Every finding on record at Elmhaven East

Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and preparation in the facility's one kitchen to prevent the spread of food borne illness to the residents of the facility. Findings included:- Initial tour of the kitchen on 06/08/2026 at 08:28 AM with Dietary Staff DD revealed the following areas of concern: Numerous baking sheets, baking pans, and cooking pots had black staining on the interior and exterior of the cookware and bakeware. Ground nutmeg and ground cloves dated 11/11/2019. An undated, unsealed bag containing a biscuit, an unsealed, undated loaf of bread, and a box of brown rice dated 05/20/2026 with an expiration date of 03/04/2026. There were food items not clearly dated, which created an inability to confirm what year was intended for those items. One container of ketchup dated 02/12, one large container of picante sauce dated 02/24, one large container of relish dated 03/24, one jar of spicy mustard dated 06/04, one unsealed bag of meat dated 06/04, one unsealed bag of meat dated 06/05, numerous packages of butter dated 05/11, and a few packages of butter dated 06/04. There were items that were either not dated and/or the packaging was unsealed: one jar of horseradish mustard not dated, one bag of whole carrots unsealed and undated, one unsealed and undated bag of mandarin oranges, one pan of fruit cobbler that was not labeled or dated and one pan of chocolate chip cookies that was not labeled or dated sitting on top of baking sheets and pans located underneath the cooks prep table. Further observation of the cooler documented that there were five uncovered crates of eggs on the bottom of the cooler, exposed to open packages of meat and food on the open shelf above them. Five boxes of pancake mix dated 06/04, five bags oatmeal dated 05/21, and one bag of oatmeal dated 06/07, ten containers of syrup dated 05/28, three cans of jellied cranberries dated 04/03, one jug of Worcestershire sauce dated 01/19, one jug of teriyaki sauce dated 10/23, one unsealed bag of tortillas dated 06/05, two bags of sliced oranges and two bags of red grapes dated 06/04 on cart in unrefrigerated pantry, one box of no bake cheesecake dated 04/24, one package of walnut pieces dated 04/13, seven bags of powdered sugar dated 09/18, five bags of sugar dated 05/14, one unsealed bag of potato chips, one undated package of dried cranberries, an unsealed and undated large package of spaghetti noodles,. One bag of frozen sausage patties dated 5/10, one bag of sausage links dated 06/06, and one bag of uncooked frozen roll dough was unsealed, undated, and not labeled. Observation on 06/08/2026 at 09:01 AM documented a chest freezer containing several packages of frozen food without a thermometer inside the freezer. The chest freezer temperature log for June 2026 documented the following temperatures:06/09/2026 AM -4 degrees PM 3 degrees06/08/2026 AM 5 degrees PM 5 degrees06/07/2026 AM 5 degrees PM no documented temperature06/06/2026 AM 5 degrees PM -4 degrees06/05/2026 no documented temperatures06/04/2026 AM -5 degrees PM -5 degrees06/03/2026 AM -5 degrees PM 4 degrees06/02/2026 AM -5 degrees PM 5 degrees06/01/2026 AM -5 degrees PM 4 degrees Observation on 06/10/2026 at 08:15 AM documented the cooler with six bottles of undated protein shakes. During an interview on 06/08/2026 09:07 AM, Dietary Staff DD reported that the chest freezer should have a thermometer in it and that if the thermometer falls to the bottom of the freezer or it is just not in there staff does not dig through the freezer to find it and if the thermometer is not found they just put a temperature on the temperature log close to what temperatures had previously been recorded. Dietary Staff DD further reported that when using the sheets & pans that are blackened, she uses tin foil to cover the pans and sheets prior to using them. During an interview on 06/10/2026 at 10:23 AM, Dietary Staff BB reported that the coolers and freezers should always have a working thermometer, and any recorded temperature should be the observed temperature; staff should never document a temperature if it was not observed. All food items should be dated with a visible and readable date that includes the day, month, and year. Dietary Staff BB also reported that spices & any food item that is expired should be removed and not used, and food packaging should be secured. Eggs should have protection if they are stored underneath open food items. Food should never be stored on bakeware and should always be labeled and dated. Dietary Staff BB did dispose of the undated and unlabeled cobbler and cookies as soon as she saw them. During an interview on 06/10/2026 at 11:12 AM, Dietary Staff CC reported that staff should be dating food items accurately, and the date should have the year on it as well. Food items should always be accurately dated and labeled with the contents of the container. Dietary Staff CC further reported that no temperature should ever be logged if it was not observed. All coolers and freezers should always have a working thermometer, and temperatures should be monitored daily, eggs should not be stored below any food item that has the possibility to contaminate them. The facility's undated Food Storage (Dry, refrigerated, and frozen) guideline documented that all food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety.

Based on interview and record review, the facility failed to ensure the mandatory 12 hours of education was completed for Certified Nurse Aides (CNA)/Certified Medication Aides (CMA) as required. Findings included:- A review of the facility's staffing list revealed the following CNAs were employed with the facility for more than 12 months: CNA M was hired on 11/20/2024. She had no specific hours tracked for in-service training.CNA O was hired on 01/23/2023. She had no specific hours tracked for in-service training.CNA LL was hired on 07/18/2024. He had no specific hours tracked for in-service training.CNA PP was hired on 07/19/2021. She had no specific hours tracked for in-service training.CNA QQ was hired on 08/16/2024. She had no specific hours tracked for in-service training. Upon request of the CNA in-service hours, the facility provided monthly in-service sign-in sheets for the months from 05/2025 through 05/2026 that included staff names and signatures in attendance. The list lacked staff certification or position. The sheets lacked specific times for the required topics. During an interview on 06/09/2026 at 01:46 PM, Administrative Staff A stated that there was CNA/CMA training throughout the year as needed, with meetings where they review the policy, including in-house videos, huddles with education, and constant in-service meetings with staff that were documented, and he felt that was acceptable as it keeps track of all hours of the meetings. He stated he had another sheet to keep track of the hours for that and would bring it to us. During a second interview on 06/09/2026 at 02:03 PM, Administrative Staff A stated that he did not have anything that showed that the hours and training were done for the specific training, just timecards showing they clocked in and out for the day, and he had a meeting for training but nothing that kept track of each one individually and what the training was. He had a sign-in sheet for in-service meetings. During an interview on 06/10/2026 at 10:38 AM, Administrative Nurse F stated that they do not use any computer-based training. They use an outline on a written sign in sheet and give handouts for staff to refer to. Administrative Nurse F stated they do not keep track of specific hours. During an interview on 06/10/2026 at 11:17 AM, CNA M stated that they received annual abuse, neglect, and exploitation training and that they have meetings where they would watch videos as a group and receive paperwork to refer to by clocking in for the meeting if they were not already clocked in.The facility policy In-Service Training Program, Nurse Aide dated 2001, revised on 12/2016, documented that all nurse aide personnel would participate in regularly scheduled in-service training classes. Annual in-services must be no less than 12 hours per employment year.

Based on interviews, record reviews and observation, the facility staff failed to implement adequate infection control practices related to hand hygiene and sanitization of shared equipment. The facility staff also failed to implement adequate Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 1 while flushing his urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Findings included:- Observed on 06/09/2026 at 07:50 AM, R16 had an EBP gown and gloves with signage outside her room. Observed on 06/09/2026 at 07:58 AM, Licensed Nurse (LN) G performed hand hygiene and then donned a gown and gloves and proceeded to apply skin lotion to R16's arms and legs. R16 had a skin tear to her left forearm, a scabbed wound on her left hand, a deep tissue wound to her right heel, and a wound on her right shin that had Steri-strips (adhesive wound closures) on it. LN G did not change gloves or perform hand hygiene before applying lotion to R16's different limbs. Once the lotion was applied, LN G removed her gloves, performed hand hygiene and then put on clean gloves and placed the clean dressing supplies directly on R16's bed sheet, next to her right leg. The bed sheet was visibly soiled and had a large amount of blood on it next to her head. LN G then performed wound care on R16's right leg and heel without placing a barrier between the leg and the bed sheet. LN G cleaned the wound and applied the clean dressings without changing gloves and performing hand hygiene. Once the wound care was completed, LN G removed her gloves, touched the clean dressing with her bare hand, and dated it. Observed on 06/09/2026 at 08:50 AM, the Hoyer lift was taken into R16's room without being sanitized. Staff used the Hoyer and then it was removed from R16's room and taken to another room without being sanitized. Observed on 06/09/2026 at 08:57 AM, LN G performed hand hygiene, donned clean gloves, and then flushed R1's urinary catheter. She did not wear a gown for EBP. On 06/09/2026 at 10:40 AM, LN G stated that she should have changed gloves and performed hand hygiene when she applied lotion to each limb of R16, and she should have had a barrier on the sheet when she performed wound care. She also said that she should not have placed the clean wound supplies directly on the sheet, should have changed gloves and performed hand hygiene between each step of the wound care, and should have maintained gloves when dating the dressing. LN G also said she should have worn a gown along with gloves when performing the catheter flush. On 06/09/2026 at 11:05 AM, Administrative Nurse E stated that when handling or performing any urinary catheter care, there should have been gloves and a gown worn. She also said that after every Hoyer lift use, it was to be properly sanitized regardless of EBP PPE. Administrative Nurse then said that gloves and hand hygiene were to be performed from dirty to clean dressing changes and from wound area to wound area, and there should have been a barrier placed on the surface under the limb or body part that the wound was on, and the clean supplies should not have been placed directly on a surface without barrier protection. The facility policy Infection Control Policy, dated 05/21/2023, documented that hand hygiene would be performed before and after contact with a resident, immediately after touching blood, body fluids, non-intact skin, mucous membranes or contaminated items (even when gloves were worn during contact), immediately after removing gloves, when moving from contaminated body sites to clean body sites during resident care, and after touching objects and medical equipment in immediate resident care area. The policy also documented that routine cleaning and disinfection of resident care equipment, including equipment shared among residents, would be performed prior to and after each use.

Based on interview, observation, and record review, the facility failed to protect the dignity of Resident (R) 16 when staff left her breasts exposed unnecessarily while proving care and did not offer or place to a cover for the exposed areas not being cared for. Findings included:- The Electronic Medical Record (EMR) for R16 documented diagnoses of anorexia nervosa (an eating disorder and serious mental health condition), history of falling, gout (inflammation of the joints), type 2 diabetes mellitus with diabetic neuropathy (a common complication of type 2 diabetes mellitus where chronically high blood sugar damages nerves throughout the body), and major depression. R16's admission Minimum Data Set (MDS), dated 05/06/2026, documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment documented that she used a wheelchair for mobility. The MDS did not indicate R16 used a mechanical lift for transfers. The MDS documented that she required substantial to maximum assistance with oral and personal hygiene, as well as upper-body dressing. R16 was dependent on staff for all other activities of daily living (ADL) and all transfers. R16's ADL-Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/06/2026, documented that she had falls, contractures (abnormal fixation of a joint or muscle), was incontinent, required substantial to maximum assistance for oral and personal hygiene and upper body dressing, and was dependent on staff for all other ADL's. R16's Urinary Incontinence and Indwelling Catheter CAA, dated 05/06/2026, documented that she was always incontinent of bowel and bladder. R16's Care Plan, dated 05/10/2026, documented that she was no longer capable of completing her own ADL's due to a decline in physical functioning from multiple past falls at home before admission that have resulted in overwhelming fear of falling again. The interventions, dated 05/10/2026, documented that R16 was dependent on staff for toileting hygiene and lower body dressing, and she required substantial staff assistance for personal hygiene and upper body dressing. Observed on 06/09/2026 at 08:21 AM, R16 had a bowel movement, and Licensed Nurse (LN) G, Certified Nurse Aide (CNA) M, and CNA N cleaned her up and then dressed her. During the entire ADL care process, she was left fully naked on her bed with no dignity cover offered or placed over her body. Her breasts were left exposed unnecessarily. On 06/09/2026 at 08:51 AM, CNA N said that during the ADL cares performed on R16, a sheet should have been placed over R16's upper body for dignity. On 06/09/2026 at 11:05 AM, Administrative Nurse E stated that when ADL cares were performed on a naked resident, there should have been some type of dignity cover placed over the resident, the curtain pulled, and the door closed. On 06/09/2026 at 11:17 AM, Administrative Nurse D stated that when ADL cares were performed on a resident, staff should have ensured the window blinds were closed, the privacy curtain and/or door were shut, and the area where the resident cares were not performed should have had a dignity cover. The facility policy Resident Rights, dated December 2016, documented that employees would treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to ensure Resident (R) 7's psychotropic as-needed (PRN) medication had the required 14 days stop date or a specified duration with a physician documented, rationale for the extended duration. Findings included:-R7's Electronic Medical Record (EMR) revealed the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), and dementia (a progressive mental disorder characterized by failing memory and confusion) with delusions and/or hallucinations. R7's 12/10/2025 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R7 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), anticonvulsant, and opioid (a class of controlled drugs used to treat pain). R7's 12/10/2025 Psychotropic Drug Use Care Area Assessment (CAA) documented that R7 had behaviors and was transferred to a behavior unit. R7 returned with an antipsychotic and appeared cheerful and no longer tried to exit without staff knowledge. R7 took an antidepressant and an antianxiety routine as needed. R7's Care Plan documented that R7 took two different antianxiety medications, an antidepressant, and an antipsychotic. R7's Physician's Orders documented an order for Ativan (medication to treat anxiety) 0.5mg twice a day as needed, start date 12/24/2025. The order lacked a stop date. On 06/08/26 at 10:25 AM, R7 went to her room and invited this nurse in to visit. R7 appeared relaxed, in a very pleasant mood, and answered questions appropriately. On 06/09/26 at 10:42 AM, Administrative Nurse E stated she called the doctor every two weeks to continue the order for the as needed Ativan, but the order did not have a stop date. She did not know it was a requirement for the order to have an actual stop date. Administrative Nurse E stated the doctor did not provide a rationale for extending the as-needed Ativan stop date longer than two weeks. On 06/10/2026 11:23 AM, Administrative Nurse D stated she was unaware that antianxiety medications that were given PRN were required to have a two week stop date unless there is a rationale for an extended duration with a stop date. The facility policy for Antipsychotic Medication Use, undated, documented that the need to continue as-needed orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration for the as needed order will be indicated in the order.

Based on observation, interview, and record review, the facility failed to provide Resident (R) 3 with a written notification of transfer to the resident and/or his representative as soon as practicable after R3 was transferred to the hospital. Findings included:- R3's Electronic Medical Record (EMR) revealed a diagnosis of severe sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), renal failure (inability of the kidneys to excrete waste, concentrate urine, and conserve electrolytes), and below-the-knee amputation (surgical removal of a body part). R3's 04/27/2026 at 10:04 AM Nurse's Note documented that he lay on his bed staring off. R3's pupils were dilated, and his response was sluggish. R3 slurred his words; he was unable to finish a sentence, unable to communicate what was wrong, and his breathing was rapid. The nurse notified the doctor, and R3 was transported to the hospital by ambulance. R3's EMR lacked evidence that written notification of the transfer was provided to R3 or his representative. Upon request, the facility was unable to provide evidence. Observed on 06/08/2026 at 09:13 AM, R3 sat on his bed while putting on his below-the-knee prosthesis. He had a dialysis port on his chest that he reported was placed when he was in the hospital with renal failure. On 06/09/2026 at 09:05 AM, Social Services X stated that she had obtained the signed bed holds. Social Services X said she had not been aware of the regulation that required residents or their representative to be notified in writing of transfers and the reason for the transfer. On 06/09/2026 at 10:30 AM, Administrative Staff A stated he had notified the ombudsman when a resident was transferred out of the facility but had not notified the residents' representative in writing of the discharge or transfer. The facility's undated policy Transfer or Discharge Documentation documented that upon a transfer or discharge, appropriate notice was provided to the resident or legal representative and would be documented in the chart.

Based on observation, interview, and record review, the facility failed to review and revise Resident (R) 6's Care Plan to reflect her current and accurate advance directives. Findings included:R6's Electronic Medical Record (EMR) documented diagnoses of anxiety, depression, weakness, and hemiplegia (paralysis of one side of the body)and hemiparesis (weakness and paralysis on one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven, indicating a severe impairment. R6's Care Plan dated [DATE] and revised on [DATE] documented that cardiopulmonary resuscitation (CPR) would be initiated when the resident's heart function or respirations ceased. CPR would continue until emergency medical staff arrived to transport R6 to the emergency department. R6's EMR, under the Documents tab, listed a DNR Do-Not-Resuscitate Directive signed by R6 on [DATE]. Observation of R6' s name tag on [DATE] at 11:53 AM revealed a red heart sticker. During an interview on [DATE] at 11:47 AM, Certified Nurse Aid (CNA)N stated that the code status of a resident was on their name tag on the outside of their door with a red heart sticker for DNR or a yellow heart sticker for a full code. CNA N stated that R6 had a red sticker next to her name outside her door indicating that she was a DNR. CNA N also stated there was a list at the nurse's station that documented R6 was a DNR, and it would be in her chart. During an interview on [DATE] at 11:53 AM, Licensed Nurse (LN) G stated that there is a red or yellow heart sticker on the resident's door next to their name indicating their code status. LN G stated that R6 showed that she was a DNR on her door. LN G stated that it would be indicated on the MAR, on the nurse shift report sheet, and on the care plan. During an interview on [DATE] at 11:57 AM Administrative Nurse D. Administrative Nurse D stated that she was not sure if the code status should be documented in the care plan, as Administrative Nurse F oversees care plan revisions. During an interview on [DATE] at 12:01 PM, Administrative Nurse F stated the code status was documented in the care plan. Administrative Nurse F said the director of nursing and the charge nurse could update the care plans if needed. She confirmed that R6's Care Plan was not updated to show the code status of DNR, and she would make sure it would be updated. The facility policy Care Plans. Comprehensive Person-Centered, undated, documented it was the policy for a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident.

