Every finding on record at Eaglecrest Nursing and Rehab

Based on observation, interview and record review, the facility failed to ensure nail care was provided for 1 (Resident #37) sampled resident on the 200 Hall who was dependent on staff for nail care. The findings are: Resident #37 had a diagnosis of Dementia. A Quarterly Minimum Data Set (QMDS) with an Assessment Review Date (ARD) of 11/16/23 documented a Brief Interview for Mental Status (BIMS) score of 4 (0-7 severe cognitive impairment) and required substantial/maximal assistance with bathing and partial/moderate assistance with personal hygiene. A Care Plan with an initiated date of 2/27/23 documented, .[name] has an ADL self-care performance deficit r/t [related to] Impaired balance . Personal Hygiene: The resident requires limited-extensive assistance) by (X) staff with personal hygiene and oral care . The Care Plan did not address nail care. On 12/10/23 at 12:47 PM Resident #37 was sitting up on the side of the bed eating lunch. The Surveyor observed the fingernails on both hands were 1/4 - 1/2 inch in length past the fingertips with a brown substance visible underneath the nails. Both thumbnails were 3/4 inches past the fingertips. The right thumbnail was curving in on the left edge and digging into Resident #37's skin. On 12/11/23 at 04:20 PM, Resident #37 was lying in bed awake. The fingernails on both hands remained the same length and had jagged edges and pointed corners. There was a dark brown substance visible under the fingernails. On 12/12/23 at 10:29 AM, Resident #37 was lying in bed. The fingernails on both hands remained 1/4 - 1/2 inches in length past the fingertips, varying in length with some jagged edges, and pointed corners. There was a medium to dark brown substance visible under the fingernails. The right thumbnail was curving in on the left edge and digging into Resident #37's skin. On 12/12/23 at 10:30 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 into Residents #37's room and asked her to describe Resident #37's fingernails. LPN #1 answered, They need to be addressed. Yes. They are really long and pretty filthy. The Surveyor asked how often fingernails were checked and how nail care was done. LPN #1 answered, Weekly, but this week they probably missed her. The Surveyor asked who was responsible for resident nail care. LPN#1 answered, The Activity Director makes the schedule. Nurses do the diabetics, and a Podiatrist comes whenever scheduled. The Surveyor asked why nail care was important to do on a regular basis. LPN #1 answered, For hygiene, and they might scratch their skin. There's lots of germs in there if she eats. It needs to be checked daily as part of their care. On 12/12/23 at 10:33 AM, the Surveyor asked Certified Nurse Assistant (CNA) #2 to describe Resident #37's fingernails. CNA #2 answered, They need to be cut and cleaned with an orange stick. The Surveyor asked how often nails should be checked. CNA #2 answered, They are supposed to be checked daily. The Surveyor asked who was responsible for nail care. CNA #2 answered, The Aides if they are not diabetic. If they are, the nurses. The Surveyor asked why regular nail care was important. CNA #2 answered, They use their hands to eat. If there is feces under their nails, that's going to get into their food. On 12/14/23 at 10:00 AM, the Surveyor asked the Director of Nursing (DON) what the process was for tracking Activities of Daily Living (ADL's) and nail care. The DON answered, We use POC [Plan of Care] for documentation and the CNAs use the closet care plans. We follow up as needed per assessment. The Surveyor asked who was responsible for resident nail care. The DON answered, Our CNAs The Surveyor asked how often resident nail care should be done. The DON answered, They usually do them on shower days, that would be a minimum of 2 days a week where they are cleaned and trimmed as needed and per request. The Surveyor asked why regular nail care was important. The DON answered, For infection control, cleanliness, and safety to make sure no sharp edges cause skin issues. Also, appearance. Nobody wants to look unkept. On 12/13/23 at 03:03 PM, the Nurse Consultant provided a facility policy titled, Fingernails/Toenails, Care of which documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines, 1. Nail care includes daily cleaning and regular trimming . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, interview and record review the facility failed to ensure resident safety when providing meals to 2 (Residents #9 and #37) sampled residents on the 200 Hall. The findings are: 1. Resident #9 had diagnoses of Atrial Fibrillation and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 7/15/23 documented a Brief Interview for Mental Status (BIMS) score of 12 (8-12 indicates moderate cognitive impairment) and required a therapeutic and a mechanically altered diet. a. A Physicians Order dated 11/16/23 documented, .Regular, NAS [No Added Salt] diet, Regular texture, Regular consistency Please send finger foods for all meals . b. A Care Plan initiated 10/23/20 documented, .Provide, serve diet as ordered. Monitor intake and record q [every] meal. Food allergy to Caffeine . 2. Resident #37 had a diagnosis of Dementia. The Quarterly MDS with an ARD of 11/16/23 documented a BIMS score of 4 (0-7 indicates severe cognitive impairment) and required a therapeutic diet. a. A Physicians Order dated 11/21/23 documented, Regular, NAS Enhanced diet, Regular texture, Regular consistency Diet . b. A Care Plan with an initiation date of 2/20/23 documented, [Resident #37] has nutritional problem or potential nutritional problem . Provide, serve diet as ordered. Monitor intake and record q meal. Red napkin program, enhanced diet . 3. On 12/10/23 at 12:47 PM Resident #37 was sitting up on the side of the bed eating lunch. Resident #37 had the wrong tray with the wrong diet as evidenced by the name on the dietary meal intake slip and the menu on the tray was Resident #9's. Resident #37 ate approximately 75% of the lunch tray. 4. On 12/10/23 at 12:50 PM, Resident #9 was lying in bed with the overbed table over her lap with a meal tray on it. The dietary meal slip, and the menu on the tray on Resident #9's table had the roommate's (Resident #37's) name on it. Resident # 9 stated, I can't eat any of this. Take it away. Observed Resident #9 drink the milk on the tray. 5. On 12/10/23 at 01:23 PM, the Surveyor observed Certified Nursing Assistant (CNA) #1 at the meal cart on the 200 Hall outside of Resident #37's room and asked if she had passed the trays out for lunch to Resident #37. CNA #1 answered, Yes. The Surveyor asked if the meal slips were checked for Resident #9 and Resident #37 to make sure they matched up with the correct resident. CNA #1 answered, Well I asked their names when I went in, and they said yes. I'm the only one down here. I also got the menus mixed up. The Surveyor asked CNA #1 how to ensure the right meal is served to the right resident. CNA #1 answered, I go by what they tell me The Surveyor asked what could happen if the wrong diet is served to the wrong resident, and if there could be any negative outcomes to residents if that happened. CNA #1 answered, Yes, allergies, allergic reactions. If they are diabetic, they are not supposed to have too much sugar. 6. On 12/13/23 at 2:20 PM, the Surveyor asked the Dietary Manager (DM) who was responsible for making sure meal trays are served to the right resident. The DM answered, Me, and the Certified Nursing Assistants put menus together in the order of the tables, and whoever the CNA that loads the meal cart puts it in order from top to bottom by matching the room numbers. The Surveyor asked the DM what could happen if the wrong tray is served to the wrong resident. The DM answered, A lot. That means they could get the wrong diet, texture, fluid consistency, or allergy could be gotten wrong. The Surveyor asked what happens if the wrong meal was served to the wrong resident on the hall. The DM answered, Whoever made the error would come back to us and tell us. We would call the nurse and tell the Director of Nursing (DON). Then we would get the resident the right tray. The Surveyor asked how and where documentation would be found. The DM answered, I would write it in a progress note. She [DON] would do the same. The Surveyor asked who assigns the CNAs from the floors to load the trays. The DM answered, The floor nurse for that specific hall. d. On 12/14/23 at 08:27 AM, the Surveyor accompanied Certified Nursing Assistant (CNA) #3 to Resident #9's room and asked to see the dietary breakfast slips for Resident #9 and Resident #37 and what the process was for documenting resident menus, making sure they get the correct trays, and documenting resident dietary intake. CNA #3 answered, We are not allowed to leave the meal slips on the trays. The Surveyor asked why. CNA #3 answered, I was told it's a dignity issue. We pick up the trays after breakfast. I usually hold on to it, then I go to the Kiosk in the hallway to chart it, and after that, it gets shredded. The Surveyor asked CNA #3 for documentation of Resident #37's and Resident #9's dietary intake slips for breakfast. CNA #3 answered, I keep it in my head, [Resident #9] ate 100% and 480cc [cubic centimeters], [Resident #37] ate 75% and 240cc. On 12/14/23 at 11:10 PM, the Surveyor asked the DON who was responsible for making sure the right trays were delivered to the right residents and what is the process. The DON answered, It's a collective effort. Multiple people starting with CNAs collecting the menu preferences from the resident. They take it to the kitchen where dietary staff makes sure the meal ticket and menu is correct on the tray. The CNAs are responsible for delivering to the residents. The Surveyor asked if documentation was available to review for the process if the wrong tray was delivered to the wrong resident. The DON answered, To be honest, No, it hasn't happened before. I was not on my game. It was her third shift. The Surveyor asked if it should be documented if residents receive the wrong tray and why that was important. The DON answered, Yes, it should be. It could be a safety issue. e. On 12/13/23 at 11:18 AM, a Kitchen In Service dated 7/25/23 documented, .When we are on the tray line, we need to be sure to watch and pay attention to what is ordered and written on the menus. Pay very close attention to TRAY CARD. Diet, utensils, plates, dislikes, standing orders. These items need to be present and correct for proper eating and nutritional needs .

