Every finding on record at DeSoto Nursing & Rehabilitation Center

Based on observation, interview and record review the facility failed to 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 for 1 of 5 residents (Residents #9) reviewed for infection control. LVN A failed to put on a gown and mask prior to assisting Resident #9 who vomited. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.Findings include: A record review of Resident #9's nursing home and swing bed tracking item set MDS Assessment, dated 05/06/2026, reflected Resident #9 was a [AGE] year old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had active diagnoses which included Chronic respiratory failure with hypoxia (a long-term condition where the respiratory system cannot adequately oxygenate the blood) and Obstructive uropathy and reflux uropathy (closely related conditions affecting the urinary tract, both capable of causing kidney damage). A record review of Resident #9's admission MDS assessment, dated 05/27/2025, noted Resident #9 had a BIMS of 3, which indicated her cognition was severely impaired. Resident #9 had a feeding tube. A record review of Resident #9's care plan, dated 04/29/2026, indicated contact precautions were to be used when providing resident care. A record review of the facility EBP sign stated all providers and staff must wear gloves and a gown for high-contact activities. Resident #9 had discharged to the hospital and was not observed during through the duration of the survey. During an observation on 05/20/2026 at 10:55 a.m., of a video Resident #9's family member provided from 05/18/2026 at 5:41 a.m. revealed LVN A walked in Resident #9's room without gloves or gown and assisted the resident who vomited. LVN A held a rubber bin near Resident #9's face as he continued to vomit. During an interview on 05/20/2026 at 10:27 a.m. Resident #9's family member stated staff had not followed infection control procedures when they cared for Resident #9. Resident #9's family member stated Resident #9 had been diagnosed with C-Diff (a bacterium that causes severe inflammation of the colon [colitis] and watery diarrhea) and had been placed on isolation. Resident #9's family member stated they had video of a staff member who had not followed EBP. During an interview on 05/20/2026 at 1:03 p.m., the ADON stated Resident #9 had a diagnosis of C-Diff which had the side effects of diarrhea and vomiting. The ADON stated Resident #9 was placed on contact isolation and if staff provided care they were required to put on PPE. The ADON stated gloves and gowns were placed outside the room and staff were required to place gown and gloves outside the room. She said she expected the nurses to adhere to Enhanced Barrier Precautions when providing direct care to residents. She said EBP required staff wore gloves and gowns when providing direct care to residents with exposure to bodily fluids. She said the purpose was to reduce the risk of spreading infections and diseases. The ADON stated that no other residents in the facility had C-Diff. During an interview on 05/20/2026 at 3:38 p.m., LVN A said she should have put on a gown prior to entering Resident #9's room because Resident #9 had C-Diff which required EBP. LVN A said EBP was important for preventing the spread of infection. LVN A said she forgot to put on a gown because she believed it was more important to ensure Resident #9 did not choke on his vomit. A record review of the facility's, undated, policy titled Standard Precautions indicated Standard precautions are based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are intended to be applied to the care of all persons in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of standard precautions constitutes the primary strategy for preventing healthcare associated transmission of infectious agents among residents and healthcare personnel. Appropriate infection control measures should be used in each resident interaction.

Based on observation, interview and review record the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #7) reviewed for ADL Care. The facility failed to provide Resident #7 with scheduled showers between 05/07/2026 - 05/20/2026. This failure could place residents at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.The findings include: Record review of Resident #7's Nursing Home PPS MDS assessment, dated 05/14/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His BIMS was a 09, which indicated moderate cognitive impairment. His diagnoses included Metabolic encephalopathy (a broad term for brain dysfunction caused by chemical imbalances in the blood, organ failure, or systemic illness, rather than direct physical injury), Atelectasis (partial or complete collapse of a lung or a specific section [lobe] of a lung) and Idiopathic gout (a painful inflammatory arthritis caused by an excess of uric acid in the blood). Resident #7 was dependent on staff for showering/bathing, upper body dressing and lower body dressing. Record review of Resident #7's Comprehensive Person-Centered Care Plan, dated 05/07/2026, reflected Resident #7 had an ADL performance deficit. Goal to maintain or improve current level of education in personal hygiene with the intervention that Resident #7 was totally dependent on staff to provide bed bath/shower as necessary. Record review of the facility's shower sheet log for the month of May reflected staff had only provided Resident #7 with a shower/bed bath on 05/15/2026. Observation of photos provided by Resident #7's family member revealed a blue air mattress with a dried brown substance. Resident #7 was not observed in the photo. During an interview on 05/18/2026 at 5:46 p.m., Resident #7's family member stated Resident #7 had concerns with the facility. She stated Resident #7 had only received one shower/bath since he was admitted to the facility, and she said she had to bring it to the facility attention. Resident #7's family member stated on 05/13/2026 upon arrival, Resident #7 was dirty with dried feces on the bed that she had pictures of. Resident #7's family member stated his shower days were supposed to be Monday, Wednesday and Friday's. During an interview and observation on 05/19/2026 at 9:47 a.m. of Resident #7 revealed he gets his showers as scheduled now, but when he first got here arrived at the facility he was not provided with a shower for the first few days. Observation of Resident #9 in bed revealed the resident had no odors and did not look dirty and the mattress was clean. An attempt to contact the DON on 05/19/2026 at 2:20 p.m., was unsuccessful. A voicemail was left. Did not receive a return call prior to exit. During an interview on 05/19/2026 at 2:41 p.m., the Director of Rehabilitation (DOR) revealed on05/13/2026 Resident #7's family member stated to the DON that Resident #7 was dirty. The DOR stated the DON had gotten staff to get him up and showered and Resident #7's family sat with him and fed him. During an interview on 05/19/2026 at 3:00 p.m., CNA F stated they were assigned to Resident #7's hallway, and Resident #7's shower days were Monday, Wednesday and Friday. CNA F stated he had provided Resident #7 his showers on his scheduled shower days. CNA F stated he could not tell me why Resident #7 would state he did not receive showers. He stated if a resident received a shower or bed bath they documented it on a shower sheet and turned the shower sheet into the nurse. She stated even if a resident refused a shower or bed bath, they documented the resident refused. CNA F stated showers/bed baths were documented in the resident electronic health record. CNA F stated if a sheet was not provided either the aide had forgotten to document on the sheet, may have forgotten to turn the shower sheet in or did not provide a shower to the resident. She stated if a resident was not provided with a shower, they would become dirty and they had the right to be clean. During an interview on 05/20/2026 at 3:38 p.m., LVN A stated residents stated they had not received their showers. LVN A stated she would inform the aide of the residents request or she would provide the resident a shower if an aide was not available. LVN A stated aides were required to document on shower sheets and in the electronic health record that showed it was completed. LVN A stated if it was not documented, it did not happen. During an interview on 05/13/2026 at 4:49 p.m., the Administrator stated her expectation was for residents to receive their scheduled shower on Monday, Wednesday, Friday or Tuesday, Thursday, Saturday which was established at admission. The Administrator stated her expectation was for showers to have occurred on the scheduled days, and the risk to residents who had not received a shower would be skin breakdown and dignity issues. The Administrator stated the DON never reported any complaints from family members who stated a resident had not received a shower. During record review of the printed shower documentation, from 05/07/2026 through 05/20/2026, reflected Resident #7 was only provided a PRN shower on 05/15/2026. Record review of the facility's, undated, policy, titled, Bath, Shower/Tub, reflected bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation and relaxation.Goals:The resident will experience improved comfort and cleanliness be bathing.2. The resident will maintain intact skin integrity.The resident will be free from soil, odor, dryness, and pruritus following bathing

Based on observation and interviews, the facility failed to provide a safe, functional, sanitary environment and comfortable environment for residents, staff and the public for 1 of 3 unoccupied resident room air condition unit reviewed for environment. The unoccupied resident room air conditioning was detached from the wall and exposed outside. This deficient practice could place residents at risk of pests, exposure to the outside elements, pest and an unpleasant environment.The findings were: During an observation on 05/20/2025 at 10:37 a.m., an unoccupied resident room had air conditioner that was not attached to the wall properly. The air conditioner allowed exposure to outside. During an interview on 05/20/2026 at 11:52 a.m., the Maintenance Director stated he was responsible for fixing any broken items within his expertise. The Maintenance Director stated the facility used maintenance care to report any maintenance issues or concerns. The Maintenance Director stated he checked maintenance care every hour to see if there were any maintenance requests. The Maintenance Director stated he did not have a maintenance request for any air conditioning units. The Maintenance Director observed the unoccupied room air conditioner unit and stated it looked like someone either kicked the unit or pushed it out, because it was broken away from the wooden frame it sat in to prevent outside from being exposed. He stated he would have it fixed today. He stated the risk to the facility would be leaks or an access point to pets. The Maintenance Director stated that staff checked room daily for any items broken. He stated that he also made rounds at least once per week but was unable to state why that air conditioning unit had been missed. During an interview on 05/20/2026 at 4:49 p.m. the ADM stated it was her expectation that staff observed and reported any maintenance concerns to the maintenance department immediately. She stated all air conditioner units were sealed properly and free of any air space or outside view, to prevent inclement weather or pest from access to the facility. A record review of the facility's, undated, policy, Maintaining a Safe, Functional Environment, revealed, It is the policy of the facility to develop and implement plans, programs and process to promote and maintain safe functional, controlled and comfortable environment suitable to the care, treatment and services provided.The facility keep furnishings and equipment safe and in good repair.

Based on observation, interview, and record review, the facility failed to maintain medical records on each resident that were accurately documented for 1 of 7 residents (Residents #2) reviewed for medical records. The facility failed to document at least once per shift that the task turn/reposition for Resident #2 was completed. This failure could place residents at risk of developing skin breakdowns.Findings included: During a record review on 04/29/2026 at 8:45 a.m. of Resident #2's MDS Nursing Home PPS Item Set assessment, dated 03/24/2026, reflected a [AGE] year-old female admitted [DATE]. Her BIMS score was a 10 which indicated moderate problems with thinking and memory were moderately impaired. Her diagnoses included Atherosclerotic Heart Disease (coronary artery disease), Dementia (symptoms affecting memory, thinking and social abilities), and Rheumatoid Arthritis (chronic inflammation disorder). The resident required substantial/maximal assistance on staff for repositioning to her back, left, and right side. The resident had two stage three pressure ulcers and one stage four pressure ulcer listed on admission. During a record review on 04/29/2026 at 8:47 a.m. of Resident #2's task Turn/Reposition located in Resident #2's EHR for April 2026 reflected missing documentation of the task being completed on the following:04/17/2026 - third shift04/19/2026 - third shift04/20/2026 - third shift04/28/2026 - second and third shift Record review on 04/29/2026 at 8:53 a.m. of Resident #2's care plan, dated 04/06/2026, reflected:Resident #2 had pressure ulcer development or potential for pressure ulcer development.Goal:The resident's pressure ulcer will show signs of healing and remain free from infection.Interventions/TaskFollow facility police/protocols for the prevention of skin breakdownThe resident needs assistance to turn/reposition at least every two hours. During an observation on 04/29/2026 at 2:59 Resident #2 in activities. During an interview on 04/29/2026 at 1:09 p.m., CNA A revealed that residents were required to be checked and changed every two hours and, during that time they were turned and repositioned. CNA A stated that they have to chart once per shift in EHR. CNA A stated that if staff did not chart at least once per shift that they had did turn/reposition that would mean the staff member forgot to document the task or that they had not completed the task. She stated the risk to the resident if task was not documented would potentially lead to skin break downs. During an observation and interview on 04/30/2026 at 12:40 p.m., Resident #2 located in the common area revealed that staff do check and change her and reposition her. During an interview on 04/30/2026 at 12:59 p.m., LVN B revealed the facility policy was to check/change and turn/reposition residents every two hours. She stated that the aides were required to chart in the EHR system at least once per shift. LVN B stated that if it was not charted it did not happen. LVN B stated the risk of staff not documenting residents being checked/changed and turned/repositioned at least once per shift meant that the task wasn't completed and that could cause skin to break down. During an interview on 04/30/2026 at 3:49 p.m., the DON stated that it was expectation for staff to check/change and turn/reposition every two hours. She stated that staff are required to chart once per shift. She stated if EHR did not show they charted it meant it meant the task was not performed. The DON stated that if the care provided was not documented the risk to the resident was skin breakdowns. During an interview on 04/30/2026 at 4:45 p.m., the ADM stated that her expectations to document for check and change/repositioning and turning was once per shift. She stated if it was not documented it did not happen. The ADM stated that if it is not documented the risk to the resident would be skin breakdowns. Requested facility policy on charting incontinence care and turning and repositioning on 04/30/2026 at 4:04 p.m., via email to facility ADM but did not receive prior to exit.

Based on interview and record review, the facility failed to provide or obtain laboratory services as ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for one (Resident #7) of two residents reviewed for labs. The facility failed to obtain urinalysis (UA) for Resident #7 as ordered by physician on 02/25/2026. This failure could place residents at risk of a delay in receiving the necessary treatments to treat their medical condition.Findings included: Record review on 04/30/2026 at 10:00 a.m. of Resident #7's MDS, dated [DATE], reflected a [AGE] year-old male admitted [DATE] and readmitted on [DATE]. His BIM score of 00 indicated severe problems with thinking or memory. His diagnoses include Acute Respiratory Failure with Hypoxia (lungs cannot adequately oxygenate the blood), Dysarthria (speech disorder) following Cerebral Infraction (stroke), and Alzheimer's Disease (brain condition that damages memory). Record review of Resident #1's electronic physician orders for June 2025 revealed an order dated 10/17/24 for CBC (measures varies components of your blood), CMP (blood test that measures fourteen different substances in the blood), lipid (broad group of organic compounds which include fats, waxes, sterols, fat-soluble vitamins, monoglycerides, diglycerides, phospholipids, and others), and Valproic acid a blood test to measure the concentration of valproic acid (medication used to treat certain types of seizures) in the bloodstream) every six months and Hgb (a protein in red blood cells) and A1C (is a blood test that provides an average of blood sugar levels over the past 2-3 months) every three months. Record review of Resident #7's change of condition form, dated 02/25/2026, revealed physician ordered a UA to be completed. Record review of Resident #7's electronic clinic record from 02/25/2026 to 04/30/2026 revealed there were no UA labs results. During an interview on 04/30/2026 at 3:49 p.m., the ADON revealed she was unsuccessful in locating the UA results for Resident #7 for 02/26/2026 as requested by the physician. She stated it had to be done because the physician ordered antibiotics. She stated she would contact the laboratory to see if they were able to locate them. She stated that if they were not successful in obtaining a sample that would have been documented. Requested facility policy on labs on 04/30/2026 at 4:04 p.m., via email to facility ADM but did not receive prior to exit. Attempted an interview on 04/302026 at 4:06 p.m., with the facility's Medical Director at the contact number provided by the facility with no call back prior to exit. During an interview on 04/30/2026 at 4:11 p.m., the DON revealed that she was unable to find the UA results in EHR and stated the physician ordered the UA so the staff should have gotten the UA lab from Resident #7. The DON stated the staff was aware of change of condition, documented, reached out to the physician and the physician ordered Resident #7 antibiotics so the facility was treating Resident #7 for infection and Resident #7's vitals were in normal range so would not have caused concern by the nursing staff. The DON stated the risk when UA were not done would not be able to determine what type of infection Resident #7 had. During an interview on 04/30/2026 at 4:45 p.m., the ADM revealed her expectation of her clinical staff was to follow physician orders. She stated if they could not obtain a sample they were to document that in EHR. The ADM stated the risk to the residents was that could lead to potential health issues that the physician would not be able to address.

Based on observation, interview and record review, the facility failed to ensure one (Resident #1) of five residents was properly supervised when Resident #1 eloped from the facility on 1/17/2026 at approximately 4:30 a.m.The facility failed on 1/17/26 to ensure Resident #1 received adequate supervision to ensure that residents were not exposed to possible hazards or injury when Resident #1 eloped from the facility and wandered toward a bridge over an active creek, which could have led to possible injuries. An immediate jeopardy existed from 1/17/26 4:30 a.m. to 1/17/26 5:00 a.m. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.This deficient practice placed residents at risk for falls, injuries, hospitalization, and death.Findings included:Review of Resident #1's undated face sheet revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis that included: Unspecified Dementia (a decline in cognitive function), unspecified Severity without Behavioral Disturbance, Generalized Anxiety Disorder and Major Depressive Disorder.Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 09, indicating moderate cognitive impairment of noticeable memory problems, disorientation or confusion. Section E of MDS (Behavior) reflected that Resident #1 did not exhibit wandering behavior. Section G (Functional Abilities) reflected no impairment with range of motion, the resident used a walker to assist in ambulation, could walk 150 feet with minimal assistance, and did not use a wheelchair. Review of Resident #1's Care Plan dated 2/11/26 reflected that the Care plan had been updated on 1/17/2026 that Resident #1 was at risk for wandering History of attempts to leave facility unattended, with an intervention that reflected that Resident #1 would reside in the secure unit. The care Plan further reflected that Resident #1 was at risk for elopement as evidenced by exit seeking (1/19/26) with a goal of Resident #1 will remain safe within the facility unless accompanied by staff or other authorized person through review date, and interventions of Assess/record/report to MD risk factors for potential elopement such as: Wandering. Repeated requests to leave facility, statements such as I'm leaving, I'm going home, attempts to leave the facility, elopement attempts from previous facility, home or hospital.Record Review of an Elopement Risk assessment dated [DATE] and signed by ADON, revealed that Resident #1 had no history of attempts to leave own residence/facility. No restlessness or anxiety and was found to be at moderate risk for elopement due to cognitive impairment.Record Review of an Elopement Risk assessment dated [DATE] and signed by LVN J, revealed that Resident #1 had no history of attempts to leave own residence/facility. No restlessness or anxiety and was found to be at moderate risk for elopement due to cognitive impairment. Record Review of an Elopement Risk assessment dated [DATE] and signed by ADON, revealed that Resident #1 had an attempt to leave own residence/facility. No restlessness or anxiety and was found to be at high risk for elopement due to cognitive impairment.Record Review of the facility census revealed that Resident #1 moved from room [ROOM NUMBER]-A (Semi-Private) to room [ROOM NUMBER]-B (Secured unit) on 1/17/26.Record Review of Resident #1's progress notes revealed: A note written by LVN D on 1/17/2026 at 08:44:00 the note text read Resident eloped through 200 hall exit door, event was unwitnessed. Staff went outside facility to look for resident, resident found down the street from facility. Resident was safe, no complaint of discomfort or pain voiced at this time. Resident transferred to secure unit for safety measure. A note written by LVN D on 1/17/2026 at 09:11:00, the note text read Temperature of skin: Warm, Bruise present: No, Skin Tear Present: No, Abrasion present: No, Laceration present: No, Other skin findings present: No.In an interview on 2/10/26 at 1:26 p.m. Resident #1 stated that she had thought she was late for work that morning and had left out of the door. She stated that she did remember telling a man in a car that she would not get into a car with a strange man and that she later got into the car because the nurse was in the car. She stated that she had volunteered to move into the secure unit, and she felt safer in the secure unit because she had not meant to leave the facility.In an interview on 2/10/26 at 1:20 p.m. LVN G revealed that she had received in-services related to the elopement of Resident #1, she stated that the facility had changed all door codes, and the Maintenance Director had checked alarms for all exit doors everyday since the elopement incident. She correctly described the procedures/protocol of what to do in case of a resident elopement.In an interview on 2/10/26 at 1:32 p.m. LVN D revealed that she had been one of the nurses on duty the morning that Resident #1 had eloped from the facility. She stated that she had been charting when an alarm sounded on the panel located behind the nursing station where she had been charting. She stated that LVN L had been closer to the panel and identified that an exit alarm had sounded on the 200-hall, and CNA K started to check the rooms on the 200-hall to identify if all residents were present and discovered that Resident #1 was not in her room. She stated that she looked outside the 200-hall exit and did not see Resident #1. She then returned to the nursing station to notify the ADM and DON and that LVN L went outside the building to do a perimeter search and CNA K got into his car to search for Resident #1. She stated she was still in the process of notifying the appropriate staff when LVN L and CNA K returned with Resident #1 after approximately 20-30 minutes of being outside the facility unsupervised. She stated she and LVN L did assessments on Resident #1 and found no injuries, and that Resident #1 volunteered later to move to the 300-hall Secure Unit. She stated that the facility conducted elopement drills, conducted in-services, and had placed new alarms on each exit door in the facility.In an interview on 2/10/26 at 1:44 p.m. with CNA K revealed that he had been in the break room on the 100-hall near the nursing station when he heard the central alarm panel sounding around 4:30 a.m. in the morning. He stated that LVN L was already at the panel and told him that the alarm door for the 200-hall had been set off. He stated that he then checked all the rooms on the 200-hall and found that Resident #1 was not in her room. He stated that LVN D looked outside the exit from the 200-hall and did not see Resident #1. He stated that LVN L then went outside to do a perimeter check of the facility and that he went out to his car to search for Resident #1 on the street. He stated that as he approached the driveway to the street, he saw Resident #1 on the sidewalk about 25 feet south of the driveway he was at. He stated that he pulled up next to Resident #1. He tried to get Resident #1 to get into the vehicle, but Resident #1 refused because she would not get into a vehicle with a strange man she did not know. CNA K then discovered he did not have his phone with him to contact the facility and then proceeded to go back to the facility to get help from one of the nurses. He stated that he was able to call out to LVN L in the parking lot and then proceeded back to Resident #1 with LVN L. He stated that Resident #1 had walked further south to a small bridge when LVN L. was able to stop Resident #1 and convince her to get into the vehicle [approximately 500 ft from entrance to facility]. He stated that he participated in in-services related to the elopement incident, had participated in elopement drills and was able to describe the correct procedures/protocols in case of elopement.In an interview on 2/11/26 at 5:23 a.m. CNA M revealed that she had participated in in-services related to the elopement incident. She stated that she had participated in an elopement drill and was able to describe the correct procedures/protocols in case of an elopement. She stated that the facility had changed all of the door codes and had put new alarms at each exit.In an interview on 2/11/26 at 5:36 a.m. LVN L revealed that she had been one of the nurses on duty the morning that Resident #1 had eloped from the facility. She stated that she was next to the alarm panel when the exit alarm sounded. She stated that after CNA K discovered it was Resident #1 that was missing she left the front of the facility and did a perimeter search around the facility. She stated that she was just coming back around to the front of the facility and in the parking lot when she saw CNA K in his car calling out to her. She then got into CNA K's car and they went around 500 ft down to the start of the bridge and she was able to get Resident #1 into CNA K's car and then she and LVN D assessed Resident #1 and found no injuries. She then stated that Resident #1 agreed to transfer into the secure unit for her own safety. She stated participated in the in-services related to the elopement incident and in the elopement drills subsequent to the incident. She stated that the facility had also installed new alarms at each exit door and that she had observed the Maintenance Director do alarm checks on the door since the elopement incident occurred.In an interview on 2/11/26 at 5:36 a.m. with CNA M, she revealed that she had been working in the 300-hall Secure unit the morning of the elopement of Resident #1. She stated that she had become aware of the elopement when Resident #1 had been brought back to the facility that morning. She stated that Resident #1 appeared to have no injuries and had gone immediately to sleep after a room was made ready for her on the secure unit. She stated that she and the oncoming staff had started 1:1 monitoring of Resident #1 and they had continued that for 3 days, she stated that Resident #1 had not attempted to leave the secure unit. She stated that she had completed all of the in-services related to the elopement incident, and he participated in two of the elopement drills. She was able to correctly describe the procedures and protocols of how to respond to an elopement. She stated that the facility had changed the door codes and had installed new alarms on the exit doors around the facility. In an interview on 2/11/26 at 5:47 a.m. with CNA N she revealed that she had been working the morning of Resident #1's elopement incident. She stated that she had been working on the 400-hall and that she had started to check all of those rooms to make sure all of her residents had been accounted for. She stated that Resident #1 had come back with LVN L and CNA K not too long after the alarm had gone off. She stated that she had participated in both the in-services and elopement drills related to the elopement incident. She was able to describe the protocols and procedures associated with resident elopements and she stated that the facility had changed all of the door codes and had installed new alarms on each exit door.In an interview on 2/11/26 at 6:00 a.m. CNA O revealed she had been working on the 300 hall the morning Resident #1 had eloped from the facility, she stated that she had been at the end of the 300-hall engaged in resident care at the time the alarm and had not heard it immediately. She stated that when she found out about the alarm she started to check all of her resident rooms on the 300 and 100 halls. She stated that Resident #1 was back at the facility pretty quick, but she was unsure about the time. She stated that she had participated in both the in-services and elopement drills related to the elopement incident. She was able to describe the protocols and procedures associated with resident elopements and she stated that the facility had changed all of the door codes and had installed new alarms on each exit door. She stated that she had heard the new alarms go off when the maintenance manager was testing them and that the new alarms are very loud.In an interview on 2/11/26 at 11:22 a.m. the Maintenance Director stated that he had installed new alarms at each door, he stated that he had also conducted training for the staff on how to read/use the alarm panel. He stated that he had changed the door codes and had also been checking he doors and alarms since the day of the elopement and he was still checking the doors/alarms everyday.In an interview on 2/12/26 at 9:50 a.m. the ADM stated that Resident #1 had almost made it to a small bridge close to the facility. He stated that had Resident #1 fallen into the creek or had gone off the sidewalk she could have been exposed to multiple hazards, injuries or worse. He stated that the facility had conducted in-services as soon as possible, they had procured and installed new alarms on the exit doors and that there had been no other incidents with Resident #1 or any other resident at the facility since the incident occurred. Incident was reported to state authority, police, Medical Director and Resident #1 family member.PNC IJ Template presented to ADM on 2/12/26 at 2:35 p.m. The facility implemented the following interventions: Record review of a document titled [Resident #1] 1:1 monitoring schedule dated 01/17/2026 to 01/20/2026 found that 1:1 monitoring had been conducted with Resident #1 by LVN B, CNA M, CNA N, CNA A, CNA I and LVN H.Record review of a set of documents titled Door Alarm Monitoring dated 01/17/2026 to 2/12/2026 found that door alarms had been tested each day at all exits.Record review of a set of documents titled In-Service and dated 01/18/2026 and 01/19/2026 found that In-Service training had been conducted in the subjects of Elopement, Alarm Panel Policy, Missing Resident Policy, Resident Abuse and neglect and Resident Rights had been conducted with all staff at the facility.Record review of the Facility Policy entitled Wandering and Elopements reflected that, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residentsRecord review of the facility Missing Resident / Elopement Policy, revealed, Purpose: To ensure the immediate safety and rapid recovery of any resident who leaves the facility without authorization. Prevention: Residents must sign in / out when leaving, Staff monitor return times, At-risk residents identified in service plans, Annual elopement training and drills. When a resident is Missing: 1. Search entire facility (rooms, bathrooms, outside), 2. Notify Manager, 3. Check sign-in/out log; ask staff/residents for info, 4. Search surrounding areas (sidewalks, stores, bus stop), 5. If not found within 15 minutes, call 911, 6. Notify healthcare provider and responsible party. 7. Document all actions. When Resident is Found: Assess for injuries or changes in condition, Notify Manager and healthcare provider. Update care plan and incident report. Documentation: Incident report, progress note, follow-up assessment same day. Record review of a facility policy entitled Memory Care Alarm Policy reflected that .If resident is not by the door and alarm has been triggered, notify the nurse and co-workers of possible elopement.Check all stairwells and each floor for possible elopement, once resident is found turn alarm offAn immediate jeopardy existed from 1/17/26 4:30 a.m. to 1/17/26 5:00 a.m. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation.

Based on observations, interviews, and record reviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one (Resident #39) of five residents, reviewed for pharmacy services. The facility failed to ensure LVN C and LVN H documented administration of morphine at the time of administration to Resident #39 on the MAR and the narcotic record. The facility failed to ensure LVN D, LVN E, RN F, and LVN G documented administration of morphine at the time of administration on the medication administration record for Resident #39. These failures could place residents at risk of being over medicated or under medicated if the doses are not documented on the medication administration record.Findings included: Review of Resident #39's Quarterly MDS Assessment, dated 01/09/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The BIMS was 15. The resident was cognitively intact. Her diagnoses included cancer. Over the past five days, the resident's activities were limited occasionally. Review of Resident #39's Care Plans, dated 07/07/25, reflected:Resident was on pain medication therapy related to diagnosis of lung cancer with metastasis. Facility interventions: Administer medication as ordered. Review of Resident #39's Order Summary Report, dated 01/25/25, reflected:Morphine Sulfate oral tablet 15 milligrams. Give 15 milligrams by mouth every 4 hours as needed for pain. Review of Resident #39's Medication Administration Records for February 2026 reflected Resident #39 received one dose of Morphine Sulfate 15 milligrams on 02/06/26. Review of Resident #39's Narcotic Count Record, dated February 2026, reflected Resident #39 received a dose of Morphine Sulfate 15 milligrams on the following dates:02/07/26 1:00 AM by LVN D02/07/26 7:00 AM by LVN E02/07/26 3:35 PM by RN F02/07/26 7:20 PM by RN F02/08/26 12:30 AM by LVN D02/08/26 6:00 AM by LVN D02/09/26 1:30 AM by LVN G02/09/26 5:30 AM by LVN G02/09/26 4:00 PM by unknown nurse02/10/26 3:00 AM by LVN D02/10/26 9:40 AM by LVN C 02/10/26 7:00 PM by LVN C 02/11/26 8:00 AM by LVN H02/11/26 12:30 PM by LVN C An interview on 02/10/26 at 10:30 AM with Resident #39 revealed she was grimacing and crying out in pain. The resident said she had breast cancer and said, I think I'm dying, I am having a lot of pain. The resident said her pain level on a scale of 1-10 was 15. LVN C entered the resident's room and said she gave the resident a dose of Morphine at 9:40 AM. LVN C left the resident's room and returned with medication. LVN C said she was going to give the resident a dose of Tramadol. An interview on 02/11/26 at 11:25 AM with LVN C revealed she did not document the morphine dose on the MAR. She said she documented it on the narcotic record and the 24-hour report. She said she knew she was supposed to document on the MAR but said state was in the building, and she was moving too fast. LVN C said there was a risk to the resident if the dose was not documented on the MAR, because the resident could be double-dosed or not medicated at all. An observation of medication pass on 02/11/26 at 12:20 PM revealed Resident #39 was crying out and said her pain level was 12. CNA I was in the hall and said she was going to get LVN C. LVN C grabbed the medication cart and went to Resident #39's room. LVN C said she was going to give the resident morphine. LVN C signed out the medication on the narcotic count record. The narcotic count record reflected the resident received a dose at 7:00 PM on 02/10/26. The dose was not documented in the MAR. An interview on 02/11/26 at 12:55 PM with LVN H revealed she medicated Resident #39 with Morphine the morning of 02/11/26. She said she did not document the dose on the narcotic record or the MAR. She said she was going to document the dose but got busy. An interview on 02/12/26 at 11:55 AM with LVN H revealed she medicated Resident #39 with Morphine at 7:30 AM on 02/11/26. An observation on 02/12/26 at 12:28 PM revealed Resident #39 was on Hospice and resting comfortably. An interview on 02/12/26 at 1:50 PM with LVN D revealed she said she administered doses of Morphine to Resident #39 and thought she documented the doses on the MAR but might have gotten busy and did not document. She said she had been trained to document medication on the MAR. LVN D said failure to document could cause the nurse to not know when Resident #39 last received a dose. An interview on 02/12/26 at 1:55 PM with LVN G revealed she administered doses of Morphine to Resident #39 and she forgot to document the doses on the MAR. LVN G said she was trained to document on the MAR. LVN G said failure to document on the MAR could place the nurse at risk of not being able to read the narcotic record and not know what dose the resident received. A phone interview was attempted with LVN E on 02/12/26 at 1:58 PM. LVN E did not return the call of the Surveyor. An interview on 02/12/26 at 2:00 PM with RN F revealed she administered doses of Morphine to Resident #39 and did not know why she did not document the doses on the MAR. RN F said she was trained to document on the MAR. RN F said the resident was at risk of not having her pain assessed if the doses were not documented. An interview on 02/12/26 at 1:00 PM with the Corporate Nurse revealed staff were supposed to document Resident #39's dose of Morphine on the narcotic record and the MAR. She said failure to document placed the resident at risk of not receiving a dose or receiving an extra dose. Record review of the facility policy, Medication Administration and General Guidelines, not dated, reflected: .The resident's MAR is initialed by the person administering the medication.if utilizing the electronic medical record, the initials of the nurse are automatically stamped into the record.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure that temperatures for food items stored in a reach-in freezer had been logged twice daily and that there was an additional thermometer in the freezer to ensure accurate readings.2. The facility failed to ensure ice scoops were stored in a manner that protected against dust contamination and/or mold/mildew build up for the facilities only ice-machine. These failures could place residents at risk for food borne illness.Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure that temperatures for food items stored in a reach-in freezer had been logged twice daily and that there was an additional thermometer in the freezer to ensure accurate readings.2. The facility failed to ensure ice scoops were stored in a manner that protected against dust contamination and/or mold/mildew build up for the facilities only ice-machine. These failures could place residents at risk for food borne illness.Findings included:In an observation on 2/10/26 at 9:15 a.m. Temperature logs for two reach in refrigerators and the walk-in refrigerator were found to be missing entries for morning temperature checks for 2/3, 2/6, 2/7, 2/8 and 2/9. Further observations of the reach-in freezer closest to the steam tables found that the freezer had no secondary thermometer inside the freezer. In an interview on 2/10/26 at 9:19 a.m. [NAME] revealed that he knew that every refrigerated unit had to have a separate thermometer but he could not locate the thermometer at that time. He stated it was important to have a separate thermometer to verify that the built-in unit thermometer was accurate. He stated that it was important to check the freezer and refrigerator temperatures at least twice a day to make sure that foods in them do not refreeze or go above 41 degrees Fahrenheit which could cause foods to spoil and expose residents to possible food borne illnesses.In an observation and interview on 2/10/26 at 9:27 a.m. the DM revealed that 2 ice-scoops were observed stored bowl-side up on a tray on top of the only ice machine in the facility. The tray was found to have wet areas directly under the ice-scoops that were continually exposed to dust contamination on top of the ice-machine. The DM stated that they had previously had a self-drying container but the lid had broken off and the container had come loose from the wall several months ago. She stated that ice-scoops should be protected from dust and not stored in standing water because it could contaminate the ice and expose resident to possible illness. She also stated that it was important to check refrigerator and freezer temperatures daily as foods outside of safe temperatures could expose residents to food-borne illnesses.Record review of the facility policy titled Policy: Food Holding, And Service, Policy Number: 03.005, Date Revised: June 1, 2019, review in the following documentation, Policy: To ensure that all food served by the facility is a good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. Procedure:2. Refrigerators . d. Refrigerators and freezers must have separate, free-standing thermometers to ensure proper functioning of internal/built in freezer/refrigerator unit thermometers.f. Temperatures logs must be kept for all refrigerator/freezer units that contain potentially hazardous foods (PHF's), to ensure that PHF's stay at or below 32 degrees Fahrenheit for freezers and at or below 41 degrees Fahrenheit for refrigerators.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #29) of three residents reviewed for care plans. The facility failed to ensure Resident #29 had a comprehensive care plan for pain. This failure could place residents at risk of staff not knowing how to care for their pain.Findings included: Review of Resident #29's admission MDS Assessment, dated 02/02/26, reflected the resident was a [AGE] year-old male. He admitted to the facility on [DATE]. He had a BIMs score of 13. The resident's cognition was moderately impaired. The Resident had diagnoses which included heart failure, kidney failure, and non-Alzheimer's dementia. The assessment did not reflect the resident had pain. Review of Resident #29's Comprehensive Care Plan, not dated, reflected the resident did not have a care plan for pain. Review of Resident #29's Order Summary Report, dated February 2026, reflected:01/20/26 Tylenol with Codeine #3 Tablet 300-30 MG (Acetaminophen-Codeine), orally, every 6 hours as needed for pain. Review of Resident #29's Medication Administration Record, dated February 2026, reflected the resident received a dose of Tylenol with Codeine #3 on 02/03/26 and 02/07/26. An interview and observation with Resident #29 on 02/10/26 at 11:45 AM revealed he required pain medication because of pain in his right hip. He said he was having pain and told a CNA (unknown). He said he fell at another facility and had suffered with hip pain since then. An interview on 02/11/26 at 4:50 pm with the DON revealed she did not know why Resident #29 did not have a care plan for pain. She said care plans were developed by the [NAME] President of Clinical Services based on assessments and the comprehensive assessment. The DON said care plans were necessary so that nursing staff would know interventions in place for the resident's pain. Review of the facility policy, Comprehensive Care Planning, not dated, reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident.

Based on observations, interviews, and record reviews the facility failed to 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 for two (Resident #41 and Resident #8) of five residents, reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #41. The facility failed to ensure LVN B performed hand hygiene during wound care for Resident #8. These failures could place residents at risk for healthcare associated cross contamination and infections.Findings included: Review of Resident #41's Annual MDS Assessment, dated 01/06/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident did not understand others and was not able to make herself understood. Her diagnoses included non-Alzheimer's dementia and seizure disorder. The resident was always incontinent of urine and bowel movement. Review of Resident #41's care plan dated 02/18/22 reflected:Resident had an activities of daily living deficit.Facility interventions: Resident required one staff assist for toilet use. An observation on 02/10/26 at 10:35 AM of incontinence care for Resident #41 revealed she was lying in bed. The resident was positioned onto her left side. CNA A cleaned the resident's buttocks. CNA A did not change gloves or perform hand hygiene. CNA A applied barrier cream to the resident's buttocks with her soiled gloves. CNA A did not change her gloves or perform hand hygiene. CNA A placed a new brief on the resident with the soiled gloves. An interview on 02/10/26 at 1:20 PM with CNA A revealed she did not change her gloves or perform hand hygiene because she was nervous. She said she was trained to change gloves and perform hand hygiene during incontinence care. CNA A said it was important to perform hand hygiene and change gloves during incontinence care to prevent the spread of infection. 2. Review of Resident #8's admission MDS Assessment, dated 12/22/25, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. His cognitive skills for daily decision making were severely impaired. His BIMs score was 2. His diagnoses included seizure disorder. The resident was at risk for developing pressure ulcers. Review of Resident #8's Care Plans, dated 12/22/25, reflected:The resident has a pressure ulcer or potential for pressure ulcer development: trauma injury to sacrum.Facility interventions included:The resident needs assistance to turn/reposition at least every 2 hours. Review of Resident #8's Order Summary Report, dated 02/11/26, reflected: Cleanse wound to sacrum with wound cleanser, pat dry, apply hydrogel and cover with a dry dressing daily and as needed. An observation on 02/12/26 at 10:11 AM of wound care for Resident #8 revealed LVN B removed the dressing on the sacrum. LVN B changed her gloves but did not perform hand hygiene. LVN B cleaned the wound and changed her gloves. LVN B did not perform hand hygiene. LVN B patted the wound dry, changed her gloves, but did not perform hand hygiene. LVN B applied the treatment to the wound. LVN B changed her gloves but did not perform hand hygiene. LVN B applied the dressing. An interview on 02/12/26 at 10:20 AM with LVN B revealed she forgot to perform hand hygiene during wound care. LVN B said she had been trained to perform hand hygiene after changing her gloves. LVN B said hand hygiene was important to prevent the spread of germs. An interview on 02/11/26 at 4:45 PM with the Corporate Nurse revealed staff were supposed to perform hand hygiene and change gloves while performing incontinence care. She said failure to do so could cause infection. An interview on 02/12/26 at 10:22 AM with the Corporate Nurse revealed staff were supposed to perform hand hygiene when changing gloves their gloves. The Corporate Nurse said staff needed to perform hand hygiene after changing gloves, because there could be something on the staff's hands. Record review of the facility policy, Hand Hygiene, not dated, reflected: You may use alcohol-based hand cleaner or soap/water for the following:.After removing gloves.You must use soap/water for the following.when hands are visibly soiled, before and after assisting resident with toileting.

Based on observation, interview and record review, the facility failed to ensure that each resident has the right to privacy for 1 of 4 residents (Resident #1) reviewed for privacy and confidentiality: The facility failed to ensure CNA A provided privacy when providing Resident #1 with incontinent care. The door was left open to the hallway, and the privacy curtains were not closed properly. as CNA A began to uncover Resident #1, exposing his body to the open hallway. This failure could place residents at risk for a loss of privacy, emotional distress, and low self-esteem.Findings included: Record review of Resident #1's quarterly MDS dated [DATE] revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. Diagnoses included: Post traumatic stress disorder (mood disorder), hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), and renal insufficiency (kidneys are slow to work). Resident #1 was alert and oriented and able to make decisions. Record review of Resident #1's care plan dated 09/03/2025 reflected the resident had incontinence of bowel and bladder. Required the assistance of one staff for incontinence and two staff for transfer using a mechanical lift. An observation on 10/07/2025 at 9:15 a.m., CNA A entered Resident #1's room and without closing the door removed the covers from the resident exposing his body to the hallway. CNA A preceded to talk to the resident, informing him she was going to perform incontinent care for a bowel movement he had and then get him up and take him to the shower. An observation on 10/07/2025 at 9:20 a.m. revealed CNA A was assisting to take the gown off Resident #1, exposing his entire body to the hallway, at which time the CNA looked up and saw the surveyor partially closed the door to the hallway. The surveyor knocked on the partially closed door and entered the room, at which time the CNA informed the surveyor she was performing patient care and completely shut the door. During an interview on 10/07/2025 at 9:35 a.m., Resident #1 stated he did not notice if the door and privacy curtain were not closed properly. He said he would be visible to others if the door and the curtain were not closed properly. Resident #1 did comment when asked about the open door when CNA A removed his gown, he stated he did not want others to see this old broken-down body. During an interview on 10/07/2025 at 11:35 a.m. with CNA A stated, by not closing the door and the curtain, the privacy and dignity of Resident #1 was compromised as anyone passed by the room could see the care provided. When asked about the training she received on resident's rights, CNA A stated she was fully aware of resident's right to have privacy, dignity, and respect and received in-service on resident's rights at least once a year. During an interview 10/07/2025 at 1:00 p.m., the DON stated privacy and dignity must be provided during nursing care and the door and privacy curtain to Resident #1 and room should have been closed completely by CNA A. The DON stated the training was an ongoing process and resident rights was one of the in-services given annually. During an interview on 04/17/24 at 4:30 p.m., the Administrator stated the residents' rights at the facility should be maintained during nursing care. She said staff was expected to respect privacy and dignity by making sure doors to rooms were closed, privacy curtains fully drawn, and the window blinds were shut properly. Review of the facility's policy Resident Rights undated, reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside our facility, including those specified in the policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lord.We protect and promote the following rights of each resident. Privacy and Confidentiality-The resident has a right to personal privacy and confidentiality. 1. Privacy includes accommodations, medical treatment, personal care.

Based on observation, interview and record review, the facility failed to 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 for one (CNA A) of two staff observed for infection control. CNA A failed to change their soiled gloves and wash hands during incontinent care to Resident #1. This failure could place residents at risk of the spread of infection through cross-contamination. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. Diagnoses included: Post traumatic stress disorder (mood disorder), hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), and renal insufficiency (kidneys are slow to work). Resident #1 was alert and oriented and able to make decisions. Record review of Resident #1's care plan dated 09/03/2025 reflected the resident had incontinence of bowel and bladder. Required the assistance of one staff for incontinence care and two staff for transfer using a mechanical lift. Observation of incontinence care on 10/07/2025 at 09:30 a.m. revealed CNA A used hand gel in the hallway and donned (placed gloves on hands) clean gloves. CNA A entered the room; Resident #1 was lying on his back. CNA A unfastened the resident's brief tabs and wiped the pubic area with a disposable wipe, discarding the wipe in the trash bag. CNA A wiped the genitals, discarding the wipe in the trash bag. CNA A wiped the shaft of the penis and discarding the wipe in the trash bag and then cleaned the head of the penis and discarding the wipe in the trash bag. CNA A positioned Resident #1 on his left side with the help of Resident #1. CNA A wiped the rectal area that was soiled with bowel movement and discarded the wipe, using another wipe CNA A completed cleaning the rectal area of bowel movement, discarding the wipe. CNA A wiped the left buttocks, which were soiled with urine, discarding the wipe. Repositioning Resident #1 with her soiled gloves to his right side, CNA A cleaned the right buttocks, which was soiled with urine, discarding the wipe. CNA A assisted, with her soiled gloves, the other staff member to reposition Resident #1 on his back. CNA A pulled the clean brief up underneath him with the soiled gloves and fastened the brief, removing the soiled brief placing it in the trash. CNA A then left Resident #1 with his clean gown in the bed, to be transferred to the shower bed. CNA A removed her dirty gloves and used hand sanitizer when she came outside in the hallway. CNA A obtained the mechanical lift and assisting staff brought the shower bed into the room, preparing for transfer of Resident #1. In an interview on 10/07/2025 at 11:35 a.m., CNA A said she was to perform hand hygiene before and after the procedure and between changes of gloves. The glove changes should occur at the beginning and at the end of the incontinent care. She said she did not do it this time because she was nervous and talking. She stated the risk would be spread of infection. In an interview on 10/07/2025 at 1:00 p.m., the DON stated the expectation was to perform hand hygiene and glove changes before and after any care, and any time after removing dirty gloves. If your hands are visibly soiled clean with soap and water, otherwise can use hand sanitizer. The DON stated the risk is not performing hand hygiene, would be cross contamination. The DON stated she would be doing in-servicing concerning handwashing and the changing of gloves starting today. Review of in-services reflected an in-service performed by the DON on 07/2025 covering hand hygiene and incontinent care. CNA A was reflected as having attended the in-service. Review of the facility's policy Perineal Care dated May 2022, revealed, Policy Statement This procedure aims to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. procedure content: 10) perform hand hygiene 11) don gloves.24) doff gloves 25) perform hand hygiene.26) provide resident comfort and safety by re-clothing (if applicable-incontinence pads(s) and briefs, . 31) perform hand hygiene . Review of the facility' policy Infection Control Guidelines for all Nursing Procedures undated reflected, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. The measures make up the fundamental for infection control precautions.1. Hand hygiene: hand hygiene continues to be the primary means of preventing the transmission of infection. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. failure to change gloves, and wash hands between resident contacts is an infection control hazard.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended, in the memory care unit, on 07/15/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation and interview on 07/15/25 at 1:59 AM, Medication Cart #1 was observed unlocked and unattended in an open, unlocked office in the memory care unit. All residents were in their rooms, and CNA A and CNA B were sitting in the hallway of the memory care unit. CNA A stated she was not aware the medication cart was unlocked, did not know how long it was unlocked, and that a staff member from the previous shift must have left the medication cart unlocked. CNA A stated she did not know how to lock the medication cart. In an interview on 07/15/25 at 2:05 AM, the Charge Nurse stated she took new medications to the medication cart earlier that night and must have forgotten to lock the medication cart. She stated the risk of the unlocked medication cart was residents could get the medications off the medication cart. In an interview on 07/15/25 at 5:47 PM, the Administrator stated the staff received an in-service today, on unlocked medication carts, the facility planned to put a lock on the door where the medication cart was kept in memory care, and she stated the risk of the unlocked medication cart was residents could have gotten medication from the medication cart. In an interview on 07/15/25 at 6:05 PM, the DON stated the risk of the unlocked medication cart was the risk of residents getting medications from the medication cart. Record review of the facility's policy dated 03/25, titled, Medication Administration and General Guidelines, reflected the following: 17. When administering PRN medications at times other than the medication pass, the dose may be prepared in the medication cart storage area and taken to the resident's bedside, leaving the cart locked and secured. Checklist for completing proper steps in the administration of medications Adheres to the 6 Rights of Medication Administration:1) Right Dose2) Right Route3) Right Resident4) Right Medication5) Right Time6) Right Documentation Observes the resident take the medications Documents the administration of each medication on the MAR & Controlled Medications on the Control Sheet Documents the administration of PRN Medications including:a) time givenb) reason it was given (symptoms)c) number of tabletsd) effectiveness Returns the medication to locked storage area

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: In an observation and interview on 05/15/24 at 9:39 AM, Medication Cart #1 was observed unlocked an unattended in an open, unlocked office in the memory care unit. Two residents and housekeeping staff were observed walking near the open office. Charge Nurse A was in the hallway and walked into the office. Charge Nurse A stated she was the one responsible for the unlocked and unattended medication cart. She stated she did not know she left it unlocked, and Charge Nurse A proceeded to lock the medication cart. Charge Nurse A stated the medication cart should have been locked and the risk was a resident could have gotten into the medication on the cart. In an interview on 05/16/24 at 2:37 PM, DON B stated all staff were trained on locked medication carts and knew medication carts should not be unlocked when unattended. She stated the risk of the unlocked medication cart was someone taking the medications from the medication cart. In an interview on 05/16/24 at 3:16 PM, Administrator C stated the medication cart should not be unlocked and unattended. Administrator C stated the risk of the unlocked medication cart was the memory care residents could wonder to the medication cart and take medication that could be harmful. Record review of the facility's policy dated 09/18, titled, Medication Administration General Guidelines, reflected the following: Policy 17. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage and kitchen sanitation. 1. The facility failed to adequately clean the kitchen which resulted in an accumulation of food and dirt on the equipment surfaces and appliances. 2. The facility failed to clean the kitchen and floors thoroughly and replace the dish racks that were old, discolored, chipped and appeared unclean. These failures could place residents at risk for ingesting cross contaminated food, which could result in food-borne illnesses, health decline and serious illness. Findings Included: Observation on 10/03/23 beginning at 9:30 am revealed the metal door around the handle of the walk-in refrigerator was black with what appeared to be 1 foot of dirt buildup and the plastic curtain was missing approximately 3 strips and one strip that was torn and about to tear completely. There was 2 small boxes on the floor by the exit door of the kitchen and the flooring around the exit door had accumulated blackish dirt in the corners and one white glue pest trap appeared brownish, jagged and frayed. The mop bucket had several areas of blackish dirt buildup around it and cloth like debris on it. A red three shelf serving cart appeared to have dirt buildup and crumbs on it, which had 8 serving spoons on the top of it. The shelf under the steam table had several brownish and blackish rust spots with approximately 12 baking pans on it. The dishwasher door had a large brownish rust stain approximately 3x4 inches in length, the dish racks appeared worn, with blackish and yellowish dirt buildup. The top of the dishwasher had debris particles on it and the drain next to the dishwasher appeared to have several layers of blackish built up of dirt. The floors had several areas of blackish dirt build up along the base boards by the 2 boxes on the floor, the exit door, around the dish washer and stove. The floor drain by the dishwasher appeared clogged with several layers of accumulated dirt and the table and legs of the dishwasher appeared to have blackish and brownish rust stains on it. And the garbage disposal underneath the dishwasher had several layers of brownish debris, grime and brownish stain spots on it. Interview on 10/03/23 at 10:00 am, the Dietary Director stated when cleaning the red serving cart, they were not able to get everything to come off of it, she stated everyone was responsible for cleaning the kitchen and equipment daily. She stated they mopped daily and in between meals and the night shift did the last cleaning for the day of sweeping, mopping and deep cleaning. She stated the two small boxes of lids and juice cups, sitting on the floor next to a metal rack by the exit door, she got from storage a few days ago and had not had a chance to stock them yet. She stated the yellow mop bucket in the utility room did appear dirty with brown stains and mop debris on it and was not sure when the last time it was cleaned. She stated she would have to ask the cook because he probably took it outside to clean it with soap and water. She stated the dishwasher was cleaned daily and was not able to explain why there was a 5 inch x 3 inch brownish rust stain on the dishwasher door and why the rack holding the 2 large cleaning solutions had brownish rust all over it. She stated she was not sure why the walk in refrigerator door had accumulated layers of dirt by the door handle and were about to replace the plastic curtains. She stated she was not sure why the dishwasher racks were cracked and discolored with yellow and blackish stains. She stated she was not sure why the corner of the dishwasher counter had accumulated layers of blackish dirt with what appeared to be glue. She stated she was not sure why the floors and floor drains had not been cleaned yet or why the shelves under the counter tops had brownish rust on them. Interview on 10/05/23 at 1:20 pm, Cook F stated it was kind of hard to get the dietary staff to do their jobs and this facility was an old place and stated the bottom shelf where the pots and pans were cleaned, were old. He stated they cleaned the kitchen Monday thru Thursday and went by a schedule by initialing what they cleaned and said they tried to clean the kitchen on a daily basis . He stated they kept the kitchen cleaned as best as they could. He stated he was by himself today in the kitchen with one dietary Aide G was new and was not much help because he needed training still. He stated he had to cook and mop and wipe the walls down by the coffee machine today, 10/05/23, and stated they needed another floor scrubber to clean the floors better. He stated their mop bucket should be cleaned and drained daily and was not sure when the last time mop bucket was cleaned. He stated he mainly focused on cooking and had not noticed the walk in fridge door being dirty. He stated boxes were not to be on the floor due to the risk of cross contamination, if mopping and the mop touched the boxes and to prevent pests from getting in them. He stated they tried cleaning the red rolling serving cart yesterday, 10/04/23, and was not sure why it had not been replaced before now because of the stains on it. He stated the dish racks had been here since he had been working here for the past two years. He stated he had not noticed any grime or dirt buildup on the dish racks and added he was waiting on another dietary Aide H to come back to work tomorrow to help clean the kitchen. He stated they currently had four staff (1 cook and 3 dietary aides plus the dietary director). He stated they needed 2 more cooks and 2 more dietary aides and were actively looking for more staff. He stated sometimes they were not able to clean as good as he preferred and tried to get the kitchen cleaned. He stated he was having a hard time cleaning the debris from the top of the garbage disposal. He stated the Dietary Director was responsible for ensuring the kitchen was cleaned and equipment in good condition. Interview 10/04/23 at 11:48 am, the Administrator stated she noticed the kitchen floors and walls were dirty yesterday and she told the dietary staff to put an emphases to cleaning things and go by their cleaning schedule Monday thru Friday. She stated they deep cleaned the kitchen as far as she knew and said the kitchen walls, dish machine and trays, garbage disposal under the counter and the corner of the dishwasher counter needed to be cleaned and was not sure why it had not been done. She stated she was not aware of the mop bucket being dirty, or that the refrigerator door had a large dirt stain on it or that the shelved under the counter tops were rusty. She stated she was not aware of boxes being left on the floor and not having a clean and sanitary kitchen could cause cross contamination risks. She stated the Dietary Manager was responsible for making sure the kitchen was cleaned. Record review of the Facility's September 2023 Kitchen Cleaning schedule Sheet revealed, the Week of: Was blank and there was not any initials of anything cleaned on Saturday, Sunday and Monday. And on Tuesday 17 out of 20 items was initialed cleaned, and Wednesday, Thursday and Friday 18 out of 20 items was initialed cleaned. Record review of the Facility's October 2023 Kitchen Cleaning schedule Sheet revealed, the Week of: Was blank and for Sunday there was 20 out of 20 items initialed cleaned on Monday there was 13 out of 20 items initialed cleaned and there was not any other initials on anything cleaned on Tuesday, Wednesday, Thursday, Friday and Saturday. Record review of the facility's Sanitization Policy dated 2001 and revised October 2008 revealed, Policy Statement: The food service area shall be maintained in a clean and sanitary manner .Policy interpretation and implementation: 1. All kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .2. All utensil, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning, seals, hinges and fasteners will be kept in good repair .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soil by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and all tasks, and to clean after each task before proceeding to the next assignment.