Based on interview and record review, the facility failed to offer and administer or obtain an informed declination for the influenza (highly contagious viral infection) immunization for Resident (R) 21 and R12. This placed the residents at risk for complications related to influenza infections. Findings included:- R21's Electronic Medical Record (EMR) revealed a signed vaccine record that documented he declined the influenza immunization on 08/09/2023. R21's EMR lacked evidence that the vaccine was offered and/or lacked evidence of informed declination for the 2025 flu season. - R12's EMR revealed a signed vaccine record that documented that her legal representative had declined for her to have the influenza immunization on 05/10/2024. R12's EMR lacked evidence that the vaccine was offered and/or lacked evidence of informed declination for the 2025 flu season. On 06/08/2026 at 01:45 PM, Administrative Nurse E stated there are no vaccine refusals for the 2025/2026 influenza season for R21 and R12. She said that they were verbally offered the immunizations and declined, but it was not documented. On 06/09/2026 at 11:25 AM, Administrative Nurse D stated that she did not know when or how often the influenza immunization was offered to residents and said she would have to ask Administrative Nurse E. A few minutes later, Administrative Nurse D said that residents were to be offered influenza immunizations annually regardless of past refusals and then documented in the chart. The facility policy Influenza, Prevention and Control of Seasonal documented that the infection preventionist would promote and administer the seasonal influenza vaccine. Unless contraindicated, all residents and staff would be offered the vaccine.

The facility reported a census of 30 residents. Based on observation, interview, and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight consecutive hours as required. This placed the residents in the facility at risk for unsupervised nursing care and services. Findings included: - Review of the facility's Daily Staff Posting from 05/01/24 through 07/30/24, revealed the facility did not have the required eight consecutive hours of RN coverage, as required, on 05/05/24, 06/02/24, 06/16/24, 07/13/24, 07/14/24, 07/20/24, 07/21/24, 07/27/24, and 07/28/24. On 04/23/25 at 08:17 AM, Administrative Nurse E was unable to verify the facility had an RN for eight consecutive hours on the mentioned dates. The facility did not provide a policy for having an RN on duty for at least eight consecutive hours every 24 hours.

The facility had a census of 30 residents. The sample included 14 residents. Based on record review and interview, the facility failed to complete the comprehensive Minimum Data Set Assessment (MDS) for three sampled residents, Resident (R)4, R16, R26, R15, R30, and R22 when staff failed to ensure the triggered Care Area Assessments (CAA) were completed as required. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - Review of R4's Electronic Medical Record (EMR) recorded a quarterly MDS, dated [DATE]. R4's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAAs, as required. Review of R16's EMR recorded a quarterly MDS, dated [DATE]. R16's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAA, as required. Review of R26's EMR recorded a quarterly MDS, dated [DATE]. R26's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAA, as required. Review of R15's EMR recorded a quarterly MDS, dated [DATE]. R5's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAA, as required. Review of R30's EMR recorded a significant change MDS, dated [DATE], which lacked completion of the triggered CAA, as required. Review of R22's EMR recorded a quarterly MDS, dated [DATE]. R22's EMR recorded a comprehensive MDS, dated [DATE], which lacked completion of the triggered CAA, as required. The facility follows the Resident Assessment Instrument (RAI) in accurate completion of the MDSs.

The facility reported a census of 30 residents with 14 residents selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to properly inform families of the risks and benefits associated with psychotropic (alters mood or thoughts) medications for Resident (R) 8 and R7. It also failed to properly monitor for adverse reactions and behaviors related to an antipsychotic medication (class of medications used to treat major mental conditions which cause a break from reality) for R8. These deficient practices placed the affected residents at risk for adverse effects associated with the use of psychotropic medications. Findings: - R8's Electronic Medical Record (EMR) documented a diagnosis of anxiety (class of medications that calm and relax people), insomnia (inability to sleep), unspecified psychosis (any major mental disorder characterized by a gross impairment in reality perception), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The 08/22/24 admission Minimum Data Set (MDS) documented R8 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition, and a PHQ-9 severity score of zero indicating no depression. R8 had no behaviors documented. R8 took an antianxiety (class of medications that calm and relax people), and antidepressant (class of medications used to treat mood disorders) on a routine basis. The 08/22/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R8 was admitted on an antianxiety medication and two antidepressants. R8 had no adverse effects with these medications. R8 cried very easily when she did not get her way. The 02/20/2025 Quarterly MDS documented a BIMS of 15 and a PHQ-9 score of zero indicating no depression. R8 had no behaviors and took antianxiety and antidepressant medications. R8's Care Plan documented she received antidepressant medication for her diagnosis of depression and bipolar disorder. The plan noted R8 took Trazodone, duloxetine, and clonazepam dated 04/14/16. The plan directed staff to assess and record the effectiveness of the drug treatment. The plan directed staff to monitor and report signs of sedation, hypotension (low blood pressure), or anticholinergic symptoms (dry mouth, constipation, urinary retention, blurred vision, dilated pupils, and increased heart rate) initiated on 04/14/16 . Those medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R8's Care Plan lacked information regarding her Latuda (an antipsychotic medication) and lacked nonpharmacological interventions for behaviors. R8's Physicians orders documented an order for clonazepam one milligram (mg), give one capsule by mouth three times a day, date ordered 03/13/25. R8's Physicians orders documented an order for duloxetine 60mg, give one capsule by mouth once a day, date ordered 03/13/25. R8's Physicians orders documented an order for trazodone 100mg, give two capsules by mouth at bedtime, date ordered 04/22/25. R8's Physicians orders documented an order for Latuda 40mg, give half a tab daily at supper, date ordered 03/06/25. R8's Physicians Orders listed the BBW for clonazepam, duloxetine, and Trazodone. R8's Physicians Orders did not address the BBW for Latuda. R8's Progress Notes lacked documentation of monitoring of adverse reactions related to the start of Latuda. During an observation on 04/21/25 at 08:22 AM, R8 was tearful as staff assisted her to dress and transfer. R8 wanted only one staff to help her, but she required two staff. The staff comforted her and explained that there needed to be two staff. She eventually settled down. During an interview on 04/23/25 at 09:35 AM, Licensed Nurse (LN) H stated that when she received a new order for psychotropic medication, she notified the family and the pharmacy of the order, put the order in the computer, and documented it. During an interview on 04/23/25 at 09:48 AM, Administrative Nurse E reported that the facility put all psychotropic medications on the care plan and the Latuda should have been on the care plan, and they should have been monitoring. During an interview on 04/23/25 at 09:58 AM, Administrative Nurse E stated that they missed putting Latuda on the care plan. They review the orders from the day before in the morning meeting and add the BBW and monitoring at that time. The facility's Psychotropic Medications, Monitoring Policy dated 08/30/2017, documented the purpose was to ensure residents are free from unnecessary medications. Nonpharmacological interventions are always attempted first to reduce behavior. Target behaviors will be identified and implemented in the care plan with interventions. - R7's Electronic Medical Record (EMR) documented a diagnosis of schizoaffective disorder (a mental illness characterized by symptoms of both schizophrenia (like hallucinations and delusions) and a mood disorder (like bipolar disorder or depression), panic disorder [episodic paroxysmal anxiety], irritability and anger, seizure disorder (violent involuntary series of contractions of a group of muscles), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (class of medications that calm and relax people), insomnia (inability to sleep), and depressive disorder (major mood disorder which causes persistent feelings of sadness). The 10/08/24 admission Minimum Data Set (MDS) documented R7 had a Brief Interview for Mental Status (BIMS) of nine, indicating moderate cognitive decline, and a PHQ-9 severity score of one indicating no depression. R7 had no behaviors documented. R7 took an antidepressant (class of medications used to treat mood disorders), and an anticonvulsant (medication used to prevent seizures) on a routine basis. The 10/08/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R7 was admitted on an antidepressant medication. R7 had no adverse effects with these medications but had four falls since the last review. The 01/06/25 Quarterly MDS documented a BIMS of nine. PHQ-9 score of one. R7 had no behaviors documented and took and antidepressant and an anticonvulsant. The 03/18/25 Quarterly MDS was not completed. R7's Care Plan documented she received antidepressant medication observe for side effects initiated on 10/08/23. R7's plan directed staff to encourage her to verbalize her thoughts to a trusted staff member and assist R7 to identify and implement effective coping skills, initiated on 10/08/23. Those medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R7's Physicians orders documented an order for citalopram 20 milligrams (mg), give one tablet once a day, date ordered 03/04/25. During an observation on 04/21/25 at 10:21 AM, R7 was in bed with her eyes closed. R7 was not aroused when staff talked in the room or called her name. Staff reported that she slept a lot. During an interview on 04/23/25 at 09:35 AM, Licensed Nurse (LN) H stated that when she received a new order for psychotropic medication, she notified the family and the pharmacy of the order, put the order in the computer and documented it. During an interview on 04/23/25 at 09:48 AM, Administrative Nurse E reported that the facility completed a consent form informing the family or the resident about the risks and benefits with side effects on antipsychotic medications. During an interview on 04/23/25 at 09:58 AM, Administrative Nurse D confirmed that the facility completed a consent form informing the family or the resident about the risks and benefits with side effects on antipsychotic medications, but not on other psychotropic medications. The facility's Psychotropic Medications, Monitoring Policy dated 08/30/2017, documented the purpose was to ensure residents are free from unnecessary medications and to assure that residents are fully informed of the medications they are prescribed.

The facility reported a census of 30 residents with 14 residents sampled. Based on observation, interview, and record review, the facility failed to verify Resident (R) 10's advanced directives (a legal document in which a person specifies what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether, or not, to withhold medical intervention in the event the resident's heart stops] order). Additionally, the facility failed to ensure R10's DNR was signed by the resident. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care. Findings included: - Review of the Electronic Health Record (EHR) for R10 included diagnoses of Parkinson's disease (a progressive neurodegenerative disorder that primarily affects the central nervous system, leading to both motor and non-motor symptoms), atherosclerotic heart disease of native coronary artery (a condition where plaque builds up inside the coronary arteries, which are the blood vessels that supply oxygen-rich blood to the heart), unspecified epilepsy (a person is known to have epilepsy but the specific type [focal, generalized, etc.] is not known or can't be determined), heart failure (a condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup in the lungs, legs, and other areas), essential hypertension (persistent elevated blood pressure with no identifiable cause The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 14, which indicated intact cognition. The Quarterly Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 14, which indicated intact cognition. R10's Care Plan documented on 03/21/25 that hospice care started, and the primary care physician had given a terminal diagnosis and estimated life expectancy of less than six months. R10' Care Plan documented on 03/21/25 that R10 wished to remain a DNR. A look back review of R10's EHR revealed a hospice certificate of terminal illness, dated 03/21/25, and listed R10 as full code. A look back review of the Physician Orders revealed an order for DNR, the date on the DNR was unreadable R10's EHR Home screen documented R10's code status (full code or DNR) as DNR. R10's EHR, under the scanned documents section, revealed a Do-Not-Resuscitate Directive signed by the physician, dated 02/24/23. The directive was not signed by the resident or representative. During an interview on 04/21/25 at 11:38 AM, R10 reported that she wished to be a DNR. During an interview on 04/21/25 at 01:56 PM, Administrative Nurse D reported that the DNR, dated 02/24/23, in the EHR was not signed by the resident and should have been. During an interview on 04/21/25 at 02:24 PM, Licensed Nurse (LN) G stated that the EMR lists the code status of the residents and that R10's code status listed her as DNR. LN G then reviewed R10's DNR and reported that it was not signed by R10. On 08/15/24 at 02:24 PM, Administrative Nurse D stated that if a discrepancy between the DNR order and the full code order was present, the expectation was for staff to honor the advanced directives that had the most recent date. The facility did not provide a policy for Advanced Directives.

The facility identified a census of 30 residents, with 14 residents sampled, including five residents reviewed for unnecessary medications. Based on record review, interview, and observation, the facility failed to notify the physician when Resident (R) 8 had a weight gain in 24 hours while on a diuretic (a class of medications used to promote the formation of urine and prevent fluid accumulation). This placed R8 at risk for delayed physician involvement and treatment options. Findings included: - R8's Electronic Medical Record (EMR) documented a diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The 08/22/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R8 weighed 289 pounds and took a diuretic. The 08/22/24 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R8 took a diuretic medication. The 02/20/25 Quarterly MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The MDS recorded R8 weighed 286 pounds and took a diuretic. R8's Care Plan documented R8's weight was monitored daily due to being on a diuretic. R8's EMR under the Physician Orders documented an order for daily weight due to being on a diuretic, dated 01/04/24. R8's EMR under the Physician Orders documented an order for furosemide (diuretic) 20 milligrams daily, dated 12/28/23 R8's EMR from 01/01/25 through 04/01/25, revealed the resident gained weight on the following dates: On 01/21/25, R8 gained seven pounds from the previous day. On 01/26/25, R8 gained four pounds from the previous day. On 02/10/25, R8 gained 5.6 pounds from the previous day. On 02/15/25, R8 gained four pounds from the previous day. On 03/31/25, R8 gained four pounds from the previous day. R8's EMR lacked documentation of physician notification for the above dates with weight gain noted. During an observation on 04/23/25 at 09:02 AM, R8 sat in her wheelchair in the dining area. She had some swelling in her legs. She reported that sometimes the swelling was worse. She was wearing support hose and reported she wore them to keep the swelling down. During an observation on 04/21/25 at 08:22 AM, staff assisted R8 to get dressed, then assisted her to sit up on the side of the bed and transfer with a sit to stand lift. R8 was short of breath with the activity but recovered quickly once in the chair. During an interview on 04/22/25 at 04:38 PM, Licensed Nurse (LN) H stated that Administrative Nurse E tracked the weights and called the doctor except on the weekends, and then the nurse on duty did it. During an interview on 04/22/25 at 04:40 PM, Administrative Nurse E stated that the nurse on duty should call the doctor, following the order; or if the order does not have parameters, they should use their nursing judgment and call if the resident has a three-pound weight gain in a day. Administrative Nurse E said the nurse should have called the doctor for those weights. During an interview on 04/23/25 09:58 AM, Administrative Nurse D stated that the nurse should notify the doctor according to the parameters in the order. Administrative Nurse B said if there were no parameters ordered, she would reweigh the resident and notify the doctor if there was a 3-5 pound weight gain. The facility did not have a policy related to notifying a provider of weight changes for a resident with CHF and on a diuretic.

The facility reported a census of 30 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to complete the Minimum Data Set for Resident (R) 7 within the required timeframes. This placed the resident at risk for unidenitfied care needs and inadequate plan of care. Findings included: - R7's Electronic Medical Record (EMR) documented a diagnosis of schizoaffective disorder (a mental illness characterized by symptoms of both schizophrenia (like hallucinations and delusions) and a mood disorder (like bipolar disorder or depression), panic disorder [episodic paroxysmal anxiety], irritability and anger, seizure disorder (violent involuntary series of contractions of a group of muscles), post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (class of medications that calm and relax people), insomnia (inability to sleep), and depressive disorder (major mood disorder which causes persistent feelings of sadness). The 10/08/24 Admission Minimum Data Set (MDS) documented R7 had a Brief Interview for Mental Status (BIMS) of nine, indicating moderate cognitive decline, and a PHQ-9 severity score of one indicating no depression. R7 had no behaviors documented. R7 took an antidepressant (a class of medications used to treat mood disorders), and an anticonvulsant (medication used to prevent seizures) on a routine basis. The 10/08/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R7 was admitted on an antidepressant medication. R7 had no adverse effects with these medications but had four falls since the last review. The 01/06/25 Quaterly MDS documented a BIMS of nine. PHQ-9 score of one. R7 had no behaviors documented and took and antidepressant and an anticonvulsant. The 03/18/25 Quarterly MDS was not completed. R7's Care Plan documented she received antidepressant medication observe for side effects initiated on 10/08/23. R7's plan directed staff to encourage her to verbalize her thoughts to a trusted staff member and assist R7 to identify and implement effective coping skills, initiated on 10/08/23. Those medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). During an observation on 04/21/25 at 10:21 AM, R7 was in bed with her eyes closed. R7 was not aroused when staff talked in the room or called her name. Staff reported that she slept a lot. During an interview on 04/23/25 at 09:58 AM, Administrative Nurse D stated she expected the MDS and CAAs to be completed accurately. The Resident Assessment Instrument (RAI- is a comprehensive, standardized tool used in long-term care facilities to assess residents, guide care planning, and monitor quality of care.) documented a quarterly assessment must be completed every 92 days.