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for F656 Develop/Implement Comprehensive Care Plan. The findings are: A Recertification survey was conducted on 12/14/23 at the facility. During this survey, F656 was cited for facility failure to implement and ensure a comprehensive plan of care was developed for a resident for diabetic interventions. Review of the facility's Plan of Correction, with a correction date of 12/31/22 indicated: During a recertification survey conducted on 10/6/22 the facility was cited for F656 failure to update the care plan related to catheter care. The plan of correction noted: Minimum Data Set (MDS) Coordinators were in-serviced by the Administrator on 10/07/22 on care plans and the need to accurately capture all items on the care plans for each resident, to specifically include catheters. The MDS Coordinators completed a record review of all the residents in the facility to ensure that all care plans were correct and accurately reflected the residents care needs, specifically those residents that have catheters. Monitoring: the Director of Nursing (DON) will review three charts weekly for the next eight weeks or until compliance is achieved to ensure resident care plans accurately reflect resident care needs. Any negative findings will be corrected immediately and reported to the Administrator or designee. All findings will be reported to the QA (Quality Assurance) committee monthly by the DON for review and recommendations. Completion date is 10/31/22. 1. A facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan (Revised April 2014), provided by the Administrator on 12/10/23 at 12:00 PM documented, Policy Statement This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI plan designed to monitor evaluate and the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation The objectives of the QAPI Plan are to: . l. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services; 3. Provide structure and processes to correct identified quality and/or safety deficiencies; 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5. Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability; 6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and 7. Establish systems, and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program. 5. On 12/14/23 at 1:10 PM, the Surveyor asked the Administrator how the QAA Committee knows when an issue arises in any department. The Administrator said that it can be reported by staff or residents, or it can be found in electronic records. The Surveyor asked how the QAA Committee knows when a deviation from performance or a negative trend is occurring. The Administrator said through electronic health records and progress reports or outcomes. The Surveyor asked how the QAA Committee decides which issues to work on. The Administrator said they prioritize off of quality of care and concerns. The Surveyor asked how long the QAA Committee will monitor an issue that has been corrected. The Administrator said as it is ongoing, they monitor through data entry, reports electronic health records, monitoring through walking rounds and visualizing progress and outcomes.

Based on observation and interview, the facility failed to ensure the environment was maintained in a sanitary and safe condition for residents, staff, and the public, as evidenced by failure to ensure a shower room on Rehabilitation (Rehab) hall and a clean linen closet was locked to prevent accidental ingestion of chemicals and injury prevented. The findings are: 1. On 12/10/23 at 12:46 pm, a clean linen closet located on the Rehab Hall was unlocked. Inside the linen closet, there was a wood 5 door cabinet approximately 4 feet tall with the doors open. Inside the first cabinet on the top shelf was a one quart size squirt bottle of professional strength cleaner and odor eliminator and one quart size squirt bottle of industrial cleaner, a gallon jug of shampoo and assorted personal items. Across the hall a bathroom was unlocked. It had a 3 drawer plastic container. In the top drawer was 5 disposable razors, a can of shaving cream, a plastic bottle of corn starch, and a 4 ounce bottle of mouthwash. 2. On 12/10/23 at 12:50 am, upon entering an unlocked shower room between the 200 and 300 Halls a hair dryer was hanging from a hook on the wall and was plugged in to an electrical outlet. Around the corner was a 4 door cabinet that had locks on each side but was easily opened. On the left side of the cabinet, the doors were easily opened but had the metal key engaged, but not working. Inside the cabinet on the top shelf were 3 quart squirt bottles of professional strength cleaner and odor eliminator, 2 gallon jugs of shampoo and various bottles of shampoo and lotions. On the bottom shelf was a plastic 3 drawer container. In the top drawer, were approximately 30 disposable razors, 2 pairs of metal nail clippers, a can of shaving cream and 5 rolls of deodorant bottles. 3. On 12/11/23 at 9:23 am, observed that the shower room between the 200 and 300 Halls was still unlocked and accessible to residents. 4. On 12/14/23 at 11:11 am, a Safety Data Sheet for the professional strength cleaner and odor eliminator was provided by the Director of Nursing (DON). The Safety Data Sheet documented .SECTION - 2. HAZARDS INFORMATION .May be harmful is swallowed. Avoid eye contact and inhalation of mist. Use personal protective equipment as required . 5. On 12/14/23 at 11:00 am, the Surveyor asked Certified Nursing Assistant (CNA) #4 if the shower room doors should be closed and locked. CNA #4 said yes. The Surveyor asked who is responsible for ensuring doors are closed and locked. CNA #4 stated whoever is walking in or walking out at the time. The surveyor asked should chemicals be locked up after use. CNA #4 said always. The Surveyor asked what could happen? CNA #4 said chemicals could be mixed, spilt or a resident could ingest it. The Surveyor asked who uses the Rehab Hall shower room? CNA #4 said therapy primarily uses the rehab hall shower, it's always supposed to be locked on the Rehab Hall side. 6. On 12/14/23 at 11:05 am, the Surveyor asked the DON if shower doors should be closed and locked. The DON said yes. The Surveyor asked who is responsible for ensuring doors are closed and locked. The DON said the CNAs, other staff, and nurses. The Surveyor asked should chemicals be locked up after use. The DON said yes. The Surveyor asked what could happen. The DON said it could be a safety issue, burning skin, ingestion.

Based on observation and interview, the facility failed to ensure privacy was provided during incontinent care 1 (Resident #44) of 12 residents who required assistance with incontinent care on the 200 Hall based on a list provided by the Director of Nursing (DON) on 12/14/23 at 12:09 PM. The findings are: Resident #44 had a diagnosis of Chronic Respiratory Failure with Hypoxia. An Admission Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 10/8/23 documented a Brief Interview for Mental Status (BIMS) score of 12 (8-12 indicates moderate cognitive impairment) and was dependent for toileting, showering and personal hygiene. The Care Plan with an initiated date of 10/25/2023 documented, .TOILET USE: The resident requires total assistance) by 2 staff for toileting.The resident's dignity and autonomy will be maintained at highest level through the review date . On 12/10/23 at 03:40 PM, Resident #44 was lying in bed awake. Certified Nursing Assistant (CNA) #1 and Registered Nurse (RN) #1 entered the room and changed Resident #44's brief without drawing the curtain between Resident #44 and the roommate exposing Resident #44's backside to the roommate. The Surveyor asked RN #1 if staff changed resident briefs without drawing the privacy curtain between residents on a regular basis. RN #1 stated No. The Surveyor asked RN #1 if not drawing the curtain was standard practice. RN #1 answered, No. On 12/14/23 at 11:20 PM, the Surveyor asked the DON what the definition of dignity was. The DON answered, To me, it's giving people that sense of pride, independence, and privacy. On 12/13/23 at 03:02 PM, the Nurse Consultant provided a facility policy titled, Resident Rights (Revised December 2016) that documented under Policy Interpretation and Implementation, .1. Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity .

Based on observation and interview, the facility failed to ensure the medication cart was secured and the medical information from the Medication Administration Record (MAR) was not visible and accessible to visitors, staff, or other residents for 1 (Resident #56) sampled resident. The findings are: 1.On 12/11/23 at 09:20 am, observed a medication cart in the hall, outside Resident #56's room. The cart was unlocked, and the laptop screen on the computer was visible with Resident #56's picture and Medication Administration Record (MAR) was visible on the laptop screen. No staff were in sight of the medication cart. The door was open to another room across the hall and the resident in that room had visitors who could have seen Resident #56's private medical information or opened drawers on the medication cart. 2. On 12/11/23 at 09:28 am, observed Licensed Practical Nurse (LPN) #2 exiting from Resident #56's room. LPN was asked before you leave a medication cart, what should be done? LPN #2 stated, Lock it and shut the computer screen down. The Surveyor asked what is the importance of locking the medication cart? LPN #2 stated, So no one else can get in it. 3. On 12/14/23 at 12:12 pm, the Director of Nursing (DON) was asked what is the importance of locking a medication cart located in the hall in front of a resident's room? The DON said, Safety. The surveyor asked the DON what is the importance of closing the laptop screen when the nurse is away from the cart? The DON said HIPPA (Health Insurance Portability and Accountability Act). 4. The facility policy provided on 12/14/23 at 12:23 pm by the DON titled, Security of Medication Cart documented, Policy Statement The medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry . 3.The cart must be locked before the nurse enters the resident's room . 5. The facility policy provided on 12/14/23 at 12:23 pm by the DON titled Confidentiality of Information and Personal Privacy documented Policy Statement Our facility will protect and safeguard resident confidentiality and personal privacy. Policy Interpretation and Implementation l. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.4. Access to resident personal and medical records will be limited to authorized staff and business associates .

Based on record review and interview, the facility failed to ensure a comprehensive, person-centered care plan was developed to address the necessary care and monitoring related to the administration of insulin, to enable staff to determine the effectiveness of the medication and promptly identify any potential adverse effects for 1 (Resident #44) of 1 sampled resident who had a physician order for insulin. The findings are: Resident #44 was admitted on [DATE] and had a diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The Admission Minimum Data Set (MDS) dated [DATE] documented Resident #44 had received insulin injections 7 days of the 7 day lookback period. The Physicians Order dated 10/12/23 documented, Insulin Regular Human Solution 100 Unit/ML [milliliter] Inject 80 unit subcutaneously one time a day for diabetes . The Physicians Order dated 10/12/23 documented, Accucheck two times a day related to Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease . The Care Plan with an initiated date of 10/25/23 documented, .Administer medications as ordered. Monitor/document for side effects and effectiveness . There were no diabetes goals or interventions addressed in the Care Plan. On 12/14/23 11:20 AM, the Surveyor asked the MDS Coordinator who develops care plans for residents on insulin. The MDS Coordinator answered, I usually put that they have Diabetes on the Care Plan, but there are a lot of other people too put their parts like Dietary. The Surveyor asked who was responsible for Nursing Interventions for residents on insulin. The MDS Coordinator answered, I am, Yes. The Surveyor asked what residents on insulin should be monitored for. The MDS Coordinator answered, I don't know, I'm not sure what you are asking. Hyper or Hypo glycemia. The Surveyor asked if insulin side effects or adverse signs and symptoms should be included on care plan interventions. The MDS Coordinator answered, You mean like if they get too much or too little their sugars can drop or be too high. We monitor the glucose. The Surveyor asked why it was important to include side effects and signs and symptoms for Diabetic residents on insulin. The MDS Coordinator answered, So people know what to look for. The Surveyor asked the MDS Coordinator to pull up Resident #44's Care Plan Interventions and asked if there were any listed on the Care Plan. The MDS Coordinator answered, Nope. The Surveyor asked if there should be interventions. The MDS Coordinator answered, Yes, but we have 14 to 21 days to get the Care Plan set up. The Surveyor asked if they were in that time frame. The MDS Coordinator answered, No. On 12/14/23 at 10:05 AM, The Surveyor asked the Director of Nursing (DON) who was responsible for Care Plan and MDS Development. The DON answered, My MDS Coordinator. The Surveyor asked why it was important for care plans to be accurate and up to date. The DON answered, Because that's how staff know how to care for the resident. The MDS is important because it goes to the Office of Long Term Care and CMS [Central Medicare and Medicaid Services] for the amount and type of care residents received in the facility.