Based on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, on each resident that are- complete; accurately documented; readily accessible; and, systematically organized for 1 of 3 residents (Resident #1). The facility failed to maintain medical records for Resident #1's progress notes from his mental health visit on 8/18/23 that were complete and accurate until 10/05/23. This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (kidney failure), schizophrenia (psychological disorder), post-traumatic stress disorder, and Hypertension (high blood pressure). He had a BIMS of 08 (mild cognitive impairment). Resident #1 required limited to extensive assistance with ADLs. Record review of Resident #1's Physician Order dated 05/26/23. It read psych services to evaluate and treat PRN (as needed) an order for Aripiprazole 5mg 1 tablet by mouth at bedtime related to schizoaffective disorder, and Amitriptyline HCl 25mg 1 tablet at bedtime related to post-traumatic-stress disorder. Record review of Resident #1's MAR dated 10/01/23 revealed she received psychotropic medications on 5 out of 5 days reviewed. Record review of Resident #1's MAR dated 09/01/23 revealed she received psychotropic medications on 28 out of 30 days reviewed. Record review of Resident #1's MAR dated 08/01/23 revealed she received psychotropic medications on 30 out of 30 days reviewed. Record review of Resident #1's care plans dated 06/13/23 revealed a psychotropic medication (aripiprazole) care plan with an intervention of consult with pharmacy, MD to consider dosage reduction when clinically appropriate; monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications. Record review of Resident #1's care plan dated 6/13/23 revealed a psychotropic medication (amitriptyline) care plan with an intervention of monitor/document/report to MD prn ongoing s/sx (signs and symptoms) of depression. Record review of Resident #1's progress notes from 05/26/23 to 10/05/23 revealed there was no MD or psych services provided to Resident to include medication and or behavioral management review was provided. Interview on 10/05/23 at 12:16pm with LVN E revealed that Resident #1's psychotropic medications are evaluated by the psych doctor, but she was unsure if the Resident was seen in the facility or outpatient. She stated if he went outpatient then the after-visit notes should be uploaded to the EMR under the miscellaneous section and there should be a progress note from the date the resident left and returned to the facility. Residents return from appointments with an after-visit summary and if was not brought back with the residents than the facility could miss new orders or future appointment that were scheduled. She stated the DON and Medical Records are the ones who are responsible to make sure the notes are in the chart. Interview on 10/05/23 at 2:01pm with Medical Records revealed there should be an after-visit summary uploaded to the EMR after the residents return from outpatient appointments. He stated there was no pending documents needing uploading for Resident #1 and he requested last after visit summary from outpatient facility to be faxed on 10/05/23. Interview on 10/05/23 at 2:33pm with the ADON revealed that Resident #1 received psych services and medication management outside of facility. She stated that the notes for this visit should be under the miscellaneous tab on the EMR. She stated if the residents came back from appointments without the after visit summary, then the facility would reach out to the outpatient clinic to request the information. The person who would do this would be DON, ADON or Medical Records. She stated if this was not done than it meant there must be no changes to their medications or treatment plan . Interview on 10/05/23 at 3:13pm with Medical Records revealed he received the outpatient after visit summary via fax dated 8/18/23 and stated it was not in the EMR. This could cause the residents to miss getting the proper care due to missing information or follow up. He also stated that it should be in the EMR under the miscellaneous tab. He stated he is responsible to upload the documents and the DON or ADON is responsible to make sure the after-visit summary is reviewed for changes to plan of care and to make sure it was not missing. Record review of Resident #1's Mental Health Outpatient Note dated 8/18/23 revealed Resident was seen by an outside provider, note revealed Resident #1 as not appropriate to attend future appointments without a caregiver and Facilities management of psychotropic medications was unclear. Interview on 10/05/23 at 4:23pm with the DON revealed Resident #1 had been seen by an outpatient psych services provider. She stated they did not have the notes in the EMR because it was difficult to get them from the social workers at the outpatient facility. She stated her expectation is that the Medical Records and nurse managers make sure the notes were received after appointments because it could lead to residents not getting the appropriate care and changes to medications and lead to adverse effects. Request for accuracy or medical records policy from Administrator and DON on 10/05/23 at 4:40pm revealed the facility did not have one.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three ( #2, #16, #71) of 8 residents reviewed for ADL care. The facility failed to ensure Residents' (#2, #16, #71) hair was cut and combed, faces shaved, and fingernails clipped. These failures could place residents at risk of infections and skin tears resulting in pain, discomfort and decrease their dignity which could lead to a decreased psycho-social well-being and feeling of self worth. Findings included: A)Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed a [AGE] year old male who admitted [DATE] and had a BIMS Score of 03 (Severe Cognitive deficit) .with diagnosis of hypertension, Gastroesophageal Reflux (Stomach acid) , Renal insufficiency (kidney failure), arthritis (joint inflammation), aphasia (language deficit), cerebrovascular accident (stroke), hemiplegia (one side paralysis), seizure disorder (electricity burst in brain), malnutrition (nutrient deficit), depression (mood disorder), vascular dementia (memory loss). And total dependence one person assist for personal hygiene by CNA. Record review of Resident #2's Care Plan revealed communication problem related to expressive aphasia (anticipate and meet needs), cognitive function and impaired thought processes related to CVA, terminal prognosis hospice (Adjust provision of ADL's to compensate for resident's changing abilities and ADL Self-care performance deficit related to hemiplegia, stroke: Personal hygiene/oral care: the resident requires (x1) staff participation with personal hygiene and oral care by CNA) Observation and interview on 10/03/23 at 10:38 am, Resident #2 was lying in bed and his hair was 2 inches long the edges were different lengths, his nails were 1/4 inch long from the nail bed and he gestured nodding his head yes, he would like to get his nails cut. Observation and interview on 10/04/23 at 9:02 am of Resident #2 revealed his nails were 1/4 inch long from the nail bed on both hands. He gestured by nodding his head yes , he would like to get his nails clipped and was not sure when they were last clipped. Record review of Resident #2's Shower Sheets were requested from ADON on 10/04/23 at 9:43 am and was not provided. B) Record review of Resident #16's Admission MDS assessment dated [DATE] revealed a [AGE] year old male who admitted on [DATE] with a BIMS score of 07 (Severe cognitive deficit) .with diagnoses of Anemia, Atrial Fibrillation (irregular heart beat), Hypertension (high blood pressure), Peripheral Vascular Disease (circulatory disorder), Renal insufficiency (kidney failure), Pneumonia (lung infection), diabetes mellitus (high blood sugar), hyperlipidemia (high cholesterol) and non-Alzheimer's Dementia (memory impairment) and required extensive one person assist for personal hygiene by CNA. Record review of Resident #16's Care plan revealed he required pain management (chronic) pain related to diabetic neuropathy (diabetic nerve damage) and PVD .ADL Self-care performance deficit related to Dementia, impaired balance, ADL self-care performance deficit (Personal hygiene/oral care: the resident requires extensive (x1) staff participation by CNA. Observation and interview of Resident #16 on 10/03/23 /23 at 11:17 am, Resident #16's hair was 2 inches long and fingernails were 1/2 inch long from the nail bed and had a 1/4 inch beard and long uneven mustache. He stated he was last shaved last week and needed to be shaved again and needed his fingernails clipped. He stated CNA C was supposed to shave his face as soon as she got some free time. He stated getting bed baths as he preferred three times weekly but did not get shaved on a regular basis. He stated he had some hair clippers in the closet and said if he could get someone here to cut his hair would be nice, maybe CNA C could do it. He stated he felt better after being shaved, haircut and nails clipped. He stated the staff told him they would groom him when they could get to him and said he felt they always put him off. He stated he spoke to the SW about needing to be groomed and she said okay she would see about it and added his family member cut his hair about three weeks ago. Observation and interview of Resident #16 on 10/05/23 at 9:15 am, Resident #16's hair was 2 inches long and his nails were 1/2 long from his nail bed and four of the nails were broken, he stated he was not sure when his fingernails had last been clipped. Record review of Resident #16's Shower Sheets revealed he was showered on 09/20/23, 09/22/23 and bed bath on 09/25/23, 09/27/23, 09/29/23, 10/02/23 and 10/04/23. C) Record review of Resident #71's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old male who admitted [DATE] with a BIMS score of 07 (severe cognitive deficit), did not resist care, with diagnoses hypertension, Alzheimer's Disease (cognitive impairment), Cerebrovascular Accident (stroke), muscle wasting, muscle weakness, lack of coordination .Personal hygiene/oral care: the resident requires extensive (x1) staff participation by CNA. Record review of Resident #71's Care Plan on 10/05/23 revealed terminal prognosis (work cooperatively with the hospice team to ensure the resident's .physical needs are met by LVN .ADL self-care performance deficit related to Alzheimer's). Personal/oral care: the resident requires extensive (x1) person staff participation by CNA. Observation and interview on 10/03/23 at 11:50 am, Resident #71 hair was 2 inches long and uneven and his nails were 1/2 inch long from the nail bed and he said he would like to get them clipped. Observation and interview on 10/04/23 at 9:20 am, Resident #71 hair was not combed and appeared uneven, and his nails were approximately 1/2 inch long from the nail bed. He stated he needed his nails clipped and if someone would give him some nail clippers he would clip them himself. He stated his family member cut his hair and was not sure when it was last cut. Record review of Resident #71's Shower Sheet revealed he was showered by his hospice aide on 09/22/23, 09/25/23, 09/27/23, 09/29/23, 10/02/23 and 10/04/23. Interview on 10/04/23 at 9:25 am, LVN A stated after the residents showered their nails were cleaned and clipped if needed and said the nurses and CNA's were responsible for the resident's ADL Care. She stated Resident #71's nails did appear to be long. She stated the residents' hair should be washed every shower and said she told the CNA's to please remember to shave and wash their hair and clip their nails. She stated they used shower sheets to reflect what care was provided to the residents. She stated if a resident's nails were not clipped on a regular basis the resident could be a danger to themselves by tearing off and scratching their skin or by having physical contact with another resident. She stated unclipped nails was a source for germs to accumulate, increasing infection. She explained to Resident #71 that he would not be able to clip his own nails and told him she would get his CNA to clip them. Interview 10/04/23 at 4:40 pm, CNA B stated Resident #71 was showered on a regular basis and assigned to care for him recently and said she sometimes noticed he was not shaved, and his nails were long. She stated a week ago she noticed his nails were long and she reported it to his hospice nurse and thought they had been clipped but was not for sure if that had been done. She stated she never saw a beautician doing the resident's hair since she worked here nine months ago. She stated every time a resident showered there were supposed to get shaved, and if they noticed the resident's nails were long she clipped them unless the resident was a diabetic then the nurse would clip them. She stated if the resident's nails were not done they could get an infection under their nails from food and nasty stuff under their nails. She stated they could scratch skin and get an infection. She stated if residents were not shaved regularly, they could get an infection on their face. Interview 10/04/23 4:51 pm, CNA C stated the last time she saw a beautician here was 5 months ago. She stated on the Resident's shower days their hair was washed, bed linen changed, teeth brushed, and nails were done as needed. She stated she noticed Resident #2's nails were long for a couple of weeks and had not cut his nails because he leaned and was unsteady and had not spoken to anyone about assisting her because she got busy and forgot. She stated residents with long nails could scratch themselves or someone else and dirt could get off in their nails. She stated she provided care to Resident #71 in the past and had not noticed his nails or hair needed to be cut. She stated if they residents hair was not combed the other residents could possibly laugh at them and they could feel embarrassed. She stated she never combed his hair but a month ago she clipped his nails, because he asked her to clip them. She stated the nurses were responsible for ensuring the CNA's did ADL care appropriately. Interview on 10/04/23 at 5:09 pm, SW D stated the facility did not have a beautician and had not seen a beautician come in to do the resident's hair since she started working here 3 months ago. She stated she spoke to the Administrator about getting the resident's hair done by a beautician and the Administrator told her the family members did the resident's hair in the beauty shop room. She stated the CNA's, and the Nurses were responsible for ensuring the residents hair was done and if a resident requested to get a perm or other service, she would ask their Responsible party if it was okay and then talk to the BOM to see what funding they had. She stated she was not sure what could happen to a resident if their hair was not done honestly .it could look like they were not being taken care of. She stated she was not sure but thought she would be responsible for arranging the resident's beautician appointments. Interview on 10/05/23 at 9:22 am, Transporter/Barber stated she was a licensed barber and at times she cut the residents hair while they currently looked for another beautician because the last one had not been here in a while. She stated she could not remember the last time she saw a beautician at this facility, since working here a year. She stated she did not do perms or curl the resident's hair but cut the male residents hair at times if the request was known. She stated the nursing staff used shower sheets to document the resident's ADL services such shaving, podiatry, skin and nail care. She stated if the resident's ADL's were not done it could affect their self-esteem by lowering it. Interview on 10/05/23 at 9:46 am, the BOM stated the current Beautician used to come out monthly and the last time she did the resident's hair was around Memorial Day (May 2023). She stated the female residents did not always get their hair done because it was their choice to get their hair done or not. She stated was not sure who was responsible for ensuring the beautician was scheduled but she made sure the residents had the money in their accounts to get their hair done or asked their family's to pay. She stated basic ADL care should also be done and had spoken to the DON and Administrator about the residents hair not being done and they would say okay they would look into it. Interview on 10/05/23 at 10:35 am, SW D stated she noticed yesterday Resident #71's hair looked a little fluffy, it was 2 inches all around his head and scruffy around his face. She stated Resident #71 said he wanted to get his hair cut and it was done this morning. She stated she was responsible for getting the beauty shop list created and beautician scheduled. She stated since working here for the past 3 months she had not contacted the beautician because no one asked to get their hair done. She stated she did not have the beautician's contact information to schedule the resident's hair appointment but would get it from the Administrator. Interview on 10/05/23 at 10:35 am, the Administrator stated the residents were showered 3 times weekly and the nursing staff were responsible to ensure their hair was washed, nails checked and shaved. She stated when the resident were showered the CNA's were to provide ADL Care. She stated if a resident was getting hospice services, the caregiver took care of all the resident's ADL care and if they did not, her staff was responsible for cutting the resident's nails and shaving them. She stated she was not sure when the beautician was last out to do the resident's hair, She stated Resident #16 had stubble on his face and she went to the nurse or CNA to address. She stated if the resident's ADL care was not done timely it could make them feel bad or unkept and ungroomed and their nails could get dirty if too long. She stated her expectation for ADL care was for everyone to be well groomed and for ADL care to be ever Q shift and as often as necessary. She stated she saw Resident #71's nails needed to be clipped and stated she would start looking at the residents nails when she made her rounds. Interview on 10/05/23 at 11:00 am, the BOM said SW D was responsible for getting the resident seen by beautician. Interview on 10/05/23 at 11:48 am, the Administrator stated SW D would be responsible for arranging the beauty shop appointments and getting a list of residents to get their hair done. She stated ADL care fell under nursing services and the DON and ADON was responsible for ensuring the residents ADL care was done. Interview on 10/05/23 at 3:04 pm, the ADON stated the charge nurse and herself followed up with the residents and if they were hospice patient's, the nurse or herself contacted hospice if they noticed their ADLs were not being done. She stated they stepped in also to provide their hospice resident's ADL care also. She stated she had not noticed any of the resident's had long nails, facial hair and hair undone and the felt the nursing staff did a good job with the residents ADL care. She stated they had enough staff to care for the resident, but had they not had any request to get her hair done by. She stated Resident #16 had not requested to get ADL care and Resident #2 never requested he needed his nails clipped and Resident #71 they offered to clip his nails and he said no. She stated they had enough staff to care for the residents, but the residents had not requested to get their hair done by the beautician. She stated when the residents were showered or bathed their hair was washed, nails cleaned and clipped, and they were shaved and skin moisturized. She stated if ADL care was not done she was not sure how it could affect the residents then said it could make them feel unkept and not clean. Interview on 10/05/23 at 3:23 pm, the Activity Director stated Resident #16 had long nails, but he said he did not want his nails clipped. She stated she noticed Resident #71's fingernails long one day ago (Wednesday 10/04/23). She stated she notice Resident #71's fingernails were long about 2 weeks ago, and he said no to getting them clipped. She stated 2 weeks ago she trimmed Resident #2's fingers nails and was not sure if they were long or not. She stated if the resident's fingernails were long they should be getting their nails and hair done by the CNA's when they get showered and was not sure why the CNA's were not doing the ADL care right. She stated she had not asked nursing why and would try to clip their nails. Interview on 10/05/23 at 4:23 pm, the DON stated she was responsible for insuring the residents received adequate ADL Care. She stated ADL Care started with the CNA's and for hospice residents her nursing staff was supposed to notify the hospice provider if ADL care was lacking. She stated the department heads visited the resident's daily to ensure there ADL Care needs were met they. She stated all of the residents were getting appropriate ADL care including Residents #2, #16, #71. Record review of the facility's ADL Care undated revealed, Policy Statement: Residents will provide with care, treatment and services as appropriate to maintain and improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene

Based on observations, interviews and record reviews the facility failed the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of two (Residents #13 and #35) of 8 residents reviewed for accommodation of needs and preferences. The facility failed to ensure Resident #13 and #35 personal hair care needs were addressed. These failures could cause residents to be at risk of having a loss of dignity and self-worth which could cause a decline in their psycho-social and physical well-being. Findings included: Record review of Resident #13's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old female who admitted on [DATE] and current BIMS score of 13 (no cognitive impairment), ADL: personal hygiene was extensive 2 person assistance with diagnoses of hypertension, neurogenic bladder, CVA (Stroke), hemiplegia, multiple sclerosis. Record review of Resident #13's Care Plans Target date: 12/20/23 ADL Self-care performance deficit related to visually impaired, functionally decline for bathing/showering, dressing. Interview and observation on 10/03/23 at 10:40 am, Resident #13 was sitting in wheelchair and her hair was approximately 4 inches long and combed straight back. She stated they did not have a beautician to do their hair and it had been two or three months since her hair had been done by a beautician. She stated she did not know if they were looking into getting another beautician but really would like to get her hair styled and permed because it was hard to manage her hair into a style currently. She stated she asked Housekeeper I to braid her hair and was waiting on if she could do it. She stated the facility needed to get a beautician to come in once a month or every 2 weeks to keep her hair looking nice. She stated she had spoken to the nursing staff about wanting the beautician to come out to do her hair and so far no beautician had come out yet. She stated it was not a good feeling to have her hair not groomed and the CNA's tried to comb it but there were not able to style it in any kind of way. She stated the AD braided it one time 3 weeks ago and her hair had since been taken a loose about a week ago and now her hair was just sitting on the top of her head. She stated she wanted a perm and freeze wave hairstyle. Record review of Resident #35's Quarterly MDS assessment dated [DATE] revealed a [AGE] year old female who admitted to this facility 11/03/14 and current BIMS Score 1 (severe cognitive deficit), ADL: Personal Hygiene was extensive one person assistance with diagnoses anemia, aphasia, CVA (Stroke), Non-Alzheimer's dementia, hemiplegia, depression and asthma. Record review of Resident #35's Care Plans Target date: 11/05/23 ADL Self Care performance deficit related to dementia. Interview and observation on 10/05/23 at 11:30 am, Resident #35's hair was in two ponytails and twisted to the ends and she stated she would like to get her hair done. Interview 10/04/23 at 4:40 pm, CNA B stated she never saw a beautician doing the resident's hair since she worked here nine months ago. Interview 10/04/23 4:51 pm, CNA C stated the last time she saw a beautician here was 5 months ago. She stated if the residents hair was not combed the other residents could possibly laugh at them and they could feel embarrassed. Interview on 10/04/23 at 5:09 pm, SW D stated the facility did not have a beautician and had not seen a beautician come in to do the resident's hair since she started working here 3 months ago. She stated she spoke to the Administrator about getting the resident's hair done by a beautician and the Administrator told her the family members did the resident's hair in the beauty shop room. She stated the CNA's, and the Nurses were responsible for ensuring the residents hair was done and if a resident requested to get a perm or other service, she would ask their Responsible party if it was okay and then talk to the BOM to see what funding they had. She stated she spoke to Resident #13 today about getting a perm and she said she wanted one. She stated she was not sure what could happen to a resident if their hair was not done honestly .it could look like they were not being taken care of. She stated she was not sure but thought she would be responsible for arranging the resident's beautician appointments. Interview on 10/05/23 at 9:22 am, Transporter/Barber stated she was a licensed barber and at times she cut the residents hair while they currently looked for another beautician because the last one had not been here in a while. She stated she could not remember the last time she saw a beautician at this facility, since working here a year. She stated she did not do perms or curl the resident's hair but cut the male residents hair at times if the request was known. Interview on 10/05/23 at 9:46 am, the BOM stated the current Beautician used to come out monthly and the last time she did the resident's hair was around Memorial Day (May 2023). She stated the female residents did not always get their hair done because it was their choice to get their hair done or not. She stated the last time Resident #13 saw the beautician was May 2023 when she got her hair braided. She stated at times she noticed the resident's hair messed up and notified the nurses. She stated Resident #13 and #35 had their hair done by the beautician in the past and also saw them out in activities with their hair not done. She stated Resident #13's family member did her hair but did not come out to do it all the time. She stated was not sure who was responsible for ensuring the beautician was scheduled but she made sure the residents had the money in their accounts to get their hair done or asked their family's to pay. Interview o 10/05/23 at 10:35 am, SW D stated she was responsible for getting the beauty shop list created and beautician scheduled. She stated since working here for the past 3 months she had not contacted the beautician because no one ask to get their hair done . She stated she did not have the beautician's contact information to schedule the resident's hair appointment but would get it from the Administrator. Interview on 10/05/23 at 10:35 am, the Administrator stated she noticed Resident #13 wore her hair combed straight back and had not thought to get the beautician because the resident or family did not make a request to get her hair done . She stated the facility had a contracted cosmetologist/barber, but she was not sure when the beautician was last out to do the resident's hair. She stated if the resident's ADL care was not done timely it could make them feel bad or unkept and ungroomed. Interview on 10/05/23 at 11:00 am, the BOM said SW D was responsible for getting the resident seen by the beautician. Interview on 10/05/23 at 11:48 am, the Administrator stated SW D would be responsible for arranging the beauty shop appointments and getting a list of residents to get their hair done. Interview on 10/05/23 at 3:23 pm, the Activity Director stated Resident #13's family member did her hair at times. She stated she braided Resident #13's hair about 3 weeks ago and the beautician braided it was either June 2023 or July 2023. Record review of the facility's Social Service dated 2002 and revised October 2010 revealed, Policy Statement: Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practical physical, mental, or psychological well-being .Policy interpretation and implementation: .f. assistance in meeting the social and emotional needs of residents .

Based on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for one of four medication carts (hall 400 medication cart) reviewed for medication storage. The facility failed to ensure medication supplies were secured or attended by authorized staff when LVN A's medication cart for hall 400 was left unlocked and unattended by LVN A. This failure could result in resident access and ingestion of medications leading to a risk for harm and possible drug diversion. Findings included: Review of Resident #1's Admission record dated 09/29/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Admission record dated 09/29/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Admission record dated 09/29/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 09/29/22 at 8:40 a.m. revealed LVN A entering residents' room [ROOM NUMBER] and administrating medications to the residents. The medication cart was left in the hallway unlocked facing out to the hallway with the lock visibly unlocked, not in direct site of the LVN, with residents and staff on the hallway. Further observation revealed LVNA coming out of residents' room [ROOM NUMBER] obtaining an item off the top of the medication cart and returning to the room closing the door, leaving the medication cart unlocked. An observation on 09/29/22 at 9:15 a.m. revealed LVN A entering residents' room [ROOM NUMBER] and administrating medications to the residents. The medication cart was left in the hallway unlocked facing out to the hallway with the lock visibly unlocked, not in direct site of the LVN, with residents and staff on the hallway. An observation on 09/29/22 at 9:30 a.m. revealed LVN A entering residents' room [ROOM NUMBER] and administrating medications to the other resident. The medication cart was left in the hallway unlocked facing out to the hallway with the lock visibly unlocked, not in direct site of the LVN, with other residents and staff on the hallway. An observation on 09/29/22 at 10:00 a.m. revealed LVN A leaving the medication cart for Hall 400 at the main nurse's station unlocked. The medication cart was left facing out to the hallways with the lock visibly unlocked, not in direct site of the LVN, there were no other staff at the nurse's station. In an interview on 09/29/22 at 11:04 a.m. with LVN A revealed she was aware that she was supposed to lock the medication cart when not in use. She stated this was her first time to work at this facility, she worked for an agency. LVN A stated she knew it was the policy of the facility to keep the medications carts locked when not in use, that was universal. The LVN stated she was trying to make sure the residents received the correct medication, but the narcotic box was always locked. LVN A was asked did she not think that the other medications could harm a resident if taken inappropriately, she said yes. In an observation and interview on 09/29/22 at 1:00 p.m. with LVN A of the medication cart revealed: for Resident #1's [MEDICATION(S)] 10mg (hypertension), astrovastin calcium 10mg (high cholesterol), [MEDICATION(S)] 10mg (depression), [MEDICATION(S)] 20mg (depression), and famotidine 20mg (gastric reflux); Resident #2's [MEDICATION(S)] 25mg (depression), atrovastin calcium 80mg (high cholesterol), cetirizine HCL 10mg (allergies), [MEDICATION(S)] 75mg ([CONDITION(S)]), and [MEDICATION(S)] 50mg (depression); and Resident #3's [MEDICATION(S)] [MEDICATION(S)] 5mg (hypertension), escalopram oxalate 5mg (anxiety), [MEDICATION(S)] 7.5mg (appetite stimulant), [MEDICATION(S)] sodium 100mg (stool softener), [MEDICATION(S)] 50mg (hypertensions), [MEDICATION(S)] HCL 5mg (anxiety), and [MEDICATION(S)] 100mg (nerve pain). When LVN A was asked if these were the resident' ordered medications listed above, she said yes. The observation was a sample list of medications that were left unsecured in the unlocked cart. In an interview on 09/29/22 at 3:00 p.m., the DON revealed it was her expectation the medication carts should be locked when not in use. The DON said the nurses and medication aides were responsible to keep the medication carts locked when not in use. The DON stated if they were not locked, residents and unauthorized staff could get into the cart and there would be opportunities for harm and medication diversion. When the DON was asked who was responsible to monitor the carts to ensure they were locked she said that would be the staff that was using the carts. In an interview on 0/29/22 at 3:45 p.m., the Administrator stated it was her expectation medication carts should be locked when not in use. The Administrator stated if they were not locked, residents and unauthorized staff could get into the cart and there would be opportunities for harm and medication diversion. The Administrator stated the staff member using the cart should be held accountable for securing the medications cart. Review of the Policy and Procedure Security of Medication Cart dated April 2007 reflected, The medication cart shall be secured during medication passes .the nurse must secure the medication cart during the medication pass to prevent unauthorized entry .the cart must be locked .Medication carts must be securely locked at all times when out of the nurse's view

Based on observation, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for three (Residents #1, #2, and #3) of three residents reviewed for privacy, in that: LVN A left the electronic medical record screen unlocked on the medication cart on hall 400, as they gave medications to Resident #1, Resident #2, and Resident #3. Resident #1's, Resident #2's and Resident #3's personal and medical information was left open on the screen. This failure could affect the residents residing in the facility by placing them at risk of losing their right to privacy and confidentiality. Finding included: Review of Resident #1's Admission record dated 09/29/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 09/29/22 at 8:40 a.m. outside of Resident #1's door revealed the medication computer screen had been left with the EMR screen on, facing the hallway, with all the personal information showing for Resident #1. LVN A was in Resident #1's room with the door closed. Review of Resident #2's Admission record dated 09/29/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 09/29/22 at 9:15 a.m. outside of Resident #2's door revealed the medication computer screen had been left with the EMR screen on, facing the hallway, with all the personal information showing for Resident #2. LVN A was in Resident #2's room with the door closed. Review of Resident #3's Admission record dated 09/29/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 09/29/22 at 9:30 a.m. outside of Resident #3's door revealed the medication computer screen had been left with the EMR screen on, facing the hallway, with all the personal information showing for Resident #3. LVN A was in Resident #3's room with the door closed. In an interview on 09/29/22 at 11:04 a.m. LVN A revealed she knew that she was supposed to lock the screen on the computer before leaving the medication cart. LVN A said if the screen was not locked then the information concerning the resident was visible. LVN A stated she forgot to lock the screen. She stated this would be a HIPPA violation because the information concerning the resident's treatment would be visible to the public. In an interview on 09/29/22 at 3:00 p.m. with the DON revealed she had not observed the nursing staff leaving the medication computer screens unlocked on the medication carts. The DON sated she expected the nurses to lock the computer screen on the medications carts to protect the resident's private information and if they were not locking the computer screen and leaving it open then anyone can review their personal information, that was not good. In an interview on 09/29/22 at 3:45 p.m. with the Administrator revealed she had not observed the nursing staff leaving the computer screen open on the medication carts. When the Administrator was asked if she knew what it meant when the resident's personal information was left visible for the general public to see, she said yes, it was a HIPPA violation, against the resident's right to privacy. Review of the Policy and Procedure Protected Health Information, safeguarding electronic dated February 2014 reflected, .This facility ensures the confidentiality, integrity, and availability of all e-PHI (electronic personal health information) maintained by our information system

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 10 residents reviewed for neglect. 1. CNAs A and B failed to keep the Hoyer lift sling underneath Resident #1 when he was placed on the shower gurney. 2. Staff failed to elevate Resident #1's head when they placed him on the shower gurney even though they knew he could not lie flat due to his breathing problems. 3. The DON failed to initiate emergency care by moving Resident #1 into a sitting position with staff assistance to help him breathe. 4. The DON failed to have staff on both sides of the shower gurney, according to manufacturer ' s instructions, when they tried to roll Resident #1 to put the Hoyer lift sling underneath him. 5. The facility failed to have a full oxygen tank on the crash cart when it was brought to the shower room for Resident #1. Resident #1 rolled off the shower gurney onto the floor. He stopped breathing, did not have a pulse, CPR was initiated and he was transported to the ER. Resident #1 was placed on a ventilator and diagnosed with [REDACTED]. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 59 residents in the facility who were bariatric and/or full code, by placing them at risk for serious injuries, delayed emergency care, delayed oxygen supply and/or death. Findings included: Review of Resident #1's Face Sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1's admission physician's orders [REDACTED].@ 2 liters per minute via nasal cannula continuously. He was diagnosed with [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] and completed by LVN L, reflected he had irregular breathing, used oxygen via nasal cannula, had an irregular pulse, was unable to breathe lying flat and had range of motion impairment on both sides. Review of Resident #1's MDS assessment dated [DATE] reflected he had mild cognitive impairment, total dependence for bathing with two staff, shortness of breath and trouble breathing with exertion, at rest and while lying flat, and one fall with a major injury since his admission. He was 6'2 and weighed 316 pounds. Review of Resident #1's 72-hour care plan dated [DATE] did not address his respiratory issues, need for oxygen, or his restriction in lying flat. Review of an initial care plan dated [DATE] did not reflect any need for oxygen, his need to be elevated, or that he was a full code. Review of a hand written care plan meeting form dated [DATE] did not address Resident #1's respiratory issues, need for oxygen or his need to not to lie flat. The meeting notes reflected Resident #1 was a full code. The care plan meeting sheet was signed by Resident #1, the social worker, DON, LVN G, ADON and LVN D. Review of an incident report dated [DATE] (unsigned), reflected Nurse notified by another nurse that the resident had fallen out of a shower chair onto the floor. When I came into the shower, room pt was on the floor without a pulse and CPR was initiated while another nurse went and got the crash cart and AED. CPR was continued until 911 arrived at the facility. Review of the facility's Provider Investigation Report dated [DATE] reflected Resident was in distress when trying to reposition. Resident proceeded to lose consciousness. Resident stopped breathing and no pulse evident. CPR initiated. 911 called. Resident was transported via ambulance to hospital. Provider action taken post-investigation as of [DATE] reflected in-services were provided and shower beds were taken out of service. An interview with CNA A on [DATE] at 11:25 AM revealed Resident #1 was large in size and required a two-person lift. CNA A said when he arrived at work on [DATE], LVN I told him the DON said Resident #1 had to take a shower that morning. CNA A stated, The resident had no business being bathed in a shower bed lying down. He stated he worked the weekend Resident #1 admitted to the facility and provided incontinent care to him shortly after his arrival. He said the resident was laid down flat on the bed and kept saying he was going to black out. CNA A stated from the moment of admission, Resident #1 always freaked out if he was laid down. He said Resident #1 told him he was claustrophobic and would panic and be scared that he could not breathe, so CNA A started to do incontinent care with his head of bed elevated and he was okay. CNA A stated on [DATE] he helped CNA B put Resident #1 in a Hoyer lift. He said Resident #1 did not like it and was scared but the DON told the CNAs he had to be showered. When asked why he did not speak up and say something, he responded, I am an aide and I receive orders from above, so I didn't dispute it. But now looking back, I should have spoken up. CNA A said he felt a really good bed bath could have done just as good a job as the resident being showered, with aides using a sheet to move him around in the bed. CNA A stated when they got Resident #1 onto the shower gurney he was fine for about two minutes while they began bathing him. Then he started to panic and said, Lift me up! Lift up my head! I can't breathe! CNA A said he realized Resident #1 looked really scared and he was not pretending. He revealed he left CNA B and went to the nurses' station and told them he needed help because Resident #1 was hard to provide care to. He said the DON said she could help but he did not think she would be able to because she was small of stature. When they got back to the shower room after a few minutes, Resident #1's eyes were rolling back. The DON checked Resident #1's pulse and said he was verbally and physically unresponsive. He was not able to move his eyes and did not react to the DON or any other staff who called his name. CNA A went to get the sling for the Hoyer lift at the DON's request. Continued interview with CNA A on [DATE] at 11:25 AM revealed when he returned with the mechanical lift sling, he said Resident #1 had a large bowel movement and the DON told him and the other CNA they needed to rinse the BM off before rolling him over and putting the sling on him. He said the resident remained unresponsive. He said, I would have just kept going with getting him up but we did what she instructed us to do. CNA A stated the shower gurney wheels were locked the whole time but Resident #1 had been looking squished in the bed because of his girth and the narrowness of the bed. He said he put the side rails down and after they cleaned the BM, and they (CNA A, CNA B and the DON) tried to put the sling underneath him by rolling him over on his side. He said the shower bed moved or slid and Resident #1 fell over the side onto the floor. He said the DON checked his pulse and he was unresponsive, not moving. CNA A revealed the DON told another nurse to get the crash cart and she and a nurse started CPR. He stated he felt the shower gurney was not appropriate for him, because he was too big for it and should have received a bed bath. Period. Interview with CNA B was not attempted as she had terminated her employment with the facility and moved out of state. Her signed witness statement dated [DATE] provided by the ADM reflected she and CNA A transported Resident #1 to the shower gurney via a Hoyer lift and Geri chair. In the shower room, they placed him on the shower gurney via the Hoyer lift and she moved Resident #1 over and took the sling from under him and began showering him. They were showering Resident #1 when he began to complain of discomfort. CNA A left to get help. She continued to rinse off Resident #1 when CNA A returned with the DON. The DON and CNA B went to turn Resident #1 and he fell off the shower bed. Interview with the DON on [DATE] at 10:00 AM revealed the morning of [DATE], she then told Resident #1 he was going to be showered and He said he did not want a shower. He said 'No baby, I don't need one.' The DON said Resident #1 was worried the CNAs did not know how to transfer him. She said she told Resident #1 the lift and Geri-chair would be used and he agreed to it. She said he was more concerned the CNAs did not know how to move him and give him a shower. Later that morning on [DATE], she was at the nurses' station when CNA A stated he needed help turning Resident #1 in the shower room. The DON revealed LVN C was at the nurses' station. The DON said she went into the shower room and saw that Resident #1 was not responsive. He was lying on the shower gurney. She said she raised Resident #1's head, shook it, and there was no response. She stated he was wearing oxygen with a nasal cannula at the time with an e-tank. She stated there was no Hoyer sling under him at the time, but he had been placed on the shower gurney by the aide via a mechanical Hoyer lift. She said CNA A returned to the shower room with a Hoyer sling. She said CNA A and CNA B were present. The DON stated she asked a nurse to get the crash cart. At that time, the DON was still holding Resident #1's head up with he hands because she said it seemed like he was having a hard time breathing. She did not pull him up with staff assistance at that time because he was too heavy and they needed the sling to help them pull him up into a sitting position. She stated the CNAs tried to get the sling underneath Resident #1 on the shower gurney, but he was about 350 pounds. She stated, When we went to put the sling under him, the shower gurney moved and he fell . The DON revealed the shower gurney's wheels were locked at the time and the side rails were up on both sides, including the side from which he fell . The DON said she knew the wheels were locked because she had to unlock them when Resident #1 hit the floor. She stated he fell on to the floor on his side then she and the CNAs moved him onto his back. She checked Resident #1 and he had no pulse. She stated 911 was called and CPR was started. She stated, We used the crash cart because we got the oxygen mask out of there. He needed O2. The DON stated when EMS arrived, they did CPR, and he started breathing then stopped. Then they did CPR again then they took him out to the emergency room . She stated he was in ICU for a while. The DON stated he did not have any injuries from the fall from the shower gurney. She stated after this incident, he did not want to return to the facility. When the DON was queried what she thought had occurred that caused Resident #1 to fall and become unconscious, she responded, Maybe he had an anxiety attack because his wife said he never had a shower recently and he stayed in his wheelchair. Maybe the staff pushed him too strongly to get the sling underneath him. An interview with the DON on [DATE] at 5:44 PM revealed there were four bariatric residents, three who were in bariatric beds. The DON said it was not possible to move Resident #1 to a sitting position because he was wet and did not have full trunk control. The DON was queried how she made the assessment that Resident #1 had stopped breathing. She said she saw that his eyes had opened, then closed. When he fell , she flipped him back over and his abdomen was not moving. She then said she checked his pulse and there was nothing, then CPR was initiated. An interview with LVN C, on [DATE] at 12:54 PM revealed she was at the nurses' station with the DON when CNA A asked the DON if she would help with a resident in the shower room. She stated the DON said to her, C'mon (LVN C). LVN C asked the DON if they could get another person to help them because Resident #1 was a big guy and the DON responded they could do it, and they had done it before the other day. LVN C stated that was true, but it was a dressing change in his room, not a shower room. When they arrived at the shower room, Resident #1's eyes were opened and looking up to the side. He was not responsive. She heard the DON tell one of the CNAs to wash the feces off the resident (he had a bowel movement). LVN C saw the CNAs turn him on his side, trying to clean up the bowel movement and put the sling under him. She stated the side rails were up. When they moved him on his side, he started rolling and rolling, then he fell over the shower gurney rails. She stated she was asked to call 911 when the resident fell and his breathing stopped. She stated in the past, when she had done wound care to Resident #1's buttocks (which occurred once a day), she would have to complete it as fast as possible because she could not lay him down flat; he would complain of difficulty breathing and being claustrophobic. She stated even with the nasal cannula oxygen in his nose, he seemed like he had difficulty breathing when she would interact with him during wound care. LVN C did not know if it was more an issue of anxiety or not. She stated if he told her he could not breathe during wound care, she stopped and would not proceed. LVN C stated, I do not think he should have been showered that way because he shouldn't have been laid down on the shower bed. Prior to the shower and fall, he had been given bed bathes by the aides per LVN C. She stated he did not want to go to the shower, he was anxious and claustrophobic. LVN C stated, This could have been prevented by not making him go to a shower and taking a bed bath. An interview with LVN I on [DATE] at 1:24 PM revealed she knew Resident #1 was on continuous oxygen because it was in his chart. She said after he admitted to the facility, she asked one of the CNAs to provide incontinent care and observed Resident#1 become fearful of being laid down, even with his oxygen connected. She said he was anxious and was scared he would not be able to breathe. He had received bed baths for the five days he had been at the facility, but she was concerned his feces was embedded in his wound bandages on his buttocks. On [DATE], around ,[DATE]:30 AM, the DON came to her and said he needed to be showered. She said the DON was aware he had been putting the showers off. LVN I said Resident #1 was fine with the shower. She got an e-tank ready for him out of the supply closet and hooked him to it via a nasal cannula. She said everything seemed fine. She told the CNAs to shower him but did not specify via shower chair or shower gurney. Because he was obese, she said he would not have fit in the shower chair; it could not hold over 300 pounds. Since the shower chair was impossible, the shower gurney was the only option. She said Resident #1 was capable of sitting up in the shower chair but did lean to the side. Not being showered in a chair was an issue of size. She said ,[DATE] minutes after CNA A and CNA B took him to the shower room, LVN C came to tell her Resident #1 fell . LVN I said she got her blood pressure cuff and went to the shower room. When she got there, she saw CNA A, CNA B and the DON kneeled down next to Resident #1. CNA B was checking his carotid artery and the DON was checking his radial pulse. She said Resident #1 was on the floor and he was blue. CNA B told her he was not breathing. LVN I stated she started CPR. LVN I said Resident #1 had a nasal cannula tube in his nose but it was not connected to the e-tank which was nearby. She did not know why it was not connected but called out for someone to connect it. After the nasal cannula was connected, she saw there was no oxygen coming out. She did not know why. She said by that time, a crash cart was brought in by the ADON and she helped him start the AED while LVN C called 911. The e-tank on the crash cart did not have any oxygen in it, according to LVN I. She said the ADON and LVN D tried to turn it on, but there was nothing, it was empty. Then she went to get Resident #1's oxygen concentrator from his room. LVN I said Resident #1 started breathing again, but was making gurgling sounds. She said she told the DON to tilt his head back so he could breathe. She observed Resident #1's lips to be blue in color. LVN I stated the e-tank on the crash cart was supposed to be full. She did not know why it was not full. She stated she, the ADON and the DON did chest compressions until the paramedics arrived. An interview with the LVN D on [DATE] at 1:20 PM revealed she was walking the 400 Hall when she heard a boom, went into the shower room and saw Resident #1 on the floor on his side facing the wall. She stated she went in, and the DON and two CNAs tried to roll him on his back. She stated he was breathing at that time. She said they were calling out his name but he was not responding. She stated he had no oxygen on him at the time she saw him. She stated she knew he did not have his oxygen on him because someone had to go and get the portable crash cart which had oxygen on it and she was the one who had opened up a new nasal cannula tube for him to use. LVN D stated the first O2 tank from the crash cart did not work, so another portable O2 was brought and it did not work then a concentrator was found, which worked. She said at that point, Resident #1 had already stopped breathing so the ADON brought in a defibrillator. She stated chest compressions were started first by the DON who had determined his heart had stopped. LVN D stated Resident #1 had respiratory issues and could not tolerate lying flat from what she had heard about him after his admission. She stated whenever he had been laid flat over the past few days he was at the facility, he would say, No. No. I can't breathe laying down flat! She said Resident #1 told staff and management knew through talking amongst the staff that he did not want to take a shower because it got hot in the shower room, and when he laid flat, he could not breathe. She confirmed it was hot in the shower room when she saw Resident #1 on the floor. LVN D stated, I don't see why a resident cannot have O2 in the shower room. They could have used an oxygen tank. The aides wouldn't have known to do that, the nurse would have needed to tell them to take the O2 or check his stats ahead to see. LVN D stated she felt the shower gurney was too narrow for a bariatric resident. She said the action of getting the mesh sling for the Hoyer lift after he was found unresponsive was immaterial and he should have been provided emergency care where he was, instead of staff trying to move him. LVN D stated a care plan meeting had taken place the day prior to Resident #1's fall, where it was documented that he should not be placed lying down on his back. When asked what she felt the failure was with Resident #1, she responded, I don't feel that he should have never even gone to the shower room. I don't think he should have been lying flat if he has respiratory issues. There should have been another person on the other side of the shower bed. It was not effective, he was wet. I think that could have prevented him from falling, especially for a bariatric person. To roll him over on a wet shower gurney with no one on the other side is bad. An interview with the DON on [DATE] at 3:27 PM revealed the reason there was not a person on each side of Resident #1's shower gurney during the incident was because it was an emergency. She stated Resident #1 had known respiratory issues. She said if a resident had continuous oxygen, it was done with the shower. She stated the LVN I had set Resident #1 up for an e-tank prior to his shower and he had oxygen on during the shower. She thought she may have turned it up at one point and then someone brought in an oxygen concentrator which was used when he fell and after he stopped breathing. She stated she saw his initial assessment when he admitted to the facility. The DON was asked why the CNAs did not elevate his head when he was laid on the shower gurney. She responded the CNAs would not have known to do that and the charge nurse should have advised them. She stated the CNAs, charge nurse and herself should have known Resident #1 had a problem with breathing in a flat on back position. Review of the local EMS Patient Care Report dated [DATE], reflected they arrived and found Resident #1 lying on the floor of the shower room unconscious and unresponsive. The EMS responder noticed Resident #1 was apneic (suspension of breathing) and pulseless. Chest compressions were started, pads placed and monitored. Resident #1 was transported to the hospital. Review of hospital medical and discharge records from [DATE] through [DATE] reflected Resident #1 was admitted on [DATE] through the emergency room with status [REDACTED]. Resident #1 was found by EMS without a pulse at the nursing home. Upon arrival at the ER, he was found to have labored breathing and he was placed on ventilator support. He was found to have healthcare-acquired pneumonia. He also developed acute [MEDICAL CONDITION] which was further complicated by significant pneumonitis. Due to his loss of consciousness prior to admission, he received an EEG that was abnormal due to [MEDICAL CONDITION] (malfunction of the brain). Further interview with the DON on [DATE] at 5:05 PM revealed the night nurses were responsible for ensuring the crash carts were stocked and accurate. She said there was an inventory checklist that had to be completed by the night nurse every day and if anything was missing, it went on the 24 hour report, which was then discussed during the weekday morning nursing meeting. She stated as the DON, she checked the crash cart periodically but not daily. She stated e-tanks were the oxygen used on the crash cart. She stated the reason she had staff bring her one from the crash cart was because Resident #1 ' s e-tank he had from his room in the shower, had run out of oxygen. She stated the second oxygen tank that was brought in from the crash cart was fine and had a sufficient supply of oxygen and could last seven to eight hours continuously, but she wanted him to be on the concentrator because it was stronger. She felt she did not know how long it would take EMS to arrive so she wanted to switch him over to the concentrator. The DON said she the oxygen would not have helped Resident #1 breathe when we lost him and he stopped breathing. She stated that was when the chest compressions and intubation (bagging) was used. The DON was queried why she tendered her resignation to the facility after the investigation had begun into the incident. She stated that she knew what happened to Resident #1 was not entirely her fault, but as the DON, she felt responsible for what happened to him. Observation of the shower rooms on the 400 and 100 Hall of the facility and a shower gurney on [DATE] at 10:45 AM revealed the shower gurney was made out of PVC piping mostly and plastic sheet for the bed. The side rails consisted of pvc piping and rose approximately six inches up. The wheels were locked. However, the gurney was able to be moved easily on the dry tile floor. An interview with the DON in the 400 Hall shower room on [DATE] at 10:40 AM revealed. Resident #1 was placed in the shower gurney and then the shower gurney was placed up against the wall of the bathroom. She moved the shower gurney against the wall. The shower gurney was not able to be flush against the wall because there was a grab bar on the wall which prevented it. The bed was actually against the grab bar, not the wall. The DON stated that was the normal way in which residents were bathed in the shower gurney. Interview with CNA F on [DATE] at 5:10 PM revealed she typically left the shower sling in place during when a resident was showered. When the shower was finished, the wet sling got transferred with the resident to a blanket on their bed, where the resident was positioned and a dry sling placed underneath him/her. CNA F was queried how the shower gurneys had been used by staff in the past before they were taken out of rotation. She responded the mesh sling stayed with the resident and did not get removed. She stated there should be one person on each side or the shower gurney and the gurney cannot be up against the wall because the resident could fall off as the gurney was not balanced. Interview with CNA E on [DATE] at 5:15 PM revealed mesh slings were to stay under the resident when they were showered. She stated the CNAs had recently been in-serviced on those topics, but that was protocol before that training anyway. An interview with the ADM on [DATE] at 5:30 PM revealed the shower gurney Resident #1 was on could not have been tilted up, even though that was in the manufacturer ' s instructions. He stated they two shower gurneys they had in-house did not have that option. An interview with Resident #1's family member on [DATE] at 9:23 AM revealed Resident #1 had kept telling the staff at the facility he was not supposed to be showered because he could not stand up and he was afraid of them using the Hoyer lift, because he is a big guy. The family member stated, Staff kept insisting on a shower. The family member said they got Resident #1 up in a sling and dropped him; he did not wake up. She said CPR was done all the way to the hospital where he was in a coma from [DATE]-[DATE]. An interview with Resident #1's wife on [DATE] at 9:40 AM revealed she was at the facility the morning of [DATE]. When she walked down the hall towards Resident #1's room, she heard someone say a man had fallen. She went to the shower room on the hall because she knew Resident #1 had received a shower. She said she did not see him on the shower gurney, only naked on the floor. She said he had been admitted because he was not able to walk, was weak, and had pneumonia. She stated he had a stroke on the left side and had only received bed baths in the recent past. She stated CNA A was training a new aide the morning Resident #1 fell in the shower room. She said when Resident #1 went to the hospital, the medical staff told her it took Resident #1 awhile to come back to 2015. Resident #1's wife stated she felt the facility did not pay enough attention to him. Review of the Operation Instructions for the Shower Bed Model 500# Capacity, dated [DATE], and reflected, When using a lift to transfer the patient in and out of the shower bed, manufacturer recommends keeping the side rails up and locked at all times. Optional Headrest- all shower beds offer an optional headrest. To operate, raise headrest to desired height and lock racket system into place. Precautions: Do not roll user way from you unless there is a partner caregiver on the other side. Review of the facility's shower gurney policy, dated [DATE], reflected, Purpose: To transport residents in a horizontal position and to use as a platform for showering .Usage Recommendation: Recommended for showering people who are unable to stand or sit in a chair .Procedure: Use caution after showering as gurney will be wet and slippery .Exaggerated user movement in any direction or rolling to the edge may cause the gurney to tip. Review of the facility's Abuse Prohibition Standards of Practice revised [DATE], reflected, Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An IJ was identified on [DATE]. The facility's ADM, DON and ADON were notified at4:45PM on [DATE] of the IJ and a Plan of Removal was requested. An interview with the ADM on [DATE] at 4:55 PM revealed the social worker had remembered completing a care plan meeting where Resident #1 ' s need to not be laid flat were discussed, but she could not locate the actual written care plan reflected that information. An interview with the DON on [DATE] at 5:56 PM revealed what she thought caused the Immediate Jeopardy situation was the positioning of the resident. She said Resident #1 had oxygen on the whole time and when the CNAs put him on the shower bed, his head should have been propped up with pillows. She felt the charge nurse should have instructed the CNAs to do that. An interview with the ADM on [DATE] at 6:05 PM revealed he felt the Immediate Jeopardy situation was caused due to poor nursing assessment that determined the resident could lay flat during a shower. The Plan of Removal was accepted at12:35 PM on [DATE] and reflected the following: In reference to Incident involving (Resident #1)-Plan of Removal for Immediate Jeopardy Relating to Neglect and Quality of Care Please accept this as our plan of Abatement to the deficiencies leading to the Immediate Jeopardy. (ADM) will be responsible for monitoring this plan (Resident #1) was admitted on [DATE] at 6:54 p.m. [DIAGNOSES REDACTED].) [MEDICAL CONDITION] with acute respiratory infection (Resident #1) had physician orders [REDACTED]. (Resident #1) was initially assessed on [DATE] by Admission data set. The assessment didn't indicate shower or bathing procedures but that he shouldn't be laid flat. On [DATE], approximately 11a.m. (Resident #1) was transferred to shower gurney, the resident had O2 because the nurse, (LVN I), transferred the O2 from the concentrator to the portable tank. During shower resident became distressed. (Resident became unresponsive to verbal stimuli and eyes were fixed. (CNA A) and (CNA B) (sic). (CNA A) alerted DON who assisted. DON was calling his name and lifted his head to help him to breathe when DON assessed his head was lifted to help him breathe (sic), DON stated resident was breathing checked carotid pulse and it was preset. (CNA A) retrieved sling Resident was breathing but unable to respond. DON made decision to transfer resident. The two C.N.A ' s attempted to roll (Resident #1) to place sling under him while DON held his head up, the bed was secured against the wall, and while turning resident he rolled and fell to the floor. The bed shifted from the wall during the rolling process. The resident fell landing (sic) on his left side. There were no apparent injuries due to the fall. Nasal Cannula was on resident. (Resident #1) was rolled on to his back and DON initiated CPR. Crash Cart was obtained. According to statements from (CNA A, CNA B, and DON), O2 was present. O2 nasal cannula was on the resident and on the crash cart which had arrived. (LVN J) called 911. The wife was at the building in the hallway while CPR was ongoing. EMS transported Resident to ER. Resident did not return to facility. Facility has been unable to retrieve any further documentation from hospital. (Resident #1) could have had the option for shower chair but due to his size and not good trunk control it was decided to use a shower gurney. This would a nursing judgment decision. The DON instructed that resident needed a shower. The Nurse instructed CNAs to give a shower. Shower chair did not seem to be valid option due to weight and trunk control. (Resident #1) had been laid flat. C.N.A.'s lay flat because shower bed was a flat surface. According to statements by (CNA A and CNA B) [DATE] 12 pm. (sic) was not in distress initially. (Resident #1) then became during the course of the shower disoriented and unresponsive. Unsure, why resident ' s conditions changed. According to statements, by (CNA A, CNA B and DON) [DATE] at 12pm, resident had O2 in shower room. Policy is resident with continuous O2 should b