The facility identified a census of 30 residents. The sample included 14 residents with one sampled for catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, interview, and record review, the facility failed to address catheter care on Resident (R) 83's baseline care plan. This deficient practice had the risk for adverse outcomes and complications for R83 due to uncommunicated care needs. Findings: - R83's Electronic Medical Record (EMR) documented a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The 04/14/25 Admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) of 11, indicating moderately impaired cognition. The MDS recorded R83 required assistance from staff with activities of daily living (ADLs) and had a catheter. The 04/14/25 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) R83 had a diagnosis of neurogenic bladder. She was unable to bear weight to access the toilet. The CAA noted the catheter was put in while she was in the hospital. R83's Baseline Care Plan, dated 04/09/25, documented R83 will have her wounds assessed and pain addressed. R83's Baseline Care Plan lacked documentation that R83 had a catheter or instructions for catheter care. R83's EMR under the Orders tab documented the following orders: Foley catheter with dependent drainage for neurogenic bladder and to prevent skin breakdown started on 04/14/2025. On 04/22/25 at 08:22 AM, R83 laid in bed with her catheter bag hanging on the side of her bed. The catheter bag had dark red urine. On 04/22/25 at 08:50 AM, Certified Medication Aide (CMA) R reported that R83 always had red, dark urine. On 04/23/25 at 09:16 AM, Certified Medication Aide (CMA) T reported that the staff look up information on how to care for the residents by looking on the matrix. On 04/23/25 at 09:48 AM, Administrative Nurse E stated the catheter care should be on the Baseline Care Plan that is completed on admission. On 04/23/25 at 09:58 AM, Administrative Nurse D stated that the Baseline Care Plan should have included catheter care. The facility policy for 48-hour Care Plan, undated, noted the facility will develop and implement a baseline care plan for each resident to meet their immediate care needs.

The facility reported a census of 30 residents with 14 residents sampled, including two residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to recognize, assess, and implement interventions consistent with Resident (R)26's current level and/or mode of assistance required for transfers. This placed the resident at risk for injury and further ADL decline. Findings included: - R26's Electronic Medical Record (EMR) revealed a diagnosis of cerebrovascular accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She required substantial to maximal assistance of staff for transfers and had an impairment on one side of her lower extremity (LE). The Functional Abilities Care Area Assessment (CAA), and the Fall CAA, dated 01/29/25, triggered but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15. She had an impairment in her range of motion (ROM) on one side of her upper extremity (UE) and LE. R26's Care Plan for ADL, revised 01/29/25, instructed staff the resident had a CVA affecting her right side. Staff were to ensure the resident's feet were flat on the floor during the transfer and she required substantial assistance of one staff for transferring. Review of the resident's EMR lacked staff documentation of the assistance required to transfer the resident. On 04/22/25 at 09:50 AM, Certified Nurse Aide (CNA) N and CNA O transferred the resident from her wheelchair to her recliner in her room. Staff utilized a gait belt and transferred the resident with total assist of both staff. The resident was unable to bear weight on either leg during the transfer and her feet were not flat on the floor. On 04/22/25 at 08:30 AM, CNA O stated the resident could bear weight at times, but not always. CNA O confirmed the resident's feet were not flat on the floor during the transfer. On 04/22/25 at 08:30 AM, CNA N stated the resident could bear weight at times, but it depended on the day. On 04/22/25 at 09:59 AM, Administrative Nurse D stated a resident should be able to bear weight during a transfer. The facility policy for ADLs was not available.

The facility reported a census of 30 residents with 14 residents sampled, including four residents reviewed for positioning and range of motion (ROM). Based on observation, interview and record review, the facility failed to perform restorative cares for Residents (R)4, R26, and R16 and failed to properly position R4 while in her Geri-chair (a specialized wheelchair). Findings included: - R4's Electronic Medical Record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had a limitation in functional ROM on both sides of her lower extremities and was dependent on staff for transfers and wheelchair mobility. The resident did not receive restorative cares during the assessment period. The Functional Ability Care Area Assessment (CAA), dated 02/25/25, triggered but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15. She had a limitation in ROM to her bilateral lower extremities and was dependent on staff for transfers and wheelchair mobility. The resident did not receive restorative cares during the assessment period. R4's Care Plan revised 04/17/25 instructed staff the resident received restorative care with active range of motion to her bilateral upper extremities (UE) for 20 repetitions in a pain-free range, six to seven days per week for 15 minutes, to maintain her current functional capacity as well as flexion (bending) and extension (straightening) of the resident's shoulders, elbows and arms, six to seven days per week for 15 minutes, to maintain her current functional capacity. Review of the resident's EMR from February 1, 2025, through 04/22/25, revealed restorative cares had not been completed with the resident. On 04/22/25 at 08:26 AM, Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) R entered the resident's room to perform cares. The resident bilateral lower extremities were contracted in an abnormal manner and her UE had no limitation in ROM. CNA N and CMA R transferred the resident from her bed to her Geri-chair and took her to the dining room for breakfast. Once at the dining room table, staff sat the Geri-chair up from a reclining position to set the resident at the dining table. The resident's bilateral feet dangled above the dining room floor by several inches and had no support. On 04/22/25 at 09:19 AM, the resident's feet continued to dangle above the dining room floor as she sat in her Geri-chair. On 04/22/25 at 09:50 AM, CNA O stated restorative cares were documented in the computer every time they were done. CNA O stated she was unaware the resident's feet dangled above the floor while her Geri-chair was in a sitting position. On 04/22/25 at 10:01 AM, CNA N stated she did not know the resident's feet did not have support when the Geri-chair was put up into the upright position for meals. CNA N stated the restorative cares are done by the restorative person and that CNAs did not do restorative cares. On 04/22/25 at 11:17 AM, Administrative Nurse D stated the restorative cares had not been getting done. Administrative Nurse D confirmed the resident's feet needed some type of support while her Geri-chair was in an upright sitting position at the dining room table. The facility policy for Wheelchair Positioning, implemented 12/18/24, included: All wheelchair users will be positioned appropriately to support optimal posture, functional mobility, comfort, and skin integrity. The facility policy for Restorative Nursing Programs, revised 01/06/25, included: The facility shall provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. - Review of R26's Electronic Medical Record (EMR) revealed a diagnosis of cerebrovascular accident (CVA-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had no functional limitation in range of motion (ROM) and required substantial to maximal staff assistance with transfers; she did not ambulate during the assessment period. The resident did not receive restorative care during the assessment period. The Functional Abilities Care Area Assessment (CAA), dated 01/29/25, triggered but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15. She had a limitation in ROM on one side of her lower extremity and required substantial to maximal staff assistance with transfers. The resident did not ambulate during the assessment period. She received passive range of motion (PROM) and active range of motion (AROM) two days of assessment period. R26's Care Plan revised 01/29/25 instructed staff the resident was on a restorative nursing program and to perform AROM with her lower extremitiees for 20 repetitions in a pain-free range, six to seven days per week for 15 minutes. Staff were instructed to complete upper extremity exercises with the resident with one-pound weights with her left arm for 10 repetitions each for shoulder and elbow flexion (bend) and flexion (straighten), for 15 minutes, six to seven days per week. Review of the resident's EMR from 02/01/25 through 04/22/25, revealed the resident received restorative cares for 12 days in February, eight days in March and one day in April. No other restorative cares were documented. On 04/22/25 at 09:50 AM, Certified Nurse Aide (CNA) N and CNA O transferred the resident from her wheelchair to her recliner in her room. Staff utilized a gait belt and transferred the resident with total assist of both staff. The resident was unable to bear weight on either leg during the transfer. On 04/22/25 at 09:50 AM, CNA O stated the resident was to receive daily restorative cares but was not getting it daily. On 04/22/25 at 09:59 AM, Administrative Nurse D stated restorative cares would be documented in the computer. Administrative Nurse D confirmed the facility was not getting the restorative cares done at this time. The facility policy for Restorative Nursing Programs, revised 01/06/25, included: The facility shall provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. - Review of R16's Electronic Medical Record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. She had no limitation in range of motion (ROM) and did not receive restorative care during the assessment period. The Functional Abilities Care Area Assessment (CAA), dated 04/14/24, triggered but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She had no impairment in ROM and did not receive restorative care during the assessment period. R16's Care Plan revised 01/15/25 instructed staff to complete upper extremity ) exercises with the resident with one-pound weights with her left arm for 10 repetitions each for shoulder and elbow flexion (bend) and flexion (straighten), for 15 minutes, six to seven days per week. Review of the resident's EMR revealed she had not received restorative cares. On 04/22/25 at 09:50 AM, Certified Nurse Aide (can) O stated the resident was to receive daily restorative cares but was not getting it daily. On 04/22/25 at 09:59 AM, Administrative Nurse D stated restorative cares would be documented in the computer. Administrative Nurse D confirmed the facility was not getting the restorative cares done at this time. The facility policy for Restorative Nursing Programs, revised 01/06/25, included: The facility shall provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.

The facility reported a census of 30 residents. The sample included 14 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement adequate and acceptable infection control practices for Resident (R) 15 whose oxygen tubing was allowed to drag the floor as he wheeled himself through the facility. This deficient practice placed the resident at risk of infections. Findings included: - During an observation on 04/21/25 at 08:30 AM, R15 sat in the dining room in his wheelchair wearing an oxygen nasal cannula (a device that delivers extra oxygen through a tube and into your nose). R15's oxygen tubing was wrapped around part of his wheelchair and dragging on the floor. During an observation on 04/21/25 at 10:13 AM, R15 was wearing continuous oxygen, and his oxygen tubing was tangled on his wheelchair axle and dragging on the floor as he wheeled himself down the hall. During an observation on 04/21/25 at 01:31 PM, R15 was sat in his room watching TV and his oxygen tubing was on the floor under his wheelchair. During an observation on 04/22/25 at 08:15 AM, R15 was in the dining room, sitting in his wheelchair and his oxygen tubing draped over his wheelchair axle and rested on the floor. During an interview on 04/22/25 at 08:24 AM, Licensed Nurse (LN) G reported that R15's oxygen tubing should not have been dragging on the floor, it should have been stored in the black pouch on the back of his wheelchair. During an interview on 04/22/25 at 08:28 AM, Administrative Staff A stated that R15's excess oxygen tubing should have been secured in the pocket on the back of his wheelchair. During an interview on 04/22/25 at 08:32 AM, Administrative Nurse D reported that R15's oxygen tubing should not have been draped over the wheelchair axles or dragging on the floor. During an interview on 04/22/25 at 08:58 AM, Certified Nurse Aide (CNA) P reported that oxygen tubing should not have been dragging the ground or have been wrapped around the wheelchair, tubing should have been placed in the wheelchair pocket. The facility's policy titled Oxygen Administration, dated 12/18/24, failed to document the storage and management of oxygen-delivering devices to prevent contamination or infection.

The facility reported a census of 30 residents with 14 residents sampled, including three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, when two staff members entered her room during cares. This placed the resident at risk for impaired dignity and embarrassment. Findings included: - Review of R4's Electronic Medical Record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She was dependent on staff for rolling side to side in bed, toileting, and wheelchair mobility. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 02/25/25, triggered but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15. She was dependent on staff for rolling side to side in bed, toileting, and wheelchair mobility. R4's Care Plan revised 04/17/25, revealed the resident was dependent on two staff for bed mobility and dependent on one staff for toileting. On 04/22/25 at 08:26 AM, Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) R were doing morning cares with the resident. The resident laid on top of the bed, uncovered, while staff were providing peri-care. The privacy curtain in the room was not pulled around the resident's bed. CNA M knocked on the resident's door to which CNA N responded, resident care. At that time, CNA M opened the door to the resident's room and spoke to the staff, with the door open, leaving the resident visible to residents or staff in the hall. On 04/22/25 at 08:30 AM, CMA R stated staff should not enter a resident's room while cares were being done. On 04/22/25 at 10:01 AM, CNA N stated staff should not enter a resident's room while cares were being done. On 04/22/25 at 11:17 AM, Administrative Nurse D stated it was the expectation for staff to not enter a resident's room while the resident received cares. The facility policy for Promoting/Maintaining Resident Dignity, revised 12/18/24, included: The facility shall protect and promote resident's rights and treat each resident with respect and dignity while maintaining the resident's privacy.

Findings included: - Review of the facility's Daily Staffing Sheets, for the past 30 days, revealed the actual hours worked had not been completed on the daily staffing sheets. On 04/23/25 at 08:17 AM, Administrative Nurse E stated she was unaware the daily staff postings needed to include the actual hours worked. The facility policy for Posting Direct Care Daily Staffing Numbers, revised July 2016, included: The facility shall post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents, including the actual time worked during that shift for each category.

