Record) indicates RN E (Registered Nurse) administered Acetaminophen 975 mg (milligrams) and [MEDICATION(S)] 1,200 mg during the PM shift. The administration time is not visible. R119's pain ratings are as follows: 8/27/2022 9:35 PM (8) 8/27/2022 5:27 PM (7) 8/27/2022 11:32 AM (7) 8/27/2022 11:22 AM (7) 8/27/2022 8:23 AM (7) 8/27/2022 3:50 AM (6) 8/27/2022 3:02 AM (8) 8/27/2022 12:02 AM (6) 8/26/2022 7:14 AM (8) 8/26/2022 7:13 AM (8) 8/26/2022 4:47 AM (6) 8/25/2022 11:12 PM (5) 8/25/2022 11:06 PM (5) 8/25/2022 5:12 PM (6) 8/25/2022 7:51 AM (7) 8/25/2022 12:07 AM (0) 8/24/2022 6:52 PM (7) R119's MAR (Medication Administration Record) documents the following: [MEDICATION(S)] Sulfate Tablet 15 mg - Give 1 tablet by mouth in the evening for pain. Order Date: 2:55 PM - The facility scheduled this for Noon PM and AM. On 8/24/22 (PM shift), RN E documented the following this as a 7 which indicates Other/See Nurses Notes - Note, this was not administered. On 8/24/22 at 6:52 PM, RN C (Registered Nurse) documented the following progress note for R119: .R119 was admitted to the facility today at approximately 3:00 PM from the hospital via wheelchair cab accompanied by driver and her family member. R119 is admitted to receive rehab therapies and skilled nursing care after hospitalization for closed left hip fracture s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical histories includes, CHF ([CONDITION(S)]), [CONDITION(S)] (hypertension), IBS (Irritable Bowel Syndrome), asthma, DJD ([CONDITION(S)] joint disease), [CONDITION(S)], RA ([CONDITION(S)]), depression, anxiety, R119 is A&ox4 (oriented to person, place, time, and event).R119 currently rates pain as 7/10, which she reports is typical for her due to chronic pain associated with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], DJD, and [CONDITION(S)]. She does have acute pain with movement and weight bearing of LLE (left lower extremity) post-surgical On 8/25/22 at 12:40 AM, RN E (Registered Nurse) documented the following progress note: Res' (Resident's) family member, Family Member G, visiting for much of this evening. Res and Family Member G both had questions regarding facility, assistance for res and meds. R119 gave okay for staff discuss cares, changes etc. with Family Member G. On 8/25/22 at 8:38 AM, RN C administered the first dose of [MEDICATION(S)] to R119 since she arrived at the facility. The [MEDICATION(S)] administered to R119 was brought in by her other family member. On 8/25/22 at 8:42 AM, Family Member G sent the following email to the facility's NHA A (Nursing Home Administrator): Good morning, I am the (family member) of R119 who was admitted yesterday afternoon. Last night she went without her scheduled [MEDICATION(S)] due to a denial from insurance. She was really in rough shape, and I stayed til about 11:30 PM trying to troubleshoot it with RN F (Registered Nurse) and RN E (Registered Nurse). Unfortunately, she went without. I wanted to shoot you a quick email and will try calling you shortly. On 8/25/22 at 11:45 AM, NP H (Nurse Practitioner) saw R119 at the facility for a Transitional visit from Hospital to Skilled Nursing Facility. NP H's visit notes document, in part, the following: Pain controlled now that [MEDICATION(S)] is available . Reports significant anxiety today. Notes she does have anxiety at home, but symptoms worse today d/t (due to) move to nursing home and medication issues this morning ([MEDICATION(S)] not delivered from pharmacy on time) . On 9/7/22 at 11:22 AM, and 9/13/22 at 12:42 PM, Surveyor spoke with R119. R119 stated to Surveyor that she went nearly 1 (one) day without her ordered [MEDICATION(S)] for pain control and that she had uncontrolled pain for the first two (2) days she was in the facility. R119 stated she has chronic pain and was going through withdrawal. R119 stated she arrived at the facility on 8/24/22 in the early afternoon. R119 stated her pain was 8/10 and she received Tylenol. R119 stated, The first night was traumatic, the panic I was feeling was tough. R119 stated, coming into a new place (the facility) and still in a trauma place from my injury and no pain meds, I thought it was really insane. R119 stated, I cannot imagine other people in pain like me and not having pain meds, it's incomprehensible. R119 added, being in that level of pain doesn't help recovery. R119 stated, this situation (no [MEDICATION(S)] available) made me worried that it can happen again. R119 stated 3 (three) is the lowest her pain has been in [AGE] years. R119 added, If I'm at a 3/10 that's good. Note, this is R119's pain goal. R119 stated she has [CONDITION(S)] and [CONDITION(S)] and is at the facility due to a hip fracture she sustained following a fall at home. On 9/13/22 at 9:22 AM, Surveyor spoke with RN C (Registered Nurse). Surveyor asked RN C, what time did R119 arrive to the facility? RN C stated, R119 arrived on 8/24/22 at approximately 3:00 PM. Surveyor asked RN C, was there an issue with her medication arriving? RN C stated the [MEDICATION(S)] was not available and she's not sure about the other medications. RN C stated, on 8/25/22 at approximately 6:00 AM, the information she received in report was that RN E (Registered Nurse) (PM shift) called pharmacy because R119's [MEDICATION(S)] had not come. RN E was looking for an authorization code to pull it out of contingency. The pharmacy told her they couldn't fill the [MEDICATION(S)] order due to an issue with billing. RN C stated, RN F (Registered Nurse) worked the NOC shift on 8/24/22 into the morning hours of 8/25/22. RN C stated, RN F reported to her that R119 was having A lot of pain. RN C stated she called NP H (Nurse Practitioner) that morning asking for some assistance trying to work through this issue. RN C stated she also updated NHA A (Nursing Home Administrator). RN C stated she asked for permission if R119's family could bring [MEDICATION(S)] from home (Per NP H's recommendation) while we're working through this problem, and she called FM I (Family Member). FM I brought R119's [MEDICATION(S)] in from home, we both counted it and signed the narcotic sheet together and RN C stated she administered a dose of the [MEDICATION(S)] at 8:38 AM. RN C stated, NHA A contacted the pharmacy that morning. RN C stated there was a glitch on pharmacy's end that they were unable to print the medication label. Pharmacy did a Stat delivery later that morning. RN C stated when the [MEDICATION(S)] order arrived that morning, RN C notified FM I, counted off the [MEDICATION(S)] from home and returned it to FM I. RN C stated on 8/24/22 she stayed over to do R119's admission. RN C stated RN E (Registered Nurse) was the PM nurse and RN F (Registered Nurse) was the NOC shift nurse. Surveyor asked RN C was R119 in pain at the time she saw her (upon admission)? RN C stated, no, she came from the hospital, and they medicated her before she arrived at the facility. RN C stated she does not recall the specific pain level RN E and RN F stated R119 was experiencing. Surveyor asked RN C if a narcotic medication is not available, what should staff do? RN C stated staff should contact pharmacy and ask if the medication can be delivered stat. RN C stated staff should check contingency to see if the medication is available. RN C stated that particular [MEDICATION(S)] we did not have in contingency. Surveyor asked RN C, when you saw R119 the morning of 8/25/22, what was her appearance and demeanor? RN C stated, She was angry, she was telling FM I she wanted to get out of here, she was sitting up in bed and was very agitated. RN C stated she reported this to NP H first thing that morning at approximately 8:00 AM. RN C stated she administered scheduled Acetaminophen prior to administering [MEDICATION(S)] that morning. Surveyor asked RN C, what time did you administer [MEDICATION(S)] on 8/25/22? RN C stated she administered the first dose of [MEDICATION(S)] at 8:38 AM. RN C stated staff did administer acetaminophen on the PM shift and NOC shift documented R119's pain as 0. On 9/13/22 at 1:11 PM, Surveyor spoke with RN E. Surveyor asked RN E if she recalls R119 and when she was admitted to the facility? RN E stated, yes, I do remember when she arrived, we did not have her medication from pharmacy yet. RN E stated there's a cut off time for pharmacy orders and if the order is not submitted in time, we don't get them. RN E stated R119's biggest issue is that R119's [MEDICATION(S)] was not available and not in contingency. RN E stated there was a delay on her [MEDICATION(S)] and that was her biggest issue that night. Surveyor asked RN E, what was R119's pain level? RN E stated, I believe it was moderate. RN E stated she remembers that R119 was having pain in her legs. Surveyor asked RN E, did you chart regarding her pain? RN E stated she may have put in a note that her pain meds are not available. If the medication is showing up on the MAR (Medication Administration Record) she will usually write in progress note if the medication is not available. Surveyor asked RN E, did you contact the Nurse Practitioner or Physician regarding R119's [MEDICATION(S)] not being available and that she is having uncontrolled pain? RN E stated, I had not, when I got around to getting meds ready it was shift change. RN E stated she reported it off to RN F (Registered Nurse) (NOC Nurse). RN E stated at 10:00 PM when RN F arrived, she went upstairs for the rest of the evening. RN E stated she did not look at R119's medication or realize that her [MEDICATION(S)] was not available until 9:45 PM. RN E stated FM G was at the facility that evening. RN E stated she and RN F were talking to R119's FM G (Family member) about her [MEDICATION(S)] not being available. RN E stated RN F has been employed at the facility longer and is more experienced than she is (RN E is a newer nurse). RN E stated she knows an option was to send R119 out (to the Emergency Department) if the pain is unbearable or we saw signs/symptoms of withdrawal. Surveyor asked RN E, what signs/symptoms would you watch for? RN E stated, shaky, chills, sweating, change in level of consciousness. RN E stated she did not observe any signs/symptoms of withdrawal. Surveyor asked RN E, did you consult with R119's Physician regarding her [MEDICATION(S)] not being available and R119 was in pain. RN E stated, No. RN E stated she should have consulted with R119's Physician. RN E stated she should have looked at R119's medications and what she needed early in the evening. RN E stated she has changed her process for new admissions and now checks early in her shift to make sure medications are available. RN E stated she has learned her lesson to check medications as soon as possible. Surveyor asked RN E, did the facility provide any training to you and other staff after this incident? RN E stated no. RN E added she knew she was going to have to run up to contingency to get R119's medication and wanted to get the rest (medication pass, tasks, etc.) out of the way. Surveyor asked RN E, did your receive training upon hire regarding what to do in this situation? RN E stated, no, not specifically with this facility. RN E stated that consultation with the Physician is crucial. On 9/13/22 at 1:38 PM, Surveyor spoke with NP H (Nurse Practitioner). Surveyor asked NP H, would you expect staff to contact you or the Physician if a resident's ordered [MEDICATION(S)] (scheduled and PRN) is not available? NP H stated, in general when a medication (prescription and not over the counter) is not available the protocol is to check with pharmacy to see when it's due to be delivered. NP H stated if the time is outside the administration window, they should check the ADU (Automatic Dispensing Unit) where contingency medications are stored. NP H stated staff will look in the ADU for the controlled substance to see if it's available. If the medication is available from contingency, they should be able to call pharmacy to get an authorization code to do a one-time pull from contingency. NP H stated now, during the daytime, when a provider is available to call, they can get a one-time order. NP H stated, she can give them (staff) a 1 (one) time order electronically for them to pull in addition to the regular script. NP H stated at nighttime, I think they get that order after the fact and then pull it. NP H stated staff should check with the pharmacy, check contingency, if available, obtain authorization code from pharmacy. NP H stated, On nights and weekends there is a Physician available. NP H stated, if the patient is having uncontrolled pain, yes, they should call the provider. With R119 being on such high scheduled doses, I was concerned with symptoms of withdrawal. NP H stated, the morning of 8/25/22, she was made aware that R119's [MEDICATION(S)] was not available since her admission. NP H stated she was on her way to work when the facility notified her. NP H stated her first call at 8:00 AM is that R119's [MEDICATION(S)] is not being covered by insurance. NP H stated the pharmacy told her it was a computer issue, and they were calling corporate. NP H stated the Pharmacist called her 30 minutes later, the issue was resolved, the delay was not due to a lack of coverage and they were sending the [MEDICATION(S)] stat. NP H stated in that time she arranged for the family to bring in a supply of R119's [MEDICATION(S)] from home and directed RN C to count the medications with the family member bringing in the medication, and for them both to sign off on the [MEDICATION(S)] received. Once we received the [MEDICATION(S)] from pharmacy, she gave RN C instructions to send the remaining [MEDICATION(S)] back home with the family member. Surveyor asked NP H, when you saw R119 the morning of 8/25/22 how did she appear? NP H stated when she saw R119 around 11:00 AM, her pain was controlled (the [MEDICATION(S)] from home had been administered a few hours prior). NP H stated physically she was not in distress, emotionally she was anxious and much calmer after I explained to her that the [MEDICATION(S)] was on the way, and we have a supply in the cart, and she will not miss the next dose. NP H stated R119 visibly relaxed during our conversation once she heard this. Surveyor asked NP H if she assessed signs/symptoms of withdrawal? NP H stated she did not observe any signs/symptoms of withdrawal (there was no sweating, nausea, increased respirations.) NP H stated, R119 visibly relaxed when she knew we had a plan in place and the [MEDICATION(S)] was available. Surveyor asked NP H, would you expect staff to ask R119, what is her acceptable level of pain (pain goal)? NP H stated I would expect that with any pain assessment. NP H stated when completing a pain assessment, asking the resident what is their tolerable pain level is part of a good pain assessment. Surveyor asked NP H if a resident is experiencing pain at a 6, 7 or 8, what should staff do? NP H stated she would expect staff to do an assessment, look at possible pain for the resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP H stated, Always, if pain is uncontrolled using current prescribed or attempted methods, I would expect to get a phone call. Surveyor asked NP H, would you expect staff to contact you when R119's ordered [MEDICATION(S)] was not available? NP H stated, Yes, I would. NP H added, I would expect them to call if they put meds in on day shift and we don't have them here, I would have expected a phone call then. NP H added, staff will also call her asking if it's ok for various residents to miss a dose of medication when it's not available. NP H stated, I'm not going to order a missed dose, to me that's a medication error. On 9/13/22 at 2:12 PM, Surveyor interview IDON B (Interim Director of Nursing). Surveyor asked IDON B, do staff ask residents their acceptable pain rating upon admission? IDON B stated it should be done on their assessment. Note, there is no acceptable pain goal documented for R119. Surveyor asked IDON B, if a resident's medication does not arrive from pharmacy what is the process staff should follow? IDON B stated staff should call pharmacy to see if the script is available, and if the script did not arrive, get the authorization to release the medication if available in contingency. IDON B stated if a medication is not in contingency, staff should contact the Physician to let them know what is available in contingency or ask if there is something else we could use in the interim. IDON B stated staff should check to see if there is anything else available to help such as ice, position changes, and anti-[CONDITION(S)] until we get the medication available. Surveyor asked IDON B, should staff consult with a Physician to make them aware of a resident with uncontrolled pain? IDON B stated, yes, if the pain is ongoing and we're not meeting the resident's pain need or if staff administer a pain medication and it's not effective, she expects staff to consult with the Physician. IDON B stated she would expect if a resident were continuing with unrelenting pain that we would reach out to a provider to say this is worsening. IDON B added that sometimes pharmacy delivers medications at 10:00 PM especially for a 3:00 PM admission. Surveyor asked IDON B, in the example of R119 where her she has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? IDON B stated, That would be an expectation. On 9/13/22 at 2:23 PM, Surveyor spoke with NHA A (Nursing Home Administrator) and RN Consultant D (Registered Nurse Consultant). Surveyor asked NHA A if she is aware of any issue with R119's medication when she was admitted ? NHA A stated she recalls hearing about this the next morning in clinical where staff go over admissions and medications. NHA A stated she recalls the facility not having R119's [MEDICATION(S)] here. NHA A stated FM G sent her an email on 8/25/22 regarding R119's [MEDICATION(S)]. NHA A provided Surveyor a copy of the email and stated she called FM G right after he sent the email. Surveyor asked NHA A, did the facility complete any training following this incident? NHA A stated we've done continuous education but nothing in relation to this incident. This medication tends to be a problem and we could get this stocked in Pixis. FM G reached out to me the next morning and asked if he could bring [MEDICATION(S)] from home. We reached out to pharmacy, and they sent the [MEDICATION(S)] stat the morning of 8/25/22. NHA A stated pharmacy sent the medication on 8/25/22 at 10:00 AM. NHA stated pharmacy told us R119's insurance was denied. NHA A stated that doesn't make sense because she's on Medicare. NHA A stated after the [MEDICATION(S)] arrived, she reached back out to FM G, let him know the [MEDICATION(S)] is in house and not to worry. NHA A stated the issue was with pharmacy not being able to print the medication label. Surveyor asked NHA A, did you provide any education to RN E, RN F, and other nurses following this incident? NHA A stated, no, she doesn't not have anything in writing. On 9/15/22 at 10:14 AM, Surveyor spoke with RN F. Surveyor asked RN F, were there any issues with R119's medications? RN F stated, yes, when he came in on PM shift, RN E informed him that R119's [MEDICATION(S)] was not delivered. RN F stated, RN E was trying to find out what was going on. RN F stated RN E is a brand-new nurse and doesn't know protocols. RN F stated FM G (Family Member) was at the facility and was getting into this. R119 gave permission for FM G to speak on her behalf. RN F stated RN E was having a hard time appeasing FM G (FM G was advocating for R119) and getting him to understand that pharmacy was not filling the order. RN F stated he told FM G that he will see what's going on and took over from there. RN F stated RN E was pretty baffled with the situation. RN F stated he told FM G it's going to take a little bit, let him see what's going on with the orders. RN F stated RN E brought up contacting the on-call Physician. RN F stated he told RN E the on-call will not fill these scripts. RN F stated they (providers) will literally chew out people (staff) not keeping up with scripts. RN F stated he has seen providers make staff members cry. RN F stated he reached out to pharmacy; pharmacy stated R119's insurance denied the claim so they would not fill the [MEDICATION(S)]. RN F stated when FM G came back, he explained the issue was not on our end, it had to do with insurance denying payment. RN F stated sometimes this can happen due to wording in the billing or something simple. RN F stated FM G asked him, what if she wakes up and she's in all this pain? RN F stated he had not got report from RN E and didn't know how much pain R119 was in. RN F stated FM G asked if he could bring in R119's [MEDICATION(S)] from home. RN F stated he told FM G, absolutely not, everything must come from pharmacy. RN F stated this could potentially jeopardize R119. RN F stated he has seen before where a family member brings in extra narcotics and they need [MEDICATION(S)]. RN F stated since R119 is her own person, she can take herself to the ER (emergency room ). RN F stated if R119's pain is so excruciating she could go to ER. The ER would ask me to fax her medication list. RN F stated, the ER has more authority than he has here. RN F stated when he spoke with pharmacy, they checked to see if R119's ordered [MEDICATION(S)] was in contingency which it was not. RN F stated, we're caught between a rock and a hard place, even if I have authorization to pull it, we don't carry it, and it takes 2 nurses to get in with an authorization code. RN F stated FM G was being persistent about bringing R119's medication in. RN F stated FM G asked if he could take her out to the street and give her [MEDICATION(S)] instead of taking her to the ER. RN F stated that would be looked at as leaving AMA (Against Medical Advice). RN F stated, if she's in that amount of pain where she is that desperate for [MEDICATION(S)], we'll send her to ER. RN F stated, once he understood, he seemed ok with that. RN F stated when he saw R119 that night she was sleeping and is not aware if she woke up before 5:00 AM. Surveyor asked RN F, how frequently did you check on R119 that night? RN F stated every 2 hours. RN F stated R119 was pushing her call light a lot around 5:00 AM. RN F stated she didn't act like she was in a lot of pain. RN F stated he did administer Tylenol to R119 that night. Surveyor asked RN F, did you and other staff receive any training following this incident? RN F stated, Not that I know of, I didn't know it was an issue. RN F stated the following night he did not hear there was any issue. Surveyor asked RN F, do staff receive training regarding admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? RN F stated he has seen the process change so many times and it was the most organized under the prior management. RN F stated since we have had so many new DONs (Directors of Nursing) and Managers, each one has something they think is more important and they're trying to reinvent the wheel. RN F added, some of us that have been here the longest end up fixing the mistakes. RN F stated, When new staff come in, the training is not the best. RN F stated agency staff also need this training. Surveyor asked RN F, should he or one of the other nurses have consulted with the on-call Physician to notify them that R119's [MEDICATION(S)] is not available, offer contingency options that are available, and ask how they would like to proceed? RN F stated he did not think to do that. RN F stated our policy is to consult with the on-call Physician and update them on the situation. RN F agreed the facility should have consulted with the on-call Physician.