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 10 residents reviewed for accidents. 1. CNAs A and B failed to keep the Hoyer lift sling underneath Resident #1 when they placed him on the shower gurney. 2. The DON failed to have staff on both sides of the shower gurney, according to the manufacturer's operation instructions, when they tried to roll Resident #1 to put the Hoyer lift sling underneath him. Resident #1 was lying flat on a shower gurney with no head support and rolled off the shower gurney onto the floor. He stopped breathing, did not have a pulse, CPR was initiated and he was transported to the ER. Resident #1 was placed on a ventilator and diagnosed with [REDACTED]. He was at the hospital for two weeks before transferring to a different nursing facility. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the four residents in the facility who were bariatric and dependent on staff for transfers, by placing them at risk for significant injuries and falls. Findings included: Review of Resident #1's Face Sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1's admission physician's orders [REDACTED].@ 2 liters per minute via nasal cannula continuously. He was diagnosed with [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] and completed by LVN L, reflected he had irregular breathing, used oxygen via nasal cannula, had an irregular pulse, was unable to breathe lying flat and had range of motion impairment on both sides. Review of Resident #1's MDS assessment dated [DATE] reflected he had mild cognitive impairment, total dependence for bathing with two staff, shortness of breath and trouble breathing with exertion, at rest and while lying flat, and one fall with a major injury since his admission. He was 6'2 and weighed 316 pounds. Review of Resident #1's 72-hour care plan dated [DATE] did not address his respiratory issues, need for oxygen, or his restriction in lying flat. Review of an initial care plan dated [DATE] did not reflect any need for oxygen, his need to be elevated, or that he was a full code. Review of a hand written care plan meeting form dated [DATE] did not address Resident #1's respiratory issues, need for oxygen or his need to not to lie flat. The meeting notes reflected Resident #1 was a full code. The care plan meeting sheet was signed by Resident #1, the social worker, DON, LVN G, ADON and LVN D. Review of an incident report dated [DATE] (unsigned), reflected Nurse notified by another nurse that the resident had fallen out of a shower chair onto the floor. When I came into the shower, room pt was on the floor without a pulse and CPR was initiated while another nurse went and got the crash cart and AED. CPR was continued until 911 arrived at the facility. Review of the facility's Provider Investigation Report dated [DATE] reflected Resident was in distress when trying to reposition. Resident proceeded to lose consciousness. Resident stopped breathing and no pulse evident. CPR initiated. 911 called. Resident was transported via ambulance to hospital. Provider action taken post-investigation as of [DATE] reflected in-services were provided and shower beds were taken out of service. An interview with CNA A on [DATE] at 11:25 AM revealed Resident #1 was large in size and required a two-person lift. CNA A said when he arrived at work on [DATE], LVN I told him the DON said Resident #1 had to take a shower that morning. CNA A stated, The resident had no business being bathed in a shower bed lying down. He stated he worked the weekend Resident #1 admitted to the facility and provided incontinent care to him shortly after his arrival. He said the resident was laid down flat on the bed and kept saying he was going to black out. CNA A stated from the moment of admission, Resident #1 always freaked out if he was laid down. He said Resident #1 told him he was claustrophobic and would panic and be scared that he could not breathe, so CNA A started to do incontinent care with his head of bed elevated and he was okay. CNA A stated on [DATE] he helped CNA B put Resident #1 in a Hoyer lift. He said Resident #1 did not like it and was scared but the DON told the CNAs he had to be showered. When asked why he did not speak up and say something, he responded, I am an aide and I receive orders from above, so I didn't dispute it. But now looking back, I should have spoken up. CNA A said he felt a really good bed bath could have done just as good a job as the resident being showered, with aides using a sheet to move him around in the bed. CNA A stated when they got Resident #1 onto the shower gurney he was fine for about two minutes while they began bathing him. Then he started to panic and said, Lift me up! Lift up my head! I can't breathe! CNA A said he realized Resident #1 looked really scared and he was not pretending. He revealed he left CNA B and went to the nurses' station and told them he needed help because Resident #1 was hard to provide care to. He said the DON said she could help but he did not think she would be able to because she was small of stature. When they got back to the shower room after a few minutes, Resident #1's eyes were rolling back. The DON checked Resident #1's pulse and said he was verbally and physically unresponsive. He was not able to move his eyes and did not react to the DON or any other staff who called his name. CNA A went to get the sling for the Hoyer lift at the DON's request. Continued interview with CNA A on [DATE] at 11:25 AM revealed when he returned with the mechanical lift sling, he said Resident #1 had a large bowel movement and the DON told him and the other CNA they needed to rinse the BM off before rolling him over and putting the sling on him. He said the resident remained unresponsive. He said, I would have just kept going with getting him up but we did what she instructed us to do. CNA A stated the shower gurney wheels were locked the whole time but Resident #1 had been looking squished in the bed because of his girth and the narrowness of the bed. He said he put the side rails down and after they cleaned the BM, and they (CNA A, CNA B and the DON) tried to put the sling underneath him by rolling him over on his side. He said the shower bed moved or slid and Resident #1 fell over the side onto the floor. He said the DON checked his pulse and he was unresponsive, not moving. CNA A revealed the DON told another nurse to get the crash cart and she and a nurse started CPR. He stated he felt the shower gurney was not appropriate for him, because he was too big for it and should have received a bed bath. Period. Interview with CNA B was not attempted as she had terminated her employment with the facility and moved out of state. Her signed witness statement dated [DATE] provided by the ADM reflected she and CNA A transported Resident #1 to the shower gurney via a Hoyer lift and Geri chair. In the shower room, they placed him on the shower gurney via the Hoyer lift and she moved Resident #1 over and took the sling from under him and began showering him. They were showering Resident #1 when he began to complain of discomfort. CNA A left to get help. She continued to rinse off Resident #1 when CNA A returned with the DON. The DON and CNA B went to turn Resident #1 and he fell off the shower bed. Interview with the DON on [DATE] at 10:00 AM revealed the morning of [DATE], she then told Resident #1 he was going to be showered and He said he did not want a shower. He said 'No baby, I don't need one.' The DON said Resident #1 was worried the CNAs did not know how to transfer him. She said she told Resident #1 the lift and Geri-chair would be used and he agreed to it. She said he was more concerned the CNAs did not know how to move him and give him a shower. Later that morning on [DATE], she was at the nurses' station when CNA A stated he needed help turning Resident #1 in the shower room. The DON revealed LVN C was at the nurses' station. The DON said she went into the shower room and saw that Resident #1 was not responsive. He was lying on the shower gurney. She said she raised Resident #1's head, shook it, and there was no response. She stated he was wearing oxygen with a nasal cannula at the time with an e-tank. She stated there was no Hoyer sling under him at the time, but he had been placed on the shower gurney by the aide via a mechanical Hoyer lift. She said CNA A returned to the shower room with a Hoyer sling. She said CNA A and CNA B were present. The DON stated she asked a nurse to get the crash cart. At that time, the DON was still holding Resident #1's head up with he hands because she said it seemed like he was having a hard time breathing. She did not pull him up with staff assistance at that time because he was too heavy and they needed the sling to help them pull him up into a sitting position. She stated the CNAs tried to get the sling underneath Resident #1 on the shower gurney, but he was about 350 pounds. She stated, When we went to put the sling under him, the shower gurney moved and he fell . The DON revealed the shower gurney's wheels were locked at the time and the side rails were up on both sides, including the side from which he fell . The DON said she knew the wheels were locked because she had to unlock them when Resident #1 hit the floor. She stated he fell on to the floor on his side then she and the CNAs moved him onto his back. She checked Resident #1 and he had no pulse. She stated 911 was called and CPR was started. She stated, We used the crash cart because we got the oxygen mask out of there. He needed O2. The DON stated when EMS arrived, they did CPR, and he started breathing then stopped. Then they did CPR again then they took him out to the emergency room . She stated he was in ICU for a while. The DON stated he did not have any injuries from the fall from the shower gurney. She stated after this incident, he did not want to return to the facility. When the DON was queried what she thought had occurred that caused Resident #1 to fall and become unconscious, she responded, Maybe he had an anxiety attack because his wife said he never had a shower recently and he stayed in his wheelchair. Maybe the staff pushed him too strongly to get the sling underneath him. An interview with the DON on [DATE] at 5:44 PM revealed there were four bariatric residents, three who were in bariatric beds. The DON said it was not possible to move Resident #1 to a sitting position because he was wet and did not have full trunk control. The DON was queried how she made the assessment that Resident #1 had stopped breathing. She said she saw that his eyes had opened, then closed. When he fell , she flipped him back over and his abdomen was not moving. She then said she checked his pulse and there was nothing, then CPR was initiated. An interview with LVN C, on [DATE] at 12:54 PM revealed she was at the nurses' station with the DON when CNA A asked the DON if she would help with a resident in the shower room. She stated the DON said to her, C'mon (LVN C). LVN C asked the DON if they could get another person to help them because Resident #1 was a big guy and the DON responded they could do it, and they had done it before the other day. LVN C stated that was true, but it was a dressing change in his room, not a shower room. When they arrived at the shower room, Resident #1's eyes were opened and looking up to the side. He was not responsive. She heard the DON tell one of the CNAs to wash the feces off the resident (he had a bowel movement). LVN C saw the CNAs turn him on his side, trying to clean up the bowel movement and put the sling under him. She stated the side rails were up. When they moved him on his side, he started rolling and rolling, then he fell over the shower gurney rails. She stated she was asked to call 911 when the resident fell and his breathing stopped. She stated in the past, when she had done wound care to Resident #1's buttocks (which occurred once a day), she would have to complete it as fast as possible because she could not lay him down flat; he would complain of difficulty breathing and being claustrophobic. She stated even with the nasal cannula oxygen in his nose, he seemed like he had difficulty breathing when she would interact with him during wound care. LVN C did not know if it was more an issue of anxiety or not. She stated if he told her he could not breathe during wound care, she stopped and would not proceed. LVN C stated, I do not think he should have been showered that way because he shouldn't have been laid down on the shower bed. Prior to the shower and fall, he had been given bed bathes by the aides per LVN C. She stated he did not want to go to the shower, he was anxious and claustrophobic. LVN C stated, This could have been prevented by not making him go to a shower and taking a bed bath. An interview with LVN I on [DATE] at 1:24 PM revealed she knew Resident #1 was on continuous oxygen because it was in his chart. She said after he admitted to the facility, she asked one of the CNAs to provide incontinent care and observed Resident#1 become fearful of being laid down, even with his oxygen connected. She said he was anxious and was scared he would not be able to breathe. He had received bed baths for the five days he had been at the facility, but she was concerned his feces was embedded in his wound bandages on his buttocks. On [DATE], around ,[DATE]:30 AM, the DON came to her and said he needed to be showered. She said the DON was aware he had been putting the showers off. LVN I said Resident #1 was fine with the shower. She got an e-tank ready for him out of the supply closet and hooked him to it via a nasal cannula. She said everything seemed fine. She told the CNAs to shower him but did not specify via shower chair or shower gurney. Because he was obese, she said he would not have fit in the shower chair; it could not hold over 300 pounds. Since the shower chair was impossible, the shower gurney was the only option. She said Resident #1 was capable of sitting up in the shower chair but did lean to the side. Not being showered in a chair was an issue of size. She said ,[DATE] minutes after CNA A and CNA B took him to the shower room, LVN C came to tell her Resident #1 fell . LVN I said she got her blood pressure cuff and went to the shower room. When she got there, she saw CNA A, CNA B and the DON kneeled down next to Resident #1. CNA B was checking his carotid artery and the DON was checking his radial pulse. She said Resident #1 was on the floor and he was blue. CNA B told her he was not breathing. LVN I stated she started CPR. LVN I said Resident #1 had a nasal cannula tube in his nose but it was not connected to the e-tank which was nearby. She did not know why it was not connected but called out for someone to connect it. After the nasal cannula was connected, she saw there was no oxygen coming out. She did not know why. She said by that time, a crash cart was brought in by the ADON and she helped him start the AED while LVN C called 911. The e-tank on the crash cart did not have any oxygen in it, according to LVN I. She said the ADON and LVN D tried to turn it on, but there was nothing, it was empty. Then she went to get Resident #1's oxygen concentrator from his room. LVN I said Resident #1 started breathing again, but was making gurgling sounds. She said she told the DON to tilt his head back so he could breathe. She observed Resident #1's lips to be blue in color. LVN I stated the e-tank on the crash cart was supposed to be full. She did not know why it was not full. She stated she, the ADON and the DON did chest compressions until the paramedics arrived. An interview with the LVN D on [DATE] at 1:20 PM revealed she was walking the 400 Hall when she heard a boom, went into the shower room and saw Resident #1 on the floor on his side facing the wall. She stated she went in, and the DON and two CNAs tried to roll him on his back. She stated he was breathing at that time. She said they were calling out his name but he was not responding. She stated he had no oxygen on him at the time she saw him. She stated she knew he did not have his oxygen on him because someone had to go and get the portable crash cart which had oxygen on it and she was the one who had opened up a new nasal cannula tube for him to use. LVN D stated the first O2 tank from the crash cart did not work, so another portable O2 was brought and it did not work then a concentrator was found, which worked. She said at that point, Resident #1 had already stopped breathing so the ADON brought in a defibrillator. She stated chest compressions were started first by the DON who had determined his heart had stopped. LVN D stated Resident #1 had respiratory issues and could not tolerate lying flat from what she had heard about him after his admission. She stated whenever he had been laid flat over the past few days he was at the facility, he would say, No. No. I can't breathe laying down flat! She said Resident #1 told staff and management knew through talking amongst the staff that he did not want to take a shower because it got hot in the shower room, and when he laid flat, he could not breathe. She confirmed it was hot in the shower room when she saw Resident #1 on the floor. LVN D stated, I don't see why a resident cannot have O2 in the shower room. They could have used an oxygen tank. The aides wouldn't have known to do that, the nurse would have needed to tell them to take the O2 or check his stats ahead to see. LVN D stated she felt the shower gurney was too narrow for a bariatric resident. She said the action of getting the mesh sling for the Hoyer lift after he was found unresponsive was immaterial and he should have been provided emergency care where he was, instead of staff trying to move him. LVN D stated a care plan meeting had taken place the day prior to Resident #1's fall, where it was documented that he should not be placed lying down on his back. When asked what she felt the failure was with Resident #1, she responded, I don't feel that he should have never even gone to the shower room. I don't think he should have been lying flat if he has respiratory issues. There should have been another person on the other side of the shower bed. It was not effective, he was wet. I think that could have prevented him from falling, especially for a bariatric person. To roll him over on a wet shower gurney with no one on the other side is bad. An interview with the DON on [DATE] at 3:27 PM revealed the reason there was not a person on each side of Resident #1's shower gurney during the incident was because it was an emergency. She stated Resident #1 had known respiratory issues. She said if a resident had continuous oxygen, it was done with the shower. She stated the LVN I had set Resident #1 up for an e-tank prior to his shower and he had oxygen on during the shower. She thought she may have turned it up at one point and then someone brought in an oxygen concentrator which was used when he fell and after he stopped breathing. She stated she saw his initial assessment when he admitted to the facility. The DON was asked why the CNAs did not elevate his head when he was laid on the shower gurney. She responded the CNAs would not have known to do that and the charge nurse should have advised them. She stated the CNAs, charge nurse and herself should have known Resident #1 had a problem with breathing in a flat on back position. Review of the local EMS Patient Care Report dated [DATE], reflected they arrived and found Resident #1 lying on the floor of the shower room unconscious and unresponsive. The EMS responder noticed Resident #1 was apneic (suspension of breathing) and pulseless. Chest compressions were started, pads placed and monitored. Resident #1 was transported to the hospital. Review of hospital medical and discharge records from [DATE] through [DATE] reflected Resident #1 was admitted on [DATE] through the emergency room with status [REDACTED]. Resident #1 was found by EMS without a pulse at the nursing home. Upon arrival at the ER, he was found to have labored breathing and he was placed on ventilator support. He was found to have healthcare-acquired pneumonia. He also developed acute respiratory failure which was further complicated by significant pneumonitis. Due to his loss of consciousness prior to admission, he received an EEG that was abnormal due to [DIAGNOSES REDACTED] (malfunction of the brain). Further interview with the DON on [DATE] at 5:05 PM revealed the night nurses were responsible for ensuring the crash carts were stocked and accurate. She said there was an inventory checklist that had to be completed by the night nurse every day and if anything was missing, it went on the 24 hour report, which was then discussed during the weekday morning nursing meeting. She stated as the DON, she checked the crash cart periodically but not daily. She stated e-tanks were the oxygen used on the crash cart. She stated the reason she had staff bring her one from the crash cart was because Resident #1 ' s e-tank he had from his room in the shower, had run out of oxygen. She stated the second oxygen tank that was brought in from the crash cart was fine and had a sufficient supply of oxygen and could last seven to eight hours continuously, but she wanted him to be on the concentrator because it was stronger. She felt she did not know how long it would take EMS to arrive so she wanted to switch him over to the concentrator. The DON said she the oxygen would not have helped Resident #1 breathe when we lost him and he stopped breathing. She stated that was when the chest compressions and intubation (bagging) was used. The DON was queried why she tendered her resignation to the facility after the investigation had begun into the incident. She stated that she knew what happened to Resident #1 was not entirely her fault, but as the DON, she felt responsible for what happened to him. Observation of the shower rooms on the 400 and 100 Hall of the facility and a shower gurney on [DATE] at 10:45 AM revealed the shower gurney was made out of PVC piping mostly and plastic sheet for the bed. The side rails consisted of pvc piping and rose approximately six inches up. The wheels were locked. However, the gurney was able to be moved easily on the dry tile floor. An interview with the DON in the 400 Hall shower room on [DATE] at 10:40 AM revealed. Resident #1 was placed in the shower gurney and then the shower gurney was placed up against the wall of the bathroom. She moved the shower gurney against the wall. The shower gurney was not able to be flush against the wall because there was a grab bar on the wall which prevented it. The bed was actually against the grab bar, not the wall. The DON stated that was the normal way in which residents were bathed in the shower gurney. Interview with CNA F on [DATE] at 5:10 PM revealed she typically left the shower sling in place during when a resident was showered. When the shower was finished, the wet sling got transferred with the resident to a blanket on their bed, where the resident was positioned and a dry sling placed underneath him/her. CNA F was queried how the shower gurneys had been used by staff in the past before they were taken out of rotation. She responded the mesh sling stayed with the resident and did not get removed. She stated there should be one person on each side or the shower gurney and the gurney cannot be up against the wall because the resident could fall off as the gurney was not balanced. Interview with CNA E on [DATE] at 5:15 PM revealed mesh slings were to stay under the resident when they were showered. She stated the CNAs had recently been in-serviced on those topics, but that was protocol before that training anyway. An interview with the ADM on [DATE] at 5:30 PM revealed the shower gurney Resident #1 was on could not have been tilted up, even though that was in the manufacturer ' s instructions. He stated they two shower gurneys they had in-house did not have that option. An interview with Resident #1's family member on [DATE] at 9:23 AM revealed Resident #1 had kept telling the staff at the facility he was not supposed to be showered because he could not stand up and he was afraid of them using the Hoyer lift, because he is a big guy. The family member stated, Staff kept insisting on a shower. The family member said they got Resident #1 up in a sling and dropped him; he did not wake up. She said CPR was done all the way to the hospital where he was in a coma from [DATE]-[DATE]. An interview with Resident #1's wife on [DATE] at 9:40 AM revealed she was at the facility the morning of [DATE]. When she walked down the hall towards Resident #1's room, she heard someone say a man had fallen. She went to the shower room on the hall because she knew Resident #1 had received a shower. She said she did not see him on the shower gurney, only naked on the floor. She said he had been admitted because he was not able to walk, was weak, and had pneumonia. She stated he had a stroke on the left side and had only received bed baths in the recent past. She stated CNA A was training a new aide the morning Resident #1 fell in the shower room. She said when Resident #1 went to the hospital, the medical staff told her it took Resident #1 awhile to come back to 2015. Resident #1's wife stated she felt the facility did not pay enough attention to him. Review of the Operation Instructions for the Shower Bed Model 500# Capacity, dated [DATE], and reflected, When using a lift to transfer the patient in and out of the shower bed, manufacturer recommends keeping the side rails up and locked at all times. Optional Headrest- all shower beds offer an optional headrest. To operate, raise headrest to desired height and lock racket system into place. Precautions: Do not roll user way from you unless there is a partner caregiver on the other side. Interview with the Administrator on [DATE] at 5:30 PM revealed the facility had two shower gurneys that layed flat all the way across, and had no hinge option. Review of the facility's shower gurney policy, dated [DATE], reflected, Purpose: To transport residents in a horizontal position and to use as a platform for showering .Usage Recommendation: Recommended for showering people who are unable to stand or sit in a chair .Procedure: Use caution after showering as gurney will be wet and slippery .Exaggerated user movement in any direction or rolling to the edge may cause the gurney to tip. Review of the facility's Abuse Prohibition Standards of Practice revised [DATE], reflected, Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An IJ was identified on [DATE]. The facility's ADM, DON and ADON were notified at4:45PM on [DATE] of the IJ and a Plan of Removal was requested. An interview with the ADM on [DATE] at 4:55 PM revealed the social worker had remembered completing a care plan meeting where Resident #1's need to not be laid flat were discussed, but she could not locate the actual written care plan reflected that information. An interview with the DON on [DATE] at 5:56 PM revealed what she thought caused the Immediate Jeopardy situation was the positioning of the resident. She said Resident #1 had oxygen on the whole time and when the CNAs put him on the shower bed, his head should have been propped up with pillows. She felt the charge nurse should have instructed the CNAs to do that. An interview with the ADM on [DATE] at 6:05 PM revealed he felt the Immediate Jeopardy situation was caused due to poor nursing assessment that determined the resident could lay flat during a shower. The Plan of Removal was accepted at12:35 PM on [DATE] and reflected the following: In reference to Incident involving (Resident #1)-Plan of Removal for Immediate Jeopardy Relating to Neglect and Quality of Care Please accept this as our plan of Abatement to the deficiencies leading to the Immediate Jeopardy. (ADM) will be responsible for monitoring this plan (Resident #1) was admitted on [DATE] at 6:54 p.m. [DIAGNOSES REDACTED].) COPD with acute respiratory infection (Resident #1) had physician orders [REDACTED]. (Resident #1) was initially assessed on [DATE] by Admission data set. The assessment didn't indicate shower or bathing procedures but that he shouldn't be laid flat. On [DATE], approximately 11a.m. (Resident #1) was transferred to shower gurney, the resident had O2 because the nurse, (LVN I), transferred the O2 from the concentrator to the portable tank. During shower resident became distressed. (Resident became unresponsive to verbal stimuli and eyes were fixed. (CNA A) and (CNA B) (sic). (CNA A) alerted DON who assisted. DON was calling his name and lifted his head to help him to breathe when DON assessed his head was lifted to help him breathe (sic), DON stated resident was breathing checked carotid pulse and it was preset. (CNA A) retrieved sling Resident was breathing but unable to respond. DON made decision to transfer resident. The two C.N.A ' s attempted to roll (Resident #1) to place sling under him while DON held his head up, the bed was secured against the wall, and while turning resident he rolled and fell to the floor. The bed shifted from the wall during the rolling process. The resident fell landing on his left side. There were no apparent injuries due to the fall. Nasal Cannula was on resident. (Resident #1) was rolled on to his back and DON initiated CPR. Crash Cart was obtained. According to statements from (CNA A, CNA B, and DON), O2 was present. O2 nasal cannula was on the resident and on the crash cart which had arrived. (LVN J) called 911. The wife was at the building in the hallway while CPR was ongoing. EMS transported Resident to ER. Resident did not return to facility. Facility has been unable to retrieve any further documentation from hospital. (Resident #1) could have had the option for shower chair but due to his size and not good trunk control it was decided to use a shower gurney. This would a nursing judgment decision. The DON instructed that resident needed a shower. The Nurse instructed CNAs to give a shower. Shower chair did not seem to be valid option due to weight and trunk control. (Resident #1) had been laid flat. C.N.A.'s laid flat because shower bed was a flat surface. According to statements by (CNA A and CNA B) [DATE] 12 pm. (sic) was not in distress initially. (Resident #1) then became during the course of the shower disoriented and unresponsive. Unsure, why resident ' s conditions changed. According to statements, by (CNA A, CNA B and DON) [DATE] at 12pm, resident had O2 in shower room. Policy is resident with continuous O2 should be showered if needed with O2. O2 was connected during shower according to DON by nasal cannula and E tank. The Administrator and

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for of one resident (Resident #1) of 10 residents reviewed for quality of care and neglect. The DON failed to ensure charge nurses elevated Resident #1's head when they placed him on the shower gurney even though they knew he could not lie flat due to his breathing problems per assessments. Charge Nurse, LVN I, failed to ensure CNAs were aware of assessments that identified Resident #1 had difficulty breathing when lying flat on his back and ensure the Hoyer sling was underneath him when they placed him on the gurney. The DON failed to ensure charge nurses checked the oxygen supply on the crash cart and the cart had oxygen. When Resident #1 needed additional oxygen in the shower room the oxygen tank on the crash cart was empty. Resident #1 was lying flat on a shower gurney with no head support and rolled off the shower gurney onto the floor. He stopped breathing, did not have a pulse, CPR was initiated and he was transported to the ER. Resident #1 was placed on a ventilator and diagnosed with [REDACTED]. He was at the hospital for two weeks before transfering to a different nursing facility. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 59 residents who were bariatric and/or full code, by placing them at risk for serious injuries, delayed emergency care, delayed oxygen supply and/or death. Findings included: Review of Resident #1's Face Sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1's admission physician's orders [REDACTED].@ 2 liters per minute via nasal cannula continuously. He was diagnosed with [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] and completed by LVN L, reflected he had irregular breathing, used oxygen via nasal cannula, had an irregular pulse, was unable to breathe lying flat and had range of motion impairment on both sides. Review of Resident #1's MDS assessment dated [DATE] reflected he had mild cognitive impairment, total dependence for bathing with two staff, shortness of breath and trouble breathing with exertion, at rest and while lying flat, and one fall with a major injury since his admission. He was 6'2 and weighed 316 pounds. Review of Resident #1's 72-hour care plan dated [DATE] did not address his respiratory issues, need for oxygen, or his restriction in lying flat. Review of an initial care plan dated [DATE] did not reflect any need for oxygen, his need to be elevated, or that he was a full code. Review of a hand written care plan meeting form dated [DATE] did not address Resident #1's respiratory issues, need for oxygen or his need to not to lie flat. The meeting notes reflected Resident #1 was a full code. The care plan meeting sheet was signed by Resident #1, the social worker, DON, LVN G, ADON and LVN D. Review of an incident report dated [DATE] (unsigned), reflected Nurse notified by another nurse that the resident had fallen out of a shower chair onto the floor. When I came into the shower, room pt was on the floor without a pulse and CPR was initiated while another nurse went and got the crash cart and AED. CPR was continued until 911 arrived at the facility. Review of the facility's Provider Investigation Report dated [DATE] reflected Resident was in distress when trying to reposition. Resident proceeded to lose consciousness. Resident stopped breathing and no pulse evident. CPR initiated. 911 called. Resident was transported via ambulance to hospital. Provider action taken post-investigation as of [DATE] reflected in-services were provided and shower beds were taken out of service. An interview with CNA A on [DATE] at 11:25 AM revealed Resident #1 was large in size and required a two-person lift. CNA A said when he arrived at work on [DATE], LVN I told him the DON said Resident #1 had to take a shower that morning. CNA A stated, The resident had no business being bathed in a shower bed lying down. He stated he worked the weekend Resident #1 admitted to the facility and provided incontinent care to him shortly after his arrival. He said the resident was laid down flat on the bed and kept saying he was going to black out. CNA A stated from the moment of admission, Resident #1 always freaked out if he was laid down. He said Resident #1 told him he was claustrophobic and would panic and be scared that he could not breathe, so CNA A started to do incontinent care with his head of bed elevated and he was okay. CNA A stated on [DATE] he helped CNA B put Resident #1 in a Hoyer lift. He said Resident #1 did not like it and was scared but the DON told the CNAs he had to be showered. When asked why he did not speak up and say something, he responded, I am an aide and I receive orders from above, so I didn't dispute it. But now looking back, I should have spoken up. CNA A said he felt a really good bed bath could have done just as good a job as the resident being showered, with aides using a sheet to move him around in the bed. CNA A stated when they got Resident #1 onto the shower gurney he was fine for about two minutes while they began bathing him. Then he started to panic and said, Lift me up! Lift up my head! I can't breathe! CNA A said he realized Resident #1 looked really scared and he was not pretending. He revealed he left CNA B and went to the nurses' station and told them he needed help because Resident #1 was hard to provide care to. He said the DON said she could help but he did not think she would be able to because she was small of stature. When they got back to the shower room after a few minutes, Resident #1's eyes were rolling back. The DON checked Resident #1's pulse and said he was verbally and physically unresponsive. He was not able to move his eyes and did not react to the DON or any other staff who called his name. CNA A went to get the sling for the Hoyer lift at the DON's request. Continued interview with CNA A on [DATE] at 11:25 AM revealed when he returned with the mechanical lift sling, he said Resident #1 had a large bowel movement and the DON told him and the other CNA they needed to rinse the BM off before rolling him over and putting the sling on him. He said the resident remained unresponsive. He said, I would have just kept going with getting him up but we did what she instructed us to do. CNA A stated the shower gurney wheels were locked the whole time but Resident #1 had been looking squished in the bed because of his girth and the narrowness of the bed. He said he put the side rails down and after they cleaned the BM, and they (CNA A, CNA B and the DON) tried to put the sling underneath him by rolling him over on his side. He said the shower bed moved or slid and Resident #1 fell over the side onto the floor. He said the DON checked his pulse and he was unresponsive, not moving. CNA A revealed the DON told another nurse to get the crash cart and she and a nurse started CPR. He stated he felt the shower gurney was not appropriate for him, because he was too big for it and should have received a bed bath. Period. Interview with CNA B was not attempted as she had terminated her employment with the facility and moved out of state. Her signed witness statement dated [DATE] provided by the ADM reflected she and CNA A transported Resident #1 to the shower gurney via a Hoyer lift and Geri chair. In the shower room, they placed him on the shower gurney via the Hoyer lift and she moved Resident #1 over and took the sling from under him and began showering him. They were showering Resident #1 when he began to complain of discomfort. CNA A left to get help. She continued to rinse off Resident #1 when CNA A returned with the DON. The DON and CNA B went to turn Resident #1 and he fell off the shower bed. Interview with the DON on [DATE] at 10:00 AM revealed the morning of [DATE], she then told Resident #1 he was going to be showered and He said he did not want a shower. He said 'No baby, I don't need one.' The DON said Resident #1 was worried the CNAs did not know how to transfer him. She said she told Resident #1 the lift and Geri-chair would be used and he agreed to it. She said he was more concerned the CNAs did not know how to move him and give him a shower. Later that morning on [DATE], she was at the nurses' station when CNA A stated he needed help turning Resident #1 in the shower room. The DON revealed LVN C was at the nurses' station. The DON said she went into the shower room and saw that Resident #1 was not responsive. He was lying on the shower gurney. She said she raised Resident #1's head, shook it, and there was no response. She stated he was wearing oxygen with a nasal cannula at the time with an e-tank. She stated there was no Hoyer sling under him at the time, but he had been placed on the shower gurney by the aide via a mechanical Hoyer lift. She said CNA A returned to the shower room with a Hoyer sling. She said CNA A and CNA B were present. The DON stated she asked a nurse to get the crash cart. At that time, the DON was still holding Resident #1's head up with he hands because she said it seemed like he was having a hard time breathing. She did not pull him up with staff assistance at that time because he was too heavy and they needed the sling to help them pull him up into a sitting position. She stated the CNAs tried to get the sling underneath Resident #1 on the shower gurney, but he was about 350 pounds. She stated, When we went to put the sling under him, the shower gurney moved and he fell . The DON revealed the shower gurney's wheels were locked at the time and the side rails were up on both sides, including the side from which he fell . The DON said she knew the wheels were locked because she had to unlock them when Resident #1 hit the floor. She stated he fell on to the floor on his side then she and the CNAs moved him onto his back. She checked Resident #1 and he had no pulse. She stated 911 was called and CPR was started. She stated, We used the crash cart because we got the oxygen mask out of there. He needed O2. The DON stated when EMS arrived, they did CPR, and he started breathing then stopped. Then they did CPR again then they took him out to the emergency room . She stated he was in ICU for a while. The DON stated he did not have any injuries from the fall from the shower gurney. She stated after this incident, he did not want to return to the facility. When the DON was queried what she thought had occurred that caused Resident #1 to fall and become unconscious, she responded, Maybe he had an anxiety attack because his wife said he never had a shower recently and he stayed in his wheelchair. Maybe the staff pushed him too strongly to get the sling underneath him. An interview with the DON on [DATE] at 5:44 PM revealed there were four bariatric residents, three who were in bariatric beds. The DON said it was not possible to move Resident #1 to a sitting position because he was wet and did not have full trunk control. The DON was queried how she made the assessment that Resident #1 had stopped breathing. She said she saw that his eyes had opened, then closed. When he fell , she flipped him back over and his abdomen was not moving. She then said she checked his pulse and there was nothing, then CPR was initiated. An interview with LVN C, on [DATE] at 12:54 PM revealed she was at the nurses' station with the DON when CNA A asked the DON if she would help with a resident in the shower room. She stated the DON said to her, C'mon (LVN C). LVN C asked the DON if they could get another person to help them because Resident #1 was a big guy and the DON responded they could do it, and they had done it before the other day. LVN C stated that was true, but it was a dressing change in his room, not a shower room. When they arrived at the shower room, Resident #1's eyes were opened and looking up to the side. He was not responsive. She heard the DON tell one of the CNAs to wash the feces off the resident (he had a bowel movement). LVN C saw the CNAs turn him on his side, trying to clean up the bowel movement and put the sling under him. She stated the side rails were up. When they moved him on his side, he started rolling and rolling, then he fell over the shower gurney rails. She stated she was asked to call 911 when the resident fell and his breathing stopped. She stated in the past, when she had done wound care to Resident #1's buttocks (which occurred once a day), she would have to complete it as fast as possible because she could not lay him down flat; he would complain of difficulty breathing and being claustrophobic. She stated even with the nasal cannula oxygen in his nose, he seemed like he had difficulty breathing when she would interact with him during wound care. LVN C did not know if it was more an issue of anxiety or not. She stated if he told her he could not breathe during wound care, she stopped and would not proceed. LVN C stated, I do not think he should have been showered that way because he shouldn't have been laid down on the shower bed. Prior to the shower and fall, he had been given bed bathes by the aides per LVN C. She stated he did not want to go to the shower, he was anxious and claustrophobic. LVN C stated, This could have been prevented by not making him go to a shower and taking a bed bath. An interview with LVN I on [DATE] at 1:24 PM revealed she knew Resident #1 was on continuous oxygen because it was in his chart. She said after he admitted to the facility, she asked one of the CNAs to provide incontinent care and observed Resident#1 become fearful of being laid down, even with his oxygen connected. She said he was anxious and was scared he would not be able to breathe. He had received bed baths for the five days he had been at the facility, but she was concerned his feces was embedded in his wound bandages on his buttocks. On [DATE], around ,[DATE]:30 AM, the DON came to her and said he needed to be showered. She said the DON was aware he had been putting the showers off. LVN I said Resident #1 was fine with the shower. She got an e-tank ready for him out of the supply closet and hooked him to it via a nasal cannula. She said everything seemed fine. She told the CNAs to shower him but did not specify via shower chair or shower gurney. Because he was obese, she said he would not have fit in the shower chair; it could not hold over 300 pounds. Since the shower chair was impossible, the shower gurney was the only option. She said Resident #1 was capable of sitting up in the shower chair but did lean to the side. Not being showered in a chair was an issue of size. She said ,[DATE] minutes after CNA A and CNA B took him to the shower room, LVN C came to tell her Resident #1 fell . LVN I said she got her blood pressure cuff and went to the shower room. When she got there, she saw CNA A, CNA B and the DON kneeled down next to Resident #1. CNA B was checking his carotid artery and the DON was checking his radial pulse. She said Resident #1 was on the floor and he was blue. CNA B told her he was not breathing. LVN I stated she started CPR. LVN I said Resident #1 had a nasal cannula tube in his nose but it was not connected to the e-tank which was nearby. She did not know why it was not connected but called out for someone to connect it. After the nasal cannula was connected, she saw there was no oxygen coming out. She did not know why. She said by that time, a crash cart was brought in by the ADON and she helped him start the AED while LVN C called 911. The e-tank on the crash cart did not have any oxygen in it, according to LVN I. She said the ADON and LVN D tried to turn it on, but there was nothing, it was empty. Then she went to get Resident #1's oxygen concentrator from his room. LVN I said Resident #1 started breathing again, but was making gurgling sounds. She said she told the DON to tilt his head back so he could breathe. She observed Resident #1's lips to be blue in color. LVN I stated the e-tank on the crash cart was supposed to be full. She did not know why it was not full. She stated she, the ADON and the DON did chest compressions until the paramedics arrived. An interview with the LVN D on [DATE] at 1:20 PM revealed she was walking the 400 Hall when she heard a boom, went into the shower room and saw Resident #1 on the floor on his side facing the wall. She stated she went in, and the DON and two CNAs tried to roll him on his back. She stated he was breathing at that time. She said they were calling out his name but he was not responding. She stated he had no oxygen on him at the time she saw him. She stated she knew he did not have his oxygen on him because someone had to go and get the portable crash cart which had oxygen on it and she was the one who had opened up a new nasal cannula tube for him to use. LVN D stated the first O2 tank from the crash cart did not work, so another portable O2 was brought and it did not work then a concentrator was found, which worked. She said at that point, Resident #1 had already stopped breathing so the ADON brought in a defibrillator. She stated chest compressions were started first by the DON who had determined his heart had stopped. LVN D stated Resident #1 had respiratory issues and could not tolerate lying flat from what she had heard about him after his admission. She stated whenever he had been laid flat over the past few days he was at the facility, he would say, No. No. I can't breathe laying down flat! She said Resident #1 told staff and management knew through talking amongst the staff that he did not want to take a shower because it got hot in the shower room, and when he laid flat, he could not breathe. She confirmed it was hot in the shower room when she saw Resident #1 on the floor. LVN D stated, I don't see why a resident cannot have O2 in the shower room. They could have used an oxygen tank. The aides wouldn't have known to do that, the nurse would have needed to tell them to take the O2 or check his stats ahead to see. LVN D stated she felt the shower gurney was too narrow for a bariatric resident. She said the action of getting the mesh sling for the Hoyer lift after he was found unresponsive was immaterial and he should have been provided emergency care where he was, instead of staff trying to move him. LVN D stated a care plan meeting had taken place the day prior to Resident #1's fall, where it was documented that he should not be placed lying down on his back. When asked what she felt the failure was with Resident #1, she responded, I don't feel that he should have never even gone to the shower room. I don't think he should have been lying flat if he has respiratory issues. There should have been another person on the other side of the shower bed. It was not effective, he was wet. I think that could have prevented him from falling, especially for a bariatric person. To roll him over on a wet shower gurney with no one on the other side is bad. An interview with the DON on [DATE] at 3:27 PM revealed the reason there was not a person on each side of Resident #1's shower gurney during the incident was because it was an emergency. She stated Resident #1 had known respiratory issues. She said if a resident had continuous oxygen, it was done with the shower. She stated the LVN I had set Resident #1 up for an e-tank prior to his shower and he had oxygen on during the shower. She thought she may have turned it up at one point and then someone brought in an oxygen concentrator which was used when he fell and after he stopped breathing. She stated she saw his initial assessment when he admitted to the facility. The DON was asked why the CNAs did not elevate his head when he was laid on the shower gurney. She responded the CNAs would not have known to do that and the charge nurse should have advised them. She stated the CNAs, charge nurse and herself should have known Resident #1 had a problem with breathing in a flat on back position. Review of the local EMS Patient Care Report dated [DATE], reflected they arrived and found Resident #1 lying on the floor of the shower room unconscious and unresponsive. The EMS responder noticed Resident #1 was apneic (suspension of breathing) and pulseless. Chest compressions were started, pads placed and monitored. Resident #1 was transported to the hospital. Review of hospital medical and discharge records from [DATE] through [DATE] reflected Resident #1 was admitted on [DATE] through the emergency room with status [REDACTED]. Resident #1 was found by EMS without a pulse at the nursing home. Upon arrival at the ER, he was found to have labored breathing and he was placed on ventilator support. He was found to have healthcare-acquired pneumonia. He also developed acute [MEDICAL CONDITION] which was further complicated by significant pneumonitis. Due to his loss of consciousness prior to admission, he received an EEG that was abnormal due to [MEDICAL CONDITION] (malfunction of the brain). Further interview with the DON on [DATE] at 5:05 PM revealed the night nurses were responsible for ensuring the crash carts were stocked and accurate. She said there was an inventory checklist that had to be completed by the night nurse every day and if anything was missing, it went on the 24 hour report, which was then discussed during the weekday morning nursing meeting. She stated as the DON, she checked the crash cart periodically but not daily. She stated e-tanks were the oxygen used on the crash cart. She stated the reason she had staff bring her one from the crash cart was because Resident #1 ' s e-tank he had from his room in the shower, had run out of oxygen. She stated the second oxygen tank that was brought in from the crash cart was fine and had a sufficient supply of oxygen and could last seven to eight hours continuously, but she wanted him to be on the concentrator because it was stronger. She felt she did not know how long it would take EMS to arrive so she wanted to switch him over to the concentrator. The DON said she the oxygen would not have helped Resident #1 breathe when we lost him and he stopped breathing. She stated that was when the chest compressions and intubation (bagging) was used. The DON was queried why she tendered her resignation to the facility after the investigation had begun into the incident. She stated that she knew what happened to Resident #1 was not entirely her fault, but as the DON, she felt responsible for what happened to him. Observation of the shower rooms on the 400 and 100 Hall of the facility and a shower gurney on [DATE] at 10:45 AM revealed the shower gurney was made out of PVC piping mostly and plastic sheet for the bed. The side rails consisted of pvc piping and rose approximately six inches up. The wheels were locked. However, the gurney was able to be moved easily on the dry tile floor. An interview with the DON in the 400 Hall shower room on [DATE] at 10:40 AM revealed. Resident #1 was placed in the shower gurney and then the shower gurney was placed up against the wall of the bathroom. She moved the shower gurney against the wall. The shower gurney was not able to be flush against the wall because there was a grab bar on the wall which prevented it. The bed was actually against the grab bar, not the wall. The DON stated that was the normal way in which residents were bathed in the shower gurney. Interview with CNA F on [DATE] at 5:10 PM revealed she typically left the shower sling in place during when a resident was showered. When the shower was finished, the wet sling got transferred with the resident to a blanket on their bed, where the resident was positioned and a dry sling placed underneath him/her. CNA F was queried how the shower gurneys had been used by staff in the past before they were taken out of rotation. She responded the mesh sling stayed with the resident and did not get removed. She stated there should be one person on each side or the shower gurney and the gurney cannot be up against the wall because the resident could fall off as the gurney was not balanced. Interview with CNA E on [DATE] at 5:15 PM revealed mesh slings were to stay under the resident when they were showered. She stated the CNAs had recently been in-serviced on those topics, but that was protocol before that training anyway. An interview with the ADM on [DATE] at 5:30 PM revealed the shower gurney Resident #1 was on could not have been tilted up, even though that was in the manufacturer ' s instructions. He stated they two shower gurneys they had in-house did not have that option. An interview with Resident #1's family member on [DATE] at 9:23 AM revealed Resident #1 had kept telling the staff at the facility he was not supposed to be showered because he could not stand up and he was afraid of them using the Hoyer lift, because he is a big guy. The family member stated, Staff kept insisting on a shower. The family member said they got Resident #1 up in a sling and dropped him; he did not wake up. She said CPR was done all the way to the hospital where he was in a coma from [DATE]-[DATE]. An interview with Resident #1's wife on [DATE] at 9:40 AM revealed she was at the facility the morning of [DATE]. When she walked down the hall towards Resident #1's room, she heard someone say a man had fallen. She went to the shower room on the hall because she knew Resident #1 had received a shower. She said she did not see him on the shower gurney, only naked on the floor. She said he had been admitted because he was not able to walk, was weak, and had pneumonia. She stated he had a stroke on the left side and had only received bed baths in the recent past. She stated CNA A was training a new aide the morning Resident #1 fell in the shower room. She said when Resident #1 went to the hospital, the medical staff told her it took Resident #1 awhile to come back to 2015. Resident #1's wife stated she felt the facility did not pay enough attention to him. Review of the Operation Instructions for the Shower Bed Model 500# Capacity, dated [DATE], and reflected, When using a lift to transfer the patient in and out of the shower bed, manufacturer recommends keeping the side rails up and locked at all times. Optional Headrest- all shower beds offer an optional headrest. To operate, raise headrest to desired height and lock racket system into place. Precautions: Do not roll user way from you unless there is a partner caregiver on the other side. Review of the facility's shower gurney policy, dated [DATE], reflected, Purpose: To transport residents in a horizontal position and to use as a platform for showering .Usage Recommendation: Recommended for showering people who are unable to stand or sit in a chair .Procedure: Use caution after showering as gurney will be wet and slippery .Exaggerated user movement in any direction or rolling to the edge may cause the gurney to tip. Review of the facility's Abuse Prohibition Standards of Practice revised [DATE], reflected, Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. An IJ was identified on [DATE]. The facility's ADM, DON and ADON were notified at4:45PM on [DATE] of the IJ and a Plan of Removal was requested. An interview with the ADM on [DATE] at 4:55 PM revealed the social worker had remembered completing a care plan meeting where Resident #1's need to not be laid flat were discussed, but she could not locate the actual written care plan reflected that information. An interview with the DON on [DATE] at 5:56 PM revealed what she thought caused the Immediate Jeopardy situation was the positioning of the resident. She said Resident #1 had oxygen on the whole time and when the CNAs put him on the shower bed, his head should have been propped up with pillows. She felt the charge nurse should have instructed the CNAs to do that. An interview with the ADM on [DATE] at 6:05 PM revealed he felt the Immediate Jeopardy situation was caused due to poor nursing assessment that determined the resident could lay flat during a shower. The Plan of Removal was accepted at12:35 PM on [DATE] and reflected the following: In reference to Incident involving (Resident #1)-Plan of Removal for Immediate Jeopardy Relating to Neglect and Quality of Care Please accept this as our plan of Abatement to the deficiencies leading to the Immediate Jeopardy. (ADM) will be responsible for monitoring this plan (Resident #1) was admitted on [DATE] at 6:54 p.m. [DIAGNOSES REDACTED].) [MEDICAL CONDITION] with acute respiratory infection (Resident #1) had physician orders [REDACTED]. (Resident #1) was initially assessed on [DATE] by Admission data set. The assessment didn't indicate shower or bathing procedures but that he shouldn't be laid flat. On [DATE], approximately 11a.m. (Resident #1) was transferred to shower gurney, the resident had O2 because the nurse, (LVN I), transferred the O2 from the concentrator to the portable tank. During shower resident became distressed. (Resident became unresponsive to verbal stimuli and eyes were fixed. (CNA A) and (CNA B) (sic). (CNA A) alerted DON who assisted. DON was calling his name and lifted his head to help him to breathe when DON assessed his head was lifted to help him breathe (sic), DON stated resident was breathing checked carotid pulse and it was preset. (CNA A) retrieved sling Resident was breathing but unable to respond. DON made decision to transfer resident. The two C.N.A ' s attempted to roll (Resident #1) to place sling under him while DON held his head up, the bed was secured against the wall, and while turning resident he rolled and fell to the floor. The bed shifted from the wall during the rolling process. The resident fell landing on his left side. There were no apparent injuries due to the fall. Nasal Cannula was on resident. (Resident #1) was rolled on to his back and DON initiated CPR. Crash Cart was obtained. According to statements from (CNA A, CNA B, and DON), O2 was present. O2 nasal cannula was on the resident and on the crash cart which had arrived. (LVN J) called 911. The wife was at the building in the hallway while CPR was ongoing. EMS transported Resident to ER. Resident did not return to facility. Facility has been unable to retrieve any further documentation from hospital. (Resident #1) could have had the option for shower chair but due to his size and not good trunk control it was decided to use a shower gurney. This would a nursing judgment decision. The DON instructed that resident needed a shower. The Nurse instructed CNAs to give a shower. Shower chair did not seem to be valid option due to weight and trunk control. (Resident #1) had been laid flat. C.N.A.'s laid flat because shower bed was a flat surface. According to statements by (CNA A and CNA B) [DATE] 12 pm. (sic) was not in distress initially. (Resident #1) then became during the course of the shower disoriented and unresponsive. Unsure, why resident ' s conditio

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 10 residents reviewed for neglect. 1. CNAs A and B failed to keep the Hoyer lift sling underneath Resident #1 when he was placed on the shower gurney. 2. Staff failed to elevate Resident #1 ' s head when they placed him on the shower gurney even though they knew he could not lie flat due to his breathing problems. 3. The DON failed to initiate emergency care by moving Resident #1 into a sitting position with staff assistance to help him breathe. 4. The DON failed to have staff on both sides of the shower gurney, according to manufacturer ' s instructions, when they tried to roll Resident #1 to put the Hoyer lift sling underneath him. 5. The facility failed to have a full oxygen tank on the crash cart when it was brought to the shower room for Resident #1. Resident #1 was lying flat on a shower gurney with no head support and rolled off the shower gurney onto the floor. He stopped breathing, did not have a pulse, CPR was initiated and he was transported to the ER. Resident #1 was placed on a ventilator and diagnosed with [REDACTED]. He was at the hospital for two weeks before transferring to a different nursing facility. On [DATE] at 4:45 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 59 residents who were bariatric and/or full code, by placing them at risk for serious injuries, delayed emergency care, delayed oxygen supply and/or death. Findings included: Review of the facility's Abuse Prohibition Standards of Practice revised [DATE], reflected, Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the facility's shower gurney policy, dated [DATE], reflected, Purpose: To transport residents in a horizontal position and to use as a platform for showering .Usage Recommendation: Recommended for showering people who are unable to stand or sit in a chair .Procedure: Use caution after showering as gurney will be wet and slippery .Exaggerated user movement in any direction or rolling to the edge may cause the gurney to tip. Review of Resident #1's Face Sheet dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #1's admission physician's orders [REDACTED].@ 2 liters per minute via nasal cannula continuously. He was diagnosed with [REDACTED]. Review of Resident #1's Admission assessment dated [DATE] and completed by LVN L, reflected he had irregular breathing, used oxygen via nasal cannula, had an irregular pulse, was unable to breathe lying flat and had range of motion impairment on both sides. Review of Resident #1's MDS assessment dated [DATE] reflected he had mild cognitive impairment, total dependence for bathing with two staff, shortness of breath and trouble breathing with exertion, at rest and while lying flat, and one fall with a major injury since his admission. He was 6'2 and weighed 316 pounds. Review of Resident #1's 72-hour care plan dated [DATE] did not address his respiratory issues, need for oxygen, or his restriction in lying flat. Review of an initial care plan dated [DATE] did not reflect any need for oxygen, his need to be elevated, or that he was a full code. Review of a hand written care plan meeting form dated [DATE] did not address Resident #1's respiratory issues, need for oxygen or his need to not to lie flat. The meeting notes reflected Resident #1 was a full code. The care plan meeting sheet was signed by Resident #1, the social worker, DON, LVN G, ADON and LVN D. Review of an incident report dated [DATE] (unsigned), reflected Nurse notified by another nurse that the resident had fallen out of a shower chair onto the floor. When I came into the shower, room pt was on the floor without a pulse and CPR was initiated while another nurse went and got the crash cart and AED. CPR was continued until 911 arrived at the facility. Review of the facility's Provider Investigation Report dated [DATE] reflected Resident was in distress when trying to reposition. Resident proceeded to lose consciousness. Resident stopped breathing and no pulse evident. CPR initiated. 911 called. Resident was transported via ambulance to hospital. Provider action taken post-investigation as of [DATE] reflected in-services were provided and shower beds were taken out of service. An interview with CNA A on [DATE] at 11:25 AM revealed Resident #1 was large in size and required a two-person lift. CNA A said when he arrived at work on [DATE], LVN I told him the DON said Resident #1 had to take a shower that morning. CNA A stated, The resident had no business being bathed in a shower bed lying down. He stated he worked the weekend Resident #1 admitted to the facility and provided incontinent care to him shortly after his arrival. He said the resident was laid down flat on the bed and kept saying he was going to black out. CNA A stated from the moment of admission, Resident #1 always freaked out if he was laid down. He said Resident #1 told him he was claustrophobic and would panic and be scared that he could not breathe, so CNA A started to do incontinent care with his head of bed elevated and he was okay. CNA A stated on [DATE] he helped CNA B put Resident #1 in a Hoyer lift. He said Resident #1 did not like it and was scared but the DON told the CNAs he had to be showered. When asked why he did not speak up and say something, he responded, I am an aide and I receive orders from above, so I didn't dispute it. But now looking back, I should have spoken up. CNA A said he felt a really good bed bath could have done just as good a job as the resident being showered, with aides using a sheet to move him around in the bed. CNA A stated when they got Resident #1 onto the shower gurney he was fine for about two minutes while they began bathing him. Then he started to panic and said, Lift me up! Lift up my head! I can't breathe! CNA A said he realized Resident #1 looked really scared and he was not pretending. He revealed he left CNA B and went to the nurses' station and told them he needed help because Resident #1 was hard to provide care to. He said the DON said she could help but he did not think she would be able to because she was small of stature. When they got back to the shower room after a few minutes, Resident #1's eyes were rolling back. The DON checked Resident #1's pulse and said he was verbally and physically unresponsive. He was not able to move his eyes and did not react to the DON or any other staff who called his name. CNA A went to get the sling for the Hoyer lift at the DON's request. Continued interview with CNA A on [DATE] at 11:25 AM revealed when he returned with the mechanical lift sling, he said Resident #1 had a large bowel movement and the DON told him and the other CNA they needed to rinse the BM off before rolling him over and putting the sling on him. He said the resident remained unresponsive. He said, I would have just kept going with getting him up but we did what she instructed us to do. CNA A stated the shower gurney wheels were locked the whole time but Resident #1 had been looking squished in the bed because of his girth and the narrowness of the bed. He said he put the side rails down and after they cleaned the BM, and they (CNA A, CNA B and the DON) tried to put the sling underneath him by rolling him over on his side. He said the shower bed moved or slid and Resident #1 fell over the side onto the floor. He said the DON checked his pulse and he was unresponsive, not moving. CNA A revealed the DON told another nurse to get the crash cart and she and a nurse started CPR. He stated he felt the shower gurney was not appropriate for him, because he was too big for it and should have received a bed bath. Period. Interview with CNA B was not attempted as she had terminated her employment with the facility and moved out of state. Her signed witness statement dated [DATE] provided by the ADM reflected she and CNA A transported Resident #1 to the shower gurney via a Hoyer lift and Geri chair. In the shower room, they placed him on the shower gurney via the Hoyer lift and she moved Resident #1 over and took the sling from under him and began showering him. They were showering Resident #1 when he began to complain of discomfort. CNA A left to get help. She continued to rinse off Resident #1 when CNA A returned with the DON. The DON and CNA B went to turn Resident #1 and he fell off the shower bed. Interview with the DON on [DATE] at 10:00 AM revealed the morning of [DATE], she then told Resident #1 he was going to be showered and He said he did not want a shower. He said 'No baby, I don't need one.' The DON said Resident #1 was worried the CNAs did not know how to transfer him. She said she told Resident #1 the lift and Geri-chair would be used and he agreed to it. She said he was more concerned the CNAs did not know how to move him and give him a shower. Later that morning on [DATE], she was at the nurses' station when CNA A stated he needed help turning Resident #1 in the shower room. The DON revealed LVN C was at the nurses' station. The DON said she went into the shower room and saw that Resident #1 was not responsive. He was lying on the shower gurney. She said she raised Resident #1's head, shook it, and there was no response. She stated he was wearing oxygen with a nasal cannula at the time with an e-tank. She stated there was no Hoyer sling under him at the time, but he had been placed on the shower gurney by the aide via a mechanical Hoyer lift. She said CNA A returned to the shower room with a Hoyer sling. She said CNA A and CNA B were present. The DON stated she asked a nurse to get the crash cart. At that time, the DON was still holding Resident #1's head up with he hands because she said it seemed like he was having a hard time breathing. She did not pull him up with staff assistance at that time because he was too heavy and they needed the sling to help them pull him up into a sitting position. She stated the CNAs tried to get the sling underneath Resident #1 on the shower gurney, but he was about 350 pounds. She stated, When we went to put the sling under him, the shower gurney moved and he fell . The DON revealed the shower gurney's wheels were locked at the time and the side rails were up on both sides, including the side from which he fell . The DON said she knew the wheels were locked because she had to unlock them when Resident #1 hit the floor. She stated he fell on to the floor on his side then she and the CNAs moved him onto his back. She checked Resident #1 and he had no pulse. She stated 911 was called and CPR was started. She stated, We used the crash cart because we got the oxygen mask out of there. He needed O2. The DON stated when EMS arrived, they did CPR, and he started breathing then stopped. Then they did CPR again then they took him out to the emergency room . She stated he was in ICU for a while. The DON stated he did not have any injuries from the fall from the shower gurney. She stated after this incident, he did not want to return to the facility. When the DON was queried what she thought had occurred that caused Resident #1 to fall and become unconscious, she responded, Maybe he had an anxiety attack because his wife said he never had a shower recently and he stayed in his wheelchair. Maybe the staff pushed him too strongly to get the sling underneath him. An interview with the DON on [DATE] at 5:44 PM revealed there were four bariatric residents, three who were in bariatric beds. The DON said it was not possible to move Resident #1 to a sitting position because he was wet and did not have full trunk control. The DON was queried how she made the assessment that Resident #1 had stopped breathing. She said she saw that his eyes had opened, then closed. When he fell , she flipped him back over and his abdomen was not moving. She then said she checked his pulse and there was nothing, then CPR was initiated. An interview with LVN C, on [DATE] at 12:54 PM revealed she was at the nurses' station with the DON when CNA A asked the DON if she would help with a resident in the shower room. She stated the DON said to her, C'mon (LVN C). LVN C asked the DON if they could get another person to help them because Resident #1 was a big guy and the DON responded they could do it, and they had done it before the other day. LVN C stated that was true, but it was a dressing change in his room, not a shower room. When they arrived at the shower room, Resident #1's eyes were opened and looking up to the side. He was not responsive. She heard the DON tell one of the CNAs to wash the feces off the resident (he had a bowel movement). LVN C saw the CNAs turn him on his side, trying to clean up the bowel movement and put the sling under him. She stated the side rails were up. When they moved him on his side, he started rolling and rolling, then he fell over the shower gurney rails. She stated she was asked to call 911 when the resident fell and his breathing stopped. She stated in the past, when she had done wound care to Resident #1's buttocks (which occurred once a day), she would have to complete it as fast as possible because she could not lay him down flat; he would complain of difficulty breathing and being claustrophobic. She stated even with the nasal cannula oxygen in his nose, he seemed like he had difficulty breathing when she would interact with him during wound care. LVN C did not know if it was more an issue of anxiety or not. She stated if he told her he could not breathe during wound care, she stopped and would not proceed. LVN C stated, I do not think he should have been showered that way because he shouldn't have been laid down on the shower bed. Prior to the shower and fall, he had been given bed bathes by the aides per LVN C. She stated he did not want to go to the shower, he was anxious and claustrophobic. LVN C stated, This could have been prevented by not making him go to a shower and taking a bed bath. An interview with LVN I on [DATE] at 1:24 PM revealed she knew Resident #1 was on continuous oxygen because it was in his chart. She said after he admitted to the facility, she asked one of the CNAs to provide incontinent care and observed Resident#1 become fearful of being laid down, even with his oxygen connected. She said he was anxious and was scared he would not be able to breathe. He had received bed baths for the five days he had been at the facility, but she was concerned his feces was embedded in his wound bandages on his buttocks. On [DATE], around ,[DATE]:30 AM, the DON came to her and said he needed to be showered. She said the DON was aware he had been putting the showers off. LVN I said Resident #1 was fine with the shower. She got an e-tank ready for him out of the supply closet and hooked him to it via a nasal cannula. She said everything seemed fine. She told the CNAs to shower him but did not specify via shower chair or shower gurney. Because he was obese, she said he would not have fit in the shower chair; it could not hold over 300 pounds. Since the shower chair was impossible, the shower gurney was the only option. She said Resident #1 was capable of sitting up in the shower chair but did lean to the side. Not being showered in a chair was an issue of size. She said ,[DATE] minutes after CNA A and CNA B took him to the shower room, LVN C came to tell her Resident #1 fell . LVN I said she got her blood pressure cuff and went to the shower room. When she got there, she saw CNA A, CNA B and the DON kneeled down next to Resident #1. CNA B was checking his carotid artery and the DON was checking his radial pulse. She said Resident #1 was on the floor and he was blue. CNA B told her he was not breathing. LVN I stated she started CPR. LVN I said Resident #1 had a nasal cannula tube in his nose but it was not connected to the e-tank which was nearby. She did not know why it was not connected but called out for someone to connect it. After the nasal cannula was connected, she saw there was no oxygen coming out. She did not know why. She said by that time, a crash cart was brought in by the ADON and she helped him start the AED while LVN C called 911. The e-tank on the crash cart did not have any oxygen in it, according to LVN I. She said the ADON and LVN D tried to turn it on, but there was nothing, it was empty. Then she went to get Resident #1's oxygen concentrator from his room. LVN I said Resident #1 started breathing again, but was making gurgling sounds. She said she told the DON to tilt his head back so he could breathe. She observed Resident #1's lips to be blue in color. LVN I stated the e-tank on the crash cart was supposed to be full. She did not know why it was not full. She stated she, the ADON and the DON did chest compressions until the paramedics arrived. An interview with the LVN D on [DATE] at 1:20 PM revealed she was walking the 400 Hall when she heard a boom, went into the shower room and saw Resident #1 on the floor on his side facing the wall. She stated she went in, and the DON and two CNAs tried to roll him on his back. She stated he was breathing at that time. She said they were calling out his name but he was not responding. She stated he had no oxygen on him at the time she saw him. She stated she knew he did not have his oxygen on him because someone had to go and get the portable crash cart which had oxygen on it and she was the one who had opened up a new nasal cannula tube for him to use. LVN D stated the first O2 tank from the crash cart did not work, so another portable O2 was brought and it did not work then a concentrator was found, which worked. She said at that point, Resident #1 had already stopped breathing so the ADON brought in a defibrillator. She stated chest compressions were started first by the DON who had determined his heart had stopped. LVN D stated Resident #1 had respiratory issues and could not tolerate lying flat from what she had heard about him after his admission. She stated whenever he had been laid flat over the past few days he was at the facility, he would say, No. No. I can't breathe laying down flat! She said Resident #1 told staff and management knew through talking amongst the staff that he did not want to take a shower because it got hot in the shower room, and when he laid flat, he could not breathe. She confirmed it was hot in the shower room when she saw Resident #1 on the floor. LVN D stated, I don't see why a resident cannot have O2 in the shower room. They could have used an oxygen tank. The aides wouldn't have known to do that, the nurse would have needed to tell them to take the O2 or check his stats ahead to see. LVN D stated she felt the shower gurney was too narrow for a bariatric resident. She said the action of getting the mesh sling for the Hoyer lift after he was found unresponsive was immaterial and he should have been provided emergency care where he was, instead of staff trying to move him. LVN D stated a care plan meeting had taken place the day prior to Resident #1's fall, where it was documented that he should not be placed lying down on his back. When asked what she felt the failure was with Resident #1, she responded, I don't feel that he should have never even gone to the shower room. I don't think he should have been lying flat if he has respiratory issues. There should have been another person on the other side of the shower bed. It was not effective, he was wet. I think that could have prevented him from falling, especially for a bariatric person. To roll him over on a wet shower gurney with no one on the other side is bad. An interview with the DON on [DATE] at 3:27 PM revealed the reason there was not a person on each side of Resident #1's shower gurney during the incident was because it was an emergency. She stated Resident #1 had known respiratory issues. She said if a resident had continuous oxygen, it was done with the shower. She stated the LVN I had set Resident #1 up for an e-tank prior to his shower and he had oxygen on during the shower. She thought she may have turned it up at one point and then someone brought in an oxygen concentrator which was used when he fell and after he stopped breathing. She stated she saw his initial assessment when he admitted to the facility. The DON was asked why the CNAs did not elevate his head when he was laid on the shower gurney. She responded the CNAs would not have known to do that and the charge nurse should have advised them. She stated the CNAs, charge nurse and herself should have known Resident #1 had a problem with breathing in a flat on back position. Review of the local EMS Patient Care Report dated [DATE], reflected they arrived and found Resident #1 lying on the floor of the shower room unconscious and unresponsive. The EMS responder noticed Resident #1 was apneic (suspension of breathing) and pulseless. Chest compressions were started, pads placed and monitored. Resident #1 was transported to the hospital. Review of hospital medical and discharge records from [DATE] through [DATE] reflected Resident #1 was admitted on [DATE] through the emergency room with status [REDACTED]. Resident #1 was found by EMS without a pulse at the nursing home. Upon arrival at the ER, he was found to have labored breathing and he was placed on ventilator support. He was found to have healthcare-acquired pneumonia. He also developed acute [MEDICAL CONDITION] which was further complicated by significant pneumonitis. Due to his loss of consciousness prior to admission, he received an EEG that was abnormal due to [MEDICAL CONDITION] (malfunction of the brain). Further interview with the DON on [DATE] at 5:05 PM revealed the night nurses were responsible for ensuring the crash carts were stocked and accurate. She said there was an inventory checklist that had to be completed by the night nurse every day and if anything was missing, it went on the 24 hour report, which was then discussed during the weekday morning nursing meeting. She stated as the DON, she checked the crash cart periodically but not daily. She stated e-tanks were the oxygen used on the crash cart. She stated the reason she had staff bring her one from the crash cart was because Resident #1 ' s e-tank he had from his room in the shower, had run out of oxygen. She stated the second oxygen tank that was brought in from the crash cart was fine and had a sufficient supply of oxygen and could last seven to eight hours continuously, but she wanted him to be on the concentrator because it was stronger. She felt she did not know how long it would take EMS to arrive so she wanted to switch him over to the concentrator. The DON said she the oxygen would not have helped Resident #1 breathe when we lost him and he stopped breathing. She stated that was when the chest compressions and intubation (bagging) was used. The DON was queried why she tendered her resignation to the facility after the investigation had begun into the incident. She stated that she knew what happened to Resident #1 was not entirely her fault, but as the DON, she felt responsible for what happened to him. Observation of the shower rooms on the 400 and 100 Hall of the facility and a shower gurney on [DATE] at 10:45 AM revealed the shower gurney was made out of PVC piping mostly and plastic sheet for the bed. The side rails consisted of pvc piping and rose approximately six inches up. The wheels were locked. However, the gurney was able to be moved easily on the dry tile floor. An interview with the DON in the 400 Hall shower room on [DATE] at 10:40 AM revealed. Resident #1 was placed in the shower gurney and then the shower gurney was placed up against the wall of the bathroom. She moved the shower gurney against the wall. The shower gurney was not able to be flush against the wall because there was a grab bar on the wall which prevented it. The bed was actually against the grab bar, not the wall. The DON stated that was the normal way in which residents were bathed in the shower gurney. Interview with CNA F on [DATE] at 5:10 PM revealed she typically left the shower sling in place during when a resident was showered. When the shower was finished, the wet sling got transferred with the resident to a blanket on their bed, where the resident was positioned and a dry sling placed underneath him/her. CNA F was queried how the shower gurneys had been used by staff in the past before they were taken out of rotation. She responded the mesh sling stayed with the resident and did not get removed. She stated there should be one person on each side or the shower gurney and the gurney cannot be up against the wall because the resident could fall off as the gurney was not balanced. Interview with CNA E on [DATE] at 5:15 PM revealed mesh slings were to stay under the resident when they were showered. She stated the CNAs had recently been in-serviced on those topics, but that was protocol before that training anyway. An interview with the ADM on [DATE] at 5:30 PM revealed the shower gurney Resident #1 was on could not have been tilted up, even though that was in the manufacturer ' s instructions. He stated they two shower gurneys they had in-house did not have that option. An interview with Resident #1's family member on [DATE] at 9:23 AM revealed Resident #1 had kept telling the staff at the facility he was not supposed to be showered because he could not stand up and he was afraid of them using the Hoyer lift, because he is a big guy. The family member stated, Staff kept insisting on a shower. The family member said they got Resident #1 up in a sling and dropped him; he did not wake up. She said CPR was done all the way to the hospital where he was in a coma from [DATE]-[DATE]. An interview with Resident #1's wife on [DATE] at 9:40 AM revealed she was at the facility the morning of [DATE]. When she walked down the hall towards Resident #1's room, she heard someone say a man had fallen. She went to the shower room on the hall because she knew Resident #1 had received a shower. She said she did not see him on the shower gurney, only naked on the floor. She said he had been admitted because he was not able to walk, was weak, and had pneumonia. She stated he had a stroke on the left side and had only received bed baths in the recent past. She stated CNA A was training a new aide the morning Resident #1 fell in the shower room. She said when Resident #1 went to the hospital, the medical staff told her it took Resident #1 awhile to come back to 2015. Resident #1's wife stated she felt the facility did not pay enough attention to him. Review of the Operation Instructions for the Shower Bed Model 500# Capacity, dated [DATE], and reflected, When using a lift to transfer the patient in and out of the shower bed, manufacturer recommends keeping the side rails up and locked at all times. Optional Headrest- all shower beds offer an optional headrest. To operate, raise headrest to desired height and lock racket system into place. Precautions: Do not roll user way from you unless there is a partner caregiver on the other side. An IJ was identified on [DATE]. The facility's ADM, DON and ADON were notified at4:45PM on [DATE] of the IJ and a Plan of Removal was requested. An interview with the ADM on [DATE] at 4:55 PM revealed the social worker had remembered completing a care plan meeting where Resident #1 ' s need to not be laid flat were discussed, but she could not locate the actual written care plan reflected that information. An interview with the DON on [DATE] at 5:56 PM revealed what she thought caused the Immediate Jeopardy situation was the positioning of the resident. She said Resident #1 had oxygen on the whole time and when the CNAs put him on the shower bed, his head should have been propped up with pillows. She felt the charge nurse should have instructed the CNAs to do that. An interview with the ADM on [DATE] at 6:05 PM revealed he felt the Immediate Jeopardy situation was caused due to poor nursing assessment that determined the resident could lay flat during a shower. The Plan of Removal was accepted at12:35 PM on [DATE] and reflected the following: In reference to Incident involving (Resident #1)-Plan of Removal for Immediate Jeopardy Relating to Neglect and Quality of Care Please accept this as our plan of Abatement to the deficiencies leading to the Immediate Jeopardy. (ADM) will be responsible for monitoring this plan (Resident #1) was admitted on [DATE] at 6:54 p.m. [DIAGNOSES REDACTED].) [MEDICAL CONDITION] with acute respiratory infection (Resident #1) had physician orders [REDACTED]. (Resident #1) was initially assessed on [DATE] by Admission data set. The assessment didn't indicate shower or bathing procedures but that he shouldn't be laid flat. On [DATE], approximately 11a.m. (Resident #1) was transferred to shower gurney, the resident had O2 because the nurse, (LVN I), transferred the O2 from the concentrator to the portable tank. During shower resident became distressed. (Resident became unresponsive to verbal stimuli and eyes were fixed. (CNA A) and (CNA B) (sic). (CNA A) alerted DON who assisted. DON was calling his name and lifted his head to help him to breathe when DON assessed his head was lifted to help him breathe (sic), DON stated resident was breathing checked carotid pulse and it was preset. (CNA A) retrieved sling Resident was breathing but unable to respond. DON made decision to transfer resident. The two C.N.A ' s attempted to roll (Resident #1) to place sling under him while DON held his head up, the bed was secured against the wall, and while turning resident he rolled and fell to the floor. The bed shifted from the wall during the rolling process. The resident fell landing on his left side. There were no apparent injuries due to the fall. Nasal Cannula was on resident. (Resident #1) was rolled on to his back and DON initiated CPR. Crash Cart was obtained. According to statements from (CNA A, CNA B, and DON), O2 was present. O2 nasal cannula was on the resident and on the crash cart which had arrived. (LVN J) called 911. The wife was at the building in the hallway while CPR was ongoing. EMS transported Resident to ER. Resident did not return to facility. Facility has been unable to retrieve any further documentation from hospital. (Resident #1) could have had the option for shower chair but due to his size and not good trunk control it was decided to use a shower gurney. This would a nursing judgment decision. The DON instructed that resident needed a shower. The Nurse instructed CNAs to give a shower. Shower chair did not seem to be valid option due to weight and trunk control. (Resident #1) had been laid flat. C.N.A.'s lay flat because shower bed was a flat surface. According to statements by (CNA A and CNA B) [DATE] 12 pm. (sic) was not in distress initially. (Resident #1) then became during the course of the shower disoriented and unresponsive. Unsure, why resident ' s conditions changed. According