The facility reported a census of 31 residents. Based on interview and record review, the facility failed to ensure residents remained free from neglect when administrative staff did not respond timely to the report of inappropriate/concerning behavior of a Licensed Nurse, on duty from 06:00 PM on 05/03/23 to 06:00 AM on 05/04/23. A Nurse Aide on duty witnessed the erratic behaviors of Licensed Nurse (LN) G and text messaged the on-call Administrative Nurse D on 05/03/23 at 11:10 PM to report she felt the residents were not safe with LN G, and reported LN G was talking to herself, laughing, grunting, and kicked over a trash can. Administrative Nurse D responded back with a text message encouraging her to write up a statement of what she saw and heard, and Administrative Nurse D would talk to administrative staff in a morning meeting on 05/04/23. Administrative Nurse D did not investigate the allegation of LN G's erratic behavior further on 05/03/23; therefore, LN G remained on duty as the only LN in the facility, to provide LN care/oversight for all of the residents. On 05/04/23 at 04:32 AM, Housekeeping Staff U entered the facility, noticed the concerning/erratic behavior of LN G, and texted Administrative Nurse F at 05:15 AM. Over an hour later (06:32 AM), Administrative Nurse F responded to the text, and arrived at the facility on 05/04/23 at 07:00 AM. The facility conducted a urine drug screening of LN G, which was positive for numerous controlled medications which included: methamphetamines, morphine, oxycodone, amphetamine, and methadone. The facility conducted a controlled medication count and identified three different narcotic medications (eight tablets total) missing from three different residents: Resident (R)1, R2, and R3. Furthermore, LN G delegated/instructed the Nurse Aide in Training to administer pain medication to R1 on 05/03/23 at 11:30 PM (a task that was outside of the scope of practice for a Nurse Aide). Additionally, LN G failed to document the medication administration in the Medication Administration Record and failed to complete physician ordered treatments for R1, while on duty. This deficient practice placed all residents under the care of LN G in immediate jeopardy for neglect. Findings included: - The facility nursing department schedule dated 04/29/23-05/14/23 revealed: 1. Licensed Nurse (LN) G scheduled 05/03/23 at 06:00 PM. 2. Certified Medication Aide (CMA) S scheduled for medications for the day shift (lacked time of shift) for 05/03/23. 3. CMA R scheduled on 05/03/23 at 02:00 PM. 4. Nurse Aide in Training (NAT) M scheduled on 05/03/23 at 10:00 PM. 5. Certified Nurse Aide (CNA) N scheduled on 05/03/23 at 10:00 PM. The facility Complaint Investigation Witness Statement of Facts dated 05/04/23 revealed CMA R counted controlled medications with CMA S on 05/03/23 at 05:15 PM and the count was correct, and again counted on 05/03/23 at 11:00 PM with LN G and the count was correct. The facility Complaint Investigation Witness Statement of Facts dated 05/04/23 by NAT M revealed on 05/03/23 at 11:30 PM LN G gave NAT M two white, long pills to give to R1 and said it was his pain medication. NAT M took the pills to R1 and watched him take them. The statement revealed LN G was acting out of her mind and was dancing around and talking to herself one minute and the next minute screaming at herself and the next thing she knew LN G was crying. Housekeeping Staff (HS) U arrived at 05:00 AM as LN G got off the phone and LN G ran over to housekeeping Staff U and almost knocked her over and asked if Administrative Nurse D was still on call for the week. NAT M's statement then revealed the next thing she knew LN G was laying on the floor in a vacant resident room talking to herself and clipboard. LN G was standing over the bed holding the clip board to her face screaming at it then started dancing and acting out more and that is when the day shift showed up and took over from there. The statement lacked evidence any of LN G's behaviors were reported to the facility administrative staff prior to when HS U arrived to the facility the morning of 05/04/23. The Complaint Investigation Witness Statement of Facts dated 05/04/23 by HS U revealed upon arrival to the facility on [DATE] at 04:32 AM, LN G came from around the nurses' station and tried to hug HS U, who almost fell over. LN G was bobbing her head up and down and slurring her words. At 05:10 AM LN G stated she was going to check on the resident in room (a vacant room of the facility) and HS U told her no resident resided in that room. When HS U entered that room, LN G was on the floor with the clipboard from the nurse's station that had the daily schedule on it. LN G acted like she was talking on the telephone with the clipboard. HS U asked if she was okay, and LN G did not respond. LN G began banging her head up and down pulling her hair. At that time, HS U heard her name called by NAT M, who asked HS U to tell LN G that R1 needed his pain medicine. When informed of this, LN G responded with slurred words and stated, no he did not need the pain medicine. HS U told NAT M of LN G's response, then exited the room. HS U then sent a text message to Administrative Nurse F at 05:15 AM, asking Administrative Nurse F to call her if she was awake. At 05:19 AM HS U called Consultant Staff GG and left a voicemail, while NAT M called Administrative Staff A to tell her of the situation. HS U then got her cleaning cart and started cleaning around the nurse's station. LN G came out of the vacant resident room and sat down at the nurse's station and the chair almost fell over. LN G then picked up the phone and acted like she was talking on it then dropped the headset. HS U picked it up and hung it back up, and LN G got up and went out the back door, and acted like she was looking for something in the trunk of her car. At 06:32 AM Administrative Staff F called HS U, who informed her of everything. Administrative Staff F told HS U she was getting ready and not to let LN G leave when the day shift nurse (LN H) arrived to take over. The Complaint Investigation Witness Statement of Facts dated 05/04/23 by Administrative Nurse D revealed when she got up that morning, she had a text message from HS U to call her. Administrative Nurse D called HS U, who said there was a problem with the charge nurse LN G on duty, she was not acting right. Administrative Nurse D said she would get dressed and get there as soon as she could and asked if anyone else had been called. HS U said NAT M called Administrative Nurse E with no answer and Administrative Staff A, who supposedly said it was the medication she was on. Administrative Nurse F arrived at the facility, clocked in at 07:00 AM, and noted LN G sat at the nurse's station mumbling and slurring her words and making jerky, erratic movements. Administrative Nurse F got a drug testing cup and asked LN G to come to the employee bathroom and provide a witnessed urine sample. Administrative Nurse F asked CMA S when she arrived at 07:44 AM to do a shift change count of controlled medication with the charge nurse or CMA. After a few minutes, CMA S stated there were two hydrocodone (controlled narcotic analgesic used to treat moderate to severe pain) missing on one medication card and one on another medication card for R3, and one oxycodone unaccounted for on a medication card for R2 and R1. Administrative Nurse F informed Administrative Nurse E via text message, while LN G continued to sit on the toilet until 08:50 AM when Administrative Nurse E arrived and took over trying to obtain the urine specimen. Administrative Nurse E handed Administrative Nurse F the urine specimen which was positive for numerous controlled medications. While Administrative Nurse E questioned LN G about unaccounted medications on the narcotic shift change count, LN G was sobbing and continuing with her slurred and mumbled words and her erratic, jerky movements. LN G was difficult to understand and started getting really loud and upset. The Complaint Investigation Witness Statement of Facts by Administrative Nurse E, dated 05/04/23, revealed she arrived to work at approximately 08:50 AM after receiving a message from Administrative Nurse D that when she arrived to work, she believed LN G was impaired and requested a urine drug test from her. LN G was in the employee bathroom with the door cracked open and sobbing loudly. After the collection of the urine sample, Administrative Nurse E asked LN G to come to the nursing office, due to reports of missing medications from the morning count. LN G's behavior was very erratic, not normal for her, lots of twisting type/jerky motions, slurred speech, profuse sweating Administrative Nurse E noted LN G did not sit in the chair for long and she ended up sitting/lying on the office floor. Administrative Nurse E attempted to ask questions to learn the locations of the missing medications, however, LN G was unable to carry on a coherent conversation. LN G did stated she had asked NAT M to walk and give R1 his oxycodone the night before, however, NAT M reported the pills she gave were white and long. The Complaint Investigation Witness Statement of Facts dated 05/04/23 by Administrative Nurse D revealed when arriving to work at approximately 09:00 AM she observed Administrative Nurse F and Administrative Nurse E standing outside of the employee restroom and Administrative Nurse E talked to LN G through the crack in the door. Administrative Nurse D overheard LN G crying from the restroom. After an undetermined amount of time, Administrative Nurse D, Administrative Nurse F, and LN G entered the office shared by Administrative D and Administrative E. LN G was sobbing and her body movements were a combination of jerking and swaying she was constantly moving her mouth her words were slightly slurred and she had difficulty verballing sentences fluidly. CMA S brought the medication cart to the office and Administrative Nurse E and CMA S counted the narcotics. Following the count, Administrative Nurse E asked LN G questions about last night's med pass and which resident's received pain medication. LNG sat on the floor crying and moving around, rocking back and forth, rubbing her head, moving legs, and sobbing. At approximately 09:30 AM Administrative Nurse E told Administrative Nurse D to call the police. After stepping out of the office to make the call, Administrative Nurse D returned to the office and LN G was still on the floor crying and moving around. When monitoring her after Administrative Nurse E stepped out of the office, LN G was moving around on the floor, at times sitting crossed legged and rocking back and forth, and at times she was lying down curled up in a semi-fetal position, rolling back and forth and noted at one point LN G turned over on her stomach as she continued to cry, her legs moving. Several times LN G made the comment she made a mistake and stated I can't believe I did that stupid [expletive]. I know better and the sad part is I like working here. The police officers arrived, spoke with LN G, exited the room with Administrative Nurse E for several minutes while LN G continued her crying, restless, non-stop moving behavior throughout the entire time. When the police officers re-entered the room, they read LN G her rights, asked her to stand, then handcuffed and arrested her. The statement lacked if any of the facility staff had notified her, at any time while on call, of LN G's abnormal behavior. Review of R1'sMedications Administration History dated 05/01-05/08/23, for acetaminophen (Tylenol - an analgesic), 500 milligrams (mg), give two tabs, orally, every six hours, as needed for pain, lacked documentation the staff administered the medication at any time on 05/03-05/04/23. R1's Medications Administration History dated 05/01-05/08/23, lacked documentation LN G administered oxycodone (a controlled narcotic for treatment of moderate to severe pain) at any time on 05/03/23 and on 05/04/23. R1's Individual Resident's Controlled Substance Record dated 04/03/23 through 05/04/23, for oxycodone, 5 mg, revealed a signature by LN G, which was larger than other signatures on the page, lacked a date, the time had a 2 that had a line through it and a dash and a five under the time column, the amount given was illegible, and eight for the number of tablets remaining. The corrected count on 05/04/23 at 09:00 AM on the form was change to seven tabs from eight, indicating one tab not accounted for. R1's Licensed Medication Administration Record (MAR) dated 05/01/23 through 05/08/23 lacked any signature verifying the completion of the physician order for 05/03/23 at 09:30 PM to empty the urinary catheter every shift. R1's Treatment Administration Record (TAR), dated 05/01-05/08/23, lacked any signatures verifying the completion of the following physician order treatments: 1. On 05/03/23 at 06:00 PM through 11:00 PM, check heels and toes every morning and every bedtime. 2. On 05/03/23 at 09:00 PM through 05/04/23 06:00 AM, moisturize feet and legs every bedtime. 3. On 05/03/23 at 06:00 PM through 05/04/23 06:00 AM, flush the supra pubic catheter (urinary catheter inserted into the bladder through the skin) with 30 milliliters (ml), of normal saline, twice daily, and as needed. 4. On 05/03/23 at 08:00 PM, triamcinolone (used to treat skin conditions) cream, 0.025%, 60-gram cream, topical, administer a thin layer to his face, for seborrheic dermatitis (skin condition that causes scaly patches and red skin). R3's Medications Administration History dated 05/01-05/08/23 revealed staff did not administer the as needed hydrocodone/acetaminophen (Lortab) tablet, 7.5/325 mg, as needed, at least four hours apart from scheduled Lortab, for low back pain on 05/03/23 and 05/04/23. R3's Individual Resident's Controlled Count Substance Record dated 04/05/23 through 05/04/23, for Lortab, 7.5/325 mg, twice daily and PRN, revealed a corrected count on 05/04/23 at 09:00 AM for zero tabs remaining instead of one, indicating one tab not accounted for. The sheet lacked signature for 05/03/23 through 05/04/23 by LN G of removing any of the medication from the controlled medication card. R3's Individual Resident's Controlled Count Substance Record dated 04/05/23 through 05/04/23, for Lortab, 7.5/325 mg, twice daily and PRN revealed a corrected count on 05/04/23 at 09:00 AM for 28 tabs instead of 30, indicating two tabs not accounted for. R2's Medication Administration History dated 05/01-05/08/23, for oxycodone/acetaminophen, 5/325 mg, every six hours, revealed lack of documentation to verify LN G administered the medication at the scheduled time of 12:00 AM on 05/04/23. The dose scheduled on 05/04/23 at 06:00 AM included notation by Administrative Nurse E the staff did not administer the medication, due to being unsure if resident received. R2 possibly missed two doses of her scheduled pain medication. R2's pain rating was at a level 7 (on the zero to 10 pain scale, with a zero being no pain and a ten being the worst pain) for the 05/03/23 06:00 PM dose, and when she received the scheduled dose for 12:00 PM on 05/04/23, she rated her pain as a 10. R2's Individual Resident's Controlled Count Substance Record dated 03/24/23 through 05/04/23, for oxycodone/acetaminophen, 5/325mg, revealed an entry following the 05/03/23 at 06:00 PM line of six tabs remaining, with a date of 05/03/23 with what appeared to be a 4 written over the day of the month three, the time column was illegible, five tablets remaining, and a signature by LN G, which did not match a previous signature of hers on 04/29/23. On 05/04/23 at 09:00 AM the count was corrected from five to three tabs, indicating two tabs were not accounted for. On 05/08/23 at 12:09 PM CNA N stated he was on duty for the 05/03/23 10:00 PM shift to 05/04/23 at 06:00 AM with NAT M and LN G. CNA N stated when he arrived to shift LN G was acting strange, shaking her head, walking around and talking. CNA N stated he had worked with LN G a couple of times before and thought she was strange and did not think anything about it. As the shift progressed LN G was shaking, talking a lot, like she was drunk and did not know what was going on at the time. HS U arrived and talked to them about LN G's behavior. CNA N stated he was just trying to do his job, while NAT M and HS U tried to call someone about LN G. CNA M stated LN G acted weirder as the night went on. He heard her talk to herself quite a bit and noted she was brushing her hair weird. CNA M stated he left his shift right after 06:00 AM when he was relieved by the day shift. CNA N stated he did not attempt to notify anyone of LN G's behavior, he was busy doing his job. On 05/08/23 at 12:23 PM NAT M stated she worked with LN G before 05/03/23 and she was always off but had never acted the way she did when NAT M worked on 05/03/23 from 10:00 PM to 05/04/23 06:00 AM. NAT M stated when she arrived for duty at 10:00 PM, LN G sat at the nurses desk and looked really drowsy. NAT M stated LN G was dancing around, screaming and crying at a clipboard, jumping around during the shift. NAT M stated on 05/03/23 at 11:30 PM she told LN G that R1 wanted pain medication, LN G got the medicine out and gave NAT M two, white, long, pills to take to R1. NAT M stated she thought since the nurse asked me to take it to them it was okay. NAT M stated around midnight she asked Administrative Nurse D about LN G's behavior, stating that LN G was acting strange and did not know if could work with her or not because of the way she [LN G] was acting. Administrative Nurse D told NAT M to write down what LN G was doing, give it to her, and stated that they had a meeting that day and she would let everyone know what was going on. NAT M stated first she tried to call Administrative Staff D, who was on-call but did not answer, so she sent her a text message. On 05/04/23 at 05:30 AM the behavior of LN G got really bad and she contacted Administrative Staff A on 05/04/23 at 05:50 AM, who responded stating the day nurse should be coming any minute, and by then, the day shift arrived and contacted people. NAT M stated someone contacted Administrative Nurse F around 05:30 AM. NAT M stated she got off work at 06:00 AM on 05/04/23. Between 05:30 AM and when NAT M left, LN G was in an empty resident room and stated she needed to check on a guy in that room. On 05/08/23 at 12:38 PM LN H stated he worked the day shift on 05/03/23 and when LN G arrived for her shift for that night LN G was a bit antsy, not really too abnormal, nothing outrageous and LN H said some days she was like that and some days not. LN H said he arrived on 05/04/23 after CNA O came to his house, knocked on his door and stated he was really needed to relieve this nurse, she is really out there. LN H stated he did not touch the medication cart when he arrived, as it was taken over by CMA S and Administrative Nurse F. R2 was in extra pain that day, it was also a rainy day, and she hurts more at those times and we could not tell if she (R2) had got the medications or not, so we had to wait until her scheduled time. LN H stated R2's pain level did get back down to normal that day and stated R2 was alert and oriented. On 05/08/23 at 12:49 PM HS U stated when she arrived to the facility at 04:32 AM on 05/04/23, LN Gt came around the desk and about knocked her over. HS U stated LN G had a lot of body jerky motions and her mouth would move around and she would say I feel really weird. At 05:10 AM LN G stated she was going to check on the resident in a room (which was empty) and HS U told LN G nobody was in that room. HS U stated LN G was banging her head on the clipboard and the side of the bed and her words were slurred. HS U stated she texted Administrative Nurse Fat 05:15 AM and asked if she could call. Then she attempted to reach Consultant Staff U with no response, while NAT M called Administrative Staff A. HS U stated Administrative Staff U called back at 06:32 AM, and she told her how LN G was acting. She said Administrative Nurse F asked her to not let LN G leave the building. On 05/08/23 at 01:12 PM R1 stated NAT M brought him medicine last week and said it was Tylenol, which was long and white. R1 stated the oxycodone he took was real small and white. R1 stated the LN did not perform an assessment of his pain location, or level of his pain. He told NAT M the location and level and depending on the level affected which medication they brought him or how many pills. R1 stated his pain level was at an 8 out of 10 last week, and the Tylenol really did not help. R1 stated he did not see a nurse at all that night, even though he had asked for his catheter flush to be done before he went to sleep, and nobody showed up to do it, and said thankfully, [he] did not have problems with the catheter that night. On 05/08/23 at 02:06 PM Administrative Nurse D stated she was the on-call nurse last week, so if someone were to call-in she would help find coverage, or if the nurse had a question or a problem they could call and she would help them. Administrative Nurse D confirmed (by checking her phone) on 05/03/23 at 11:10 PM she received a text message from NAT M which said I can't do this job with this woman, if you seen her right now you would see what I am talking about, there are no way these residents are safe with her up here, talking to herself and laughing, grunting, kicked over the trash can. Administrative Nurse D stated she knew a lot of times LN G would listen to books on tape while she worked and responded back to NAT M she would talk to Administrative Staff A, Administrative Nurse E, and Consultant Staff HH in the meeting tomorrow, thanked her for saying something, and encouraged her to write up a statement of everything she saw and heard. Administrative Nurse D stated she received another text from NAT M at 11:00 AM on 05/04/23 noting things got way worse last night into this morning. Administrative Nurse D stated she did not feel the need to check on LN G when she received the text message, as she knew LN G had a lot of quirks and NAT M had the tendency to exaggerate significantly. Administrative Nurse D stated she questioned NAT M on why she did not call when LN G's behavior became more erratic, as she would have gone to the facility. NAT M told her it did not get worse until about 05:00 AM. However, Administrative Nurse D stated CMA T called at 05:50 AM on 05/04/23 and she did not wake up. Administrative Nurse D stated LN G had called her at 06:25 AM to report LN H was not at work yet, and said LN G did not sound different on the phone, and said LN G had always had a little bit of movements with her mouth, so her speech was different Administrative Nurse D stated she let Administrative Nurse E know NAT M texted about LN H's behaviors, and when she arrived at work that morning, she was surprised at how LN G acted compared to how she was on the phone earlier that morning. On 05/08/23 at 02:23 PM Administrative Nurse F stated Housekeeping Staff U sent a text on 05/04/23 at 05:30 AM, however, she did not know about the text until 06:32 AM and called to see what was going on. Administrative Nurse F stated she got ready, clocked in at 07:00 AM, and when she arrived LN G sat in a chair at the nurse's station and CMA P was in the vicinity keeping an eye on her. When LN G saw her come down the hallway from the front doors, LN G threw her arms up, her mouth was wide open, and she said Hi really loud and had exaggerated arm movements. Administrative Nurse F stated she then opened the door to Administrative E's office, sat down her bag, grabbed a drug test, and had LN G come with her to the bathroom, meanwhile, she stood outside the door with it cracked open for two hours, awaiting the urine drug sample from LN G. Administrative Nurse F stated when CMA R arrived for duty, she requested a medication count with LN H or CMA T, and CMA R returned and stated five pills were unaccounted for. On 05/08/23 at 03:19 PM Administrative Nurse E stated if she had received the text message from NAT M that Administrative Nurse D did, regarding the behavior of LN G, she would have come up here. Then, Administrative Nurse D stated if anyone other than NAT M had texted her the concern about LN G's behavior, she would have come in and NAT M overexaggerates, but not this time. The facility policy Abuse updated 10/25/22 revealed any alleged violation involving abuse, neglect, exportation (exploitation), or mistreatment including injuries of unknown source and misappropriation of resident property shall be reported immediately to the Administrator and the Director of Nursing. The facility staff failed to report the neglectful situation immediately to the Administrator and the Director of Nursing. The identified noncompliance placed all residents of the facility at risk for the likelihood of a serious adverse outcome when the facility allowed an suspectedly impaired Licensed Nurse to remain on duty as the charge nurse and administer all cares, treatments, and assessments for all residents from 05/03/23 at 11:10 PM (when staff alerted the concern with the Licensed Nurse's erratic behavior) until 05/04/23 at 07:00 AM when the staff removed the Licensed Nurse from the floor. The Licensed Nurse was on duty for seven hours and 50 minutes after the staff first reported the erratic behavior until another Licensed Nurse arrived at the facility to take over. On 05/09/23 at 10:00 AM Administrative Staff A was informed the residents of the facility were in immediate jeopardy and provided the Immediate Jeopardy template for failure to prevent a period of neglect when the Administrative Nurse did not respond timely to the report of inappropriate/concerning behavior of a Licensed Nurse, who worked on 05/03/23 from 06:00 PM until 05/04/23 at 07:00 AM and exhibited erratic behavior while on duty. The facility provided a plan for removal of the immediacy on 05/09/23 at 04:34 PM, accepted on 05/09/23 at 04:38 PM, which included the following corrective measure on to be completed by 05/09/23 at 10:00 PM. 1. LN G was relieved from duty on 05/04/23 at 07:06 AM. 2. Revised Emergent Notification to Administrative Staff policy to include facility staff not text but to call the Administrator/Director of Nursing/Assistant Director of Nursing/Nurse on call with issues related to resident's safety, completed 05/09/23 at 10:00 AM. 3. Notified the Medical Director on 05/09/23 at 11:14 AM for QAPI meeting to discuss findings and plan of correction, completed 05/09/23 at 12:02 PM. 4. In servicing began on 05/04/23 at 02:10 PM related to topics of Abuse and facility reporting and on 05/09/23 at 12:00 PM on updated Emergent Notification to Administrative Staff policy and procedure, will be completed 05/09/23 by 10:00 PM. The surveyor verified the implementation of the above corrective actions onsite on 05/11/23 at 11:51 AM and the deficient practice remained at a F scope and severity.