Based on observation, interview, and record review, the facility did not provide adequate supervision and assistive devices to prevent accidents for 1 (R69) of 3 residents reviewed for falls out of a total sample of 20 residents. R69 sustained a subarachnoid hemorrhage, a T1 spinous process fracture, T2 vertebral body fracture, and two rib fractures when the facility failed to complete R69's walking program as care planned and recommended by therapy, failed to have an RN assess R69 after multiple falls, and failed to provide adequate supervision to keep R69 from falling again after multiple falls in one day. Evidenced by: Facility policy entitled, Managing Falls and Fall Risk, updated [DATE], includes, in part: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls . If falling reoccurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. R69 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of unspecified cerebellar artery, dementia, history of falling, and cornea transplant. R69's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of [DATE], indicated R69's cognition was severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R69's MDS also indicates he requires limited physical assistance of one staff member to meet his needs in walking in his room, transfers, and personal hygiene. It also indicates R69 requires extensive physical assistance by one staff member to meet his needs in toilet use and dressing. R69's MDS also indicates R69 has had one fall since his prior assessment and there was no injury. R69's Physician Orders, ,d+[DATE], include: [MEDICATION(S)] ([MEDICATION(S)]) 2.5 mg by mouth 2 times daily . R69's Comprehensive Care Plan, includes: [DATE] initiated: Standby assist walk to meals Transfer assistance of (1) with 4 wheeled walker, gait belt Toileting assistance of (1) l as needed . incontinent at times, encourage to bathroom before and after meals, check on rounds at night Walking assistance of one with 4-wheeled walker Lower bed to lowest position when patient is in bed . fall mat on floor next to bed. Physical Therapy consult for strength and mobility. Ambulate up to 150 feet with assist of (1) and gait belt with w/c to follow for safety at least 2x/day Date Initiated: [DATE] Activities will provide a monthly activity calendar for his room. Also provide reading, listening, and watching materials for his room as needed. Date Initiated: [DATE] [DATE] initiated: Assist to wear non-skid socks [DATE] initiated: Encourage resident to use wheelchair when self-mobilizing [DATE] Initiated: Staff should redirect resident when ambulating by self in hallway R69's Medical Record, includes: NN (Nurse Notes), FR (Fall Report), CP (Care Plan) NN [DATE] 13:54 patient wandering without walker, staff having to keep talking to patient. NN [DATE] 14:30 Morning nurse reported R69's glasses are broken d/t (due to) him running them over today. Nurse reports family has been updated. FR [DATE] at 8:00 PM CNA (Certified Nursing Assistant) notified this writer that she believed R69 had just fallen. R69 was found on his knees by the wall. He was grasping at a picture book of his family. Unable to give description of what happened due to dementia and being alert and oriented times 1 at baseline. Resident vitals taken. Assessed for injuries. Observed blancheable [CONDITION(S)] to bilateral knees. CNA and this writer assisted into wheelchair. Resident was able to stand and assist with transfer. Moves all extremities with no complaints of pain or discomfort . Neuros initiated. (It is important to note the documentation does not include an RN assessment. This note is typed by an LPN.) CP [DATE] Intervention added: Keep environment well-lit and free of clutter. Fall Assessment, dated [DATE], includes reason for assessment recent fall . ,d+[DATE] falls in past 3 months . ambulation/elimination status: ambulatory/Continent . Gait Balance: balance problems while standing, lower extremity weakness, requires use of assistive devices . Medications: yes . Predisposing Diseases: yes [DATE] Summary of Care Plan Review: Son in attendance for care plan meeting . Nurse shared he continues to need cues to use his walker while ambulating at facility as he often stated he does not need it . Plan of care to continue as written . NN [DATE] Orders received and noted for Physical Therapy/Occupational Therapy evaluation and treat for deconditioning weakness and fall prevention .Writer encouraged R69 to ambulate with 1 assist for safety. Therapy Notes indicate R69 was in therapy from [DATE]-[DATE] for strengthening and fall prevention. NN [DATE] 22:24 Resident found to be self-transferring, ambulating down the hallway x 4. Staff redirected resident and assisted him back to his room either to lay down or sit in his recliner which ever resident choose. Gait continues to be unsteady. FR [DATE] at 7:15 AM R69 had an unwitnessed fall in hallway Possible root cause: hungry Intervention added: offer snack while waits for breakfast in recliner Fall Risk Assessment, [DATE]: Reason for assessment- recent fall . ambulation/elimination status- ambulatory/incontinent . Gait balance- balance problem while standing, balance problem while walking, lower extremity weakness, requires use of assistive devices . Medications: yes .No changes to medications . Predisposing diseases: yes . Summary of findings: Resident is at risk for falls . score 14 [DATE] IDT report - IDT met to review unwitnessed fall on [DATE] when R69 was ambulating independently. R69 fell and hit his head. Sent to ED (Emergency Department) for evaluation . Returned [DATE] with no new orders. NP (Nurse Practitioner) updated and HCPOA (Healthcare Power of Attorney). R69 just woke up and was awaiting breakfast. Intervention includes keeping walker and wheelchair near R69 when in bed or recliner due to him forgetting to use his wheelchair to get around his room. Nursing to continue to monitor . R69's MAR/TAR (Medication/Treatment Administration Record), for June and [DATE], includes Walk in room/walk in hall: 11 out of 34 days R69's walking program is not signed out as completed. (It is important to note the recommendation of 150 feet is not listed on the MAR/TAR at all, just walk in hallway/walk. It is also important to note staff were not walking R69 twice daily for 150 ft per care plan and therapy recommendations.) FR [DATE] at 4:40 AM unwitnessed fall in bathroom Possible root cause: Impulsive NN [DATE] 4:48 AM Writer was alerted by 2nd floor CNA that R69 was found on bathroom floor, bleeding from head. 3rd floor and 1st floor nurse came to R69's room and assisted R69 up into wheelchair . Emergency Medical Services (EMS) arrived and transported R69 to hospital per HCPOA request. Blood in hair/head was cleaned up by writer with wet wash cloth. Observed ,d+[DATE] small lacerations to back of head. R69 was unable to verbalize pain, only moaning. Nonverbal signs of pain noted while cleaning blood out of hair; grimacing, pulling away . ER (emergency room ) Notes, dated [DATE] at 5:23 AM Reason for Visit: Unwitnessed fall. Laceration to left posterior scalp. Bleeding controlled on arrival. R69 anticoagulated. Arrived alert and oriented to self per baseline. Fall, initial encounter: laceration of scalp . History: [AGE] year-old male presents after an unwitnessed fall. He reportedly falls regularly at his nursing home. He is anticoagulated with [MEDICATION(S)]. Baseline is alert and oriented times 1. fell on the 25th since which time he reportedly has had ecchymosis of the left periorbital region. He was seen in this Emergency Department at this time. He denies any pain or difficulty breathing. Due to baseline mental status, further history is limited . CT scan (Computed Tomography - x-ray) non-contrast- impression- No fracture or traumatic malalignment involving the cervical spine . X-ray Chest: Impression- No focal consolidation, pleural effusion, or pneumothorax. Procedure: Laceration Repair- a superficial minimally contaminated 4 cm laceration of left scalp . Closure: wound was closed in one layer. Skin closed with 3 staples . Although hemoglobin is 1.7 below [DATE], it is only 0.8 below [DATE]. R69 likely had a blow loss from the scalp injury. NN [DATE] 5:54 AM Hospital called for update, R69 being released back to facility, 3 staples in back of head, can be removed in 7 days. CT scan of head and cervical spine were negative, hemoglobin slightly low but higher than the last one when seen previously at the ER, all other labs are ok, son is returning with resident. NN [DATE] at 1:55 PM Called to dining room per staff. R69 sitting on floor wheelchair directly behind him. Right hand on floor holding himself upright. Vitals obtained, full range of motion. Staff assist with gait belt to standing position walker in front of him. Sat back in wheelchair. R69 did have gripper socks on. Stayed still until writer could obtain vitals, then wheeling around facility. MD updated. No new orders. Left message with HCPOA. FR [DATE] at 1:55 PM unwitnessed fall in dining room IDT review: At 1355 R69 had a 2nd fall. He had been self-propelling his wheelchair in the dining room when the fall occurred. Nursing assessed him no injury was noted. Neuros at baseline and no pain noted. MD and POA were notified. Immediate intervention was to provide 1:1 activity until resident was calm and encourage to eat in the dining room and participate in group activities. FR [DATE] at 6:15 PM unwitnessed fall in room Intervention added: toilet every 3 hours IDT review: At 6:15 PM R69 had a 3rd fall. He had been sitting in his bed side chair eating his supper with staff. He had eaten 75% and his call light was in reach when staff left the room. Wheelchair was near Resident while he was sitting in his recliner. Nursing assessed him and noted that the laceration to the back of his head from earlier fall was bleeding no other injury was noted. Neuros at baseline and no pain noted. MD and POA were notified. Immediate intervention was to send resident to the ER for evaluation and treatment. [DATE] Care Plan: Added entry: frequent checks. Added entry: room check every 3 hours NN [DATE] at 7:04 PM R69 fell in his room at 6:15 PM bedside his recliner in which he was sitting prior. R69 had eaten 75% of his dinner and call light was in reach. HCPOA was updated and stated he would meet R69 at the hospital. This writer updated NHA A (Nursing Home Administrator) and the on-call MD. LPN K (Licensed Practical Nurse) signed. NN [DATE] at 8:44 PM R69 fell , and head is bleeding. MD called and waiting for callback. 911 was called and R69 sent to hospital ER. HCPOA called and informed that R69 was going to hospital and that he hit his head. HCPOA stated that he was on his way to hospital and did not understand why R69 kept falling and was going to speak to management at facility. R69 got into ambulance and is en route to ER. LPN O signed (It is important to note facility provided no evidence of an RN assessment being completed.) NN [DATE] at 9:34 PM R69 found to be on floor of his room between the recliner he was sitting in and the door to his room. 1st floor nurse assessed and 911 called for transfer to ER for evaluation. HCPOA updated and on call MD updated. NHA A updated. LPN K signed ER Note, [DATE] TIME Reason for visit: fall times 3 today. Was seen this morning. R69 is on blood thinners. Alert and oriented times 1 at baseline. 10:50 PM Report called to RN at facility to let them know R69 would not be returning back tonight. History: [AGE] year-old male presents after 2 falls this afternoon at his nursing home. He was seen by myself early this morning after a fall. He additionally fell on the 25th and was evaluated at that time. He has a history of falls. He is on [MEDICATION(S)] with history of prior [CONDITION(S)] (Cerebral Vascular Accident) and TAVR (Transcatheter aortic valve replacement). His baseline is alert and oriented to himself and that is the case upon presentation today. When asked if he has any pain he states, I don't know. Staples in place to laceration to left posterior scalp, no active bleeding. CT Head Scan Without Contrast: Impression- large left parietal contusion and laceration. Small volume subarachnoid hemorrhage within the bilateral parietal lobes. Critical Results Finding: Undiagnosed Acute ICH (Intracerebral brain hemorrhage). CT Head Without Contrast: Impression- Contusion overlying the left parietal calvarium without underlying calvarial fracture or acute intracranial abnormality. CT Chest Scan Without Contrast: Impression- acute nondisplaced left first and second rib fractures. Acute T1 spinous process fracture and acute mild T2 vertebral body compression deformity. No acute cardiopulmonary findings. CT Cervical Spine Scan Non-contrast: Impression- no acute cervical spine fracture or traumatic malalignment. X-ray Chest: impression- transcatheter type aortic valve replacement redemonstrated. No focal consolidation, pleural effusion, or pneumothorax. History: [AGE] year-old patient on [MEDICATION(S)] presents today following multiple falls at his nursing home. No definitive areas of pain on exam although the patient has a history of dementia and is baseline alert and oriented times 1 (this is the case today as well). Notable for scalp laceration which I repaired myself this morning. Healed skin tear to right hand which is old. Left periorbital ecchymosis which is not new. No definitive areas of reproducible pain. R69 at baseline has periods of agitation and moaning- this had been discussed with the nurse manager at his nursing home this morning. R69 given [MEDICATION(S)] and [MEDICATION(S)] to complete imaging. Laboratory work up here today . CT head appears to show contusion with small volume SAH (subarachnoid hemorrhage). His blood pressure is spontaneously controlled. He is on [MEDICATION(S)] with history of TAVR. We discussed consideration of reversal of [MEDICATION(S)] with PCC but will hold at this time given TAVR. Necessary transfer . Sending to (larger hospital) Emergency Department. [DATE] 11:54 PM Hospital ER nurse called, resident is being transferred to (larger hospital) due to brain bleed, fractured spine, and fractured ribs, POA has also been notified per ER nurse. R69 has advanced dementia which results in poor safety awareness, is impulsive did not use his call light for assistance. Care plan was being followed. Care plan to be evaluated upon return for wheelchair positioning, transfer status and fall interventions. [DATE] Care Plan interventions room check every 3 hours [DATE] Staff will stay with Resident when in the bathroom [DATE] (larger hospital) Notes: R69 is a [AGE] year-old male patient with past medical history significant for dementia, [MEDICATION(S)] for TAVR presenting as a Level 2 Trauma Activation, involved in a series of ground level falls over the past 2 days . Patient arrived via EMS as transfer from outside hospital. Patient initially was presented to outside ED for falls as above however the CT imaging demonstrated bilateral subarachnoid hemorrhages and T spine fractures and rib fractures, arranged for transfer to here. No reversal prior to transfer. Patient is alert and oriented times 1, at baseline, same per EMS . Physical Exam: Awake, oriented times 1, pupils equal and reactive to light 3 mm to 2mm, midface stable, no nasal septal hemotympanum, no cracked teeth or bleeding in the mouth . Extremities: no gross deformities, no tenderness at elbows, wrist, knees, ankles . Patient arrives in stable condition, initial vital signs unremarkable. Primary survey unremarkable, no immediate resuscitation needs identified. Trauma imaging survey included chest x-ray and pelvis x-ray demonstrating no additional acute traumatic injuries aside from those demonstrated at outside facility. Trauma surgery team ordered over reads of outside imaging. After discussion with Neurosurgery, at their recommendation we did a repeat head CT here demonstrating no significant interval evolution of known intracranial bleed as above., and CT angio neck which demonstrates no vascular injury in the setting of high T-spine fractures. Medications during ED course include [MEDICATION(S)] IV and [MEDICATION(S)] per neurosurgery, along with [MEDICATION(S)] IV for pain. Anticoagulant was reversed with [MEDICATION(S)] and he was given [MEDICATION(S)]. Injuries identified during ED course: SAH (Subarachnoid Hemorrhage), T1 spinous process fracture and T2 vertebral body fracture, left 1st and 2nd rib fractures . For further management of multiple traumatic injury, R69 has been admitted to Trauma Surgery Services . A complete trauma evaluation was conducted, and the following injuries have been identified: SAH, T1 spinous process fracture and T2 vertebral body fracture, left 1st and 2nd rib fractures . Cervical Spine: Cervical collar on at all times T/L spine: Strict precautions. Bed to remain flat at all times, team logroll only . [DATE] 5:48 PM IDT review: Note Text: IDT note concerning unwitnessed falls that occurred on [DATE]. At 4:30 AM R69 was in the bathroom where he had fallen on the floor. He had self-transferred from bed and self-ambulated to the bathroom. He had last been checked around 3:00 AM. He was sleeping in bed and dry. Fall mat was next to bed, bed in low position and was wearing grip socks, call light was not on but was next to him in bed. Nursing assessed him and noted a laceration to the back of his head post fall. Neuros at baseline and nonverbal pain noted. MD and POA were notified. Immediate intervention was to send him to the ER (emergency room ) for evaluation and treatment. ER called, resident being released back to facility, 3 staples to back of head, can be removed in 7 days, EKG no change from last one, CT scan of head and cervical spine were negative, hemoglobin slightly low but higher than the last one when seen previously at the ER, all other labs are ok, son is returning with resident. At 1:55 PM R69 had a second fall. He had been self-propelling his wheelchair in the dining room when the fall occurred. Nursing Assessed him. No injury was noted. Neuros at baseline and no pain noted. MD and HCPOA were notified. Immediate intervention was to provide one on one activity until R69 was calm and encouraged to eat in dining room and participate in group activities. At 6:15 PM R69 had a third fall. He had been sitting in his bedside chair eating his supper with staff. He had eaten 75% and his call light was in reach when staff left the room. Wheelchair was near R69 while he was sitting in recliner. Nursing assessed him and noted that the laceration to the back of his head from earlier fall was bleeding; no other injury was noted. Neuros at baseline and no pain noted. MD and HCPOA notified. Immediate intervention was to send to emergency room (ER) for evaluation and treatment, Hospital ER nurse called, R69 is being transferred to (larger hospital) for brain bleed, fractured spine, and fractured ribs. HCPOA has been notified per ER nurse. R69 has dementia which results in poor safety awareness, is impulsive, did not use call light for assistance. Care plan was being followed. Care plan to be evaluated upon return for wheelchair positioning, transfer status, and fall interventions. (Larger Hospital) Inpatient Discharge Summary, dated [DATE]: Briefly, R69 was hospitalized after a ground level fall and was found to have a subarachnoid hemorrhage and several fractures. His family elected to pursue comfort-focused care and he died peacefully on [DATE]. Primary Discharge Diagnosis: Subarachnoid hemorrhage . Secondary Discharge Diagnosis: Toxic Metabolic [CONDITION(S)], dementia, fracture of right ribs 1 and 2, fracture of first thoracic vertebra spinous process, and on anticoagulation for history of transcatheter aortic valve replacement and history of stroke . Discharge Disposition: deceased . On [DATE] at 3:13 PM, CNA J indicated R69 was self-ambulating all of the time, looking for someone, and when she saw him, she would run to bring him his walker and assist him to where he was going. CNA J indicated R69 needed more help some days than others. CNA J indicated staff did not assist him with his walking program daily and she figured he got his exercise by self-ambulating. CNA J indicated she does not document when R69 is self-ambulating or trying to transfer without assistance. On [DATE] at 3:34 PM, CNA/Scheduler/MT M (Medication Technician) indicated R69 was very demented, and he thought everybody in a wheelchair was his wife. CNA M stated, He would walk all of the time. We would have to catch him. Sometimes when he gets up to walk, we just have to follow him. CNA M recalls on [DATE], R69 had multiple falls, one on the night shift before she came and one at the change of shift, towards the end of her shift. CNA M indicated after R69's night shift fall he came back to the facility and R69's son requested that R69 stay in bed for the day. Then R69 slept and woke up and was restless again so CNA M took him to lunch. CNA M recalled R69 picked at his lunch but kept trying to stand up without assistance. CNA M indicated she would redirect him to his lunch, but she could not stay one on one with him, because she had other residents to assist. CNA M indicated she does not document when R69 is ambulating without assistance, but she does let the nurse know. CNA M indicated she did not walk R69 two times a day and was unsure if he had a walking program. On [DATE] at 7:55 AM, RN Consultant D indicated they added more frequent checks to R69's care plan and this meant staff were to check on him more frequently than they already did. RN Consultant D indicated staff should have kept him in view after the second fall in a day, but they didn't, because he had a third unwitnessed fall. RN Consultant D indicated she expects staff to document in nurses notes when a resident continues to walk without assistance, and she expects staff to execute walking programs as they are recommended by therapy or planned interventions. On [DATE] at 8:19 AM, LPN L stated R69 was always independent, and he will get mad if you try to do too much for him. LPN L indicated R69 was always trying to get up without help and sometimes he would get wrapped up in his blankets and fall. LPN L indicated when R69 returned from the hospital, he fell again. LPN L indicated it was an unwitnessed fall and she thought it was due to him not having any Dycem under his wheelchair cushion like he was supposed to. LPN L indicated CNA N found R69 on floor in dining room and came to get her. LPN L indicated she is the one who assessed R69 while on floor and then LPN K, CNA N, and herself assisted him off the floor to his wheelchair. LPN L indicated she did not consult an RN before making the decision to get R69 up off the floor. LPN L indicated she did not know she was not supposed to assess residents/that LPNs could not assess. LPN L indicated R69 went back to tooling around doing his thing and his care did not change. LPN L indicated the staff stayed with him a few minutes until he was calmed and then continued to care for other residents. LPN L indicated R69's supervision did not increase after the second fall, but maybe someone should have stayed with him or kept him in view. LPN L indicated she would have to look to see if R69 is on a walking program and when she finds him self-ambulating, she does not always document it. On [DATE] at 8:31 AM, CNA N indicated R69 always got up without assistance and walked around. We had to keep an eye out for him. CNA N indicated R69 had a fall on [DATE] on the night shift before she arrived and when he came back, his son told her to leave him in bed. CNA N indicated as soon as R69's son left he was back to trying to ambulate without assistance. R69 indicated she found him walking in his room several times and assisted him back to bed, but eventually she got him up and took him to lunch in his wheelchair. CNA N indicated she was assisting other residents out of the dining room and to the bathroom, so she was coming in and out of the dining room. CNA N indicated someone else told her R69 fell in the dining room, so she went to get LPN L. LPN L then assessed R69. LPN K also came. LPN K, LPN L, and CNA N assisted R69 off the floor and into his wheelchair. CNA N indicated staff did not keep R69 in line of sight after the fall, but she checked on him and listened for him frequently. CNA N indicated she was not sure if R69 was on a daily walking program. CNA N indicated she tells the Nurse when R69 attempts to transfer without assistance or is found ambulating without assistance, but she does not document this anywhere. On [DATE] at 8:39 AM, LPN K indicated R69 was cognitively unaware and very impulsive. LPN K stated, R69 was up walking a lot. We would run to his assistance and offer him his wheelchair or recliner. LPN K was unsure if R69 was on a walking program. LPN K recalled he came in at 2pm on [DATE] and R69 had a fall in the dining room. Then R69 fell at 6:15 PM while LPN K was on break. LPN K indicated he got LPN O to assist him with the fall and she sent R69 out. LPN K indicated the staff could not force R69 to stay in their line of sight, but they looked in on him when they passed his room, stating he was hard to redirect, very impulsive and anxious. LPN K indicated there were no witnesses to the fall and that a CNA was walking by his room and found R69 on the floor. LPN K indicated he doesn't always document R69's attempts to self-transfer or when staff find R69 up walking without assistance. LPN K indicated an LPN can perform assessments without consulting an RN at this facility. On [DATE] at 9:14 AM, NHA A indicated on [DATE] an entry was added to the care plan to check on R69 every 3 hours and she was not sure why. NHA A indicated frequent checks is more often than every three hours. NHA A indicated she expects staff to document when a resident is self-ambulating when they are assessed to need assistance and to complete walking programs as recommended by therapy. NHA A indicated R69's plan of care did not change to keep him in the line of sight after any of his falls, but she expected staff to check in when they walked by his room and keep an eye on him if he was restless. If staff saw R69 walking without assistance she expected staff to get near him, encourage him to sit down, or encourage him to propel in his wheelchair. Surveyor asked NHA A if LPNs could perform assessments per current standards of practice and NHA A indicated she did not know. On [DATE] at 10:30 AM, Interim DON B, NHA A, and RN Consultant D indicated they were unaware that LPNs cannot perform assessments. IDON B, NHA A, and RN Consultant D indicated staff should be documenting when a resident who requires assistance is ambulating or attempting to ambulate without assistance. IDON B, NHA A, and RN Consultant D indicated staff should have been walking R69 two times daily per therapy recommendations and care plan, but the documentation does not support that this was happening. On [DATE] at 12:48 PM, NHA A indicated during the first two falls there was not an RN in the building so her expectation is the LPN would call one to consult, using the collected data, before moving resident. NHA A indicated they called the MD, but not until after they assisted R69 off the floor. On [DATE] at 1:33 PM, NHA A and RN Consultant D indicated again they were unaware that an LPN could not assess patients who have falls or a change in condition.