Based on interview and record review, it was determined the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of four residents reviewed for assessments. Resident #1 was a morbidly obese resident, who had movement limitations. Resident #1 was seen by a physician (Dermatologist) once on 03/08/14, for a "rash" in four months without any follow-up. The resident was treated with [MEDICATION NAME] (anti-microbial), but there was no follow-up when the antibiotic was completed. The facility continued to treat Resident #1 without any documentation of assessments, reports to the physicians and/or timely treatment changes by the physician. Resident #1 was transferred to the hospital, admitted and received inpatient treatment for [REDACTED]. These failures could affect the facility's 87 residents including Resident #1, who received preventative skin care, and placed them at risk for delayed identification of non-pressure wounds, skin problems and/or rashes, delayed treatment treatment and prolonged healing. Findings included: 1) Review of the Face Sheet, dated 07/02/14, revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE], with a readmission of 11/11/13. Review of the most recent yearly MDS assessment, dated 05/09/14, revealed Resident #1's [DIAGNOSES REDACTED]. The MDS revealed Resident #1 weighed 294 pounds at 5 foot six inches tall, with limitation of range of motion on one side of her upper body, requiring extensive assistance of two staff members for mobility and transfers. Review of Physician's Consolidated Order dated 07/14 revealed Resident #1 to have additional [DIAGNOSES REDACTED]. Review of the most current quarterly MDS assessment, dated 06/20/14, revealed [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 had a BIMS (cognitive ability) score of 13 (indicating alert and oriented), was totally dependent for bathing, with extensive assistance of two staff members for all activities of daily living (ADLs), including mobility and transfers, and limited assistance of one staff member for eating. Further review of the MDS dated [DATE] revealed Resident #1's range of motion was impaired on one side concerning her upper extremities and impaired on both sides concerning her lower extremities. Review of the MDS assessments, dated 05/09/14 and 06/20/14, and discharge assessment, dated 07/03/14, revealed Resident #1 had other skin problems with ointments/medications applied. Review of Resident #1's Care Plan, dated 05/14/14, revealed no goals or approaches for Resident #1's rash. Further review revealed a care plan meeting conference sheet, dated 05/15/14,which reflected under the comment section: "TAC Cream (topical corticosteroid cream) to Body Rash-site improving." On 07/22/14 at 8:30 AM, during initial tour, it was determined what residents had pressure sores, and there were no residents in the facility that had non-pressure areas (rashes). Observation during initial tour revealed no residents, who were observed to have visible rashes on their extremities or faces. An interview on 07/22/14 at 10:30 AM with the Administrator, revealed he was aware Resident #1 had problems, which had developed with her skin. The Administrator stated he thought Resident #1 had a rash. The Administrator said the DON came to him and told him she was going to have to send Resident #1 to the hospital. An interview on 07/22/14 at 11:30 AM, with the Wound Treatment Nurse revealed her responsibilities were to assess and treat pressure ulcers only. The charge nurses were responsible for the assessment and treatment for [REDACTED]. The Wound Treatment Nurse stated the charge nurses were responsible to document the residents' condition on the "Skin Inspection Report" and document the treatment on the "Treatment Administration Reports." When the surveyor queried about Resident #1's rash, the Wound Treatment Nurse said she was aware the resident had a rash for a long time; it would dry up and the resident's skin would peel off and then the rash would come back; however, she was unclear when the rash had come back and seemed to think the resident had never been without a rash. The Wound Treatment Nurse stated she had suggested the staff stop using the perfumed soaps and use an antibacterial soap, but did not know what happened with that as it was never discussed with her. The surveyor queried had the Wound Treatment Nurse seen the rash as she was treating the pressure ulcer to Resident #1's coccyx. She said, "Yes," she had seen the rash and thought the staff was treating the rash because she had to wipe the cream off Resident #1's buttocks to allow her dressing to adhere to the skin. The surveyor asked the Wound Treatment Nurse why she had not inquired of the nursing staff as to why the rash had not improved. The Wound Treatment Nurse stated she presumed the nursing staff was assessing, treating, and communicating with the physician, and just not continuing to use the same treatment over and over again. The Wound Treatment Nurse said she was not aware the nurses were not communicating with the physician every two weeks and addressing the non-healing rash as she did with her pressure ulcers. An interview 07/22/14 at 11:30 AM with the DON, revealed she had not seen the rash on Resident #1's body until 07/02/14 (day prior to the transfer of the resident to the hospital), and the nurses had not communicated with her they were treating a rash on Resident #1. Interview on 07/22/14 at 11:45 AM with the Dermatologist, revealed he had assessed and treated Resident #1 in March 2014, but had not had any follow-up information from the facility until this month (July 2014) when the facility called and said they needed him to come and see Resident #1 as soon as possible. The Dermatologist told the facility he could not come right then, but would come as soon as possible. The Dermatologist said he went about two days later after the facility had called only to be told Resident #1 was in the hospital. The Dermatologist said he did recall telling the facility to call and follow-up with him if Resident #1 had any further problems, but this was the first time he had heard from them. An interview on 07/22/14 at 12:30 PM with CNA B, revealed she had been employed at the facility since March 2014, and had taken care of Resident #1 until she left for the hospital. CNA B stated the entire time she had assisted Resident #1 with her activities of daily living (ADLs) there had been a red raw and scabbed rash on different parts of her body, and at times it would be on her entire body. CNA B said Resident #1 told her she sure wished they would figure out what was wrong with her and make the rash go away. An interview on 07/22/14 at 1:15 PM with CNA D, revealed she had been employed at the facility for approximately one year. CNA D stated she took care of Resident #1 when she worked, and the entire time Resident #1 had a rash on her body. CNA D said Resident #1 had the rash on her upper torso/chest/breast area that was red, scabbed and oozing (draining). CNA D said she cared for Resident #1 up until she left to go to the hospital. The entire time she had a rash, which never went away. CNA D said Resident #1 never really complained, other than she would say she sure wished they would figure out what was wrong with her and fix it so the "ugly" rash would go away. CNA D said she reported to the nurses all the time about Resident #1's rash and they just kept putting cream on her. An interview on 07/22/14 at 1:30 PM with the DON, revealed she happened to walk into Resident #1's room on 07/02/14, and saw the rash for the first time. The DON stated she asked the CNA how long it had been that way. The DON stated she had no idea the resident had a rash like that, and the CNA told her it had been this way for a while. The DON said she went to see the Social Worker and told her they needed to find a Dermatologist to treat Resident #1. The DON said the Social Worker told her it had been this way before and there was a Dermatologist that had seen Resident #1 before, and she would contact them. The DON stated that she told the Social Worker, "...well somebody needs to treat her and if this Dermatologist cannot heal her, then we need to find somebody else." The DON stated the next day (07/03/14) the Social Worker told her she could not find a Dermatologist, who could come right away to see Resident #1. The DON said she decided to send Resident #1 to the hospital. The DON said she contacted the family and the physician and sent Resident #1 to the hospital. The surveyor asked the DON why she had not been aware of the rash before. The DON stated the nursing staff did not communicate with her concerning Resident #1's rash. The surveyor asked the DON who reviewed the weekly Skin Inspection Reports, and the DON said she had not seen any reports concerning Resident #1's non-pressure skin condition. The DON further stated said she had spoken to the nurses who had treated Resident #1's rash and was told they were using the cream ordered by the physician. When the DON asked the nurses why they did not call the physician, the nurses told her, "We do not know." The DON said she asked the nurses about the assessments and documentation concerning the rash on Resident #1's body. The nurses said there was no place to document, concerning rashes on the skin reports. The DON said she asked them about the nurses notes, and they said, "No, we just put she had a rash and we were putting the cream on it." The surveyor asked if the DON conducted any in-services with the nursing staff on assessing of the skin and documentation, and she replied, "No." An interview on 07/22/14 at 1:40 PM with LVN C, revealed he felt there were two completely different rashes. LVN C stated he felt Resident #1 had dry skin and then this rash started back in May 2014, and this was why the rash got progressively worse. LVN C said the Dermatologist had come to see Resident #1 in March 2014, but had not been back since that time. LVN C said he had tried to call the Dermatologist right before Resident #1 had gone to the hospital, but he could not come right away. The surveyor asked LVN C what he was supposed to do if he assessed a non-pressure area on a resident. LVN C stated he would call the physician and do his skin assessment sheets. During the same interview, LVN C said the skin assessment sheets were to be done weekly and if the condition had changed, he would contact the physician concerning a change in treatment. The surveyor asked LVN C why he had not contacted the physician concerning the rash on Resident #1 getting worse. LVN C said he felt it was staying the same and at times it would get worse. LVN C added Resident #1 had been treated with TAC Cream (topical corticosteroid cream) and [MEDICATION NAME] (anti-fungal antibiotic) by two different physicians. The surveyor asked LVN C what type of documentation he had completed on the rash. LVN C stated he used the facility's Skin Reports in the computer system and then put additional documentation in the nurse's notes. The surveyor asked what type of documentation did the nurse remember putting in the nurse's notes. LVN C stated, just that there was a rash and it was treated with the cream with no negative reaction. An interview on 07/22/14 at 2:45 PM with the Administrator and DON, revealed they were unaware there had been no follow-up on Resident #1's skin rash. The DON stated she had not reviewed any skin assessment sheets or nurses notes related to Resident #1's rash until after the resident had left for the hospital. The DON was unaware and unable to find any documentation in the Skin Inspection Reports. The DON was unaware there was no plan of care with goals or approaches related to Resident #1's rash. The surveyor inquired about physician progress notes [REDACTED].#1. The Administrator stated Physician F treated Resident #1 and was very slow to provide information concerning his visits. The surveyor at the time of the exit, had not received any progress notes concerning Physician F's visits regarding Resident #1. On 07/23/14, the surveyor requested that the facility provide current physician progress notes [REDACTED]. Multiple attempts were made to contact Physician F on 07/22/14 at 11:58 AM, 1:00 PM, and 3:30 PM, with messages left, and no return calls from Physician F. The surveyor followed up with the facility on 07/23/14, and provided a fax number for the facility to provide physician progress notes [REDACTED]. At the end of the day on 07/23/14, no information had been provided. An interview on 07/22/14 at 2:50 PM with LVN E, revealed she had been employed by the facility for over a one year. LVN E stated she never recalled treating Resident #1, but if there was a rash on a resident, she would call the physician and get an order, and if the resident did not improve, she would tell her supervisor to get guidance on what to do next, so the resident's rash improved. The surveyor inquired why LVN E's named was in the computer to have assessed Resident #1's skin. LVN E stated it must be a mistake because she knew she had never looked at Resident #1's skin. An interview on 07/22/14 at 3:13 PM with RN G, revealed he was the nurse who had called and gotten the physician to come and see Resident #1. The surveyor asked how long ago, and RN G said, "a long time ago. " RN G stated he recalled Resident #1 had been treated multiple times with TAC cream and a couple of time with [MEDICATION NAME]. RN G said the rash would improve, but never would go away, and he knew it could get "bad very quick." RN G said he thought the rash was improving at times because the resident's skin would "peel" off her body and new fresh pink tissue would be there. The surveyor queried whether that happened often, and RN G said, "Yes." RN G said he told the Social Worker Resident #1 needed to see the dermatologist right before she left for the hospital. The surveyor queried did RN G report Resident #1's rash to the DON, and he said, "No." The surveyor showed RN G the "Skin Inspection Report," and he said there was no place to document rashes in the system, and you should put that in his nurse's notes. RN G said all the computer system was good for was documenting on the residents who had pressure ulcers. An interview on 07/22/14 at 3:30 PM, CNA H revealed she had been employed by the facility since May 2014, and part of that time was on an as needed basis. CNA H stated every time she cared for Resident #1, she had a rash on her body. CNA H said the rash was all over Resident #1's body, was red. On her hip, the rash was open and had bloody drainage at times. CNA H said she had worked a lot with Resident #1 since March 2014, and she really thought at one time, the "gnats" were eating her up because the rash was scabbed and her skin was peeling off her body, and she had "gnats" in her room. When asked if the CNA reported this to the nurses, she said, "Yes, they knew." An interview on 07/22/14 at 3:40 PM with CNA I, revealed she had been employed for two months and had taken care of Resident #1 two times. CNA I stated Resident #1 had the rash both times, it was bad, reddened and had open areas and other areas were scabbed. CNA I said she asked the nurses about it, and they told her they were treating the rash. An interview on 07/22/14 at 4:00 PM with LVN J, revealed she had worked at the facility for almost two years on the night shift. LVN J was aware Resident #1 had a rash, as she had been shown the rash by the CNAs some time ago, but said the evening shift nurses did the skin assessments. LVN J stated the night shift made sure the residents were kept dry, clean and turned. LVN J said she knew the physician was aware of the rash, and the day and evening nurses were putting cream on it. An interview on 07/22 14 at 4:20 PM with ADON A and the Wound Treatment Nurse, revealed the Wound Treatment Nurse was identified as the "Skin Management Nurse." It was stated, "We do have weekly skin meetings." The Wound Treatment Nurse said in the meeting they talked about "skin," but not all the "skin." "Obviously we did not discuss (Resident #1's) rash. The surveyor queried whether the Wound Treatment Nurse performed any follow-up on the "Skin Assessment Sheets" in the new system. She said, "No." ADON A said she did not know who was supposed to do the follow-up for skin, the system was "broke" for follow-up, and she had talked with the Administrator today about that. An interview on 07/22/14 at 4:30 PM with the DON, revealed the DON was starting an in-service on assessment and documentation of non-pressure areas with the nursing staff. An interview on 07/22/14 at 4:30 PM with LVN L, revealed she was aware Resident #1 had a rash, but the day and evening shift nurses put the cream on the resident. LVN L stated, "We all knew about the rash." When the surveyor queried the progressive worsening of the rash on Resident #1's body, LVN L said she had only seen the rash once or twice, and the other nurses on the day and evening shift took care of it. An interview on 07/22/14 at 5:10 PM, with the Power of Attorney (POA) for Resident #1, revealed the resident had been relocated to another facility following her hospital stay and was doing much better. The physicians at the hospital had determined what was wrong and where the rash was coming from. The POA stated the facility had asked her to provide "Dial" soap, but she did not ever see any change and the rash just continued to get worse over a period of about two-three months. Review of the "Consolidated Physician Monthly Orders," dated May, June and July 2014, revealed no orders for TAC Cream, or any treatments related to a rash on Resident #1's body. Review of "Physician Telephone Orders," dated 03/08/14, revealed TAC 0.1% Ointment apply twice per day to rashes on trunk, shoulder, and arms for three weeks or clear, refill one time. Further review revealed on the same order [MEDICATION NAME] (for itching) 25 milligrams three times a day for three weeks for itching no refills. Review of "Physician Telephone Orders," dated 04/10/14, revealed Fluconazole ([MEDICATION NAME] anti-fungal) 100 milligrams by mouth one time a day for 14 days. Review of the Medication Administration Records (MARs), dated March 2014, revealed there were no "Treatment Sheets." Further review of the "Pain Medication Sheets," revealed on 03/08/14, an ordered TAC 0.1% ointment 80 milligrams to be applied two times per day to rashes on trunk, shoulders, and arm for three weeks or clear. The treatment documented to be started on 03/04/14, continuing through the 31st of the month, with multiple omissions for treatment on the day and evening shifts. The MARs for March 2014 reflected [MEDICATION NAME] 25 milligrams by mouth three times a day initial dose on 03/09/14 at 9:00 PM, at night, with one omission. Review of the MARs, dated April 2014, reflected [MEDICATION NAME] was discontinued on 04/02/14, with the final dose at 1:00 PM, and Fluconazole 100 mg by mouth daily for 14 days, initial dose given on 04/12/14, and completed on 04/25/14. Further review revealed no ointments were noted on the "Treatment Sheets," dated April, May or June 2014. Review of the nurses' notes, dated 03/04/14, revealed Resident #1 was receiving TAC Cream, with no indication what the TAC Cream was being used for. On 03/06/14, Social Services contacted a Dermatologist to schedule an appointment for a rash. On 03/08/14, the Dermatologist consulted with Resident #1 giving new orders for TAC .1% 80 milligrams to be applied twice a day to rash, and [MEDICATION NAME] 25 milligrams three times per week for three weeks. Review of nurses notes revealed on 03/09/14, 03/17/14, 03/19/14, 03/20/14, 03/21/14, 03/24/14, 03/25/14, 03/26/14, 03/28/14, 04/01/14, 04/02/14, 04/14/14, 04/15/14, 04/16/14, 04/17/14, 04/21/14, 04/22/14, 04/24/14, 04/26/14, 04/29/14, 04/30/14, 05/01/14, 05/02/14, 05/05/14, 05/06/14, and 05/07/14, there was documentation of a rash on Resident #1's entire body (no description of the rash) being treated by TAC cream. Further review of nurses' notes, dated 04/11/14, revealed Resident #1 was placed on Fluconazole ([MEDICATION NAME]) 100 mg for a rash. Nurses' notes, dated 04/14/14, 04/15/14, 04/16/14, 04/17/14, 04/21/14, 04/22/14, 04/24/14, 04/26/14, and 04/27/14, all documented Resident #1 was on an antibiotic for a skin rash, with no description/assessment of the rash or if Resident #1's rash was improving. There were no nurses' notes available for review for the month of June 2014. Review of the facility's "Skin Inspection Report," dated 03/03/14, 03/10/14, 03/17/14, 03/24/14, 03/31/14, 04/07/14, 04/15/14, 04/23/14, 04/30/14, 05/07/14, 05/14/14, 05/21/14, 05/28/14, 06/04/14, and 06/19/14 revealed, "...skin not Intact-Existing..." There was no further description documented. Review of a "Monthly Skilled Note," dated 06/09/14, revealed Resident #1 had no skin/ulcer treatment: only apply ointments/medications. Review of a "physician progress notes [REDACTED]. The physician prescribed TAC 0.1% ointment (topical corticosteroid) apply daily to affected area twice a day. To treat for 3 weeks or until clear, the facility should call if condition worsens, with follow-up in three weeks. Review of a "Wound Care Specialist Evaluation," dated 06/02/14, 06/09/14, 06/16/14, 06/23/14, and 06/30/14, revealed no documentation or assessment concerning Resident #1's rash on her body. Review of the nurses' notes, dated 07/02/14, revealed Resident #1 "...continues on TAC cream to affected parts of the body, other parts heal and new ones develop, and (Resident #1) continues to itch despite the continuation of treatment...called physician who had prescribed the cream (in March 2014) and left a message...will follow-up tomorrow...." Review of nurses' notes, dated 07/03/14, revealed Resident # 1 was transported to the hospital for a rash covering her body. Review of the "Transfer Summary," dated 07/03/14, revealed Resident #1 was transferred to the emergency room for a rash all over her body. Further review of the Current Plan of Care provided to the emergency room revealed no problem related to Resident #1's rash or a history of previous treatment that had been provided concerning the rash. Current "Consolidated Medication Orders" provided to the emergency room revealed no current/previous treatment concerning Resident #1's rash. Review of the hospital "History and Physical," dated 07/03/14, revealed Resident #1's assessment and plan was for Desquamating (to peel off in scales) rash: Blistering present, apparently with mucosal (mucous membrane layer of skin) involvement. Review of the "Physician Discharge Summary," dated 07/10/14, revealed Resident #1 had been diagnosed with [REDACTED]. (Resident #1) was discharged to a new nursing home to receive adequate care." Review of the facility's current Policy and Procedure for "Skin System," revised September 2004,and provided by the DON revealed: "Purpose: As agents of the Quality Assurance Committee, this sub-committee will review the skin status of all residents and coordinate appropriate interdisciplinary interventions to maximize skin integrity. Procedure: 1. All residents will be assessed on admission, readmission, and quarterly and with each change in condition assessment for their individual risk for skin compromise and current condition. ...3. The skin committee, comprised of Skin Management nurse, nursing representative, and representative of Nursing Administration, will meet at least weekly to discuss changes, complex wounds, or problems related to the skin, for each resident currently being treated... 4. Medical records, family, resident, and physician input will be used to assist the appropriate documentation of the kind of wound found... 5. ...Interact III tools (tools necessary for thorough assessment, documentation, change of condition, &/or possible transfer) must be used to ensure thorough assessment and timely intervention. ...8. A weekly skin assessment will be completed by a licensed nurse and kept as part of the medical record... 9. Physician and family will be notified of any changes of skin condition... ...11. Tracking and trending will be completed by the Skin Management Nurse or DON designee..." CMS Form 672, Resident Census and Conditions of Residents, dated 07/22/14 and signed by the DON, reflected a facility census of 90, 0 (zero) residents with rashes and 87 residents, who received preventative skin care.

Based on observation, interview, and record review, the Administrator (ADM) and the Director of Nursing (DON) failed to utilize the facility's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for (A) two (Residents #2 and #8) of three residents reviewed with [DEVICE]s and for nine (Residents #1, #3, #4, #5, #9, #12, #14, #18, and #21) of 19 residents who were reviewed for BP medications. A) The ADM failed to: 1) supervise the DON to ensure nursing staff were competent in the use of [DEVICE] decloggers. 2) ensure facility-specific policies and procedures (P/P) were developed and in place for the use of feeding tube decloggers. 3) supervise the DON to ensure nursing staff were following physician's orders when administering medications. The DON failed to: 1) monitor and supervise the licensed nursing staff to ensure physician orders had been obtained for the use of a [DEVICE] declogger, the residents' [DEVICE]s were measured to ensure the appropriate size was being used and were knowledgable in the use of a declogger. . Licensed Vocational Nurse (LVN) K used a declogger on Resident #8's [DEVICE] to unclog it. The resident complained of pain and the LVN was unsuccessful at opening the [DEVICE] (a tube placed into the stomach for long-term administration of fluid, food and medications). The facility failed to ensure: a) There were physician's orders to use the declogger. b) LVN K measured the [DEVICE] to ensure the declogger was the correct size. c) LVN K and other facility staff were knowledgeable and trained in the use of the declogger. d) A policy/procedure (P/P) was in place for the facility's use of a declogger and staff were trained. On 01/09/13, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/14/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the plan of removal. These failures resulted in Resident #8's complaining of pain during the declogging procedure and could affect the facility's 16 residents, who were identified as receiving tube feedings and placed them at risk for the potential of having a declogger used when their [DEVICE] became clogged, causing increased pain and perforation of the [DEVICE] and/or intestinal wall, resulting in the need for hospitalization to replace the [DEVICE] and/or repair of the intestinal wall. B) The ADM failed to supervise the DON to ensure nursing staff were competent in the assessment and provision of care and services for residents who received BP medications. The DON failed to monitor and supervise nursing staff to ensure: a) they notified the physician of low/fluctuating BP readings and/or of BP medications that were held/not held for Residents #1, #3, #4, #5, #9, #12, #14, #18, and #21. b) they followed physician's orders when administering BP medications. c) they contacted the physician for BP parameters and/or to clarify BP parameters. d) they conducted assessments for residents with fluctuating/low BP readings for Residents #3, #4, #5, #14, #18, and #21. e) they implemented physician orders for BP medications for Resident #14. f) they did not hold BP medications and that BP medications were administered according to physician's orders for Resident #3. g) they notified charge nurses of BP medications held for Residents #1, #5, and #18. h) BP parameters were obtained from the physician and followed for Residents #5, #9, #12, and #18. 1. Resident #4's [MEDICATION NAME] (for elevated BP) was held without physician's orders, without a BP reading, and not notifying the physician of the low BP and holding the [MEDICATION NAME]. No assessment was conducted with low BP readings. 2) Resident #5's [MEDICATION NAME] and [MEDICATION NAME] XL were held even though the resident's BP was above the physician-ordered BP parameters, holding the medications was ot reported to the charge nurse, the resident was not assessed and the physician was not notified. 3) Resident #14's order for [MEDICATION NAME] was not implemented until surveyor intervention on 01/11/13. [MEDICATION NAME] and [MEDICATION NAME] were held without a physician's order and without regard to the resident's BP. The physician was not notified of low BP readings and of [MEDICATION NAME] and [MEDICATION NAME] being held. No assessment was conducted with low BP readings. 4) Resident #21's had orders to receive [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. Facility failures included: LVN B held the [MEDICATION NAME] and [MEDICATION NAME] due to a low BP, but administered the [MEDICATION NAME] (incorrectly) because she "overlooked it." The [MEDICATION NAME] and [MEDICATION NAME] were held more often than they were administered in January 2013, but the resident was not assessed and the physician was not informed of medications being held and the resident's low BP. The frequency of holding the resident's diuretics likely contributed to the resident's 3+ to 4+ [MEDICAL CONDITION] when she was sent to the hospital on [DATE]. 5) Resident #1 had orders to receive [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. Failures included: Despite holding 27 of 31 doses of [MEDICATION NAME] and not administering any [MEDICATION NAME] during January 2013, the physician was not notified. LVN B did not notify the charge nurse when she held the resident's [MEDICATION NAME]. The physician was not contacted to clarify the two sets of BP parameters for holding medication. 6) Resident #3 had orders to receive [MEDICATION NAME] and [MEDICATION NAME] (HCTZ) and orders for BP parameters to hold the BP medications. Facility failures included: [MEDICATION NAME] and [MEDICATION NAME] (HCTZ) were not held and administered according to the physician's orders. Documentation on the January 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] With fluctuating BPs, the resident was not assessed. The physician was not notified when medications were held. 7) Resident #12 had orders for [MEDICATION NAME] (for treatment of [REDACTED]. Facility failings included: The physician's BP parameters were not followed as ordered. The physician was not notified when the [MEDICATION NAME] was held. 8) Resident #18 had orders for the following medications for treatment of [REDACTED]. There were BP parameters ordered to hold the BP meds. The physician's BP parameters were not followed as ordered. The resident had a BP of 90/59 and there was no evidence of an assessment being conducted. The charge nurse/physician were not informed when medications were held or when the resident's BP was 90/59 and the [MEDICATION NAME] was not held. 9) Resident #9 had orders for a daily BP check and for [MEDICATION NAME] to treat the resident's BP. Facility failures included: The resident's clinical record had not been reviewed, the physician had not been contacted for BP parameters to hold the [MEDICATION NAME], or when to be contacted for low BP readings until surveyor intervention on 01/13/13. On 01/11/13, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/14/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still inservicing staff and monitoring the implementation of the plan of removal. These failures could affect the 76 residents in the facility who received medication to treat their high blood pressure, including Residents #1, #3, #4, #5, #9, #12, #14, #18 and #21, and could result in the potential for a change in condition, sudden drop in blood pressure, elevation of the BP, stroke, dizziness, falls, fatigue, weakness, loss of consciousness, fluid retention, respiratory distress and possibly death resulting in the need for emergency help and/or hospitalization . Findings included: A) [DEVICE] decloggers: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was admitted originally to the facility on [DATE]. The MDS assessment reflected Resident #8 had the following active Diagnoses: [REDACTED]. The MDS assessment also reflected Resident #8 was cognitively intact, having scored a 13 out of 15 on the BIMS. The MDS assessment further reflected she received her nutrition via a feeding tube. Resident #8's Face Sheet dated 10/08/12 reflected additional diagnoses, which included: Lupus, Nausea and Vomiting, Anorexia, Vitamin Deficiency and Gastrostomy Status. During the initial rounds on 01/08/13 at 9:55 a.m., the surveyor observed Resident #8. Assistant Director of Nursing (ADON) D stated Resident #8 was mobile via a wheelchair in the facility, was incontinent of bowel and bladder, required total assistance with all her Activities of Daily Living (ADLs), received her nourishment via a [DEVICE], and was alert and oriented to person, place and time. On entering the resident's room, the surveyor observed the resident was resting in bed in her room and watching her television. The surveyor also observed in the corner of her room a pump with [MEDICATION NAME] 1.5 (formula) infusing at 50 cc (centimeters)/hr via her [DEVICE] with a normal saline flush, which was set to infuse 167 cc of normal saline every three hours. On 01/08/13 at 1:30 p.m., the surveyor observed LVN K administering medication to Resident #8 via the [DEVICE]. LVN K crushed one tablet of [MEDICATION NAME] (narcotic pain reliever) 10/325 mg and placed it in the medication cup. She also poured 10 cc of [MEDICATION NAME] (for GERD) into a med cup. LVN K was observed to take the two medication cups with medicine and two cups of water into Resident #8's room and place the items on the overbed table in the room. She turned off the [DEVICE] pump and donned gloves and disconnected the [DEVICE] from the pump tubing. LVN K used a 60 cc syringe to check for placement of the [DEVICE], pulling back on the syringe after having inserted 10 cc of air. The syringe would not pull air and/or formula into the piston. LVN K told the surveyor there was no residual. LVN K then removed the piston and poured water into the syringe, but the water did not infuse. The surveyor observed LVN K attempting to open the tube by squeezing the bottom part of the [DEVICE] for approximately 20 minutes, but the water was still not moving. LVN K then plunged the syringe with the piston, trying to use force to infuse the water. LVN K then added water to the crushed [MEDICATION NAME] and poured it into the syringe, which was still connected to the [DEVICE]. The LVN continued to squeeze the [DEVICE] to try and get the medication mixture to infuse, but it remained at the tip of the [DEVICE] even with the nurse continuing to squeeze the tubing. Resident #8 was moaning at three different times and complaining to LVN K the squeezing and tugging of the [DEVICE] was causing her pain. LVN K apologized to the resident for causing her pain and informed her she was just trying to give the resident her pain medication. After another 25 minutes, the [MEDICATION NAME] was still at the tip of the [DEVICE]. LVN K removed the syringe and placed the contents into the water cup, telling the surveyor the [DEVICE] was clogged, and she was going to retrieve the declogger. LVN K removed her gloves and searched through the resident's dresser drawer for the "declogger." LVN K then stated there was no declogger there, and she was going to the supply room to retrieve another one. LVN K had previously told the surveyor the resident's [DEVICE] was always clogging up, so she would leave a few decloggers in Resident #8's dresser drawer. LVN K went to the supply room and returned within approximately 10 minutes with the Bionix enteral feeding tube declogger. This declogger device was observed to be a long thin flexible probe about 16 inches in length with screw-like ridges throughout the shaft with a pointed end. This particular declogger was yellow in color. LVN K was not observed to measure the size or length of the [DEVICE] before using the declogger. The LVN opened the declogger packet and proceeded to place the yellow declogger probe into the [DEVICE] with the [MEDICATION NAME] still observed on the tip of the tubing. The surveyor inquired of the nurse what would happen to the medication when she put the declogger probe into the tubing. LVN K then attempted to remove the medication from the [DEVICE] without success. She went ahead and placed the enteral feeding tube declogger into the [DEVICE] and pushed the tip past the skin level. At that time, Resident #8 screamed out to LVN K, "Be careful! That hurts!" LVN K apologized to the resident and told her she was not trying to hurt her, but administer her medication. LVN K pulled out the declogger. She then put the syringe back into the [DEVICE] and poured the rest of the medication and water into the syringe. However, the medication was not flowing freely into the abdomen. LVN K tried milking the [DEVICE] to loosen the clog but the medication still did not infuse. The LVN tried the declogger device again. At that time, Resident #8 told her to stop, because the LVN was hurting her with the declogger. LVN K again apologized to the resident and left the room to call the physician. On 01/08/13 at 3:00 p.m. LVN K came and informed the surveyor one of the ADONs had gone to Resident #8's room, had asked the resident to count one to ten as the medication was being administered, and it infused without problem. LVN K added Resident #8 was also being treated for [REDACTED]. At that time, the surveyor asked LVN K if she was comfortable using the Bionix declogger device. LVN K stated she was not because the last [DEVICE] Resident #8 had was long and was clogged "all the time." LVN K said she had to frequently declog the [DEVICE]. She had observed the [DEVICE] leaking at the sides of the [DEVICE] and thought it had been punctured. She said she notified the wound care nurse, who told her to notify the physician. Resident #8 was then sent to the hospital for the [DEVICE] to be changed and had returned with this new tube. LVN K stated with the old, longer [DEVICE], she was able to stop at the middle of the tube to declog it. LVN K stated she thought when she used the Bionix declogger device, she stopped the tip of it at skin level, but the surveyor informed her the tip of the declogger had gone into the [DEVICE], which was below the skin. The surveyor stated it was when the resident yelled out for LVN K to be careful. The surveyor inquired whether LVN K had any training regarding how to use the declogger. LVN K stated she received training during orientation from one of the facility ADONs. She said she had watched the ADON use the declogger, and then she (LVN K) had been watched when she used the declogger. LVN K said she was not comfortable using the declogger. The surveyor interviewed the Medical Records Supervisor (MRS), who was an LVN, on 01/08/13 at 4:00 p.m. The MRS told the surveyor the facility had been using the enteral feeding tube declogger for approximately a year-and-a-half. She said the declogger was the last resort to declog a [DEVICE]. She also stated milking the tubing, warm water, sprite, coke and/or cranberry juice was tried first before using the declogger. The MRS said when everything had been tried, some of the residents had to be sent to the hospital. The MRS told the surveyor when she was working out on the floor and a resident's [DEVICE] became clogged, she asked ADON C or ADON D to try declogging the resident for her. The MRS added staff should have used other means before using the declogger. The MRS stated the facility's weekend supervisor refused to use the Bionix enteral feeing tube declogger. Instead, she would send the resident to the hospital. ADON D was interviewed on 01/09/13 at 9:05 a.m. The surveyor asked ADON D how the facility made the decision to order the Bionix enteral feeding tube declogger. ADON D stated the company gave facility staff a list of company-approved items, and CNA Q ordered supplies from that list. ADON D said the facility started using the Bionix declogger product over six months ago. ADON D stated the facility was sending lots of residents to the hospital to have their [DEVICE]s declogged. ADON D told the surveyor they had found the residents with the most problems with their [DEVICE] clogging were mostly those residents, who were sent to a certain area hospital for [DEVICE] changes. ADON D stated the facility's Medical Director was aware of the problem with the [DEVICE]s. When asked about training she had received to use the declogger, ADON D said she did not receive any training before she started using the declogger. When the surveyor asked about the risks of using the declogger, ADON D stated a potential risk of not using the declogger properly would be the potential to perforate the [DEVICE] bulb and/or the intestinal wall (bowel) with the declogger wire. When asked about training provided to new staff, ADON D told the surveyor the current floor nurses worked with the new nurses and instructed them on how to use the different facility equipment. She added she or ADON C would follow new staff if they had no knowledge of certain procedures such as using a PICC line. ADON D said she had used the declogger only one time on Resident #27. When asked whether a physician's order was needed to us a declogger, ADON D said the company, which made the decloggers, told them they did not have to have a physician's order to use the declogger with a [DEVICE]. In another interview with ADON D on 01/09/13 at 2:35 p.m. the ADON told the surveyor there were two types of decloggers: a short one for short tubes and a long one for long tubes. According to ADON D, the procedure for using the declogger was to insert it into the feeding tube and twist it around. When queried how far the declogger should be inserted into the feeding tube, she stated, "It would only go so far." LVN L was interviewed on 01/09/13 at 10:50 a.m. During the interview, LVN L stated she had seven [DEVICE] residents on her hall (Hall 100). LVN L stated there was a time when she had problems with almost all her residents with [DEVICE]s. LVN L said some of the [DEVICE]s were pulled out by the resident and others were clogged. LVN L stated she used milking the tube, water, and a syringe to declog the [DEVICE]. If it did not work, she would send the resident to the hospital. LVN L stated she had at one time used the declogger on a resident, who had a long [DEVICE], and she used the smaller, brown colored declogger. When asked about training, LVN L said she did not have any training from the facility on how to use the enteral feeding tube declogger. She added, however, she had used the declogger in a previous facility. When asked how a declogger was used, LVN L told the surveyor, staff were to measure the declogger to the size of the [DEVICE], then put the declogger into the [DEVICE] and twist the declogger. Staff were then to listen for air coming from the [DEVICE], which would indicate the [DEVICE] had declogged. LVN L stated if someone was not properly trained to use the declogger, it could "go through the end of the tubing on the other side" and cause a perforation of the balloon and/or the bowel. The DON was interviewed on 01/09/13 at 11:00 a.m. When questioned about physician orders to use the declogger, the DON responded, the physicians wrote orders for flushes for [DEVICE]s, but there were no orders for declogging the [DEVICE]s. She added if a device other than a natural mechanism was used, she thought the physician should write orders for it. She added, as a nurse, she would like to have a physician's order to declog the [DEVICE]s. During this interview, the DON was asked if there was any concerns she had with use of the declogger. The DON said if staff were not properly trained to use the declogger and ensured the proper size was used, it could cause a perforation in the [DEVICE], especially if it was old and worn. The DON said staff should know the size, depth and length of the declogger before using it. She then stated she preferred the "old school way" of using cranberry juice, warm water, etc. to declog the [DEVICE]. On 01/09/13 at 11:00 a.m., LVN A was queried about the procedure he used to un-clog [MEDICAL CONDITION] feeding tubes. The LVN stated he had used the declogger device for Resident #2. When queried about what size he used for Resident #2's [DEVICE], he responded, "One size fits all." During this interview, LVN A stated he had received training on how to use the declogger device from the facility's nursing managers and felt comfortable using it. When queried how far the declogger should be inserted into the [DEVICE], LVN A stated, "When you meet resistance, stop." In an interview with ADON D and ADON C on 01/09/13 at 11:40 a.m., the ADONs were asked about a facility P/P for the use of the declogger with [DEVICE]s. They said there was no facility P/P for the use of the declogger. ADON D stated she and ADON C oriented facility nurses on the use of the declogger. ADON C stated he had received orientation on how to use the declogger where he had worked in the past and had used that information to orient nursing staff at the facility. ADON D was queried about what material and/or information was used to instruct the nurses on the use of the declogger. ADON D stated he did not have any documented information on information provided during training on the use of the declogger, but had trained staff on what he remembered from his training at a previous job. ADON D added there were no written instructions/information available and none had been used. Additionally, she stated facility nurses were provided with just the information she had learned from ADON C. According to ADON D, she had communicated with the facility's corporate office on 01/08/13 after the surveyors had interviewed staff about the use of the declogger. ADON D stated she had been informed by the corporate office, the decision to use the declogger was a nursing judgement and no physician's order was needed. When asked if she had ever contacted the corporate office about the use of the declogger prior to the surveyor's questions, ADON D stated she had not ever communicated with the corporate office about the use of the declogger prior to 01/08/13. Resident #8's physician was interviewed on 01/09/13 at 1:00 p.m. in regard to the facility's use of a declogger with [DEVICE]s. The physician informed the surveyor he was not aware of the facility's methods for declogging [DEVICE]s. He stated whatever the facility was using had been working, and they should continue to use it. The surveyor then told the physician that staff were being trained to use the declogger device without directions or any instructions to refer to for guidance, staff were using what they had learned at other facilities on the use of the declogger and in fact, were training other staff based on this. The physician was also informed there were no facility P/P for the declogger. The physician then stated he was not aware of this, would speak to the DON and make some new changes for declogging [DEVICE]s. Resident #8 was interviewed on 01/10/13 at 5:45 p.m. in her room. During the interview, Resident #8 told the surveyor she could feel the declogger poking her when LVN K was trying to declog her [DEVICE]. She also stated when LVN K was milking or squeezing the [DEVICE], she was tugging on it hard and it hurt. When asked about the declogger being used previously, Resident #8 said when staff used the declogger, she could feel pain inside her abdomen when they "poked" the declogger into the [DEVICE]. Review of Resident #8's care plans dated 10/01/12 revealed there was no care plan, which addressed the potential problem of the resident's [DEVICE] becoming clogged or the use of a declogger. Review of Resident #8's consolidated physician orders for December 2012 and January 2013 revealed there were no orders/guidance for using a declogger when the resident's [DEVICE] became clogged. Review of Resident #8's nurse's notes from 01/25/12 at 8:00 p.m. to 01/08/13 at 6:00 a.m. revealed no evidence staff had ever declogged the resident's [DEVICE]. The nurse's note dated 01/08/13 at 1:30 p.m. reflected Resident #8's [DEVICE] did not "go with gravity, declog ned (sic) just to the end of the transparent tube." Observation of the package containing the Bionix enteral feeding tube declogger revealed information on the label reflected product sizes and lengths. The following information was included on the label of the packet: 1. Select the proper size Declogger that conforms to the length and diameter of the patient's tube. 2. Verify the tube length and confirm that no alterations have been made to the tube. 3. Gently insert the threaded end of the Declogger into the tube using a twisting motion. ...5. Flush the feeding tube with the appropriate solution. PRECAUTIONS: Prior to any use of the product, the length of the feeding tube should be known. Use a declogger that is shorter than the feeding tube. Caution: Federal law restricts this device to sale by or on the order of a physician." A telephone interview on 01/10/13 at 10:48 a.m. with a representative of the Food and Drug Administration revealed an order was required from a physician or an authorized person to use the declogger. Interview on 01/12/13 at 11:00 a.m. with the ADM revealed he had begun in-services on the 10 p.m. - 6 a.m. crew on the night (01/09/13) the problem was found. The ADM said, "I would not let them go on the floor to work until they had the in-service." On 01/14/13 at 3:15 p.m., the surveyor asked the ADM how he monitored the DON to ensure residents were receiving the proper care and services to meet their needs. The ADM stated he provided a monthly calendar of topics/care areas to be addressed by the various departments. Rounds were conducted. Assignments were made. Morning meetings were conducted with department heads. If a problem was identified, he would follow up on it. The ADM stated he checked with staff to ensure assignments were completed by the assigned individual/department. He stated information was shared among the department heads and followed up on. The ADM added, "I do the best I can." The surveyor asked the ADM what happened to cause the IJ involving the [DEVICE] decloggers. Regarding the [DEVICE] decloggers, he stated he had seen decloggers in a hospital, but he had never known anyone to have a policy in regard to the decloggers. Review of the Bionix Medical Technologies policy on use of the Enteral Feeding Tube Decloggers revealed the following: Instructions on [MEDICATION NAME] Usage: 1. Determine the size of the gastrostomy (G) or Jejunostomy (J) tube. 2. Obtain appropriate size Declogger that corresponds to the size of the tube. ...5. Gently insert the appropriate size Declogger into the opening of the enteral tube. 6. Slowly rotate the Declogger in a clockwise fashion until the stop disc meets the opening of the enteral tube. 7. To remove, pull back the Declogger in a counter-clockwise fashion. 8. Flush the tube with 30-60 cc of water. 9. Reconnect the delivery tube and restart enteral feeding. (The instructions for a blocked [MEDICAL CONDITION] or Jejunostomy tube same as above.)" "DO NOT ATTEMPT TO FORCE THE DECLOGGER THROUGH THE ENTIRE BLOCKAGE." Frequently asked questions: Can the declogger harm the patient in any way? The Declogger has a small disc at the handle that prevents over-insertion. The design of the device with its standardized length and flexible plastic molding are added safeguards. There five different sizes and two lengths of the Declogger that is illustrated in this table: Gastrostomy or Jejunostomy (Foley of red rubber type) Product # Product size Length 911-Blue 12 - 14 Fr 39.5 cm 912-Yellow 16 - 18 Fr 39.5 cm 913 -Green 20 - 22 Fr 39.5 cm Peg type or replacement type: 921 -Brown 12 - 16 Fr 21.5 cm 922 -Orange 18 - 24 Fr 21.5 cm Proper Usage: "You should understand what different occurrences cause clogs in enteral feeding tubes so you know why exactly you are unclogging a tube. Here are some examples: kinks in the lines of the tubes, not flushing after putting medication in, dense formulas, small-bore feeding tubes and slow flowing formula can sometimes cause residue that forms buildup. [MEDICAL CONDITION] acids can mix with the formula when the [MEDICAL CONDITION] residuals are being checked." Review of the facility's current policy and procedure entitled Maintaining Patency of A Feeding Tube (Flushing) dated as revised October 2010 revealed the following in regard to clogged feeding tubes: Occlusion or clogged tube procedures 1. Check feeding tube for kinks. A kink is a twist or curl, as in a thread, rope, tube, wire, or hair, caused by its doubling or bending upon itself. 2. Attach sixty (60) cc syringe with plunger and gently pull back on the plunger to dislodge the clog. 3. If blockage remains, draw up 30 cc of warm water into the 60 cc syringe and gently instill water into the tube. Do not force fluid into tube. Gently pull back and forth on the plunger to dislodge the clog. 4. The feeding tube can be milked with fingers from the insertion site to assist in removing the clog. 5. If attempts are not successful, notify the physician. The facility's policy/procedure had no documentation in regard to using or not using a declogger. On 01/09/13 at 3:30 p.m., the Administrator and the DON were notified an IJ was identified in the area of Quality of Care related to the use of the declogger. A plan of removal for the IJ was requested. The facility's plan of removal for the IJ was accepted on 01/10/13 and reflected the following: --Review of an Addendum to the facility's [DEVICE] policy for declogging [DEVICE]s, received on 01/28/13 from the Administrator revealed the use of decloggers has been discontinued and they are not allowed at the facility. --Decloggers were collected and removed from circulation effective 01/09/13 at 4:15 p.m. --All residents with [DEVICE]s were assessed for clogs and/or pain by the ADONs effective 01/09/13. --The Charge nurses were in-serviced by the DON and the ADONs on the discontinued use of the decloggers effective 01/10/13, and all nurses were to be in-serviced before providing care to any resident with a [DEVICE]. --If a [DEVICE] is found to be clogged, facility staff will call the physician and obtain an order for [REDACTED]. --All care plans will be updated on Feeding Tube residents to include interventions for occlusion or clogged tube procedures effective 01/10/13. --All licensed nursing staff will assess all residents with feeding tubes effective 01/10/13 by checking placement and documenting it. Placement will be checked by instilling an air [MEDICATION NAME] and listening for gurgle with stethoscope and/or by aspirating stomach contents. --The DON or Designee will monitor for clogs prior to medication administration, before flushing, before hanging formula via pump and/or [MEDICATION NAME] feedings at every shift by checking placement and flushing per order including residents who have a feeding tube, which is not actively used for nutrition. --A skill check-off list would be completed upon hiring nurses and annually to ensure proficiency in the proper care of residents with [DEVICE]s effective 01/10/13. Interviews were conducted with nursing staff on 01/10/13 regarding their response when a resident's [DEVICE] became clogged revealed the following: --At 3:00 p.m., LVN K revealed she had been in-serviced not to use the declogger. She said she was told to notify the physician for an order if [DEVICE] was clogged. --At 5:40 p.m., Registered Nurse (RN) R revealed he had an in-service on 01/09/13 concerning [DEVICE]s and