The facility reported a census of 36 residents, with 10 residents selected for review. Based on observation, interview, and record review, the facility failed to conduct a thorough assessment of one Resident (R)1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication (medication to promote the formation and excretion of urine) on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level (the percentage of oxygen in the blood), when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided cardio-pulmonary resuscitation (CPR- the manual application of chest compressions and ventilations to patients in cardiac arrest) when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. Findings included: - The Face Sheet for Resident (R)1 included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), lymphedema (tissue swelling as a result of blockage in the lymphatic system), cirrhosis (chronic degenerative disease of the liver) without ascites (excess abdominal fluid), infection and inflammatory reaction due to indwelling urethral catheter (tube inserted into the bladder to drain urine), and benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) with lower urinary tract symptoms. The Orders tab for R1 included these orders, however lacked an order for oxygen: 1. Flomax (medication used to treat BPH, 0.4 milligrams (mg), by mouth, daily for BPH with lower urinary tract systems, ordered on [DATE]. 2. Spironolactone (medication used to treat fluid retention), 100 mg, by mouth, once a day, for edema, ordered on [DATE]. 3. Torsemide (medication used to treat fluid retention caused by CHF, kidney failure, or liver disease), 20 mg, by mouth, twice a day, at 07:00 AM and 02:00 PM, must take seven hours apart, for edema, ordered on [DATE]. 4. Urinary catheter, size 16 French, change every 30 days, on the first of the month, ordered on [DATE], for urinary tract infection (UTI). 5. Chart catheter output, every shift, three times a day, for infection and inflammatory reaction due to indwelling catheter, ordered on [DATE]. 6. Flush urinary catheter, as needed for clogging due to sediment, for urinary tract infection, ordered on [DATE]. 7. Sodium chloride, one gram, by mouth, once a day, ordered on [DATE]. The Admission Minimum Data Set, dated dated dated [DATE], revealed R1 admitted to the facility on [DATE]. He had clear speech, could make himself understood, and could understand others. He had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 did not have any behavior symptoms or rejection of care. He required extensive assistance of two or more staff for bed mobility and was dependent of two or more staff for transfers and toilet use. R1 had an indwelling catheter in place, sepsis (systemic infection), and a history of a urinary tract infection (UTI) in the past 30 days. He received a diuretic medication seven days and an antibiotic two days of the seven-day assessment period. The Activities of Daily Living (ADL's) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE], revealed R1 required extensive to total assistance with ADL's and had several co-morbidities that made it difficult for him to do much. The Urinary Incontinence and Indwelling Catheter CAA dated [DATE], revealed R1 had a catheter, admitted with diagnosis of UTI, and was on an antibiotic (medication to fight bacterial infections). The Dehydration/Fluid Maintenance CAA dated [DATE], revealed R1 was aware of his own thirst, could grasp a cup and get his own drink, was on a 2,000 milliliter (ml) fluid restriction, and required two diuretics (medication to promote the formation and excretion of urine): spironolactone and torsemide. The Care Plan dated [DATE], revealed R1 required total assistance from two or more staff for toileting. The care plan lacked notification to staff that R1 had an indwelling catheter and/or management of the catheter, lacked presence of edema, and lacked medications used to treat edema. The Progress Notes dated [DATE] at 10:44 AM, revealed Consultant Physician Extender GG was at the facility, saw R1, and gave verbal orders for therapy to assess him for lymphedema wraps and if the resident did not qualify, apply ACE (all cotton elastic) wraps in the am and take them off at HS (hour of sleep) . increase torsemide (medication to promote the formation and excretion of urine) to 40 milligrams (mg), twice daily, for five days, then decrease back to 20 mg daily. The physician Progress Notes dated [DATE], revealed this was an annual wellness visit. R1 reported to Consultant GG Physician Extender that he felt well, they discussed his full code status (when the heart stopped beating and/or breathing stopped, all resuscitation procedures were to be provided to keep the person alive) and risks/benefits, and R1 wished to remain with a full code status. The nursing staff reported progression of lower extremity edema and felt he would benefit from a medication adjustment at this time. During exam, the resident had no shortness of breath, his lung sounds were clear, his abdomen was soft and nontender, and he had bilateral (both) lower extremity edema at 3+ (five to six millimeters of depression to skin when pressed with a rebound time of ,d+[DATE] seconds). He received spironolactone (medication to promote the formation and excretion of urine), 100 mg, by mouth, every morning, and torsemide, 20 mg, by mouth twice daily. The Progress note included to increase the torsemide to 40 mg, by mouth, twice daily, for five days, then resume 20 mg, by mouth twice daily, for CHF. The Medication Administration Record (MAR) dated ,d+[DATE]-[DATE], revealed R1 received torsemide, 40 mg, by mouth on [DATE] at 05:00 PM dosing time, [DATE] at 08:00 AM dosing time, [DATE], he refused the 05:00 PM dose, received both doses on [DATE] and [DATE]. On [DATE] he received the 08:00 AM dose, but did not receive the dose at 05:00 PM Due to condition documented at 04:10 PM by Certified Medication Aide (CMA) S. The Urine Output log revealed on [DATE] at 05:26 AM, R1 had 100 ml of urine output. On [DATE] at 10:31 PM, he had 100 ml of output. On [DATE] at 05:13 AM, zero output, [DATE] at 05:30 AM, he had 100 ml output. The urine output tracking log lacked documentation of output again until [DATE] at 06:14 AM, for a total of 13 hours and 14 minutes. The Urine output revealed on [DATE] at 06:14 AM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:19 PM, revealed another nurse changed R1's catheter and had output noted at that time. However, the note lacked the amount of urine output with the catheter insertion. The Progress Note dated [DATE] at 09:24 AM, revealed the off-going charge nurse reported to Administrative Nurse E that R1's catheter was changed [DATE] and since that time there had been minimal output. Administrative Nurse E assessed R1 for urine output and Noted urine in catheter tubing. Administrative Nurse E flushed the catheter and met no resistance. The note lacked the amount of fluid returned after flushing the catheter. The Urine Output log revealed on [DATE] at 01:53 PM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:20 PM, revealed R1 complained of penile pain related to the catheter and stated it felt like the catheter was partially out. Administrative Nurse E noted there was urine in the tubing and flushed the catheter without difficulty. R1 continued to complain of pain. Administrative Nurse E removed the urinary catheter and inserted a new catheter and there was no urine output with the insertion of a new catheter. When Administrative Nurse E inflated the urinary catheter balloon (located at the tip of the catheter behind the drainage eyelets, inflated after a urinary catheter is properly placed to help keep the tubing seated in the bladder) R1 complained of pain. The note included Administrative Nurse E would monitor R1 for urine output and complaints of pain. The Urine output log revealed no further urine output documented from [DATE] at 01:53 PM until [DATE] at 01:44 AM, which was documented as zero urinary output. The facility documented zero urinary output again at 04:39 AM. The Progress Note dated [DATE] at 04:40 AM revealed R1 had no urine output since the catheter had been changed and he denied discomfort. Administrative E flushed the catheter without difficulty and was unable to palpate for bladder distention due to size of abdomen. The Progress Note dated [DATE] at 11:07 AM, revealed Administrative Nurse D was asked to check on R1 by Licensed Nurse (LN) G who was the charge nurse. The note revealed R1 complained of not feeling good but did not elaborate and was not wanting to talk, which was not unusual for him. Administrative Nurse D assessed his lungs to be clear, did not appear to be short of breath, did not appear to be in distress, and was unable to obtain his oxygen saturation measurement on his fingers or his earlobe. Staff applied warm packs and an extra blanket to attempt to warm his fingers, without success. The assessment lacked any measurement of vital signs (blood pressure, pulse, respirations, temperature), lacked further head to toe assessment including assessment of urinary function, and lacked physician notification. The Progress Note date [DATE] at 01:20 PM, revealed after evaluating the resident again, staff requested to send the resident to the emergency room (ER) and noted R1's hands and arms were cool to touch despite warming attempts and now stated he was short of breath although he did not appear to be. Staff were unable to measure the resident's oxygen saturation level and notified family. R1's lungs remained clear, and the resident's oxygen was at three liters-per-minute. The family member attempted to call R1's cell phone, but R1 was unable to speak to the family member, so Administrative Nurse D spoke with the family member and the family member wished not to call EMS and to elevate the head of R1's bed instead. R1 was agreeable to this and the staff elevated the head of his bed. The note lacked measurement of vital signs and physician notification. The Urine output log revealed on [DATE] at 02:20 PM the resident had zero urinary output. R1 lacked urinary output from [DATE] at 01:53 PM through [DATE] at 02:20 PM, a time span greater than 24 hours. The facility further failed to notify R10's physician during this time. Review of the facility's video footage for [DATE], along with Administrative Staff F, revealed an unidentified staff member carrying an oxygen bottle to R1's room at 01:01 PM, Administrative Nurse D exited R1's room at 01:15 PM, and no further licensed nurses entered his room until approximately 05:52 PM (over 4.5 hours later) when LN G and LN H entered the room. The video footage had intervals of skipping from 20 seconds to several minutes during the time frame reviewed. The Progress Notes lacked any further assessment of the resident until documentation at 06:38 PM, which revealed LN G and LN H were notified R1's vital signs has ceased. LN G and LN H performed assessments and a Certified Nurse Aid (CNA) start CPR. EMS notified and came to the facility and confirmed the resident's vital signs had ceased. During an interview on [DATE] at 11:27 AM, LN G stated R1 passed away during change of shift on [DATE]. LN G stated he was the off-duty nurse at that time and called 911, while CMA S and LN H (the on-coming nurse), and was not sure if there was anyone else, that performed CPR. LN G stated R1 reported to him he could not breathe during his shift. Administrative Nurse D and LN G checked R1's oxygen saturation, but R1's hands were cold, and they could not get them warm enough to get an accurate reading, so Administrative Nurse D took over. R1's lungs were clear and Administrative Nurse D reported those findings to a family member and had asked if staff could send R1 out to ER, but the family member wanted to hold off and have him re-evaluated in a little bit. LN G stated the family member never called back. LN G stated around 05:,d+[DATE]:30 PM, the staff turned R1, he wanted a drink at that time, and then around 06:15 PM the staff went to deliver R1's hall tray and found him unresponsive. LN G stated R1 had a catheter and the staff monitored output, the aides would document the output every shift and the nurses would document it as well. The aides would empty the catheter bags once a shift towards the end of their shift and LN G stated he could not recall if R1 had a change in his urinary output that day. On [DATE] at 01:24 PM, R1's family member stated on [DATE] at approximately 02:00 PM or 2:30 PM, the facility was to call him back in an hour after staff assessed the resident. The family member stated he never heard anything back and assumed everything was okay. The family stated the facility reported the resident complained of chest pain and difficulty breathing, but his lungs sounded good, and he appeared to be breathing fine. Staff informed the family member that the resident's hands were to too cold to get an oxygen saturation reading. There was not a sense of urgency when talking to the facility about his condition and he did not realize that going to the hospital was recommended. The facility was going to sit the resident up and call the family back in an hour. The family member stated he did not receive a call until the facility's nurse called to say the resident had passed away. On [DATE] at 08:54 AM, LN H stated she worked on [DATE], then was off duty until [DATE] for the 06:00 PM shift. LN H stated she did not notice any abnormal swelling on [DATE] and Consultant Physician Extender GG had seen R1 on [DATE]. LN H stated she was trying to see if R1's catheter situation had been addressed and low output was normal for him around ,d+[DATE] ml per shift. R1 would drink water during her shift and the CNA's would empty the catheter. The catheters were emptied as needed, but at least once a shift at the end of the shift. LN H stated she was getting report from LN G when one of the CNA's said R1 was not breathing, so her and LN G went to assess R1, and he lacked vital signs. LN G went to check his record while CPR was started by CMA S and EMS contacted. Compressions continued until EMS took over. LN H stated she was not aware of any difficulty with compressions because at that point she was at the desk and LN G was assisting. LN G called 911 and notified a family member. On [DATE] at 10:28 AM, Administrative Nurse E stated she recalled R1 having no urinary output and did not recall if the physician was notified or not. After checking documentation, Administrative Nurse E stated she did not notify the doctor and assumed the day shift would do so as she would not notify the physician in the middle of the night for that reason, and passed it on in report to LN G. Administrative Nurse E stated R1's output fluctuated between ,d+[DATE] ml but did not specify per shift or day, the charge nurse monitored output, and confirmed his output from ,d+[DATE]-[DATE] was not appropriate with the increase in the torsemide on [DATE], and Consultant Physician Extender GG should have been notified. On [DATE] at 11:16 AM, Administrative Nurse D stated the nurses were responsible for monitoring urinary output and the CNA's emptied and reported the amount to the charge nurse. Administrative Nurse D stated she would expect the nurse to notify the physician if there was little or no urinary output present and would expect an increase in output with administration of Torsemide. Administrative Nurse D stated she was under the impression someone notified the physician of low urine output. Administrative Nurse D reported on [DATE], LN G was the charge nurse and at approximately 11:07 AM asked her to go look at R1 as he could not get R1's oxygen saturation, his hands were cold, he did not feel good, and R1 would not talk to LN G, so she went down to his room to assess him. R1 had on oxygen when she went to assess him, his lungs were clear, no shortness of breath, his hands were really cold, so she did warm packs and warm blankets on his hands and arms to try and warm them up. R1 would not talk to her, and she was not able to get a measurement of his oxygen saturation. Administrative Nurse D stated she contacted Consultant Physician Extender GG around noonish and was told he could be sent to ER if we needed to, but the whole time R1 did not want to go. Administrative Nurse D stated she went back around 01:20 PM and his hands and arms were cold and he refused to go to ER so she then called the family member who stated if R1 did not want to go do not make him, but try to raise the head of the bed to see if that helps, and did not believe when she talked to the family member she specifically said they had an order to send R1 to the ER. Administrative Nurse D stated she was not aware that R1 lacked urinary output and did not talk to the physician extender about urinary output, and stated she was in and out of the room that afternoon to check on R1 until she left, which was usually around 04:00 PM. Administrative Nurse D stated LN G should have checked his vital signs and would expect staff to document vital signs. On [DATE] at 01:14 PM, Consultant Physician Extender GG reported on her visit on [DATE], R1 had more swelling in his legs, so she increased the diuretic, and the staff had reported his edema was gradually increasing, and staff elevated his legs. Consultant Physician Extender GG stated she expected an increase in urinary output with the increase in the diuretic and should have been notified of lack of increase in the urine output and lack of urine output, as that was a problem. Consultant Physician Extender GG stated the facility should have made her aware of any urinary output less than 30 ml in an hour. Consultant Physician Extender GG stated she was not aware of R1's change of condition on [DATE]. If staff would have notified the physician extender, she would have given the order to send him to the ER. On [DATE] at 01:47 PM, CMA R stated CNAs emptied the catheters at least once on an eight-hour shift, and some nurses wanted the output documented in the electronic record and some wanted it on a piece of paper so they could see it and document the output themselves. CMA R stated staff should report to the nurse if there was lack of urine output or change in the urine color. On [DATE] at 02:51 PM CNA M reported she recalled on [DATE], R1 had 100 ml of urine output the whole shift. He liked tea, and she made him a big mug and he drank all of what was in the mug. On [DATE], she could feel fluid when rolling R1 and holding him over, it was leaving indentions where she would touch his leg and told the nurse. She reported the resident had the same edema on [DATE]. CNA M stated R1 was breathing okay on [DATE] and he would change the level of the head of the bed and liked it lower, but not flat. She did not notice any increase in his abdominal swelling however, his scrotum was swollen too, so she arranged the catheter tubing to see if that would improve urinary output and placed his legs on a pillow to elevate his legs. On [DATE] at 03:10 PM, CNA O stated on [DATE] she came in at 02:00 PM and when exiting another resident room, she glanced at R1 and noticed his head of bed was straight up and thought that was weird as he never liked to sit up straight. The resident had an oxygen concentrator in the room, which was new. CNA O offered him a drink as his mouth was really dry and R1 shook his head no. He was trying to talk and seemed like he was trying to catch his breath. The resident's nasal cannula was off, and staff placed the resident's oxygen nasal cannula back on him. CNA O stated she did not tell the nurse at that time as she felt the nurse was probably already aware since R1 had oxygen in place. CNA O stated his hand was cold and had noticed before that day his edema was real bad. CNA O stated when staff would roll R1 over and hold him, fingerprints would stay in his skin and be that way for quite some time to his legs and his back. CNA O stated on [DATE] or [DATE], he was hardly having any urinary output and it was a little bloody and she reported she notified the nurse. CNA O stated his output was around 100 ml, but he was still drinking the same amount as usual. On [DATE] at 04:14 PM, CMA S stated on [DATE], R1 took his morning medication, but not his afternoon ones, because he was very out of it that afternoon and had a hard time breathing. He was on oxygen. CMA S stated she prepared his afternoon medications, she was having a hard time understanding what he was saying, and his voice was raspy and stated this was not normal for him at all. CMA S stated she told LN G he was having a hard time breathing and then talked to Administrative Nurse D, and asked if anyone had been called as she did not think he was doing well and Administrative Nurse D told her she had called a family member and there was a little decline, and R1 did not want to go to the hospital so the family member said to respect his wishes and do not send him. CMA S stated that was probably around noon. CMA S stated she saw him again around 04:00 PM to 05:00 PM, and R1 was coherent and said thank you but could not get any other words out, and he did not take his medications at that time. CMA S stated while she was counting medications with the nurse, a staff member reported R1 was unresponsive. CMA S stated she started CPR and when she gave the first compression it sounded like water like he was completely full of fluid. CMA S stated she provided CPR until EMS arrived and took over. CMA S stated the week before she had emptied R1's catheter and his urine had been cloudy and thick, like sediment and pus and stated she had reported that to the charge nurse. The facility's policy for Edema dated [DATE], revealed the current primary care provider would be notified immediately of any shortness of breath, difficulty breathing, or chest pain as these can be signs of pulmonary edema, which requires prompt treatment. The staff were to notify the primary care provider of any new or worsening signs and symptoms of edema and follow recommendations. The facility policy PCP (primary care physician) Notification of Change dated [DATE] included to observe and report significant change in condition and included to monitor resident's condition frequently until stable. The facility failed to conduct a thorough assessment of R1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level, when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided CPR when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. On [DATE] at 01:55 PM, Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to conduct a thorough assessment with a change in condition, failure to notify physician with little and lack of output following an increase in diuretic medication, and failure to provide further ongoing assessments of R1 after his complaint of difficulty breathing and inability to measure his oxygen saturation level. The facility removed the immediate jeopardy on [DATE] at 06:30 PM when they completed the following: 1. The physician and/or nurse practitioner or physician's assistant will be notified of significant changes in a resident's condition. If after hours, call their cell phone. If no answer, call the hospital and ask the operator to page the physician and/or nurse practitioner or physician's assistant or the alternate physician that is taking call for the resident's primary care provider. 2. If a resident experiences any significant change and they are not on Hospice Palliative Care, or skilled End of Life, the resident will be automatically sent to the ER. Admission packet will be modified for new admissions to state that fact. All current residents will receive and sign an addendum to the Admission Agreement. 3. All staff will be in-serviced and trained on the change of practice. Immediate in-service will start on [DATE] and be completed on [DATE]. Completion of staff in-service was [DATE] at 06:30 PM 4. The daily skilled charting observation form in Matrix had been updated to include change of condition charting, which includes the mandatory inclusion of vital signs, PCP notification, and urinary output. This will go into effect immediately and will include any skilled resident or any resident that has had a change in condition. 5. A focused QAPI meeting addressing the finding was held with Administrator, Director of Nursing and Medical Director in attendance on [DATE] The facility provided an acceptable plan for removal of the immediate jeopardy on [DATE] at 06:00 PM. the survey team validated the immediate jeopardy was removed on [DATE] at 06:30 PM following the facility's implementation of the plan for removal of the immediate jeopardy. This deficient practice remained at a scope and severity of J (a situation in which immediate corrective action is necessary because of the likeliness to cause serious injury, harm, impairment, or death) and was lowered to a scope and severity of G (isolated with actual harm) following the removal of the immediate jeopardy.