Based on observation and interview, the facility failed to ensure 1 of 2 clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services. This failed practice had the potential to affect 66 residents whose laundry was done by the facility according to a list provided by the Director of Nursing (DON) on 12/14/23 at 12:02 pm. The findings are: a. On 12/12/23 at 09:01 am, in the clean side of laundry room, there were 2 dryers, 1 was not working. Laundry Staff (LS) #1 was asked how often do you clean under the dryer? LS #1 said every 2 hours. The surveyor asked LS #1 to open the lint trap drawer. There was approximately 2 inches of light gray fluffy lint on both sides of the filter pushed towards the back, and a white folded item on the floor in the middle. The Surveyor touched the item and it felt fluffy. LS #1 was asked when was the last time the area under the dryer was cleaned out? LS #1 said at 08:00 this morning. The Surveyor asked how do you clean that area out? LS #1 said, I take a broom and sweep it out. The surveyor asked is there a log sheet you sign when you clean it out? LS #1 said yes. The log sheet was reviewed and there were no initials for the date of 12/12/23. b. On 12/14/23 at 11:30 am, the Maintenance Supervisor was asked what the importance is of having the lint removed under the dryers. The maintenance supervisor said to prevent a fire hazard. c. On 12/14/23 at 12:03 pm, the Administrator said we do not have a policy regarding cleaning under the dryer.

Based on observation, record review, and interview, the facility failed to ensure indwelling catheter drainage bags were not touching the floor to prevent the potential complications and possible infections for 2 (Residents #33 and #37) of 3 (Residents #27, #33 and #37) sampled residents who had indwelling catheters. This failed practice had the potential to affect three residents who had catheters according to a list provided by the Administrator on 10/05/22 at 8:47 AM. The findings are: 1. Resident #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/22 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and had an indwelling catheter. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 05/26/21 documented, . has Suprapubic Catheter . Position catheter bag and tubing below the level of the bladder and away from entrance room door . Check tubing for kinks each shift . c. On 10/03/22 at 11:13 AM, Resident #33 was lying in bed, her foley catheter drainage bag was hanging on the right side of the bed touching the floor. A privacy bag was hanging beside the drainage bag, but the drainage bag was not in it. d. On 10/04/22 at 8:39 AM, Resident #33 was lying in bed, her foley catheter drainage bag was hanging on the right side of the bed touching the floor. A privacy bag was hanging beside the drainage bag. e. On 10/05/22 at 9:15 AM, Resident #33 was lying in bed, her foley catheter drainage bag was hanging from the right side of bed in a privacy sleeve with no bottom and was touching the floor. The Director of Nursing (DON) was called into the resident's room and made aware of the finding of the last two days. The Surveyor asked if it was appropriate for it to be touching the floor now. The DON stated, It should be hanging from the end of the bed, so it doesn't touch the floor. 2. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/23/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had a a Foley catheter. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 07/14/22 did not address that the resident had a Foley catheter or interventions and/or task to care for the foley catheter. c. On 10/03/22 at 10:58 AM, Resident #37 was lying in bed. Her Foley catheter bag was lying on the floor. d. On 10/04/22 at 8:31 AM, Resident #37's family member was sitting beside the bed and holding Resident #37's hand. The Foley catheter was secured to the left side of bed, touching the floor. e. On 10/04/22 at 11:20 AM, the Surveyor requested Certified Nursing Assistant (CNA) #2 to follow the Surveyor into Resident #37's room. Resident #37 was sitting up in bed with her family member sitting next to her holding her hand. The Surveyor asked CNA#2, Where is her catheter bag? She stated, .It is touching the floor. It is hard to find a place to hook. I didn't know where else to put it . because the bed is so low . f. On 10/04/22 at 11:24 AM, the Surveyor asked CNA #2, What is a potential negative outcome of her urinary catheter sitting on the floor? She stated, Germs could get in it . We raise the bed up and her husband lowers it so he can put his arm around her, and he leans on her bed . g. On 10/04/22 at 1:16 PM, the Surveyor asked the Administrator for a policy regarding catheters. The Administrator stated, Is this regarding [Resident #37]? If it is, she is a little demented and he [family member] has been educated in not lowering the bed so her catheter is not on the floor. I can't help what resident's and their families do when we are not in there . 3. The facility policy titled, Catheter Care, Urinary, provided by the Administrator on 10/04/22 at 1:18 PM documented, .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Infection Control . b. Be sure the catheter tubing and drainage bag are kept off the floor .

Based on record review and interview, the facility failed to ensure a comprehensive plan of care was developed for a resident who had a Foley Catheter to assure the resident's individual needs were met and maintained for 1 (Resident #37) of 3 (Residents #27, #33 and #37) sampled residents who had a catheter. The findings are: 1. Resident #37 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/23/22 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had a Foley catheter. a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 07/14/22 documented, . has an ADL [activities of daily living] self-care performance deficit . TOILET USE: The resident requires extensive assistance by 1 staff for toileting . The Care Plan did not address that the resident had a Foley catheter or interventions and/or task to care for the foley catheter. c. On 10/03/22 at 10:58 AM, Resident #37 was lying in bed. Her Foley catheter bag was lying on the floor. d. On 10/04/22 at 8:31 AM, Resident #37's family member was sitting beside the bed and holding Resident #37's hand. The Foley catheter was secured to the left side of the bed, touching the floor. e. On 10/04/22 at 11:20 AM, the Surveyor requested Certified Nursing Assistant (CNA) #2 to follow the surveyor into Resident #37's room. Resident #37 was sitting up in bed with her family member sitting next to her holding her hand. The Surveyor asked CNA#2, Where is her catheter bag? She stated, .It is touching the floor. It is hard to find a place to hook. I didn't know where else to put it . because the bed is so low . f. On 10/06/22 at 10:18 AM, the Surveyor asked the MDS Coordinator, Does [Resident #37] have a Foley Catheter? She stated, Yes . The Surveyor asked, What care plan interventions do you have in place for the Foley catheter? She looked at her computer screen and stated, I can't find anything in there about the catheter . The Surveyor asked, What is a potential negative outcome of Foley catheter interventions not being on the care plan? She stated, If there are orders in place then it's being taken care of. The Surveyor requested a Care Plan policy. k. At the time of exit on 10/6/22 at 1:08 PM, a Care Plan policy had not been provided.

Based on observation, record review, and interview, the facility failed to ensure an oxygen tank was not stored in a resident's room to prevent the potential for injury for 1 (Resident #56) of 6 (Residents #15, #32, #37, #55, #56 and #65) sampled residents who received oxygen therapy. The findings are: 1. Resident #56 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS (Brief Interview for Mental Status) and receive oxygen therapy and Non-Invasive Mechanical Ventilator ([CONDITION(S)] [Bilevel Positive Airway Pressure]/[CONDITION(S)] [Continuous positive airway pressure]). a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . OXYGEN- may self-remove if desired as needed for SHORTNESS OF BREATH 3 LITERS/[per] MIN PER NASAL CANNULA PRN . b. On 10/03/22 at 11:19 AM, Resident #56 was sitting up in her room with oxygen in use per concentrator. A large oxygen tank was laying on resident's spare bed in her room, not in use. c. On 10/03/22 at 11:26 AM, Resident #56 was sitting in her room with oxygen at 5 liter per mask. An oxygen tank was laying on the bed not in use. d. On 10/03/22 at 12:06 PM, the Surveyor requested the Nurse Manager to come to Resident #56's room. A large oxygen tank was lying on the empty bed in the resident's room. The Surveyor asked the Nurse Manager, Who is responsible for ensuring the oxygen tanks are stored safely? She stated, Nursing. The Surveyor asked her to describe where the oxygen tank was and she stated, It's lying on the bed. The Surveyor asked, Is it stored safely? She stated, No. The Surveyor asked, What is a potential negative outcome of the oxygen laying on the bed and not stored safety? She stated, It could roll off the bed and be a tripping hazard and . on an extreme outcome it could explode. The Nurse Manager removed the tank from the room. 2. The facility policy titled, Oxygen Safety, provided by the Administrator on 10/4/22 at 1:18 PM documented, Oxygen Safety: .Store oxygen cylinders in racks with chains, sturdy portable carts .Never leave oxygen cylinders free-standing. Do not store oxygen cylinders in any resident room .