Based on interview and record review the facility did not promptly consult with the physician when there was a significant change of condition and a need to significantly alter treatment for 1 (Resident 8) of 10 sampled residents. Resident 8 had a fall with head injury. Resident 8's physician and family were not immediately consulted regarding the fall. Licensed Practical Nurse (LPN) I should have completed a full set of neurological checks per facility protocol including vital signs, which consist of a blood pressure, pulse and respirations. LPN I stated vital signs were not able to be completed for Resident 8 as Resident 8 was agitated. Of note, this could reflect a complication from a head injury. Certified Nursing Assistants (CNA) staff working with Resident 8 stated Resident 8 was lethargic, holding her head and not as jovial as she normally was. This would also be a change of condition, which LPN I did not promptly report to the physician. Within hours of Resident 8's fall, Resident 8 became unresponsive and later died at the hospital from a subdural hematoma. The failure to notify the physician promptly with a fall with head injury and inability to recognize a change of condition (COC) in Resident 8 created a finding of Immediate Jeopardy that began on [DATE]. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy was removed on [DATE]. The immediate jeopardy was cited at past non-compliance as the deficient practice was corrected on [DATE]. This is evidenced by: According to<<https://my.clevelandclinic.org/services/neurological_institute/[MEDICAL CONDITION]-center/diseases-conditions/hic-intracranial-hemorrhage>.>Any type of bleeding inside the skull or brain is a medical emergency. It is important to get the person to a hospital emergency room immediately to determine the cause of the bleeding and begin medical treatment. Unchecked bleeding enlarges the hematoma and increases pressure on the blood vessels supplying the brain tissue, depriving them of oxygen .Prompt assessment and interventions are the keys to a good prognosis. (Essentials of Human Diseases and Conditions.) According to Interventions to Reduce Acute Care Transfers II (INTERACT) the physician should be notified immediately with a fall with any suspected serious injury; any head injury with change in level of consciousness (LOC), other mental status change or any focal neurological findings; and with an abrupt significant personality change, from usual, associated with new onset of abnormal neurological signs. The facility's Fall Procedure undated states in part; 1. Nursing assessment to be completed by the RN; 2. Neurological (Neuro) checks to be started per the Neuro Check flow sheet with any unwitnessed fall or any fall with head injury of any kind. 3. Call the MD and update on all falls. 4. Call family. 5. Complete a full fall investigation . 6. All falls need to be reported immediately to the Director of Nursing (DON) if the DON is unavailable call the Nursing Home Administrator (NHA). Resident 8 was an [AGE] year-old female with the following Diagnoses: [REDACTED]. Resident 8 had an Activated Health Care Power of Attorney (AHCPOA) and desired to be a full code. Resident 8's comprehensive care plan Alteration in cognition related to dementia evidenced by does not remember she needs assist with ambulation and does it on her own at times dated [DATE] states in part; assess for cause if note change in cognition, MD notification if needed. Resident 8's Physician Orders, dated [DATE] state: Full code Vital Sign parameters: Blood Pressure: call MD if systolic blood pressure <90 or >180 or diastolic blood pressure <50 or >100. Pulse parameters: Call MD if pulse <50>110. Aspirin 81 mg 1 tablet by mouth daily for hypertension. Of note, Aspirin can also have an antiplatelet effect and increase bleeding risk. Nursing notes dated [DATE] (no time) state in part; patient fell at 2:15 hit back of head; laceration some blood assessed (sic) and assisted to wheelchair with lift. Wrapped head with bandage. Blood pressure (BP) ,[DATE], Pulse (P) 80 and respirations (R) 18; hand grasp strong equal; alert and talking with staff; up in wheelchair. Nursing notes dated [DATE], late entry for [DATE] at 2:30 PM, state in part; Resident 8 had fallen in large lounge upon report of fall went down to assess the resident. Resident 8 was found on floor with bleeding noted coming from posterior skull; CNA applied a towel to the bleeding area with some pressure. Resident 8 moved extremities without difficulty, had strong equal hand grasps and was hoyer lifted (mechanical full body lift) off the floor into the wheelchair. [MEDICAL CONDITION] immediately assessed and was found that there was a superficial approximately 2 inch laceration that upon palpation was not to have clotted off as no further bleeding was noted. A dry gauze Kerlix dressing was applied to resident head to protect wound and prevent clotting from being interrupted. Resident was assisted to the nurse's desk and was noted as verbalizing per baseline and had no acute complaints except that her head was sore. LPN I was instructed to completed fall paperwork and call the MD and family right away due to resident having sustained an injury. LPN I verbalized understanding and stated I will notify them. Indicating this would be taken place immediately. Of note, this is the only full set of vital signs after the fall. There was no call placed to the MD or the family to consult regarding the fall with head injury. On [DATE] at 1:30 PM Surveyor interviewed Registered Nurse (RN) J regarding Resident 8's fall. RN J stated that at 2:15 PM on [DATE], at the end of RN J's shift, the CNA came and stated that Resident 8 had fallen. LPN I and I responded and RN J assessed Resident 8. RN J stated Resident 8 was able to move her extremities, vital signs were stable, Resident 8 complained of a head hurting where she had hit it and she was bleeding from her head. Resident 8 had about a 2 inch laceration that was superficial; by the time we sat Resident 8 up her head had stopped bleeding. LPN I put a dressing on Resident 8's head and RN J stated to LPN I to call the doctor and family and continue with neuro checks. Resident 8 did not display any neurological issues when I assessed her. If Resident 8 would have displayed any neurological issues, or if I had thought that there was anything out of the ordinary for Resident 8. I would have called the MD myself. RN J stated she delegated LPN I to call the MD and family as she thought LPN I could handle the call and RN J thought she could trust LPN I to follow through with the calls and neuro checks. Surveyor asked RN J about the late entry in Resident 8's medical record. RN J stated that usually the fall paperwork and documentation is completed by the nurse on duty and since Resident 8 had expired and RN J felt she needed to document her assessment in Resident 8's record. RN J stated she was scheduled to return on the night shift just 8 hours later and stated she was dumbfounded when she heard Resident 8 had passed away. The facility's Neurological Observation Checklist dated [DATE] for Resident 8 states: This checklist should be used at the following intervals for follow-up of all falls. Any change in resident condition requires a phone call to the primary care physician. Initial Assessment followed by every 15 minutes times 4, every 30 minutes times 2, every hour times 2 and once per shift for 72 hours. Neuro checks, taken at 2:15 PM, 2:30 PM, 2:45 PM, 3:00 PM, 3:30 PM, and 4:00 PM were normal, although vital signs were not taken after 2:15 PM, when they were BP = ,[DATE]; P =80; R= 18. As indicated in his interview, below, LPN I stated he could not get vital signs because the resident was getting agitated when he attempted to take vital signs. LPN I did not consult with the physician about the fact that Resident 8 was agitated and that he could not obtain vital signs. Resident 8's January Medication Administration Record [REDACTED]. The neuro check at 4:35 PM states in hand writing - nonresponsive to room ambulance called. BP - 0 P = 106 and R = 22. There is no documentation on pupil response or other areas on the checklist. Nursing notes dated [DATE] at 4:50 PM state in part; patient unresponsive in wheel chair; 911 called enroute to take to emergency room for evaluation. Nursing notes, dated [DATE] at 5:15 PM, state in part; ambulance service here to transport to (hospital name) for evaluation. The prehospital report Emergency Medical Services (EMS) report dated [DATE] states in part; dispatch notified at 4:58 PM. Provider Impression: Priority :critical Provider primary impression: altered level of consciousness; Enroute: 5:03 PM; at Scene: 5:08 PM; at patient: 5:09. Narrative: call for unresponsive patient; upon arrival found patient lying in bed unconscious, but breathing normally. Staff reported that at approximately 2:00 PM that patient had fell from her wheelchair in the dining room striking her head. Patient had a laceration on the back of the head described by staff as 3 to 4 centimeters (cm) the wound was bandaged. Staff report the patient has Alzheimer's and is normally conscious and chatty. When staff checked patient at 4:45 PM the patient was unresponsive. Vital signs taken BP ,[DATE]; Medical Injury: Loss of Consciousness: yes; Mental Status: unresponsive; Neurological: Decorticate Posturing (is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain). Patient Symptoms and Complaints: Chief Complaint: patient unconscious; Secondary Complaint: [MEDICAL CONDITION]; Primary Symptom: Change in Responsiveness. Departed facility: 5:19 Arrived at hospital 5:26. Nursing notes dated [DATE] at 5:20 PM state in part; family was called and updated related to transport to (hospital name) and patient is in emergency room for evaluation. Of note, this is the first time the family is notified of the fall with head injury after Resident 8 is sent to the emergency room . Nursing notes dated [DATE], no time documented state in part; (hospital name) called with update give on fall. emergency room report dated [DATE] states in part; Hospital Problems: Subdural hematoma/Subdural Hemorrhage- Physical exam: General Appearance: unresponsive to painful stimuli; Right Pupil is 5 millimeters (mm) and unresponsive; left is 1 (mm) Neurological Exam: unresponsive; flaccid extremities. Nursing notes dated [DATE] at 6:50 PM state in part; call placed to (hospital name) and patient is in emergency room for further evaluation. Nursing notes dated [DATE], no documented time, state in part; patient son called to report patient has passed. On [DATE] at 1:00 PM Surveyor interviewed CNA F regarding Resident 8's fall. CNA F stated that at about 2:15 PM a resident came up to her and stated that Resident 8 had fallen. CNA F and CNA G responded. CNA F stated that Resident 8 was lying on her right side and there was a decent amount of blood on Resident 8's head. CNA F stated the wound was more like an abrasion not very deep and about 2 inches in length. CNA F stated Resident 8 complained of her head hurting real bad. CNA F stated that Resident 8 was her usual self prior to the fall but after the fall she was just not acting right. CNA F described Resident 8 as normally spicy but after the fall CNA F stated Resident 8 was quiet which was quite unusual for Resident 8. CNA F stated she would walk past Resident 8 and ask how she was and Resident 8 would reply Okay or All right. CNA F stated about 4:30 PM she walked past Resident 8 to go assist another resident and Resident 8's face was real red CNA F stated she asked if she was okay and Resident 8 stated I'm okay. CNA F stated about ,[DATE] minutes later CNA F and CNA G exited a resident room and Resident 8 was slumped over in her chair, breathing heavy and drooling. CNA F immediately sought out LPN I and reported her observation of Resident 8. CNA F stated LPN I in no particular hurry came up to the nurses station and told CNA F and CNA G to lie Resident 8 down. CNA F stated LPN I did not assess Resident 8, just stated to lie Resident 8 down. CNA F stated she and CNA G attempted to get Resident 8's vital signs and CNA F even took a flashlight to look into Resident 8's eyes and noted Resident 8's eyes were all glazed over. CNA F stated the fact that LPN I did not assess Resident 8 and his directive to lie Resident 8 down did not sit well with her so she immediately sought out RN D, who was on another floor, to come and assess Resident 8. Surveyor asked CNA F if Resident 8 was agitated after the fall CNA F stated, No not at all. Surveyor asked CNA F if LPN I completed Neuro checks. CNA F stated I saw LPN I do them at least once. On [DATE] at 2:40 PM Surveyor interviewed CNA G regarding Resident 8's fall on [DATE]. CNA G stated that at about 2:15 PM a resident came up to her and CNA F and stated that Resident 8 had fallen. CNA G and CNA F responded. CNA G stated that Resident 8 was lying on her right side and was bleeding from her head. CNA G stated she held pressure to Resident 8's head. CNA G stated Resident 8 stayed in her wheelchair at the nurse's station so they could observe her. CNA G stated Resident 8 was normally funny and sassy but after the fall she was just blah. CNA G stated she could tell Resident 8 was hurting she kept stating she had a headache and her nose hurt. CNA G stated that all shift LPN I stated Resident 8 will have a headache when they would report to LPN I that Resident 8 was complaining of a headache. Surveyor asked CNA G if LPN I did neuro checks. CNA G stated she never saw him do neuro checks. Surveyor asked CNA G if Resident 8 was agitated on [DATE]. CNA G stated Resident 8 was never agitated. CNA G stated she was not her normal self just kind of blah, which was very unusual for Resident 8. CNA G stated she and CNA F were assisting another resident about 5:00 PM; when they exited the resident's room they noticed Resident 8 was unresponsive in her wheelchair. CNA F went to tell LPN I and he slowly walked to the nurse's station. LPN I looked at Resident 8 and stated to CNA G and CNA F, Resident 8 looks tired she had a long day go lay her down. CNA G stated LPN I never assessed Resident 8. CNA G stated she and CNA F did vital signs after Resident 8 was unresponsive. LPN I never directed us to complete the vital signs but we knew something was very wrong. CNA G stated CNA F ran to get RN D to assess Resident 8 because we knew something was very wrong. CNA G stated RN D took one look at Resident 8 and yelled to LPN I call 911. LPN I stated, I told them to lie her down and RN D stated, Call 911, we need lights and siren. Of note, CNA staff had recognized the change of condition in Resident 8 yet LPN I did not. Even after Resident 8 becomes unresponsive LPN I directed the staff to lie her down versus updating the MD with this significant change of condition. The following is a written statement from LPN I dated [DATE] which states in part; at 2:15 another patient came up the hall and stated a lady is on the floor LPN I and RN J went to assess observed Resident 8 on the floor on right side with some blood from laceration. Vital signs and neuro checks were completed. Resident 8 was taken to the nurse's station for continual observations and a dressing was applied to Resident 8's head. LPN I gave Resident 8 Tylenol for complaints of head hurting. At 4:35 PM staff reporting patient non-responsive. Writer came to patient and informed staff to take patient to room and put Resident 8 to bed for assessment. Staff unable to obtain BP, CNA left patient room and went to another floor and got RN D. RN D told LPN I don't put patient in bed call 911. LPN I called 911. A facility phone interview on [DATE] with LPN I states in part; Resident 8 was responding normally, LPN I stated Resident 8 was at the nurse's station so that staff could monitor her closely. LPN I stated he had started neuro's but did not get vital signs due to the fact that Resident 8 was getting agitated when he attempted to take vital signs. LPN I stated he continued to attempt but Resident 8 refused. LPN I stated Resident 8 became non-responsive very quickly. LPN I stated he told the CNA's to put Resident 8 to bed so that LPN I could assess Resident 8. LPN I stated the CNA's decided to go to the third floor and get RN D. LPN I stated RN D assessed Resident 8 and directed LPN I to call 911. Of note, LPN I states Resident 8 was combative with attempting vital signs yet he did not update the physician he was unable to obtain this vital part of a neuro assessment. CNA staff stated the resident was lethargic, not her usual self, and complained of a headache, yet LPN I did not consult with a physician regarding these changes. A facility phone interview with RN D dated [DATE] states in part; at about 4:45 PM - 5:00 PM a CNA from second floor asked me to assess a resident who had fallen earlier that day. I told the CNA's to try to keep Resident 8 awake and I tried to wake Resident 8. Resident 8 was non-responsive, RN D stated she tried a sternal rub and Resident 8 did not respond. RN D stated she checked Resident 8's pupils and they were non-reactive to light. RN D instructed LPN I to call 911. On [DATE] at 4:00 PM Surveyor interviewed DON B, RN C and NHA A regarding the Resident 8's fall with head injury. Surveyor asked NHA A what areas of concern they had recognized with the incident that had occurred with Resident 8 on [DATE]. NHA A stated we recognized a concern with lack of MD notification, family notification and lack of documentation. Surveyor asked if management had been notified of Resident 8's change of condition on the evening of [DATE] including Resident 8 presenting with lethargy. RN C stated we did not receive the information that Resident 8 was more labile. If we would have been aware of this we would have known there was a change in Resident 8's condition. Surveyor asked DON B if she would have expected LPN I to phone the physician with a fall with head injury or when Resident 8 became unresponsive. DON B stated I would have expected him to call the MD and family. DON B stated I could not trust him as a nurse we had to let him go. On [DATE] at 3:40 PM Surveyor spoke with MD H regarding Resident 8's fall with head injury. MD H stated that a call would be expected for any fall with head injury. MD H stated that since this fall occurred over a weekend the on-call doctor should have been notified, however there was no documentation to indicate the on-call physician was consulted regarding a fall with head injury for Resident 8. According to the hospital discharge summary dated [DATE], Resident 8 died at the hospital on [DATE] at 8:50 PM. Resident 8's final [DIAGNOSES REDACTED]. Systemically, the facility's failure to promptly consult with the physician for Resident 8 immediately after the fall and after Resident 8 was so agitated that vital signs could not be obtained, or lethargic and complaining of a headache, created an immediate jeopardy situation which began [DATE]. The facility removed the immediate jeopardy and corrected the deficient practice on [DATE] by taking the following actions: *All staff was educated prior to their shift on the fall protocol and need to notify the physician family and DON of all falls. * All staff was educated on fall assessment and investigation procedures. * Neuro check education was provided and changes to look for with neuro checks. *Education was provided by the medical director on MD notification and head injuries.