The facility reported a census of 36 residents, with 10 residents selected for review, including two residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to conduct a thorough assessment of one Resident (R)1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication (medication to promote the formation and excretion of urine) on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level (the percentage of oxygen in the blood), when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided cardio-pulmonary resuscitation (CPR- the manual application of chest compressions and ventilation to patients in cardiac arrest) when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. Findings included: - The Face Sheet for Resident (R)1 included diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), lymphedema (tissue swelling as a result of blockage in the lymphatic system), cirrhosis (chronic degenerative disease of the liver) without ascites (excess abdominal fluid), infection and inflammatory reaction due to indwelling urethral catheter (tube inserted into the bladder to drain urine), and benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections) with lower urinary tract symptoms. The Orders tab for R1 included these orders, however lacked an order for oxygen: 1. Flomax (medication used to treat BPH, 0.4 milligrams (mg), by mouth, daily for BPH with lower urinary tract systems, ordered on [DATE]. 2. Spironolactone (medication used to treat fluid retention), 100 mg, by mouth, once a day, for edema, ordered on [DATE]. 3. Torsemide (medication used to treat fluid retention caused by CHF, kidney failure, or liver disease), 20 mg, by mouth, twice a day, at 07:00 AM and 02:00 PM, must take seven hours apart, for edema, ordered on [DATE]. 4. Urinary catheter, size 16 French, change every 30 days, on the first of the month, ordered on [DATE], for urinary tract infection (UTI). 5. Chart catheter output, every shift, three times a day, for infection and inflammatory reaction due to indwelling catheter, ordered on [DATE]. 6. Flush urinary catheter, as needed for clogging due to sediment, for urinary tract infection, ordered on [DATE]. 7. Sodium chloride, one gram, by mouth, once a day, ordered on [DATE]. The Admission Minimum Data Set, dated dated dated [DATE], revealed R1 admitted to the facility on [DATE]. He had clear speech, could make himself understood, and could understand others. He had a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 did not have any behavior symptoms or rejection of care. He required extensive assistance of two or more staff for bed mobility and was dependent of two or more staff for transfers and toilet use. R1 had an indwelling catheter in place, sepsis (systemic infection), and a history of a urinary tract infection (UTI) in the past 30 days. He received a diuretic medication seven days and an antibiotic two days of the seven-day assessment period. The Activities of Daily Living (ADL's) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated [DATE], revealed R1 required extensive to total assistance with ADL's and had several co-morbidities that made it difficult for him to do much. The Urinary Incontinence and Indwelling Catheter CAA dated [DATE], revealed R1 had a catheter, admitted with diagnosis of UTI, and was on an antibiotic (medication to fight bacterial infections). The Dehydration/Fluid Maintenance CAA dated [DATE], revealed R1 was aware of his own thirst, could grasp a cup and get his own drink, was on a 2,000 milliliter (ml) fluid restriction, and required two diuretics (medication to promote the formation and excretion of urine): spironolactone and torsemide. The Care Plan dated [DATE], revealed R1 required total assistance from two or more staff for toileting. The care plan lacked notification to staff that R1 had an indwelling catheter and/or management of the catheter, lacked presence of edema, and lacked medications used to treat edema. The Progress Notes dated [DATE] at 10:44 AM, revealed Consultant Physician Extender GG was at the facility, saw R1, and gave verbal orders for therapy to assess him for lymphedema wraps and if the resident did not qualify, apply ACE (all cotton elastic) wraps in the am and take them off at HS (hour of sleep) . increase torsemide (medication to promote the formation and excretion of urine) to 40 milligrams (mg), twice daily, for five days, then decrease back to 20 mg daily. The physician Progress Notes dated [DATE], revealed this was an annual wellness visit. R1 reported to Consultant GG Physician Extender that he felt well, they discussed his full code status (when the heart stopped beating and/or breathing stopped, all resuscitation procedures were to be provided to keep the person alive) and risks/benefits, and R1 wished to remain with a full code status. The nursing staff reported progression of lower extremity edema and felt he would benefit from a medication adjustment at this time. During exam, the resident had no shortness of breath, his lung sounds were clear, his abdomen was soft and nontender, and he had bilateral (both) lower extremity edema at 3+ (five to six millimeters of depression to skin when pressed with a rebound time of ,d+[DATE] seconds). He received spironolactone (medication to promote the formation and excretion of urine), 100 mg, by mouth, every morning, and torsemide, 20 mg, by mouth twice daily. The Progress note included to increase the torsemide to 40 mg, by mouth, twice daily, for five days, then resume 20 mg, by mouth twice daily, for CHF. The Medication Administration Record (MAR) dated ,d+[DATE]-[DATE], revealed R1 received torsemide, 40 mg, by mouth on [DATE] at 05:00 PM dosing time, [DATE] at 08:00 AM dosing time, [DATE], he refused the 05:00 PM dose, received both doses on [DATE] and [DATE]. On [DATE] he received the 08:00 AM dose, but did not receive the dose at 05:00 PM Due to condition documented at 04:10 PM by Certified Medication Aide (CMA) S. The Urine Output log revealed on [DATE] at 05:26 AM, R1 had 100 ml of urine output. On [DATE] at 10:31 PM, he had 100 ml of output. On [DATE] at 05:13 AM, zero output, [DATE] at 05:30 AM, he had 100 ml output. The urine output tracking log lacked documentation of output again until [DATE] at 06:14 AM, for a total of 13 hours and 14 minutes. The Urine output revealed on [DATE] at 06:14 AM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:19 PM, revealed another nurse changed R1's catheter and had output noted at that time. However, the note lacked the amount of urine output with the catheter insertion. The Progress Note dated [DATE] at 09:24 AM, revealed the off-going charge nurse reported to Administrative Nurse E that R1's catheter was changed [DATE] and since that time there had been minimal output. Administrative Nurse E assessed R1 for urine output and Noted urine in catheter tubing. Administrative Nurse E flushed the catheter and met no resistance. The note lacked the amount of fluid returned after flushing the catheter. The Urine Output log revealed on [DATE] at 01:53 PM, R1 had 100 ml of urine output. The Progress Note dated [DATE] at 05:20 PM, revealed R1 complained of penile pain related to the catheter and stated it felt like the catheter was partially out. Administrative Nurse E noted there was urine in the tubing and flushed the catheter without difficulty. R1 continued to complain of pain. Administrative Nurse E removed the urinary catheter and inserted a new catheter and there was no urine output with the insertion of a new catheter. When Administrative Nurse E inflated the urinary catheter balloon (located at the tip of the catheter behind the drainage eyelets, inflated after a urinary catheter is properly placed to help keep the tubing seated in the bladder) R1 complained of pain. The note included Administrative Nurse E would monitor R1 for urine output and complaints of pain. The Urine output log revealed no further urine output documented from [DATE] at 01:53 PM until [DATE] at 01:44 AM, which was documented as zero urinary output. The facility documented zero urinary output again at 04:39 AM. The Progress Note dated [DATE] at 04:40 AM revealed R1 had no urine output since the catheter had been changed and he denied discomfort. Administrative E flushed the catheter without difficulty and was unable to palpate for bladder distention due to size of abdomen. The Progress Note dated [DATE] at 11:07 AM, revealed Administrative Nurse D was asked to check on R1 by Licensed Nurse (LN) G who was the charge nurse. The note revealed R1 complained of not feeling good but did not elaborate and was not wanting to talk, which was not unusual for him. Administrative Nurse D assessed his lungs to be clear, did not appear to be short of breath, did not appear to be in distress, and was unable to obtain his oxygen saturation measurement on his fingers or his earlobe. Staff applied warm packs and an extra blanket to attempt to warm his fingers, without success. The assessment lacked any measurement of vital signs (blood pressure, pulse, respirations, temperature), lacked further head to toe assessment including assessment of urinary function, and lacked physician notification. The Progress Note date [DATE] at 01:20 PM, revealed after evaluating the resident again, staff requested to send the resident to the emergency room (ER) and noted R1's hands and arms were cool to touch despite warming attempts and now stated he was short of breath although he did not appear to be. Staff were unable to measure the resident's oxygen saturation level and notified family. R1's lungs remained clear, and the resident's oxygen was at three liters-per-minute. The family member attempted to call R1's cell phone, but R1 was unable to speak to the family member, so Administrative Nurse D spoke with the family member and the family member wished not to call EMS and to elevate the head of R1's bed instead. R1 was agreeable to this and the staff elevated the head of his bed. The note lacked measurement of vital signs and physician notification. The Urine output log revealed on [DATE] at 02:20 PM the resident had zero urinary output. R1 lacked urinary output from [DATE] at 01:53 PM through [DATE] at 02:20 PM, a time span greater than 24 hours. The facility further failed to notify R10's physician during this time. Review of the facility's video footage for [DATE], along with Administrative Staff F, revealed an unidentified staff member carrying an oxygen bottle to R1's room at 01:01 PM, Administrative Nurse D exited R1's room at 01:15 PM, and no further licensed nurses entered his room until approximately 05:52 PM (over 4.5 hours later) when LN G and LN H entered the room. The video footage had intervals of skipping from 20 seconds to several minutes during the time frame reviewed. The Progress Notes lacked any further assessment of the resident until documentation at 06:38 PM, which revealed LN G and LN H were notified R1's vital signs has ceased. LN G and LN H performed assessments and a Certified Nurse Aid (CNA) start CPR. EMS notified and came to the facility and confirmed the resident's vital signs had ceased. During an interview on [DATE] at 11:27 AM, LN G stated R1 passed away during change of shift on [DATE]. LN G stated he was the off-duty nurse at that time and called 911, while CMA S and LN H (the on-coming nurse), and was not sure if there was anyone else, that performed CPR. LN G stated R1 reported to him he could not breathe during his shift. Administrative Nurse D and LN G checked R1's oxygen saturation, but R1's hands were cold, and they could not get them warm enough to get an accurate reading, so Administrative Nurse D took over. R1's lungs were clear and Administrative Nurse D reported those findings to a family member and had asked if staff could send R1 out to ER, but the family member wanted to hold off and have him re-evaluated in a little bit. LN G stated the family member never called back. LN G stated around 05:,d+[DATE]:30 PM, the staff turned R1, he wanted a drink at that time, and then around 06:15 PM the staff went to deliver R1's hall tray and found him unresponsive. LN G stated R1 had a catheter and the staff monitored output, the aides would document the output every shift and the nurses would document it as well. The aides would empty the catheter bags once a shift towards the end of their shift and LN G stated he could not recall if R1 had a change in his urinary output that day. On [DATE] at 01:24 PM, R1's family member stated on [DATE] at approximately 02:00 PM or 2:30 PM, the facility was to call him back in an hour after staff assessed the resident. The family member stated he never heard anything back and assumed everything was okay. The family stated the facility reported the resident complained of chest pain and difficulty breathing, but his lungs sounded good, and he appeared to be breathing fine. Staff informed the family member that the resident's hands were to too cold to get an oxygen saturation reading. There was not a sense of urgency when talking to the facility about his condition and he did not realize that going to the hospital was recommended. The facility was going to sit the resident up and call the family back in an hour. The family member stated he did not receive a call until the facility's nurse called to say the resident had passed away. On [DATE] at 08:54 AM, LN H stated she worked on [DATE], then was off duty until [DATE] for the 06:00 PM shift. LN H stated she did not notice any abnormal swelling on [DATE] and Consultant Physician Extender GG had seen R1 on [DATE]. LN H stated she was trying to see if R1's catheter situation had been addressed and low output was normal for him around ,d+[DATE] ml per shift. R1 would drink water during her shift and the CNA's would empty the catheter. The catheters were emptied as needed, but at least once a shift at the end of the shift. LN H stated she was getting report from LN G when one of the CNA's said R1 was not breathing, so her and LN G went to assess R1, and he lacked vital signs. LN G went to check his record while CPR was started by CMA S and EMS contacted. Compressions continued until EMS took over. LN H stated she was not aware of any difficulty with compressions because at that point she was at the desk and LN G was assisting. LN G called 911 and notified a family member. On [DATE] at 10:28 AM, Administrative Nurse E stated she recalled R1 having no urinary output and did not recall if the physician was notified or not. After checking documentation, Administrative Nurse E stated she did not notify the doctor and assumed the day shift would do so as she would not notify the physician in the middle of the night for that reason, and passed it on in report to LN G. Administrative Nurse E stated R1's output fluctuated between ,d+[DATE] ml but did not specify per shift or day, the charge nurse monitored output, and confirmed his output from ,d+[DATE]-[DATE] was not appropriate with the increase in the torsemide on [DATE], and Consultant Physician Extender GG should have been notified. On [DATE] at 11:16 AM, Administrative Nurse D stated the nurses were responsible for monitoring urinary output and the CNA's emptied and reported the amount to the charge nurse. Administrative Nurse D stated she would expect the nurse to notify the physician if there was little or no urinary output present and would expect an increase in output with administration of Torsemide. Administrative Nurse D stated she was under the impression someone notified the physician of low urine output. Administrative Nurse D reported on [DATE], LN G was the charge nurse and at approximately 11:07 AM asked her to go look at R1 as he could not get R1's oxygen saturation, his hands were cold, he did not feel good, and R1 would not talk to LN G, so she went down to his room to assess him. R1 had on oxygen when she went to assess him, his lungs were clear, no shortness of breath, his hands were really cold, so she did warm packs and warm blankets on his hands and arms to try and warm them up. R1 would not talk to her, and she was not able to get a measurement of his oxygen saturation. Administrative Nurse D stated she contacted Consultant Physician Extender GG around noonish and was told he could be sent to ER if we needed to, but the whole time R1 did not want to go. Administrative Nurse D stated she went back around 01:20 PM and his hands and arms were cold and he refused to go to ER so she then called the family member who stated if R1 did not want to go do not make him, but try to raise the head of the bed to see if that helps, and did not believe when she talked to the family member she specifically said they had an order to send R1 to the ER. Administrative Nurse D stated she was not aware that R1 lacked urinary output and did not talk to the physician extender about urinary output, and stated she was in and out of the room that afternoon to check on R1 until she left, which was usually around 04:00 PM. Administrative Nurse D stated LN G should have checked his vital signs and would expect staff to document vital signs. On [DATE] at 01:14 PM, Consultant Physician Extender GG reported on her visit on [DATE], R1 had more swelling in his legs, so she increased the diuretic, and the staff had reported his edema was gradually increasing, and staff elevated his legs. Consultant Physician Extender GG stated she expected an increase in urinary output with the increase in the diuretic and should have been notified of lack of increase in the urine output and lack of urine output, as that was a problem. Consultant Physician Extender GG stated the facility should have made her aware of any urinary output less than 30 ml in an hour. Consultant Physician Extender GG stated she was not aware of R1's change of condition on [DATE]. If staff would have notified the physician extender, she would have given the order to send him to the ER. On [DATE] at 01:47 PM, CMA R stated CNAs emptied the catheters at least once on an eight-hour shift, and some nurses wanted the output documented in the electronic record and some wanted it on a piece of paper so they could see it and document the output themselves. CMA R stated staff should report to the nurse if there was lack of urine output or change in the urine color. On [DATE] at 02:51 PM CNA M reported she recalled on [DATE], R1 had 100 ml of urine output the whole shift. He liked tea, and she made him a big mug and he drank all of what was in the mug. On [DATE], she could feel fluid when rolling R1 and holding him over, it was leaving indentions where she would touch his leg and told the nurse. She reported the resident had the same edema on [DATE]. CNA M stated R1 was breathing okay on [DATE] and he would change the level of the head of the bed and liked it lower, but not flat. She did not notice any increase in his abdominal swelling however, his scrotum was swollen too, so she arranged the catheter tubing to see if that would improve urinary output and placed his legs on a pillow to elevate his legs. On [DATE] at 03:10 PM, CNA O stated on [DATE] she came in at 02:00 PM and when exiting another resident room, she glanced at R1 and noticed his head of bed was straight up and thought that was weird as he never liked to sit up straight. The resident had an oxygen concentrator in the room, which was new. CNA O offered him a drink as his mouth was really dry and R1 shook his head no. He was trying to talk and seemed like he was trying to catch his breath. The resident's nasal cannula was off, and staff placed the resident's oxygen nasal cannula back on him. CNA O stated she did not tell the nurse at that time as she felt the nurse was probably already aware since R1 had oxygen in place. CNA O stated his hand was cold and had noticed before that day his edema was real bad. CNA O stated when staff would roll R1 over and hold him, fingerprints would stay in his skin and be that way for quite some time to his legs and his back. CNA O stated on [DATE] or [DATE], he was hardly having any urinary output and it was a little bloody and she reported she notified the nurse. CNA O stated his output was around 100 ml, but he was still drinking the same amount as usual. On [DATE] at 04:14 PM, CMA S stated on [DATE], R1 took his morning medication, but not his afternoon ones, because he was very out of it that afternoon and had a hard time breathing. He was on oxygen. CMA S stated she prepared his afternoon medications, she was having a hard time understanding what he was saying, and his voice was raspy and stated this was not normal for him at all. CMA S stated she told LN G he was having a hard time breathing and then talked to Administrative Nurse D, and asked if anyone had been called as she did not think he was doing well and Administrative Nurse D told her she had called a family member and there was a little decline, and R1 did not want to go to the hospital so the family member said to respect his wishes and do not send him. CMA S stated that was probably around noon. CMA S stated she saw him again around 04:00 PM to 05:00 PM, and R1 was coherent and said thank you but could not get any other words out, and he did not take his medications at that time. CMA S stated while she was counting medications with the nurse, a staff member reported R1 was unresponsive. CMA S stated she started CPR and when she gave the first compression it sounded like water like he was completely full of fluid. CMA S stated she provided CPR until EMS arrived and took over. CMA S stated the week before she had emptied R1's catheter and his urine had been cloudy and thick, like sediment and pus and stated she had reported that to the charge nurse. The facility's policy for Edema dated [DATE], revealed the current primary care provider would be notified immediately of any shortness of breath, difficulty breathing, or chest pain as these can be signs of pulmonary edema, which requires prompt treatment. The staff were to notify the primary care provider of any new or worsening signs and symptoms of edema and follow recommendations. The facility policy PCP (primary care physician) Notification of Change dated [DATE] included to observe and report significant change in condition and included to monitor resident's condition frequently until stable. The facility failed to conduct a thorough assessment of R1 with a change in condition. The facility failed to notify the physician when R1 did not have an increase in urinary output following an increase in physician ordered diuretic medication on [DATE]. The facility failed to notify the physician on [DATE] when the resident lacked urinary output for greater than 24 hour and complained of difficulty breathing. On [DATE] the facility further failed to provide ongoing assessments of R1 by a licensed nurse after the resident had complaints of difficulty breathing, and inability to obtain oxygen saturation level, when the resident had coolness of his hands and arms after application of a warm blanket, and after application of oxygen for over four hours from 01:15 PM to approximately 05:52 PM. The facility provided CPR when staff found the resident unresponsive until medical emergency services (EMS) arrived. The resident died on [DATE] at 06:38 PM. The lack of ongoing assessments and monitoring placed all residents in the facility in immediate jeopardy. On [DATE] at 01:55 PM, Administrative Staff A was informed the residents were in immediate jeopardy and was provided the Immediate Jeopardy Template for failure to conduct a thorough assessment with a change in condition, failure to notify physician with little and lack of output following an increase in diuretic medication, and failure to provide further ongoing assessments of R1 after his complaint of difficulty breathing and inability to measure his oxygen saturation level. The facility removed the immediate jeopardy on [DATE] at 06:30 PM when they completed the following: 1. The physician and/or nurse practitioner or physician's assistant will be notified of significant changes in a resident's condition. If after hours, call their cell phone. If no answer, call the hospital and ask the operator to page the physician and/or nurse practitioner or physician's assistant or the alternate physician that is taking call for the resident's primary care provider. 2. If a resident experiences any significant change and they are not on Hospice Palliative Care, or skilled End of Life, the resident will be automatically sent to the ER. Admission packet will be modified for new admissions to state that fact. All current residents will receive and sign an addendum to the Admission Agreement. 3. All staff will be in-serviced and trained on the change of practice. Immediate in-service will start on [DATE] and be completed on [DATE]. Completion of staff in-service was [DATE] at 06:30 PM 4. The daily skilled charting observation form in Matrix had been updated to include change of condition charting, which includes the mandatory inclusion of vital signs, PCP notification, and urinary output. This will go into effect immediately and will include any skilled resident or any resident that has had a change in condition. 5. A focused QAPI meeting addressing the finding was held with Administrator, Director of Nursing and Medical Director in attendance on [DATE] The facility provided an acceptable plan for removal of the immediate jeopardy on [DATE] at 06:00 PM. the survey team validated the immediate jeopardy was removed on [DATE] at 06:30 PM following the facility's implementation of the plan for removal of the immediate jeopardy. This deficient practice remained at a scope and severity of J (a situation in which immediate corrective action is necessary because of the likeliness to cause serious injury, harm, impairment, or death) and was lowered to a scope and severity of G (isolated with actual harm) following the removal of the immediate jeopardy.