Based on interview and record review, the facility failed to ensure residents and/or resident representatives received a refund of prepaid funds within 30 days of discharge or expiration for 2 (Residents #122 and #123) of 3 (Residents #122, #123 and #124) sampled residents whose closed records were reviewed and were due a refund. The findings are: 1. Resident #122 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Admission Agreement dated [DATE] provided by the Administrator on [DATE] at 3:15 PM documented, . Facility Obligations . F. Refunds. The Facility agrees to refund any unused portions of prepaid charges based on basic rate schedules upon the discharge of the Patient within 30 days following discharge . b. The Transaction Report for [DATE] to [DATE] provided by the Administrator on [DATE] at 7:40 AM documented a partial refund of $4,760.30 was issued on [DATE] and $1,532.70 was retained due to coinsurance portion owed. c. Refund check # dated [DATE] provided by the Administrator on [DATE] at 10:30 AM documented a refund of $4,760.30 was paid to the order of [POA/spouse name], 53 days after discharge. 2. Resident #123 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On [DATE], Resident #123 was chosen for sample along with complaint due to receiving a refund from facility. b. The Transaction Report for [DATE] to [DATE] provided by the Administrator on [DATE] at 7:40 AM documented a refund of $1,319.75 was issued on [DATE]. The Administrator stated, DHS [Department of human Services] is behind in calculating level of care for hospice, so this is one of those cases. c. Refund check # dated [DATE] provided by the Administrator on [DATE] at 7:40 AM documented a refund was paid to the order of [POA/daughter name] for $1,319.75, 45 days from the date of discharge/expiration to the date of the refund check issuance. 3. On [DATE] at 7:40 AM, the Surveyor asked the Administrator, What was the date that [Resident #123] discharged /expired? The Administrator looked up the information in her computer and stated, [DATE]. FYI [For your information], she was one of the level care hospice ones. LTC [Long Term Care] has held those up from being refunded because of that level issue. The Surveyor asked, What date was her refund check issued? The Administrator responded, [DATE]. The Surveyor asked, What was the date that [Resident #122] discharged ? The Administrator looked up the information in her computer and stated, [DATE]. The Surveyor asked, What date was his refund check issued? The Administrator responded, [DATE]. That's the same thing as [Resident #123]. It is not considered unused since they still owe money. We still need insurance to pay. Am I making sense? The Surveyor asked, When should the non-coinsurance portion have been refunded? The Administrator stated, Once the account is cleared. The Surveyor asked, What is the requirement for refunds? The Administrator asked, Whose requirements? OLTC [Office of Long Term Care]? The Surveyor responded, CMS [Centers for Medicare and Medicaid Services] requirements. The Administrator stated, I've never seen or read a CMS requirement for refunds. The Surveyor asked, What does the facility's policy and admission agreement state? The Administrator stated, I believe it says something about the account being clear and will refund in so many days after that. Do you, have it? Would you read it? The Surveyor read the section from the Admission Agreement aloud .Refunds. The Facility agrees to refund any unused portions of prepaid charges based on basic rate schedules upon discharge of the Patient within 30 days following discharge . The Administrator stated, Read that first part again. The Surveyor read the statement again. The Administrator stated, Technically it means unused portion, but not before the account is cleared. We still have not been paid for her [Resident #123] hospice yet, but we still issued her refund.

Based on observation, interview, and record review, the facility failed to ensure medical information on a computer screen was not visible to other staff, residents and/or visitors to prevent private medical information from being improperly divulged as evidenced by computer screens left open with resident information visible for 2 (Residents #125 and #170) of 2 sampled residents. This failed practice had the potential to affect 74 residents per the Resident Census provided by the Administrator on 10/3/22. The findings are: 1. On 10/04/22 at 2:23 PM, the Surveyor entered the therapy room at the end of the 400 Hall. A computer tablet was sitting on a desk with Resident #170's information still up on the screen with no staff present. The Surveyor waited until 2:29 PM to see if a therapist was going to return to the room. As the Surveyor stepped out of the therapy room, Resident #65's family member was outside door. The Surveyor informed the family member that there was not a therapist in the room right now and the family member continued down the hall to Resident #65's room. a. On 10/04/22 at 2:32 PM, the Surveyor informed the Administrator of the computer screen being left up in the therapy room with Resident #170's information visible. The Surveyor asked the Administrator, Should computers be left up when staff leaves their desk and the room their computer is in? The Administrator stated, No, never, but even if they do, ours rolls to the privacy screen in a few seconds. The Surveyor asked, Are all the computers in the facility set up that way? The Administrator stated, All the kiosks and touch books do. The Surveyor asked, Does therapy use that system? The Administrator stated, Oh no, they are on a different system. The Surveyor informed Administrator about laptop computer in the therapy room being left up with a resident's information showing. The Administrator stated she was not sure what therapists were still in the building but would see. 2. On 10/4/22 at 2:40 PM, the Surveyor asked Occupational Therapist (OT) #1 as she was exiting Resident #15's room on the 200 Hall, When you leave your desk or therapy room should computers be left open? OT #1 responded, No, and you should not leave a screen up with resident info [information] on it. Physical Therapist (PT) #1 walked up to the Surveyor and OT #1 and the Surveyor informed them that a computer in the therapy room was left up with resident information on it. 3. On 10/4/22 at 2:45 PM, PT #1 and the Administrator came to Surveyor and PT #1 stated therapy had just received new computer software yesterday (Monday) and it does not go to the privacy screen automatically like the last system did. PT #1 stated they were not use to not the new system not doing that. The Administrator confirmed this statement. 4. On 10/4/22 at 3:50 PM, the Surveyor was on the 400 Hall and noticed a computer in the Nurses Station was on with Resident #125's information on the screen and no staff nearby. 5. On 10/4/22 at approximately 3:55 PM, the Surveyor informed the Administrator of another computer screen left up. The Surveyor accompanied the Administrator to the 400 Hall Nurses Station. The computer screen was still open with the resident's information visible. The Administrator stated, She only walked away a minute ago because I heard her voice. The Surveyor asked if the computer screen should have been left up. The Administrator stated, She should be close by. I just heard her. The Administrator closed the screen and logged the computer out.

Based on observation, record review and interview, the facility failed to ensure staff sat with residents and did not stand over them while assisting them with eating, to promote dignity for 3 (Residents #4, #13, #17) of 9 (Residents #4, #11, #13, #17, #24, #38, #62, #64, and #69) sampled residents who were dependent on staff for eating. The findings are: 1. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/17/21 documented the resident scored 1 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required limited assistance with eating and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. a. The Care Plan revised on 2/21/20 documented, . [Resident] has an ADL [activity of daily living] self-care performance deficit r/t [related to] impaired balance . EATING: is able to feed self after tray set up . b. On 06/07/21 at 12:36 PM, Certified Nursing Assistant (CNA) #4 standing up on the right side of the resident to feed resident with a fork and giving resident several drinks of milk during the lunch meal. c. On 6/10/21 at 2:23 PM, CNA #2 was asked, What is the proper way to assist a resident during meal service with eating? CNA #2 stated, Set up their tray and apply a clothing protector, then set down across from them. CNA #2 was asked, Is it appropriate to stand up to feed a resident? CNA #2 stated, No ma'am. CNA #2 was asked, Why not? CNA #2 stated, It is like you are towering over them when you stand up. d. On 6/10/21 at 2:28 PM, Licensed Practical Nurse (LPN) #2 was asked, What is the proper way to assist a resident during meal service with eating? LPN #2 stated, Sit down, make eye contact, talk to them about the food and if they like it. If they don't like it, offer them something else to eat. Make sure to alternate food and liquids. LPN #2 was asked, Is it appropriate to stand up to feed a resident? LPN #2 stated, Absolutely not. You always sit down to make them feel comfortable. This is their home. LPN #2 was asked, Why not? LPN #2 stated, You have to respect them and be mindful of their dignity. You don't want to stand over them. f. On 6/10/21 at 2:40 PM, the Director of Nursing (DON) was asked, What is the proper way to assist a resident during meal service with eating? DON stated, Clean dry hands. Sanitize hands between residents and sitting down with them. DON was asked, Is it appropriate to stand up to feed a resident? DON stated, No. DON was asked, Why not? DON stated, Because of dignity reasons. It is easier to sit down with them and they are more likely to eat better if you are sitting down. g. On 6/10/21 at 3:38 PM, the facility provided a policy titled Assistance with Meals. The policy documented, Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . Residents Requiring Full Assistance: .2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Ensure resident is positioned properly b. Ensure resident can visually see you c. Ensure interactions are at a minimum . All Residents: .3. All employees who provide assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. 2. Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS with an ARD of 3/19/21 documented resident is severely impaired in cognitive skills for daily decision making according to the Staff Assessment for Mental Status, required limited assistance for eating, and extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. a. The Care Plan initiated on 12/24/19 documented, . [Resident] has an ADL self-care performance deficit r/t decreased mobility . EATING: The resident requires assistance by (X) [times] 1 staff to eat . b. On 06/07/21 at 12:40 PM, CNA #3 was standing up on the right side of the resident feeding resident during the lunch meal service. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with ARD of 6/8/21 documented a Brief Interview for Mental Status (BIMS) score of 2 (0-7 indicates severely impaired) and required limited assistance with eating. a. The care plan initiated on 11/1/19 documented, [Resident #4] has an ADL self-care performance deficit r/t decreased mobility . EATING: Provide finger foods when the resident has difficulty using utensils . Monitor/record/report to MD [Physician] PRN [as needed] s/sx [signs and symptoms] of malnutrition: Monitor intake and record q [every] meal . Enhanced diet, Red napkin . b. On 06/07/21 at 12:36 PM, CNA #3 was standing bent over Resident #4 in the dining room. She had a spoon in her hand with food on it and was placing the food in the mouth of Resident #4. At times, CNA #3 would place the utensil in the resident's hand and guide her hand with the spoon to Resident #4's mouth from a standing position.