Based on record review and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 10 residents (Resident 8). Resident 8 had a fall with a head injury. Resident 8 did not have a comprehensive set of neurological (neuro) checks completed per facility protocol including vital signs which consist of a blood pressure, pulse and respirations. Licensed Practical Nurse (LPN) I stated vital signs were not able to be completed for Resident 8 as Resident 8 was agitated. Of note, this could reflect a sign of complications from head injury. Certified Nursing Assistant (CNA) staff working with Resident 8, on the other hand, stated Resident 8 was lethargic, holding her head and not as jovial as she normally was after her fall. LPN I did not recognize this change of condition (COC) thus no evaluation or assessment was completed of Resident 8's condition. Within hours of Resident 8's fall, Resident 8 became unresponsive. LPN I did not recognize Resident 8's change of condition and LPN I instructed CNA staff to lie Resident 8 down as she appeared tired. CNA staff notified the RN in the facility; the RN immediately assessed Resident 8 and found Resident 8 unresponsive and directed LPN I to call 911. Resident 8 died at the hospital from a subdural hematoma. The failure to complete comprehensive neuro checks following a fall with head injury and the inability to recognize a change of condition (COC) in Resident 8 created a finding of Immediate Jeopardy that began on [DATE]. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy was removed on [DATE]. The immediate jeopardy was cited at past non-compliance as the deficient practice was corrected on [DATE]. This is evidenced by: According to< <http://www.webmd.com/brain/subdural-hematoma-symptoms-causes-treatments> > Subdural hematoma is usually caused by a head injury, such as from a fall, motor vehicle collision, or an assault. The sudden blow to the head tears blood vessels that run along the surface of the brain. This is referred to as an acute subdural hematoma. People with a bleeding disorder and people who take blood thinners are more likely to develop a subdural hematoma. (http://www.webmd.com/heart-disease/ss/slideshow-tips-for-taking-blood-thinners). A relatively minor head injury can cause subdural hematoma in people with a bleeding tendency. Elderly people are at higher risk for chronic subdural hematoma because brain shrinkage causes these tiny veins to be more stretched and more vulnerable to tearing. Symptoms of subdural hematoma depend mostly on the rate of bleeding; in head injuries with sudden, severe bleeding causing a subdural hematoma, a person may lose consciousness and become comatose immediately. Symptoms of subdural hematoma can include headache <http://www.webmd.com/migraines-headaches/default.htm>, confusion, change in behavior, <http://www.webmd.com/first-aid/understanding-dizziness-basics>dizziness, nausea <http://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomiting>, lethargy or excessive drowsiness, <http://www.webmd.com/a-to-z-guides/weakness-and-fatigue-topic-overview>weakness and apathy. People may vary widely in their symptoms of subdural hematoma. Besides the size of the subdural hematoma, a person's age and other medical conditions can affect the response to having a subdural hematoma. Subdural hematomas can be serious and can lead to decreased quality of life or death. Patients with an acute subdural hematoma have a poor prognosis. The mortality rate for patients treated for [REDACTED]. <http://www.merck.com/mkgr/mmg/sec6/ch44/ch44e.jsp>. [MEDICATION NAME] hematomas have a death rate up to 40% depending upon the age of the individual. According to<<https://my.clevelandclinic.org/services/neurological_institute/[MEDICAL CONDITION]-center/diseases-conditions/hic-intracranial-hemorrhage>.>Any type of bleeding inside the skull or brain is a medical emergency. It is important to get the person to a hospital emergency room immediately to determine the cause of the bleeding and begin medical treatment. Unchecked bleeding enlarges the hematoma and increases pressure on the blood vessels supplying the brain tissue, depriving them of oxygen .Prompt assessment and interventions are the keys to a good prognosis. (Essentials of Human Diseases and Conditions.) According to Interventions to Reduce Acute Care Transfers II (INTERACT) the physician should be notified immediately with a fall with any suspected serious injury; any head injury with change in level of consciousness (LOC), other mental status change or any focal neurological findings; and with an abrupt significant personality change, from usual, associated with new onset of abnormal neurological signs. The facility's Fall Procedure (undated) states in part; 1. Nursing assessment to be completed by the RN; 2. Neurological (Neuro) checks to be started per the Neuro Check flow sheet with any unwitnessed fall or any fall with head injury of any kind. 3. Call the MD and update on all falls. 4. Call family. 5. Complete a full fall investigation . 6. All falls need to be reported immediately to the Director of Nursing (DON) if the DON is unavailable call the Nursing Home Administrator (NHA). Resident 8 was an [AGE] year old female with the following Diagnoses: [REDACTED]. Resident 8 had an Activated Health Care Power of Attorney (AHCPOA) and desired to be a full code. Resident 8's comprehensive care plan Alteration in cognition related to dementia evidenced by does not remember she needs assist with ambulation and does it on her own at times dated [DATE] states in part; assess for cause if note change in cognition, MD notification if needed. Resident 8's Physician Orders, dated [DATE], state: Full code Vital Sign parameters: Blood Pressure: call MD if systolic blood pressure <90 or >180 or diastolic blood pressure <50 or >100. Pulse parameters: Call MD if pulse <50>110. Aspirin 81 mg 1 tablet by mouth daily for hypertension. Of note, Aspirin can also have an antiplatelet effect and increase bleeding risk. Nursing notes dated [DATE] (no time) state in part; patient fell at 2:15 hit back of head; laceration some blood assessed (sic) and assisted to wheelchair with lift. Wrapped head with bandage. Blood pressure (BP) ,[DATE], Pulse (P) 80 and respirations (R) 18; hand grasp strong equal; alert and talking with staff; up in wheelchair. Of note, this is the only full set of vital signs after the fall. LPN I stated vital signs were unable to be obtained due to Resident 8 being agitated. There was no call placed to the MD notifying the physician that vital signs are unable to be obtained post fall with a head injury. LPN I did not recognize the potential sign of agitation as a potential COC post fall with a head injury. Nursing notes dated [DATE], late entry for [DATE] at 2:30 PM, state in part; Resident 8 had fallen in large lounge upon report of fall went down to assess the resident. Resident 8 was found on floor with bleeding noted coming from posterior skull; CNA applied a towel to the bleeding area with some pressure. Resident 8 moved extremities without difficulty, had strong equal hand grasps and was Hoyer lifted (mechanical full body lift) off the floor into the wheelchair. [MEDICAL CONDITION] immediately assessed and was found that there was a superficial approximately 2 inch laceration that upon palpation was noted to have clotted off as no further bleeding was noted. A dry gauze Kerlix dressing was applied to resident head to protect wound and prevent clotting from being interrupted. Resident was assisted to the nurse's desk and was noted as verbalizing per baseline and had no acute complaints except that her head was sore. LPN I was instructed to complete fall paperwork and call the MD and family right away due to resident having sustained an injury. LPN I verbalized understanding and stated I will notify them. Indicating this would be taken place immediately. On [DATE] at 1:30 PM, Surveyor interviewed Registered Nurse (RN) J regarding Resident 8's fall. RN J stated that at 2:15 PM on [DATE], at the end of RN J's shift, the CNA came and stated that Resident 8 had fallen. LPN I and I responded and I assessed Resident 8. RN J stated Resident 8 was able to move her extremities, vital signs were stable, Resident 8 complained of a head hurting where she had hit it and she was bleeding from her head. Resident 8 had about a 2 inch laceration that was superficial by the time we sat Resident 8 up her head had stopped bleeding. LPN I put a dressing on Resident 8's head and RN J stated to LPN I to call the doctor and family and continue with neuro checks. Resident 8 did not display any neurological issues when I assessed her. If Resident 8 would have displayed any neurological issues, if I had thought that there was anything out of the ordinary for Resident 8, I would have called the MD myself. RN J stated she delegated LPN I to call the MD and family as she thought LPN I could handle the call and RN J thought she could trust LPN I to follow through with the calls and neuro checks. Surveyor asked RN J about the late entry in Resident 8's medical record. RN J stated that usually the fall paperwork and documentation is completed by the nurse on duty and since Resident 8 had expired, RN J felt she needed to document her assessment in Resident 8's record. RN J stated she was scheduled to return on the night shift just 8 hours later and stated she was dumbfounded when she heard Resident 8 had passed away. The facility's Neurological Observation Checklist dated [DATE] for Resident 8 states: This checklist should be used at the following intervals for follow-up of all falls. Any change in resident condition requires a phone call to the primary care physician. Initial Assessment followed by every 15 minutes times 4, every 30 minutes times 2, every hour times 2 and once per shift for 72 hours. 2:15 PM - Orientation: Person; Eyes Open: 4 = opens eyes spontaneously and purposely; Hand Responses: right/left 4 = normal power; Arms: right/left 4 = normal power; Legs: right left 4=normal power; Vital Signs: BP = ,[DATE]; P =80; R= 18. Pupils: 2 + right = normal/reactive and 2+ left = normal/reactive. 2:30 PM - Orientation: Person; Eyes Open: 4 = opens eyes spontaneously and purposely; Hand Responses: right/left 4 = normal power; Arms: right/left 4 = normal power; Legs: right left 4=normal power; Vital Signs: refused. Pupils: 2 + right = normal/reactive and 2+ left = normal/reactive. 2:45 PM - Orientation: Person; Eyes Open: 4 = opens eyes spontaneously and purposely; Hand Responses: right/left 4 = normal power; Arms: right/left 4 = normal power; Legs: right left 4=normal power; Vital Signs: refused. Pupils: 2 + right = normal/reactive and 2+ left = normal/reactive. Resident 8's January Medication Administration Record [REDACTED]. The facility's Neurological Observation Checklist dated [DATE] for Resident 8 states: 3:00 PM - Orientation: Person; Eyes Open: 4 = opens eyes spontaneously and purposely; Hand Responses: right/left 4 = normal power; Arms: right/left 4 = normal power; Legs: right left 4=normal power; Vital Signs: refused. Pupils: 2 + right = normal/reactive and 2+ left = normal/reactive. 3:30 PM - Orientation: Person; Eyes Open: 4 = opens eyes spontaneously and purposely; Hand Responses: right/left 4 = normal power; Arms: right/left 4 = normal power; Legs: right left 4=normal power; Vital Signs: refused. Pupils: 2 + right = normal/reactive and 2+ left = normal/reactive. 4:00 PM - Orientation: Person; Eyes Open: 4 = opens eyes spontaneously and purposely; Hand Responses: right/left 4 = normal power; Arms: right/left 4 = normal power; Legs: right left 4=normal power; Vital Signs: refused. Pupils: 2 + right = normal/reactive and 2+ left = normal/reactive. 4:35 PM - States in hand writing nonresponsive to room ambulance called. BP - 0 P = 106 and R = 22. There is no documentation on pupil response or other areas on the checklist. Nursing notes dated [DATE] at 4:50 PM state in part; patient unresponsive in wheel chair; 911 called enroute to take to emergency room for evaluation. Nursing notes, dated [DATE] at 5:15 PM, state in part; ambulance service here to transport to (hospital name) for evaluation. The prehospital report Emergency Medical Services (EMS) report dated [DATE] states in part; dispatch notified at 4:58 PM. Provider Impression: Priority: critical Provider primary impression: altered level of consciousness; Enroute: 5:03 PM; at Scene: 5:08 PM; at patient: 5:09. Narrative: call for unresponsive patient; upon arrival found patient lying in bed unconscious, but breathing normally. Staff reported that at approximately 2:00 PM that patient had fell from her wheelchair in the dining room striking her head. Patient had a laceration on the back of the head described by staff as 3 to 4 centimeters (cm) the wound was bandaged. Staff report the patient has Alzheimer's and is normally conscious and chatty. When staff checked patient at 4:45 PM the patient was unresponsive. Vital signs taken BP ,[DATE]; Medical Injury: Loss of Consciousness: yes; Mental Status: unresponsive; Neurological: Decorticate Posturing (is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain). Patient Symptoms and Complaints: Chief Complaint: patient unconscious; Secondary Complaint: [MEDICAL CONDITION]; Primary Symptom: Change in Responsiveness. Departed facility: 5:19 Arrived at hospital 5:26. Nursing notes dated [DATE] at 5:20 PM state in part; family was called and updated related to transport to (hospital name) and patient is in emergency room for evaluation. Nursing notes dated [DATE], no time documented, state in part; (hospital name) called with update given on fall. emergency room report dated [DATE] states in part; Hospital Problems: Subdural hematoma/Subdural Hemorrhage- Physical exam: General Appearance: unresponsive to painful stimuli; Right Pupil is 5 millimeters (mm) and unresponsive; left is 1 (mm) Neurological Exam: unresponsive; flaccid extremities. Nursing notes dated [DATE] at 6:50 PM state in part; call placed to (hospital name) and patient is in emergency room for further evaluation. Nursing notes dated [DATE], no documented time, state in part; patient son called to report patient has passed. On [DATE] at 1:00 PM Surveyor interviewed CNA F regarding Resident 8's fall. CNA F stated that at about 2:15 PM a resident came up to her and stated that Resident 8 had fallen. CNA F and CNA G responded. CNA F stated that Resident 8 was lying on her right side and there was a decent amount of blood on Resident 8's head. CNA F stated the wound was more like an abrasion not very deep and about 2 inches in length. CNA F stated Resident 8 complained of her head hurting real bad. CNA F stated that Resident 8 was her usual self prior to the fall but after the fall she was just not acting right. CNA F described Resident 8 as normally spicy but after the fall CNA F stated Resident 8 was quiet which was quite unusual for Resident 8. CNA F stated she would walk past Resident 8 and ask how she was and Resident 8 would reply Okay or All right. CNA F stated about 4:30 PM she walked past Resident 8 to go assist another resident and Resident 8's face was real red. CNA F stated she asked if she was okay and Resident 8 stated I'm okay. CNA F stated about ,[DATE] minutes later CNA F and CNA G exited a resident room and Resident 8 was slumped over in her chair, breathing heavy and drooling. CNA F immediately sought out LPN I and reported her observation of Resident 8. CNA F stated LPN I in no particular hurry came up to the nurses station and told CNA F and CNA G to lie Resident 8 down. CNA F stated LPN I did not assess Resident 8 just stated to lie Resident 8 down. CNA F stated she and CNA G attempted to get Resident 8's vital signs and CNA F even took a flashlight to look into Resident 8's eyes and noted Resident 8's eyes were all glazed over. CNA F stated the fact that LPN I did not assess Resident 8 and his directive to lie Resident 8 down did not sit well with her so she immediately sought out RN D, who was on another floor, to come and assess Resident 8. Surveyor asked CNA F if Resident 8 was agitated after the fall. CNA F stated no not at all. Surveyor asked CNA F if LPN I completed Neuro checks CNA F stated I saw LPN I do them at least once. On [DATE] at 2:40 PM Surveyor interviewed CNA G regarding Resident 8's fall on [DATE]. CNA G stated that at about 2:15 PM a resident came up to her and CNA F and stated that Resident 8 had fallen. CNA G and CNA F responded. CNA G stated that Resident 8 was lying on her right side and was bleeding from her head. CNA G stated she held pressure to Resident 8's head. CNA G stated Resident 8 stayed in her wheelchair at the nurse's station after the fall so they could observe her. CNA G stated Resident 8 was normally funny and sassy but after the fall she was just blah. CNA G stated she could tell Resident 8 was hurting she kept stating she had a headache and her nose hurt. CNA G stated that all shift LPN I stated Resident 8 will have a headache when they would report to LPN I that Resident 8 was complaining of a headache. Surveyor asked CNA G if LPN I did neuro checks CNA G stated she never saw him do neuro checks. Surveyor asked CNA G if Resident 8 was agitated on [DATE]. CNA G stated Resident 8 was never agitated. CNA G stated she was not her normal self just kind of blah, which was very unusual for Resident 8. CNA G stated she and CNA F were assisting another resident about 5:00 PM or so when they exited the resident's room Resident 8 was unresponsive in her wheelchair. CNA F went to tell LPN I and he slowly walked to the nurse's station. LPN I looked at Resident 8 and stated to CNA G and CNA F. Resident 8 looks tired she had a long day go lay her down. CNA G stated LPN I never assessed Resident 8. CNA G stated she and CNA F did vital signs. LPN I never directed us to complete the vital signs but we knew something was very wrong. CNA G stated CNA F ran to get RN D to assess Resident 8 because we knew something was very wrong. CNA G stated RN D took one look at Resident 8 and yelled to LPN I to call 911. LPN I stated, I told them to lie her down and RN D stated, Call 911 we need lights and siren. Of note, CNA staff had recognized the change of condition in Resident 8 yet LPN I did not. Resident 8 complained of a headache, a sign of head injury, yet LPN I did not recognize this as COC or potential concern post fall with head injury. Even after Resident 8 became unresponsive, LPN I directed the staff to lie her down. LPN I did not call an RN to assess or update the MD with this significant change in condition. The following is a written statement from LPN I dated [DATE], which states in part; at 2:15 PM another patient came up the hall and stated a lady is on the floor LPN I and RN J went to assess and observed Resident 8 on the floor on right side with some blood from a laceration to her head. Vital signs and neuro checks were completed. Resident 8 was taken to the nurse's station for continual observations and a dressing was applied to Resident 8's head. LPN I gave Resident 8 Tylenol for complaints of head hurting. At 4:35 PM staff reported patient non-responsive. Writer came to patient and informed staff to take patient to room and put Resident 8 to bed for assessment. Staff unable to obtain BP. CNA left patient room and went to another floor and got RN D. RN D told LPN I don't put patient in bed call 911 LPN I called 911. A facility phone interview on [DATE] with LPN I states in part; Resident 8 was responding normally. LPN I stated Resident 8 was at the nurse's station so that staff could monitor her closely. LPN I stated he had started neuro's but did not get vital signs due to the fact that Resident 8 was getting agitated when he attempted to take vital signs. LPN I stated he continued to attempt but Resident 8 refused. LPN I stated Resident 8 became non-responsive very quickly. LPN I stated he told the CNA's to put Resident 8 to bed so that LPN I could assess Resident 8. LPN I stated the CNA's decided to go to the third floor and get RN D. LPN I stated RN D assessed Resident 8 and directed LPN I to call 911. Of note, LPN I states Resident 8 was combative with attempting vital signs yet he did not update the physician he was unable to obtain this vital part of a neuro assessment; nor did LPN I recognize that agitation is a potential sign of head injury thus warranting notification of the physician with this change of condition. A facility phone interview with RN D dated [DATE] states in part; at about 4:45 PM - 5:00 PM a CNA from second floor asked me to assess a resident who had fallen earlier that day. I told the CNA's to try to keep Resident 8 awake and I tried to wake Resident 8. Resident 8 was non-responsive, RN D stated she tried a sternal rub and Resident 8 did not respond. RN D stated she checked Resident 8's pupils and they were non-reactive to light. RN D instructed LPN I to call 911. On [DATE] at 4:00 PM Surveyor interviewed DON B, RN C and NHA A regarding the Resident 8's fall with head injury. Surveyor asked NHA A what areas of concern they had recognized with the incident that had occurred with Resident 8 on [DATE]. NHA A stated we recognized a concern with lack of MD notification, family notification and lack of documentation. Surveyor asked if management had been notified of Resident 8's change of condition on the evening of [DATE] including Resident 8 presenting with lethargy. RN C stated we did not receive the information that Resident 8 was more labile. If we would have been aware of this we would have known there was a change in Resident 8's condition. Surveyor asked DON B if she would have expected LPN I to phone the physician with a fall with head injury or when Resident 8 became unresponsive. DON B stated I would have expected him to call the MD and family. Surveyor asked DON B regarding the assessment for Resident 8. DON B stated LPN I stated that Resident 8 was sleepy and did not complete an assessment this was a big reason we did not bring LPN I back to work and we terminated him. DON B stated I could not trust him as a nurse we had to let him go. DON B stated even after interviewing LPN I and speaking with him I did not feel like he got it. Surveyor asked DON B what she would have expected LPN I to do. DON B stated, I would have expected him to recognize a COC and to call the physician, complete an assessment of Resident 8 and document the findings and call 911 when Resident 8 was unresponsive. On [DATE] at 3:40 PM Surveyor spoke with MD H regarding Resident 8's fall with head injury. Surveyor asked MD H if it would be expected that the physician be notified if vital signs were unable to be obtained as part of a comprehensive neuro check due to agitation post fall with head injury. MD H stated that this would most certainly warrant a call to the physician. According to the hospital discharge summary dated [DATE], Resident 8 died at the hospital on [DATE] at 8:50 PM. Resident 8's final [DIAGNOSES REDACTED]. Systemically, the facility's failure to complete comprehensive neuro checks or recognize a change in Resident 8's condition (agitation, lethargy) and consult with the physician regarding a COC created an immediate jeopardy situation which began [DATE]. The facility removed the immediate jeopardy and corrected the deficient practice, on [DATE], by taking the following actions: *All staff was educated prior to their shift on the fall protocol and need to notify the physician family and DON of all falls. * All staff was educated on fall assessment and investigation procedures. * Neuro check education was provided with focus on nursing assessment and changes to look for with neuro checks. *Education was provided by the medical director on MD notification and head injuries.