Based on observation, interview and record review, it was determined the facility failed to ensure a resident who was fed by a gastrostomy tube received the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities for two (Residents #2 and #8) of three residents reviewed for tube feedings. 1) LVN K used a declogger on Resident #8's [DEVICE] to unclog it. The resident complained of pain and the LVN was unsuccessful at opening the [DEVICE] (a tube placed into the stomach for long-term administration of fluid, food and medications). The facility failed to ensure: 2) There were physician's orders to use the declogger. 3) LVN K measured the [DEVICE] to ensure the declogger was the correct size. 4) LVN K and other facility staff were knowledgeable and trained in the use of the declogger. 5) A policy/procedure (P/P) was in place for the facility's use of a declogger and staff were trained. On 01/09/13, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/14/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the plan of removal. These failures resulted in Resident #8's complaining of pain during the declogging procedure and could affect the facility's 16 residents, who were identified as receiving tube feedings and placed them at risk for the potential of having a declogger used when their [DEVICE] became clogged, causing increased pain and perforation of the [DEVICE] and/or intestinal wall, resulting in the need for hospitalization to replace the [DEVICE] and/or repair of the intestinal wall. 6) LVN A administered medication via a [MEDICAL CONDITION] feeding tube (a tube placed into the stomach for long-term administration of fluid, food and medications) to Resident #2 without verifying placement of the tube. 7) On 01/08/13 at 1:30 p.m. LVN K failed to verify placement of Resident #8's [DEVICE] after attempting to declog the [DEVICE]. 8) LVN K failed to flush the [DEVICE] with 30 to 60 cc water after declogging Resident #8's [DEVICE]. These failures to verify placement prior to the administration of medications and after attempting to declog the [DEVICE] as well as failing to flush after declogging placed all 16 residents, who had [MEDICAL CONDITION] feeding tubes, including Residents #2 and #8, at risk for aspiration pneumonia and infection. Findings included: 1) Resident #8's MDS assessment dated [DATE] reflected the resident was admitted originally to the facility on [DATE]. The MDS assessment reflected Resident #8 had the following active Diagnoses: [REDACTED]. The MDS assessment also reflected Resident #8 was cognitively intact, having scored a 13 out of 15 on the BIMS. The MDS assessment further reflected she received her nutrition via a feeding tube. Resident #8's Face Sheet dated 10/08/12 reflected additional diagnoses, which included: Lupus, Nausea and Vomiting, Anorexia, Vitamin Deficiency and Gastrostomy Status. During the initial rounds on 01/08/13 at 9:55 a.m., the surveyor observed Resident #8. ADON D stated Resident #8 was mobile via a wheelchair in the facility, was incontinent of bowel and bladder, required total assistance with all her ADLs, received her nourishment via a [DEVICE], and was alert and oriented to person, place and time. On entering the resident's room, the surveyor observed the resident was resting in bed in her room and watching her television. The surveyor also observed in the corner of her room a pump with [MEDICATION NAME] 1.5 (formula) infusing at 50 cc/hr via her [DEVICE] with a normal saline flush, which was set to infuse 167 cc of normal saline every three hours. On 01/08/13 at 1:30 p.m., the surveyor observed LVN K administering medication to Resident #8 via the [DEVICE]. LVN K crushed one tablet of [MEDICATION NAME] (narcotic pain reliever) 10/325 mg and placed it in the medication cup. She also poured 10 cc of [MEDICATION NAME] (for GERD) into a med cup. LVN K was observed to take the two medication cups with medicine and two cups of water into Resident #8's room and place the items on the overbed table in the room. She turned off the [DEVICE] pump and donned gloves and disconnected the [DEVICE] from the pump tubing. LVN K used a 60 cc syringe to check for placement of the [DEVICE], pulling back on the syringe after having inserted 10 cc of air. The syringe would not pull air and/or formula into the piston. LVN K told the surveyor there was no residual. LVN K then removed the piston and poured water into the syringe, but the water did not infuse. The surveyor observed LVN K attempting to open the tube by squeezing the bottom part of the [DEVICE] for approximately 20 minutes, but the water was still not moving. LVN K then plunged the syringe with the piston, trying to use force to infuse the water. LVN K then added water to the crushed [MEDICATION NAME] and poured it into the syringe, which was still connected to the [DEVICE]. The LVN continued to squeeze the [DEVICE] to try and get the medication mixture to infuse, but it remained at the tip of the [DEVICE] even with the nurse continuing to squeeze the tubing. Resident #8 was moaning at three different times and complaining to LVN K the squeezing and tugging of the [DEVICE] was causing her pain. LVN K apologized to the resident for causing her pain and informed her she was just trying to give the resident her pain medication. After another 25 minutes, the [MEDICATION NAME] was still at the tip of the [DEVICE]. LVN K removed the syringe and placed the contents into the water cup, telling the surveyor the [DEVICE] was clogged, and she was going to retrieve the declogger. LVN K removed her gloves and searched through the resident's dresser drawer for the "declogger." LVN K then stated there was no declogger there, and she was going to the supply room to retrieve another one. LVN K had previously told the surveyor the resident's [DEVICE] was always clogging up, so she would leave a few decloggers in Resident #8's dresser drawer. LVN K went to the supply room and returned within approximately 10 minutes with the Bionix enteral feeding tube declogger. This declogger device was observed to be a long thin flexible probe about 16 inches in length with screw-like ridges throughout the shaft with a pointed end. This particular declogger was yellow in color. LVN K was not observed to measure the size or length of the [DEVICE] before using the declogger. The LVN opened the declogger packet and proceeded to place the yellow declogger probe into the [DEVICE] with the [MEDICATION NAME] still observed on the tip of the tubing. The surveyor inquired of the nurse what would happen to the medication when she put the declogger probe into the tubing. LVN K then attempted to remove the medication from the [DEVICE] without success. She went ahead and placed the enteral feeding tube declogger into the [DEVICE] and pushed the tip past the skin level. At that time, Resident #8 screamed out to LVN K, "Be careful! That hurts!" LVN K apologized to the resident and told her she was not trying to hurt her, but administer her medication. LVN K pulled out the declogger. She then put the syringe back into the [DEVICE] and poured the rest of the medication and water into the syringe. However, the medication was not flowing freely into the abdomen. LVN K tried milking the [DEVICE] to loosen the clog but the medication still did not infuse. The LVN tried the declogger device again. At that time, Resident #8 told her to stop, because the LVN was hurting her with the declogger. LVN K again apologized to the resident and left the room to call the physician. On 01/08/13 at 3:00 p.m. LVN K came and informed the surveyor one of the ADONs had gone to Resident #8's room, had asked the resident to count one to ten as the medication was being administered, and it infused without problem. LVN K added Resident #8 was also being treated for [REDACTED]. At that time, the surveyor asked LVN K if she was comfortable using the Bionix declogger device. LVN K stated she was not because the last [DEVICE] Resident #8 had was long and was clogged "all the time." LVN K said she had to frequently declog the [DEVICE]. She had observed the [DEVICE] leaking at the sides of the [DEVICE] and thought it had been punctured. She said she notified the wound care nurse, who told her to notify the physician. Resident #8 was then sent to the hospital for the [DEVICE] to be changed and had returned with this new tube. LVN K stated with the old, longer [DEVICE], she was able to stop at the middle of the tube to declog it. LVN K stated she thought when she used the Bionix declogger device, she stopped the tip of it at skin level, but the surveyor informed her the tip of the declogger had gone into the [DEVICE], which was below the skin. The surveyor stated it was when the resident yelled out for LVN K to be careful. The surveyor inquired whether LVN K had any training regarding how to use the declogger. LVN K stated she received training during orientation from one of the facility ADONs. She said she had watched the ADON use the declogger, and then she (LVN K) had been watched when she used the declogger. LVN K said she was not comfortable using the declogger. The surveyor interviewed the Medical Records Supervisor (MRS), who was an LVN, on 01/08/13 at 4:00 p.m. The MRS told the surveyor the facility had been using the enteral feeding tube declogger for approximately a year-and-a-half. She said the declogger was the last resort to declog a [DEVICE]. She also stated milking the tubing, warm water, sprite, coke and/or cranberry juice was tried first before using the declogger. The MRS said when everything had been tried, some of the residents had to be sent to the hospital. The MRS told the surveyor when she was working out on the floor and a resident's [DEVICE] became clogged, she asked ADON C or ADON D to try declogging the resident for her. The MRS added staff should have used other means before using the declogger. The MRS stated the facility's weekend supervisor refused to use the Bionix enteral feeing tube declogger. Instead, she would send the resident to the hospital. ADON D was interviewed on 01/09/13 at 9:05 a.m. The surveyor asked ADON D how the facility made the decision to order the Bionix enteral feeding tube declogger. ADON D stated the company gave facility staff a list of company-approved items, and CNA Q ordered supplies from that list. ADON D said the facility started using the Bionix declogger product over six months ago. ADON D stated the facility was sending lots of residents to the hospital to have their [DEVICE]s declogged. ADON D told the surveyor they had found the residents with the most problems with their [DEVICE] clogging were mostly those residents, who were sent to a certain area hospital for [DEVICE] changes. ADON D stated the facility's Medical Director was aware of the problem with the [DEVICE]s. When asked about training she had received to use the declogger, ADON D said she did not receive any training before she started using the declogger. When the surveyor asked about the risks of using the declogger, ADON D stated a potential risk of not using the declogger properly would be the potential to perforate the [DEVICE] bulb and/or the intestinal wall (bowel) with the declogger wire. When asked about training provided to new staff, ADON D told the surveyor the current floor nurses worked with the new nurses and instructed them on how to use the different facility equipment. She added she or ADON C would follow new staff if they had no knowledge of certain procedures such as using a PICC line. ADON D said she had used the declogger only one time on Resident #27. When asked whether a physician's order was needed to us a declogger, ADON D said the company, which made the decloggers, told them they did not have to have a physician's order to use the declogger with a [DEVICE]. In another interview with ADON D on 01/09/13 at 2:35 p.m. the ADON told the surveyor there were two types of decloggers: a short one for short tubes and a long one for long tubes. According to ADON D, the procedure for using the declogger was to insert it into the feeding tube and twist it around. When queried how far the declogger should be inserted into the feeding tube, she stated, "It would only go so far." LVN L was interviewed on 01/09/13 at 10:50 a.m. During the interview, LVN L stated she had seven [DEVICE] residents on her hall (Hall 100). LVN L stated there was a time when she had problems with almost all her residents with [DEVICE]s. LVN L said some of the [DEVICE]s were pulled out by the resident and others were clogged. LVN L stated she used milking the tube, water, and a syringe to declog the [DEVICE]. If it did not work, she would send the resident to the hospital. LVN L stated she had at one time used the declogger on a resident, who had a long [DEVICE], and she used the smaller, brown colored declogger. When asked about training, LVN L said she did not have any training from the facility on how to use the enteral feeding tube declogger. She added, however, she had used the declogger in a previous facility. When asked how a declogger was used, LVN L told the surveyor, staff were to measure the declogger to the size of the [DEVICE], then put the declogger into the [DEVICE] and twist the declogger. Staff were then to listen for air coming from the [DEVICE], which would indicate the [DEVICE] had declogged. LVN L stated if someone was not properly trained to use the declogger, it could "go through the end of the tubing on the other side" and cause a perforation of the balloon and/or the bowel. The DON was interviewed on 01/09/13 at 11:00 a.m. When questioned about physician orders to use the declogger, the DON responded, the physicians wrote orders for flushes for [DEVICE]s, but there were no orders for declogging the [DEVICE]s. She added if a device other than a natural mechanism was used, she thought the physician should write orders for it. She added, as a nurse, she would like to have a physician's order to declog the [DEVICE]s. During this interview, the DON was asked if there was any concerns she had with use of the declogger. The DON said if staff were not properly trained to use the declogger and ensured the proper size was used, it could cause a perforation in the [DEVICE], especially if it was old and worn. The DON said staff should know the size, depth and length of the declogger before using it. She then stated she preferred the "old school way" of using cranberry juice, warm water, etc. to declog the [DEVICE]. On 01/09/13 at 11:00 a.m., LVN A was queried about the procedure he used to un-clog [MEDICAL CONDITION] feeding tubes. The LVN stated he had used the declogger device for Resident #2. When queried about what size he used for Resident #2's [DEVICE], he responded, "One size fits all." During this interview, LVN A stated he had received training on how to use the declogger device from the facility's nursing managers and felt comfortable using it. When queried how far the declogger should be inserted into the [DEVICE], LVN A stated, "When you meet resistance, stop." In an interview with ADON D and ADON C on 01/09/13 at 11:40 a.m., the ADONs were asked about a facility P/P for the use of the declogger with [DEVICE]s. They said there was no facility P/P for the use of the declogger. ADON D stated she and ADON C oriented facility nurses on the use of the declogger. ADON C stated he had received orientation on how to use the declogger where he had worked in the past and had used that information to orient nursing staff at the facility. ADON D was queried about what material and/or information was used to instruct the nurses on the use of the declogger. ADON D stated he did not have any documented information on information provided during training on the use of the declogger, but had trained staff on what he remembered from his training at a previous job. ADON D added there were no written instructions/information available and none had been used. Additionally, she stated facility nurses were provided with just the information she had learned from ADON C. According to ADON D, she had communicated with the facility's corporate office on 01/08/13 after the surveyors had interviewed staff about the use of the declogger. ADON D stated she had been informed by the corporate office, the decision to use the declogger was a nursing judgement and no physician's order was needed. When asked if she had ever contacted the corporate office about the use of the declogger prior to the surveyor's questions, ADON D stated she had not ever communicated with the corporate office about the use of the declogger prior to 01/08/13. Resident #8's physician was interviewed on 01/09/13 at 1:00 p.m. in regard to the facility's use of a declogger with [DEVICE]s. The physician informed the surveyor he was not aware of the facility's methods for declogging [DEVICE]s. He stated whatever the facility was using had been working, and they should continue to use it. The surveyor then told the physician that staff were being trained to use the declogger device without directions or any instructions to refer to for guidance, staff were using what they had learned at other facilities on the use of the declogger and in fact, were training other staff based on this. The physician was also informed there were no facility P/P for the declogger. The physician then stated he was not aware of this, would speak to the DON and make some new changes for declogging [DEVICE]s. Resident #8 was interviewed on 01/10/13 at 5:45 p.m. in her room. During the interview, Resident #8 told the surveyor she could feel the declogger poking her when LVN K was trying to declog her [DEVICE]. She also stated when LVN K was milking or squeezing the [DEVICE], she was tugging on it hard and it hurt. When asked about the declogger being used previously, Resident #8 said when staff used the declogger, she could feel pain inside her abdomen when they "poked" the declogger into the [DEVICE]. Review of Resident #8's care plans dated 10/01/12 revealed there was no care plan, which addressed the potential problem of the resident's [DEVICE] becoming clogged or the use of a declogger. Review of Resident #8's consolidated physician orders for December 2012 and January 2013 revealed there were no orders/guidance for using a declogger when the resident's [DEVICE] became clogged. Review of Resident #8's nurse's notes from 01/25/12 at 8:00 p.m. to 01/08/13 at 6:00 a.m. revealed no evidence staff had ever declogged the resident's [DEVICE]. The nurse's note dated 01/08/13 at 1:30 p.m. reflected Resident #8's [DEVICE] did not "go with gravity, declog ned (sic) just to the end of the transparent tube." Observation of the package containing the Bionix enteral feeding tube declogger revealed information on the label reflected product sizes and lengths. The following information was included on the label of the packet: 1. Select the proper size Declogger that conforms to the length and diameter of the patient's tube. 2. Verify the tube length and confirm that no alterations have been made to the tube. 3. Gently insert the threaded end of the Declogger into the tube using a twisting motion. ...5. Flush the feeding tube with the appropriate solution. PRECAUTIONS: Prior to any use of the product, the length of the feeding tube should be known. Use a declogger that is shorter than the feeding tube. Caution: Federal law restricts this device to sale by or on the order of a physician." A telephone interview on 01/10/13 at 10:48 a.m. with a representative of the Food and Drug Administration revealed an order was required from a physician or an authorized person to use the declogger. Interview on 01/12/13 at 11:00 a.m. with the ADM revealed he had begun in-services on the 10 p.m. - 6 a.m. crew on the night (01/09/13) the problem was found. The ADM said, "I would not let them go on the floor to work until they had the in-service." On 01/14/13 at 3:15 p.m., the surveyor asked the ADM how he monitored the DON to ensure residents were receiving the proper care and services to meet their needs. The ADM stated he provided a monthly calendar of topics/care areas to be addressed by the various departments. Rounds were conducted. Assignments were made. Morning meetings were conducted with department heads. If a problem was identified, he would follow up on it. The ADM stated he checked with staff to ensure assignments were completed by the assigned individual/department. He stated information was shared among the department heads and followed up on. The ADM added, "I do the best I can." The surveyor asked the ADM what happened to cause the IJ involving the [DEVICE] decloggers. Regarding the [DEVICE] decloggers, he stated he had seen decloggers in a hospital, but he had never known anyone to have a policy in regard to the decloggers. Review of the Bionix Medical Technologies policy on use of the Enteral Feeding Tube Decloggers revealed the following: Instructions on [MEDICATION NAME] Usage: 1. Determine the size of the gastrostomy (G) or Jejunostomy (J) tube. 2. Obtain appropriate size Declogger that corresponds to the size of the tube. ...5. Gently insert the appropriate size Declogger into the opening of the enteral tube. 6. Slowly rotate the Declogger in a clockwise fashion until the stop disc meets the opening of the enteral tube. 7. To remove, pull back the Declogger in a counter-clockwise fashion. 8. Flush the tube with 30-60 cc of water. 9. Reconnect the delivery tube and restart enteral feeding. (The instructions for a blocked [MEDICAL CONDITION] or Jejunostomy tube same as above.)" "DO NOT ATTEMPT TO FORCE THE DECLOGGER THROUGH THE ENTIRE BLOCKAGE." Frequently asked questions: Can the declogger harm the patient in any way? The Declogger has a small disc at the handle that prevents over-insertion. The design of the device with its standardized length and flexible plastic molding are added safeguards. There five different sizes and two lengths of the Declogger that is illustrated in this table: Gastrostomy or Jejunostomy (Foley of red rubber type) Product # Product size Length 911-Blue 12 - 14 Fr 39.5 cm 912-Yellow 16 - 18 Fr 39.5 cm 913 -Green 20 - 22 Fr 39.5 cm Peg type or replacement type: 921 -Brown 12 - 16 Fr 21.5 cm 922 -Orange 18 - 24 Fr 21.5 cm Proper Usage: "You should understand what different occurrences cause clogs in enteral feeding tubes so you know why exactly you are unclogging a tube. Here are some examples: kinks in the lines of the tubes, not flushing after putting medication in, dense formulas, small-bore feeding tubes and slow flowing formula can sometimes cause residue that forms buildup. [MEDICAL CONDITION] acids can mix with the formula when the [MEDICAL CONDITION] residuals are being checked." Review of the facility's current policy and procedure entitled Maintaining Patency of A Feeding Tube (Flushing) dated as revised October 2010 revealed the following in regard to clogged feeding tubes: Occlusion or clogged tube procedures 1. Check feeding tube for kinks. A kink is a twist or curl, as in a thread, rope, tube, wire, or hair, caused by its doubling or bending upon itself. 2. Attach sixty (60) cc syringe with plunger and gently pull back on the plunger to dislodge the clog. 3. If blockage remains, draw up 30 cc of warm water into the 60 cc syringe and gently instill water into the tube. Do not force fluid into tube. Gently pull back and forth on the plunger to dislodge the clog. 4. The feeding tube can be milked with fingers from the insertion site to assist in removing the clog. 5. If attempts are not successful, notify the physician. The facility's policy/procedure had no documentation in regard to using or not using a declogger. On 01/09/13 at 3:30 p.m., the Administrator and the DON were notified an IJ was identified in the area of Quality of Care related to the use of the declogger. A plan of removal for the IJ was requested. The facility's plan of removal for the IJ was accepted on 01/10/13 and reflected the following: --Review of an Addendum to the facility's [DEVICE] policy for declogging [DEVICE]s, received on 01/28/13 from the Administrator revealed the use of decloggers has been discontinued and they are not allowed at the facility. --Decloggers were collected and removed from circulation effective 01/09/13 at 4:15 p.m. --All residents with [DEVICE]s were assessed for clogs and/or pain by the ADONs effective 01/09/13. --The Charge nurses were in-serviced by the DON and the ADONs on the discontinued use of the decloggers effective 01/10/13, and all nurses were to be in-serviced before providing care to any resident with a [DEVICE]. --If a [DEVICE] is found to be clogged, facility staff will call the physician and obtain an order for [REDACTED]. --All care plans will be updated on Feeding Tube residents to include interventions for occlusion or clogged tube procedures effective 01/10/13. --All licensed nursing staff will assess all residents with feeding tubes effective 01/10/13 by checking placement and documenting it. Placement will be checked by instilling an air [MEDICATION NAME] and listening for gurgle with stethoscope and/or by aspirating stomach contents. --The DON or Designee will monitor for clogs prior to medication administration, before flushing, before hanging formula via pump and/or [MEDICATION NAME] feedings at every shift by checking placement and flushing per order including residents who have a feeding tube, which is not actively used for nutrition. --A skill check-off list would be completed upon hiring nurses and annually to ensure proficiency in the proper care of residents with [DEVICE]s effective 01/10/13. Interviews were conducted with nursing staff on 01/10/13 regarding their response when a resident's [DEVICE] became clogged revealed the following: --At 3:00 p.m., LVN K revealed she had been in-serviced not to use the declogger. She said she was told to notify the physician for an order if [DEVICE] was clogged. --At 5:40 p.m., RN R revealed he had an in-service on 01/09/13 concerning [DEVICE]s and how to check and confirm placement of the tube. RN R said, "We were told to never use the de-clogger." RN R also stated, "We were told to try 30 ml of warm water and 'milk' the tube, and if the tube does not declog we are to call the physician for his guidance." --At 5:45 p.m., LVN P revealed they had been in-serviced on the procedure for checking placement of a [DEVICE]. LVN P said if the tube was clogged they were to "milk" the tube, if the [DEVICE] did not become clear, they were to report to the DON and call the physician. --At 5:45 p.m., RN U stated she would "milk" and/or aspirate the [DEVICE] if was clogged. The RN further stated she would also use approximately 30 ml of warm water and aspirate the feeding tube in an attempt to unclog it. Additionally, RN U stated she would notify the physician if all of the above efforts were unsuccessful. --At 6:00 p.m., LVN T stated she would initially "milk" the tube to remove the clog. If milking was unsuccessful, she would use approximately 15 ml of warm water and aspirate the tube with a syringe. She further stated she might let the warm water "sit" awhile before she aspirated the tube. If all the above procedures failed to unclog the tube, LVN T stated she would phone the physician for additional orders. --At 6:10 p.m., LVN N stated she would "milk" the tubing first, then try to aspirate with a plunger and if the [DEVICE] was still clogged, she would add 15 to 20 ml of warn water and let it sit for approximately 30 minutes and try to aspirate again. If the [DEVICE] was still clogged, LVN N stated she would then call the physician. While the IJ was removed on 01/14/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with potential for more than minimal harm, that is not immediate jeopardy," because the facility was still in-servicing staff and monitoring the implementation of the plan of removal. Non-IJ examples: 2) Resident #8's January 2013 Physician's Orders reflected a current admission date of [DATE], and [DIAGNOSES REDACTED]. Resident #8 was observed on 01/08/13 at 9:55 AM lying in her bed. The resident was receiving a tube feeding via gastrostomy tube ([DEVICE].) LVN K was observed on 01/08/13 at 1:30 PM administering medication to Resident #8. LVN K checked the [DEVICE] for placement and residual. When LVN K pulled back on the syringe piston, the piston did not pull back when she pulled back. LVN K placed the piston on a clean surface then poured 30 cc water into the syringe to flush the [DEVICE]. The water did not flow down. LVN K stated the tube was a small tube and it took time to infuse. After about 20 to 25 minutes attempting to administer the 30 cc water by milking the tube, Resident #8 complained of pain. Finally, LVN K used the piston to forcefully push the fluid into the abdomen. LVN K proceeded to pour [MEDICATION NAME] 10/325 mg one crushed tablet in water in the medication cup into the syringe. The medication did not flow down and no air bubbles were observed. After about another twenty minutes LVN K disconnected the syringe to go retrieve a declogger device. After a while she came back with a feeding tube declogger to open up the [DEVICE]. This declogger was a single-use device made of [MEDICATION NAME] flexible plastic probe with a special screw-and-thread designed to clear clogs from Gastrostomy and Jejunostomy enteral feeding tubes. LVN K placed the declogger into the [DEVICE] twice to clear the clog. Resident #8 complained twice that she was hurting her with the poking of the declogger. After the attempt to declog, LVN K proceeded to administer the medication without rechecking for placement and residual. The medications still did not flow down after the declogging device was used in the [DEVICE]. During an interview with LVN K on 01/08/13 at 3:00 p.m., she told the surveyor she did not have any training on how to declog the [DEVICE] with the (name brand) declogging device. She observed one of the LVNs demonstrate its use one time and was observed one time using the device. The interview revealed she had problems before with the resident's previous [DEVICE] changed on 12/27/12. The declogger packet usage instructions were reviewed. These instructions reflected that the [DEVICE] was to be flushed with the appropriate solution after successful declogging. Review of the manufacturer instructions for a blocked [MEDICAL CONDITION] or Jejunostomy tube declogging reflected to flush the [DEVICE]/j-tube with 30 to 60 cc of water after declogging. The facility's P/P related to administering medications via a [MEDICAL CONDITION] feeding tube, dated revised October 2010, was provided by the Administrator on 01/11/13 and was identified as current. According to the P/P placement and [MEDICAL CONDITION] contents should be checked prior to the administration of medications. The procedure was as follows: Auscultate the abdomen approximately three inches below the sternum while injecting 10 ml of air from the syringe and listen for a "whooshing" sound. Pull back gently on the syringe to aspirate stomach content. Administer medication by gravity flow. 3) Resident #2's January 2013 Physician's Orders reflected a current admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #2 was observed on 01/09/13 at 9:10 a.m. lying in bed. The resident was receiving tube feedings via a [MEDICAL CONDITION] feeding tube. LVN A was observed administering medications to Resident #2 on 01/09/13 at 11:00 a.m. Prior to administering the medications, the nurse stated he was "going" to check the tube for placement. LVN A used a 60 ml piston syringe to administer 30 ml of water, while using a stethoscope to auscultate the resident's abdomen. LVN A then removed the plunger from the syringe

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received and the facility provided the necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for nine (Residents #1, #3, #4, #5, #9, #12, #14, #18 and #21) of 19 residents reviewed, who received BP medications. 1) Resident #4 was ordered to receive [MEDICATION NAME] (for elevated BP). Facility failures included: The [MEDICATION NAME] was held for eight days in December 2012 and two days in January 2013 without physician's orders [REDACTED]. The [MEDICATION NAME] was held without a BP reading for four days in December 2012. The physician was not notified of low BP readings and [MEDICATION NAME] being held. No assessment was conducted with low BP readings. 2) Resident #5 had orders for [MEDICATION NAME] and [MEDICATION NAME] XL with BP parameters for holding the medication. Facility failures included: [MEDICATION NAME] XL, [MEDICATION NAME] and [MEDICATION NAME] were held even though the resident's BP was above the physician-ordered BP parameters. LVN B did not report to the charge nurse when she held the resident's medications. The resident was not assessed and the physician was not notified when the medications were held. 3) Resident #14 had orders for [MEDICATION NAME] and [MEDICATION NAME] and had no BP parameters for holding his BP medication. Facility failures included: The physician's orders [REDACTED]. [MEDICATION NAME] and [MEDICATION NAME] were held without a physician's orders [REDACTED]. The physician was not notified of abnormal BP readings and of [MEDICATION NAME] and [MEDICATION NAME] being held. No assessment was conducted with abnormal BP readings. 4) Resident #21 had orders to receive [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. Facility failures included: LVN B held the [MEDICATION NAME] and [MEDICATION NAME] due to a low BP, but administered the [MEDICATION NAME] (incorrectly) because she "overlooked it." The [MEDICATION NAME] and [MEDICATION NAME] were held more often than they were administered in January 2013, but the resident was not assessed and the physician was not informed of medications being held and the resident's low BP. The frequency of holding the resident's diuretics likely contributed to the resident's 3+ to 4+ [MEDICAL CONDITION] when she was sent to the hospital on [DATE]. 5) Resident #1 had orders to receive [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. Failures included: Despite holding 27 of 31 doses of [MEDICATION NAME] and not administering any [MEDICATION NAME] during January 2013, the physician was not notified. LVN B did not notify the charge nurse when she held the resident's [MEDICATION NAME]. The physician was not contacted to clarify the two sets of BP parameters for holding medication. 6) Resident #3 had orders to receive [MEDICATION NAME] and [MEDICATION NAME] (HCTZ) and orders for BP parameters to hold the BP medications. Facility failures included: [MEDICATION NAME] and [MEDICATION NAME] (HCTZ) were not held and administered according to the physician's orders [REDACTED]. Documentation on the January 2012 MAR indicated [REDACTED] With fluctuating BPs, the resident was not assessed. The physician was not notified when medications were held. 7) Resident #12 had orders for [MEDICATION NAME] (for treatment of [REDACTED]. Facility failings included: The physician's BP parameters were not followed as ordered. The physician was not notified when the [MEDICATION NAME] was held. 8) Resident #18 had orders for the following medications for treatment of [REDACTED]. There were BP parameters ordered to hold the BP meds. The physician's BP parameters were not followed as ordered. The resident had a BP of 90/59 and there was no evidence of an assessment being conducted. The charge nurse/physician were not informed when medications were held or when the resident's BP was 90/59 and the [MEDICATION NAME] was not held. 9) Resident #9 had orders for a daily BP check and for [MEDICATION NAME] to treat the resident's BP. Facility failures included: The resident's clinical record had not been reviewed, the physician had not been contacted for BP parameters to hold the [MEDICATION NAME], or when to be contacted for low BP readings until surveyor intervention on 01/13/13. On 01/11/13, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/14/13, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still inservicing staff and monitoring the implementation of the plan of removal. These failures could affect the 76 residents in the facility who received medication to treat their high blood pressure, including Residents #1, #3, #4, #5, #9, #12, #14, #18 and #21, and could result in the potential for a change in condition, sudden drop in blood pressure, elevation of the BP, stroke, dizziness, falls, fatigue, weakness, loss of consciousness, fluid retention, respiratory distress and possibly death resulting in the need for emrgency help and/or hospitalization . Findings included: 1) The Janurary 2013 consolidated physician orders [REDACTED]. Observation on 01/08/13 at 11:30 a.m. during initial tour, revealed Resident #4 was in bed in a dark room watching television. Resident #4 appeared to be disheveled, but when asked about assistance in getting up, she said she did not care to have her clothing or her bed changed. Further observation revealed Resident #4 had a large amount of personal items in her room, including a refrigerator. At that time, LVN J told the surveyor Resident #4 was difficult to please and a challenge. Interview on 01/10/13 at 11:00 a.m. with Resident #4 revealed at times she would refuse certain medications, but not the blood pressure medications, because she had already had one stroke and she did not want to have another one. Resident #4 told the surveyor the staff sometimes would not let her have her blood pressure medication because of her blood pressure. Resident #4 said she did not know if the staff "knew what they were doing half the time." Interview on 01/10/13 at 1:00 p.m. with the Social Service Director and ADON C revealed Resident #4 was a difficult person to please, but they did not feel she had a true understanding of the depth of her illness, and by refusing different types of treatments what the outcome would be. The Social Service Director said the psychologist was already treating Resident #4, but she would have him re-visit this particular subject. The surveyor mentioned Resident #4 recognized certain medications, which were beneficial to her, and she did not understand why other medications were necessary and she needed them all the time. The Social Service Director and ADON C agreed and said this was a very difficult problem. Resident #4's consolidated physician orders [REDACTED]. There were no BP parameters ordered to direct the nursing staff when to give BP medications or when to hold them. Resident #4's physician telephone orders dated from 10/12/12 through 01/10/13 reflected there were no BP parameters ordered. Resident #4's MARs for December 2012 reflected [MEDICATION NAME] 25 mg was scheduled to be given twice a day at 8:00 a.m. and 5:00 p.m. The MAR indicated [REDACTED]. Resident #4's December 2012 MAR indicated [REDACTED] Resident #4's December 2012 MAR indicated [REDACTED] 12/19/12 at 8:00 a.m. BP 113/70; 12/30/12 at 5:00 p.m. with no BP reading; and 12/31/12 at 8:00 a.m. BP 13?/7?. Resident #4's December 2012 MAR indicated [REDACTED]. Resident #4's MAR for January 2013 reflected the [MEDICATION NAME] was given on the following dates and times and with BP readings: 01/01/13 at 8:00 a.m. BP 106/72, and 01/04/13 at 8:00 a.m. BP 116/76. The MAR indicated [REDACTED]. Review of Resident #4's entire clinical record revealed there was no assessment documented in regard to when the resident had abnormal BPs or evidence to indicate Resident #4's physician was contacted regarding abnormal BP readings or when medication was held or given. During an interview on 01/11/13 at 3:00 p.m., LVN B was asked about holding BP medications in relation to the resident's BP. LVN B replied, "I know when to hold blood pressure medications." When the surveyor queried how, LVN B said, "I just know." Resident #4's care plan dated 10/23/12 reflected Hypertension was identified as a problem with the goal being, "...will not experience any complications r/t heart or hypertensive medications... Will not have any side effects r/t medications ... (Approaches) Monitor B/P weekly-recheck is greater than 150/90... Notify MD of abnormal BPs...." 2) The consolidated physician's orders [REDACTED]. Observation of Resident #5 on 01/08/13 at 11:45 a.m. revealed the resident was in the dining room in a Geri- chair at the assistive feeding table. Resident #5 was well-groomed and was conversing with the staff in a slurred speech. Interview on 01/08/13 at 11:45 a.m. with an unknown CNA revealed Resident #5 required staff assistance with all ADLs. The consolidated physician's orders [REDACTED]. [MEDICATION NAME] 1.25 mg one by mouth every day, [MEDICATION NAME] 10 mg one by mouth every day, and [MEDICATION NAME] XL 25 mg one tablet by mouth every p.m. Also ordered were parameters to hold BP medications for a systolic BP (top number) of less than 110 and a diastolic BP (bottom number) of less than 60, and then notify the physician for each of these medications as indicated on the physician orders. Resident #5's MAR for December 2012 reflected her [MEDICATION NAME] XL was given on 12/19/12 at 5:00 p.m. with a BP reading of 106/74 and another day in December with a BP reading of 102/57. Both BP readings were below the physician-ordered parameters and the [MEDICATION NAME] XL should have been held. The MAR indicated [REDACTED]. Resident #5's MAR for December 2012 also reflected her [MEDICATION NAME] was given on 12/25/12 at 9:00 a.m. with no BP reading. The MAR indicated [REDACTED]. Further review of Resident #5's December 2012 MAR indicated [REDACTED]. Review of Resident #5's MAR for January 2013 revealed the following: on 01/01/13 at 9:00 a.m., the resident's BP was 107/81 and LVN B held both [MEDICATION NAME] and [MEDICATION NAME]. On 01/01/13 at 5:00 p.m., LVN B gave [MEDICATION NAME] XL. On 01/05/13 at 9:00 a.m., the resident's BP was 101/77 and [MEDICATION NAME] and [MEDICATION NAME] were given. In an interview on 01/11/13 at 3:00 p.m., LVN B was asked whether she had reported Resident #5's 9:00 a.m. low bood pressure to the charge nurse. LVN B said she did not report the 9:00 a.m. low BPs to the charge nurse. LVN B said she knew she was supposed to report when she held medications, but she got busy and she would forget. When the surveyor queried whether LVN B every recalled reporting when she held BP medications on any of the residents, LVN B said, "No. I did not report any of the blood pressure medications that I held...." The surveyor queried holding BP medications for the resident's morning dose and then administering the BP medication at 5:00 p.m. LVN B said she did not feel uncomfortable, because the blood pressure was fine. When the surveyor queried LVN B why she did not report holding BP medication for more than one day or the BP irregularities throughout a period of time, LVN B just "shrugged" her shoulders and did not answer. Review of Resident #5's entire clinical record revealed there was no assessment completed when the resident had an abnormal BP, no consistency with holding the resident's BP medications and nothing to indicate the physician was aware of the resident's BP and when medication was being held. 3) The Face Sheet dated 11/30/12 reflected Resident #14, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #14's MDS assessment dated [DATE] reflected active [DIAGNOSES REDACTED]. Observation on 01/11/13 at 2:00 p.m. revealed Resident # 14 was sitting in his wheelchair in his room, was well-groomed and dressed appropriately. The resident appeared comfortable and in no pain. Resident # 14 spoke to the surveyor for a short time. During this observation by the surveyor, Resident # 14 appeared alert, but confused and very forgetful. The surveyor queried if the resident understood what type of medication he was taking, and the resident could not answer the surveyor. Resident # 14's consolidated physician orders [REDACTED]. --[MEDICATION NAME] 20 mg tab, one by mouth every other day, [DIAGNOSES REDACTED]. --[MEDICATION NAME] 6.25 mg tab, one by mouth twice a day, [DIAGNOSES REDACTED]. --Linsinopril 10 mg tab, one by mouth twice a day, [DIAGNOSES REDACTED]. Resident #14's consolidated physician orders [REDACTED]. Resident #14's MAR for December 2012 reflected: --12/01/12 - [MEDICATION NAME] 5 p.m. dose and Linsinopril 5 p.m. doses were documented as held due to physician guidelines for low blood pressure. --12/02/12 - Linsinopril (5 p.m. dose), [MEDICATION NAME] (9 a.m. dose), and [MEDICATION NAME] (5 p.m. dose) were documented as held. The a.m. BP reading for 12/02/12 was 110/64. --12/03/12 - Linsinopril (5 p.m. dose) was held and [MEDICATION NAME] (5 p.m. dose) was held. --12/04/12 - The 5 p.m. doses of [MEDICATION NAME] and Linsinopril were held. The night BP was 135/97. --12/14/12 - [MEDICATION NAME] (5 p.m. dose) was held, BP was 138/74. --12/20/12 - [MEDICATION NAME] was held at 9 a.m. and 5 p.m. and Linsinopril was held at 9 a.m. The BP at 9 a.m. was 112/66. The BP for 5 p.m. was documented in two different areas: 117/88 and 127/68. --12/23/12 - [MEDICATION NAME] was given at 5:00 p.m. with a BP of 113/60. --12/24/12 - Linsinopril was held at 5:00 p.m. with a BP of 113/80. --12/27/12 - The 9:00 a.m. and 5:00 p.m. doses of [MEDICATION NAME] were held for a "nite" BP of 120/82. --12/29/12 - Linsinopril was given at 5:00 p.m. and [MEDICATION NAME] was held at 5:00 p.m. with a BP of 98/50. Resident #14's MAR for December 2012 reflected the resident's [MEDICATION NAME] had only been held once, on 12/02/12, even though the [MEDICATION NAME] and [MEDICATION NAME] had been held. Resident #14's January 2013 MAR indicated [REDACTED]. [MEDICATION NAME] was omitted on 01/03/13 with a BP of 116/88. Resident #14's January 2013 MAR further reflected: --01/09/13 - 9 a.m. doses of [MEDICATION NAME] and [MEDICATION NAME] were given with a BP of 91/82. --01/10/13 - [MEDICATION NAME] was given at 9:00 a.m. with a BP 102/73. - [MEDICATION NAME] was given at 5:00 p.m. with BP 98/74. --01/11/13 - [MEDICATION NAME] and [MEDICATION NAME] were given at 9:00 a.m. and 5:00 p.m. 9 a.m. BP of 98/76 and 5 p.m. BP of 101/74. Further review of Resident #14's entire medical record revealed no evidence the physician had been notified by facility staff regarding the BP medications being held or the BP medications had been held four days in a row. Review of Resident #14's clinical record revealed a "Note to Attending Physicians/Prescriber" dated 12/07/12 from the pharmacy consultant. The pharmacy consultant had suggested to the physician to decrease Resident #14's [MEDICATION NAME] 10 mg from twice a day to once a day, because the evening dose of Resident #14 [MEDICATION NAME] was held almost daily for a low BP. Further review revealed the physician had agreed to order Resident #14's Linsinopril 10 mg once a day. Resident #14's entire clinical record reflected no evidence the pharmacy consultant's recommendations and the physician's response had been implemented. Review of Resident #14's consolidated physician orders [REDACTED]. The physician's orders [REDACTED]. Resident #14's physician telephone order dated 01/11/13 reflected it clarified the parameters when BP medication was to be held. The physician-ordered parameters for holding BP medication were a systolic BP of less than 108 (top number) and/or a diastolic BP of less than 60. Further review of this telephone order indicated the Linsinopril 10 mg was adjusted to once daily as ordered in December 2012. Following surveyor intervention, review on 01/12/13 revealed Resident #14's January 2013 MARs were rewritten with the clarified parameters, one place for BP readings, an area to identify when the physician was notified and an area for further documentation to explain why the medication had been held. On 01/13/13, Resident #14's MAR for January 2013 reflected the new MAR included documentation of Linsinopril, [MEDICATION NAME], and [MEDICATION NAME] being held and the corresponding BP. Further review of the new MAR indicated [REDACTED]. Resident #14's care plan dated 11/01/12 reflected a problem onset identified as cardiac alteration. The goal and target area indicated cardiac stability would be maintained with the current medical regime and included the following approaches: administer medications as ordered. Monitor for effectiveness and side effects: notify physician if warranted.... Further review indicated no approaches or goals set for monitoring BP medications and/or reporting to the physician any abnormalities. Resident #14's care plan updated on 01/11/13 reflected a problem onset for all BP meds with [DIAGNOSES REDACTED]. Hold BP medications if systolic BP is less than 100 and diastolic BP is less than 60. Notify physician for BP medications held for three consecutive days for [MEDICAL CONDITION]. During an interview on 01/14/13 at 11:00 a.m. LVN J revealed Resident #14 was taking [MEDICATION NAME], a BP medication. LVN J stated the resident's BP medication, Linsinopril, had been changed recently. The surveyor queried LVN J why the physician orders [REDACTED]. LVN J stated, "I do not know. I guess someone just missed it." Interview on 01/14/13 with the DON at 12:15 p.m. revealed she did not know the Linsinopril had been given following the physician changing Resident #14's orders on 12/07/12 until the audit of the blood pressure medications was done on the night of 01/11/13. The DON said at that time, the pharmacy consultant recommendations were found in Resident #14's chart and the medication Linsinopril had been given inappropriately, the physician was notified that the medication had been given inappropriately, since 12/07/12, the blood pressure medication had been reduced to daily. 4) Resident #21 was initially observed during rounds on 01/08/13 at 9:10 a.m. with CNA V. The resident was in bed in her room and staff was providing morning care. The resident was described as being confused at times, requiring assistance with meals at times and was incontinent of bowel and bladder. Resident #21's most current MDS assessment dated [DATE] reflected a [DIAGNOSES REDACTED]. Resident #21's consolidated physician orders [REDACTED]. An additional [DIAGNOSES REDACTED]. Resident #21's consolidated physician orders [REDACTED]. Resident #21 was also ordered to receive the diuretic (helps to reduce the build-up of excess fluid in the body) [MEDICATION NAME] 100 mg daily and 60 mg of [MEDICATION NAME] three times a day to treat her Hypertension and [MEDICAL CONDITION]. A physician's telephone order dated 01/08/13 reflected the [MEDICATION NAME] had been increased from 100 mg to 150 mg daily. On 01/09/13 at 8:10 a.m., LVN B was observed to prepare and administer medications for Resident #21. LVN B obtained a BP measurement prior to administering any medications. The resident's BP was 111/68. Medications administered included the diuretic [MEDICATION NAME] 150 mg. Resident #21's [MEDICATION NAME] and [MEDICATION NAME] were not administered. Reconciliation of the medication pass with Resident #21's consolidated physician orders [REDACTED]. was below the parameters of 120/80. LVN B held [MEDICATION NAME], and [MEDICATION NAME], but the LVN did not hold Resident #21's Spironoloactone, and she should have. LVN B was queried on 01/10/13 at 11:40 a.m. why she had held the [MEDICATION NAME] and [MEDICATION NAME] on 01/09/13, but had administered the [MEDICATION NAME] when the physician's orders [REDACTED]. LVN B stated, "I guess I overlooked it." The January 2013 MAR indicated [REDACTED]. The January 2013 MAR indicated [REDACTED] [DATE] - BP 111/68 [DATE] - BP 118/72 [DATE] - BP 90/58 [DATE] - BP 110/68 [DATE] - BP 135/70 [DATE] - BP 136/71 [DATE] - BP 111/68 [DATE] - BP 113/69 Resident #21's consolidated physician orders [REDACTED]. It was held during the following additional times: [DATE] - 4:00 p.m. BP 101/52 [DATE] - 12:00 p.m. BP 128/65 - 4:00 p.m. BP 130/70 [DATE] - 12:00 p.m. BP 106/60 - 4:00 p.m. BP 100/63 Of the 31 doses of [MEDICATION NAME] ordered to be administered from 8:00 a.m. on 01/01/13 to 8:00 a.m. on 01/11/13, Resident #21 received only 12 doses. Resident #21 only received four of the 11 doses ordered of the diuretic [MEDICATION NAME] from 01/01/13 to 01/11/13. There were no documented BPs for 12:00 p.m. on 01/01/13, 01/02/13 and 01/03/13. The [MEDICATION NAME] was administered on these dates at 12:00 p.m. An interview with ADON C on 01/13/13 at 10:55 a.m. revealed Resident #21 had been transferred to the hospital on [DATE] due to respiratory distress and [MEDICAL CONDITION] (excess fluid in the body). According to a Resident Transfer form dated 01/11/13, Resident #21 was transferred to the hospital on [DATE] due to neck vein distention, 3+ to 4+ [MEDICAL CONDITION] and agonal breathing. (An extremely serious medical sign of an abnormal breathing pattern characterized by gasping and labored breathing requiring immediate medical attention.) On 01/14/13 at 11:15 a.m., the DON was informed of the frequent holding of Resident #21's diuretics (ordered to treat the resident's BP and [MEDICAL CONDITION]) without any evidence the physician was notified. When queried during this time about whether she was aware the diuretics had been held on multiple occasions, the DON's response was, "(Resident #21's) [MEDICAL CONDITION] was generalized only on one side when she was transferred to the hospital." Review of Resident #21's entire clinical record revealed there was no documentation of the physician being notified the resident's BP was low, and the BP medications and diuretics were being held. Prior to exit on 01/14/13, no additional information was provided related to facility staff frequently holding Resident #21's diuretics without notifying the physician. 5) Resident #1's most current MDS assessment dated [DATE] reflected [DIAGNOSES REDACTED]. Resident #1's consolidated physician orders [REDACTED]. The orders further reflected Resident #1 was ordered to receive medications to treat Hypertension and [MEDICAL CONDITION]. The medications were [MEDICATION NAME] 20 mg orally every morning and [MEDICATION NAME] 12.5 mg orally twice a day. The [MEDICATION NAME] was to be held for a BP of 120/80 or lower and the Metoporlol was to be held for a BP of 100/70 or below. There were no clarification orders to reflect which of the two BP parameters should be followed. Review of Resident #1's entire clinical record revealed there was no care plan related to the two different blood pressure parameters for holding the resident's medications. There was no care plan related to when the physician should be notified if the resident's blood pressure medications were not being administered as ordered. Review of Resident #1's MAR for January 2013 revealed the resident had not received eleven ordered doses of the diuretic [MEDICATION NAME] during the month of January 2013 (01/01/13 to 01/11/13). The MAR indicated [REDACTED]. According to the January 2013 MAR, Resident #1 had only received four of the 31 doses of [MEDICATION NAME] during January 2013 (8:00 a.m. on 01/01/13 to 8:00 a.m. on 01/11/13). The MAR indicated [REDACTED]. Resident #1's January 2013 MAR indicated [REDACTED]. Resident #1's January 2013 MAR indicated [REDACTED]. However, the 4:00 p.m. dose of [MEDICATION NAME] was still administered. An interview with LVN B on 01/11/13 at 2:55 p.m. revealed she had not informed the charge nurse on 01/11/13 of the need to hold Resident #1's [MEDICATION NAME]. When queried during this time about how she determined which parameter she was following when she administered the [MEDICATION NAME] and [MEDICATION NAME] for Resident #1, the nurse stated, "I gave the [MEDICATION NAME] according to its parameters and [MEDICATION NAME] according to its parameters." LVN B further stated during this time, she felt it was strange to have two sets of blood pressure parameters for holding two different medications but she thought it was the way the physician wanted it and had not attempted to obtain clarification from the physician. LVN B stated LVN A was the charge nurse. Further review of Resident #1's clinical record revealed there was no care plan, which identified the two sets of BP parameters for holding the resident's medication. There was also no care plan related to when the physician should be notified if the resident's BP medication was held. During an interview with LVN B on 01/11/13 at 2:55 p.m., the surveyor asked why she did not get a clarification order for the physician's BP parameters. LVN B provided no explanation. During an interview with the DON on 01/11/13 at 3:25 p.m., she stated the physician should be notified if there were 2-3 consecutive days when a resident's medications were held as the physician may need to adjust the medication. 6) Resident #3's most recent MDS assessment dated [DATE] reflected the resident's current admitted was 05/17/11. Resident #3's consolidated physician orders [REDACTED]. The orders reflected Resident #3 was ordered to receive medications to treat hypertension. The medications were [MEDICATION NAME] 20 mg every morning, [MEDICATION NAME] 10 mg every day and [MEDICATION NAME] 25 mg every morning orally. The orders further reflected the [MEDICATION NAME] and [MEDICATION NAME] should not be administered if the resident's blood pressure was below the physician ordered parameters of a systolic (top number) blood pressure (SBP) less than 120 and a diastolic (bottom number) blood pressure (DBP) less than 60. These orders also reflected additional orders to "Hold B/P meds (medication) for SBP less than 110 and DBP less than 60. Resident #3's physician's telephone order dated 12/17/12 reflected the medication [MEDICATION NAME] 25 mg two times a day should also be administered orally and held if Resident #3's SBP was less than 110 and the DBP was less than 60. A Pharmacy Consultant's note to the attending physician dated 12/05/12 reflected the following: "Please clarify the HOLD parameters you would like to see on this resident'[MEDICAL CONDITION]. Right now there are two sets of HOLD parameters listed on this resident's orders. To avoid possible med (medication) error, please select one of HOLD parameters for [MEDICAL CONDITION]." The note reflected the physician's response was dated 12/07/12 and the parameters of a SBP less than 110 and a DBP less than 60 was ordered for holding all of Resident #3's hypertension medications. A physician's telephone order dated 12/24/12 reflected the [MEDICATION NAME] should be held if Resident #3's SBP was less than 110 and the DBP was less than 60. Resident #3's MAR for January 2013 reflected blood pressure parameters for the [MEDICATION NAME] of a SBP less than 120 and a DBP less than 60 had been crossed out and new hold parameters of SBP less than 110 and DBP less than 60 had been added. According to the January 2013 MAR, the [MEDICATION NAME] and the a.m. dose of [MEDICATION NAME] were not administered during the following times: 01/01/13 for a BP of 119/70 (FYI-this result is within the parameters and the medications should have been administered). 01/04/13 for a BP of 90/53 01/05/13 for a BP of 104/79 The holding parameters for the Lisinopri

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for two (Residents #2 and #3) of eleven residents reviewed for neglect. 1) LVN G failed to order Resident #2's scheduled [MEDICATION NAME] and [MEDICATION NAME] mouthwash, when the resident had 17 teeth extracted. Resident #2 only received six of 12 scheduled doses of [MEDICATION NAME], and she did not receive any of the 32 doses of [MEDICATION NAME] mouthwash. Staff failed to ensure Resident #2's pain was addressed. Staff failed to follow Resident #2's Oral Surgeon's directions to not use a straw. Staff failed to recognize Resident #2 had a change in condition after her teeth were removed. Staff failed to address Resident #2's teeth extractions and possible complications on her Care Plan. Staff failed to write the Physician's Telephone Order for Resident #2's Bactrim DS for her Urinary Tract Infection. Resident #2 only received two of the ten ordered doses. These failures resulted in Resident #2 suffering from unrelieved pain, becoming dehydrated, continuing to have a Urinary Tract Infection, having a critical Sodium level and being admitted to the hospital for seven days. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring implementatin of the Plan of Removal. These failures could affect any of the facility's 92 residents, who could receive care from any of the nurses who rotated halls, by placing them at risk for delays in or omission of needed medical care and treatment, deterioration in clinical conditions, and an over-all decline in their health and well-being. 2) The facility Van Driver failed to properly secure Resident #3 in the facility van and hit a bump in the road, while transporting the resident, causing her to fall out of her wheelchair and immediately complain of pain in her legs. The Van Driver failed to call 911 for emergency assistance even though Resident #3 was screaming with pain to her leg. The Van Driver failed to contact the facility and inform them of Resident #3's accident and injury and get further instructions. The Van Driver failed to follow facility's protocol and moved Resident #3 when she was on the floor and tried to straighten out the resident's leg. The Van Driver failed to take Resident #3 immediately back to the facility after the accident. She took the resident to [MEDICAL TREATMENT], even though the resident was asking for an ambulance to be called. The Van Driver drove around with Resident #3 in the van for approximately two hours. These failures resulted Resident #3 suffering severe pain from a fractured leg, being hospitalized , and continuing severe pain, which required a central line. These failures could affect the 55 residents, who could ride in the van in a wheelchair, by placing them at risk for injuries, serious injuries, and anxiety. This failure resulted in an acute fracture for Resident #3 with increased pain and discomfort as well as increased anxiety and frustration when the driver failed to listen to her pleas for medical attention. Findings included: 1. The facility's Abuse Prohibition Policy and Procedure dated June 2005 and provided by ADON B , who identified it as current, reflected: "The facility's leadership will prohibit neglect...of patients/residents from staff..., visitors, or other patients/residents...Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect...." 2. Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. A water pitcher was in Resident #2's room atop a dresser that was situated across the room from her bed and between the first and second beds. No water pitchers were seen on either resident's night tables. When asked how often they offered fluids to the residents, CNA F stated they should offer fluids every time they check on the residents. When asked who the water pitcher on the dresser belonged to, both CNAs indicated they did not know. Resident #2's roommate entered the room at that time and was asked if she knew to whom the water pitcher belonged. The roommate replied, "Oh honey, I have no idea." Resident #2's Physician's Telephone Order dated 09/18/12 reflected "UA/C&S (urinalysis with culture and sensitivity)." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for [MEDICATION NAME] 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours as needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Urine Culture results dated 09/21/12 reflected Gram Negative Rods and Escherichia Coli. A handwritten entry on the lab result reflected, "(Physician E) notified 11:00 AM (Medical Director) notified Bactrim DS (one) PO BID X 5 days." Resident #2's Telephone Physician's Orders did not reflect an order for [REDACTED]. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) [MEDICATION NAME] 5/500 (one) po (by mouth) q 6 (every six hours) X (times) 72 hrs. 2) pureed diet, [MEDICATION NAME] Rinse 15 cc rinse X 30 sec. (seconds) swish & spit X 1 bottle BID (twice a day) 3) V/S (vital signs), & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? [MEDICATION NAME] bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for [MEDICATION NAME] 5/500 one by mouth every six hours for 72 hours. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR also reflected an entry dated 09/22/12 for [MEDICATION NAME] rinse 16 ounce bottle, 15 cc (half an ounce) rinse for 30 seconds, swish and spit twice a day times one bottle. The scheduled times for administration were 8:00 AM and 8:00 PM. The following doses were initialed as given: 09/23/12 at 8:00 AM and 8:00 PM. No other doses were initialed as given. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan updated on 08/18/12 did not reflect an update regarding her full mouth extraction or the complications which could develop. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." Resident #2's September 2012 MAR reflected she received [MEDICATION NAME] on 09/22/12 at 12:00 PM The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM the resident was "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." Resident #2's September 2012 MAR reflected on 09/23/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID (no Physician's Telephone Order was written), 9/22/12 [MEDICATION NAME] q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." Interview with LVN I on 10/31/12 at 8:32 AM revealed he was assigned to Resident #2 the evening after her teeth were extracted. LVN I stated he checked her mouth and smelled an odor "...that's when I used the mouthwash." When asked if it was the [MEDICATION NAME], LVN I stated it was regular mouthwash and showed the bottle to the surveyor. When asked why he did not use the [MEDICATION NAME] as ordered, LVN I did not answer. During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's September 2012 MAR reflected on 09/24/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, [MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's September 2012 MAR reflected no other doses of [MEDICATION NAME] were given after 09/24/12 at 6:00 AM. During an interview on 10/26/12 at 1:34 PM, LVN H was shown Resident #2's Controlled Drug Record and MAR and asked why only six doses of pain medication were administered to Resident #2 after her tooth extractions. LVN H replied that was all the [MEDICATION NAME] that was available for Resident #2. When LVN H was shown Resident #2's orders dated 09/22/12 ([MEDICATION NAME] 5/500 mg one tablet every six hours for 72 hours), he stated the physician had to call the pharmacy for [MEDICATION NAME]. When asked if he ever told the physician there was not enough medications available, LVN H did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." When LVN H was shown the order for [MEDICATION NAME] he stated he did not know why only two doses were given. When asked if he knew what [MEDICATION NAME] was used for, LVN H replied, "Yes, it's for after oral surgery, keeps the gums soft and prevents infection." During another interview with LVN H on 10/30/12 at 8:18 AM, when asked if he remembered ever seeing a bottle of [MEDICATION NAME] on the medication cart for Resident #2, he stated he never saw one. Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never received an order for [REDACTED]. . The Pharmacist stated the pharmacy never received the order for Resident #2's scheduled [MEDICATION NAME] and none was delivered to the facility. On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H "jogged her memory," and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Review of Emergency Kit Documentation Forms provided by the DON for September 2012 revealed only two doses of Bactrim had been removed from the facility's emergency drug kit for Resident #2. One tablet was removed on 09/23/12 at 9:00 AM and another tablet was removed on 09/26/12 at 4:00 AM. On 10/30/12 at 2:00 PM the DON explained she had contacted the pharmacy and spoke with the pharmacist to obtain their copies of the forms. When the DON was asked whether the Bactrim had ever been ordered, she replied, "No." Interview on 10/30/12 at 2:05 PM with LVN G revealed when asked where she obtained the doses she signed as given on 09/22/12 at 9:00 PM, 09/24/12 at 9:00 PM and 09/25/12 at 9:00 PM, she replied, "I know I pulled the initial dose from the E-Kit (emergency kit) and on the third day when I returned I called the pharmacy myself." When asked what she was told by the pharmacy, she replied, "We'll put it on the next shipment. That's what they always say." Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never processed an order for [REDACTED]. The 24 Hour Report Book reflected on 09/26/12 Night: "Cont. on Bactrim DS for UTI, NARN, stable" Day: "Still on Bactrim UTI, Appetite good" Evening: "Cont. on Bactrim for UTI" Interview with MA J on 10/30/12 at 2:09 PM revealed she signed out a dose of Bactrim on 09/26/12 and she stated she always informed the Charge Nurse if more than one dose of a medication was pulled from the emergency kit. The MA indicated she informed LVN H. Interview with LVN H on 10/30/12 at 2:11 PM revealed he was told about the Bactrim by the MA and called the pharmacy. LVN H could not remember what he was told by the pharmacy or whether they requested an order. The DON joined the interview and stated the pharmacy would not send the medication without an order and nobody sent them one. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good." Resident #2's Nurse's Notes dated 09/28/12 at 2:00 AM reflected: "Post ABT for UTI..." The 24 Hour Report Book reflected on 09/28/12 Night: "Bactrim UTI completed." Day: "PABT /UTI" Evening: "PABT ? problems" The 24 Hour Report Book reflected on 09/30/12: Evening: "Small amt (amount) blood noted from rectum when cleaning resident. Purplish red in color, (Physician E) called, N/O rec'd (received) for CBC in AM, Hemacults (sic) (test for blood in stool), (Lab company) called re: lab stool collected in fridge." Review of Resident #2's September 2012 MAR revealed an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. The 24 Hour Report Book reflected on 10/01/12 Night: "(s) (small) amt of blood noted from rectum. N/O Lab: CBC in AM, occult blood 1. No stool collected- (lab company) notified of lab orders/(Physician E), need stool specimen X1" Day: "In bed (decreased) appetite" Evening: "cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "Daughter notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to (decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" The 24 Hour Report Book reflected on 10/03/12: Night "90%-fed by nurse (2-10) stable, lab result f/u." Day: " appetite, (decreased) weight vs 120/63, 89 call placed to MD" Evening: "Hospital" An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's clinical record revealed a hospital record dated 10/10/12 that reflected: "[MEDICAL CONDITION] - Adult. Definition - [MEDICAL CONDITION] is a condition in which the level of water and sodium in the body - too little water, too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of [MEDICAL CONDITION] is having more water leave your body than entre it. This causes dehydration. A person can become dehydrated in different ways, such as: ? Drinking too little fluids ? Vomiting ? Diarrhea ? Using diuretics (medicines that increase urine output) ? Sweating a lot ? Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: ?Not getting enough fluids ? Losing too much fluid ? Advanced age ? Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: ? Being thirsty ? Dry mouth ? Serious symptoms: ? [MEDICAL CONDITION] ? Confusion ? Muscle twitching ? [MEDICAL CONDITION] ? Coma If left untreated, the condition may lead to death." Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection..." An interview on 10/31/12 at 7:52 AM with ADON A revealed when asked if she knew how dehydrated Resident #2 was at the hospital, ADON A stated, "...it didn't alarm us, we attributed it to her not eating due to her teeth being pulled." On 10/30/12 at 12:43 PM, the DON was asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." An interview on 10/30/12 at 9:35 AM with Physician E revealed when asked if he was aware Resident #2 had teeth extracted, he replied, "No." Physician E, was looking at his personal tablet and stated, "I have no records of being notified. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received none of the 32 doses ordered of the [MEDICATION NAME]. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Interview with the Administrator on 10/31/12 at approximately 9:15 AM revealed LVN G had been terminated. An interview on 10/31/12 at 8:32 AM with LVN I revealed nurses were to call the physician "as soon as you see a change." An interview on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." The facility's Abuse Prohibition Policy and Procedure dated June 2005 and provided by ADON B , who identified it as current, reflected: "The facility's leadership will prohibit neglect...of patients/residents from staff..., visitors, or other patients/residents...Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect..." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified, and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: A. Physician was notified of Resident #2's change in condition. All Resident #2's orders were verified and an assessment of her mouth was completed. The results of the assessment were called to her dentist's office. B. All residents who had recently received dental care or complained of oral concerns had an assessment of their mouth completed by 11/01/12. All residents with current UTIs or with symptoms of UTI were assessed by a nurse to ensure all interventions were in place. C. Any Resident who has a change of condition will be assessed by the assigned nurse who will document findings and report to the physician and responsible party. Nursing Administration will follow-up daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. D. Physician's Orders received will be followed through per facility protocol. All new orders and changes of condition will be reported on the facility 24 hour report. E. Nursing Administration will follow daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. F. Pain assessments will be completed upon admission and with any change of condition. The physician and family will be notified. Nursing Administration will follow daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. G. All changes of condition will be documented in the medical record. The INTERACT II SBAR form will be used to indicate the initial identification of a change of condition. Regional Nurse RN will in-service DON, ADON, MDS nurses, Skin Nurse on INTERACT II SBAR. All licensed nursing staff will be in-serviced on policy and proper use of these forms by Nursing Administration. H. Quality Assurance (QA) Systems for Assessments, Pharmacy Pocedure, Notification of Change and Pain were re-implemented starting 10/31/12/ Implementation of the QA Systems included in-services by Regional Nurse for Nursing Administration. For all licensed nursing staff, medication aides and CNAss, in-services began on 10/31/12. In-services included:. Oral assessment, changes of condition Procedures, INTERACT II,