Based on observation, record review and interview, the facility failed to ensure residents' fingernails were cleaned and trimmed regularly to promote grooming, good personal hygiene and to decrease the risk of infections or complications for 2 (Residents #22, #78) of 11 (Residents #4, #11, #13, #17, #22, #24, #38, #62, #63, #64, and #78) sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/23/21 documented the resident scored 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status, required limited assistance for eating and extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. a. A Care Plan with revision date of 2/11/19 documented, [Resident #22] has an ADL [activity of daily living] self-care performance deficit r/t [related to] toileting, mobility, hygiene, and bathing . Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short b. On 06/08/21 at 08:54 AM, Resident #22 fingernails on each hand were approximately 1/4-inch-long with dark brown substance under the nails. 2. Resident #78 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/30/21 documented a Brief Interview of Mental Status (BIMS) score of 07 (0-7 indicates severely impaired), required supervision with eating, and was extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. a. The Comprehensive Care Plan initiated 7/22/20 documented, [Resident #78] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Impaired balance, Limited Mobility, Musculoskeletal impairment, pubis fracture . PERSONAL HYGIENE: The resident requires extensive assistance by (X)1 staff with personal hygiene and oral care . b. On 06/07/21 at 10:42 AM, Resident #78 was sitting in her wheelchair in her room. Her fingernails extended approximately 1/2 inch beyond the tip of her finger and had discolored debris under them. She was asked, Do you like your fingernails that long? She stated, No ma'am. They need to be cut. They look terrible. I can't cut them, I'm afraid I might cut my finger. c. On 06/08/21 at 10:54 AM, Resident #78 was sitting in her wheelchair. Her fingernails are approximately 1/2-inch-long and had discolored debris under the nail. The resident stated, They [fingernails] need trimmed. I don't do it myself, I'm afraid I'll cut my own self. d. On 06/09/21 at 09:29 AM, Resident #78 returned to her room from her shower. She was asked, Did you get a shower? She replied, Yes, but I'm disappointed, they didn't cut my fingernails and they look dirty. Her fingernails were unchanged, and debris was seen under the nail. e. On 06/09/21 at 02:32 PM, Certified Nursing Assistant (CNA) #1 was asked, Who is responsible for nailcare on the residents? She replied, Typically, the aides, shower aides, and the Activities Director who is also a CNA, she does nails on Thursdays. The nurses do the diabetic nails. She accompanied me to Resident # 8's room and the resident was asked, Did you get your bath today? She replied, Yes. She was asked, Did they trim your nails? She replied, No they didn't, while holding up her hand for us to see. CNA #1 was asked, What do you think about them? She replied, They do look like they could use some trimming. She then spoke to Resident #78 and stated, Why didn't you tell me you wanted your nails cut? Resident #78 looked down at her nails and stated, Well I'd just do it myself if I could. f. On 06/09/21 at 02:39 PM, Licensed Practical Nurse (LPN) #1 was asked, Who is responsible for nailcare on the residents? She replied, The CNAs unless diabetic then the nurses do it. She was asked, When is it performed, do they have a schedule they go by? She replied, Shower days, the shower aide or CNAs on the hall, tasks will pop up on their charting for nailcare. She was asked, Can you look to see if she triggers for the task? She looked and replied, I don't see one. g. On 06/09/21 at 03:01 PM, the Assistant Director of Nursing (ADON) was asked, Who is responsible for nailcare on the residents and when is it done? She replied, Well there is no set schedule. In the Kardex there should be a check nail. The MDSC [Minimum Data Set Coordinator] or nurse who does the admission will usually schedule that task. She was asked, Do you see one for this resident? She looked in the computer and stated, Not on the Kardex but on her care plan it says to keep fingernails short. I'm not sure why that is not pulling to the Kardex. h. On 6/10/21 at 08:30 AM, the Administrator provided a document titled, Fingernails/Toenails, Care of which documented, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Review the resident's care plan to assess for any special needs of the resident . Nail care includes daily cleaning and regular trimming . Proper nail care can aid in the prevention of skin problems around the nail bed .

Based on observation, record review, and interview, the facility failed to ensure call lights were kept within resident's reach to allow resident's to summon assistance to accommodate their individual needs for 3 (Residents #6, #32 and #60) of 25 (Residents #6, #230, #41, #42, 332, #14, #4, 349, 360, #48, #63, #20, #33, #56, 32, 351, 344, #1, #79, #64, #3, #38, #180, #182, and #31)sampled residents who were dependent on staff assistance and were capable of using the call light system. This failed practice had the potential to affect 86 residents who were dependent on staff for assistance and were capable of utilizing the call light system according to a Daily Census form provided by the Administrator on 1/2/20. The findings are: 1. Resident #32 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/19 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); and required extensive physical assistance of 1 person for bed mobility, transfer, dressing, toilet use, and personal hygiene; had no upper or lower extremity impairment; and was occasionally incontinent of bladder and was always continent of bowel. a. The Care Plan dated of 12/16/19 documented, .has [MEDICAL CONDITION] in her hands and has trouble grasping at times. Drops call light button at times .prefers to have call light draped across table .Check on .more often to make sure call light is within reach . b. On 12/16/19 at 11:26 a.m., Resident #32's call light was on the floor. The call light was approximately 2 feet out of reach of the Resident #32's reach. Resident #32 was asked, Can you reach your call light? She stated, No. d. On 12/17/19 at 3:18 p.m., Licensed Practical Nurse (LPN) #3 was asked, Will the care plan show an initiated time? LPN #3 stated, Sometimes it does. LPN #3 was asked, What time was Resident #32's care plan initiated on 12/16/19 with the resident drops the call button at times? LPN #3 stated, I did it yesterday, the Certified Nursing Assistant (CNA) saw you (this surveyor) down the hall and went in and picked up Resident #32's call light and told me we needed to update the care plan. LPN #3 was asked, Did you update the care plan after I left Resident #32's room? LPN #3 stated, I guess, I'm not sure. 2. Resident #6 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 12/13/19 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), required total physical assistance of 2 persons for bed mobility, transfer, and toilet use, and required extensive physical assistance of 1 person for dressing, and personal hygiene, and was always incontinent of bowel and of bladder. a. The Care Plan dated 12/16/19 documented, the resident had a communication problem .Ensure / provide a safe environment: Call light in reach . b. On 12/16/19 at 11:02 a.m., Resident #6 was lying in her bed. Resident #6's call light was on her pillow. Her call light was approximately 2 feet out of the reach of the resident. 3. Resident #60 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 11/26/19 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; and required extensive physical assistance of 2 person for bed mobility, was totally dependent of 2 persons for transfers; required extensive physical assistance of 1 person for dressing, eating, toilet use, and personal hygiene; was always incontinent of bowel; and had an indwelling catheter. a. The Care Plan dated 12/3/19 documented, .Vision / hearing problems .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 12/17/19 at 1:10 p.m., Resident #60 was lying in her bed. The call light was on the nightstand. The call light was approximately 4 feet out of the reach of the resident. 4. On 12/17/19 at 2:35 p.m., the Director of Nursing was asked, Should the call lights be in reach of residents for use. The DON replied, yes. 5. On 12/17/19 at 3:09 p.m., CNA #1 was asked, Should the call lights be in reach of the residents? CNA #1 stated, Yes. 6. On 12/19/19 at 12:13 p.m., the Administrator was asked, Should the call lights be in reach of the residents. The Administrator stated, Yes.

Based on observation, record review, and interview the facility failed to ensure positioning devices were in place to prevent the potential for further contractures for 1 (Resident #6) of 2 (Resident #6 and #60) sampled residents who had contractures. This failed practice had the potential to affect 3 residents who had orders for positioning devices as documented on a list provided by the Business Office Manager (BOM) on 12/20/19 at 9:01 a.m. The findings are: Resident #6 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/19 documented the resident was severely impaired moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); and required total physical assistance of 2 persons for bed mobility, transfer, and toilet use, and required extensive physical assistance of 1 person for dressing, personal hygiene; and was always incontinent of bowel and bladder; had functional limitation in range in motion for both of the upper and lower extremities. a. The Care Plan dated 11/6/19 documented, .The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) [MEDICAL CONDITION] secondary [MEDICAL CONDITION] . .Contractures: The resident has contractures of the hands. Provide skin care to keep clean and prevent skin breakdown. Place stuffed animals in hands as hand rolls . b. On 12/16/19 at 11:00 a.m., both of Resident #6's hands and arms were contracted and there were no positioning devices in place. c. On 12/19/19 at 3:34 p.m., Certified Nursing Assistant (CNA) #2 was asked, Is Resident #6 supposed to have splints / braces / animals in place for upper body contractions? CNA #2 stated, Yes. Animals. d. On 12/19/19 at 3:35 p.m., CNA #3 was asked, Is Resident #6 supposed to have splints / braces / animals in place for upper body contractions? CNA #3 stated, Yes, Stuffed animals. e. On 12/19/19 at 3:36 p.m., CNA #4 was asked, Is Resident #6 supposed to have splints / braces / animals in place for upper body contractions? CNA #4 stated, yes. f. On 12/19/19 at 03:37 p.m., the Director of Nursing (DON) was asked, Should assistive devices be in place for residents to prevent contractures if it is care planned? g. On 12/20/19 at 8:18 a.m., the Administrator was asked, Should assistive devices be in place to prevent further contractions for residents be implemented? The Administrator stated, If there is an order for [REDACTED].>