Based on record review and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 5 residents (Resident 1). Resident 1 has a [DIAGNOSES REDACTED]. Resident 1 also receives scheduled narcotics which have the potential to increase constipation risk. Resident 1 did not have a scheduled laxative order to help promote bowel evacuation despite her narcotic usage nor did the facility implement non-pharmacological interventions for Resident 1 to prevent constipation. Resident 1 developed a fecal impaction and was admitted to the hospital. This is evidence by: On 1/5/16 at 4:30 PM Surveyor requested the facility bowel policy related to constipation from Director of Nursing (DON) B and Nurse Consultant (NC) C. NC C stated the facility does not have a policy related to bowel/constipation. The facility is to follow the facility standing orders signed by each individual resident physician. Resident 1's [DIAGNOSES REDACTED]. Resident 1's Quarterly Minimum Data Set (MDS) with a completion date of 10/14/15: Resident 1 has a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident 1 is alert and oriented times 3. Resident 1 needs extensive assist of 1 with bed mobility, transfer and toilet use. Resident 1 is continent of bowel and not on a bowel program. Question H0600: Constipation present mark Yes or No. This area of the MDS was left blank by the assessor. Resident 1's care plan titled Alteration in bowel elimination, dated 7/28/15 in part; Focus: Lack of exercise, Nutrition and Medications. Goal: Comfortable and regular bowel movements. Interventions: Eliminate foods causing adverse effects for constipation. Evaluate need for medication that causes constipation. Follow bowel protocol as per policy (Laxative, suppository and enema). Increase fluid intake. Monitor abdomen for distention. Monitor bowel sounds. Record Bowel movement (BM): Note size and consistency. report any abnormalities. Resident 1's care plan titled Potential for pain, dated 11/24/14 in part, related to chronic pai[DIAGNOSES REDACTED]. Interventions: Give PRN medications per request per Medical Doctor (MD) orders note effectiveness, Acknowledge presence of pain. (Note Resident 1's pain Care plan does not include the use of interventions to aide in bowel movements related to medication use.) Of note there is no non-pharmacological bowel interventions care planned for Resident 1. Resident 1's Medication Administration Record [REDACTED]. (Note: Resident MAR indicated [REDACTED].) Other medications included [MEDICATION NAME] ([MEDICATION NAME]) 10 mg daily, and [MEDICATION NAME] sulfate 325 mg daily. Resident 1's Physician standing orders, signed on 11/4/15 in part, medications: [REDACTED] *As needed (PRN) [MEDICATION NAME] - 2 tablets every bedtime (hs) for constipation if no Bowel Movement (BM) in 48 hours. *PRN [MEDICATION NAME] 10 mg suppository 1 per rectum in AM if no results from PO [MEDICATION NAME] given the night before. *PRN fleets enema 1 Per rectum at HS if no results from [MEDICATION NAME] suppository given that morning. Discontinue any other PRN [MEDICATION NAME] orders. Review of Resident 1's Bowel Movement flow sheet dated December 2015 indicates the following: *December 1st through December 4th = No BM for 4 days Resident 1's MAR indicated [REDACTED]. Resident 1 did not have BM on 12/3 or 12/4 from the [MEDICATION NAME] tablets. Resident 1 did not receive the [MEDICATION NAME] suppository or enema per physician order [REDACTED]. Review of Resident 1's Bowel Movement flow sheet dated December 2015 indicates the following: *December 5th Large BM *December 6th through December 9th = No BM for 4 days Resident 1's MAR indicated [REDACTED]. Resident 1 did not have BM on 12/8 or 12/9 from the [MEDICATION NAME] tablets. Resident 1 did not receive the [MEDICATION NAME] suppository or enema per physician order [REDACTED]. Resident 1 again received [MEDICATION NAME] tablet on 12/10/15. Resident 1's bowel regimen was not followed per Resident 1's physician orders. Review of Resident 1's Bowel Movement flow sheet dated December 2015 indicates the following: *December 10th small BM *December 11th Large BM. Review of Resident 1's Bowel Movement flow sheet dated December 2015 indicates the following: *December 10th small BM *December 11th Large BM. *December 12th through December 17th No BM for 6 days. Resident 1's MAR indicated [REDACTED]. Resident 1 did not have a BM on 12/12 or 12/13 from the [MEDICATION NAME] tablets. Resident 1 did not receive the [MEDICATION NAME] suppository or enema per physician order [REDACTED]. Resident 1 again received [MEDICATION NAME] tablet on 12/15/15 for no BM on 12/14/15. Resident 1 did not have a BM on 12/15, 12/16/12/17 or 12/18/15 AM. Resident 1's bowel regimen was not followed per Resident 1's physician orders. Resident 1's MAR indicated [REDACTED]. Resident 1 did not have BM from 12/12 through 12/18/15 AM shift from the [MEDICATION NAME] tablets. Resident 1 did not receive the [MEDICATION NAME] suppository or enema per physician order [REDACTED]. Resident 1's MAR indicated [REDACTED]. Resident 1 did have a small BM on 12/18/15 AM shift from the [MEDICATION NAME] tablets. Resident 1 received another dose of the [MEDICATION NAME] tablets even though Resident 1 was documented as having had a BM. Review of Resident 1's Bowel Movement flow sheet dated December 2015 indicates the following: *December 19th through December 20th no BM for 2 days. Resident 1's MAR indicated [REDACTED]. Resident 1 was given a [MEDICATION NAME] enema on 12/21/15 at 5:30 AM for no BM on 12/20/15. Resident 1 did not receive the enema on 12/20/15 at bedtime per the MD order no BM from the suppository. Resident 1's Nurse Practitioner note dated 12/21/15 at 9:00 AM, in part, Subject: Saw member (Resident 1) for wound follow up. Per staff member has been constipated. Has received [MEDICATION NAME] suppository and fleets enema with only smears. Objective: Member sleeping in bed fluids at bedside. Abdomen (Abd) positive (+) hypoactive Bowel sounds (BS), non-tender, non-distended. Assessment/Plan: Constipation - encourage staff to use as needed (PRN) [MEDICATION NAME] already ordered, hold [MEDICATION NAME] SR for constipation, PRN Senna Plus ordered. Staff to notify if member does not have bowel movement (BM). Resident 1's Physician order [REDACTED]. Hold for loose stools. Encourage fluids and mobility. Hold PM dose of [MEDICATION NAME] today one time only due to constipation. Review of Resident 1's Bowel Movement flow sheet dated December 2015 indicates the following: *December 22 through December 25th no BM for 4 days. Resident 1's NP was not notified per the NP order. *December 26th Medium BM. *December 27th and 28th No BM *December 29th large BM *December 30th admitted to hospital with fecal impaction. A review of Resident 1's nursing notes regarding appetite and fluid intake and bowel movements from 12/1/15 through 12/30/15 described Resident 1's ongoing decline in appetite, mental status and use of laxatives. Excerpts from these notes include: *12/1/15 at 2:00 PM Resident admitted from hospital with left lower extremity wound infection. *12/3/15 at 11:00 AM, Turned and repositioned. Poor appetite. Fluids encouraged. (Note: There is no evidence in the medical record of and abdominal assessment or the use of the medications list on the standing orders for the bowel protocol.) *12/4/15 at (Unable to determine time) Incontinent of bowel and bladder. *12/7/15 at 9:30 AM, Alert and oriented times 3. Poor appetite . Bowel sounds active times 4. Abdomen soft and non-tender. *12/8/15 at 5:00 AM, No stools incontinent of urine. *12/8/15 at 10:30 AM, on bed rest .has [MEDICAL CONDITION]. Poor intake. Bowel wounds active times 4. [MEDICATION NAME] 1 tablet given. Continue to monitor. *12/9/15 at 11:30 AM, Ate 25% of oatmeal drank milk, juice and water. *12/10/15 at 9:40 AM, Poor appetite. Bowel sounds active times 4 Abdomen soft and non-tender. As needed (PRN) [MEDICATION NAME] given due to constipation. * 12/10/15 at 12:30 PM, Returned from MD appointment. New orders received to extend [MEDICATION NAME] (antibiotic). Restart [MEDICATION NAME]. *12/11/15 at 11:30 AM, Did refuse morning medications. Poor appetite. Eats in room. Bowel sounds active times 4. Abdomen soft and non-tender. *12/12/15 at 1:10 PM, Poor appetite at breakfast and lunch - ate meal in room. Bowel sounds active times 4. Abdomen soft and non-tender/non distended. Will continue to monitor. *12/13/15 at 2:00 PM, Low Blood pressure, encourage fluids. (BP from vital sign flow sheet BP 88/44) *12/14/15 at 3:30 AM: Checked due to incontinent of bowel and bladder. *12/14/15 at 10:40 AM, Call from Nurse Practitioner with new orders to discontinue [MEDICATION NAME] due to insurance and start [MEDICATION NAME] SR 15 mg twice daily. Continue with PRN [MEDICATION NAME] *12/15/15 at 9:30 AM. Bowel sounds active on lower quadrants (quads).(Note: This is a change in the bowel assessment) Abdomen soft and non-tender. Had PRN [MEDICATION NAME] 2 tablets for day 2 of no Bowel Movement (BM) Poor appetite. *12/16/15 at 9:30 AM, Bowel sounds active on lower quad. Abdomen soft and non-tender. *12/17/15 at 1:30 PM, Appetite fair at breakfast. Bowel sounds active times 4. Abdomen soft and non-tender. *12/18/15 at 9:15 AM: Bowel sounds active times 4. *12/20/15 at 10:45 AM, Resident complained of being tired. Did not want to get out of bed (OOB) keeping eyes closed much of time. Poor appetite. Resident needed lot of cueing to take medications. Resident received rectal suppository for constipation. Bowel sounds Hypoactive all 4 quads (Note a decline in bowel assessment) Resident passing gas. *12/21/15 at 9:00 AM, Complained of pain in left lower leg. Resident did not want to get OOB as of yet. Resident is sleepy. Poor appetite. Fluids encouraged. NP here to see and assess resident orders received to start Senna Plus (+) 2 tablets twice a day for constipation. (Scheduled Laxative started 21 days after Resident 1 returned from the hospital with narcotic medication orders) Suggested resident be OOB daily, encourage fluid intake. Try giving [MEDICATION NAME] PRN for constipation as well as other PRN laxatives. *12/22/15 at 9:30 AM, Poor appetite. Fluids encouraged. Bowel sounds active times 4. Soft/non tender. Has PRN [MEDICATION NAME]. 12/23/15 at 10:30 AM, Emesis after administration of morning antibiotic. Poor appetite. Fluids encouraged. Will continue to Monitor. *12/25/15 at 10:30 AM, Resident is sleeping a lot Poor appetite fluids encouraged. Incontinent of Bowel and bladder. Bowel sounds active times 4. Abdomen soft and non-tender. *12/26/15 at 8:00 AM, Resident refused breakfast. Resident asking staff to leave her alone. Resident then falls asleep. Had PRN [MEDICATION NAME] for constipation. Resident having trouble with pills. Resident sleeping; eyes closed through most of assessment. Bowel sounds active in lower quads. Refusing to get out of bed. Making needs known less and using call light less. Message left for NP with update. (Note: NP was not consulted and there is no evidence the NP received the message or returned a call to facility related to update.) *12/27/15 at 9:30 AM, Poor intake, drinking some. Alert and oriented times 2 to person and time (Note: Resident 1 was alert and oriented times 3, this is a decline in cognition.) Bowel sounds active times 4. Abdomen soft and non-tender. Face is pale. Resident is very sleepy and refusing to talk. Making needs known less, using call light less frequently. Fluids encouraged. *12/27/15 at 2:00 PM, Resident resting in bed. Not as alert; sleepy. Breathing rate of 40. Moving some and appears a little restless. Nail beds are blue in color more right then left. Resident is pale in the face. Message left for grandson. Continue to monitor. Vital sign sheet - Pulse 72 apical. Respiration 40 Blood pressure (/) unable to obtain. (Note: There is no evidence Physician was not consulted with Resident 1 change in condition or documentation a Registered Nurse assessment was completed.) *12/28/15 at 9:00 AM, Resident is sleepy. Nail beds are still blue. Bowel sounds active times 4 Abdomen soft and non-tender. *12/29/15 at 6:00 AM, Resident has been refusing to wear oxygen tube, staff had been attempting to put it as close to her as possible. It was also reported that PM shift on 12/28/15 was also having issues with this and had reported doing the same thing. *12/29/15 at 12:45 PM, Resident has been refusing cares and medications called provider. Provider will visit on 30th to evaluate. Hold [MEDICATION NAME] order received and noted. Called grandson per provider request. *12/30/15 at 9:00 AM, Resident restless; picking at blankets and gown. Resident pale in color, will not make eye contact. Will not speak. Resident spits medications out. NP came to assess. Resident being sent to (hospital name) for evaluation per NP and grandson request. Resident large dark foul smelling emesis. Resident 1's NP progress note dated 12/30/15 at 8:30 AM in part, Subject: Met with member due to staff report that member has been refusing oral (PO) medications, inhalers, oxygen (O2) and PO food and fluids. Member has been refusing medications on and off since her last hospital discharge, though with coaxing were able to encourage her to take them. Started refusing oxygen yesterday despite staff frequently reproaching. Member has had poor po intake and has been completely refusing - stating I give up. Per staff she is not on the constipation list. Oxygen: Member presents sleeping in bed with Oxygen tubing next to her in reach. Rousable but lethargic. Member initially refused O2, after explaining that the lack of O2 is impairing her ability to make decisions, she did agree to wear it, though continued to pull it off throughout discussion, but did refuse it being replaced. Before I could examine her, member began vomiting foul dark brown emesis. At that point did recommend that member be evaluated in the emergency room (ER), member initially refused. Members' grandson was contacted, when updated on her health condition his opinion that she should go to ER was conveyed to Resident 1. Resident agreed and was transported to hospital. Assessment/Plan: Emesis with concern for obstruction versus (vs) bleeding. Dehydration and Anorexia. Resident 1's emergency department hospital note dated 12/30/15 in part, Chief complaint: Altered Mental status. Resident 1 is a [AGE] year old with altered mental status. Per nursing home report, the patient has had a gradual decline over several days but much worse yesterday. They report her baseline mental status alert and oriented times (x) 4. She confirms she vomited today and has a headache. She indicates that she does not have abdominal tenderness with palpitation (of the abdomen). According to nursing report, the patient has had slowing of her bowels. Heart monitor applied and Intravenous (IV) placed and 1 liter fluid bolus was given. X-rays: Per review: Abdominal x-ray shows dilated bowel loop. Computed Tomography (CT) Scan abdomen shows evidence of aspiration pneumonia as well as fecal impaction. Patient remains obtunded. I was able to manually disimpact her and removed a large amount of stool from the rectum. Resident will be admitted to the hospital. Final Impression: Fecal impaction in the rectum. Resident 1's hospital history and physical note, dated 12/30/15 in part, Chief complaint: General decline over the past 2 days. Resident 1 sent in because of lethargy and general decline over the last 2 days. She is quite obtunded. Physical examination: Blood pressure 83/43. Pulse 85. General: Frail elderly female, obtunded, arouses to painful stimuli and loud voice. Mucous membranes are dry. [MEDICAL CONDITION]/chest: Very poor effort. Diffuse rhonchi. Neurologic: Awakens and answers to name. Will not follow commands. Assessment/Plan: Gradual decline over 2 days. Now obtunded with fecal impaction and likely large bilateral aspiration pneumonia. Dehydration: Based on exam. Poor by mouth intake for 48 hours. IV bolus given in ER. Continue gentle hydration overnight. [MEDICAL CONDITION] - Give IV fluids. Telemetry overnight. [MEDICAL CONDITION]: She is within her range currently Resident 1 is clinically dry on exam. Gentle IV fluids over the evening. Supratherapeutic INR - likely with poor by mouth intake possibly some Vitamin K deficiency. No apparent bleeding. Will hold [MEDICATION NAME] overnight. Fecal impaction with history of constipation disimpacted in the ER. Continue aggressive bowel regimen. On 1/5/16 at 4:40 PM Surveyor interviewed Director of Nursing (DON) B regarding the facility protocol for no bowel movements. NC C stated the facility is to follow the Resident signed standing orders for bowel regimen. DON B stated the nurses are to check the bowel movement flow sheet daily and follow the protocol listened for each Resident. Surveyor and DON B reviewed Resident 1's bowel protocol from the facility standing orders. DON B stated yes the protocol should have been followed from giving the oral medication to the suppository next and then the enema per the orders. DON B stated if the resident continues to have no BM then the Physician should have been called. On 1/5/16 at 2:45 PM Surveyor interviewed DON B and NC C regarding the facility policy for using a schedule laxative with narcotic medication use. NC C stated the nurse should have called for a scheduled laxative when Resident 1 started receiving the narcotics on a daily bases. DON B stated she would have expected the nurse to notify the Physician and request a scheduled laxative especially if the resident was using as needed medication and was still having no BM results. NC C also stated she would expect the dietary care plan to have non pharmalogical food choices for constipation especially when a resident is on a narcotic medication or any other medications that would have constipation as a side effect. The facility did not provide interventions or follow Resident 1's bowel management program to help prevent constipation for Resident 1 even though she was on narcotic medications. The facility also did not update the NP or Physician when Resident 1 continued not to have bowel movements or update Resident 1's care plan when Resident 1 did not have Bowel movement. Resident 1 was admitted to the hospital with [REDACTED].