Based on observation, interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit neglect of residents for two (Residents #2 and #3) of 11 residents reviewed for neglect. The facility neglected Resident #2 and #3 in the following manner: 1) Staff failed to order Resident #2's scheduled [MEDICATION NAME] and [MEDICATION NAME] mouthwash, when the resident had 17 teeth extracted. Resident #2 only received six of 12 scheduled doses of [MEDICATION NAME], and she did not receive any of the 32 doses of [MEDICATION NAME] mouthwash. Staff failed to ensure Resident #2's pain was addressed. Staff failed to recognize Resident #2 had a change in condition after her teeth were removed. Staff failed to address Resident #2's teeth extractions and possible complications on her Care Plan. Staff failed to write the Physician's Telephone Order for Resident #2's Bactrim DS for her Urinary Tract Infection and failed to order it. Resident #2 only received two of the ten ordered doses. These failures resulted in Resident #2 suffering from unrelieved pain, becoming dehydrated, continuing to have a Urinary Tract Infection, having a critical Sodium level and being admitted to the hospital for seven days. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring implementatin of the Plan of Removal. These failures could affect any of the facility's 92 residents, who could receive care from any of the nurses who rotated halls, by placing them at risk for delays in or omission of needed medical care and treatment, deterioration in clinical conditions, and an over-all decline in their health and well-being. 2) The facility Van Driver failed to properly secure Resident #3 in the facility van and hit a bump in the road, while transporting the resident, causing her to fall out of her wheelchair and immediately complain of pain in her legs. The Van Driver failed to call 911 for emergency assistance even though Resident #3 was screaming with pain to her leg. The Van Driver failed to contact the facility and inform them of Resident #3's accident and injury and get further instructions. The Van Driver failed to follow facility's protocol and moved Resident #3 when she was on the floor and tried to straighten out the resident's leg. The Van Driver failed to take Resident #3 immediately back to the facility after the accident. She took the resident to [MEDICAL TREATMENT], even though the resident was asking for an ambulance to be called. The Van Driver drove around with Resident #3 in the van for approximately two hours. These failures resulted Resident #3 suffering severe pain from a fractured leg, being hospitalized , continued severe pain which required a central line. These failures could affect the 55 residents, who could ride in the van in a wheelchair, by placing them at risk for injuries, serious injuries, and anxiety. This failure resulted in an acute fracture for Resident #3 with increased pain and discomfort as well as increased anxiety and frustration when the driver failed to listen to her pleas for medical attention. Findings included: 1) Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. A water pitcher was in Resident #2's room atop a dresser that was situated across the room from her bed and between the first and second beds. No water pitchers were seen on either resident's night tables. When asked how often they offered fluids to the residents, CNA F stated they should offer fluids every time they check on the residents. When asked who the water pitcher on the dresser belonged to, both CNAs indicated they did not know. Resident #2's roommate entered the room at that time and was asked if she knew to whom the water pitcher belonged. The roommate replied, "Oh honey, I have no idea." Resident #2's Physician's Telephone Order dated 09/18/12 reflected "UA/C&S (urinalysis with culture and sensitivity)." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for [MEDICATION NAME] 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours as needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Urine Culture results dated 09/21/12 reflected Gram Negative Rods and Escherichia Coli. A handwritten entry on the lab result reflected, "(Physician E) notified 11:00 AM (Medical Director) notified Bactrim DS (one) PO BID X 5 days." Resident #2's Telephone Physician's Orders did not reflect an order for [REDACTED]. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) [MEDICATION NAME] 5/500 (one) po (by mouth) q 6 (every six hours) X (times) 72 hrs. 2) pureed diet, [MEDICATION NAME] Rinse 15 cc rinse X 30 sec. (seconds) swish & spit X 1 bottle BID (twice a day) 3) V/S (vital signs), & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? [MEDICATION NAME] bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for [MEDICATION NAME] 5/500 one by mouth every six hours for 72 hours. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR also reflected an entry dated 09/22/12 for [MEDICATION NAME] rinse 16 ounce bottle, 15 cc (half an ounce) rinse for 30 seconds, swish and spit twice a day times one bottle. The scheduled times for administration were 8:00 AM and 8:00 PM. The following doses were initialed as given: 09/23/12 at 8:00 AM and 8:00 PM. No other doses were initialed as given. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan updated on 08/18/12 did not reflect an update regarding her full mouth extraction or the complications which could develop. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." Resident #2's September 2012 MAR reflected she received [MEDICATION NAME] on 09/22/12 at 12:00 PM The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM the resident was "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." Resident #2's September 2012 MAR reflected on 09/23/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID (no Physician's Telephone Order was written), 9/22/12 [MEDICATION NAME] q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." Interview with LVN I on 10/31/12 at 8:32 AM revealed he was assigned to Resident #2 the evening after her teeth were extracted. LVN I stated he checked her mouth and smelled an odor "...that's when I used the mouthwash." When asked if it was the [MEDICATION NAME], LVN I stated it was regular mouthwash and showed the bottle to the surveyor. When asked why he did not use the [MEDICATION NAME] as ordered, LVN I did not answer. During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's September 2012 MAR reflected on 09/24/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, [MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's September 2012 MAR reflected no other doses of [MEDICATION NAME] were given after 09/24/12 at 6:00 AM. During an interview on 10/26/12 at 1:34 PM, LVN H was shown Resident #2's Controlled Drug Record and MAR and asked why only six doses of pain medication were administered to Resident #2 after her tooth extractions. LVN H replied that was all the [MEDICATION NAME] that was available for Resident #2. When LVN H was shown Resident #2's orders dated 09/22/12 ([MEDICATION NAME] 5/500 mg one tablet every six hours for 72 hours), he stated the physician had to call the pharmacy for [MEDICATION NAME]. When asked if he ever told the physician there was not enough medications available, LVN H did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." When LVN H was shown the order for [MEDICATION NAME] he stated he did not know why only two doses were given. When asked if he knew what [MEDICATION NAME] was used for, LVN H replied, "Yes, it's for after oral surgery, keeps the gums soft and prevents infection." During another interview with LVN H on 10/30/12 at 8:18 AM, when asked if he remembered ever seeing a bottle of [MEDICATION NAME] on the medication cart for Resident #2, he stated he never saw one. Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never received an order for [REDACTED]. . The Pharmacist stated the pharmacy never received the order for Resident #2's scheduled [MEDICATION NAME] and none was delivered to the facility. On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H "jogged her memory," and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Review of Emergency Kit Documentation Forms provided by the DON for September 2012 revealed only two doses of Bactrim had been removed from the facility's emergency drug kit for Resident #2. One tablet was removed on 09/23/12 at 9:00 AM and another tablet was removed on 09/26/12 at 4:00 AM. On 10/30/12 at 2:00 PM the DON explained she had contacted the pharmacy and spoke with the pharmacist to obtain their copies of the forms. When the DON was asked whether the Bactrim had ever been ordered, she replied, "No." Interview on 10/30/12 at 2:05 PM with LVN G revealed when asked where she obtained the doses she signed as given on 09/22/12 at 9:00 PM, 09/24/12 at 9:00 PM and 09/25/12 at 9:00 PM, she replied, "I know I pulled the initial dose from the E-Kit (emergency kit) and on the third day when I returned I called the pharmacy myself." When asked what she was told by the pharmacy, she replied, "We'll put it on the next shipment. That's what they always say." Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never processed an order for [REDACTED]. The 24 Hour Report Book reflected on 09/26/12 Night: "Cont. on Bactrim DS for UTI, NARN, stable" Day: "Still on Bactrim UTI, Appetite good" Evening: "Cont. on Bactrim for UTI" Interview with MA J on 10/30/12 at 2:09 PM revealed she signed out a dose of Bactrim on 09/26/12 and she stated she always informed the Charge Nurse if more than one dose of a medication was pulled from the emergency kit. The MA indicated she informed LVN H. Interview with LVN H on 10/30/12 at 2:11 PM revealed he was told about the Bactrim by the MA and called the pharmacy. LVN H could not remember what he was told by the pharmacy or whether they requested an order. The DON joined the interview and stated the pharmacy would not send the medication without an order and nobody sent them one. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good." Resident #2's Nurse's Notes dated 09/28/12 at 2:00 AM reflected: "Post ABT for UTI..." The 24 Hour Report Book reflected on 09/28/12 Night: "Bactrim UTI completed." Day: "PABT /UTI" Evening: "PABT ? problems" The 24 Hour Report Book reflected on 09/30/12: Evening: "Small amt (amount) blood noted from rectum when cleaning resident. Purplish red in color, (Physician E) called, N/O rec'd (received) for CBC in AM, Hemacults (sic) (test for blood in stool), (Lab company) called re: lab stool collected in fridge." Review of Resident #2's September 2012 MAR revealed an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. The 24 Hour Report Book reflected on 10/01/12 Night: "(s) (small) amt of blood noted from rectum. N/O Lab: CBC in AM, occult blood 1. No stool collected- (lab company) notified of lab orders/(Physician E), need stool specimen X1" Day: "In bed (decreased) appetite" Evening: "cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "Daughter notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to (decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" The 24 Hour Report Book reflected on 10/03/12: Night "90%-fed by nurse (2-10) stable, lab result f/u." Day: " appetite, (decreased) weight vs 120/63, 89 call placed to MD" Evening: "Hospital" An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's clinical record revealed a hospital record dated 10/10/12 that reflected: "[MEDICAL CONDITION] - Adult. Definition - [MEDICAL CONDITION] is a condition in which the level of water and sodium in the body - too little water, too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of [MEDICAL CONDITION] is having more water leave your body than entre it. This causes dehydration. A person can become dehydrated in different ways, such as: ? Drinking too little fluids ? Vomiting ? Diarrhea ? Using diuretics (medicines that increase urine output) ? Sweating a lot ? Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: ?Not getting enough fluids ? Losing too much fluid ? Advanced age ? Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: ? Being thirsty ? Dry mouth ? Serious symptoms: ? [MEDICAL CONDITION] ? Confusion ? Muscle twitching ? [MEDICAL CONDITION] ? Coma If left untreated, the condition may lead to death." Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection..." An interview on 10/31/12 at 7:52 AM with ADON A revealed when asked if she knew how dehydrated Resident #2 was at the hospital, ADON A stated, "...it didn't alarm us, we attributed it to her not eating due to her teeth being pulled." On 10/30/12 at 12:43 PM, the DON was asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." An interview on 10/30/12 at 9:35 AM with Physician E revealed when asked if he was aware Resident #2 had teeth extracted, he replied, "No." Physician E, was looking at his personal tablet and stated, "I have no records of being notified. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received none of the 32 doses ordered of the [MEDICATION NAME]. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Interview with the Administrator on 10/31/12 at approximately 9:15 AM revealed LVN G had been terminated. An interview on 10/31/12 at 8:32 AM with LVN I revealed nurses were to call the physician "as soon as you see a change." An interview on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." The facility's Abuse Prohibition Policy and Procedure dated June 2005 and provided by ADON B , who identified it as current, reflected: "The facility's leadership will prohibit neglect...of patients/residents from staff..., visitors, or other patients/residents...Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect..." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified, and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: A. Physician was notified of Resident #2's change in condition. All Resident #2's orders were verified and an assessment of her mouth was completed. The results of the assessment were called to her dentist's office. B. All residents who had recently received dental care or complained of oral concerns had an assessment of their mouth completed by 11/01/12. All residents with current UTIs or with symptoms of UTI were assessed by a nurse to ensure all interventions were in place. C. Any Resident who has a change of condition will be assessed by the assigned nurse who will document findings and report to the physician and responsible party. Nursing Administration will follow-up daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. D. Physician's Orders received will be followed through per facility protocol. All new orders and changes of condition will be reported on the facility 24 hour report. E. Nursing Administration will follow daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. F. Pain assessments will be completed upon admission and with any change of condition. The physician and family will be notified. Nursing Administration will follow daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. G. All changes of condition will be documented in the medical record. The INTERACT II SBAR form will be used to indicate the initial identification of a change of condition. Regional Nurse RN will in-service DON, ADON, MDS nurses, Skin Nurse on INTERACT II SBAR. All licensed nursing staff will be in-serviced on policy and proper use of these forms by Nursing Administration. H. Quality Assurance (QA) Systems for Assessments, Pharmacy Pocedure, Notification of Change and Pain were re-implemented starting 10/31/12/ Implementation of the QA Systems included in-services by Regional Nurse for Nursing Administration. For all licensed nursing staff, medication aides and CNAss, in-services began on 10/31/12. In-services included:. Oral assessment, changes of condition Procedures, INTERACT II, Medication ordering procedures, Medication administration, Physician notification, Pain assessment and Intervention, and Reporting pain signs and symptoms. Post tests administered to all disciplines, and a return demonstration for Oral care. Follow-up will occur monthly through the facility QA Committee meeting. On 11/01/12 at 8:05 AM, the Regional Nurse stated the DON was suspended the night befor

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for two (Residents #2, and #6) of six residents reviewed for changes in condition. 1) Staff failed to consult with Resident #2's physician for 11 days when she resident had a change in condition, including difficulty eating and drinking, after 17 teeth were extracted. 2) Staff failed to consult with Resident #2's physician when two Stage III pressure ulcers developed. These failures resulted in Resident #2's severe dehydration, critical Sodium level, pain, and hospitalization for seven days. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could affect any of the facility's 92 residents placing them at risk for delays in needed medical care and treatment, deterioration in clinical conditions, worsening clinical conditions, and a decline in condition. 3) Staff failed to consult with Resident #6's attending physician when a Urine Culture was positive for a Urinary Tract Infection. These failures could affect all 92 residents, including Resident #6, by placing them at risk for delayed medical care and treatment which could result in exacerbation of clinical conditions, worsening clinical conditions, and decline in the residents' conditions. Findings included: 1) Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively and required the extensive assistance of one person for eating. The assessment reflected the resident did not have dental pain, discomfort or difficulty chewing, and she was at risk for developing pressure ulcers, but did not have any pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no evidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Dental Progress Notes dated 09/22/12 reflected she had "oral surgery" and "local anesthetic." The Notes also reflected she had full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan updated on 08/18/12 did not reflect any additional updates related to her teeth extractions or potential complications related to the extractions. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM reflected: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." The facility's 24 Hour Report Book (used by nursing staff to relay information from shift to shift) dated 09/22/12 reflected Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O (new order) Bactrim DS (double strength) X 5 days UTI (urinary tract infection). All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. (continue) on abt (antibiotic) Bactrim DS X 5 day R/T UTI. ? (no) c/o (complaints of) pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 % and after her teeth were pulled the resident ate < 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." The surveyor reviewed the day Resident #2 had her teeth extracted at the facility and at first LVN G did not recall being at the facility until the surveyor showed LVN G her Nurse's Notes. LVN G stated, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got." Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." The Notes dated 09/23/12 reflected at 1:00 AM "Asleep." Further review of Resident #2's Nurse's Notes dated 09/23/12 at 9:00 AM revealed: "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing. I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw and she had not been given any special instructions regarding her care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's Nurse's Notes dated 09/24/12 on the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book dated 09/24/12 reflected Night: "[MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "...Monitor food intake." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." The 24 Hour Report Book dated 09/25/12 reflected Night: "...monitor food intake, afebrile (no fever) 96.7" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" The 24 Hour Report Book dated 09/27/12 reflected Evening: "2 Stage 3 to coccyx." Resident #2's Weekly Head to Toe Skin assessment dated [DATE] reflected, "2 Stage 3" on coccyx. No other descriptions or measurements were documented. An interview with LVN G on 10/30/12 at 1:15 PM revealed, after reviewing Resident #2's skin assessment, dated 09/27/12 and completed by LVN G, she stated a CNA told her about the pressure ulcers. LVN G stated, "2 openings, involved more than top layer of skin, had yellow edges to it." LVN G revealed, "I left a note for the treatment nurse. I put it on her desk. I cleaned it (pressure ulcer) and put a dressing on it." LVN G was asked if she called the physician to inform him of the pressure ulcers and obtain treatment orders, and LVN G replied, "I think I placed a call to the doctor and did not get a return call." The LVN was asked if she followed-up the next day, and she replied, "I really can't tell you." An interview with the DON on 10/30/12 at 11:30 AM revealed if a nurse discovered pressure ulcers the nurse should contact the physician and read the physician the facility's protocol for approval. Resident #2's Nurse's Notes dated 10/01/12 at 12:00 PM reflected: "Two Stage III's noted to sacral area. First Stage III measures 1.5 cm X 1.5 cm. Second Stage III measures 2cm X 2cm. Wound beds are 100% yellowish brown slough, no drainage or odor noted. N/O received to cleanse areas (with) wound cleanser. Apply skin prep to peri wound area. Apply Santyl to wound bed and cover with [MEDICATION NAME] dressing qod (every other day). N/O received for Vit. (vitamin) C 1000 mg tab po BID, Zinc 220 mg tab po q day X 14 days. [MEDICATION NAME] Silver tab po q day. Provide 30 cc po qday.[MEDICATION NAME] 1 pkt (packet) po BID to promote wound healing." The 24 Hour Report Book dated 10/01/12 reflected Day: "In bed (decreased) appetite" Evening: "cont. (with) appetite." An interview with ADON A on 10/31/12 at 7:52 AM revealed when she saw Resident #2 on Monday, (two days after her teeth were pulled), she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food. She stopped doing that after her teeth were pulled." ADON A stated the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." The 24 Hour Report Book dated 10/02/12 reflected Night: "...(decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." Further review of Resident #2's Nurse's Notes dated 10/03/12 at 3:00 PM revealed: "(Resident #2's family member) notified of resident going to hospital." The Notes 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to (decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12." An interview with LVN G on 10/30/12 at 1:15 PM revealed, after reviewing her Nurse's Notes regarding Resident #2 from 09/22/12 through 10/03/12, when asked if she called the physician regarding the resident's change in condition, LVN G replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When asked what the physician said, LVN G replied, "I can't say. I don't remember." When asked if she documented what the physician said in Resident #2's clinical record, LVN G replied, "Yes, but I took some medicine and I have not been the same since." During an interview on 10/26/12 at 1:34 PM, LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he replied he could not remember. He stated Resident #2 was drinking but "not a whole lot." Further interview with LVN H on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and he remembered Resident #2. CNA K stated the resident was sleeping a lot, and she would eat a little bit and then go back to sleep. When asked if Resident #2 drank for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. An interview with ADON B on 10/31/12 at 12:10 PM revealed he saw Resident #2 the day she was sent to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (that were drawn on 10/01/12) her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "anytime with labs, incidents and change in condition (residents)." An interview on 10/31/12 at 8:32 AM with LVN I revealed the physician was supposed to be called "as soon as you see a change." Resident #2's Resident Transfer Form dated 10/03/12, for her transfer to the hospital, reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." Resident #2's emergency room Record dated 10/03/12 reflected, "Patient here with acute [MEDICAL CONDITION] (elevated concentration of sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli (Gram-negative bacillus in the human colon) urinary tract infection...." Resident #2's clinical record contained a hospital record dated 10/10/12 that reflected: "[MEDICAL CONDITION] - Adult. Definition - [MEDICAL CONDITION] is a condition in which the level of water and sodium in the body - too little water, too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of [MEDICAL CONDITION] is having more water leave your body than entre it. This causes dehydration. A person can become dehydrated in different ways, such as: ? Drinking too little fluids ? Vomiting ? Diarrhea ? Using diuretics (medicines that increase urine output) ? Sweating a lot ? Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: ?Not getting enough fluids ? Losing too much fluid ? Advanced age ? Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: ? Being thirsty ? Dry mouth ? Serious symptoms: ? [MEDICAL CONDITION] ? Confusion ? Muscle twitching ? [MEDICAL CONDITION] ? Coma If left untreated, the condition may lead to death." The DON stated on 10/30/12 at 12:43 PM that the day Resident #2 went out to the hospital was the same day she saw food falling out of her mouth. When asked if she was told of her decline in condition before, the DON replied, "I noticed she didn't fuss as much as she used to. She had been more verbal." When asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." Observation on 10/26/12 at 1:14 PM of a transfer and incontinent care for Resident #2 provided by CNA D and CNA F revealed she had a dressing on her sacrum dated 10/25/12, and two small pink areas could be seen beneath the dressing. An interview on 10/30/12 at 9:35 AM with Physician E revealed he was not aware Resident #2 had teeth extracted. He was looking at his personal tablet and stated "I have no records of being notified." The surveyor asked Physician E if he was notified Resident #2 developed two Stage III pressure ulcers, and Physician E stated "No." He was asked if he expected to be notified, and he replied, "Yes. I don't have any record of being notified of pressure ulcers. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received none of the 32 doses ordered of the [MEDICATION NAME]. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." The facility's current policy "Change in a Resident's Condition or Status" dated April 2011 reflected, "Policy Statement -Our facility shall promptly notify the resident, his or Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation - 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...d. A significant change in the resident's physical/emotional/mental condition, e. A need to alter the resident's medical treatment significantly...i. Instructions to notify the physician of changes in the resident's condition. 2. A "significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one are of the resident's health status; c. Requires interdisciplinary review and/or revision of the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument... 3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when...b. There is a significant change in the resident's physical, mental, or psychosocial status...." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: Resident #2's physician was notified of the resident's change in condition. Resident #2's mouth was assessed, and the results were called to her dentist's office. All Resident #2's orders were verified. Any resident, who has a change of condition, will be assessed by the assigned nurse who will document the findings and report to the resident's physician and the resident's responsible party. Nursing Administration will follow-up daily to ensure all physician's orders [REDACTED]. Pain assessments will be completed upon admission and with any change of condition. MD and family will be notified. Nursing Administration will follow daily to ensure all physician's orders [REDACTED]. All changes of condition will be documented in the clinical record. The INTERACT II SBAR form will be used to indicate the initial identification of a change of condition. The Regional Nurse RN will in-service DON, ADON, MDS nurses, Skin Nurse on INTERACT II SBAR. All licensed nursing staff will be in-serviced on policy and proper use of these forms by Nursing Administration. Quality Assurance (QA) Systems for Notification of Change and Pain were re-implemented starting 10/31/12. Implementation of the QA Systems included in-services by the Regional Nurse for Nursing Administration. For all licensed nursing staff, medication aides and CNAs in-services began on 10/31/12. In-services included: changes of condition procedures, INTERACT II, Physician notification, and reporting pain signs and symptoms. Post-tests were administered to all disciplines. Follow-up will occur monthly through the facility QA Committee meeting. Interviews conducted from 11/01/12 at 10:20 AM through 11/02/12 at 2:20 PM with LVN P, LVN I, LVN S, LVN H, LVN C, LVN R, and RN M revealed the physician should be called for wound treatments, changes in condition, and orders. Interviews conducted from 11/01/12 at 11:00 AM through 11/02/12 at 10:40 AM with MA Q, CNA N, CNA T, and CNA L revealed they were to notify their Charge Nurses if the residents exhibited any changes in condition. On 11/01/12 at 8:05 AM, the Regional Nurse stated the DON was suspended the night before. The Administrator was notified on 11/02/12 at 3:12 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. Non-IJ findings included: 2) Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she had unclear speech and was rarely/never understood. Review of Resident #6's Physician's Telephone Order dated 09/18/12 revealed an Urinalysis with Culture and Sensitivity, and the "Indication-DX" was "Confusion/combativeness." Resident #6's Nurse's Notes dated 09/19/12 at 1:40 PM reflected: "Resident combative earlier. Urine for UA/C&S collected. Lab called. Urine to be picked up in AM." Review of Resident #6's Urine Culture Results dated 09/22/12 at 4:15 PM revealed the culture tested positive for Gram Negative Rods and Proteus Mirabilis. A handwritten note on the lab result reflected, "Faxed to MD office 09/24/12 1:20 PM." Resident #6's Nurse's Notes dated 09/24/12 at 1:20 PM reflected, "Resident urine culture called and faxed to MD." The Notes dated 09/24/12 reflected for the 2:00 PM to 10:00 PM shift, "Unable to reach (Physician V) regarding urine sensitivity due to phone ringing at the office and not the answering service." Resident #6's Physician's Telephone Order dated 09/26/12 reflected, "Treat UTI Proteus Mirabilis (pathogen), [MEDICATION NAME] (antibiotic) 50 mg TID X 7d." Resident #6's Nurse's Notes dated 09/26/12 at 10:00 AM reflected, "New order [MEDICATION NAME] 500 mg PO TID X 7days from MD noted faxed to pharmacy and on MAR. ID (initial dose) at 10 AM." An interview with LVN H on 10/31/12 at 12:00 PM revealed, when asked about the delay in the treatment of [REDACTED]. It was later." When asked if he called the next day on 09/25/12, LVN H replied, "Some doctors don't call right away, some we fax." When asked what the facility's policy was if a doctor did not return their call, LVN H stated most doctors called right away, and if they did not, the staff should call the Medical Director. When asked how long he should wait to do that, LVN H stated he would first inform the DON. He stated the DON asked what the delay was for Resident #6, and he told her he had already called the physician. LVN H stated later the DON told him the physician called back. When asked when he should notify the physician, LVN H replied with any change of condition, he should assess the resident, notify the physician, family or responsible party. LVN H also stated if the physician did not return his call, he should notify the Medical Director. 3) An interview on 10/30/12 at 3:00 PM with LVN I, it was revealed he was assigned to work on different halls at times. LVN I stated some nurses, including himself, worked extra shifts and were placed where they were needed.He further stated he would switch halls if a resident or family member requested him. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 10/25/12 and signed by the Medicare Coordinator reflected a census of 92 residents.

Based on interview and record review, the facility failed to provide 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 for one (Resident #2) of nine residents reviewed for medications. LVN G failed to order Resident #2's scheduled Lortab and Peridex mouthwash, when the resident had 17 teeth extracted. Resident #2 only received six of 12 scheduled doses of Lortab, and she did not receive any of the 32 doses of Peridex mouthwash. However, two doses of the Peridex were initialed as given on the resident's September 2012 MAR. Staff failed to write the Physician's Telephone Order for Resident #2's Bactrim DS for her Urinary Tract Infection. Resident #2 only received two of the ten ordered doses. However, all the doses were initialed as given on the resident's September MAR. These failures resulted in Resident #2 suffering from unrelieved pain, being dehydrated, continuing to have a Urinary Tract Infection, discomfort, and being admitted to the hospital for seven days with intravenous antibiotics. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring implementatin of the Plan of Removal. These failures could affect any of the facility's 92 residents, who could receive care from any of the nurses who rotated halls, by placing them at risk for delays in or omission of needed medical care and treatment, deterioration in clinical conditions, and an over-all decline in their health and well-being. Findings included: 1) Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. A water pitcher was in Resident #2's room atop a dresser that was situated across the room from her bed and between the first and second beds. No water pitchers were seen on either resident's night tables. When asked how often they offered fluids to the residents, CNA F stated they should offer fluids every time they check on the residents. When asked who the water pitcher on the dresser belonged to, both CNAs indicated they did not know. Resident #2's roommate entered the room at that time and was asked if she knew to whom the water pitcher belonged. The roommate replied, "Oh honey, I have no idea." Resident #2's Physician's Telephone Order dated 09/18/12 reflected "UA/C&S (urinalysis with culture and sensitivity)." Resident #2's Physician's Telephone Order dated 09/18/12 reflected Lortab (analgesic) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for Lortab 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours a needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Urine Culture results dated 09/21/12 reflected Gram Negative Rods and Escherichia Coli. A handwritten entry on the lab result reflected, "(Physician E) notified 11:00 AM (Medical Director) notified Bactrim DS (one) PO BID X 5 days." Resident #2's Telephone Physician's Orders did not reflect an order for [REDACTED]. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) Lortab 5/500 (one) po (by mouth) q 6 (every six hours) X (times) 72 hrs. 2) pureed diet, Peridex Rinse 15 cc rinse X 30 sec. (seconds) swish & spit X 1 bottle BID (twice a day) 3) V/S (vital signs), & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? carbonated bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for Lortab 5/500 one by mouth every six hours for 72 hours. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR also reflected an entry dated 09/22/12 for Peridex rinse 16 ounce bottle, 15 cc (half an ounce) rinse for 30 seconds, swish and spit twice a day times one bottle. The scheduled times for administration were 8:00 AM and 8:00 PM. The following doses were initialed as given: 09/23/12 at 8:00 AM and 8:00 PM. No other doses were initialed as given. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan updated on 08/18/12 did not reflect an update regarding her full mouth extraction or the complications which could develop. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." Resident #2's September 2012 MAR reflected she received Lortab on 09/22/12 at 12:00 PM The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, hydrocodone in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted hydrocodone Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, hydrocodone q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one (Lortab) at noon and attempted to give (it) and it (Lortab) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for Analgesics and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving Lortab and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving Lortab and "1" out of 10 afterward. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. Hydrocodone 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM the resident was "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." Resident #2's September 2012 MAR reflected on 09/23/12 she received Lortab at 12:00 AM and 6:00 AM. The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID (no Physician's Telephone Order was written), 9/22/12 Hydrocodone q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." Interview with LVN I on 10/31/12 at 8:32 AM revealed he was assigned to Resident #2 the evening after her teeth were extracted. LVN I stated he checked her mouth and smelled an odor "...that's when I used the mouthwash." When asked if it was the Peridex, LVN I stated it was regular mouthwash and showed the bottle to the surveyor. When asked why he did not use the Peridex as ordered, LVN I did not answer. During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's PRN Flowsheet for Analgesics and Other Medications reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving Lortab and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's September 2012 MAR reflected on 09/24/12 she received Lortab at 12:00 AM and 6:00 AM. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, Hydrocodone-Acet (acetaminophen) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's September 2012 MAR reflected no other doses of Lortab were given after 09/24/12 at 6:00 AM. During an interview on 10/26/12 at 1:34 PM, LVN H was shown Resident #2's Controlled Drug Record and MAR and asked why only six doses of pain medication were administered to Resident #2 after her tooth extractions. LVN H replied that was all the Lortab that was available for Resident #2. When LVN H was shown Resident #2's orders dated 09/22/12 (Lortab 5/500 mg one tablet every six hours for 72 hours), he stated the physician had to call the pharmacy for Lortab. When asked if he ever told the physician there was not enough medications available, LVN H did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." When LVN H was shown the order for Peridex he stated he did not know why only two doses were given. When asked if he knew what Peridex was used for, LVN H replied, "Yes, it's for after oral surgery, keeps the gums soft and prevents infection." During another interview with LVN H on 10/30/12 at 8:18 AM, when asked if he remembered ever seeing a bottle of Peridex on the medication cart for Resident #2, he stated he never saw one. Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never received an order for [REDACTED]. The Pharmacist stated the pharmacy never received the order for Resident #2's scheduled Peridex and none was delivered to the facility. On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H "jogged her memory," and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it (Lortab) didn't come in time. I don't remember seeing a bottle of Peridex. I should have asked about the Peridex if it wasn't here. I can't say I followed through with the Peridex from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Review of Emergency Kit Documentation Forms provided by the DON for September 2012 revealed only two doses of Bactrim had been removed from the facility's emergency drug kit for Resident #2. One tablet was removed on 09/23/12 at 9:00 AM and another tablet was removed on 09/26/12 at 4:00 AM. On 10/30/12 at 2:00 PM the DON explained she had contacted the pharmacy and spoke with the pharmacist to obtain their copies of the forms. When the DON was asked whether the Bactrim had ever been ordered, she replied, "No." Interview on 10/30/12 at 2:05 PM with LVN G revealed when asked where she obtained the doses she signed as given on 09/22/12 at 9:00 PM, 09/24/12 at 9:00 PM and 09/25/12 at 9:00 PM, she replied, "I know I pulled the initial dose from the E-Kit (emergency kit) and on the third day when I returned I called the pharmacy myself." When asked what she was told by the pharmacy, she replied, "We'll put it on the next shipment. That's what they always say." Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never processed an order for [REDACTED]. The 24 Hour Report Book reflected on 09/26/12 Night: "Cont. on Bactrim DS for UTI, NARN, stable" Day: "Still on Bactrim UTI, Appetite good" Evening: "Cont. on Bactrim for UTI" Interview with MA J on 10/30/12 at 2:09 PM revealed she signed out a dose of Bactrim on 09/26/12 and she stated she always informed the Charge Nurse if more than one dose of a medication was pulled from the emergency kit. The MA indicated she informed LVN H. Interview with LVN H on 10/30/12 at 2:11 PM revealed he was told about the Bactrim by the MA and called the pharmacy. LVN H could not remember what he was told by the pharmacy or whether they requested an order. The DON joined the interview and stated the pharmacy would not send the medication without an order and nobody sent them one. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN," Day: "Bactrim, Appetite good." Resident #2's Nurse's Notes dated 09/28/12 at 2:00 AM reflected: "Post ABT for UTI...." The 24 Hour Report Book reflected on 09/28/12 Night: "Bactrim UTI completed." Day: "PABT /UTI" Evening: "PABT ? problems" The 24 Hour Report Book reflected on 09/30/12: Evening: "Small amt (amount) blood noted from rectum when cleaning resident. Purplish red in color, (Physician E) called, N/O rec'd (received) for CBC in AM, Hemacults (sic) (test for blood in stool), (Lab company) called re: lab stool collected in fridge." Review of Resident #2's September 2012 MAR revealed an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. The 24 Hour Report Book reflected on 10/01/12 Night: "(s) (small) amt of blood noted from rectum. N/O Lab: CBC in AM, occult blood 1. No stool collected- (lab company) notified of lab orders/(Physician E), need stool specimen X1" Day: "In bed (decreased) appetite" Evening: "cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "(Resident #2's family member) notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" The 24 Hour Report Book reflected on 10/03/12: Night: "90%-fed by nurse (2-10) stable, lab result f/u." Day: "appetite, (decreased) weight vs 120/63, 89 call placed to MD," Evening: "Hospital." An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute hypernatremia (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's clinical record revealed a hospital record dated 10/10/12 that reflected: Hypernatremia - Adult. Definition - Hypernatremia is a condition in which the the body has too little water and too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of hypernatremia is having more water leave your body than enter it. This causes dehydration. A person can become dehydrated in different ways, such as: Drinking too little fluids Vomiting Diarrhea Using diuretics (medicines that increase urine output) Sweating a lot Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: Not getting enough fluids Losing too much fluid Advanced age Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: Being thirsty Dry mouth Serious symptoms: Brain dysfunction Confusion Muscle twitching Seizure Coma If left untreated, dehydration may lead to death. Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection...." An interview on 10/31/12 at 7:52 AM with ADON A revealed when asked if she knew how dehydrated Resident #2 was at the hospital, ADON A stated, "...it didn't alarm us, we attributed it to her not eating due to her teeth being pulled." On 10/30/12 at 12:43 PM, the DON was asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." An interview on 10/30/12 at 9:35 AM with Physician E revealed when asked if he was aware Resident #2 had teeth extracted, he replied, "No." Physician E, was looking at his personal tablet and stated, "I have no records of being notified. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received two of 32 doses ordered of the Peridex. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Interview with the Administrator on 10/31/12 at approximately 9:15 AM revealed LVN G had been terminated. An interview on 10/31/12 at 8:32 AM with LVN I revealed nurses were to call the physician "as soon as you see a change." An interview on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." The facility's current policy entitled "Pain Assessment and Management," dated October 2010, reflected: "Purpose - the purpose of this procedure are to help the staff identify pain in the resident, as to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines - ...6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes of level of chronic pain and at least weekly in stable chronic pain... Identifying the Causes of Pain: ...2. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including...g. Oral health conditions; Infection: (1) Urinary tract infection... Defining Goals and Appropriate Interventions: ...3. Pain management interventions shall address the underlying causes of the resident's pain. For example, if there is acute pain associated with an infected wound the intervention shall address treating the infection in addition to pain control...." The facility's current policy "Medication Orders," dated September 2010 reflected, "Documentation of the Medication Order...2. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the Physician Order sheet (POS)/ Telephone Order Sheet (TO) if it is a verbal order, and on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). a. New orders (handwritten by prescriber or verbal orders)...Transmit the appropriate copy of the order to the pharmacy for dispensing...." The facility's current policy "Medication Ordering and Receiving From Pharmacy Provider Emergency Pharmacy Service and Emergency Kits (E-Kits)," dated September 2010 reflected, "Procedures...7. When an emergency or stat (immediate) medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, check's the resident's allergies [REDACTED]. Emergency medications are only administered with a valid prescriber's order...8. Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange. The hard copy will be retained in the nursing care center...." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified, and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: Physician was notified of Resident #2's change in condition. All Resident #2's orders were verified and an assessment of her mouth was completed. The results of the assessment were called to her dentist's office. Any Resident who has a change of condition will be assessed by the assigned nurse who will document findings and report to the physician and responsible party. Nursing Administration will follow-up daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. Physician's Orders received will be followed through per facility protocol. All new orders and changes of condition will be reported on the facility 24 hour report. Nursing Administration will follow daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. Quality Assurance (QA) Systems for Pharmacy Procedures were re-implemented starting 10/31/12/ Implementation of the QA Systems included in-services by Regional Nurse for Nursing Administration. For all licensed nursing staff, medication aides and CNAs, in-services began on 10/31/12. In-services included: Medication ordering procedures and Medication administration. Post tests administered to all disciplines, and a return demonstration for Oral care. Follow-up will occur monthly through the facility QA Committee meeting. An interview on 11/01/12 at 10:20 AM with LVN P revealed she was in-serviced on dehydration, resident's complaint of pain and nurses need to attend to them, the amount of food the resident's eat, assessing residents every time the nurse sees the resident and "not just do paperwork." She stated the nurses had to measure wounds, call the physician for wound treatments and encourage fluids. In an interview on 11/01/12 at 11:00 AM CNA O stated he was in-serviced on resident care. An interview on 11/01/12 at 12:17 PM with MA Q revealed he was in-serviced on dehydrat

Based on interview and record review, it was determined the facility failed to ensure that residents were free of any significant medication errors for one (Resident #2) of nine residents reviewed for medications. LVN G failed to order Resident #2's scheduled [MEDICATION NAME] and [MEDICATION NAME] mouthwash, when the resident had 17 teeth extracted. Resident #2 only received six of 12 scheduled doses of [MEDICATION NAME], and she did not receive any of the 32 doses of [MEDICATION NAME] mouthwash. Staff failed to write the Physician's Telephone Order for Resident #2's Bactrim DS for her Urinary Tract Infection. Resident #2 only received two of the ten ordered doses. These failures resulted in Resident #2 suffering from unrelieved pain, being dehydrated, continuing to have a Urinary Tract Infection, discomfort, and being admitted to the hospital for seven days with intravenous antibiotics. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring implementatin of the Plan of Removal. These failures could affect any of the facility's 92 residents, who could receive care from any of the nurses who rotated halls, by placing them at risk for delays in or omission of needed medical care and treatment, deterioration in clinical conditions, and an over-all decline in their health and well-being. Findings included: 1) Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. Resident #2's Physician's Telephone Order dated 09/18/12 reflected "UA/C&S (urinalysis with culture and sensitivity)." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for [MEDICATION NAME] 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours a needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Urine Culture results dated 09/21/12 reflected Gram Negative Rods and Escherichia Coli. A handwritten entry on the lab result reflected, "(Physician E) notified 11:00 AM (Medical Director) notified Bactrim DS (one) PO BID X 5 days." Resident #2's Telephone Physician's Orders did not reflect an order for [REDACTED]. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) [MEDICATION NAME] 5/500 (one) po (by mouth) q 6 (every six hours) X (times) 72 hrs. 2) pureed diet, [MEDICATION NAME] Rinse 15 cc rinse X 30 sec. (seconds) swish & spit X 1 bottle BID (twice a day) 3) V/S (vital signs), & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? [MEDICATION NAME] bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for [MEDICATION NAME] 5/500 one by mouth every six hours for 72 hours. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR also reflected an entry dated 09/22/12 for [MEDICATION NAME] rinse 16 ounce bottle, 15 cc (half an ounce) rinse for 30 seconds, swish and spit twice a day times one bottle. The scheduled times for administration of [MEDICATION NAME] were 8:00 AM and 8:00 PM. The following doses were initialed as given: 09/23/12 at 8:00 AM and 8:00 PM. No other doses were initialed as given. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan updated on 08/18/12 did not reflect an update regarding her full mouth extraction or the complications which could develop. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." Resident #2's September 2012 MAR reflected she received [MEDICATION NAME] on 09/22/12 at 12:00 PM The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM the resident was "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." Resident #2's September 2012 MAR reflected on 09/23/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID (no Physician's Telephone Order was written), 9/22/12 [MEDICATION NAME] q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." Interview with LVN I on 10/31/12 at 8:32 AM revealed he was assigned to Resident #2 the evening after her teeth were extracted. LVN I stated he checked her mouth and smelled an odor "...that's when I used the mouthwash." When asked if it was the [MEDICATION NAME], LVN I stated it was regular mouthwash and showed the bottle to the surveyor. When asked why he did not use the [MEDICATION NAME] as ordered, LVN I did not answer. During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's September 2012 MAR reflected on 09/24/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, [MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's September 2012 MAR reflected no other doses of [MEDICATION NAME] were given after 09/24/12 at 6:00 AM. During an interview on 10/26/12 at 1:34 PM, LVN H was shown Resident #2's Controlled Drug Record and MAR and asked why only six doses of pain medication were administered to Resident #2 after her tooth extractions. LVN H replied that was all the [MEDICATION NAME] that was available for Resident #2. When LVN H was shown Resident #2's orders dated 09/22/12 ([MEDICATION NAME] 5/500 mg one tablet every six hours for 72 hours), he stated the physician had to call the pharmacy for [MEDICATION NAME]. When asked if he ever told the physician there was not enough medications available, LVN H did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." When LVN H was shown the order for [MEDICATION NAME] he stated he did not know why only two doses were given. When asked if he knew what [MEDICATION NAME] was used for, LVN H replied, "Yes, it's for after oral surgery, keeps the gums soft and prevents infection." During another interview with LVN H on 10/30/12 at 8:18 AM, when asked if he remembered ever seeing a bottle of [MEDICATION NAME] on the medication cart for Resident #2, he stated he never saw one. Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never received an order for [REDACTED]. The Pharmacist stated the pharmacy never received the order for Resident #2's scheduled [MEDICATION NAME] and none was delivered to the facility. On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H "jogged her memory," and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Review of Emergency Kit Documentation Forms provided by the DON for September 2012 revealed only two doses of Bactrim had been removed from the facility's emergency drug kit for Resident #2. One tablet was removed on 09/23/12 at 9:00 AM and another tablet was removed on 09/26/12 at 4:00 AM. On 10/30/12 at 2:00 PM the DON explained she had contacted the pharmacy and spoke with the pharmacist to obtain their copies of the forms. When the DON was asked whether the Bactrim had ever been ordered, she replied, "No." Interview on 10/30/12 at 2:05 PM with LVN G revealed when asked where she obtained the doses she signed as given on 09/22/12 at 9:00 PM, 09/24/12 at 9:00 PM and 09/25/12 at 9:00 PM, she replied, "I know I pulled the initial dose from the E-Kit (emergency kit) and on the third day when I returned I called the pharmacy myself." When asked what she was told by the pharmacy, she replied, "We'll put it on the next shipment. That's what they always say." Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never processed an order for [REDACTED]. The 24 Hour Report Book reflected on 09/26/12 Night: "Cont. on Bactrim DS for UTI, NARN, stable" Day: "Still on Bactrim UTI, Appetite good" Evening: "Cont. on Bactrim for UTI" Interview with MA J on 10/30/12 at 2:09 PM revealed she signed out a dose of Bactrim on 09/26/12 and she stated she always informed the Charge Nurse if more than one dose of a medication was pulled from the emergency kit. The MA indicated she informed LVN H. Interview with LVN H on 10/30/12 at 2:11 PM revealed he was told about the Bactrim by the MA and called the pharmacy. LVN H could not remember what he was told by the pharmacy or whether they requested an order. The DON joined the interview and stated the pharmacy would not send the medication without an order and nobody sent them one. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good." Resident #2's Nurse's Notes dated 09/28/12 at 2:00 AM reflected: "Post ABT for UTI...." The 24 Hour Report Book reflected on 09/28/12 Night: "Bactrim UTI completed. "Day: "PABT/UTI" Evening: "PABT ? problems" The 24 Hour Report Book reflected on 09/30/12: Evening: "Small amt (amount) blood noted from rectum when cleaning resident. Purplish red in color, (Physician E) called, N/O rec'd (received) for CBC in AM, Hemacults (sic) (test for blood in stool), (Lab company) called re: lab stool collected in fridge." Review of Resident #2's September 2012 MAR revealed an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. The 24 Hour Report Book reflected on 10/01/12 Night: "(s) (small) amt of blood noted from rectum. N/O Lab: CBC in AM, occult blood 1. No stool collected- (lab company) notified of lab orders/(Physician E), need stool specimen X1" Day: "In bed (decreased) appetite" Evening: "cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "(Resident #2's family member) notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" The 24 Hour Report Book reflected on 10/03/12: Night "90%-fed by nurse (2-10) stable, lab result f/u." Day: " appetite, (decreased) weight vs 120/63, 89 call placed to MD" Evening: "Hospital" An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's clinical record revealed a hospital record dated 10/10/12 that reflected: [MEDICAL CONDITION] - Adult. Definition - [MEDICAL CONDITION] is a condition in which the the body has too little water and too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of [MEDICAL CONDITION] is having more water leave your body than enter it. This causes dehydration. A person can become dehydrated in different ways, such as: Drinking too little fluids Vomiting Diarrhea Using diuretics (medicines that increase urine output) Sweating a lot Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: Not getting enough fluids Losing too much fluid Advanced age Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: Being thirsty Dry mouth Serious symptoms: [MEDICAL CONDITION] Confusion Muscle twitching [MEDICAL CONDITION] Coma If left untreated, dehydration may lead to death. Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection...." An interview on 10/31/12 at 7:52 AM with ADON A revealed when asked if she knew how dehydrated Resident #2 was at the hospital, ADON A stated, "...it didn't alarm us, we attributed it to her not eating due to her teeth being pulled." On 10/30/12 at 12:43 PM, the DON was asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." An interview on 10/30/12 at 9:35 AM with Physician E revealed when asked if he was aware Resident #2 had teeth extracted, he replied, "No." Physician E, was looking at his personal tablet and stated, "I have no records of being notified. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received two of 32 doses ordered of the [MEDICATION NAME]. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Interview with the Administrator on 10/31/12 at approximately 9:15 AM revealed LVN G had been terminated. An interview on 10/31/12 at 8:32 AM with LVN I revealed nurses were to call the physician "as soon as you see a change." An interview on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." The facility's current policy entitled "Pain Assessment and Management," dated October 2010, reflected: "Purpose - the purpose of this procedure are to help the staff identify pain in the resident, as to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines - ...6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes of level of chronic pain and at least weekly in stable chronic pain... Identifying the Causes of Pain: ...2. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including...g. Oral health conditions; Infection: (1) Urinary tract infection... Defining Goals and Appropriate Interventions: ...3. Pain management interventions shall address the underlying causes of the resident's pain. For example, if there is acute pain associated with an infected wound the intervention shall address treating the infection in addition to pain control...." The facility's current policy "Medication Orders," dated September 2010 reflected, "Documentation of the Medication Order...2. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the Physician Order sheet (POS)/ Telephone Order Sheet (TO) if it is a verbal order, and on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). a. New orders (handwritten by prescriber or verbal orders)...Transmit the appropriate copy of the order to the pharmacy for dispensing...." The facility's current policy "Medication Ordering and Receiving From Pharmacy Provider Emergency Pharmacy Service and Emergency Kits (E-Kits)," dated September 2010 reflected, "Procedures...7. When an emergency or stat (immediate) medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, check's the resident's allergies [REDACTED]. Emergency medications are only administered with a valid prescriber's order...8. Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange. The hard copy will be retained in the nursing care center...." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified, and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: Physician was notified of Resident #2's change in condition. All Resident #2's orders were verified and an assessment of her mouth was completed. The results of the assessment were called to her dentist's office. Any Resident who has a change of condition will be assessed by the assigned nurse who will document findings and report to the physician and responsible party. Nursing Administration will follow-up daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. Physician's Orders received will be followed through per facility protocol. All new orders and changes of condition will be reported on the facility 24 hour report. Nursing Administration will follow daily to ensure all physician's orders are followed, all orders are validated, written and carried through; and any identified changes of condition are addressed. Quality Assurance (QA) Systems for Pharmacy Procedures were re-implemented starting 10/31/12/ Implementation of the QA Systems included in-services by Regional Nurse for Nursing Administration. For all licensed nursing staff, medication aides and CNAs, in-services began on 10/31/12. In-services included: Medication ordering procedures and Medication administration. Post tests administered to all disciplines, and a return demonstration for Oral care. Follow-up will occur monthly through the facility QA Committee meeting. An interview on 11/01/12 at 10:20 AM with LVN P revealed she was in-serviced on dehydration, resident's complaint of pain and nurses need to attend to them, the amount of food the resident's eat, assessing residents every time the nurse sees the resident and "not just do paperwork." She stated the nurses had to measure wounds, call the physician for wound treatments and encourage fluids. In an interview on 11/01/12 at 11:00 AM CNA O stated he was in-serviced on resident care. An interview on 11/01/12 at 12:17 PM with MA Q revealed he was in-serviced on dehydration and changes in a resident's condition. He also stated if he noticed a change in a resident, he was supposed to tell the Charge Nurse. MA Q said if he noticed any symptoms such as not eating, not drinking or redness in the face, he was suppposed to tell the Charge Nurse. MA Q revealed he sometimes worked as a CNA. He stated for residents who cannot reach their fluids, staff were to offer them fluids every time they went in the residents' rooms. An interview on 11/01/12 at 2:30 PM with CNA N revealed she was in-serviced on oral care, how to clean the residents' mouths, reporting redness or sores to the nurse, documenting meals, writing the percentage the resident ate on their meal tickets and leaving the meal ticket on the residents' trays. An interview on 11/01/12 at 2:40 PM with LVN I revealed he had been in-serviced on dehydration, medications, monitoring intake, oral care and notification of t

Based on observation, interview and record review, the facility failed to provide each resident with sufficient fluid intake to maintain proper hydration and health for one (Resident #2) of nine residents reviewed for hydration. Staff failed to update Resident #2's Care Plan to address her full mouth extraction and possible complications. Resident #2 had problems drinking fluids after 17 teeth were pulled. Staff failed to notify the physician and address the resident's decline in drinking fluids. These failures resulted Resident #2 being severely dehydrated, having a critical Sodium level, having two Stage III pressure ulcers, [MEDICAL CONDITION], hospitalization , continuing UTI, discomfort and receiving IV fluids and antibiotics. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring implementatin of the Plan of Removal. These failures could affect the 47 residents, who were dependent on staff for hydration, by placing them at risk for dehydration, [MEDICAL CONDITION], and hospitalization . Findings included: Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Review of Resident #2's Assessment of Risk for Dehydration dated 08/18/12 revealed she was scored at a "3" indicating, "Resident is low risk." Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Review of an "In-Service Training Report" dated 09/25/12 revealed "Topic - ADL Care ...Ice/water should be passed at the start of your shift on all shifts and water pitcher filled throughout the shift. Water cup's & Pitchers are to be within residents reach. Offer the residents' some type of fluids frequently. If you are not sure about resident's fluid intake status (i.e. [MEDICAL TREATMENT], diabeties (sic) etc.) ask the nurse." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. A water pitcher was in Resident #2's room atop a dresser that was situated across the room from her bed and between the first and second beds. No water pitchers were seen on either resident's night tables. When asked how often they offered fluids to the residents, CNA F stated they should offer fluids every time they check on the residents. When asked who the water pitcher on the dresser belonged to, both CNAs indicated they did not know. Resident #2's roommate entered the room at that time and was asked if she knew to whom the water pitcher belonged. The roommate replied, "Oh honey, I have no idea." Resident #2's Physician's Telephone Order dated 09/18/12 reflected "UA/C&S (urinalysis with culture and sensitivity)." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for [MEDICATION NAME] 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours a needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Urine Culture results dated 09/21/12 reflected Gram Negative Rods and Escherichia Coli. A handwritten entry on the lab result reflected, "(Physician E) notified 11:00 AM (Medical Director) notified Bactrim DS (one) PO BID X 5 days." Review of all of Resident #2's Telephone physician's orders [REDACTED]. Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) [MEDICATION NAME] 5/500 (one) po (by mouth) q 6 (every six hours) X (times) 72 hrs. 2) pureed diet, [MEDICATION NAME] Rinse 15 cc rinse X 30 sec. (seconds) swish & spit X 1 bottle BID (twice a day) 3) V/S (vital signs), & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? [MEDICATION NAME] bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for [MEDICATION NAME] 5/500 one by mouth every six hours for 72 hours. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR also reflected an entry dated 09/22/12 for [MEDICATION NAME] rinse 16 ounce bottle, 15 cc (half an ounce) rinse for 30 seconds, swish and spit twice a day times one bottle. The scheduled times for administration were 8:00 AM and 8:00 PM. The following doses were initialed as given: 09/23/12 at 8:00 AM and 8:00 PM. No other doses were initialed as given. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan was last updated on 08/18/12 did not reflect an update regarding her full mouth extraction or the complications which could develop. No further revisions had been made. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." Resident #2's September 2012 MAR reflected she received [MEDICATION NAME] on 09/22/12 at 12:00 PM The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM the resident was "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." Resident #2's September 2012 MAR reflected on 09/23/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID (no Physician's Telephone Order was written), 9/22/12 [MEDICATION NAME] q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." Interview with LVN I on 10/31/12 at 8:32 AM revealed he was assigned to Resident #2 the evening after her teeth were extracted. LVN I stated he checked her mouth and smelled an odor "...that's when I used the mouthwash." When asked if it was the [MEDICATION NAME], LVN I stated it was regular mouthwash and showed the bottle to the surveyor. When asked why he did not use the [MEDICATION NAME] as ordered, LVN I did not answer. During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's September 2012 MAR reflected on 09/24/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, [MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's September 2012 MAR reflected no other doses of [MEDICATION NAME] were given after 09/24/12 at 6:00 AM. During an interview on 10/26/12 at 1:34 PM, LVN H was shown Resident #2's Controlled Drug Record and MAR and asked why only six doses of pain medication were administered to Resident #2 after her tooth extractions. LVN H replied that was all the [MEDICATION NAME] that was available for Resident #2. When LVN H was shown Resident #2's orders dated 09/22/12 ([MEDICATION NAME] 5/500 mg one tablet every six hours for 72 hours), he stated the physician had to call the pharmacy for [MEDICATION NAME]. When asked if he ever told the physician there was not enough medications available, LVN H did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." When LVN H was shown the order for [MEDICATION NAME] he stated he did not know why only two doses were given. When asked if he knew what [MEDICATION NAME] was used for, LVN H replied, "Yes, it's for after oral surgery, keeps the gums soft and prevents infection." During another interview with LVN H on 10/30/12 at 8:18 AM, when asked if he remembered ever seeing a bottle of [MEDICATION NAME] on the medication cart for Resident #2, he stated he never saw one Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never received an order for [REDACTED]. On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H "jogged her memory," and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Review of Emergency Kit Documentation Forms provided by the DON for September 2012 revealed only two doses of Bactrim had been removed from the facility's emergency drug kit for Resident #2. One tablet was removed on 09/23/12 at 9:00 AM and another tablet was removed on 09/26/12 at 4:00 AM. On 10/30/12 at 2:00 PM the DON explained she had contacted the pharmacy and spoke with the pharmacist to obtain their copies of the forms. When the DON was asked whether the Bactrim had ever been ordered, she replied, "No." Interview on 10/30/12 at 2:05 PM with LVN G revealed when asked where she obtained the doses she signed as given on 09/22/12 at 9:00 PM, 09/24/12 at 9:00 PM and 09/25/12 at 9:00 PM, she replied, "I know I pulled the initial dose from the E-Kit (emergency kit) and on the third day when I returned I called the pharmacy myself." When asked what she was told by the pharmacy, she replied, "We'll put it on the next shipment. That's what they always say." Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never processed an order for [REDACTED]. The 24 Hour Report Book reflected on 09/26/12 Night: "Cont. on Bactrim DS for UTI, NARN, stable" Day: "Still on Bactrim UTI, Appetite good" Evening: "Cont. on Bactrim for UTI" Interview with MA J on 10/30/12 at 2:09 PM revealed she signed out a dose of Bactrim on 09/26/12 and she stated she always informed the Charge Nurse if more than one dose of a medication was pulled from the emergency kit. The MA indicated she informed LVN H. Interview with LVN H on 10/30/12 at 2:11 PM revealed he was told about the Bactrim by the MA and called the pharmacy. LVN H could not remember what he was told by the pharmacy or whether they requested an order. The DON joined the interview and stated the pharmacy would not send the medication without an order and nobody sent them one. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good." Resident #2's Weekly Head to Toe Skin assessment dated [DATE] reflected, "2 Stage 3" on coccyx." No other descriptions or measurements were documented. The entry was made by LVN G. During an interview on 10/30/12 at 11:30 AM, the DON was shown LVN G's entry in the 24 Hour Report Book dated 09/27/12 which reflected Resident #2 had two new Stage III pressure ulcers. The DON stated she did not know why these pressure ulcers were not addressed in the stand-up meeting on 09/28/12. The DON asked the Wound Treatment Nurse to join the interview. The Wound Treatment Nurse stated she did not work the following three days after the new pressure ulcers were identified. The DON was asked if she was aware of Resident #2's pressure ulcers and that no treatment was ordered for four days, she replied she was informed on 10/01/12 and had in-serviced the nurses. When asked what the nurse should have done, the DON replied the nurse was supposed to call the physician and read him the facility's protocol for approval. She stated the nurse should assess the wounds, measure them and document her findings. The DON revealed the nurses were to initiate pressure ulcer treatments if the Wound Treatment Nurse was not available. When the Wound Treatment Nurse returned to work, she would reassess and take over. The DON was asked if she was aware of Resident #2's intake after her teeth were extracted, and the DON stated, "I remember she wasn't eating. I noticed a couple of days later (after the extraction) the food was just coming out of her mouth. I thought she had a swallowing problem." An interview on 10/30/12 at 12:00 PM with the Wound Treatment Nurse revealed she ordered Resident #2 an air mattress on 10/01/12 when she learned about the wounds and obtained the treatment orders and supplements. The Wound Treatment Nurse stated Resident #2 never had any skin issues before while in the facility. Resident #2's Nurse's Notes dated 09/28/12 at 2:00 AM reflected: "Post ABT for UTI..." The 24 Hour Report Book reflected on 09/28/12 Night: "Bactrim UTI completed." Day: "PABT/UTI" Evening: "PABT ? problems" Review of Resident #2's September 2012 MAR revealed an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. The 24 Hour Report Book reflected on 10/01/12 Day: "In bed (decreased) appetite" Evening: "cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "Daughter notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to (decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" The 24 Hour Report Book reflected on 10/03/12: Night "90%-fed by nurse (2-10) stable, lab result f/u." Day: " appetite, (decreased) weight vs 120/63, 89 call placed to MD" Evening: "Hospital" An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." During an interview on 10/26/12 at 1:34 PM, LVN H was asked if he ever told the physician there was not enough medications available, he did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he replied he could not remember. He stated Resident #2 was drinking but "not a whole lot." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's clinical record revealed a hospital record dated 10/10/12 that reflected: "[MEDICAL CONDITION] - Adult. Definition - [MEDICAL CONDITION] is a condition in which the level of water and sodium in the body - too little water, too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of [MEDICAL CONDITION] is having more water leave your body than entre it. This causes dehydration. A person can become dehydrated in different ways, such as: ? Drinking too little fluids ? Vomiting ? Diarrhea ? Using diuretics (medicines that increase urine output) ? Sweating a lot ? Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: ?Not getting enough fluids ? Losing too much fluid ? Advanced age ? Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: ? Being thirsty ? Dry mouth ? Serious symptoms: ? [MEDICAL CONDITION] ? Confusion ? Muscle twitching ? [MEDICAL CONDITION] ? Coma If left untreated, the condition may lead to death." Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection..." An interview on 10/31/12 at 7:52 AM with ADON A revealed when asked if she knew how dehydrated Resident #2 was at the hospital, ADON A stated, "...it didn't alarm us, we attributed it to her not eating due to her teeth being pulled." On 10/30/12 at 12:43 PM, the DON was asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." An interview on 10/30/12 at 9:35 AM with Physician E revealed when asked if he was aware Resident #2 had teeth extracted, he replied, "No." Physician E, was looking at his personal tablet and stated, "I have no records of being notified. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received two of 32 doses ordered of the [MEDICATION NAME]. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Interview with the Administrator on 10/31/12 at approximately 9:15 AM revealed LVN G had been terminated. An interview on 10/31/12 at 8:32 AM with LVN I revealed nurses were to call the physician "as soon as you see a change." An interview on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." The facility's policy "Change in a Resident's Condition or Status" dated April 2011 reflected, "Policy Statement - Our facility shall promptly notify the resident, his or Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation - 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been ...d. A significant change in the resident's physical/emotional/mental condition, e. A need to alter the resident's medical treatment significantly...i. Instructions to notify the physician of changes in the resident's condition. 2. A "significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one are of the resident's health status; c. Requires interdisciplinary review and/or revision of the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument...3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when...b. There is a significant change in the resident's physical, mental, or psychosocial status...." The facility's policy "Resident Hydration and Prevention of Dehydration" dated September 2004 reflected, "Policy Statement - This facility will endeavor to provide adequate hydration and to prevent and treat dehydration - Policy Interpretation and implementation... 7. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids on a daily and routine basis as part of daily care. Intake will be documented in the medical records. 8. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan. ADL status, diagnosis, individual preferences, habits and cognitive and medical status will be considered in all interventions. Physician will be informed ...13. Nursing will monitor and document fluid intake and the dietician will be kept informed of status. Interdisciplinary team will update care plan and document resident response to interventions until team agrees that fluid intake and relations factors are resolved." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified, and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: All residents had a dehydration risk assessment completed and all residents triggered as high risk were assessed by Nursing Administration. PO intake to include nutrition and hydration will be documented with each meal by the nurse aide. The assigned nurse, DON, ADON, Skin nurse, or Reimbursement Nurse will validate meal intake by documenting P