Based on observation, record review, and interview the facility failed to ensure the call light cords were replaced when the outer layer cord layer was deteriorating paging system was maintained and in proper working order to enable resident's to call for assistance when needed for 2 (Resident #32, and #42) of 25 (Residents #6, #230, #41, #42, 332, #14, #4, 349, 360, #48, #63, #20, #33, #56, 32, 351, 344, #1, #79, #64, #3, #38, #180, #182, and #31) sample residents who use the call light system. This failed practice had the potential to affect 86 residents who were capable of using the call light system as documented a Daily Census form provided by the Administrator on 1/2/19. The findings are: 1. Resident #32 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/19 documented the resident scored 14 (13-15 cognitively intact) on a Brief Interview for Mental Status (BIMS); and required extensive physical assistance of 1 person for bed mobility, transfer, dressing, toilet use, and personal hygiene; had no upper or lower extremity impairment, was occasionally incontinent of bladder and was always continent of bowel. a. On 12/16/19 at 11:26 a.m., there were two call light plugged into the wall that had the black and white internal wires exposed. b. On 12/16/19 at 2:39 p.m., the call lights plugged into the wall were broke. The call lights had black and white internal wires exposed. c. On 12/17/19 at 9:18 a.m., Resident #32 was in bed with her eyes closed. There were black and white internal wires exposed by the base of the call lights that were plugged into the wall. d. On 12/17/19 at 1:05 p.m., the call lights that were plugged into the wall had black and white internal wires exposed. 2. Resident #42 had a [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 11/14/19 documented the resident scored 12 (8-12 moderately impaired) on a Brief Interview for Mental Status (BIMS); and required extensive physical assistance of 2 persons for bed mobility, and extensive physical assistance of 1 person for transfer, dressing, eating, toilet use, and personal hygiene; and was frequently incontinent of bladder and always incontinent of bowel. a. The Care Plan dated 11/5/19 documented, . The resident is Moderate, risk for falls r/t (related to) decrease mobility . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 12/16/19 at 11:26 a.m., the call lights plugged into the wall broken. The base of the call light had black and white internal wires exposed. c. On 12/16/19 at 2:39 p.m., the call lights plugged into the wall were broken. The base of the call lights had black and white internal wires exposed. d. On 12/17/19 at 9:18 a.m., Resident #42 was in her recliner with the call light in her lap. The call light was plugged into the wall. The call light plug had black and white internal wires exposed. 3. On 12/17/19 at 2:35 p.m., the Director of Nursing (DON) was asked, Should the call lights have internal wires exposed? The DON stated, No. The DON was asked, Are the call lights attached to an electrical system? The DON stated, I would assume so, Yes. The DON was asked, Are the internal wires exposed on the call lights have the potential for hazards. The DON stated, The wires, Yes. 4. On 12/19/19 at 12:13 p.m., the Administrator was asked, Should call lights have internal wires exposed? The Administrator stated, No. The Administrator was asked, Are the call lights attached to an electrical system? The Administrator stated, Yes. The Administrator was asked, Are the internal wires exposed on the call lights have the potential for hazards? The Administrator stated, It could be. 5. On 12/19/19 at 3:31 p.m., the Maintenance Supervisor was asked, Should internal wires be visible on call lights? The Maintenance Supervisor stated, Not normally. The Maintenance Supervisor was asked, Are the call lights attached to electricity? The Maintenance Supervisor stated, There is a small voltage of electricity. The Maintenance Supervisor was asked, Would the internal wires being exposed on the call lights have the potential for hazards? The Maintenance Supervisor stated, Not unless they were broken.

Based on observation, record review, and interview the facility failed to ensure expired drugs or biologicals were stored in a manner that was not readily available for use, and that medications and or supplies were kept safe and secure and only accessible to authorized personnel. This failed practice had the potential to affect 86 residents according to the facility roster matrix that was provided by the Administrator on 12/16/19. The facility failed to ensure expired medications were removed and placed into an area for destruction to prevent potential administration to residents for 1 (Residents #20) of 1 (Residents #20) sampled residents, of 3 residents who had physician's orders for [MEDICATION NAME] suppository according to a list provided by the Director of Nursing (DON) on 12/20/19, and for 1 (Resident # 180) of 2 (Resident # 64 and #180) sampled residents of 3 residents who had physician's orders for [MEDICATION NAME] according to a list provided by the Director of Nursing) on 12/20/19. The findings are: 1. On 12/19/19 at 9:21 a.m., during medication administration observation, Licensed Practical Nurse (LPN)# 4 added Prostat to Clearlax, mixed them together in 4 ounces (oz) of water, and set the cup on the top of the medication cart. She placed a boxed of nasal spray and a box of artificial tears in the top drawer of the medication cart. She locked the medication cart and left the cup of Prostat and Clearlax on the top of the medication cart. She picked up 1 medication cup that contained crushed medications, 1 medication cup that contained whole medications, one medication cup that contained pain medication, eye drops, gloves, and tissue. She entered the resident's room and set the medications on the over-the-bed table. She entered the resident's bathroom to wash her hands and left the medication cart in the hallway outside of the resident's room. The medication cart was not in the nurse's direct line of sight. a. On 12/19/ 19 at 9:25 a.m., LPN #4 walked to the doorway of the resident's room and retrieved the cup that contained the Prostat / Clearlax mixture and continued medication administration pass. b. On 12/19/19 at 12:40 p.m., LPN #4 was asked, Should you leave medication on the top of the medication cart unattended? She stated, No. I should not have. She was asked why medication should not be left on top of the medication cart. She stated, Someone could get ahold of it. c. On 12/19/19 at 2:28 p.m., the Director of Nursing was asked, Should medication be left on the top of the medication cart unattended? She stated, Not unattended, No. She was asked why medication should not be left unattended on the medication cart. She stated, Well, cause another resident could get it. d. A form titled Storage of Medications provided by the Administrator on 12/19/19 at 11:30 a.m. documented, .the facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs .shall not be left unattended if open or potentially available to others . 2. On 12/19/19 at 9:02 a.m., during observation of the 100 Hall medication room the following observations were made: a. On 12/19/19 at 9:02 a.m., a stock plastic jar of [MEDICATION NAME] Suppository's with an expiration date of 7/19 was in the medication refrigerator. b. On 12/19/19 at 9:06 a.m., LPN #1 was asked, Should there be expired medications in the refrigerator? LPN #1, stated No. LPN #1 was asked, Who is responsible for ensuring there are no expired medications in the building? LPN #1 stated, The nurses and nurse managers. c. On 12/19/19 at 9:13 a.m., LPN #2 was asked, What halls have access to the 100 Hall medication room? LPN #2 stated, 100 Hall, 200 Hall, 300 Hall and 1/2 of 400 Hall. 3. Resident #180 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) is in progress and not due at this time. a. The Care Plan dated 12/11/19 documented, (Resident #180) .has impaired cognitive function / dementia or impaired thought processes .was independent with bed mobility .limited assist x (times) 1 for personal hygiene, toilet use, and bathing . b. A Physician's order dated 12/12/19 documented, .[MEDICATION NAME] HCl Tablet 10 MG (milligrams) Give 1 tablet by mouth every 8 hours as needed for muscle spasms . c. The (MONTH) 2019 Medication Administration Record [REDACTED]. d. On 12/19/19 at 11:51 a.m., there was a card labeled [MEDICATION NAME] Tablet 10 mg containing 17 tablets for Resident #180 with an expiration date of 4/25/18. Registered Nurse (RN) #1 was asked, Does Resident #180 still reside in the facility? RN #1 stated, Yes. RN #1 was asked, Is this medication expired? RN #1 stated, Yes. RN #1 was asked, Should expired medications be left in the medication cart or in the medication rooms? RN #1 stated, No. e. On 12/19/19 at 12:10 p.m., the DON was asked, Should expired medications be in the medication carts and medication rooms? The DON stated, No. The DON was asked, What could happen if a resident is given an expired medication? The DON stated, They could have a reaction? The DON was asked, Who is responsible for ensuring expired medications are not used? The DON stated, The nurses and nurse supervisors. f. On 12/19/19 at 12:13 p.m., the Administrator was asked, Should expired medications be in the medication carts and medication rooms? The Administrator replied, No. The Administrator was asked, What could happen if a resident is given an expired medication? The Administrator stated, It would depend on the medication. The Administrator was asked, Who is responsible for ensuring expired medications are not used? The Administrator stated, Nurses. 4. Resident #20 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD 10/5/19 documented the resident scored 5 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required extensive physical assistance of 2 persons for bed mobility, toilet use, and required extensive physical assistance of 1 person for transfer, dressing, and personal hygiene; and was frequently incontinent of bladder and occasionally incontinent of bowel. a. On 12/16/19 at 1:11 p.m., there was a 4-ounce tube of [MEDICATION NAME] ointment on Resident #20's night stand. b. As of 12/16/19 there was no physician order for [REDACTED].>c. As of 12/16/19 there was no documentation on Resident #20's is not care plan to have [MEDICATION NAME] at her bedside. d. On 12/16/19 at 3:21 p.m., there was a 4-ounce tube of [MEDICATION NAME] ointment left on Resident #20's night stand. e. As of 12/16/19 there was no physician order for [REDACTED].>f. As of 12/16/19 there is no documentation on Resident #20's care plan to have [MEDICATION NAME] at her bedside. g. On 12/17/19 at 2:35 p.m., DON was asked, Is there any resident who has an order to self-administer medications? The DON stated, No. The DON was asked, Is [MEDICATION NAME] ointment a medication? The DON stated, They do consider it a medication. The DON was asked, Should [MEDICATION NAME] ointment be left out in the open? The DON stated, No. The DON was asked, Does the ointment that was left out in the open have the potential for hazards? The DON stated, Yes. Out in the open. h. On 12/18/19 at 11:15 a.m., the Administrator was asked, Should [MEDICATION NAME] be left out in the open? The Administrator stated, I would not recommend it. The Administrator was asked, Would this have the potential for hazards? The Administrator stated, I believe the ointment would. The Administrator was asked, Who is responsible for ensuring these items are not left out in the open? The Administrator stated, We do hall rounds, primarily the staff. i. A form titled [MEDICATION NAME] Ointment provided by the Administrator on 12/18/19 at 11:10 a.m. document, .Warning .Avoid contact with eyes .Keep out of reach of children . 5. Resident #32 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 10/23/19 documented the resident scored 14 (13-15 indicates cognitively intact) on BIMS; and required extensive physical assistance of 1 person for bed mobility, transfer, dressing, toilet use, and personal hygiene; and was occasionally incontinent of bladder and was always continent of bowel. a. On 12/16/19 at 11:26 a.m., Resident #32 was lying in her bed. There was bottle of body powder on the resident ' s bedside table. b. On 12/16/19 at 2:39 p.m., there was a 10-ounce bottle of powder that was setting on bedside table in Resident #32's room. c. On 12/17/19 at 9:18 a.m., Resident #32 was in her bed with her eyes closed. There was a 10-ounce bottle of powder setting on Resident #32's bedside table. d. On 12/17/19 at 1:05 p.m., there was a 10-ounce bottle of powder on Resident #32's bedside table. e. As of 12/17/19 there is no physician's order for Resident #32 to have body powder. f. As of 12/17/2019 Resident #32 was not care planned to have body powder at her bedside. g. On 12/17/19 at 2:37 p.m., Resident #32 stated, They were putting that powder on the small minute' area between my cheeks on my backside, but they are putting cream on it now. h. A form titled Medicated Original Strength Body Powder provided by the Administrator on 12/19/19 document, .External use only .Keep out of reach of children .is swallowed, get medical help or contact a Poison Control Center immediately .