The facility reported a census of 30 residents, with 14 residents sampled including three residents reviewed for pain. Based on observation, interview, and record review, the facility failed to implement effective pain management for one Resident (R)21, with moderate to severe pain, related to the facility not having access to the resident's pain medication for two days. Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident received pain medications, as needed (PRN). The resident reported having frequent pain which had made it difficult for her to sleep at night and had limited her day to day activities. She reported the worse pain over the past five days was a six out of ten on the pain scale. The Pain Care Area Assessment, dated 10/18/21, documented the resident had reported pain as almost constant or frequent with the verbal description of her pain being moderate to very severe. The Care Plan, updated 12/01/21, lacked staff instruction for the resident's pain. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff administered the pain medication on 12/17/21 at 02:35 PM, for pain rated 10/10. She did not receive the medication again until 12/20/21 at 02:05 PM for pain rated 9/10, due to the facility not having the pain medication available for the resident. The resident's Pain Assessment for Saturday, 12/18/21 ranged from 0-2 on the 1-10 pain scale. The resident's Pain Assessment for Sunday, 12/19/21 ranged from 0-8 on the 1-10 pain scale, however, the resident's pain medication was not available. On 12/16/21 at 08:30 AM, the resident sat in her wheelchair in her room. She had facial grimacing and vocal complaints of pain in her knees and shoulders. On 12/16/21 at 02:31 PM, the resident remained in her wheelchair in her room. Resident with slow movements of her arms due to pain in her shoulders. She had facial grimacing and vocal complaints of pain. On 12/20/21 at 10:06 AM, the resident stated she had pain in her joints, wrist, shoulders and knees, caused by arthritis. She had a pain medication which she should be able to have every six hours, but she had to ask for the medication and it was not always available to her. The medication had not been available over the weekend and she'd had a lot of pain. Resident stated she had spent much of the weekend in bed, crying from the pain. The staff did give her Tylenol, but it did not help much. The resident stated her pain over the weekend was an 8/10. On 12/20/21 at 10:18 AM, Certified Nurse Aide (CNA) N stated, the resident had a lot of pain, which was not always controlled. On 12/20/21 at 03:15 PM, CNA M stated, the resident would cry at times due to the pain in her legs. The resident had been crying from pain over the weekend and she didn't have her pain medications. The resident had been in a lot of pain. On 12/21/21 at 09:39 AM, Certified Medication Aide (CMA) R stated, she would reorder medications when they were getting low, like when there are only 6-7 pills left. The resident used her pain medications often. They were reordered on the 15th, but they did not come in. Over the weekend, the pain medication was not available for the resident. The [MEDICATION(S)]-acetaminophen did not come in until Monday afternoon. The resident only received acetaminophen over the weekend. On 12/21/21 at 10:49 AM, CMA O stated, the resident ran out of the [MEDICATION(S)]-acetaminophen on Friday (12/17/21). CMA O stated, she tried to get the medication on Saturday, but the pharmacy was waiting on a prescription from the doctor. The resident was in pain and tearful over the weekend. She needed her pain medication and it was not available. On 12/21/21 at 09:00 AM, Licensed Nurse (LN) I stated, CMAs were responsible for reordering pain medications. The CMAs were to monitor and ensure the delivery of the medication. The resident ran out of the pain medication on Friday (12/17/21). On 12/21/21 at 11:12 AM, LN G stated, the resident did not have her pain medication on Saturday or Sunday. LN G stated she called the pharmacy on Saturday and was told they were waiting on a prescription. Over the weekend, staff administered acetaminophen for her pain. On 12/21/21 at 10:07 AM, Administrative Nurse D stated, the CMAs were to order the pain medications from the pharmacy. The CMAs should then monitor to ensure the medication arrived to the facility. The facility lacked a policy for pain control. The facility failed to have access to this resident's PRN [MEDICATION(S)], causing her to experience severe pain and tearfulness.

The facility reported a census of 34 residents and identified two residents with unstageable pressure ulcers. The sample of three, included the two residents with pressure ulcers. Based on observation, interview, and record review, the facility failed to complete adequate skin assessments and failed to obtain new treatment orders when one sampled Resident (R) 1 developed an unstageable pressure ulcer to the coccyx and it declined to a tunneling 4 centimeters (cm) by 4.5 cm by 0.75 cm deep pressure ulcer. Findings included: - The electronic medical record evidenced the facility admitted resident (R1) on 02/14/19. The primary care physician documented on the Admission Record dated 02/14/19, included [DIAGNOSES REDACTED]. Resident (R) 1's Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident with intact cognition with a Brief Mental Status (BIMS) score of 14. The resident had no pressure ulcers, was not at risk for pressure ulcers per risk assessment, and used pressure relieving devices in her chair and bed. The resident was independent with bed mobility, transfers, and walking. The Quarterly MDS, dated [DATE] revealed the resident scored 13/15 on the BIMS with cognition intact. The resident independently performed bed mobility and declined in transfer ability since the last MDS and required limited assistance of one staff for transfers. The resident did not walk. The resident had a pressure relieving device in her chair but failed to have any pressure relieving devices to the bed or a turn/reposition program with the decline in ability. The resident had no current pressure ulcer. Review of the 03/03/20 Nurses' Notes confirmed the resident declined in mental ability with confusion at times, fell , and experienced a left arm fracture (broken bone) and was to wear a sling until seen by the ortho (bone) physician. The resident required additional assistance to reposition herself in the bed and with transfers with the sling. The Annual MDS, dated [DATE], revealed the resident scored 13/15 on the BIMS, with cognition intact. The resident declined further in ability as the resident required limited assistance of one staff with bed mobility, transfers, and extensive assistance with walking. The assessment identified the resident had one unstageable pressure ulcer. (Unstageable, due to coverage of wound bed by slough, characterized as being yellow, tan, green or brown in color and may be moist, loose and stringy in appearance, and/or eschar, dry, thick, leathery tissue that is often tan, brown or black). The resident was at risk for pressure ulcer development. The Care Area Assessment (CAA) for pressure ulcers, dated 06/06/20, included a Braden (pressure ulcer risk scale) completed 05/25/20 with a score of 18 which placed the resident at risk to develop pressure ulcers. The resident had an unstageable pressure area on her coccyx (a small triangular bone forming the lower extremity of the spinal column), due to the wound bed being covered with slough. The resident was unable to get an appointment with the wound care due to the Covid-19 pandemic. Will contact attending physician for an order for [REDACTED]. Have encouraged her to lay down in the afternoon and the resident complied. It was very difficult to get the resident off her back. Have placed pillows and wedges to keep her on her side and she pulled those out and wiggled until she was back on her back again. The 04/14/20 Care Plan, directed staff to conduct a systematic skin inspection weekly and to report any further skin breakdown. An addition, dated 04/15/20, included instructions to use seat lifts or change position every 15 minutes. It directed the staff to place an alternating pressure air mattress on her bed and a gel cushion in her recliner. Staff were to return the resident to bed after lunch daily and turn the resident from side to side every two hours, as the resident's pressure ulcer was progressively worse. The resident also had an order as of today (04/14/2020), to see the wound care clinic related to the pressure ulcer. The resident's medical record contained a Braden pressure ulcer risk assessment, dated 06/01/20, which identified the resident at risk to develop pressure ulcers. On 07/13/20 at 03:45 PM, per request, LN D reviewed the resident's medical record further and reported the facility staff should complete a Braden pressure ulcer risk assessment on the residents quarterly. LN D reviewed the record from 02/14/20 through 06/01/20 and found no pressure ulcer risk assessment completed prior to the 06/01/20 assessment for R1. On 04/14/20 a Progress Note included, a certified nurse aide reported to the nurse that she noticed an open red area on the resident's buttock. The area was 2.0 cm by 2.0 cm with jagged edges and a bright pink center. The staff did not note any drainage at that time. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Cover the area with border foam dressing, change it daily, and PRN (as necessary) until healed. The 04/17/20 Weekly Skin Assessment documented the resident had a pressure ulcer to the coccyx with treatment in place. It lacked any further description or measurement of the area. The 04/24/20 Weekly Skin Assessment documented no new altered skin. The assessment lacked any further description or measurement of the area. The 05/01/20 Weekly Skin Assessment documented area to the coccyx being treated. It lacked any further description or measurement of the area. The 05/08/20 Weekly Skin Assessment documented no new altered skin. It lacked any further description or measurement of the area. The 05/15/20 Weekly Skin Assessment documented the resident continued to have an open area on the coccyx with a dressing in place. The assessment lacked any further description or measurement of the area. The Progress Notes dated 05/23/20 documented the staff removed a soiled dressing from the resident's pressure ulcer area and noted approximately 80% of the dressing soiled. The foul odor was not noticeable until the staff removed the soiled dressing. The staff cleaned the area with NS, patted it dry, and applied a new bordered foam dressing. Staff measured the total area as 3.5 cm by 2.0 cm, with an inside open blackened area measuring 2.5 cm by 1.25 cm. The area between the wound edge and the blackened center area was a pale yellow. The resident made no complaint of pain or discomfort during the treatment and dressing change. The staff educated and encouraged the resident to change positions to off load the pressure. The facility staff sent a Fax to the wound clinic physician on 06/08/20, for a clinic consult for this resident, as the pressure area on her coccyx continued to become larger and the drainage increased and had a foul odor. Further review of the Care Plan, revealed additional interventions on 04/15/20, when staff placed a floatation type mattress on the resident's bed and placed a different pressure relieving cushion in the resident's recliner. Addition on 06/10/20, included a mattress overlay on the bed and a new wheelchair seat cushion. Addition, dated 06/12/20, included a new floatation mattress to the bed. A Progress Note on 06/09/20 included, the resident's coccyx area was circular shaped, being 4.5 cm long at the longest point, 4.0 cm wide at the widest point, and approximately 0.75 cm deep. The bed of the wound was green in color and soft with slough. At this time there was no drainage, but the dressing change was done earlier in the day. There was a horrific odor to the wound like dying tissue. The edges of the wound were [DIAGNOSES REDACTED]tous (exhibiting abnormal redness of the skin of the mucous membranes due to the accumulation of blood in dilated capillaries). There was undermining (going deeper/tunneling) and the resident had an appointment scheduled for 06/10/20. The Wounds Clinic Notes on 06/10/20 gave orders for scheduled outpatient surgery on 06/12/20 for debridement of the coccyx wound. The resident returned with a wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal. During the treatment, a device decreases air pressure on the wound) The new physician's orders [REDACTED]. If wound vac is off for more than 2 hours remove the dressing, apply wet to dry dressing, and notify the wound clinic. Progress Notes on 06/26/20 recorded the facility nurse called the wound clinic to report the wound vac had to be removed due to a dead battery and no means to charge the battery. However, the wound clinic closed at noon and so the nurse did not notify the clinic. The facility nurse returned to the prior treatment order of wet to dry dressing changes . (Due to this incident, the wound vac remained off of the pressure ulcer for three days.) On 06/29/20, the resident returned to the wound care clinic, after having the wound vac off of the pressure ulcer for 3 days and saw the physician. The resident returned with Physician order [REDACTED]. The new treatment included apply [MEDICATION NAME] (antibiotic) ointment and Santyl Enzymatic [MEDICATION NAME] agent with stimulant powder to sprinkle in ointment, to the sacral wound. Right buttock wound wash with soap and water, cover with Polymem (foam type dressing), change every 3 days. On 07/20/20 at 02:45 PM, LN E reported the resident only had one pressure ulcer in the sacral coccyx area. She explained she felt the nurses completing the weekly skin wound assessments, documented different names for the pressure ulcer cite, but it was only one large wound. Observation on 07/06/20 at 09:00 AM revealed the resident just returned from the wound clinic with a wound vac in place. The resident lay in bed on her left side in a fetal position. She spoke softly when spoken to and reported she was not in any pain at that time. On 07/06/20 at 09:30 AM, Administrative Nurse B stated, It (pressure ulcer) developed and went fast. She had been ambulating and toileting herself. On 07/06/20 at 11:30 AM, Administrative Nurse B verified on 06/05/20, she requested a physician's orders [REDACTED]. This was almost 2 months after the pressure ulcer development, and the staff continued to use the same physician ordered treatment. The resident's wound was not healing well and continued to look worse and had increased in drainage and odor. On 07/06/20 at 01:10 PM, licensed nurse C verified at the time the pressure ulcer developed, the resident started laying more and more in the fetal position and was not wanting to move. Nurse C also verified several of the weekly wound assessments lacked completed accurate information. Interview on 07/06/20 at 03:40 PM with Administrative Nurse B revealed the wound care clinic refused to take patients due to the Covid - 19 epidemic for awhile. She also verified she did not have a wound nurse on staff for over a year and the charge nurses were to complete the weekly assessments and change the daily dressings . On 07/06/20 at 05:15 PM, Administrative Staff A reported he felt the Covid -19 distracted the staff from patient care some. The facility's Skin Assessment policy, dated 09/25/2019 included, once a week the treatment nurse will assess any wounds being treated. The treatment nurse will record the wound assessment on the computer, under observations-focused observations. The wound documentation will include the size, drainage, color, odor, redness and tunneling . The facility failed to complete weekly skin assessments with accurate and complete information to depict the status of the current coccyx pressure ulcer. The facility failed to notify the physician and obtain new treatment orders in a timely manner, when the resident's wound continued to worsen, from 04/14/20 with initial measurements of 2 cm by 2 cm to 06/9/20 with measurements of 4.5 cm by 4 cm by 0.75 cm deep. The wound progressed to unstageable due to the presence of slough and eschar tissue.