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for two (Residents #1, #2 and #3) of 18 residents reviewed for quality of care. 1) Staff failed to order Resident #2's scheduled [MEDICATION NAME] and [MEDICATION NAME] mouthwash, when the resident had 17 teeth extracted. Resident #2 only received six of 12 scheduled doses of [MEDICATION NAME], and she did not receive any of the 32 doses of [MEDICATION NAME] mouthwash. Staff failed to ensure Resident #2's pain was addressed. Staff failed to follow Resident #2's Oral Surgeon's post-operative directions. Staff failed to recognize Resident #2 had a change in condition after her teeth were removed. Staff failed to address Resident #2's teeth extractions and possible complications on her Care Plan. Staff failed to write the Physician's Telephone Order for Resident #2's Bactrim DS for her Urinary Tract Infection. Resident #2 only received two of the ten ordered doses. These failures resulted in Resident #2 suffering from unrelieved pain, being dehydrated, continuing to have a Urinary Tract Infection, discomfort, having a critical Sodium level, and being admitted to the hospital for seven days with intravenous antibiotics. An Immediate Jeopardy (IJ) was identified on 10/31/12. While the IJ was removed, on 11/02/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring implementatin of the Plan of Removal. These failures could affect any of the facility's 92 residents, who could receive care from any of the nurses who rotated halls, by placing them at risk for delays in or omission of needed medical care and treatment, deterioration in clinical conditions, and an over-all decline in their health and well-being. Findings included: 1) Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. A water pitcher was in Resident #2's room atop a dresser that was situated across the room from her bed and between the first and second beds. No water pitchers were seen on either resident's night tables. When asked how often they offered fluids to the residents, CNA F stated they should offer fluids every time they check on the residents. When asked who the water pitcher on the dresser belonged to, both CNAs indicated they did not know. Resident #2's roommate entered the room at that time and was asked if she knew to whom the water pitcher belonged. The roommate replied, "Oh honey, I have no idea." Resident #2's Physician's Telephone Order dated 09/18/12 reflected "UA/C&S (urinalysis with culture and sensitivity)." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for [MEDICATION NAME] 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours a needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Urine Culture results dated 09/21/12 reflected Gram Negative Rods and Escherichia Coli. A handwritten entry on the lab result reflected, "(Physician E) notified 11:00 AM (Medical Director) notified Bactrim DS (one) PO BID X 5 days." Resident #2's Telephone Physician's Orders did not reflect an order for [REDACTED]. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) [MEDICATION NAME] 5/500 (one) po (by mouth) q 6 (every six hours) X (times) 72 hrs. 2) pureed diet, [MEDICATION NAME] Rinse 15 cc rinse X 30 sec. (seconds) swish & spit X 1 bottle BID (twice a day) 3) V/S (vital signs), & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? [MEDICATION NAME] bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's September 2012 MAR reflected an entry dated 09/22/12 for [MEDICATION NAME] 5/500 one by mouth every six hours for 72 hours. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The MAR also reflected an entry dated 09/22/12 for [MEDICATION NAME] rinse 16 ounce bottle, 15 cc (half an ounce) rinse for 30 seconds, swish and spit twice a day times one bottle. The scheduled times for administration were 8:00 AM and 8:00 PM. The following doses were initialed as given: 09/23/12 at 8:00 AM and 8:00 PM. No other doses were initialed as given. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Care Plan was last updated on 08/18/12 did not reflect an update regarding her full mouth extraction or the complications which could develop. No revisions had been made since 08/18/12. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." Resident #2's September 2012 MAR reflected she received [MEDICATION NAME] on 09/22/12 at 12:00 PM The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain. Per report Bactrim DS started 09/22/12 for UTI." Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM the resident was "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order...." Resident #2's September 2012 MAR reflected on 09/23/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID (no Physician's Telephone Order was written), 9/22/12 [MEDICATION NAME] q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." Interview with LVN I on 10/31/12 at 8:32 AM revealed he was assigned to Resident #2 the evening after her teeth were extracted. LVN I stated he checked her mouth and smelled an odor "...that's when I used the mouthwash." When asked if it was the [MEDICATION NAME], LVN I stated it was regular mouthwash and showed the bottle to the surveyor. When asked why he did not use the [MEDICATION NAME] as ordered, LVN I did not answer. During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's September 2012 MAR reflected on 09/24/12 she received [MEDICATION NAME] at 12:00 AM and 6:00 AM. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, [MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's September 2012 MAR reflected no other doses of [MEDICATION NAME] were given after 09/24/12 at 6:00 AM. During an interview on 10/26/12 at 1:34 PM, LVN H was shown Resident #2's Controlled Drug Record and MAR and asked why only six doses of pain medication were administered to Resident #2 after her tooth extractions. LVN H replied that was all the [MEDICATION NAME] that was available for Resident #2. When LVN H was shown Resident #2's orders dated 09/22/12 ([MEDICATION NAME] 5/500 mg one tablet every six hours for 72 hours), he stated the physician had to call the pharmacy for [MEDICATION NAME]. When asked if he ever told the physician there was not enough medications available, LVN H did not answer. LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." When LVN H was shown the order for [MEDICATION NAME] he stated he did not know why only two doses were given. When asked if he knew what [MEDICATION NAME] was used for, LVN H replied, "Yes, it's for after oral surgery, keeps the gums soft and prevents infection." During another interview with LVN H on 10/30/12 at 8:18 AM, when asked if he remembered ever seeing a bottle of [MEDICATION NAME] on the medication cart for Resident #2, he stated he never saw one. Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never received an order for [REDACTED]. . The Pharmacist stated the pharmacy never received the order for Resident #2's scheduled [MEDICATION NAME] and none was delivered to the facility. On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H" jogged her memory," and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Review of Emergency Kit Documentation Forms provided by the DON for September 2012 revealed only two doses of Bactrim had been removed from the facility's emergency drug kit for Resident #2. One tablet was removed on 09/23/12 at 9:00 AM and another tablet was removed on 09/26/12 at 4:00 AM. On 10/30/12 at 2:00 PM the DON explained she had contacted the pharmacy and spoke with the pharmacist to obtain their copies of the forms. When the DON was asked whether the Bactrim had ever been ordered, she replied, "No." Interview on 10/30/12 at 2:05 PM with LVN G revealed when asked where she obtained the doses she signed as given on 09/22/12 at 9:00 PM, 09/24/12 at 9:00 PM and 09/25/12 at 9:00 PM, she replied, "I know I pulled the initial dose from the E-Kit (emergency kit) and on the third day when I returned I called the pharmacy myself." When asked what she was told by the pharmacy, she replied, "We'll put it on the next shipment. That's what they always say." Interview with the facility's contracted pharmacist on 10/30/12 at 2:21 PM revealed the pharmacy never processed an order for [REDACTED]. The 24 Hour Report Book reflected on 09/26/12 Night: "Cont. on Bactrim DS for UTI, NARN, stable" Day: "Still on Bactrim UTI, Appetite good" Evening: "Cont. on Bactrim for UTI" Interview with MA J on 10/30/12 at 2:09 PM revealed she signed out a dose of Bactrim on 09/26/12 and she stated she always informed the Charge Nurse if more than one dose of a medication was pulled from the emergency kit. The MA indicated she informed LVN H. Interview with LVN H on 10/30/12 at 2:11 PM revealed he was told about the Bactrim by the MA and called the pharmacy. LVN H could not remember what he was told by the pharmacy or whether they requested an order. The DON joined the interview and stated the pharmacy would not send the medication without an order and nobody sent them one. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good." Resident #2's Nurse's Notes dated 09/28/12 at 2:00 AM reflected: "Post ABT for UTI..." The 24 Hour Report Book reflected on 09/28/12 Night: "Bactrim UTI completed." Day: "PABT /UTI" Evening: "PABT ? problems" The 24 Hour Report Book reflected on 09/30/12: Evening: "Small amt (amount) blood noted from rectum when cleaning resident. Purplish red in color, (Physician E) called, N/O rec'd (received) for CBC in AM, Hemacults (sic) (test for blood in stool), (Lab company) called re: lab stool collected in fridge." Review of Resident #2's September 2012 MAR revealed an entry dated 09/22/12 for Bactrim DS twice a day for five days. The order was initialed as given at 9:00 AM and 9:00 PM from 09/22/12 at 9:00 PM through 09/27/12 at 9:00 AM. The 24 Hour Report Book reflected on 10/01/12 Night: "(s) (small) amt of blood noted from rectum. N/O Lab: CBC in AM, occult blood 1. No stool collected- (lab company) notified of lab orders/(Physician E), need stool specimen X1" Day: "In bed (decreased) appetite" Evening: "cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "Daughter notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to (decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" The 24 Hour Report Book reflected on 10/03/12: Night "90%-fed by nurse (2-10) stable, lab result f/u." Day:"appetite, (decreased) weight vs 120/63, 89 call placed to MD" Evening: "Hospital" An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's clinical record revealed a hospital record dated 10/10/12 that reflected: "[MEDICAL CONDITION] - Adult. Definition - [MEDICAL CONDITION] is a condition in which the level of water and sodium in the body - too little water, too much sodium. This condition may be serious. It requires care from your doctor. Causes - The main cause of [MEDICAL CONDITION] is having more water leave your body than entre it. This causes dehydration. A person can become dehydrated in different ways, such as: ? Drinking too little fluids ? Vomiting ? Diarrhea ? Using diuretics (medicines that increase urine output) ? Sweating a lot ? Having certain medical conditions (eg, diabetes or kidney disorder) Risk Factors - Risk factors include: ?Not getting enough fluids ? Losing too much fluid ? Advanced age ? Having certain medical conditions (eg, diabetes or kidney disorder) Symptoms - Symptoms may include: ? Being thirsty ? Dry mouth ? Serious symptoms: ? [MEDICAL CONDITION] ? Confusion ? Muscle twitching ? [MEDICAL CONDITION] ? Coma If left untreated, the condition may lead to death." Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection..." An interview on 10/31/12 at 7:52 AM with ADON A revealed when asked if she knew how dehydrated Resident #2 was at the hospital, ADON A stated, "...it didn't alarm us, we attributed it to her not eating due to her teeth being pulled." On 10/30/12 at 12:43 PM, the DON was asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." An interview on 10/30/12 at 9:35 AM with Physician E revealed when asked if he was aware Resident #2 had teeth extracted, he replied, "No." Physician E, was looking at his personal tablet and stated, "I have no records of being notified. I can say confidently I was not aware of any dental issues or teeth pulled." Physician E was informed that Resident #2 had 17 teeth extracted and received none of the 32 doses ordered of the [MEDICATION NAME]. Physician E stated, "Well that's not good. I don't expect to be told of anything unless there are issues." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Interview with the Administrator on 10/31/12 at approximately 9:15 AM revealed LVN G had been terminated. An interview on 10/31/12 at 8:32 AM with LVN I revealed nurses were to call the physician "as soon as you see a change." An interview on 10/31/12 at 11:45 AM with LVN H revealed, "If a resident has a change in condition we have to call the doctor and the hospice company." The facility's policy "Change in a Resident's Condition or Status" dated April 2011 reflected, "Policy Statement - Our facility shall promptly notify the resident, his or Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation - 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been ...d. A significant change in the resident's physical/emotional/mental condition, e. A need to alter the resident's medical treatment significantly...i. Instructions to notify the physician of changes in the resident's condition. 2. A "significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'); b. Impacts more than one are of the resident's health status; c. Requires interdisciplinary review and/or revision of the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument...3. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when...b. There is a significant change in the resident's physical, mental, or psychosocial status...." The facility's policy "Pain Assessment and Management" dated October 2010 reflected, "Purpose - the purpose of this procedure are to help the staff identify pain in the resident, as to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain - General Guidelines ...6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes of level of chronic pain and at least weekly in stable chronic pain...Identifying the Causes of Pain: 2. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including...g. Oral heal conditions; or H Infection: (1) Urinary tract infection ...Defining Goals and Appropriate Interventions: ...3. Pain management interventions shall address the underlying causes of the resident's pain. For example, if there is acute pain associated with an infected wound the intervention shall address treating the infection in addition to pain control...." The facility's policy "Medication Orders," dated September 2010 reflected, "Documentation of the Medication Order...2. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the Physician Order sheet (POS)/ Telephone Order Sheet (TO) if it is a verbal order, and on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). a. New orders (handwritten by prescriber or verbal orders)...Transmit the appropriate copy of the order to the pharmacy for dispensing ...." The facility's policy "Medication Ordering and Receiving From Pharmacy Provider Emergency Pharmacy Service and Emergency Kits (E-Kits)," dated September 2010 reflected, "Procedures...7. When an emergency or stat (immediate) medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, check's the resident's allergies [REDACTED]. Emergency medications are only administered with a valid prescriber's order...8. Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange. The hard copy will be retained in the nursing care center...." On 10/31/12 at 9:55 AM, the Administrator and DON were notified an IJ was identified, and a Plan of Removal for the IJ was requested at that time. The facility's Plan of Removal was accepted on 11/01/12 at 9:52 AM and reflected the following: A. Physician was notified of Resident #2's change in condition. All Resident #2's orders were verified and an assessment of her mouth was completed. The results of the assessment were called to her dentist's office. B. All residents who had recently received dental care or complained of

Based on observation, interview and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable for one (Resident #2) of six residents reviewed for pressure ulcers. 1. LVN G failed to notify the physician of Resident #2's two Stage III pressure ulcers. 2. LVN G failed to obtain treatment orders for Resident #2's Stage III pressure ulcers. 3. Staff failed to treat Resident #2's Stage III pressure ulcers from 09/27/12 through 10/01/12. 4. Staff failed to update Resident #2's Care Plan regarding possible complications of teeth extractions, including not eating, weight loss and dehydration, which could cause skin breakdown. These failures resulted in Resident #2's two Stage III pressure ulcers, discomfort, delays in needed treatment, and delays in healing and could cause infections or worsening of the pressure ulcers. These failures could affect the 76, who were in chairs all or most of the time, by placing them at risk for developing pressure ulcers, discomfort, worsening existing pressure ulcers and infections. Findings included: 1. Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was at risk for developing pressure ulcers, but she currently did not have any pressure ulcers. Resident #2's Care Plan dated 08/18/12 reflected she had the potential for developing pressure ulcers or other skin breakdown related to incontinence and decreased mobility. Approaches included: "Assist resident to turn, and/or reposition frequently for pressure reduction. Encourage activity as tolerates (sic) ...Skin checks twice weekly with bathing, and with cares (sic). CNA's to notify nurse of any reddened or broken skin, and nurse will notify physician and family. Skin check by nurse once weekly..." Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Observation on 10/26/12 at 1:14 PM of CNA D and CNA F transferring and providing incontinent care to Resident #2 revealed she had a dressing on her sacrum dated 10/25/12. Two small pink areas could be seen beneath the dressing. A water pitcher was in Resident #2's room atop a dresser that was situated across the room from her bed and between the first and second beds. No water pitchers were seen on either resident's night tables. When asked how often they offered fluids to the residents, CNA F stated they should offer fluids every time they check on the residents. When asked who the water pitcher on the dresser belonged to, both CNAs indicated they did not know. Resident #2's roommate entered the room at that time and was asked if she knew to whom the water pitcher belonged. The roommate replied, "Oh honey, I have no idea." Resident #2's Assessment of Risk for Dehydration dated 08/18/12 reflected a score of three which indicated she was at low risk for dehydration. Resident #2's Weekly Head to Toe Skin Assessments dated 05/31/12 through 09/25/12 reflected "Skin intact." During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw and she had not been given any special instructions regarding her care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's Care Plan updated on 08/18/12 did not reflect any additional updates to address her full mouth extraction and the possible complications. 09/23/12 at 12:00 AM: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain.Per report Bactrim DS started 09/22/12 for UTI." Resident #2's Weekly Head to Toe Skin assessment dated [DATE] reflected, "2 Stage 3" on coccyx." No other descriptions or measurements were documented. The entry was made by LVN G. An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 % and after her teeth were pulled, the resident ate < 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G also revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." The surveyor queried LVN G if she gave Resident #2 pain medication on Monday (09/24/12) as ordered and LVN G stated, "I took the order off (written on facility chart 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." The surveyor reviewed LVN G's Nurse's Notes with the LVN from 09/22/12 until 10/03/12. LVN G was asked if she called the physician regarding the change in the resident's condition and she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When asked what the physician said, LVN G responded, "I can't say, I don't remember." When asked if she documented what the physician said, LVN G replied, "Yes, but I took some medicine and I have not been the same since." LVN G reviewed the skin assessment she completed for Resident #2 on 09/27/12. LVN G stated a CNA told her about the pressure ulcers and the "2 openings, involved more than top layer of skin, had yellow edges to it." LVN G stated, "I left a note for the treatment nurse. I put it on her desk. I cleaned it (pressure ulcer) and put a dressing on it." LVN G revealed she did not measure the pressure ulcers. When asked if she notified the physician, she replied, "I think I placed a call to the doctor and did not get a return call." When asked if she followed-up the next day, LVN G responded, "I really can't tell you." When asked if she changed Resident #3's dressing the next day, LVN G stated, "No." During an interview on 10/30/12 at 9:35 AM, Physician E was asked if he was aware Resident #2 had teeth extracted and he replied, "No." He was asked if he was notified Resident #2 developed two Stage 3 pressure ulcers, and Physician E replied, "No." Physician E was also asked if he expected to be notified and he stated, "Yes. I don't have any record of being notified of pressure ulcers (as he looked at his tablet)." Review of the facility's 24-Hour report book (used by nursing staff to relay information from shift to shift) revealed the following entry related to Resident #2: 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good" Evening: "2 Stage 3 to coccyx" Resident #2's Nurse's Notes dated 10/01/12 at 12:00 PM reflected, "Two Stage III's noted to sacral area. First Stage III measures 1.5 cm X 1.5 cm. Second Stage III measures 2cm X 2cm. Wound beds are 100% yellowish brown slough, no drainage or odor noted. N/O received to cleanse areas (with) wound cleanser. Apply skin prep to peri wound area. Apply Santyl to wound bed and cover with [MEDICATION NAME] dressing qod (every other day). N/O received for Vit. (vitamin) C 1000 mg tab po BID, Zinc 220 mg tab po q day X 14 days. [MEDICATION NAME] Silver tab po q day. Provide 30 cc po qday.[MEDICATION NAME] 1 pkt (packet) po BID to promote wound healing." The entry was made by the Wound Treatment Nurse. During an interview on 10/26/12 at 1:34 PM, LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." During an interview on 10/30/12 at 3:25 PM, CNA K, who works the 2:00 PM to 10:00 PM shift, was asked what he remembered about Resident #2. CNA K stated she was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K stated he offered every time he entered her room. When queried whether she would drink for him, CNA K stated, "Yeah, not a lot, she'd spit it back out." CNA K stated he reported it to his charge nurse and had never been given any special instructions regarding her care. Resident #2's Resident Weight Record reflected the following weights: 07/09/12 - 125 pounds; 08/13/12 - 124 pounds; 09/20/12 - 125 pounds. Review of the facility "Weight" records provided by the restorative aide revealed Resident #3's weights were: 09/06/12 = 125 pounds, 10/10/12 = 112 pounds, 10/17/12 = 110 pounds and 10/24/12 = 117 pounds. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the following reason for transfer: "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." Review of Resident #2's emergency room record dated 10/03/12 revealed her admission weight was 113 pounds. The emergency room record further revealed, "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli (Gram-negative bacillus in the human colon) urinary tract infection...." The DON stated on 10/30/12 at 12:43 PM that the day Resident #2 went out to the hospital was the same day she saw food falling out of her mouth. When asked if she was told of the resident's decline in condition before, the DON stated, "I noticed she didn't fuss as much as she used to. She had been more verbal. When asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000, the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." Observation of Resident #2's pressure ulcers on 10/30/12 at 9:47 AM with the Wound Treatment Nurse and the Wound Care Physician revealed two, pink dime sized scars. The Wound Care Physician stated both wounds were healed. Observation on 10/30/12 at 8:40 AM Resident #2's witnessed weight was 117.3 pounds. Resident #2 was placed in a wheelchair, that was always used for weights. In an interview on 10/30/12 at 9:58 AM, the DON was asked how she was informed about the development of new skin issues. The DON explained they had weekly meetings and discussed all the wounds in the facility. She stated whenever there is a new wound it is written in the 24 hour Report and the report is reviewed every day during the daily "stand-up" meetings. During an interview on 10/30/12 at 11:30 AM, the DON was shown LVN G's entry in the 24 Hour Report Book dated 09/27/12 which reflected Resident #2 had two new Stage III pressure ulcers. The DON stated she did not know why these pressure ulcers were not addressed in the stand-up meeting on 09/28/12. The DON asked the Wound Treatment Nurse to join the interview. The Wound Treatment Nurse stated she did not work the following three days after the new pressure ulcers were identified. The DON was asked if she was aware of Resident #2's pressure ulcers and that no treatment was ordered for four days, she replied she was informed on 10/01/12 and had in-serviced the nurses. When asked what the nurse should have done, the DON replied the nurse was supposed to call the physician and read him the facility's protocol for approval. She stated the nurse should assess the wounds, measure them and document her findings. The DON revealed the nurses were to initiate pressure ulcer treatments if the Wound Treatment Nurse was not available. When the Wound Treatment Nurse returned to work, she would reassess and take over. The DON was asked if she was aware of Resident #2's intake after her teeth were extracted, and the DON stated, "I remember she wasn't eating. I noticed a couple of days later (after the extraction) the food was just coming out of her mouth. I thought she had a swallowing problem." An interview on 10/30/12 at 12:00 PM with the Wound Treatment Nurse revealed she ordered Resident #2 an air mattress on 10/01/12 when she learned about the wounds and obtained the treatment orders and supplements. The Wound Treatment Nurse stated Resident #2 never had any skin issues before while in the facility. Review of an "In-Service Training Report" dated 10/01/12 revealed "Charge nurses that discover or identify a skin issue are to document, notify family and doctor, write orders and initiate treatment per skin protocol, conduct weekly skin assessments head to toe." The facility's undated policy "Pressure Sores" reflected, "...2. The physician will be notified when a decubitus first appears, as well as when the treatment is not effective...4. A resident having pressure sores will receive necessary treatment and services to promote healing, prevent infection and promote new sores from developing." The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 10/25/12 and signed by the Medicare Coordinator reflected a 76 residents were in a chair all or most of the time.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #3) of three residents reviewed for accidents. The facility Van Driver failed to properly secure Resident #3 in the facility van and hit a bump in the road, while transporting the resident, causing her to fall out of her wheelchair and immediately complain of pain in her legs. The Van Driver failed to call 911 for emergency assistance even though Resident #3 was screaming with pain to her leg. The Van Driver failed to follow the facility's protocol and moved Resident #3 when she was on the floor and tried to straighten out the resident's leg. The Van Driver failed to take Resident #3 immediately back to the facility after the accident. She took the resident to dialysis, even though the resident was asking for an ambulance to be called. The Van Driver drove around with Resident #3 in the van for approximately two hours. These failures resulted in Resident #3 suffering severe pain from a fractured leg, being hospitalized , and having continued severe pain, which required a central line. These failures could affect the 55 residents, who could ride in the van in a wheelchair, by placing them at risk for injuries, serious injuries, and anxiety. Findings included: Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was cognitively intact with clear speech; she required extensive assistance of two persons with transfers and had impaired range of motion in her legs. The Resident Incident Report dated 10/15/12 reflected Resident #3's incident occurred at 10:10 AM, and "12 PM Facility Driver reported to me (Charge Nurse) that while (Resident #3) was in the facility van to dialysis, the driver accidently(sic) pushed (Resident #3) against another resident." The facility's "Provider Investigation Report" dated 10/15/12 reflected, "Description of the Allegation: Resident (Resident #3) fell out over wheel chair while traveling in company van...Description of injury - Both knees scared (sic) (L) (left) knee cared (sic) + swollen. C/O of severe pain in both knees...Description of Assessment - residents knees were assessed, Neuro checks, L.O.C. and moving upper ext. Without difficulty. C/O severe pain when I touch the left knee. Alert + oriented x 3...Provider Response - Van Driver was suspended follow investigation. Investigation Summary - Residents was strapped in wheelchair in facility vehicle. Transportation hit a big bump and the resident slid to the edge of her seat. The transportation employee unhooked the resident's seat belt and the resident slipped to the floor. resident sustained [REDACTED]. Employee resigned during investigation. Provider Action Taken Post-Investigation- inspection of vehicle equipment - In-service of staff and equipment use and report of incidents in vehicle - equipment monitoring done reannounced (sic) and randomly by facility." The Provider Investigation Report was signed by the ADM. Resident #3's typed statement (typed by the DON) dated 10/15/12 at 12:00 PM reflected, "I got into the van. We were driving for about 10 mins. The van hit a pot hole and a big bump. I fell out of the wheel chair to my knees. The driver pulled into a parking lot. The driver and two men picked me up off the floor and put me in my wheel chair. She drove me to dialysis; I was in to (sic) much pain to get on the dialysis machine. The driver took me back to the van. She took the other two people to their appts and brought me back to the nursing home. I was not strapped in." Resident #3's Nurse's Notes dated 10/15/12 reflected: "At 2 PM Resident sent to ER at (hospital) via ...EMS, R/T fall from w/c in facility van while going to dialysis tx (treatment), c/o generalized pain...all the responsible parties notified." Review of Resident #3's Narcotic Sign out sheet for Norco 5/325 mg revealed doses were signed out on 10/15/12 at 8:00 AM and 12:00 PM. Review of Resident #3's Emergency Department Medical Record dated 10/15/12 revealed History of Present Illness, "Pt (patient) know (sic) with pain to bilateral anterior knees. Pain L>R (left greater than right). Pain dull, constant, non-radiating, moderate severity increasing with palpation (touching) and movement." Resident #3's hospital X-ray Report dated 10/15/12 reflected: "Acute communited distal femoral shaft fracture (fracture in which bone fragments/splinters into several pieces just above the knee) with likely extension into the intercondyler portion of the femur." Resident #3 was interviewed on 10/25/12 at 9:02 AM in her hospital room. She moaned frequently and complained of " ...so much pain in my leg, I broke it." Her left leg was in a cast, which extended from her upper thigh near her groin to her toes. When Resident #3 was asked about her accident, she replied she was in the back of the van, in a wheelchair, on her way to dialysis. Resident #3 stated the driver did not attach her seat belt and, after hitting a bump in the road, she fell out of her wheelchair onto her knees. Resident #3 revealed she told the driver she needed to go to the hospital and asked her to call an ambulance. She said the driver then pulled into a lot and had two men, she did not know, help put her back into her wheelchair. Resident #3 revealed she told the driver again she wanted to go to the hospital, but the driver took her to the dialysis center instead. Resident #3 stated when she got to the dialysis center she told the staff her leg was broken and the Van Driver said, "No it's not." Resident #3 said the staff at the dialysis center asked her if she wanted to see the dialysis doctor there and she told them, "No, I need to go to the hospital, I want an ambulance! They put me back in the van to the facility, (Van Driver) drove me around and around from 9:30 (AM) to 12:00 (PM)." Resident #3 stated the driver gave her a white pill and "drove and drove and said 'you'll feel better.'" When Resident #3 was asked to clarify whether it was the van driver who gave her a pill, she replied, "Yes, then kept driving and driving." She stated she told the driver again she needed to go to the hospital. Resident #3 revealed the driver took her back to the facility, and when she arrived at the facility, she told the staff she wanted an ambulance to go to the hospital. She stated she was told by facility staff she needed an X-ray. Resident #3 said she called her family member, told him what happened, and he then called her nurse and the staff finally called her an ambulance. During the interview, Resident #3 was in pain and called her nurse for medication. When the Hospital Nurse entered and assessed her pain, Resident #3 described it as nine out of ten on a one to ten scale and was given Dilaudid (strong narcotic pain medication) via intravenous line. Interview with the Hospital Nurse on 10/25/12 at 9:20 AM revealed Resident #3 had a femur fracture. She stated Resident #3 was a candidate for surgery but refused because she felt the risks were too great. When the Hospital Nurse was asked whether the resident's high level of pain was common throughout her stay she stated it was. Resident #3's hospital Nurse's Notes dated 10/17/12 at 6:15 PM reflected: "Pt (patient) refused to be turned and reposition D/T (due to) pain during this shift." Resident #3's hospital Nurse's Notes dated 10/17/12 at 8:50 PM reflected: "...Lt(left) leg swollen on immobilizer. Pt barely move. Yelling when turned or repositioned...." Resident #3's hospital Nurse's Notes dated 10/20/12 at 10:45 AM reflected: "(Hospital physician) notified of pt's severe pain not relieved by current medications. New orders received. Will continue to monitor." Resident #3's hospital Nurse's Notes dated 10/21/12 at 1:43 PM reflected: "Started PCS (sic)(PCA is patient controlled analgesia-narcotic pain medication given through an intravenous (IV) line) per MD order...pain 8/10 (8 out of 10 on a 1-10 scale)." Resident #3's hospital Nurse's Notes dated 10/21/12 at 5:25 PM reflected: "...pain 10/10" Resident #3's hospital Nurse's Notes dated 10/23/12 at 1:30 PM reflected: "Went to patients (sic) room to start nre PCA syringe...After replacing syringe noticed patient had accidentally removed left lower arm IV. Attempted to start new peripheral IV X 3 and called (another RN) to attempt again. After three more attempts notified (hospital physician) who ordered to stop PCA and sent patient...for central line." Resident #3's hospital Nurse's Notes 10/24/12 at 10:15 PM: "Patient requests both pain medications be given at this time. Explained to patient this is against protocol and patient got noticably frustrated but verbalized understanding." The DON's typed statement dated 10/18/12 reflected, "On October 17, 2012 (LVN I) told me that he spoke to the doctor concerning (Resident #3). The doctor said to have the x-ray done in-house and not to send her to the hospital. I had no idea what (LVN I) was talking about. I asked him to explain. (LVN I) stated that the resident stated she fell in the van and hurt her knee. I then went to (Resident #3's) room to assess her. Both knees were scraped and oozing a very small amount of blood. Her left knee was swollen and had a bluish color. I asked her what happened. See attached DON statement. I told (LVN I) to call the doctor and get an order to (Resident #3) to the hospital. I then called the Administrator to report the incident. He instructed me to suspend (Van Driver). (Van Driver) stated she accidentally bumped the resident chair against another wheelchair." In an interview on 10/25/12 at 1:39 PM, LVN I was asked about the events surrounding Resident #3 on 10/15/12. LVN I replied he sent her to dialysis "sometime after 9:00 (AM)," and she went to the hospital at 2:00 PM. LVN I stated he was there when she returned to the facility, and the Van Driver told him to come and check the resident. He revealed the Van Driver told him she accidently bumped Resident #3, but Resident #3 told him she fell on the floor. When asked about Resident #3's condition, LVN I stated, "When I tried to touch her, she screamed. She said her pain was 6 (out of ten on a one to ten scale), I gave her Hydrocodone." When asked if he re-assessed her pain afterward, LVN I replied he did not because of the nature of the injury and her screaming. He revealed he tried to hurry. He stated he called Resident #3's family member, who told him to send the resident to the hospital. LVN I revealed Resident #3 asked to go to the hospital on his initial assessment of her, and he had to prepare the paperwork. Interview with the Administrator on 10/25/12 at 10:26 AM revealed the Van Driver lied to facility staff regarding the events surrounding Resident #3's injuries. He added the Van Driver resigned during the investigation, and she told the staff that she bumped the resident. The Administrator identified the residents who were on the van and witnessed the incident. Resident #5's typed statement, typed by the DON, dated 10/15/12 at 12:00 PM reflected, "(Resident #5) stated she did not see (Resident #3) fall because she was sitting in the front of the van. Stated she heard (Resident #3) screaming. (Van Driver) pulled the van into a shopping center. 2 men helped her get (Resident #3) off the floor." During an interview on 10/25/12 at 11:31 AM, Resident #5 confirmed she was aboard the van, sitting in a regular seat, on 10/15/12 with Resident #3 when she was injured. Resident #5 stated she did not see her actually fall and stated, "...all I know is she was on the floor and she was hollering." When asked where the Van Driver was when Resident #3 was on the floor, Resident #5 stated she was still in the driver's seat and told her she was going to go back there and help her. When Resident #5 was asked whether she was sitting at a good angle to tell if the resident was all the way down or hanging from her chair, Resident #5 replied, "She was fully on the floor before the driver got to her. The driver stopped, when she stopped, she was on the floor." When asked if Resident #3 was wearing a seat belt at the time, Resident #5 stated, "She didn't have a seatbelt on at all." When asked what happened next, Resident #5 replied, "She (Van Driver) had to drive to a place where some men could get her up." When asked where, she replied, "...like a filling station near some stores...there was some men standing there and she asked them to help...they got on the bus and picked her up." When asked how Resident #3 was at the time, Resident #5 replied, "She was hollering. We got to dialysis. They wouldn't take her because she was hollering. They put her back on the bus." Resident #5 stated she was taken to her appointment after that, so she did not know where Resident #3 went next. At the conclusion of the interview, Resident #5 reiterated Resident #3 was not wearing a seatbelt and was on the floor when they stopped. Resident #4's typed statement, typed by the DON, dated 10/15/12 at 12:00 PM reflected, "We were in the van. The van hit a pot hole. The resident (Resident #3) hit her knee on the lift. (Van Driver) pulled in a shopping center. She opened the back of the van to help (Resident #3) the resident was sliding out of the chair; (Van Driver) could not pick her up off the van floor. She had 2 men to help her put the resident back into the wheel chair. We then went to take her to dialysis. She was saying she was in pain. (Van Driver) took her in the dialysis building and brought her back out and put her back in the van. (Van Driver) dropped off (Resident #5) to her dialysis. She drove me to (name of hospital)." During an interview on 10/25/12 at 10:51 AM, Resident #4 said he was in a wheelchair next to Resident #3 in the back of the van at the time she sustained her injuries. He described the area behind the bus seats where wheelchairs could be locked in place. He revealed the Van Driver was traveling at normal speed, but hit a hard bump. Resident #4 stated prior to hitting the bump, the driver made a left turn and both their wheelchairs shifted from their positions. The driver then hit a hard bump, and he "bounced up, then went forward up to the seats." Resident #4 said he was able to brace himself with his feet, but Resident #3's chair was pinned against the seats in front of her. When asked if their chairs were strapped or locked in, Resident #4 stated there were straps, but they were loose. He stated the Van Driver came around and unbuckled Resident #3 and that was when she hit the floor. When asked how Resident #3 was behaving at that time, Resident #4 described her as "hysterical." He revealed she hit her leg on an iron bar at the bottom of the seats. He went on to say the driver then tried to straighten out Resident #3's legs, and the resident "...was hollering that was hurting." He stated the driver got Resident #3 back in her chair and drove her to dialysis, unloaded her and took her inside, but she did not want to go because she was in too much pain. He said the Van Driver reloaded her onto the bus. Resident #4 revealed Resident #3 still wanted to go to the hospital, but the Van Driver told her she had to go back to the facility. Resident #4 also revealed the Van Driver then dropped off another resident at her appointment and then dropped him off at his appointment. When asked how Resident #3 was tolerating the trip, he replied she was calmer, but still in pain and she yelled whenever they hit a bump. When asked if he had any transportation problems since that time, Resident #4 replied he had not seen the Van Driver again after the incident. He added they had been strapped in the right way ever since the incident. The Van Driver's undated typed statement reflected, "I (Van Driver) was putting (Resident #3) in the van incident rolled in to (Resident #4) wheel Chair I pull her from his wheel chair and she said she was a okay take her to dialysis and got her off take her in send then she complain of her leg hurting, Take my other's to ther (sic) appointment. Then she said a leg brock (sic). Bolh (sic) her back to the facility and told the chang (sic) nurse." An interview via telephone on 10/25/12 at 2:23 PM with the Van Driver revealed when asked to recount the events on 10/15/12, she stated she left the facility around 10:15 AM. She revealed, "I accidentally bumped (Resident #3's) legs-I think I did-she said she was fine." She said she strapped Resident #3 in and put her seat belt on. The Van Driver stated, "When we got past I 20 (Interstate 20) she complained of her legs hurting. I pulled over in a church parking lot, she had slid down in her chair. I unbuckled her and she slid off her chair." When asked what Resident #3 was saying at that point, the Van Driver replied the resident complained her legs hurt. The Van Driver revealed she "straightened her legs out and got her back in her chair." When asked how the resident tolerated that, she replied, "Fine." When asked if she put her back in the wheelchair by herself, the Van Driver replied, "Yes ma'am. (laughed) She put her arms around my neck so I could lift her." She revealed she strapped Resident #3 in and went on to dialysis. The Van Driver stated when she arrived at the dialysis center, Resident #3 was complaining of leg pain, so she asked the dialysis staff what she should do. The Van Driver said they told her to take her back to the facility. When asked about Resident #3's demeanor at that time, the Van Driver replied she just complained her leg hurt, but was "not crying." When the Van Driver was asked if, at any time, Resident #3 asked her to call an ambulance or take her to the hospital, she replied Resident #3 just said she wanted to go to the doctor. The Van Driver revealed she then took Resident #3 back out to the van, unloaded the other resident, put her in the van, reloaded the other resident, took the other two residents to their appointments and then headed back to the facility. When the Van Driver was asked if, at any time, she asked two men to assist her, she stated she did not. The Van Driver revealed when she returned to the facility, she took Resident #3 to her room and asked a CNA where her nurse was. When asked what she told the nurse, the Van Driver replied, "I didn't tell the nurse all that." When asked if she was also a CNA, she replied she was, but did not know her certificate number. When asked when was the last time she received any training related to transporting residents, the Van Driver replied it was right after the facility got the van and estimated it had been around six months ago. When asked whether she had any hands-on training that required her to demonstrate how to use the straps, she replied it was with the old van when new equipment had been installed. When asked about her Silverchair training related to the Wheelchair Restraint System, the Van Driver replied the training was related to the use of wheelchair restraints within the facility and had nothing to do with the van. During an interview with Dialysis Center staff on 10/25/12 at 12:27 PM, the Dialysis Nurse stated she remembered 10/15/12 because Resident #3 was supposed to be her patient that day. She stated, "When I came to pick her up in the lobby, her care giver was with her, she was grimacing and complaining of pain." The Dialysis Nurse stated the charge Nurse intercepted at that point and asked Resident #3 if she wanted to go to the hospital, and Resident #3 said "Yes." She revealed she thought the charge Nurse was calling an ambulance. The Dialysis Nurse stated she left Resident #3 with the Charge Nurse, to go back to her patients. She also revealed the Charge Nurse was out of state on vacation and unavailable for interview, but she knew the manager was involved and transferred the call to her. Interview with the Dialysis Manager on 10/25/12 at 12:35 PM revealed she was called and told Resident #3 was refusing dialysis because of pain. The Dialysis Manager stated they called a translator because the resident was upset and began using more of her native language. She said Resident #3 told the translator she "...couldn't even move her leg because the pain was so severe." The Manager revealed she thought Resident #3 had arrived by ambulance transport and would be leaving that way. She stated she left Resident #3 with the Charge Nurse after it was determined she would not have dialysis that day. When asked if she knew what time the incident occurred, the Dialysis Manager stated Resident #3's appointment was at 11:00 AM, and thought they were a little late that day, but nothing was documented so there was no way to know. The undated ADM's typed investigation statement reflected, "Administrator's Summary: Resident (Resident #3) was being transported to an appointment by the facility vehicle. The vehicle hit a bump on the route and the wheelchairs shift. The resident was shifted to the edge of her seat and complained of leg pain. The transportation pulled the vehicle over to assist the resident. The employee unhook the resident's seatbelt in the process of attempting to scoot the resident back in the seat. The resident slipped to the floor. The employee attempted to straighten the resident's leg and the resident complained of more pain. The employee picked up the resident off the floor and continued to the resident's appointment. Resident was unable to complete her appointment because of pain in her leg. The employee returned the resident to the facility after dropping off two other residents to their appointments. The employee reported to the charge nurse a different version of the incident. The employee was suspended pending the investigation. The employee was sent to (name of lab) for post incident drug screen (Results were negative). The administrator went back to the scene of the incident with the witness (Resident #4) to clarify the incident details. Employee interview was conducted. Resident interview was conducted. Employee admitted that she did not tell the truth. Employee resigned during interview." During another interview on 10/25/12 at 11:11 AM, the Administrator revealed during the process of trying to clarify the statements related to the investigation, the Van Driver stated she was going to quit and admitted her version was a lie. The Administrator stated Resident #3 was actually strapped in and the chairs just shifted. He stated after his investigation, he immediately in-serviced the remaining drivers and implemented policies like drivers must call immediately on any incident. LVN U's undated typed statement reflected, "On 10/15/12 I noticed the van driver pushing the WC with the resident (Resident #3) in it. (Resident #3) was screaming as the van driver pushed her into the small living room and then down 300 hall. The van driver later came and got the 300 hall nurse, but I am uncertain what she said." The 10/18/12 typed statement of the ADM's interview with the Business Office Manager reflected, "Business office manager states she was sitting at her desk when employee brought resident (Resident #3) back to the facility. She stated that she heard the resident moaning real loud from her desk as they went by the office door. Business Office Manager stated that employee did not tell her initially what had happened. She stated that she asked the employee what happened to the resident and why was she writing a statement." On 10/25/12 at 11:15, the Administrator asked the Maintenance Supervisor to demonstrate how to properly load and secure a resident onto the van. The maintenance Supervisor pulled the van to the front of the building, the Administrator sat in a wheelchair and the Maintenance Supervisor loaded him onto the van, secured the chair with straps attached to the van then secured the Administrator with seatbelts. The maintenance Supervisor then drove the van around the building with the surveyor on board and demonstrated sudden stops and swerving. The wheelchair and Administrator remained secure at all times. During an interview with the Administrator on 10/25/12 at 1:57 PM, when asked who was currently driving the bus, the Administrator identified the Maintenance Supervisor. He explained the Maintenance Supervisor, Activity Director, Administrative Assistant and Maintenance Assistant were all back-up drivers who had been trained in the event the Van Driver was unavailable. When the Administrator was asked about prior in-services, he stated they had a hands-on inservice back in July as well. During another interview on 10/25/12 at 2:55 PM, the Administrator was asked if the only evidence he had of the Van Driver attending the hands-on inservice in July was the sign-in sheet, he stated it was. When he was told her name was not among the attendees, the Administrator stated, "She was there, I know she was, you can ask her." The Administrator was told the Van Driver said her last hands-on training was with the old van and the new van training was not hands-on. Interview with the Administrative Assistant on 11/02/12 at 11:24 AM revealed she had had a hands-on inservice recently after an incident with Resident #3. She stated she had to strap a staff member in all the way to demonstrate competency. She stated she was taught if any incident occurred with a resident she was to pull over out of harm's way and immediately call for assistance. Interview with the Maintenance Assistant on 11/02/12 at 11:29 AM revealed he had attended a hands-on in-service and was taught how to properly secure a resident in a wheelchair. He stated he was to call immediately if there was ever an issue with a resident during a trip. The facility's current policy "Desoto Nursing and Rehabilitation Policy on Wheelchair Transporting" revised on January 2005 reflected, "...All current and new employees operating vehicles equipped with wheelchair lifts will be properly trained in the operation of the lift and securing the rider and wheelchair properly. Additionally, at least once a year you shall provide refresher training on this topic. This training shall be documented and placed in the employees personnel file. The following is a sample checklist to help in the proper training: ...Securing the Wheelchair ? Wheelchair is facing forward. ? Brakes on both sides are set. ? Power is off on motorized wheelchairs. ? Wheelchair is centered between the anchors on the floor. ? Wheelchair is anchored at 4 points according to manufacturer's instructions. ? Type of front and back straps match. ? Each wheelchair is secured with its own tie-down system. ? Strap hooks are secured to the appropriate positions on front and rear of wheelchair frame. ? Back strap is tightened first. ? Straps are not attached to wheels or detachable parts. ? Straps are not criss-crossed (sic) or twisted. ? Straps do not wrap around objects. ?Straps are secured away from sharp edges and corners..." The facility's current policy "AUTOMOBILE FLEET SAFETY POLICY AND PROCEDURES" revised January 2005 reflected, "SAFE DRIVER TRAINING ? All employees subject to driving on Company business will be provided regularly scheduled safe driver training. The training will be made available to all employees, whenever it can be accommodated in an efficient manner. ? The following safe driver training should include: 1. Defensive driving techniques 2. Inclement weather driving 3. Pedestrian and cyclist safety 4. In-service to include training on the proper operation/use of wheelchair lifts and securing wheelchairs in the vehicles. 5. Security measures for fleet vehicles IN THE EVENT OF AN ACCIDENT ? All vehicle accidents and incidents must be reported to Corporate as soon as possible, but no later than 24 hours after the incident. ?If persons are injured, immediately call for medical assistance...." Review of an "In-Service Training Report" dated 07/07/12 revealed an in-service was provided on "Transportation Procedures." The content included "Proper transport of residents in vehicle - use of safety belt - calling of EMS (Emergency Medical Services) Personnel - notifying of facility staff of incidents occurring of vehicle. Return demonstration done by all van drivers of stopping (sic) a person in wheelchair in facility vehicle. Use of backup safety belts." This in-service was presented by the facility ADM." The Van Driver's name was not listed on the sign in sheet. Review of an "In-Service Training Report" dated 07/12/12 revealed an in-service was provided on "Van Transports - Incidents." The content included: "Any resident that falls or has an injury on the van are to be visually assess by the driver and 911 to be called immediately. DO not move the resident if it is a fall. The nursing home should be notified that 911 was called and where the resident was/will be transported to. Nurse should ensure that 911 was called, what complaints resident has and what is observed by the driver. Documentation should be made in the residents...." This in-service was presented by the facility ADM. The Van Driver's name was not listed on the sign-in sheet. Review of an "In-Service Training Report" dated 10/16/12 revealed an in-service was provided on "Transportation Safety - contacting facility." The content included: "How to safely secure residents in seats and wheelchairs. What to do in event of an accident or incident. When to call facility. When to call 911. Extra seat belt location. Not to move resident from floor. Moving vehicle to safe zone." This in-service was present by the facility ADM. The Van Driver had resigned prior to this in-service. Review of a Certificate of Completion dated 01/01/12 for the Van Driver revealed she attended a Silverchair Training Program titled "Wheelchair Restraint System." A Census List dated 11/02/12 provided by ADON A identified 55 residents who could be transported in a wheelchair in the facility van.

Based on observation, interview, and record review, it was determined the facility to ensure that a resident maintained acceptable parameters of nutritional status, such as body weight for one (Resident #2) of nine residents reviewed for nutrition. Staff failed to update Resident #2's Care Plan to address her full mouth extraction and the possible complications such as not eating and not drinking. Resident #2 weighed 125 pounds prior to the extraction and when she arrived in the ER she weighed 113 pounds. Staff failed to notify the physician and dentist of Resident #2's change in condition. These failures resulted in Resident #2 losing approximately 12 pounds, being dehydrated, having two Stage III pressure ulcers, continuing to have a Urinary Tract Infection, discomfort, having a critical Sodium level, and hospitalization being admitted to the hospital for seven days with intravenous antibiotics. This failure could affect the 79 residents, who could have a procedure which could affect their appetites, by placing them at risk for weight loss, skin breakdown and decline in condition. Findings included: Resident #2 was an [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed Resident #2 was severely impaired cognitively, required extensive assistance of one person for eating, and did not have dental pain, discomfort or difficulty chewing. The MDS assessment also reflected the resident was at risk for developing pressure ulcers, but she did not currently have pressure ulcers. Resident #2's most current Care Plan updated on 08/18/12 reflected, "Problem/Need -Problem Onset: 06/05/12 - Resident has missing teeth. Does not wear dentures. Is at risk for injury/choking. Goal & Target Date - Resident will have no eidence (sic) of mouth pain or inflamed gums go unnoticed or untreated and will have no episodes of choking in the next 90 day. Approaches - Monitor for pain/inflammation of gums. Monitor oral hygiene provision intermittently. Refer to dentist/dental hygienist for evaluation and recommendations. Provided food that resident can chew and swallow without difficulty. Continue appropriate oral hygiene measures." Resident #2's Physician's Telephone Order dated 09/18/12 reflected [MEDICATION NAME] ([MEDICATION NAME]) 5/500 mg every four to six hours as needed for pain after tooth extractions with no refills. The order was for six tablets. Resident #2's Controlled Drug Record for [MEDICATION NAME] 5/500 reflected an order dated 09/18/12 which was for one tablet by mouth every 4 - 6 hours a needed for pain after tooth extractions. The Record also reflected six total doses were signed out as administered to Resident #2. Resident #2's Nurse's Notes dated 09/18/12 at 1:05 PM reflected: "Resident up in chair (with) poor positioning. Fed @ (at) meal times by nurse 100% of meals eaten. Resident put back to bed (after) lunch. Skin warm. Temp 100.2. Does respond to her name being called." The Notes reflected on 09/18/12 at 1:20 PM, "Urine for UA to be collected." Further review of Resident #2's Nurse's Notes dated 09/18/12 at 2:10 PM revealed, "Urine collected for UA/C&S. Urine very cloudy (with) foul odor. Resident tolerated procedure well." Resident #2's Physician's Telephone Order dated 09/22/12 reflected: "1) [MEDICATION NAME] 5/500 (one) po q 6 X 72 hrs 2) Pureed diet, [MEDICATION NAME] Rinse 15 cc rinse X 30 sec (seconds) swish and spit X 1 bottle BID 3) V/S, & monitor 02 sats (oxygen saturation) q2hr X 8 hrs. 4) Change gauze every hr until bleeding stops. 5) No spitting, No smoking, ? use of a straw, ? [MEDICATION NAME] bev (beverage) X 48 hrs." The order was signed as received by LVN G. Resident #2's Dental Progress Notes dated 09/22/12 reflected the resident had "oral surgery"and "local anesthetic." The Notes also reflected she had a full mouth extraction, and she was to have a follow-up in one week. Resident #2's Weekly Head to Toe Skin Assessments dated 05/31/12 through 09/25/12 reflected "Skin intact." Resident #2's Care Plan was last updated on 08/18/12 and did not reflect her full mouth extraction, the complications which could develop, or the interventions. There were no further revisions made to Resident #2's Care Plan. Resident #2's September 2012 MAR indicated [REDACTED]. The scheduled times for administration were 12:00 PM, 6:00 PM, 12:00 AM and 6:00 AM. The following doses were initialed as given: 09/22/12 at 12:00 PM, 09/23/12 at 12:00 AM, and 6:00 AM, 09/24/12 at 12:00 AM and 6:00 AM. No other doses were initialed as given. Resident #2's Nurse's Notes dated 09/22/12 at 10:30 AM revealed: "Dentist here, all teeth extracted. Pain med given as order (one) po q 6 hrs X 72 hrs. Resident in bed. Clear liquid diet served at lunch time. Clear liquid diet to be served @ dinner time and may resume pureed diet tomorrow @ breakfast time." The facility's 24-Hour Report Book (used by nursing staff to relay information from shift to shift) reflected on 09/22/12 Night (10:00 PM to 6:00 AM shift): "Teeth to be extracted today, [MEDICATION NAME] in narcotic drawer for pain." Day (6:00 AM to 2:00 PM shift): "N/O Bactrim (antibiotic) DS (double strength) X 5 days UTI. All teeth extracted [MEDICATION NAME] Q6 X 7 (sic)" Evening (2:00 PM to 6:00 AM shift): "Cont. on abt Bactrim DS X 5 day R/T UTI. ? (no) c/o pain, [MEDICATION NAME] q 6 X 7 (sic) R/T teeth extraction." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "She (Resident #2) was ok until she had her teeth pulled." LVN G stated Resident #2 "normally ate 50 - 100 %, and after her teeth were pulled the resident ate less than 10 %. I would offer her health shakes and water, Ensure (supplement) if she (Resident #2) ate poorly. She would open her mouth and food would run out." LVN G did not recall being at the facility on 09/22/12, when Resident #2 had her teeth extracted, until she reviewed her Nurse's Notes. LVN G revealed, "Oh I was here the Saturday (09/22/12) she (Resident #2) had her teeth pulled. I saw dentist come out. I changed her gauze within a couple of hours. I offered her tap water, she couldn't (drink the water), she was asleep. I figured that's why she wasn't drinking. I crushed one ([MEDICATION NAME]) at noon and attempted to give (it) and it ([MEDICATION NAME]) ran out (of resident's mouth). I don't know how much she got. Resident #2's PRN Flowsheet for [MEDICATION NAME] and Other Medications reflected on 09/23/12 at 12:00 AM her pain scale was "6" out of 10, on a 1-10 scale, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/23/12 at 6:00 AM her pain scale was 5 out of 10, prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. The Flowsheet reflected on 09/24/12 at 12:00 AM her pain scale was "4" out of 10 prior to receiving [MEDICATION NAME] and "1" out of 10 afterward. No other pain assessments were completed. Resident #2's Nurse's Notes dated 09/23/12 at 12:00 AM reflected: "Gauze removed from mouth. ? bleeding. Symptoms of grimacing/pain. [MEDICATION NAME] 5/500 (one) given crush for pain. T (temperature) 99.6. Incont (incontinent) care admin (administered). Is responsive to pain.Per report Bactrim DS started 09/22/12 for UTI." The Notes on 09/23/12 reflected at 1:00 AM the resident was asleep. Further review of the Nurse's Notes dated 09/23/12 revealed at 9:00 AM, "Assessed, stable, repositioned, ? respiratory distress, given mouth wash to wash her mouth R/T extraction of teeth, monitor pain as per order...ABT (Bactrim DS) po 1 tab given as per order..." The 24 Hour Report Book reflected on 09/23/12 Night: "9/22/12 Bactrim DS X 5 days BID 9/22/12 [MEDICATION NAME] q6 X 72 (hours)" Day: "Bactrim DS X 5 days and pain management R/T teeth extraction, stable." Evening: "Abt Bactrim DS X 5 days and pain management R/T teeth extractions." During an interview on 11/02/12 at 10:40 AM, CNA L stated she cared for Resident #2 after her teeth were extracted. She stated "The next day she wouldn't eat nothing, I let the nurse know." When asked how she was drinking, CNA L stated she drank a little but not much. CNA L also stated Resident #2 was drinking using a straw, and she was not given any special instructions regarding the resident's care. She added Resident #2 did appear to be in pain and was really sleepy the day of the procedure. The next day she was still drowsy and the following week was "not herself" and had to be fed. Resident #2's Nurse's Notes dated 09/24/12 at 4:00 AM reflected: "Cont on Bactrim DS BID X 5 days-NARN Routine pain med administered as ordered. Tolerates well...PO fluids encouraged Tolerated well. Incontinent care as needed and call light within reach." The 24 Hour Report Book reflected on 09/24/12 Night: "Abt Bactrim DS BID X 5 days NARN, [MEDICATION NAME]-Acet ([MEDICATION NAME]) Q6 hrs completed R/T tooth extraction." Day: "Cont. Abt/UTI. Monitor food intake" Evening: "Abt.Cont. for UTI" Resident #2's Nurse's Notes dated 09/24/12 for the 2:00 PM to 10:00 PM shift reflected: "Resident asleep most of this shift. Easily aroused but would not eat ...No bleeding from mouth noted. No signs of pain noted." On 10/30/12 at 10:16 AM, Resident #2's dental office was contacted. During an interview the dental office employee confirmed Resident #2 had 17 teeth extracted. When asked about the level of pain that would be expected, the employee replied, "With this many teeth, it can be quite a bit of pain." The Dental Office Employee added the dental surgeon also had to smooth down jagged edges on Resident #2's jaw bone and had to "file her down" in the lower left and right quadrants of her mouth and that would also cause pain. When asked if Resident #2 had a follow-up appointment, the Dental Office Employee stated the office called and spoke with ADON A who told them the resident was "doing fine and eating well." The employee explained they did not make a trip to examine the residents unless they were told something was going on like bleeding. An interview on 10/31/12 at 7:52 AM with ADON A revealed when she saw Resident #2 on 09/24/12, and she was quiet. ADON A stated, "She (Resident #2) usually mumbled. Attributed to pain or teeth being pulled. She used to come up to the desk and want food, she stopped doing that after her teeth were pulled." When asked if she spoke with the dentist's office when they called to follow-up, ADON A replied, "Maybe." She stated she would have told them Resident #2 was fine unless someone told her otherwise. ADON A revealed the Charge Nurses were supposed to notify the physicians "as soon as they notice a change (in condition)." ADON A said, "We (facility) sent her to the ER a few days after her teeth were pulled." Further interview with ADON A on 10/31/12 at 8:30 AM revealed LVN H "jogged her memory", and she had spoken with the dentist's office that day. She was asked, "So you thought she was just fine?" ADON A replied, "Yes." An interview on 10/30/12 at 1:15 PM with LVN G revealed, "Monday (09/24/12) sleeping (Resident #2) most of the day. She would open her eyes and wouldn't answer me. Prior to teeth pulled, she would answer me. I offered her water, it (water) rolled out of her mouth." LVN G was asked if she gave Resident #2 pain medication on Monday, 09/24/12, as ordered, and she replied, "I took the order off (written in the facility's clinical record on 09/22/12). I must have called the pharmacy, maybe it ([MEDICATION NAME]) didn't come in time. I don't remember seeing a bottle of [MEDICATION NAME]. I should have asked about the [MEDICATION NAME] if it wasn't here. I can't say I followed through with the [MEDICATION NAME] from day one." Resident #2's Nurse's Notes dated 09/25/12 for the 10:00 PM to 6:00 AM shift reflected: "Hard to stay asleep. Res in w/c (wheelchair) in front of nurse's station at this time. ? s/s of pain noted." The 24 Hour Report Book reflected on 09/25/12 Night: "Cont Abt Bactrim DS/UTI, monitor food intake, afebrile (no fever) 96.7" Day: "Continue on abt" Evening: "OOFU (out of follow-up, meaning no further follow-up was required for the resident's tooth extractions)" Resident #2's Weekly Head to Toe Skin assessment dated [DATE] reflected, "2 Stage 3" on coccyx." No other descriptions or measurements were documented. The entry was made by LVN G. The 24 Hour Report Book reflected on 09/27/12 Night: "Cont on Bactrim for UTI, NARN" Day: "Bactrim, Appetite good" Evening: "2 Stage 3 to coccyx" During an interview on 10/30/12 at 11:30 AM, the DON was shown LVN G's entry in the 24 Hour Report Book dated 09/27/12 which reflected Resident #2 had two new Stage III pressure ulcers. The DON stated she did not know why these pressure ulcers were not addressed in the stand-up meeting on 09/28/12. The DON asked the Wound Treatment Nurse to join the interview. The Wound Treatment Nurse stated she did not work the following three days after the new pressure ulcers were identified. The DON was asked if she was aware of Resident #2's pressure ulcers and that no treatment was ordered for four days, she replied she was informed on 10/01/12 and had in-serviced the nurses. When asked what the nurse should have done, the DON replied the nurse was supposed to call the physician and read him the facility's protocol for approval. She stated the nurse should assess the wounds, measure them and document her findings. The DON revealed the nurses were to initiate pressure ulcer treatments if the Wound Treatment Nurse was not available. When the Wound Treatment Nurse returned to work, she would reassess and take over. The DON was asked if she was aware of Resident #2's intake after her teeth were extracted, and the DON stated, "I remember she wasn't eating. I noticed a couple of days later (after the extraction) the food was just coming out of her mouth. I thought she had a swallowing problem." An interview on 10/30/12 at 12:00 PM with the Wound Treatment Nurse revealed she ordered Resident #2 an air mattress on 10/01/12 when she learned about the wounds and obtained the treatment orders and supplements. The Wound Treatment Nurse stated Resident #2 never had any skin issues before while in the facility. The 24 Hour Report Book reflected on 10/01/12 Night: "(s) (small) amt of blood noted from rectum. N/O Lab: CBC in AM, occult blood 1. No stool collected- (lab company) notified of lab orders/ (Physician E), need stool specimen X1" Day: "In bed (decreased) appetite" Evening: " cont. (with) (decreased) appetite." Resident #2's CBC results dated 10/02/12 at 4:43 PM reflected her white blood count was 16.8 K/uL (thousands per cubic milliliter). The normal reference range is 4.0-11.0. An elevated white blood count indicates infection. The 24 Hour Report Book reflected on 10/02/12 Night: "Hemoccult stool X 2. Collected ...to lab 10/1/12 x 10/2/12, stable (decreased) appetite" Day: "OK" Evening: "Appetite good to supper, about 90% of meal consumed fed by nurse." Resident #2's Nurse's Notes dated 10/03/12 at 12:00 PM reflected: "Resident lab back call MD, waiting for call back." The Notes on 10/03/12 at 12:45 PM reflected: "Resident continue assisted with meals in dining room on feeding table decrease appetite noted. N/O ST (speech therapy) to eval (evaluate) and treat noted..." The Notes on 10/03/12 at 3:00 PM reflected: "Daughter notified of resident going to hospital." Resident #2's Nurse's Notes dated 10/03/12 at 3:05 PM reflected: "(Ambulance) here to transport resident to (hospital) ER for eval (evaluation) related to (decreased) appetite, lethargy and decrease weight due to not eating related to having all teeth extracted on 09/22/12" An interview on 10/30/12 at 1:15 PM with LVN G revealed, after she reviewed her Nurse's Notes for Resident #2 from 09/22/12 through 10/03/12, when was asked if she called the physician with the change in the resident's condition, she replied, "I think the 6:00 AM to 2:00 PM nurse called the doctor because he called me back." When LVN G was asked what the physician stated, she replied, "I can't say. I don't remember." LVN G was asked if she documented what the physician said, and she replied, "Yes, but I took some medicine and I have not been the same since." An interview on 10/31/12 at 12:10 PM with ADON B revealed he saw Resident #2 the day she went to the hospital (10/03/12), after the nurse told him the resident did not look good. He stated, "I went to look at the resident and said she looked sick. When she came here she was hyper and had falls...she was so sleepy and tired. I asked (LVN H) to send her to the hospital. I then saw the labs (drawn on 10/01/12). Her WBC was real high." When asked when the Charge Nurses call the physicians, ADON B replied, "Anytime with labs, incidents and change in condition (residents)." An interview on 10/30/12 at 3:25 PM with CNA K revealed he worked the 2:00 PM to 10:00 PM shift, and was asked what he remembered about Resident #2. CNA K replied the resident was sleeping a lot, she would eat a little bit but just go back to sleep. When asked how often he offered her fluids, CNA K replied he offered fluids every time he entered her room. When asked whether she would drink for him, CNA K replied, "Yeah. Not a lot. She'd spit it back out." CNA K stated he reported it to his Charge Nurse. CNA K also stated he was not given any special instructions regarding her care. The 24 Hour Report Book reflected on 10/03/12: Night "90%-fed by nurse (2-10) stable, lab result f/u." Day: "appetite, (decreased) weight vs 120/63, 89 call placed to MD" Evening: "Hospital" During an interview on 10/26/12 at 1:34 PM, LVN H was asked whether he had been monitoring Resident #2 to determine whether she was eating and drinking he stated, "That's when we sent her (to the hospital), she was eating but sometimes she wouldn't eat." When asked if he explored why she was not eating, LVN H stated it was because of her teeth. When asked if he notified the physician, he stated he could not remember. He stated Resident #2 was drinking but "not a whole lot." Interview with the Dietary Manager on 10/02/12 at 10:49 AM revealed prior to her tooth extractions, Resident #2 sat at a regular table in the dining room and always fed herself 100% of her meals, The Manager stated she would offer her second helpings, but Resident #2 would refuse. The Dietary Manager stated she was not aware her teeth had been extracted until after she returned from the hospital but she knew "something was off" because she was no longer feeding herself. Resident #2's Resident Weight Record reflected the following weights: 07/09/12 - 125 pounds; 08/13/12 - 124 pounds; 09/20/12 - 125 pounds. Review of the facility "Weight" records provided by the Restorative Aide revealed Resident #3's weights were: 09/06/12 = 125 pounds, 10/10/12 = 112 pounds, 10/17/12 = 110 pounds and 10/24/12 = 117 pounds. Resident #2's Resident Transfer Form dated 10/03/12 for her transfer to the hospital reflected the reason for the transfer was "Res. (resident) had teeth pulled 9/22/12. Has been unable to eat, as usual, weight decreased. See lab report." Resident #2's emergency room Record dated 10/03/12 reflected an admission weight of 113 pounds, and "Patient here with acute [MEDICAL CONDITION] (elevated concentration of Sodium in the bloodstream), low grade temp, UTI and severe dehydration. Will admit for IV antibiotics and hydration." Resident #2's hospital Emergency Department Pt (Patient) Report Lab Results dated 10/03/12 reflected her sodium was "critical" and high at 177 mmol/L. The Reference Range is 135 - 148 mmol/L. Resident #2's Hospital Discharge Summary dated 10/10/12 reflected: "[DIAGNOSES REDACTED]. 2. Escherichia coli urinary tract infection..." Observation on 10/30/12 at 8:40 AM Resident #2's witnessed weight was 117.3 pounds. Resident #2 was placed in a wheelchair, that was always used for weights. On 10/30/12 at 12:43 PM, the DON stated the day Resident #2 went out to the hospital (10/03/12) was the day she saw food falling out of her mouth. When asked if she had been told of her decline in condition before, the DON stated "I noticed she didn't fuss as much as she used to. She had been more verbal." When asked if she knew the level of dehydration Resident #2 had when she arrived at the hospital and that her white blood count was 17,000 the DON replied, "That infection probably came from her teeth (being extracted). That's why she was so lethargic." During an observation on 10/30/12 at 8:00 AM Resident #2 was in the dining room being fed her breakfast. The resident ate 100 %. Review of the Accu-nurse revealed Resident #2 ate 50% for breakfast on 10/30/12. During an interview on 10/30/12 at 10:20 AM the surveyor queried CNA D if she inputted Resident #2's breakfast intake into Accu-nurse for 10/30/12. CNA D stated "I meant to put 25 % not 50%." The surveyor queried how she (CNA D) knew it was 25 % and CNA D stated "That is what she (Resident #2) normally eats. I just know how she eats. No one tells me." The surveyor queried CNA D if she saw Resident #2's finished breakfast tray this morning (10/30/12) and CNA D stated "No." During an interview on 10/30/12 at 10:30 AM the surveyor queried the DON when the CNA's feed the residents' how was the amount recorded into the Accu-nurse and the DON stated the CNA who feeds the resident would enter the amount through her headset (part of Accu-nurse). "She (CNA) can document the amount eaten on any resident, not just her own (residents')." During an interview on 10/30/12 at 11:30 AM the surveyor asked the DON if she was aware of Resident #2's intake after her teeth were extracted and the DON stated, "I remember she wasn't eating. I noticed a couple of days later (after the extraction) the food was just coming out of her mouth. I thought she had a swallowing problem." When asked if she knew which day that was, the DON stated she did not. An interview on 10/30/12 at 3:00 PM with LVN I, it was revealed he was assigned to work on different halls at times. LVN I stated some nurses, including himself, worked extra shifts and were placed where they were needed. He further stated he would switch halls if a resident or family member requested him. Review of an "In-Service Training Report" dated 10/01/12 revealed "Charge nurses that discover or identify a skin issue are to document, notify family and doctor, write orders and initiate treatment per skin protocol, conduct weekly skin assessments head to toe." The facility's undated policy "Pressure Sores" reflected, "...2. The physician will be notified when a decubitus first appears, as well as when the treatment is not effective...4. A resident having pressure sores will receive necessary treatment and services to promote healing, prevent infection and promote new sores from developing." The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 10/25/12 and signed by the Medicare Coordinator reflected a census of 92 residents.