Based on observation, record review, and interview, the facility failed to ensure heels were off-loaded to prevent development of pressure sores for 1 of 1 (Resident #49) sample residents who required off-loading of heels. This failed practice had the potential to affect 1 resident who was care planned to off-load heels according to a list provided by the Administrator on 1/2/19. The findings are: Resident #49 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date ARD of 11/16/19 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); and required extensive physical assistance of 2 persons for bed mobility, toilet use, was totally dependent on 2 person for transfers, and required extensive physical assistance of 1 person for dressing, eating, and personal hygiene; and was always incontinent of bladder and occasionally incontinent of bowel; was at risk for pressure ulcers and used pressure relieving devices for the bed. a. The Care Plan dated 2/11/19 documented, .The resident has potential for pressure ulcer development r/t (related to) weakness and limited mobility .Float heels while in bed . b. On 12/17/19 at 3:09 p.m., Resident #49 was lying in her bed. Resident #49's heels were not floated. Certified Nursing Assistant (CNA) #1 was asked, Is Resident #49's heels floated? CNA #1 stated, No. CNA #1 was asked, Should Resident #49's heels be floated? CNA #1 stated, Yes. c. On 12/19/19 at 3:34 p.m., CNA #2 was asked, Is Resident #49 supposed to have her heels floated while she is in bed? CNA #2 stated, Yes. d. On 12/19/19 at 3:37 p.m., the Director of Nursing (DON) was asked, Should assistive devices be in place for residents to prevent pressure ulcers if it is care planned? The DON stated, Yes. e. On 12/20/19 at 8:18 a.m., the Administrator was asked, Should assistive devices be in place to prevent pressure ulcers for residents be implemented? The Administrator stated, If there is an order for [REDACTED].>

Complaint # , was substantiated (all or in part) with these findings Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding a significant change in physical and mental function after a stay in a behavioral health hospital, which resulted in a delay in treatment for 1 (Resident #5) of 2 (Resident #2 and #5) case mix residents who were readmitted from a hospital in the past 2 months. This failed practice resulted in actual harm to Resident #5, who was hospitalized and diagnosed with [REDACTED]. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/12 documented the resident had severely impaired cognitive skills for daily decision-making per a staff assessment of mental status, required extensive assistance of 1 person for transfers, ambulation and eating and utilized a wheelchair for mobility. a. The Plan of Care dated 12/19/12 documented, "I wheel myself throughout the facility throughout the day. I like people and enjoy watching them and even socializing. I am unsteady when ambulating because I get in a big hurry and just take off and my balance is not good. I am now in a chair that leans back but that I can propel myself. They walk with me every 2 hours when I am in the wheelchair and also take me to the bathroom every 2 hours. I drool. I have abnormal facial movements with tongue thrusting so I need help with oral care. My speech is unclear but I can make myself understood". b. A Nurse's Note dated 12/12/12 and signed by Licensed Practical Nurse (LPN) #1 documented, "8:47 a.m. CNA (Certified Nursing Assistant) reports resident kicking and hitting during care, states resident resisting when they attempt to ambulate....resident states he's mad and doesn't want to be here states he feels like he is in prison here.....9:30 a.m. Ambulating resident with 2 CNA's.....Resident slapped CNA across the face...Resident sitting in the wheelchair smiling as CNA reported this to this nurse, I told him he can't act this way, he was going to hurt someone or himself and he states, 'I know it' with a smile on his face... All information passed on to Director of Nursing (DON) and Administrator. DON states he's going to try to get placement at Behavior Unit. Functional Status: Extensive assist of one person transfers, ambulation, eating. c. A Nurse's Note dated 12/13/12 documented, "9:20 a.m. Resident is propelling self throughout facility in wheelchair. Has released alarm belt several times this am, states he is mad. CNA reports that resident attempting to hit this a.m. (morning). Resident smiling at this time... Functional status: Extensive assist of one person for transfers, ambulation, eating ... 12:45 p.m. Resident transported to (Behavioral Health Facility)." The Psychiatric Discharge Summary dated 12/24/12 documented, "admitted [DATE]. Staff have reported increasing combativeness and being physically violent with CNA's. He has been admitted for evaluation and treatment. 12/24/12. Hospital course and treatment: For this patient was to utilize [MEDICATION NAME] and [MEDICATION NAME] for his agitation, [MEDICATION NAME] for his involuntary movements... In addition, we got him/her on [MEDICATION NAME] every a.m. for mood stability... Continues to have involuntary movements, although they are lessened a little bit on the [MEDICATION NAME]/[MEDICATION NAME]. No major disturbance or agitation. There is no over sedation or EPS (extrapyramidal symptoms) with the [MEDICATION NAME]. Follow up care will be with (Primary Care Physician) at the nursing home." d. A Nurse's Note dated 12/24/12 at 2:50 p.m. and signed by LPN # 2 documented, "Resident returned to facility... resident very lethargic, tired. Functional status: limited assist of one person for eating, extensive assistance of one for transfers, ambulation". e. A Nurse's Note dated 12/25/12 at 10:15 a.m. and signed by LPN #1 documented, "CNA reported lethargic this a.m. Assist X (times) 1-2 with most ADL's (activities of daily living), resident responded to verbal stimuli when this nurse administered morning meds, took all meds crushed, appetite down at breakfast..." f. A Nurse's Note dated 12/26/12 at 9:00 a.m. and signed by LPN #1 documented, "Resident up to dining room for breakfast this morning, took all meds crushed... propelling self throughout facility in wheelchair at this time, assist x 1-2 all ADL's". g. A Nurse's Note dated 12/26/12 at 6:00 p.m. and signed by LPN #2 documented, "Notified by CNA's that resident ate a bowl of tomato soup, a milkshake that consisted of ice cream, instant breakfast and Mighty Shake, drank glass of tea and glass of water for dinner..." h. A Nurse's Note dated 12/27/12 at 7:30 a.m. and signed by LPN #1 documented, "Resident very lethargic this morning at breakfast. Wouldn't hold his head up to take meds or eat, had to be fed. After breakfast continued to hold head down but was rocking self in wheelchair." There was no documentation the physician was immediately consulted regarding the resident's increased lethargy and inability to hold his own head up during the meal. i. A Nurse's Note dated as a late entry for 12/27/12 at 12:00 p.m. and signed by LPN #1 documented, "Fax sent to MD (Medical Doctor) related to resident's pupils seem fixed, resident very lethargic the past few days, resident unable to follow with his eyes, appetite poor requiring feeding assistance of 2 related to resident unable to hold his head up, resident nonverbal today, sent copy of MAR (Medication Administration Record) for review, awaiting response, past (sic) on to oncoming nurse". Vital signs documented on the fax to the physician were documented as, "BP (blood pressure) 148/54, Temp (temperature) 96.9, pulse 76, and respirations 20." There was no documentation the nurse attempted to call and speak with the physician regarding the resident's significant change in condition. 1.) On 2/6/13 at 11:00 a.m., LPN #1 stated, "(Resident) was lethargic ever since he came back from the hospital. I thought it would wear off in a few days, but he got worse. That last day he was here, he couldn't even hold his head up by himself and he quit eating. I faxed the doctor, but I didn't hear anything back before I went home. The next day, I found out they got an order to send him to the hospital." LPN #1 stated she had not called the physician on the morning of 12/27/12 when she noticed he was, a "lot worse", but that she had sent a fax to the physician, "sometime around noon". 2.) A copy of the fax transmission confirmation dated 12/27/12 and provided by the Administrator on 2/7/12 documented the fax was not transmitted to the physician until 1:36 p.m. j. On 2/7/13 at 11:00 a.m., CNA #1 stated the resident was, "a lot worse" on the morning of 12/27/12 and, " ...he couldn't even hold his head up". CNA #1 stated that CNA #2 had to hold the resident's head up with her hands while CNA #1 tried to feed him. She stated the resident, "wasn't swallowing" and, "mostly wouldn't open his mouth". She stated she did not have to report this to the nurse, because LPN #1 was in the dining room, observed the resident and informed the CNA that she would contact the doctor. k. A Telephone Encounter form dated 12/27/12 at 5:29 p.m. documented, "Spoke with (LPN #2) at (facility) and she said the patient returned to nursing home from behavioral health on 12/24/12 in the present condition. (LPN #2) said patient's vitals (vital signs) at 3 p.m. are BP 92/60, pulse 100, respirations 28, temp 100.0... gave verbal order to send patient to ER (emergency room ) and gave order to (LPN #2) over the phone." On 2/6/13 at 3:25 p.m., LPN #2 stated the resident had a, "big change" in condition that concerned her after he returned from the hospital, but that she thought medications administered to the resident in the hospital were making him lethargic. She stated the resident's vital signs were, "basically normal until the last day he was here." The LPN stated she had not immediately telephoned or faxed the physician to report the decreased blood pressure, increased temperature, pulse and respiratory rate that were obtained on 12/27/12 at 3:00 p.m. l. A Nurse's Note dated 12/27/12 at 6:00 p.m. documented, "New order to send resident to ER for eval (evaluation) ... 6:15 p.m. Ambulance here". m. The transfer form dated 12/27/12 documented, "Vital signs: BP 114/82, pulse 96, respirations 30, Temperature 101. Resident lethargic, unable to sit up in wheelchair, slumps over, no verbal communication with staff, decreased appetite, rapid respirations, BP up and down, was 92/60 earlier". n. The Hospital Discharge Summary dated 12/30/12 documented, "History of present illness: ...sudden decline of mentation and marked elevation of white count. He had been previously close to his normal baseline. Hospital Summary: ...patient initially presented in acute [MEDICAL CONDITION] with his creatinine being 14 which did improve a little with hydration, but on the day of his demise, his creatinine was back to 14. His white count was 87,000. The patient was found without heart rate, respirations, pupils were dilated and fixed, and he was unresponsive to deep pain. He was pronounced dead at 7:45 on 12/30/12. Discharge Diagnosis: [REDACTED]. 2. Acute [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. 5. Dementia." o. On 2/7/13 at 9:10 a.m. the Director of Nursing stated he was off during the time of the residents decline but added, "The nurses should have called (the physician) immediately when they noticed the change in (resident #5) condition. They (the nurses) should have not faxed the information."