Based on interviews and record reviews, the facility did not ensure that 1 (Resident 1) of 5 residents reviewed for hydration was provided with sufficient fluids to meet assessed needs. Resident 1 was admitted to the hospital on [DATE] for lower extremity [MEDICAL CONDITION], she was diagnosed with [REDACTED]. Resident 1 was readmitted to the facility with no updated plan to monitoring or increase her fluid intake. Resident 1 experienced a decrease in fluid and food intake from 12/17/15 through 12/30/15. Resident 1 consistently took less than her assessed fluid needs of 1530 milliliter each day. The intakes were not totaled on a consistent basis. Resident 1 had a 7.2% weight loss in 30 days. There is no evidence that staff analyzed the daily fluid intakes, alerted the Registered Dietician (RD) to the low fluid intakes and/or implemented approaches to assist Resident 1 in meeting her daily fluid needs. On 12/30/15 Resident 1 was transferred to the hospital due to decline in health status. The Nurse Practitioner indicated Resident 1 was dehydrated on 12/30/15 just prior to Resident 1 transferring to the hospital There were no documented assessments by nursing of the resident's hydration status after 12/2/15 that looked at whether the resident's mucous membranes, lips or tongue were moist. Resident 1 had signs and symptoms of dehydration, along with severe weight loss, and the facility did not implement interventions to provide appropriate fluid needs for the residents. This is evidenced by: According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084>), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. According to Medscape (www.medscape.com/view article/ 8) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately . In the older adult dehydration often causes atypical symptoms such as confusion, constipation, or falls Body weight proved to be the most responsive to changes in hydration Patients consuming less than 50% of meals are at high risk for dehydration. Caregivers should be aware of and anticipate this hazard. Diagnosing dehydration and monitoring fluid balance requires repeated measurement of weight, Creatinine, and physical signs such as tongue hydration. Facility hydration policy, dated 4/1/08 and revised 4/2009 in part, Policy; The facility assess all residents at their risk of hydration problem at admission and annually, as well as with significant change in condition. Procedure: *Fluids are encouraged for all residents unless contraindicated. *Resident who require assistance to reach/pour or drink fluids are provided assistance at meals and between meals. Education: Individuals risk factors for hydration problem include: Come or decreased sensorium, Uncontrolled Diabetes, fluid restriction, Functional impairment, cognitive impairment, refusal of fluids, resident's need for assistance or assistive devices, Medication that could affect hydration status, History of dehydration, Overall health status, Physical signs of dehydration. Assessment will address the individual's usual fluid intake pattern such as: Estimated daily fluid needs, do they consume most of their fluids during meals? At what time of day do they consume most fluids? What types of fluids are preferred? Resident ability to obtain fluids independently. Care plan is developed to address risk factors for hydration problem as indicated. (Of note the facility received a citation related to Dehydration on 8/6/15. The facility made a change in intake and output process related to the monitoring and tracking of resident fluid intakes). On 1/5/16 Surveyor received the facility's Intake and output process developed 8/2015 in part, Intake and output: How do we assess/consider those at risk? *All new residents are put on intake and output (I&O). * In order to accurately assess fluid intake and output, ensure no holes in the intake and output section of your shift. * Residents who are at risk or have a change in condition are added to I&O. How do we monitor new and ongoing residents for fluid deficits: * Nursing to monitor all intakes and output every shift to see if consistently meeting or not meeting fluid needs. *If a resident is not meeting fluid needs, the nurse must ensure additional fluids are being offered more frequently. *Night shift nurse is to total resident's daily fluid intake and output. Unit managers will review resident's daily fluid intakes. *If resident's average fluid intake in 3 days is lower than recommended fluid intake, a physical hydration assessment is completed and medical doctor (MD) is notified as needed for signs and symptoms of fluid volume deficit.*hydration assessments will be updated quarterly and as needed. Resident 1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Resident 1's Quarterly Minimum Data Set (MDS) with a completion date of 10/14/15, Resident 1 has a Brief Interview of Mental Status (BIMS) was a 15 indicating Resident 1 is alert and oriented times 3. Resident 1 needs extensive assist of 1 with bed mobility, transfer and toilet use. Resident 1's medications included [MEDICATION NAME] ([MEDICATION NAME]) 10 mg daily. [MEDICATION NAME] is a water pill that eliminates excess water and sodium from the body and can increase one's risk for becoming dehydrated. Resident 1's Nutrition status review, dated 10/15/15 noted in part, that Resident 1's estimated fluid needs equal 1530 milliliters and that her average fluid intakes equal 1233 ml. Even though Resident 1's nutrition assessment indicates she was not meeting fluid needs on 10/15/15, no changes were made from the dietary department to increase Resident 1's fluid intake. Resident 1's care plan titled Altered Nutrition, dated 11/20/14 in part, Focus: Altered nutrition at risk for dehydration. Resident 1 was admitted to the hospital on [DATE]. Her hospital note, dated 11/23/15, indicates she was admitted for chief complaint of left lower extremity [MEDICAL CONDITION]. Physical exam on 11/23/15; Mucous membranes are severely dry. Assessment/Plan: Hypovolemia with history of [MEDICAL CONDITION]. Intravenous fluids tonight. Repeat Basic metabolic panel in AM. Hold [MEDICATION NAME] for now given her hypovolemia and restart in few days. (It is important to note the facility document located in Resident 1 medical record made the facility aware of Resident 1's history of decreased fluid volume upon admission to the hospital on [DATE].) Subsequent to Resident 1's return to the nursing home, the facility did not update her care plan with with respect to monitoring or increasing fluid intake. Even though she was dehydrated when admitted to the hospital on [DATE], no interventions were added upon her return to ensure adequate hydration. Resident 1's Hydration assessment, dated 12/2/15 in part, 1. Is Resident on diuretics, laxatives or cardiovascular medications? Yes 2. Does Resident refuse fluids? Yes 3. Does Resident have an abnormal laboratory results? Yes is marked for BUN, Creatinine and BUN/Creatinine ratio. 4. Does Resident have sunken eyes? Yes. 5. Does resident have dark urine? Yes. 5. Does Resident have a history of dehydration? Yes. Assessment Conclusion and recommendation: Based on the professional judgment of the assessor, is the resident at risk for dehydration? YES. Explain rationale: Resident is refusing food and fluids at times. Furthermore poor intake has some signs and symptoms of dehydration; sunken eyes, dark urine, recent hospitalization for [MEDICAL CONDITIONS] and left foot wound [MEDICAL CONDITION] (MRSA). (It is important to note: The facility Hydration assessment is left for each assessor to independently determine if the resident is at risk for dehydration. The assessment does not give markers or scores to determine dehydration according to appointed risk factors.) Resident 1's nutrition at risk charting, dated 12/11/15, Readmission note in part, worsening symptoms of [MEDICAL CONDITION]. She was found to [MEDICAL CONDITION] to wound culture. Diet regular with average meal intakes. Receives ice cream at bedtime, She has ordered for nutrition supplement three times a day between meals, previously had Boost juice plus twice a day,. Recommendation submitted high cal juice supplement twice a day 400 calories 12 grams protein and supplement clarified as med pass supplement 60 ml three times a day. Continue tracking. (Resident 1's nutrition note does not identify Resident 1's fluid intake or risk for dehydration.) Resident 1's Physician dated 12/11/15, high cal juice supplement (sup) Twice a day (BID) at meals. Clarify Nutrition sup three times a day (TID) between meals as med pass sup 60 milliliters (ml) TID between meals. A review of the dietary records for 12/17/15 through 12/30/15 revealed Resident 1's meal intake had significantly declined and Resident 1 was eating less than 50% of her meals. The following documentation for food intake was written on the December intake record. 12/17/15- Breakfast Bites, Lunch Bites, Dinner Bites 12/18/15 - Breakfast 25 %, Lunch 25%, Dinner refused 12/19/15 - Breakfast 25%, Lunch 225%, Dinner 25% 12/20/15 - Breakfast 25%, Lunch 25%, Dinner 0%, 12/21/15 - Breakfast 25%, Lunch 0% Dinner 0% 12/22/15 - Breakfast 25% Lunch 25% Dinner 50% 12/23/15 - Breakfast 0 %, Lunch 0%, Dinner 0%. 12/24/15 - Breakfast 0 %, Lunch 25% Dinner Bites 12/25/15 -Breakfast 0 % Lunch 0%, Dinner 25% 12/26/15 -Breakfast 0 % Lunch 0%, Dinner Bites 12/27/15 -Breakfast 0 % Lunch 0%, Dinner refused 12/28/15 -Breakfast 0 % Lunch 0%, Dinner 0% 12/29/15 -Breakfast 25 % Lunch refused, Dinner refused 12/30/15-Breakfast 0 % admitted to hospital. Fluid intake documented, daily documentation of resident intake record for December 2015 reveals: Resident 1's fluid need to equal 1514 milliliters (ml) per day. 12/17/15 Fluid grand total in 24 hour = 1260 ml 12/18/15 Fluid grand total in 24 hours = 1200 ml 12/19/15 Fluid grand total in 24 hours = 1060 ml 12/20/15 Night and AM total = 600 ml (PM and grand total sections are blank) 12/21/15 Night and AM total = 720, PM 480 (not totaled), 24 hour total = 1200 ml (Grand total section is blank) 12/22/15 Night and AM total = 780, PM 420 (not totaled), 24 hour total = 1200 ml (Grand total section is blank) 12/23/15 Night and AM total = 660 ml (Grand total section is blank) 12/24/15 Fluid grand total in 24 hour = 1350 ml 12/25/15 Fluid grand total in 24 hour = 1230 ml 12/26/15 Fluid grand total in 24 hour = 1230 ml 12/27/15 Fluid grand total in 24 hour = 1170 ml 12/28/15 Night and AM total = 660 ml (Grand total section is blank) 12/29/15 Night and AM total = 450 ml, other fluids = 370 ml, total 24 hour = 820 ml (Grand total section is blank) 12/30/15 150 ml grand total. According to Resident 1's Nutritional assessment dated [DATE], Resident 1's fluids needs had been assessed at 1530 ml according to her body weight. Resident 1's fluid intake was less than her assessed needs during the last 2 weeks in December Resident 1's physician order [REDACTED]. Resident 1's nutrition note, dated 12/22/15 in part, Weight 108.5 pounds 7.2% weight loss in 30 days. Recommendation resubmitted to resume High calorie juice supplement twice a day. Med Pass supplements 60 ml three times a day. Submitted for medical doctor of weight loss. Continue NAR tracking. (Resident 1's nutrition note does not include risk for dehydration and not meeting fluid needs.) Resident 1's nursing notes regarding appetite and fluid intake from 12/20/15 through 12/30/15 indicate: 12/20/15 at 10:45 AM, Resident complained of being tired. Did not want to get out of bed (OOB) keeping eyes closed much of time. Poor appetite. Resident needed lot of cueing to take medications. *12/21/15 at 9:00 AM, Complained of pain in left lower leg. Resident did not want to get OOB as of yet. Resident is sleepy. Poor appetite. Fluids encouraged. NP here to see and assess resident orders received to start Senna Plus (+) 2 tablets twice a day for constipation. Suggested resident be OOB daily, encourage fluid intake. Complete blood count (CBC) and complete metabolic panel (CMP) on 12/221/5 due to [MEDICAL CONDITION] and elevated liver enzymes. *12/22/15 at 9:30 AM, Poor appetite. Fluids encouraged. *12/22/15 at 11:30 AM, Laboratory results received. Message left for NP.Results also faxed. (Potassium 3.1 Low, BUN 38 increased, Creatinine 1.3 and white blood count 14.7 elevated.} *12/22/15 at 2:30 PM, Call received from NP, Orders received to start [MEDICATION NAME] 200 mg daily. CMP in 2 weeks. *12/23/15 at 10:30 AM, Emesis after administration of morning antibiotic. Poor appetite. Fluids encouraged. *12/25/15 at 10:30 AM, Resident is sleeping a lot. Poor appetite fluids encouraged. *12/26/15 at 8:00 AM, Resident refused breakfast. Resident asking staff to leave her alone. Resident then falls asleep. Resident having trouble with pills. Resident sleeping; eyes closed through most of assessment. Refusing to get out of bed. Making needs known less and using call light less. Message left for NP with update. (Note: NP was not consulted and there is no evidence the NP received the message or returned a call to facility related to update.) *12/27/15 at 9:30 AM, Poor intake, drinking some. Alert and oriented times 2 to person and time (Note: Resident 1 was alert and oriented times 3, this is a decline in cognition.) Face is pale. Resident is very sleepy and refusing to talk. Making needs known less, using call light less frequently. Fluids encouraged. *12/27/15 at 2:00 PM, Resident resting in bed. Not as alert; sleepy. Breathing rate of 40. Moving some and appears a little restless. Nail beds are blue in color more right then left. Resident is pale in the face. Message left for grandson. Continue to monitor. Vital sign sheet - Pulse 72 apical. Respiration 40 Blood pressure (/) unable to obtain. (Note: There is no evidence Physician was not consulted with Resident 1 change in condition or documentation a Registered Nurse assessment was completed.) *12/28/15 at 9:00 AM, Resident is sleepy. Nail beds are still blue. (It is important to note 9:00 AM is the only medical record entry for 12/28/15.) *12/29/15 at 12:45 PM, Resident has been refusing cares and medications called provider. Provider will visit on 30th to evaluate. Hold [MEDICATION NAME] order received and noted. Called grandson per provider request. *12/30/15 at 9:00 AM, Resident restless; picking at blankets and gown. Resident pale in color, will not make eye contact. Will not speak. Resident spits medications out. NP came to assess. Resident being sent to (hospital name) for evaluation per NP and grandson request. Resident large dark foul smelling emesis. Resident 1's nurses notes indicates Resident 1 has a decrease in appetite, a decreased ability to fed herself and a change in mental status, which are all signs of dehydration. Resident 1's nursing notes do not show evidence a dehydration assessment was completed with Resident 1's change in condition or how fluids where monitored or encouraged. Resident 1's Physician order [REDACTED]. Resident 1's Physician order [REDACTED]. Intravenous fluids (IV) bolus 250 milliliters Leave IV in place. Discontinue [MEDICATION NAME] and continue [MEDICATION NAME] as needed. Resident 1's Physician order [REDACTED]. Resident 1's NP progress note dated 12/30/15 at 8:30 AM in part, Subject: Met with member due to staff report that member has been refusing oral (PO) medications, inhalers, oxygen (O2) and PO food and fluids. Member has been refusing medications on and off since her last hospital discharge, though with coaxing were able to encourage her to take them. Started refusing oxygen yesterday despite staff frequently re-approaching. Member has had poor po intake and has been completely refusing - stating I give up. Per staff she is not on the constipation list. Oxygen: Member presents sleeping in bed with Oxygen tubing next to her in reach. Rousable but lethargic. Member initially refused O2, after explaining that the lack of O2 is impairing her ability to make decisions, she did agree to wear it, though continued to pull it off throughout discussion, but did refuse it being replaced. Before I could examine her, member began vomiting foul dark brown emesis. At that point did recommend that member be evaluated in the emergency room (ER), member initially refused. Member grandson was contacted, when updated on her health condition his opinion that she should go to ER was conveyed to Resident 1. Resident agreed and was transported to hospital. Assessment/Plan: Dehydration and Anorexia. Resident 1's emergency department hospital note dated 12/30/15 in part, Chief complaint: Altered Mental status. Resident 1 is a [AGE] year old with altered mental status. Per nursing home report, the patient has had a gradual decline over several days but much worse yesterday. They report her baseline mental status alert and oriented times (x) 4. She confirms she vomited today and has a headache. According to nursing report, the patient has had slowing of her bowels. Physical exam: Blood Pressure 119/83, Pulse 95, and Respirations 14. Oropharynx (It includes the base of tongue, back part of roof of mouth, tonsils and side and back wall of throat.) DRY. Heart monitor applied and Intravenous (IV) placed and 1 liter fluid bolus was given. Resident 1's hospital history and physical note, dated 12/30/15 in part, Chief complaint: General decline over the past 2 days. Resident 1 sent in because of lethargy and general decline over the last 2 days. She is quite obtunded. Physical examination: Blood pressure 83/43. Pulse 85. General: Frail elderly female, obtunded, arouses to painful stimuli and loud voice. Mucous membranes are dry. [MEDICAL CONDITION]/chest: Very poor effort. Diffuse rhonchi. Neurologic: Awakens and answers to name. Will not follow commands. Assessment/Plan: Gradual decline over 2 days. Now obtunded with fecal impaction and likely large bilateral aspiration pneumonia. Dehydration: Based on exam. Poor by mouth intake for 48 hours. IV bolus given in ER. Continue gentle hydration overnight. [MEDICAL CONDITION] - Give IV fluids. Telemetry overnight. [MEDICAL CONDITION]: She is within her range currently Resident 1 is clinically dry on exam. Gentle IV fluids over the evening. Supratherapeutic INR - likely with poor by mouth intake possibly some Vitamin K deficiency. No apparent bleeding. Will hold [MEDICATION NAME] overnight. Fecal impaction with history of constipation disimpacted in the ER. Continue aggressive bowel regimen. Hospital note, dated 12/31/15, Active hospital problems: [MEDICAL CONDITION], creatinine rose above baseline, suspect she is actually dry due to recent poor oral intake. Bolus 500 centimeter meters (cm) over 2 hours to help acutely rehydrate. Continue gentle IV fluids. On 1/5/16 at 2:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding residents on fluid monitoring. (Note: LPN D was Resident 1's consistent nurse on the day shift.). LPN D stated the Resident is placed on the intake and output sheet for monitoring. The nurse is to review the intakes every 24 hour to ensure the resident is meeting their needs. Surveyor asked what it means when LPN D charts Encourage fluids. LPN D stated it means that we should give more fluids and monitor the intake sheet to make sure they are meeting their fluid needs. LPN D stated if they are not meeting their fluid needs then we must contact the Physician to let the Physician know that the resident is not drinking or meeting their fluid needs. LPN D also stated the nurse should assess and monitor for any signs or symptoms of dehydration when the resident is refusing food and fluids. On 1/5/16 at 2:45 PM Surveyor asked LPN D if she took care of Resident 1 prior to Resident 1 being admitted to the hospital. LPN D stated she was Resident 1's nurse prior to Resident 1 being admitted to the hospital. LPN D stated Resident did not eat or drink much the last week before going into the hospital. LPN D stated Resident 1 needed increased help with Activities of daily living and would not get up out of bed much. LPN D stated the NP had a conversation with Resident 1 in the past related to comfort care and Hospice. LPN D stated Resident 1 refused both comfort care and Hospice when the NP spoke to her. Surveyor asked LPN D did Resident 1 want more aggressive measures taken when she became ill and not placed on Hospice. LPN D stated yes. She wanted to be treated and sent to the hospital when she became ill. LPN D continued to state NP had multiple conversations with Resident 1 regarding Hospice and Resident 1 has denied Hospice each time. On 1/5/16 at 2:50 PM Surveyor asked LPN D did she document all of her assessment and observation in the medical record during her shift. LPN C stated yes everything I completed during my shift will be documented in Resident 1's record. Surveyor asked LPN D that would include all of your assessments and data collecting you completed during your shift will be documented in full in Resident 1's medical record. LPN C stated, Yes when I complete any assessment I document the results in the medical record. All of my assessments I completed have been documented. (It is important to note a hydration assessment or signs and symptoms of dehydration were not located in Resident 1's medical record from 12/21/15 when NP gave an order to encourage fluids through 12/30/15 when Resident 1 was admitted to the hospital.) On 1/5/16 at 4:20 PM Surveyor Interviewed Director of Nursing (DON) B and Nurse Consultant (NC) C regarding the facility hydration assessment and policy. Surveyor asked how the nurse completing the assessment determines if the resident is at risk for dehydration and is to be placed on the Intake monitoring system. DON B stated each nurse is to complete the assessment on admission, change of condition and quarterly. NC C stated the nurse is to make their assessment and then it is the nurses ' decision to place the resident at risk or not. Surveyor asked DON B and NC C what guidelines the nurse uses to determine the results of the assessment. NC C stated they look at all the [DIAGNOSES REDACTED]. (Note: The hydration risk assessment is completed by different nursing staff for each resident. The assessment does not guide or direct the nurse when to place a resident at risk. The decision to place a resident at risk is left up to the professional judgment of the assessor.) On 1/5/16 at 4:30 PM Surveyor interviewed Director of Nursing (DON) B and Nurse Consultant (NC) C regarding monitoring of Resident intakes. DON B stated Every Resident who is at risk for dehydration should be monitored and have fluids encouraged. DON B stated the fluid intake should be completed every shift and the nurses are to monitor the intake to ensure the residents are meeting their needs. DON B also stated if the resident is not coming within their fluid goals, the nurse is to try other intervention such as offer so many fluids between meals and complete another hydration assessment. NC C stated she would expect an hydration assessment to be competed every shift if a resident is not drinking or coming within their fluid goals. DON B continued to state the Physician should be notified if the resident is not drinking or meeting their fluid goal in 3 days. The facility did not do an ongoing assessment when Resident 1 was readmitted with actual signs of dehydration on 12/1/15. The facility knew the resident had a current wound infection and was declining in her intakes and did not initiate a more rigorous assessment/care plan to prevent further decline and did not discuss treatment options with the Resident 1 or her Grandson prior to 12/30/15. Resident 1 had signs and symptoms of dehydration, along with severe weight loss, and the facility did not implement interventions to provide appropriate fluid needs for the