Based on interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. One (Resident #1) of five sampled residents experienced a fall when the siderails on her bed were not in the up position, as ordered by the physician and included in her plan of care. This failure resulted in the resident falling from the bed onto the floor. The resident sustained [REDACTED]. The failure could affect ten residents identified with a recent history of falls. Findings included: Resident #1's quarterly MDS assessment, signed by the RN Assessment Coordinator/DON on 08/10/12, reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected Resident #1's active [DIAGNOSES REDACTED]. Resident #1's MDS assessment reflected the resident had severe cognitive impairment with signs of delirium to include inattention and disorganized thinking. The resident's functional assessment reflected she totally dependent upon the assistance of one person for bed mobility, and she was totally dependent upon the assistance of two people for transfers. In addition, the resident was assessed to have bilateral upper and lower extremity range of motion limitations. Further review revealed the resident had not had any falls prior to or since her admission to the facility. Resident #1's Assessment of Risk for Falls form completed on 08/15/11 reflected she scored a 15, which indicated she was a high risk for falls. A subsequent assessment completed on 11/08/11 reflected she scored an 11, which indicated she was a high risk for falls. Resident #1's August and September 2012 physician's orders [REDACTED]." The order date was 01/24/11. Resident #1's care plan, updated on 08/05/12, reflected she had a potential for falls and/or injuries related to the resident's immobility and wheelchair use. One of the identified approaches care planned was: "...Side rails as ordered...." Resident #1's Interdisciplinary Progress Notes (nurse's note), dated 08/25/12 at 3:30 PM, reflected Resident #1 rolled out of bed onto the floor where a CNA found her. The resident was assessed with [REDACTED]. The note reflected the physician and Responsible Party were notified and an x-ray was ordered. The resident V/S were BP - 133/70; Pulse rate - 78 per minute; Respiratory rate - 18 per minute. An ice pack was applied for 15 minutes and the resident was transferred back to bed. 2) The facility's Provider Investigation Report completed by the DON on 09/06/12 reflected Resident #1 rolled out of bed onto the floor because the resident's siderails were down on 08/25/12 at 3:30 PM. The resident was noted to have a hematoma to her head at the time she was found on the floor. X-rays were ordered on [DATE], but the diagnostic company did not receive the order. On 08/29/12, the resident's family requested that the resident be transferred to the hospital. The report reflected the resident was transferred to the hospital, and she was diagnosed with [REDACTED]. The report reflected facility staff was subsequently inserviced regarding safety. 3) Attached to the Investigation Report was a typed report titled, Interview with (LVN A) by Administrator. The typed report reflected LVN A, Charge Nurse for Resident #1 on 08/25/12, was notified by CNA D that Resident #1 had fallen from the bed onto the floor. LVN A revealed that he and LVN E and LVN F went to the resident's room after being told the resident was on the floor. LVN A stated CNA B was Resident #1's assigned aide. LVN A reported he spoke with both aides (CNA B and CNA C) that had transferred her. LVN A revealed he was not sure of the position height of the bed at the time of the incident. LVN A revealed he notified the physician, the family and the DON. 4) LVN A was interviewed on 09/06/12 at 3:29 PM via telephone regarding Resident #1's incident. He stated he had worked at the facility for two years. He confirmed he was Resident #1's charge nurse on 08/25/12. He stated he worked a double-shift on 08/25/12 and 08/26/12. On 08/25/12, he stated CNA D informed him that Resident #1 was on the floor. He went down to the room to assess the situation, and Resident #1 was on the floor next to her bed. He confirmed the resident's siderail was down at the time of her fall. He stated it appeared as if she had rolled out of bed, and he stated her siderails were supposed to be up. LVN A stated, when he assessed Resident #1, she had a small knot on her forehead at that time. LVN A explained he then called the resident's physician and Responsible Party to notify them of the resident's fall. He stated an x-ray was ordered at that time. He stated he called the radiology company to notify them he would be faxing the order. He then faxed the x-ray order to the radiology company, but he did not do any follow-up on 08/25/12 or 08/26/12 to confirm that the radiology company received the order. 5) Attached to the Investigation Report was a typed report titled, Interview with (CNA D) by Administrator. The report reflected CNA D initially found Resident #1 on the floor. She stated that she was working the front half of the hall and that CNA C was working the back half of the hall. She stated that as she was passing ice, Resident #2 called and beckoned for her to come down the hall. She stated she went to the end of the hall and found Resident #1 on the floor. CNA D revealed she then informed the nurses. She stated that the nurses came down to the room to help the resident. CNA D reported she did not see CNA C, Resident #1's assigned aide, on the hall. 6) CNA D was interviewed on 09/06/12 at 4:19 PM at the facility. She stated she was working on Hall 200 on 08/25/12 when she discovered Resident #1 on the floor. She stated the resident was lying on her right side, and she had a knot to her forehead. She stated she immediately notified the charge nurse. When she discovered the resident on the floor, she stated the siderail next to the wall was up, but the other siderail was down. 7) The Administrator documented an Interview with (Resident #2) on 08/31/12 that reflected Resident #2 saw Resident #1 fall on the floor. Resident #2 reported no employees were in the room at the time of the fall. Resident #2 was able to call for help and a CNA came. 8) A signed, handwritten statement from CNA B, dated 08/31/12, was also attached to the Investigation Report and reflected on the day of the incident, CNA B took Resident #1 from the dining room to her room on Hall 200. "I needed to transfer her from the wheelchair to the bed. I had no one to help because she is a two person lift and therefore I had to wait meanwhile I took the linen cart to the laundry room to stack it with clean linen. Then (CNA C) asked me whether I had the lift and I said yes but I needed help to trasfer (sic, transfer) a resident. She offered to help me and we walked down the hall way to perform the task. She said she was not feeling well and could not control the lift so I said I'll control the lift while she holds the resident. We successfully did the transfer and I took the lift out, and (CNA C) was behind me. I later went to get the linen cart from the laundry room. On my way (at the nursing station) my collegue (sic, colleague) aide on 200 Hall said she found (Resident #1) on the floor. We (I and the nurse) went there and really she was on the floor and rail was down." 9) CNA B was interviewed on 09/06/12 at 5:04 PM via telephone. He stated he worked a double-shift on 08/25/12 from 6:00 AM - 10:00 PM on Hall 200. He confirmed Resident #1 was one of the residents he was responsible for on that day. He stated he needed to transfer Resident #1 back to bed that afternoon, and he could not find the other aide assigned to the hall. He stated he left the Hoyer-lift in the hallway while he went to the linen room to gather supplies. When he was returning to Hall 200, the CNA from Hall 100, CNA B, asked him about using the Hoyer-lift. He stated he asked her if she could help him put Resident #1 back to bed, and she agreed to do this. At that time, the Hoyer-lift indicated it needed a new battery. CNA B stated he got a new battery for the Hoyer-lift, and they transferred the resident to bed. After the transfer, CNA B stated he pulled the Hoyer-lift out of the resident's room. He stated he did not go back into the room at that time because he needed to get the linen cart. He stated CNA C also left the room, and she took the Hoyer-lift to Hall 100. CNA B confirmed Resident #1's siderail was not pulled up at that time. He stated he was informed by CNA D that Resident #1 was on the floor, and he confirmed the siderail was down when the resident rolled out of bed. 10) CNA C was interviewed on 09/06/12 at 2:32 PM via telephone regarding Resident #1's incident. She confirmed she assisted CNA B with transferring Resident #1 from the wheelchair to the bed on the afternoon of 08/25/12. She stated on that date she was working on Hall 100, and she was looking for a Hoyer-lift to transfer one of her residents back to bed. CNA C stated she saw the Hoyer-lift on Hall 200. At that time, she asked CNA B, the Hall 200 CNA, about using the Hoyer-lift. CNA B informed her he needed to transfer Resident #1 back to bed, and he asked her to assist him in transferring Resident #1 to bed using the Hoyer-lift. She agreed to assist him with the transfer because she would be able to use the lift on her resident afterwards. She stated the Hoyer-lift had a message reflecting that the battery needed to be "swapped" so CNA B went and got a different battery to put on the Hoyer-lift. After the battery was exchanged, CNA C stated Resident #1 was transferred from her wheelchair to her bed. Immediately following the transfer, CNA C stated she then left the resident's room with the Hoyer-lift. She stated CNA B was still in the room with Resident #1 when she left the room to return to her hall. She stated she remember him having wipes and a brief with him, at that time, so he could provide Resident #1 for incontinent care. 11) Resident #1's Interdisciplinary Progress Notes, dated 08/29/12 at 10:15 PM, reflected Resident #1's family requested the resident be sent to the ER due to her face being swollen. The physician was notified and the resident was transferred via ambulance at 11:00 PM. 12) Resident #1's Responsible Party was interviewed via telephone on 09/06/12 at 3:11 PM. She stated she was called by LVN A on 08/25/12 and informed that Resident #1 had fallen onto the floor. She stated LVN A told her Resident #1's head hit the side of the dresser during the fall. The Responsible Party stated she came to the facility on [DATE], and observed "a little nick" on Resident #1's forehead. On 08/29/12, she stated she was informed by one of Resident #1's family members that Resident #1 had bruising to her face. Resident #1's Responsible Party stated she came to the facility on [DATE], and Resident #1's face was red and swollen. She stated it looked like she "got beat up in the face." She stated she asked about the x-ray results from 08/25/12, and she was told the results were negative for a fracture. She stated she told the nursing staff she wanted Resident #1 sent to the hospital. When the paramedics arrived at the facility, they requested the x-ray results from 08/25/12. The paramedics were told the x-ray results were negative for fracture, but they were not given the x-ray report. The paramedics then called the radiology company, and they were informed there was no order for an x-ray on 08/25/12. Resident #1's Responsible Party stated the resident was transferred via ambulance to the hospital. At the hospital, she stated Resident #1 was diagnosed with [REDACTED]. 13) Emergency Department Medical Records, time stamped 08/30/12 at 3:56:05 AM, reflected, "[AGE] years old Female PRESENT TO THE EMERGENCY DEPARTMENT WITH closed head injury ... Complaints (1) Closed Head Injury (2) Neck Pain ... UNABLE TO WALK X 1 YR...TO THE ED RE FALL AT THE NH SATURDAY (08/25/12)...HEAD INJURY. NOW HA AND NECK PAIN, NO AMS, NO N/V...." Hospital radiology reports, dated 08/30/12, reflected a CT of the brain was done on 08/30/12 and revealed, "Subtle nondisplaced fracture through the right process transversarium at C2...." Emergency Department Discharge Instructions, dated 08/30/12, reflected, "...STABLE NON-DISPLACED FRACTURE TO R TRANSVERSE PROCESS OF C2. CHIP FRACTURE TO THE TRANSVERSE PROCESS OF THE SECOND CERVICAL VERTEBRA NOT IN THE WEIGHT BEARING STRUCTURE OR THE RING OF THE VERTEBRA RECOMMEND SOFT CERVICAL COLLAR UNTIL SEEN IN FOLLOW UP...." 14) The facility's Incident Log for the time period of 08/06/12 through 09/06/12 was reviewed, and there were ten residents identified as having experienced a fall during that time frame.

Based on observation, interview, and record review it was determined the facility failed to provide care and services in accordance with the facility's policies to prevent neglect for one (Resident #1) of four residents reviewed for neglect. Resident #1 was assessed as being dependent for transfers with the assistance of two persons, utilizing the mechanical (sling-type) lift. Resident #1's leg became lodged in the siderail of her bed on 03/26/12 when only one staff member (CNA B) transferred the resident using the mechanical lift. Resident #1 was sent to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Failure to provide care and services in accordance with the facility's policies to prevent neglect resulted in injury for Resident #1 and could result in injuries affecting all 31 residents who required two-person mechanical-assisted transfers. Findings included: During the facility's Entrance Conference on 04/12/12 at 8:45 a.m. with ADON A and a Medical Records staff member revealed on 03/26/12 CNA B, who was a newly-hired employee, transferred Resident #1 using the mechanical lift without the assistance of another staff member. ADON A revealed the facility's policy was to utilize two staff members for all residents requiring mechanical lift assisted transfers. ADON A stated CNA B and all nursing staff were provided continuing education following the incident. ADON A stated CNA B was currently employed at the facility. She stated CNA B received additional training following the incident regarding the mechanical lift and was determined to demonstrate competence in operating the mechanical lift. During the Entrance Conference it was revealed that Resident #1 was alert, oriented and interviewable. The surveyor requested a listing of all residents currently residing in the facility who utilized the mechanical lift for transfers. On 04/12/12 at 9:00 a.m. the Central Supply staff member revealed there were 31 residents who utilized the mechanical lift. She revealed the facility's policy was to always have two staff members present when residents were transferred with the mechanical lift. The Central Supply staff member stated CNA B was assigned to Hall 300 on 04/12/12. She stated the CNAs were not assigned to the same halls every day, but were scheduled to rotate halls and provide care to all residents. Resident #1 was observed on 04/12/12 at 9:25 a.m. to be lying in bed with a leg brace applied to her right leg. The leg brace extended from the resident's thigh down to her ankle. At this time, Resident #1 revealed CNA B was transferring her from the geri-chair to the bed using the mechanical lift when her leg got caught in the siderail. Resident #1 stated CNA B forgot to lower the siderail and did not have any help. Resident #1 stated she screamed when her leg got caught in the siderail. CNA B dislodged the resident's leg from the siderail, completed the transfer and summoned the nurse. Resident #1 stated she received an x-ray at the facility the same day. The resident stated the nurses were good about giving her pain medication and putting ice on her leg following the incident. She stated when the pain to her leg began to increase in severity, she was sent to the hospital. Observation on 04/12/12 at 9:40 a.m. revealed CNAs D and E transferred Resident #1 from the bed to the geri-chair. Resident #1's lower legs and feet were observed to dangle from the mechanical lift sling. One CNA was observed to operate the mechanical lift while the other CNA guided the resident's leg and feet. Observation revealed Resident #1 was totally dependent and did not actively participate in the transfer process. Upon completion of the transfer Resident #1 stated, "I feel good." Review of Resident #1's most recent MDS assessment dated [DATE] revealed she was admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was assessed as being totally dependent for bed mobility and transfers. Transfer support required as reflected on the MDS assessment was two plus persons for physical assist. According to the MDS assessment Resident #1 was unable to ambulate independently and required the assistance of one person for locomotion. Resident #1 was identified as totally dependent for dressing, toilet use, personal hygiene and bathing, per the MDS assessment. Resident #1 was incontinent of both bowel and bladder according to the MDS assessment. Section Q of the MDS assessment reflected Resident #1 participated in the assessment. Review of a fall risk assessment dated [DATE] for Resident #1 revealed she was identified as non-weight bearing and received maximum assistance with transfers. Review of Resident #1's care plans revealed a care plan dated 03/07/12 regarding a potential for injury related to the use of siderails. There was a care plan dated 03/07/12 which reflected Resident #1 had the potential for falls and/or injuries due to immobility. The care plan reflected, "(Resident #1) uses a geri-chair for mobility. The care plan goal reflected the resident would remain free of falls and/or injuries. Care plan approaches included ensuring the resident was wearing appropriate footwear when ambulating or when up in the wheelchair. A care plan dated 03/07/12 reflected Resident #1 had self-care deficits related to her [DIAGNOSES REDACTED]. There was no plan of care for the usage of the mechanical lift or transfers. Interview on 04/12/12 at 12:25 p.m. with the MDS Coordinator revealed the only additional care plans available for review for Resident #1 were developed when she returned to the facility from the hospital with a Fractured Tibia which addressed pain management and the resident's risk for impaired circulation. Review of the Resident Incident report dated 03/26/12 and timed 1:30 p.m. revealed, "CNA transferring resident to bed, nurse advised res. (resident) foot became lodged in BR (bedrail) and transfer completed. Once res in bed, began complaining of knee pain. Knee assessed, res states pain mainly to knee." The Resident Incident report reflected Resident #1 was alert and oriented to person and place. The documentation reflected the siderails were in the raised position and Resident #1 was dependent for mobility. Both the resident's physician and family member were notified, per the documentation on the Resident Incident Report. LVN C signed and dated the Resident Incident Report on 03/26/12. The DON signed the Resident Incident Report, but the date of her signature was not documented. Review of the Provider Investigation Report signed by the DON and dated 03/30/12 revealed on 03/26/12 at 1:30 p.m. Resident #1 sustained a fracture to the right tibia when being transferred from the geri-chair to the bed with the hoyer lift. It was reflected Resident #1's foot became lodged between the bedrails and the CNA removed the resident's foot and proceeded with the transfer. LVN C assessed Resident #1, noted swelling and contacted the resident's physician who ordered an x-ray. An x-ray was completed on 03/26/12 and reflected it was negative for a fracture. The Provider Investigation Report reflected ice was applied to the resident's leg, pain management measures were taken and and the swelling diminished slightly. When Resident #1 complained of pain on 03/28/12 she was sent to the hospital for further evaluation. The Provider Investigation Report reflected Resident #1 was interviewable and required total assistance for functional ability. The investigation summary as reflected on the Provider Investigation Report reflected CNA B "improperly lowered resident to the bed before noticing when/how the resident's extremities were at the time of the transfer resulting in resident foot being lodged between the rails."The Provider Investigation Report reflected a report was made to DADS on 03/29/12 at 4:00 p.m. Review of the x-ray report dated 03/26/12 and timed 6:00 p.m. revealed two images were obtained of the resident's right knee. The impression as noted on the radiology report reflected, "I don't see an acute displaced fracture on this study. Hand-written documentation on the report reflected the results were faxed to the physician at 10:15 p.m. Review of the hospital radiology report dated 03/28/12 and timed 9:37 p.m. revealed x-rays were completed of the resident's right hip, right knee and right femur secondary to right leg pain. All results were negative for injury or fracture. The hospital radiology report dated 03/28/12 and timed 11:52 p.m. reflected a CT of the resident's lower extremity was positive for "Non-displaced fracturing of the tibial plateau." Review of the nurse's notes dated 03/26/12 through 03/28/12 revealed Resident #1 received pain medication and continual nursing assessment until the resident was sent to the hospital on [DATE]. Interview on 04/12/12 at 10:15 a.m. with CNA F revealed he was a newly-hired employee and had been working at the facility for one to two weeks. CNA F stated during his three-day orientation he was provided instruction regarding fall prevention. CNA F stated he was instructed during orientation to never transfer a resident alone using the mechanical lift. Interview on 04/12/12 at 10:25 a.m. with CNA B revealed on 03/26/12 during the breakfast meal, Resident #1 informed her she had been incontinent of urine. CNA B stated she rolled Resident #1 in the geri-chair to the resident's room. CNA B stated she was focused on providing care and did not ask anyone for assistance. She stated she placed Resident #1 in the mechanical lift without assistance and began transferring the resident from the geri-chair to the bed. CNA B stated she forgot to lower the side rail and Resident #1's leg became lodged in the siderail. CNA B stated the resident screamed. When CNA B saw that Resident #1's leg was caught in the siderail, she (CNA B) dislodged her leg and completed the transfer. CNA B stated after the transfer she immediately informed LVN C about what happened. According to CNA B, LVN C immediately conducted a nursing assessment and applied ice to Resident #1's leg. CNA B stated when she began her employment at the facility on 03/08/12, she was provided with orientation training which included fall prevention. She stated she was made aware during the orientation training process that the facility's policy for all mechanical assisted lifts was to have two nursing staff present during transfers. CNA B stated she felt bad about what happened to Resident #1. CNA B denied there was a shortage of staff and stated she was just focused on making Resident #1 "look nice." Review of CNA B's personnel file revealed she was hired on 03/08/12. Review of CNA B's orientation records revealed she was provided with orientation on 03/08/12 which included fall prevention and resident transfers. Review of facility in-services for February 2012, March 2012 and April 2012 revealed the following: On 03/06/12 an in-service was provided regarding Safe Lift/Transfers/Repositioning. The content of the in-service reflected two staff persons were required for all "hoyer lift" assisted transfers. On 03/29/12 an in-service was provided regarding Proper Transfer and Maintaining Safety. The content of the in-service reflected a video was shown regarding the usage of the facility's specific mechanical lift. The content included the operation of the lift when transferring residents. Review of the sign-in sheet revealed CNA B attended the in-service dated 03/29/12. Interview on 04/12/12 at 11:45 a.m. with the DON revealed the incident was not reported to DADS immediately because CNA B did not "intentionally abuse or neglect" Resident #1. She stated when it was determined on 03/29/12 that Resident #1 sustained a fracture and required medical treatment it became a reportable incident. An interview on 04/12/12 at 1:00 p.m. with the DON revealed she was taking personal leave at the time of the incident on 03/26/12. The DON stated she was not made aware of the incident until 03/29/12 during the facility's daily morning meeting. The DON revealed on the morning of 03/29/12 she learned Resident #1 had been sent to the hospital late 03/28/12 and returned to the facility on [DATE] with a [DIAGNOSES REDACTED].#1 was diagnosed with [REDACTED]. The DON revealed she did not think CNA B was suspended following the incident. Review of the Time Card Report dated 03/25/12 through 03/29/12 revealed CNA B continued to provide care in the facility following the incident of neglect on 03/26/12. It was reflected on the Time Card Report that CNA B worked on 03/27/12 from 5:50 a.m. to 2:00 p.m. The Time Card Report reflected CNA B did not work 03/28/12 and 03/29/12. Interview on 04/12/12 at 12:55 p.m. with ADON A revealed determinations about what incidents were reportable to DADS and when to report incidents were made by the Administrator and DON. ADON A stated the facility's Abuse Prohibition Coordinator was the Administrator and in his absence the DON was the designated Abuse Prohibition Coordinator. She revealed both the Administrator and DON were off work at the time of the incident. Interview on 04/12/12 at 1:40 p.m. with ADON G revealed he worked at the facility on 03/27/12 from 6:00 a.m. to 2:00 p.m. ADON G stated he learned of Resident #1's injury by reviewing the 24-hour report and 72-hour nursing report. ADON G stated he conducted an assessment of Resident #1's right knee and leg on 03/27/12. ADON G stated he did not believe the injury was a result of neglect or abuse and therefore did not report the incident to the DON or to the facility's Administrator who was the facility's Abuse Prohibition Coordinator. ADON G stated CNA B was permitted to continue providing direct resident care following the incident. Interview on 04/12/12 at 1:30 p.m. with the Administrator revealed he was the facility's Abuse Prohibition Coordinator. He stated he was unaware of the incident involving Resident #1 until he was informed by the DON on 03/29/12. In a telephone interview on 04/12/12 at 2:30 p.m. with LVN C revealed CNA B told her (LVN C) what happened on 03/26/12 when she transferred Resident #1. LVN C stated she immediately assessed Resident #1 and reported the incident to ADON A. LVN C stated she did not think it was necessary to report the incident to the Administrator who was the facility's Abuse Prohibition Coordinator. Review of the facility's policy and procedure entitled Lifting Machine, Using a Portable, dated as revised October 2010 and identified as current by the DON revealed, "The purpose of this procedure is to help lift residents using a manual lifting device. 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure." Review of the facility's policy and procedure entitled Safe Lifting and Movement of Residents, dated as revised August 2009 and identified as current by the DON revealed, "In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents...3. Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing status; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities." The Safe Lifting and Movement of Residents policy, dated as revised August 2009 further reflected, "4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices." Review of the facility's Abuse Prohibition Standards of Practice policy with an effective date of June 2005, reviewed 03/22/09 and identified as current by the Administrator revealed, "Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment of [REDACTED]. In their absence, report immediately to the Charge Nurse. This policy applies to incidents occurring anywhere in the facility, on the facility grounds, or away from the facility. The Administrator or the Director of Nursing will initiate the procedure for incident investigation and reporting. 1. The facility's leadership will prohibit neglect, mental or physical abuse...2. The facility's leadership will conduct an investigation of victims of alleged or suspected abuse, neglect or misappropriation of property, and will provide notification and the release of information to the proper authorities, according to federal regulations, state specific rules and regulation, and facility practice guidelines. 3. The facility will designate a qualified staff member as oversight of the abuse prohibition standard." The Abuse Prohibition Standards of Practice policy dated June 2005, reviewed 03/22/09 and identified as current by the Administrator reflected, "Any person who observes or becomes aware of an incident reflected, "All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management...2. The facility maintains that all alleged violations are thoroughly investigated and appropriate actions are taken. 3. Investigations are always prompt, comprehensive and responsive to the situation, well-conducted, and contain founded conclusions...5. The alleged individual of abuse is suspended during the investigation process...10. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Charge Nurse/Supervisor will initiate the investigation surrounding the event; the Charge Nurse/Supervisor will then notify the Administrator (or his/her designee) and the Director of Nurses that the incident has occurred and the investigation is in process. A policy entitled Protection of Residents During Abuse Investigations dated as revised December 2006 and identified as current by the Administrator reflected, "Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. A policy entitled Recognizing Signs and Symptoms of Abuse/Neglect dated as revised December 2006 and identified as current by the Administrator reflected, "Our facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately...2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness...b. Signs of/Actual Physical Neglect:...Inadequate provision of care.." Review of a resident roster dated 04/12/12 reflected 31 residents currently residing in the facility who utilized the mechanical lift for transfers.

Based on observation, interview and record review it was determined the facility failed to implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents for one (Resident #1) of four residents reviewed for neglect. An incident of neglect was not reported immediately to the Administrator of the facility, and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) and residents were not protected from further neglect during the investigation. Resident #1 was assessed as being dependent for transfers with the assistance of two persons, utilizing the mechanical (sling-type) lift. On 03/26/12 Resident #1's leg became lodged in the siderail of her bed when only one staff member (CNA B) transferred the resident using the mechanical lift. Resident #1 was sent to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #1's injury was not reported to the Administrator of the facility or to the State survey and certification agency until 03/29/12. CNA B continued to work in the facility following the incident of neglect, prior to receiving additional training in utilizing the mechanical lift. The failure to ensure an incident of neglect was immediately reported to the Administrator and to the State survey and certification agency and to ensure residents were protected during the investigation placed 31 residents who required two-person mechanical-assisted transfers at risk for further potential neglect resulting in injuries. Findings included: Review of the facility's Abuse Prohibition Standards of Practice policy with an effective date of June 2005, reviewed 03/22/09 and identified as current by the Administrator revealed, "Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment of [REDACTED]. In their absence, report immediately to the Charge Nurse. This policy applies to incidents occurring anywhere in the facility, on the facility grounds, or away from the facility. The Administrator or the Director of Nursing will initiate the procedure for incident investigation and reporting. 1. The facility's leadership will prohibit neglect, mental or physical abuse...2. The facility's leadership will conduct an investigation of victims of alleged or suspected abuse, neglect or misappropriation of property, and will provide notification and the release of information to the proper authorities, according to federal regulations, state specific rules and regulation, and facility practice guidelines. 3. The facility will designate a qualified staff member as oversight of the abuse prohibition standard." The Abuse Prohibition Standards of Practice policy dated June 2005, reviewed 03/22/09 and identified as current by the Administrator reflected, "Any person who observes or becomes aware of an incident reflected, "All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management...2. The facility maintains that all alleged violations are thoroughly investigated and appropriate actions are taken. 3. Investigations are always prompt, comprehensive and responsive to the situation, well-conducted, and contain founded conclusions...5. The alleged individual of abuse is suspended during the investigation process...10. Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the Charge Nurse/Supervisor will initiate the investigation surrounding the event; the Charge Nurse/Supervisor will then notify the Administrator (or his/her designee) and the Director of Nurses that the incident has occurred and the investigation is in process. A policy entitled Protection of Residents During Abuse Investigations dated as revised December 2006 and identified as current by the Administrator reflected, "Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measures: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. A policy entitled Recognizing Signs and Symptoms of Abuse/Neglect dated as revised December 2006 and identified as current by the Administrator reflected, "Our facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately...2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness...b. Signs of/Actual Physical Neglect:...Inadequate provision of care.." During the facility's Entrance Conference on 04/12/12 at 8:45 a.m. with ADON A and a Medical Records staff member revealed on 03/26/12 CNA B, who was a newly-hired employee, transferred Resident #1 using the mechanical lift without the assistance of another staff member. ADON A revealed the facility's policy was to utilize two staff members for all residents requiring mechanical lift assisted transfers. ADON A stated CNA B and all nursing staff were provided continuing education following the incident. ADON A stated CNA B was currently employed at the facility. She stated CNA B received additional training following the incident regarding the mechanical lift and was determined to demonstrate competence in operating the mechanical lift. During the Entrance Conference it was revealed that Resident #1 was alert, oriented and interviewable. The surveyor requested a listing of all residents currently residing in the facility who utilized the mechanical lift for transfers. On 04/12/12 at 9:00 a.m., the Central Supply staff member revealed there were 31 residents who utilized the mechanical lift. She revealed the facility's policy was to always have two staff members present when residents were transferred with the mechanical lift. The Central Supply staff member stated CNA B was assigned to Hall 300 on 04/12/12. She stated the CNAs were not assigned to the same halls every day, but were scheduled to rotate halls and provide care to all residents. Resident #1 was observed on 04/12/12 at 9:25 a.m. to be lying in bed with a leg brace applied to her right leg. The leg brace extended from the resident's thigh down to her ankle. At this time, Resident #1 revealed CNA B was transferring her from the geri-chair to the bed using the mechanical lift when her leg got caught in the siderail. Resident #1 stated CNA B forgot to lower the siderail and did not have any help. Resident #1 stated she screamed when her leg got caught in the siderail. CNA B dislodged the resident's leg from the siderail, completed the transfer and summoned the nurse. Resident #1 stated she received an x-ray at the facility the same day. The resident stated the nurses were good about giving her pain medication and putting ice on her leg following the incident. She stated when the pain to her leg began to increase in severity she was sent to the hospital. Review of Resident #1's most recent MDS assessment dated [DATE] revealed she was admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was assessed as being totally dependent for bed mobility and transfers. Transfer support required as reflected on the MDS assessment was two plus persons for physical assist. According to the MDS assessment Resident #1 was unable to ambulate independently and required the assistance of one person for locomotion. Resident #1 was identified as totally dependent for dressing, toilet use, personal hygiene and bathing, per the MDS assessment. Resident #1 was incontinent of both bowel and bladder according to the MDS assessment. Section Q of the MDS assessment reflected Resident #1 participated in the assessment. Review of a fall risk assessment dated [DATE] for Resident #1 revealed she was identified as non-weight bearing and received maximum assistance with transfers. Review of the Resident Incident Report dated 03/26/12 and timed 1:30 p.m. revealed, "CNA transferring resident to bed, nurse advised res. (resident) foot became lodged in BR (bedrail) and transfer completed. Once res in bed, began complaining of knee pain. Knee assessed, res states pain mainly to knee." The Resident Incident report reflected Resident #1 was alert and oriented to person and place. The documentation reflected the siderails were in the raised position and Resident #1 was dependent for mobility. Both the resident's physician and family member were notified, per the documentation on the Resident Incident Report. LVN C signed and dated the Resident Incident Report on 03/26/12. The DON signed the Resident Incident Report, but the date of her signature was not documented. Review of the Provider Investigation Report signed by the DON and dated 03/30/12 revealed on 03/26/12 at 1:30 p.m. Resident #1 sustained a fracture to the right tibia when being transferred from the geri-chair to the bed with the hoyer lift. It was reflected Resident #1's foot became lodged between the bedrails and the CNA removed the resident's foot and proceeded with the transfer. LVN C assessed Resident #1, noted swelling and contacted the resident's physician who ordered an x-ray. An x-ray was completed on 03/26/12 and reflected it was negative for a fracture. The Provider Investigation Report reflected ice was applied to the resident's leg, pain management measures were taken and and the swelling diminished slightly. When Resident #1 complained of pain on 03/28/12, she was sent to the hospital for further evaluation. The Provider Investigation Report reflected Resident #1 was interviewable and required total assistance for functional ability. The investigation summary as reflected on the Provider Investigation Report reflected CNA B "improperly lowered resident to the bed before noticing when/how the resident's extremities were at the time of the transfer resulting in resident foot being lodged between the rails."The Provider Investigation Report reflected a report was made to DADS on 03/29/12 at 4:00 p.m. Review of the x-ray report dated 03/26/12 and timed 6:00 p.m. revealed two images were obtained of the resident's right knee. The impression reflected on the radiology report reflected, "I don't see an acute displaced fracture on this study. Hand-written documentation on the report reflected the results were faxed to the physician at 10:15 p.m. Review of the hospital radiology report dated 03/28/12 and timed 9:37 p.m. revealed x-rays were completed of the resident's right hip, right knee and right femur secondary to right leg pain. All results were negative for injury or fracture. The hospital radiology report dated 03/28/12 and timed 11:52 p.m. revealed a CT of the resident's lower extremity was positive for "Non-displaced fracturing of the tibial plateau." Review of the nurse's notes dated 03/26/12 through 03/28/12 revealed Resident #1 received pain medication and continual nursing assessment until the resident was sent to the hospital on [DATE]. Interview on 04/12/12 at 10:25 a.m. with CNA B revealed on 03/26/12 during the breakfast meal, Resident #1 informed her she had been incontinent of urine. CNA B stated she rolled Resident #1 in the geri-chair to the resident's room. CNA B stated she was focused on providing care and did not ask anyone for assistance. She stated she placed Resident #1 in the mechanical lift without assistance and began transferring the resident from the geri-chair to the bed. CNA B stated she forgot to lower the side rail and Resident #1's leg became lodged in the siderail. CNA B stated the resident screamed. When CNA B saw that Resident #1's leg was caught in the siderail, she (CNA B) dislodged her leg and completed the transfer. CNA B stated after the transfer she immediately informed LVN C about what happened. According to CNA B, LVN C immediately conducted a nursing assessment and applied ice to Resident #1's leg. CNA B stated when she began her employment at the facility on 03/08/12 she was provided with orientation training which included fall prevention. She stated she was made aware during the orientation training process that the facility's policy for all mechanical assisted lifts was to have two nursing staff present during transfers. CNA B stated she felt bad about what happened to Resident #1. CNA B denied there was a shortage of staff and stated she was just focused on making Resident #1 "look nice." Review of CNA B's personnel file revealed she was hired on 03/08/12. Review of CNA B's orientation records revealed she was provided with orientation on 03/08/12 which included fall prevention and resident transfers. Review of facility in-services for February 2012, March 2012 and April 2012 revealed the following: On 03/06/12 an in-service was provided regarding Safe Lift/Transfers/Repositioning. The content of the in-service reflected two staff persons were required for all "hoyer lift" assisted transfers. On 03/29/12 an in-service was provided regarding Proper Transfer and Maintaining Safety. The content of the in-service reflected a video was shown regarding the usage of the facility's specific mechanical lift. The content included the operation of the lift when transferring residents. Review of the sign-in sheet revealed CNA B attended the in-service dated 03/29/12. Interview on 04/12/12 at 11:45 a.m. with the DON revealed the incident was not reported to DADS immediately because CNA B did not "intentionally abuse or neglect" Resident #1. She stated when it was determined on 03/29/12 that Resident #1 sustained a fracture and required medical treatment it became a reportable incident. An interview on 04/12/12 at 1:00 p.m. revealed she was taking personal leave at the time of the incident on 03/26/12. The DON stated she was not made aware of the incident until 03/29/12 during the facility's daily morning meeting. The DON revealed on the morning of 03/29/12 she learned Resident #1 had been sent to the hospital late on 03/28/12 and returned to the facility on [DATE] with a [DIAGNOSES REDACTED].#1 was diagnosed with [REDACTED]. The DON revealed she did not think CNA B was suspended following the incident. Review of the Time Card Report dated 03/25/12 through 03/29/12 revealed CNA B continued to provide care in the facility following the incident of neglect on 03/26/12. It was reflected on the Time Card Report that CNA B worked on 03/27/12 from 5:50 a.m. to 2:00 p.m. The Time Card Report reflected CNA B did not work on 03/28/12 and 03/29/12. Interview on 04/12/12 at 12:55 p.m. with ADON A revealed determinations about what incidents were reportable to DADS and when to report incidents were made by the Administrator and DON. ADON A stated the facility's Abuse Prohibition Coordinator was the Administrator and in his absence the DON was the designated Abuse Prohibition Coordinator. She revealed both the Administrator and DON were off work at the time of the incident. Interview on 04/12/12 at 1:40 p.m. with ADON G revealed he worked at the facility on 03/27/12 from 6:00 a.m. to 2:00 p.m. ADON G stated he learned of Resident #1's injury by reviewing the 24-hour report and 72-hour nursing report. ADON G stated he conducted an assessment of Resident #1's right knee and leg on 03/27/12. ADON G stated he did not believe the injury was a result of neglect or abuse and therefore did not report the incident to the DON or to the facility's Administrator who was the facility's Abuse Prohibition Coordinator. ADON G stated CNA B was permitted to continue providing direct resident care following the incident. Interview on 04/12/12 at 1:30 p.m. with the Administrator revealed he was the facility's Abuse Prohibition Coordinator. He stated he was unaware of the incident involving Resident #1 until he was informed by the DON on 03/29/12. Telephone interview on 04/12/12 at 2:30 p.m. with LVN C revealed CNA B told her (LVN C) what happened on 03/26/12 when she transferred Resident #1. LVN C stated she immediately assessed Resident #1 and reported the incident to ADON A. LVN C stated she did not think it was necessary to report the incident to the Administrator who was the facility's Abuse Prohibition Coordinator. Review of a resident roster dated 04/12/12 reflected 31 residents currently residing in the facility who utilized the mechanical lift for transfers.

Based on observation, interview and record review, it was determined the facility failed to ensure one of (Resident #1) four residents reviewed for falls. The facility failed to accurately assess Resident #1 for fracture, failed to read the X-ray report correctly and failed to transfer Resident #1 in a timely manner for treatment of [REDACTED].#1 was sent to the hospital for treatment. This deficient practice caused a delay in medical intervention and treatment for [REDACTED]. This deficient practice could also affect the additional 84 facility residents, including Resident #1, who were at risk for falls. Findings included: 1) The surveyor observed Resident #1 during rounds on 09/14/11 at 9:30 a.m. Licensed Vocational Nurse (LVN) A stated Resident #1 was alert and oriented to person only, was confused, was incontinent of bowel and bladder, used a Geri chair and required total assistance with all his activity of daily living (ADLs) needs. LVN A stated Resident #1 was easily agitated, required assistance with feeding and was on hospice care service due to End Stage [MEDICAL CONDITION]. He was a fall risk and family visited frequently. The surveyor observed Resident #1 asleep in a low bed with the side rails elevated and padded. The surveyor also observed Resident #1 had a cast on his left foot. Review of Resident #1's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed [DIAGNOSES REDACTED]. Review of the care plan dated 09/05/11 completed by Registered Nurse (RN) B revealed Resident #1 had an unwitnessed fall with no injury from attempting to transfer self. Review of the Interdisciplinary Note for Unusual Occurrence dated 09/05/11 at 3:40 p.m. revealed Resident #1 was sitting upright on the floor with the left leg bent backward. No further assessment of the leg was documented. Review of the Follow-Up Disposition attached to the above Interdisciplinary Note reflected the description of injury was "fall." There was an assessment date of 09/06/11 at 12:00 a.m. with vital signs only. The comment included "Resting in bed with eyes closed no s/s (signs/symptoms) of pain or resp (respiratory) distress." Under the above assessment, was another assessment dated [DATE] at 7:00 a.m. with vital signs. The comment reflected Resident #1 complained of pain to "(L) BLE Med Adm (sic)." Resident #1 was sent to the hospital for further evaluation. Review of the nurse's notes revealed there was no entry for 09/05/11. The note dated 09/06/11 reflected Resident #1 was sent to a nearby hospital emergency room for "further evaluation d/t (due to) fall." A late entry note for 7:30 a.m. on 09/06/11 reflected the physician reviewed the X-ray results and the resident was sent to the hospital for evaluation. Review of a Neurological Assessment Flowsheet dated 09/05/11 for Resident #1 revealed a neurological assessment was started at 4:00 p.m. and ended at 10:30 p.m. on 09/05/11. There was no documented assessment of the left leg for pain, bruising and/or disfigurement. There was also no further documentation of assessments past 10:30 p.m. on 09/05/11. Review of a physician's telephone order dated 09/05/11 for Resident #1 revealed, "Bil (bilateral) hip, femur (L) knee." Review of the "Resident transfer form" dated 09/06/11, (no time documented) revealed pain was assessed before transfer to the hospital at a level or scale of 9 of 10. The vital signs at this time reflected the blood pressure was 155/99 (normal blood pressure was 120/80). There was a handwritten notation on the bottom of the form, under "Pain Assessment" that reflected, "[MEDICATION NAME] 0.5 ml adm @6:45 a.m." Review of the nurse's note dated 09/06/11 at 9:05 a.m., revealed pain medications (the name of the medication was not documented) was given at 6:45 a.m. and [MEDICATION NAME] was given at 8:40 a.m. Review of an X-ray report for Resident #1 dated 09/05/11 revealed a report of the "Left Femur." Under "history" was, "Pain." The report reflected on the findings (1) Acute appearing mildly displaced [MEDICATION NAME] fractures through the proximal Tibia and Fibular Metaphyses. (2) Questionable age indeterminate non displaced subtrochanteric fracture (3) Chronic appearing fracture deformity of the distal femoral diaphysis (4) ORIF (Open Reduction Internal Fixation) of the left femur using an IM (sic)nail and dynamic screw. IMPRESSION... A chronic appearing fracture deformity of the distal femoral diaphysis is present. A questionable age indeterminate subtrochanteric fracture is seen. Acute appearing mildly displaced mostly [MEDICATION NAME] fracture through the proximal Tibia and Fibular Metaphyses are also seen. Review of another Interdisciplinary Note for an Unusual Occurrence dated 08/22/11 at 5:40 p.m. revealed Resident #1 was found on the floor with half side rails up and bed in low position. The unusual occurrence form reflected no further assessment of the resident after the fall. The nurse's note dated 08/22/11 at 5:40 p.m. revealed Resident #1 was "noted with incident. Confusion and agitation noted." There was no further assessment or documentation of the resident's status from 5:40 p.m. on 08/22/11 to 1:40 a.m. on 08/23/11. Review of the hospital emergency records dated 09/06/11 at 4:17 p.m. for Resident #1, revealed the X-ray report was read by the emergency physician as "new tib (tibia) and fib (fibular) fx (fracture)." The surveyor interviewed the facility Director of Nurses (DON) on 09/14/11 at 12:29 p.m. The interview revealed staff did not document issues concerning falls, accidents and/or injuries in the nurses notes. Staff was to document on the Interdisciplinary Note for Unusual Occurrence any falls or accidents in the facility. The surveyor showed the DON the documentation on the unusual occurrence report, that did not show an assessment of the resident post fall. The DON stated during this interview that staff was to document about the injury site, vital signs, pain and anything that pertained to the injured site. RN B was interviewed on 09/14/11 at 2:14 p.m. The interview revealed Resident #1 was confused and disoriented to time and place. Resident #1 fell during her shift on 09/05/11 at 3:40 p.m. Resident #1 was last seen asleep in his Geri chair. The Certified Nurse Aide (CNA) called out to RN B and when she entered his room she saw Resident #1 had slid out of his Geri chair. His (left) leg was backwards under him and the (right) leg was straight forward in front of him. Resident #1 was sitting on his left leg. She obtained his vital signs and with assistance moved him to the bed. RN B stated his vital signs were okay, so she ordered an X-ray, notified hospice staff of the fall, notified the family and attempted calling the physician, but he did not return her call and she forgot to call him again. RN B stated during this interview that when the X-ray report result came to the facility at approximately 10:00 p.m. she read the bottom part of the result but she over looked the top part of the X-ray report. The interview also revealed the physician came in on 09/06/11 at 7:30 a.m. for his regular facility visit, found the X-ray report and ordered Resident #1 be sent to the emergency room for evaluation and treatment. In addition, RN B stated Resident #1 did not complain of pain because she had given him a sleeping pill for the night. She did not assess the extremity because the left foot was turned outward and was always swollen. She did not perform range of motion because of the Left Leg Paralysis, Contractures and all her assessment was documented in the incident report. The surveyor informed the nurse that the incident report did not have any documented assessment for Resident #1. RN B did not respond when told the document did not reflect an assessment from her. Furthermore, RN B reported to the oncoming nurse to follow-up with Resident #1's fall. The surveyor asked RN B what the night shift nurse was to follow-up on. RN B stated she was to notify the day shift to contact the physician and to inform him Resident #1 had a fall. RN B stated she did not know Resident #1 had a fracture at that time and thus did not ask the night shift staff to call the physician to obtain transfer orders for treatment of [REDACTED]. The current facility undated policy "Incident and Accident Report and Follow-Up Disposition Forms" reflected "Time Notified- the actual time the initial call was placed. If an answering service is involved when there is suspected injury, the facility should place as many additional calls as necessary to obtain a response from the physician or their partner taking call. DO NOT place a single call and forget it. The facility has a responsibility to ensure the physician is aware as soon as possible to allow medical attention to be provided promptly...Complete on ALL Incidents: It is very important that all blanks be filled with the pertinent information....." Interview on 09/15/11 at 10:10 a.m. with the DON revealed the facility had assessed and identified 84 residents in the facility to be at a high risk for falls. The Form CMS-672 (Resident Census and Conditions of Residents) dated 09/15/11 and signed by the DON reflected a total census of 93 residents. Interview on 09/15/11 at 10:10 a.m. with the DON revealed the facility had assessed and identified 84 residents in the facility to be at a high risk for falls.

Based on observation, interview and record review, the facility failed to immediately consult the physician for one (Resident #1) of four residents reviewed for falls when the resident fell out of his Geri chair and sustained a fractured tibia and femur. 1. The facility staff failed to assess Resident #1 for pain and injury after a fall on 09/05/11 at 3:40 p.m., he was given a sleeping medication and it was not until 6:45 a.m. on 09/06/11 that he complained of pain and was given [MEDICATION NAME] 0.5 ml and at 8:40 a.m. less than two hours of pain medication administration Resident #1 was calling out again for pain at a pain level of 9 of 10. He was given [MEDICATION NAME] at this time. 2. The resident's physician was not notified after the fall on 09/05/11 at 3:40 p.m. The physician visited the facility for his routine rounds on 09/06/11 at 7:30 a.m. when he found and reviewed the X-ray report for Resident #1. The physician ordered Resident #1 be transferred to an emergency room for evaluation and treatment. Treatment was not sought for Resident #1 until 17 1/2 hours post fall with fracture. This deficient practice caused a delay in medical intervention and treatment for [REDACTED]. This deficient practice could also affect the additional 84 facility residents, including Resident #1, who were at risk for falls. Findings included: The surveyor observed Resident #1 during rounds on 09/14/11 at 9:30 a.m. Licensed Vocational Nurse (LVN) A stated Resident #1 was alert and oriented to person only, was confused, was incontinent of bowel and bladder, used a Geri chair and required total assistance with all his activity of daily living (ADLs) needs. LVN A stated Resident #1 was easily agitated, required assistance with feeding and was on hospice care service due to End Stage [MEDICAL CONDITION]. He was a fall risk and family visited frequently. The surveyor observed Resident #1 asleep in a low bed with the side rails elevated and padded. The surveyor also observed Resident #1 had a cast on his left foot. Review of Resident #1's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed [DIAGNOSES REDACTED]. Review of the Interdisciplinary Note for Unusual Occurrence dated 09/05/11 at 3:40 p.m. revealed Resident #1 was sitting upright on the floor with the left leg bent backward. No further assessment of the leg was documented. Review of the Follow-Up Disposition attached to the above Interdisciplinary Note reflected the description of injury was "fall." There was an assessment date of 09/06/11 at 12:00 a.m. with vital signs only. The comment included "Resting in bed with eyes closed no s/s (signs/symptoms) of pain or resp (respiratory) distress." Under the above assessment, was another assessment dated [DATE] at 7:00 a.m. with vital signs. The comment reflected Resident #1 complained of pain to "(L) BLE Med Adm (sic)." Resident #1 was sent to the hospital for further evaluation. Review of the nurse's notes revealed there was no entry for 09/05/11. The note dated 09/06/11 reflected Resident #1 was sent to a nearby hospital emergency room for "further evaluation d/t (due to) fall." A late entry note for 7:30 a.m. on 09/06/11 reflected the physician reviewed the X-ray results and the resident was sent to the hospital for evaluation. Review of a Neurological Assessment Flowsheet dated 09/05/11 for Resident #1 revealed a neurological assessment was started at 4:00 p.m. and ended at 10:30 p.m. on 09/05/11. There was no documented assessment of the left leg for pain, bruising and/or disfigurement. There was also no further documentation of assessments past 10:30 p.m. on 09/05/11. Review of a physician's telephone order dated 09/05/11 for Resident #1 revealed, "Bil (bilateral) hip, femur (L) knee." Review of an X-ray report for Resident #1 dated 09/05/11 revealed a report of the "Left Femur." Under "history" was, "Pain." The report reflected on the findings "(1) Acute appearing mildly displaced [MEDICATION NAME] fractures through the proximal Tibia and Fibular Metaphyses. (2) Questionable age indeterminate non displaced subtrochanteric fracture (3) Chronic appearing fracture deformity of the distal femoral diaphysis (4) ORIF (Open Reduction Internal Fixation) of the left femur using an IM (sic)nail and dynamic screw. IMPRESSION ... ... ... A chronic appearing fracture deformity of the distal femoral diaphysis is present. A questionable age indeterminate subtrochanteric fracture is seen. Acute appearing mildly displaced mostly [MEDICATION NAME] fracture through the proximal Tibia and Fibular Metaphyses are also seen." Review of another Interdisciplinary Note for an Unusual Occurrence dated 08/22/11 at 5:40 p.m. revealed Resident #1 was found on the floor with half side rails up and bed in low position. The unusual occurrence form reflected no further assessment of the resident after the fall. The nurse's note dated 08/22/11 at 5:40 p.m. revealed Resident #1 was "noted with incident. Confusion and agitation noted." There was no further assessment or documentation of the resident's status from 5:40 p.m. on 08/22/11 to 1:40 a.m. on 08/23/11. Review of the care plan dated 09/05/11 completed by Registered Nurse (RN) B revealed Resident #1 had an unwitnessed fall with no injury from attempting to transfer self. Review of the "Resident transfer form" dated 09/06/11, (no time documented) revealed pain was assessed before transfer to the hospital at a level or scale of 9 of 10. The vital signs at this time reflected the blood pressure was 155/99 (normal blood pressure was 120/80). There was a handwritten notation on the bottom of the form, under "Pain Assessment" that reflected, "[MEDICATION NAME] 0.5 ml adm @6:45 a.m." Review of the nurse's note dated 09/06/11 at 9:05 a.m., revealed pain medications (the name of the medication was not documented) was given at 6:45 a.m. and [MEDICATION NAME] was given at 8:40 a.m. Review of the hospital emergency records dated 09/06/11 at 4:17 p.m. for Resident #1, revealed the X-ray report was read by the emergency physician as "new tib (tibia) and fib (fibular) fx (fracture)." The surveyor interviewed the facility Director of Nurses (DON) on 09/14/11 at 12:29 p.m. The interview revealed staff did not document issues concerning falls, accidents and/or injuries in the nurses notes. Staff was to document on the Interdisciplinary Note for Unusual Occurrence any falls or accidents in the facility. The surveyor showed the DON the documentation on the unusual occurrence report, that did not show an assessment of the resident post fall. The DON stated during this interview that staff was to document about the injury site, vital signs, pain and anything that pertained to the injured site. RN B was interviewed on 09/14/11 at 2:14 p.m. The interview revealed Resident #1 was confused and disoriented to time and place. Resident #1 fell during her shift on 09/05/11 at 3:40 p.m. Resident #1 was last seen asleep in his Geri chair. The Certified Nurse Aide (CNA) called out to RN B and when she entered his room she saw Resident #1 had slid out of his Geri chair. His (left) leg was backwards under him and the (right) leg was straight forward in front of him. Resident #1 was sitting on his left leg. She obtained his vital signs and with assistance moved him to the bed. RN B stated his vital signs were okay, so she ordered an X-ray, notified hospice staff of the fall, notified the family and attempted calling the physician, but he did not return her call and she forgot to call him again. RN B stated during this interview that when the X-ray report result came to the facility at approximately 10:00 p.m. she read the bottom part of the result but she over looked the top part of the X-ray report. The interview also revealed the physician came in on 09/06/11 at 7:30 a.m. for his regular facility visit, found the X-ray report and ordered Resident #1 be sent to the emergency room for evaluation and treatment. In addition, RN B stated Resident #1 did not complain of pain because she had given him a sleeping pill for the night. She did not assess the extremity because the left foot was turned outward and was always swollen. She did not perform range of motion because of the Left Leg Paralysis, Contractures and all her assessment was documented in the incident report. The surveyor informed the nurse that the incident report did not have any documented assessment for Resident #1. RN B did not respond when told the document did not reflect an assessment from her. Furthermore, RN B reported to the oncoming nurse to follow-up with Resident #1's fall. The surveyor asked RN B what the night shift nurse was to follow-up on. RN B stated she was to notify the day shift to contact the physician and to inform him Resident #1 had a fall. RN B stated she did not know Resident #1 had a fracture at that time and thus did not ask the night shift staff to call the physician to obtain transfer orders for treatment of [REDACTED]. The current facility undated policy "Incident and Accident Report and Follow-Up Disposition Forms" reflected "Time Notified- the actual time the initial call was placed. If an answering service is involved when there is suspected injury, the facility should place as many additional calls as necessary to obtain a response from the physician or their partner taking call. DO NOT place a single call and forget it. The facility has a responsibility to ensure the physician is aware as soon as possible to allow medical attention to be provided promptly." The Form CMS-672 (Resident Census and Conditions of Residents) dated 09/15/11 and signed by the DON reflected a total census of 93 residents. Interview on 09/15/11 at 10:10 a.m. with the DON revealed the facility had assessed and identified 84 residents in the facility to be at a high risk for falls.