Complaint # , was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure necessary care and services were promptly provided to address a significant change in mental and physical status after a stay in a behavioral health hospital for Resident #5. The facility failed to immediately conduct a thorough assessment including vital signs upon discovery of the change in condition and failed to immediately consult the physician regarding the changes, which resulted in a delay in treatment for 1 (Resident #5) of 2 (Residents #2 and #5) case mix residents who were readmitted from a hospital in the past 2 months. The failed practices resulted in actual harm to Resident #5, who was hospitalized and diagnosed with [REDACTED]. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/12 documented the resident had severely impaired cognitive skills for daily decision-making per a staff assessment of mental status, required extensive assistance of 1 person for transfers, ambulation and eating and utilized a wheelchair for mobility. a. The Plan of Care dated 12/19/12 documented, "I wheel myself throughout the facility throughout the day. I like people and enjoy watching them and even socializing. I am unsteady when ambulating because I get in a big hurry and just take off and my balance is not good. I am now in a chair that leans back but that I can propel myself. They walk with me every 2 hours when I am in the wheelchair and also take me to the bathroom every 2 hours. I drool. I have abnormal facial movements with tongue thrusting so I need help with oral care. My speech is unclear but I can make myself understood." b. A Nurse's Note dated 12/12/12 and signed by Licensed Practical Nurse (LPN) #1 documented, "8:47 a.m. CNA (Certified Nursing Assistant) reports resident kicking and hitting during care, states resident resisting when they attempt to ambulate....resident states he's mad and doesn't want to be here states he feels like he is in prison here.....9:30 a.m. Ambulating resident with 2 CNAs.....Resident slapped CNA across the face...Resident sitting in the wheelchair smiling as CNA reported this to this nurse, I told him he can't act this way, he was going to hurt someone or himself and he states, 'I know it' with a smile on his face... All information passed on to Director of Nursing (DON) and Administrator. DON states he's going to try to get placement at Behavior Unit. Functional Status: Extensive assist of one person transfers, ambulation, eating." c. A Nurse's Note dated 12/13/12 documented, "9:20 a.m. Resident is propelling self throughout facility in wheelchair. Has released alarm belt several times this am, states he is mad. CNA reports that resident attempting to hit this a.m. (morning). Resident smiling at this time... Functional status: Extensive assist of one person for transfers, ambulation, eating ... 12:45 p.m. Resident transported to (Behavioral Health Facility)." The Psychiatric Discharge Summary dated 12/24/12 documented, "admitted [DATE]. Staff have reported increasing combativeness and being physically violent with CNAs. He has been admitted for evaluation and treatment. 12/24/12. Hospital course and treatment: For this patient was to utilize [MEDICATION NAME] and [MEDICATION NAME] for his agitation, [MEDICATION NAME] for his involuntary movements... In addition, we got him/her on [MEDICATION NAME] every a.m. for mood stability... Continues to have involuntary movements, although they are lessened a little bit on the [MEDICATION NAME]/[MEDICATION NAME]. No major disturbance or agitation. There is no over sedation or EPS (extrapyramidal symptoms) with the [MEDICATION NAME]. Follow up care will be with (Primary Care Physician) at the nursing home." d. A Nurse's Note dated 12/24/12 at 2:50 p.m. and signed by LPN #2 documented, "Resident returned to facility... resident very lethargic, tired. Functional status: limited assist of one person for eating, extensive assistance of one for transfers, ambulation." e. A Nurse's note dated 12/24/12 at 10:30 p.m. and signed by LPN #3 documented, "Resident resting in bed with eyes open and fixed at this time. Resident lethargic, non-verbal response to staff verbal cues and questions. Respirations even and non-labored. Increased weakness noted, increased assistance needed per staff for ADL's. No visible s/sx (signs and symptoms) distress or discomfort noted ..." f. A Nurse's Note dated 12/25/12 at 10:15 a.m. and signed by LPN #1 documented, "CNA reported lethargic this a.m. Assist X (times) 1-2 with most ADLs (activities of daily living), resident responded to verbal stimuli when this nurse administered morning meds, took all meds crushed, appetite down at breakfast..." A Nurses Note dated 12/25/12 at 2:45 p.m. and signed by LPN #2 documented, "Resident in Geri chair at this time with head laying on arm rest and pillow. Eyes open and fixed, mouth open with tongue hanging out, resident continues to be lethargic. No verbal response by resident when shook hand ...will continue to monitor." A Nurses Note dated 12/25/12 at 10:25 p.m. and signed by LPN# 3 documented, " ...resident continues with non-verbal response ..." g. A Nurse's Note dated 12/26/12 at 9:00 a.m. and signed by LPN #1 documented, "Resident up to dining room for breakfast this morning, took all meds crushed... propelling self throughout facility in wheelchair at this time, assist x 1-2 all ADLs." A Nurses Note dated 12/26/12 at 2:15 p.m. and signed by LPN #2 documented, " ...resident fidgety, moving head from side to side, tongue in and out of mouth ..." A Nurse's Note dated 12/26/12 at 6:00 p.m. and signed by LPN #2 documented, "Notified by CNAs that resident ate a bowl of tomato soup, a milkshake that consisted of ice cream, instant breakfast and Mighty Shake, drank glass of tea and glass of water for dinner... resident continues to be tired and has no energy ..." h. A Nurse's Note dated 12/27/12 at 7:30 a.m. and signed by LPN #1 documented, "Resident very lethargic this morning at breakfast. Wouldn't hold his head up to take meds or eat, had to be fed his breakfast ...did open eyes to verbal stimuli ...After breakfast at 8:30 a.m. resident in lobby with head down eyes open, rocking self in wheelchair back and forth, no s/sx of distress noted ..." A Nurse's Note dated as a late entry for 12/27/12 at 12:00 p.m. and signed by LPN #1 documented, "Fax sent to MD (Medical Doctor) related to resident's pupils seem fixed, resident very lethargic the past few days, resident unable to follow with his eyes, appetite poor requiring feeding assistance of 2 related to resident unable to hold his head up, resident nonverbal today, sent copy of MAR (Medication Administration Record) for review, awaiting response, past (sic) on to oncoming nurse." Vital signs were documented on the fax to the physician as, "BP (blood pressure) 148/54, Temp (temperature) 96.9, pulse 76, and respirations 20." There was no documentation the nurse attempted to call and speak with the physician regarding the resident's significant change in condition. 1) On 2/6/13 at 11:00 a.m., LPN #1 stated, "(Resident) was lethargic ever since he came back from the hospital. I thought it would wear off in a few days, but he got worse. That last day he was here, he couldn't even hold his head up by himself and he quit eating. I faxed the doctor, but I didn't hear anything back before I went home. The next day, I found out they got an order to send him to the hospital." LPN #1 stated she had not called the physician on the morning of 12/27/12 when she noticed he was, a "lot worse", but that she had sent a fax to the physician, "sometime around noon." 2) A copy of the fax transmission confirmation dated 12/27/12 and provided by the Administrator on 2/7/12 documented the fax was not transmitted to the physician until 1:36 p.m. There was no documentation the nurse attempted to call and speak with the physician regarding the resident's significant change in condition. i. On 2/7/13 at 11:00 a.m., CNA #1 stated the resident was, "a lot worse" on the morning of 12/27/12 and, " ...he couldn't even hold his head up." CNA #1 stated that CNA #2 had to hold the resident's head up with her hands while CNA #1 tried to feed him. She stated the resident, "wasn't swallowing" and "mostly wouldn't open his mouth." She stated she did not have to report this to the nurse, because LPN #1 was in the dining room, observed the resident and informed the CNA that she would contact the doctor. j. A Telephone Encounter form dated 12/27/12 at 5:29 p.m. documented, "Spoke with (LPN #2) at (facility) and she said the patient returned to nursing home from behavioral health on 12/24/12 in the present condition. (LPN #2) said patient's vitals (vital signs) at 3 p.m. are BP 92/60, pulse 100, respirations 28, temp 100.0... gave verbal order to send patient to ER (emergency room ) and gave order to (LPN #2) over the phone." On 2/6/13 at 3:25 p.m., LPN #2 stated the resident had a, "big change" in condition that concerned her after he returned from the hospital, but that she thought medications administered to the resident in the hospital were making him lethargic. She stated the resident's vital signs were, "basically normal until the last day he was here." The LPN stated she had not immediately telephoned or faxed the physician to report the decreased blood pressure, increased temperature, pulse and respiratory rate that were obtained on 12/27/12 at 3:00 p.m. k. A Nurse's Note dated 12/27/12 at 6:00 p.m. documented, "New order to send resident to ER for eval (evaluation)... 6:15 p.m. Ambulance here." The transfer form dated 12/27/12 documented, "Vital signs: BP 114/82, pulse 96, respirations 30, Temperature 101. Resident lethargic, unable to sit up in wheelchair, slumps over, no verbal communication with staff, decreased appetite, rapid respirations, BP up and down, was 92/60 earlier." l. The Hospital Discharge Summary dated 12/30/12 documented, "History of present illness: ...sudden decline of mentation and marked elevation of white count. He had been previously close to his normal baseline. Hospital Summary: ...patient initially presented in acute [MEDICAL CONDITION] with his creatinine being 14 which did improve a little with hydration, but on the day of his demise, his creatinine was back to 14. His white count was 87,000. The patient was found without heart rate, respirations, pupils were dilated and fixed, and he was unresponsive to deep pain. He was pronounced dead at 7:45 on 12/30/12. Discharge Diagnosis: [REDACTED]. 2. Acute [MEDICAL CONDITION]. 3. [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. 5. Dementia." m. On 2/7/13 at 9:10 a.m. the Director of Nursing stated he was off during the time of the residents decline but added, "The nurses should have called (the physician) immediately when they noticed the change in (resident #5) condition. They (the nurses) should have not faxed the information."