Based on observation, interview and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 11 residents (Residents 18, 15, and 10) reviewed for falls. Resident 18 is assessed as being at high risk for falls. Resident 18 had 14 falls between 3/2/15 and 6/3/15. The facility implemented an intervention of Direct Supervision after the fall on 5/31/15. Resident 18 was not being directly supervised and fell again. Resident 18 suffered an acute subdural hematoma and laceration above her right orbit and was hospitalized for [REDACTED]. Resident 15 was observed in her wheelchair, alone in her room, contrary to her plan of care. Resident 10 did not have gripper socks on as indicated to prevent falls. This is evidenced by the following: The facility's policy Accidents/Falls with a revision date of 2/2014, states in part, The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: (7) Each incident/accident or fall must be investigated and/or assessed to determine the cause of the episode to prevent any further injury. Witness statements should be obtained as applicable. Example 1 Resident 18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 18's quarterly Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated, 4/24/15 scored a 1 of 15 which indicates severe cognitive impairment. Resident 18 had 14 falls between 3/2/15 and 6/3/15. Resident 18 is assessed as being at high risk for falls. The facility's Falls Risk Post Fall Assessment-HDGR (Health Dimensions Group) dated 5/31/15 states, Fall Interventions currently being used: Direct Supervision. To be noted the care plan was not updated to include direct supervision. Resident 18's care plan History of falls r/t (related to) cognitive impairments unaware of safety issues secondary to dementia includes the following interventions, Activity box in her room, offer during hourly checks and when pacing / wandering. Baby doll with clothes/outfits. Date initiated: 6/1/15. On 6/3/15 at 2:15 PM, Resident 18 had a fall. The fall investigation states, Resident ambulating in hallway with walker, became unsteady/ lost balance, fell to floor; head injury present, assisted off floor into bed and sent to ER (emergency room ) for evaluation of injury. Nurses Notes dated 6/3/15 at 3:00 PM, states in part, Resident experienced fall, ambulating in hallway unwitnessed lost balance and fell to the floor- hit head causing bleeding and large laceration, vital sign changes, blood pressure decreasing, and decrease in alertness, patient ordered to be sent to ER (emergency room ) for evaluation. Head laceration was wrapped after pressure was applied. O2 (oxygen) wnl (within normal limits), pulse in 60's, resident did not respond when asked about pain. Falls Risk Post - Fall Assessment dated 6/3/15, states in part, Any additional information/interventions to be communicated to staff along with changes to the resident's care plan includes: unsteadiness during ambulation without assist, alarms implemented, resident currently in hospital thus will QA (Quality Assurance) intervention upon return. Fall Investigation/Root Cause Analysis dated 6/3/15 with the fall time of 2:15 PM, states in part,1. Where was the resident immediately prior to the fall? 'Ambulating in hall with her walker to her chair in hallway.' What was the resident doing? 'Ambulating in hall with walker.' 2. What was the resident trying to do when they fell ? 'I believe she was trying to go sit in chair at the end of hallway'. To be noted, this document was not signed by the person completing it. Resident 18's Neurosurgery New Patient Consultation notes dated 6/3/15 at 7:49 PM, states in part, (Resident's name) is a [AGE] year old female with dementia who suffered her 3rd fall since April 2015 at her SNF (Skilled Nursing Facility). Family states to Stoughton ED (Emergency Department) that 'she is still very functional'. Struck right orbit and suffered laceration. Taken to Stoughton ED (Emergency Department) where c-spine (cervical) CT (cat scan) negative but Head CT revealed left 8mm (millimeter) acute SDH. No significant mass effect. Possible non- displaced orbital floor fracture. Transferred to St. Mary's Hospital for further evaluation. Nurses Notes dated 6/9/15 at 7:00 PM, state in part, Resident was readmitted to facility following hospitalization after a fall and obtaining a subdural hematoma. Wears glasses but is not wearing them at present until headaches improve and facial pain lessens from fall. Sutures are intact to right eyebrow area. Bruising purple/ green/ yellow to right side of face, Scored 14 on falls risk assessment. Many fall interventions are now on place including bed alarm, chair (recliner) alarm, and w/c (wheel chair). Wander guard to left wrist, ½ bed rails and scoop mattress also in place. She also has a toileting routine in place to prevent falls. On 11/12/15, at 1:40PM, Surveyor interviewed Registered Nurse (RN) C and Director of Nursing (DON) B. RN C indicated that if Resident 18 is asleep she would be on frequent checks. Surveyor asked where the documentation was located for the frequent checks. RN C indicated that the Certified Nursing Assistants (CNA) will sign a sheet of paper indicating that they have done everything that was to be done for the resident on that shift. Surveyor asked DON B about the 15 minute sign off sheets that were noted in Resident 18's chart. DON B indicated that they are not using the sign off sheets any longer. To be noted the 15 minute check sheets were dated 6/26/15-7/1/15 and were not initialed on all times to be observed. Surveyor asked RN C about the direct supervision that was to be implemented for Resident 18 after her 5/31/15 fall. RN C indicated that it could have been clarified better. RN C stated, The staff knew to have her out of her room if she was awake. Surveyor asked RN C if this was noted on the care plan. RN C indicated that it was not on the care plan. RN C stated, She should have been ambulating with one assist. Surveyor asked DONB for any staff interviews regarding Resident 18's fall. DON B gave Surveyor another copy of the Falls Investigation/Root Cause Analysis documentation form. Surveyor asked DON B if the document should be signed. DON B stated, Yes. The facility sent in further information that included three staff interviews dated, 11/13/15. On 11/13/15 at 12:12 PM, NHA A interviewed CNA X. CNA X stated, The fall happened after shift change and report was done. CNA X saw Resident 18 in bed and went to break around 2:30 PM and while at break Resident 18 fell . CNA X worked a double shift this day and remembers that Resident 18 was restless during the day and had spent most of the day following her around as she would get up shortly after she sat down. On 11/13/15 at 1:38 PM, NHA A interviewed CNA Y. CNA Y stated, I came on shift and got report. CNA Y heard during report that Resident 18 was in her room lying down. CNA Y was at the nurses' desk organizing for the shift and heard a noise and then heard a resident yell help someone has fallen. CNA Y saw Resident 18 had fallen by the patio door. Resident 18 was on her way to sit in the chair by the patio and nurses station that she loved to sit in. The nurse arrived to assist in caring for Resident 18. On 11/13/15 at 2:15 PM, NHA A interviewed RN Z. RN Z stated, I saw (Resident 18) walk down long hall with walker, (RN Z) was setting down items to go assist (Resident 18) in walking to the chair and during that time heard a thud. RN Z ran to find Resident 18 on the floor next to the patio door. CNA Y came and assisted in helping Resident 18. The facility failed to implement their fall intervention of keeping Resident 18 in direct supervision which could have prevented the fall that caused a subdural hematoma and laceration. Example 2 Resident 15's [DIAGNOSES REDACTED]. Resident 15's current comprehensive care plan has a focus area dated 5/20/14 which states: Impaired mobility / risk for falls r/t (related to) deconditioning weakness and syncopy episodes. An intervention to this care plan focus area includes: not to be left alone in room while in w/c (wheelchair). Resident 15's current Care Delivery Guide states that Resident 15 is not to be left alone in room in w/c. On 11/12/15 at 12:57 pm Surveyor observed Resident 15 in her wheelchair in her room. There were no staff present in Resident 15's room. On 11/12/15 at 12:58 pm Surveyor observed Resident 15 self propel her wheelchair into her bathroom, and begin to self transfer onto the toilet. Surveyor , standing at Resident 15's room entry, began looking for a staff person to assist Resident 15. On 11/12/15 at 12:59 Surveyor observed CNA (Certified Nursing Assistant) J exit a room near Resident 15's room. Surveyor informed CNA J that Resident 15 was alone, self transferring herself onto the toilet from her wheelchair. CNA J entered Resident 15's room, assisted Resident 15 to the toilet, and remained within Resident 15's room, just outside the bathroom. Surveyor asked CNA J if it was alright for Resident 15 to be alone in her room. CNA J stated it was alright. On 11/12/15 at 2:00 pm Surveyor spoke with DON (Director of Nursing) B regarding several topics including Resident 15 and her care plan interventions. DON B confirmed care plans should be followed and Resident 15 should not have been left alone in her room in her wheelchair. Example 3 Resident 10's [DIAGNOSES REDACTED]. Per Resident 10's medical record Resident 10 has sustained multiple falls in the facility related to attempts to transfer independently. Resident 10's care plan indicates to remove shoes after supper, ensure grippie socks on, updated 10/30/15. On 11/11/15, at 9:03 AM, Surveyor was passing Resident 10's room and observed Resident 10 sitting up at the edge of the bed with bare feet attempting to stand up independently. Surveyor alerted staff to assist Resident 10. When Certified Nursing Assistant (CNA) O and P came into Resident 10's room to assist him they were not able to find any gripper socks in the room and CNA P had to leave the room to get a pair of gripper socks. On 11/12/15, at 10:31 AM, Surveyor interviewed Registered Nurse C who confirmed Resident 10 should have had gripper socks on when in bed.

Based on record review and interview the facility did not ensure each resident was provided with sufficient fluid intake to maintain proper hydration and health for 1 of 5 residents (Resident 1). The facility was not adequately monitoring Resident 1's intake. Resident 1 was hospitalized for [REDACTED]. This is evidenced by the following: Hypovolemia is a decrease in the volume of blood in your body, which can be due to blood loss or loss of body fluids. Fluid can also be lost as a result of diuretics. Inadequate fluid intake can also cause hypovolemia. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 weighs 689 pounds and is [AGE] years old. Resident 1's Hydration Assessment, completed 3/18/15, indicates Resident 1 is not at risk for dehydration. Resident 1's physician orders [REDACTED]. -[MEDICATION NAME] 40 mg daily -potassium chloride 20 meq daily Resident 1's Comprehensive Fluid Intake/Output Record for May 2015 indicates a fluid intake goal of 9480 milliliters (ml) per day. For the 31 days in May the facility only totaled 4 days: May 1st 1020 ml, May 9th-1320 ml, May 10th 1320 ml and May 12th 2130 ml. Resident 1's average fluid intake for May was 1056 per day. The last week of May 2015 includes: 5/25/15--2160 ml 5/26/15--1200 ml 5/27/15-- 630 ml 5/28/15--blank 5/29/15--360 ml 5/30/15--360 ml 5/31/15--360 ml Resident 1's Comprehensive Fluid Intake/Output Record for June indicates a fluid intake goal of 9480 ml per day. Only June 1st and 2nd were totaled by the facility. Resident 1's intakes for June: 6//1/15--1280 ml 6/2/15--1440 ml 6/3/15- 360 ml 6/4/15--1560 ml 6/5/15--1080 ml 6/6/15--2040 ml 6/7/15--1560 ml On 6/2/15 Resident 1's laboratory tests were noted as: -Sodium 138 mmol/L -Potassium 4.3 mmol/L -BUN (Blood urea nitrogen) 15 mg/dL -Creatinine 0.8 mg/dL All were in the normal range. Resident 1's nursing notes include: 6/4/15 at 8:45 PM-Lungs wheezes and congested, no temperature, urine amber colored, message left with nurse practitioner, fluids encouraged continue to monitor. 6/4/15 at 10:30 PM-fever, temperature 101.5 degrees Fahrenheit, [MEDICATION NAME] given. Message left for nurse practitioner. 6/5/15 at 9:00 AM-Urinalysis and chest X-ray ordered due to increase temperature, wheezes, congestion, dark foul urine, burning (with urination). 6/5/15 at 1:00 PM-Temperature 99.9 degrees Fahrenheit, encouraged to take deep breaths, urine specimen sent to laboratory. On 6/5/15 Resident 1's care plan was updated to include the problem area of Upper Respiratory Infection with interventions that include monitor for signs and symptoms of dehydration every shift. On 6/6/15 Resident 1's care plan was updated to include the problem area of Urinary Tract Infection with interventions that include monitor for signs and symptoms of dehydration every shift. Resident 1's Nursing Notes: 6/6/15- Antibiotic order received and dose given. States intermittent forgetfulness/confusion. 6/7/15-Alert, stated intermittent confusion. Fluids encouraged. Antibiotic therapy for UTI. 6/7/15 at 11:00 AM-Antibiotic changed to [MEDICATION NAME] 100 mg BID for 5 days for UTI. 6/7/15 at 6:00 PM-Resident 1 has had low urinary output according to Resident 1 and significant other who called her physician brother who stated Resident 1's condition may be more than a UTI. Urine was 100 ml and tea color when straight catheterized. Writer called on-call physician per family request and on-call ordered CBC, BMP, bladder scan and straight catheter. Staff unable to draw blood so on-call called. On-call stated to wait to draw blood until tomorrow so he's more hydrated. -Note there is no indication to push fluids or a hydration assessment at this time. 6/7/15 Resident 1's physician order [REDACTED]. Resident 1's Nursing notes: 6/8/15 at 8:50 AM, Nurse practitioner called about INR (international normalized ratio) (which was critically high). Also updated on confusion and culture and sensitivity. 6/8/15 at 12:30 PM, Nurse practitioner reviewed laboratory tests and order to send to emergency room to be evaluated due to abnormal CMP (complete metabolic panel). Sent to hospital, Confusion continues. There was no monitoring of Resident 1's intakes or outputs even after an infection was identified and Resident 1 voiced complaints of low urine output and the inability to draw blood. Resident 1's laboratory test results on 6/8/15: -Sodium 129 mmol/L -Potassium 5.2 mmol/L -BUN (Blood urea nitrogen) 51 mg/dL -Creatinine 2.3 mg/dL All were in the abnormal range. Resident 1's hospital History and Physical, dated 6/8/15 indicates: -Chief complaint: Hallucinations, decreased urinary output, hoarse voice, cough, and pain with urination for the past 4-5 days. -History of present illness: Resident 1 and significant other report 4-5 days ago he began having hallucination/delusions and seeing objects that aren't there. He also relates that he's had minimal urine output which he describes as really dark in color despite drinking a significant amount of fluid leading up to the decreased urinary output. He states he felt that his urination was painful. Physical exam: awake and alert, oriented times 4. Mucous membranes dry. Plan: hold [MEDICATION NAME], potassium chloride and other medications, start intravenous fluids. Resident 1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was readmitted to the facility on [DATE]. On 6/12/15 Resident 1's Hydration Assessment was completed. The question of Does resident have an abnormal lab result in the past three months? is not answered. (should be answered yes). The assessment asks is resident at risk for dehydration the staff indicated no-upon re-admission taking oral fluids well. There was no care plan developed or updated to address Resident 1's hydration status. Resident 1's Comprehensive fluid intake/output record for June: fluid goal is blank and there are no totals completed. There is no documentation until 6/13/15. Intakes include: -6/13/15--250 ml -6/14/15--720 ml -6/15/15--360 ml, 1 output -6/16/15--840 ml, 3 outputs -6/17/15--1230 ml -6/18/15--650 ml -6/19/15--720 ml -6/20/15--620 ml -6/21/15--1000 ml -6/22/15--360 ml -6/23/15--3300 ml The following weeks average was 641 ml (note 2 days are blank). Resident 1's July fluid intake/output record indicates and average daily intake of 1588 ml per day. The facility only tallied the total intake the first 3 days of the month. Resident 1's nursing notes do not address Resident 1's hydration status or an assessment of his hydration. On 7/22/15, the facility in-serviced staff, on the importance of completing charting, including the fluid intakes and outputs. On 8/6/15, at 4:08 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the intakes are monitored by the nutritionist. The Certified Nursing Assistants are responsible for monitoring and documenting intakes on the residents. The night nurse is responsible for totaling the daily fluid intakes. If the fluid goal is not met there should be a hydration assessment in the nursing notes and staff should encourage fluids. DON B stated he was aware there was a problem with documenting intakes that is why the in-service was done on 7/22/15. DON B also stated if a resident is at risk there should be a care plan to address the fluid needs. DON B stated Resident 1 took in more fluids than is documented but it was not being tracked. DON B confirmed when the documentation did not reflect adequate intake the nurse should assess the resident and document it in the nursing notes. Surveyor asked about the 6/7/15 note where they could not draw laboratory test until more hydrated. DON B stated when Resident 1's blood could not be drawn on 6/7/15 they should have encouraged fluids and the on-call should have given an order for [REDACTED]. The facility in-serviced staff on completing the intake records however staff are not completing the daily totals or acting on the days the totals fall below the recommended intake.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from drugs that were not adequately monitored and did not ensure that the drug regimen was free from adverse consequences for 1 of 8 residents reviewed (Resident 1). Resident 1 was prescribed [MEDICATION NAME], an anticoagulant medication. The facility did not complete ordered INR (international normalization ratio) monitoring for Resident 1 in December 2014. Resident 1 was placed on an antibiotic medication in January 2015. Antibiotics can potentiate the effect of [MEDICATION NAME]. The facility did not complete monitoring for symptoms of drug interactions and increased risk of bleeding. Resident 1 was subsequently hospitalized for [REDACTED]. The facility failed to ensure that Resident 1's INR was monitored while receiving the medication [MEDICATION NAME]. The facility failed to monitor Resident 1 for signs of bleeding despite her INR reaching critical levels of greater than 14.5 on 1/8/15. The facility did not monitor for the increased effects of [MEDICATION NAME] after an antibiotic was administered. Resident 1 suffered an acute subdural hematoma resultant from supra-therapeutic INR. This created an Immediate Jeopardy situation that began 12/2/14 and was removed on 2/24/15. The Interim-Director of Nursing was notified of the Immediate Jeopardy on 2/25/15. This citation continues at a "D" (potential for harm that is not immediate jeopardy/isolated) level as the facility continues to implement its action plan to correct. This is evidenced by: The facility's policy titled, "Anti-Coagulant Use" revised March 1, 2014 states in part, "Policy: Residents who require anticoagulant therapy will receive appropriate monitoring to ensure resident safety. Procedure: 1. an order for [REDACTED]. 2. Residents require INR monitoring while on [MEDICATION NAME]. The time between labs should never exceed four weeks and will be more frequent with fluctuating lab values. 3. INR is monitored after any dose adjustment; do not assume the next scheduled INR is adequate if a dose is changed. This includes holding therapy if INR is too high. 4. All health professionals are alerted to [MEDICATION NAME] therapy (dentists, therapists, physicians, pharmacists, and/or other designee). Anti-coagulant is addressed on plan of care as indicated. 5. Signs of bruising and bleeding are monitored routinely. Examples of common signs of bleeding include: black-tarry or red-looking stool, dark orange or red discolored urine, excessive bleeding from the gums or teeth, uncontrollable nose bleeds, cuts or scratches that continue to bleed despite pressure/bandages, sudden change in cognition or mental status, and excessive bruising of the skin and extremities. 6. Notify physician or designee of all INR lab results to obtain appropriate order for [MEDICATION NAME]. 7. INR values greater than 3.5 must be promptly reported to the physician or designee for adjustment in therapy. 8. INR values greater than 5 indicate high risk for bleeding. Resident's activity is restricted to reduce incidence of falls and injuries until INR has returned to normal. 9. Results of INR are called to physician or designee to obtain order for [MEDICATION NAME] prior to administrating daily dosage. Adverse Consequences: Multiple medication interactions exist which may: Significantly increase PT/INR results to levels associated with life-threatening bleeding [MEDICATION NAME] is among the most potent medications given to residents of long-term care facilities. The administration and monitoring of the drug is critical for resident safety. There is a narrow therapeutic index ...Residents that are anticoagulated from [MEDICATION NAME] have a high risk of drug interactions. Because of the narrow therapeutic range of [MEDICATION NAME], even a small alteration in [MEDICATION NAME] blood levels can increase the risk of bleeding. Common drug interactions include ...Antibiotics (Cipro, [MEDICATION NAME], Bactrim, [MEDICATION NAME], etc.) ..." Example 1 Resident 1 was admitted to the facility on [DATE]. Resident 1 has [DIAGNOSES REDACTED]. Prior to admission to the facility, Resident 1 was treated in an acute care setting for massive bilateral [MEDICAL CONDITION] emboli. The hospital drew an INR on 11/10/14 that resulted in 1.0. Discharge medications include starting "[MEDICATION NAME] 4 mg (milligram) tabs by mouth daily, in the evening. Labs: daily INR until therapeutic on [MEDICATION NAME]." Resident 1's care plan dated 11/13/14 states, "At risk for abnormal bleeding, bruising or hemorrhage r/t (related to) anticoagulant therapy. Goal: Will be free from bruising or hemorrhage. Interventions: monitor labs as ordered. Observe while providing care for s/s (signs and symptoms) of bleeding, petechiae, bruising, hematuria, and black stools report all signs immediately. Protect resident from injury. Provide instructions to residents and caregivers about anticoagulant therapy." Resident 1's "PT/INR Flow Sheet" states, Date: 11/19/14, PT/INR 4.2, Anticoagulant dose: hold today, 4 mg daily, Date next lab ordered: 11/25/14. Date: 11/25/14, PT/INR: 5.7, Anticoagulant dose: 4 mg M (Monday), W (Wednesday), Thr (Thursday), Sat (Saturday); 3 mg Tues (Tuesday), Fri (Friday), Su (Sunday). Date next lab ordered: 12/2/14. (Emphasis added.) Note: The facility missed the INR draw for Resident 1 on 12/2/14, as ordered, thus there was no monitoring of INR in December 2014. Date: 1/8 (2015). PT/INR: > (greater than) 14.5. Anticoagulant dose: Hold and give K. Date next ordered lab: 1/12." "Medication Regimen Review" dated 12/4/14 states, "INR 5.7 ? (decrease) [MEDICATION NAME]. (Checked box) NI (no new irregularities)." It is important to note that neither the facility nor the consulting pharmacist identified that an INR had not been completed as ordered on [DATE]. Resident 1's "Physician Orders" for January 2015 state, "[MEDICATION NAME] Sod (sodium) 4 mg tablet. Give 1 tablet by mouth 4x (times)/week (Mon/Wd/Thur/Sat). [MEDICATION NAME] Sod 3 mg tablet. Give 1 tablet by mouth 3x/week on Sun/Tues/Fri." Resident 1's Medication Administration Record (MAR) for January, 2015 states indicates that Resident 1 received [MEDICATION NAME] 4 milligrams on 1/1/15, 1/3/15, 1/5/15, and 1/7/15. Resident 1 received [MEDICATION NAME] 3 milligrams on 1/2/15, 1/4/15, and 1/6/15. Resident 1 received Bactrim DS on 1/1/15, 1/2/15, 1/4/15, 1/5/15, and 1/6/15. Resident 1 received [MEDICATION NAME] 500 milligrams on 1/7/15, 1/8/15, 1/9/15, 1/10/15, and 1/11/15. "Nurse's Notes" state the following: "1/1/15: A&O (alert and oriented) X 3. IV fluids infused s (without) difficulty ...CXR (chest x-ray) and UA (urinalysis) ordered. Suffered a fall while up unassisted to BR (bathroom) c (with) walker. ? (no) injury. Stated got up went ? (down) and sideways @ same time. Reviewed assistance requests c transfers and amb (ambulation), Resident in agreement and requested assistance remainder of shift. Denies pain, injury. Afebrile. Call light in reach ...0950 (9:50 AM) Resident is weak today. Reminders to use call light for assist. Resident having loose stools today. Fluids encouraged d/t poor labs showing dehydration. 1410 (2:10 PM) Resident refused lunch, encouraged fluids, obtained labs and CXR now here." "Physician's Telephone Order" dated 1/1/15 states, "1. Bactrim DS (double strength) one tab a day for 7 days. Please give a dose now." It is important to note that the facility, on 1/1/15, initiated antibiotic (Bactrim) treatment for [REDACTED]. "Physician's Telephone Order" dated 1/2/15 states, "1/2/15: D/C (discontinue) Bactrim until ID & Sens (identification and sensitivity) come back. Swab for influenza. Incentive spirometer 3Xday. CMP (comprehensive metabolic panel) & CBC (complete blood count) on Monday. Update NP (nurse practitioner) on Monday." "Nurse's Notes" continue: "1/4/15: Call to NP to update her on C&S (culture and sensitivity) results. New order received." "Physician's Telephone Order" dated 1/4/15 states, "Bactrim DS 1 (one tab) 2 X/day X 5 days. UTI." "Nurse's Notes" state, "1/6/15: Call back from NP. New orders to d/c Bactrim start [MEDICATION NAME] 500 mg X 7 days for pneumonia and UTI, also to start Florajen TID. Repeat chest x-ray on Monday." "Medication Regimen Review" dated 1/7/15 states, "INR? (Emphasis). Post IVC (inferior vena cava) removal 12/16. UTI [MEDICATION NAME]. NI (checked) and See Report for any noted irregularities and/or recommendations (checked)." It is important to note that there is no additional information related to this pharmacy review. A "Physician's Telephone Order" dated 1/7/15 states, "1. INR on 1/8/15. Fax it NP." Nurse's Notes dated 1/8/15 state, "Writer drew blood form L (left) wrist, this was second attempt. First attempt unsuccessful in L AC (antecubital)-mild bruising noted. Resident tolerated procedure well." INR results were >14.5. It is important to note that on 1/8/15, the facility became aware of Resident 1's critical INR result. The above note is the only note dated 1/8/15. The facility did not have evidence that any monitoring for signs and symptoms of bleeding was completed after they became aware of Resident 1's INR of >14.5 on 1/8/15 and when Resident 1 was receiving an antibiotic during this time. The following orders were obtained on 1/8/15: "Re-(check mark) INR stat. Hold [MEDICATION NAME]." "H&H (hemoglobin and hematocrit) d/t bloody hemorrhoid." "Hold [MEDICATION NAME] thru Monday. Vitamin K 100 mcg (micrograms) tab daily. INR Monday." "Vitamin K 100 mcg tab; take one tab by mouth one time daily." "Nurse's Notes" dated 1/9/15 state," 0300 (3:00 AM) Resident A&OX 3, pleasant and cooperative. Sleeping well this shift. Using call light to call for assist to BR c FWW (four-wheeled walker). ? (no) c/o (complaints of) pain, ? (no) SOB (shortness of breath) noted. Continues on ATB (antibiotic) for UTI and pneumonia. Fluids encouraged ...INR ? (high) today. ? signs of bleeding. Vit (vitamin) K given. VSS (vital signs stable)." The facility did not have evidence that an assessment was completed for Resident 1 from the above note written on 1/9/15 at 3:00 AM until 1/10/15 at 2:30 AM. "Nurse's Notes" dated 1/10/15 at 2:30 AM state, "Resident A&O X3-skin w/d (warm and dry). VSS. Resting quietly in recliner at this time-able to make needs known-resp (respirations) even et (and) unlabored. No c/o SOB, chest pain or any discft (discomfort)- wears O2 (oxygen) 2 L (liters)/NC (nasal cannula) 2 all times, sleeps c HOB (head of bed) ? (up) ..." The facility did not have evidence that Resident 1 was assessed for signs and symptoms of bleeding, despite Resident 1's critically high INR and antibiotic use. "Physical Therapy: Weekly TEN Details" dated 1/9/15 states, "No pain, reports just very fatigued requiring frequent therapeutic rest breaks.' "Nurse's Notes" dated 1/11/15 at 4:15 AM state, "Vit K as ordered by MD for elevated INR. No s/s of abnormal bleeding noted, or any bleeding noted." The facility completed an "SBAR-Physician/NP/PA Communication and Progress Note" on 1/11/15. This note states, "(Resident 1). The problem/symptom I am calling about it possible stroke. The problem started during the night shift 1/11/15. ? (decreased) intake/fluids, L sided weakness, L arm and drooling L side of mouth. Temp: 97.4, BP (blood pressure) 124/70 ...Labs: INR 1/8/15 ..." "Physician's Telephone Order" dated 1/11/15 states, "Order received to send to ER d/t possible stroke symptoms. POA (Power of Attorney) aware." Resident 1 was sent to the hospital on [DATE]. Hospital documentation states the following: "Emergency Department Course: Discussed case with ED provider-INR returned 1.9. CT showed acute on chronic subdural hematomas. Given PCC ([MEDICATION NAME] complex concentrate, a combination of blood clotting factors II, VII, IX and X, as well as protein C and S, prepared from fresh-frozen human blood plasma used to reverse the effects of oral anticoagulation therapy when bleeding occurs) and Vitamin K IV (intravenous). Was seen in ED by neurosurgery ...Diagnosis: [REDACTED]. Pneumonia ...Subdural Hematoma: by CT scan in setting of supra therapeutic INR (on [MEDICATION NAME], Tylenol, and [MEDICATION NAME]), Spoke with neuro surgery today and no surgical intervention. MRI ordered to [MEDICAL CONDITION]-neg (negative), acute on chronic subdural hematoma." Labs drawn upon admission to the hospital for Resident 1 are as follows: "1/11/5: HGB (hemoglobin): 8.4(*)-Range 12.1-15.3. HCT (hematocrit): 26.8(*)-Range 36.0-45.0." It is important to note that Resident 1's last recorded INR was drawn at the facility on 1/8/15, with results of greater than 14.5. An INR was not drawn in the emergency room , as PCC and Vitamin K were administered immediately, which resulted in Resident 1's INR dropping to 1.9. Resident 1 was hospitalized until 1/19/15, and an order was written on 1/27/15 for a referral for hospice care. She can no longer be on a blood thinner medication and is, therefore, at increased risk for [MEDICAL CONDITION] emboli. Surveyor spoke with Interim Director of Nursing (I-DON) B on 2/24/15 at 1:40 PM. I-DON B stated that she was not the DON at the time of this occurrence. I-DON B stated that after the critical INR for (Resident 1) was discovered, the doctor was updated and precautions and orders were followed, as ordered. Surveyor asked which symptoms nursing staff should monitor for, when a resident has a critically high INR. I-DON B stated that they should be looking for any bruising, mental status changes, any visible bleeding and complete neuro checks. Surveyor asked how often this should be completed. I-DON B stated that there is no protocol, but she thinks this should be completed frequently. Surveyor asked I-DON B how the facility monitored (Resident 1) for these signs, as there was not a lot documented in the Nurse's Notes. I-DON B stated that there was another INR to be drawn on Monday, 1/12/15 but (Resident 1) was sent out to the hospital before this. Surveyor asked I-DON B about why the facility thought it was sufficient to wait to draw another INR on 1/12/15, when the last one was drawn on 1/8/15 and critically high. I-DON B stated that this was a long time to wait and that her only thinking was that it was it was because it was over a weekend. I-DON B stated that this was not an excuse, the weekend, in the medical field. Surveyor asked I-DON B about her current understanding of [MEDICATION NAME] and antibiotic adverse reactions. I-DON B stated that when a resident is on a certain antibiotic, the effects of [MEDICATION NAME] will increase. In response to Resident 1's transfer to the emergency room , the facility completed an investigation on 1/11/15 and began inservice training. Surveyor asked I-DON B about the education provided to staff regarding this incident on 2/24/15 at 1:40 PM. I-DON B stated that the former DON did verbal education with everyone. Surveyor requested evidence that all staff who would be involved in a resident's use of [MEDICATION NAME], INRs and drug interactions were educated. I-DON B stated that the facility did change their MARs in that the administration end date is boxed out and a whole new order has to be written out for [MEDICATION NAME], when a lab is due. The facility's investigation includes "In Service Training Record" which states, "Program Content: Importance of [MEDICATION NAME] and INR Checks (checkmark) that are ordered. Objectives: 1. Ensure [MEDICATION NAME] flow sheets are being completed accurately. 2. INRs are added to lab book & drawn as ordered & timely. 3. When on ATB-we need to request more frequent INRs to be drawn. 4. Understand that orders for [MEDICATION NAME] are only good through next INR date." This in-service record is signed by seven licensed nursing staff. The facility has 27 Registered Nurses and Licensed Practical Nurses on their employee roster, dated 2/24/15. It is important to note that although education was initiated regarding Resident 1's change in condition and subsequent hospitalization , the facility did not address the lack of consistent and frequent monitoring for signs of bleeding for residents who are administered [MEDICATION NAME] and an antibiotic simultaneously. Further, most nurses were not inserviced and not all were aware of what monitoring should occur when a resident who is on [MEDICATION NAME] has an elevated INR. On 2/24/15 at 1:25 PM, Surveyor spoke with Licensed Practical Nurse (LPN) C regarding side effects of [MEDICATION NAME] use. LPN C stated she would look for bruising with anyone taking [MEDICATION NAME]. Surveyor asked LPN C if she would look for any other side effects of [MEDICATION NAME] use. LPN C stated Bruising is the major one, not sure after that. Surveyor asked LPN C what signs of increased [MEDICATION NAME] she would consider for Resident 1. LPN C stated she would not look for any different signs of [MEDICATION NAME] side effects with Resident 1. On 2/24/15 at 2:00 PM, Surveyor spoke with LPN D regarding side effects with the medication [MEDICATION NAME]. LPN D stated Bleeding, bruising, mental status changing, clotting and swelling. Surveyor asked LPN D what side effects of [MEDICATION NAME] she would consider for Resident 1. LPN D stated she would look for same side effects for Resident 1. Surveyor asked LPN D what recent facility education she received for [MEDICATION NAME] monitoring and side effects. LPN D stated she has not received any training or education related to [MEDICATION NAME] monitoring or side effects. On 2/24/15 at 2:05 PM, Surveyor spoke with LPN C regarding recent training or education related to [MEDICATION NAME] monitoring and documentation. LPN C stated she did not receive training on [MEDICATION NAME] side effects or Monitoring. LPN D stated she received training on the new documentation for new [MEDICATION NAME] physician orders. LPN C explained to Surveyor the new process related to the [MEDICATION NAME] and Physician orders. LPN C reviewed Resident 8's medication administration record (MAR). LPN C stated the new lab will be on the MAR and crossed off when completed. LPN C and Surveyor reviewed Resident 8's MAR dated 2/11/15 through 2/28/15 indicates Recheck INR on 2/16/15. Resident 8's MAR has a box to mark out 2/16/15. It is important to the MAR for 2/16/15 no initials for completion are present on the MAR. Resident 8's MAR dated 2/11/15 through 2/28/15 also indicates [MEDICATION NAME] 5 milligram orally (PO) daily, INR 3/2/15. There is an X through the dates of 2/1/15 through 2/22/15. The word "held" is written for the date of 2/23/15. It is important to note in the space titled hours (to indicate the time the medication to be given) there is no indication what time the medication should be given or if the medication is to be continued after the held date. LPN C also stated the PT/INR flow work sheet is to be completed with every order change and every new lab. LPN C and Surveyor reviewed Resident 8's current PT/INR flow sheet. The last entry on Resident 8's flow sheet reads, 2/16/15 - PT/INR results 2.5, Anticoagulant dose 5 mg Monday, Wednesday and Friday and 7.5 mg 4 times a week. Date next lab draw 2/23/15. It is important to note the new orders received on 2/23/15 were not placed on the flow sheet as indicated with the new [MEDICATION NAME] monitoring process. Surveyor asked LPN C what is the expectation for the lab draw on 2/16/15. LPN C stated the nurse should have placed her initials On the MAR in the box on the day the INR was completed. The nurse also should have completed the PT/INR flow sheet with the new orders from 2/23/15. LPN C stated, "Yes, this was the new training for [MEDICATION NAME] monitoring received." LPN C stated the MAR and flow sheet were not completed according to the new training. On 2/24/15 at 3:15 PM Surveyor spoke with Interim Director of Nursing (IDON) B regarding the facility [MEDICATION NAME] monitoring process. IDON B stated the facility had recently changed their process for [MEDICATION NAME] Monitoring. IDON B stated the [MEDICATION NAME] flow sheet is to be filled out with every [MEDICATION NAME] dose change for tracking. A new [MEDICATION NAME] order is to be written with every PT/INR even when there are no dose changes the new order is to be written on the MAR. Surveyor and IDON B reviewed Resident 8's [MEDICATION NAME] flow sheet and MAR. IDON B stated the new [MEDICATION NAME] order and lab order were to be placed on the flow sheet on 2/23/15. IDON B she would expect the MAR to be initialed and the [MEDICATION NAME] flow sheet to be completed with each lab draw and new order for all Residents receiving [MEDICATION NAME]. The failure of the facility to ensure that INRs were monitored and adverse consequences of medication interactions were monitored created a finding of Immediate Jeopardy. The Immediate Jeopardy situation was determined to be removed when the facility began implementing the following on 2/24/15: Updating care plans for monitoring risk for bleeding, all residents reviewed to ensure that INRs are being completed timely and that INR flow-sheets are used, licensed nursing staff are re-educated on INR monitoring, vitamin K administration, and [MEDICATION NAME] use and monitoring, prior to working their next shift, and a Quality Assurance meeting was held with Medical Director involvement.