The facility reported a census of 31 residents and identified 7 with elopement (exiting the facility without staff knowledge) risk. Three of these 7 were sampled for review of elopement. Based on observation, interview, and record review the facility failed to ensure 1 (#1) of the 3 sampled residents, received adequate supervision and/or functioning assistive devices to prevent an exit from the building without staff knowledge, when the front exit door failed to completely close, the resident's alarm bracelet failed to sound, and a staff member shut off the door alarm without determining who entered/exited the building. The resident was outside unaccompanied, until a visitor saw the resident through a window, walking in the street towards the next intersection. This deficient practice placed this resident and the 6 other residents identified by the facility with elopement risk, in immediate jeopardy. Findings included: - Resident #1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 9/10/18 annual MDS (minimum data set) documented his/her BIMS (brief interview for mental status) score of 4 (0-7 indicated severely impaired cognition) without behaviors, with clear speech, able to understand and be understood, independent with most ADLs (activities of daily living) and with no impairment in functional limitation in range of motion. He /she used a walker for mobility. The 9/10/18 communication CAA (care area assessment) identified the resident did become more confused on some days than other days, forgot that he/she lives here and where his/ her room was located. He/she had a decline in memory recall and required more cueing than he/she did in the past. The 9/10/18 fall CAA identified the resident was a fall risk. He/she had problems with gait and balance at times with occasional incontinence and muscle weakness. The resident ambulated safely in the hall with a front wheeled walker. He/ she had no recent falls but remained at risk for falls due to increased confusion. The 3/13/19 quarterly MDS, documented he/she was usually understood, and had signs and symptoms of [MEDICAL CONDITION], inattention that fluctuated, and had impairment on both the upper and lower extremities, in functional limitation in range of motion. The 1/3/18 fall risk assessment, documented he/she scored 9, with a score of 6-13 indicating a moderate risk for falls. The 3/14/19 elopement assessment, documented as follows: Dementia care, moderately impaired decision-making ability, independent with ADLs (activities of daily living) and with a wander guard (alarm bracelet) attached. Review of the resident's current electronic TAR (treatment administration record), revealed documentation that the staff checked the wander guard twice daily on 3/27/19 - 4/9/19, (the AM check on 4/9/19, documentation was completed). The resident's 3/20/19 care plan, revealed the following information: He/she exhibits wandering, and will wander in specified boundaries, 9/6/17. He/she was alert and oriented x 3 most of the time, with noted increased confusion over the past few months since 11/10/18, and with [DIAGNOSES REDACTED]. He/she was equipped with a device that alarmed when he/she wandered too close to the outside doorways. Checked for proper functioning of device two times daily, initiated on 6/27/18, updated on 3/14/19. Monitor him/her for safety concerns and report to the charge nurse/physician as needed. 3/27/18. On 4/6/19, (the resident) was able to elope (exit the facility without staff knowledge) from the facility. He/she now will be in the staff's line of sight, when out of his/her room and with 15-minute visual checks, when in his/her room. The 4/6/19 at 4:48 PM, nurse's notes, documented at 2:55 PM, this nurse (licensed nurse E) returned from using the restroom. At that time, the front door alarm sounded. This nurse investigated the cause of the alarms and noted the resident using his/her walker, walking through (back into) the doorway with 2 direct care staff who directed the resident to a chair across from the nurse's desk. He/she was alert and oriented to self, per normal for this resident. The resident ambulated without difficulty with the walker. He/she was assessed for pain or discomfort. His/her speech was clear and lucid, he/she complained of knee pain, which was not uncommon for this resident. He/she refused offered PRN (as needed) pain medication, vital signs were temperature-98.9 degrees, respirations- 20, pulse-86, blood pressure-119/60 and oxygen saturation -94 % on room air. His/her wander guard function was re-checked and noted working. The staff notified the administrator of the resident exiting the facility. The resident's family was also notified. The staff were to keep the resident in line of sight while awake and to complete every 15-minute safety checks, while the resident was in bed. An incident witness statement by a visitor, dated 4/6/19, documented he/she came to the facility at 2:45 PM, to visit a resident and that while the visitor sat in the resident's room, he/she could see out the window and saw a resident (#1) walking out of the parking lot with a walker. The visitor then went to the nurses' desk as 2 aides were coming to the nurses' desk. The visitor told the staff that he/she saw a (gender) resident with a walker going north out of the driveway. Three aides then ran after the resident and returned him/her to the facility. The witness statement further documented that he/she came to the facility, driving on 15th street south to the parking lot and parked on the lot near the grass and street. No one was in the parking lot that he/she saw or in the front living room of the facility, when the visitor entered. On 4/9/19 at 11:00 AM, administrative staff A reported he/she came into the facility, on 4/6/19, when the resident eloped. Staff A explained following his/her investigation of the elopement of the resident, the results revealed 3 things occurred to cause the event. 1.) The front door of the facility did not latch completely but was shut close enough to trigger the transmitter to identify it was closed. 2.) The resident's wanderguard alarm did not sound. 3.) The front door alarm, with a reset behind the nurses' station, sounded and was reset prior to ensuring a resident did not go outside. Staff A felt this incident occurred because following a previous resident elopement, he/she changed the front door alarm to alert all staff pagers. However, this confused the staff as to who was responsible to check the front door alert. Staff A changed this system on 4/4/19 (2 days prior to this resident's elopement), so that the charge nurse and the medication aide were to have the 2 pagers that alerted to the door opening and removed the alert from the other staff's pagers. Staff A placed an undated half piece of paper, with the new system change, in the staff communication book at the nurses' station, but failed to educate the staff members one to one about the change. On 4/9/19 at 11:45 PM, direct care staff K reported the resident walked around with his/her walker, but staff K had never seen the resident try to leave. The resident with confusion and needed directions to his/her room at times but was able to go to the right room after directed to the right hall. On 4/9/19 at 4:00 PM, licensed nursing staff D reported he/ she worked on 4/6/19 and was off the 3 prior days. When he/she reviewed the communication book, he/she overlooked the sheet about the changes about the pagers (from alerting all pagers, to alert only the licensed nurse and the certified medication aide's pagers). He/she did not know there were specific pagers that the nurse and medication aid used, that revealed when the front door was being open. He/she did find it in the book, after the elopement. He/she verified he/she was charge nurse on 4/6/19, and it was his/her responsibility, to monitor the front door entrance/exit. On 4/9/19 at 4:40 PM, direct care staff G, reported this past Saturday (4/6/19), he/she was told a visitor saw the resident outside with a walker. Staff G went to the front and saw 2 other direct care staff walking back inside of the facility with the resident. On 4/9/19 at 5:55 PM, direct care staff E, reported on Saturday (4/6/19), he/she and another staff member were in a resident's room, when they found out from a visitor that he/she saw a resident outside. The 2 staff then went to the front door and saw the resident walking on the right side of the road. The resident was in the road close to the grass and headed away from the facility toward the next street. The 2 staff ran to the resident and walked with him/her back to the facility, this was about 3:00 PM. Administrative staff came in and he/she in-serviced all the staff about elopements, the revised door policy and the staff all signed the sheet. The administrative staff also had all the staff check on all the wander guards too, and they all worked fine. Direct care staff E explained he/she documented these checks on a sheet with all the names of the residents with wander guards on it, as all were okay. He/she then gave the sheet to administrative staff A. On 4/9/19 at 6:00 PM, direct care staff F, reported he/she and direct care staff E came out of a room after finishing doing cares, and were told a resident was outside with a walker. They went out, and saw the resident was about hallway down the road toward the next street. It was warm that day and not raining. The resident wore capri pants, a top with a flannel over it, and had socks and tennis shoes on. Staff F added, now the staff had to keep him/her in their line of sight, and when he/she was in bed, the staff did 15- minute checks on him/her. The staff then document this information and give the sheets to the director of nursing. On 4/9/19 at 11:00 AM, the resident wore a wander guard (alarm bracelet) on the right wrist. He/she was participating in an activities group of residents with a parachute and a ball. On 4/9/19 at 12:10 PM, the resident sat in a regular chair in the dining room eating, when a family member came in and sat beside him/her, while the resident ate 100% of the meal. The undated, facility elopement policy, included; It was the policy of this facility to report and investigate all reports of missing residents. Elopement of a resident was defined as the leaving of the facility without the knowledge of staff of a resident who had impaired decision-making ability, was oblivious to his/her own safety needs and those at risk of injury outside the confines of the facility. Residents will be assessed to determine if they are an elopement risk upon admission. If a resident is considered an elopement risk, the staff update the care plan, and the Code Alert bracelet applied. Staff, who do not follow the facility's policy and procedures for prevention of elopement will be counseled and educated, as appropriate of each situation to protect the health and safety of the residents. Should neglect, or not following procedures result in loss or injury of a resident, the responsible staff member shall be suspended, and a report of neglect filed with the appropriate agencies within 24 hours of the incident. A full written report shall be filed appropriately within 7 days. The facility failed to ensure the 1 sampled resident, received adequate supervision and/or functioning devices to prevent an exit from the building without staff knowledge, when the exit door failed to completely close, the resident's alarm bracelet failed to sound, and a staff member shut off the door alarm without determining who entered/exited the building. The resident was outside unaccompanied, until a visitor saw the resident through a window, walking towards the street. This deficient practice placed this resident and the 6 other residents identified by the facility with elopement risk, in immediate jeopardy. The facility was cited as past noncompliance as of 4/8/19 at 10:45 AM, when the facility completed the following: 1.) Charge nurse re-tested the resident's wrist transmitter to ensure it was functioning and the expiration date, on 4/6/19 at 3:00 PM. 2.) Charge nurse and certified nursing assistant checked all exit doors to ensure they were securely closed and the alarm system was functioning, on 4/6/19 at 3:00 PM. 3.) Administrator assigned staff to a constant visual on the resident, until in room and asleep, then 15 minute checks, on 4/6/19 at 3:00 PM. This will continue for 3 weeks. 4.) Assigned staff to sit by the front door until further instructions, on 4/6/19 at 3:00 PM. 5.) DPOA (durable power of attorney) daughter notified, on 4/6/19 at 3:15 PM. 6.) Administrator educated staff on revised, Door Monitoring Policy. No staff will be allowed to work their scheduled shift until educated on the revised policy, on 4/6/19 at 3:30 PM. 7.) Staff were identified to continue monitoring the front door. A staff member was identified to sit in the front lobby by the front door until from 7:00 AM to 7:00 PM, until the door alarm system was replaced. Outdoor push button that allows individuals to open the door and enter the facility was de-activated during 7:00 PM to 7:00 AM, staff will continue to follow revised door monitoring policy at this time, on 4/6/19 at 3:30 PM. 8.) Maintenance director replaced closure and inspected transmitter. It was functioning at the time of the inspection, on 4/6/19 at 3:45 PM. 9.) Had internal Quality Assurance Meeting, sent minutes to the medical director, who received and approved the minutes on 4/8/19 at 10:45 AM.

The facility reported a census of 34 residents, and identified 11 as self-mobile/confused, of which 7 wore alarm bracelets for exit seeking behavior. The sample included 3 of these 7 residents. Based on observation, interview and record review the facility failed to provide adequate supervision and/or assistive devices, for one (#133) of the 3 sampled residents, to prevent this self-mobile, confused resident from exiting the facility without staff knowledge. The resident left the facility through the front door, with the door alarm turned off, without staff knowledge, in 18.5-degree Fahrenheit weather, and was found by staff approximately 8 minutes later when they happened to look out the window. This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of resident #133's physician order [REDACTED]. The admission MDS (Minimum Data Set), dated 1-7-19 revealed a BIMS (Brief Interview for Mental Status) of 10, indicating moderate cognition deficit. The resident had verbal and physical behaviors directed at others which put him/her at significant risk of physical injury and interfered with cares. The resident had rejection of care and wandering which occurred, but did not place the resident at significant risk of getting into potentially dangerous places but intruded on the privacy or activities of others. He/she was independent with ambulation and activities of daily living. The resident had a wander/elopement alarm used daily. The CAA (Care Area Assessment), dated 1-7-19, triggered cognition, communication and behaviors for further review but lacked the analysis of the findings. The care plan, dated 2-5-19, instructed staff that the facility had placed a WanderGuard on his/her wrist that staff were to check daily. When the resident was close to an open door the body alarm would sound. Staff were to ensure that the WanderGuard was functioning properly. The elopement risk, dated 1-11-19, documented the resident was at risk for elopement (exiting the facility without staff knowledge), due to dementia, and use of a WanderGuard. The WanderGuard check sheet, for the months of (MONTH) and March, documented the nursing staff checked the resident's wander guard twice a day, to ensure it worked properly. The progress note, dated 3-3-19 at 3:39 pm, documented the resident was exit seeking and demanding to be let outside. The resident stated, Would you please let me out the front door? I need to drive home. The resident was argumentative with attempts to redirect, but redirected successfully and staff would continue to monitor the resident's exit seeking behavior. The progress note, dated 3-4-19 at 1:09 pm, documented the resident was very agitated and very upset that staff would not let her out to get his/her car to do his/her errands. The progress note, dated 3-4-19 at 6:10 pm, documented the resident was seen outside of the building walking towards 15th street at 6:05. This nurse takes 15th street to work and clocked in at 6:04 pm and did not see the resident outside at that time. As this nurse walked inside onto the unit, direct care staff E alerted him/her and ran outside to assist the resident back inside. The staff gave the resident a snack and vital signs included, blood pressure 101/52, pulse 91, respirations 18, oxygen saturation 92% and temperature was 98.3 degrees. On 3-6-19 at 8:57 am, the resident stated that he/she was living in a motel, that his/her and spouse were in the middle of moving and the spouse was a salesperson. He/she took care of an ill parent, liked to go out to do yard work and shop. The resident when asked about the incident lacked any recall. On 3-6-19 at 4:18 pm, the resident stood in the dining room and in a gruff tone, demanded to staff that he/she needed to leave to take care of his/her parent. Direct care staff C spoke with the resident in a soft tone and redirected him/her to have a seat in the dining room and gave him/her a drink of juice. On 3-6-19 at 8:30 am, upon entering the facility, the front door delayed in closing. Housekeeping staff H explained the front door has up to an 8 second delay, before it locked. On 3-6-19 at 10:00 am, the facilities front door, failed to completely close and remained slightly ajar, with no alarm sounding. On 3-6-19 at 10:05 am, after notification of the lack of the door alarm, administrative staff I went up to the nurses' desk and turned the alarm back on for the front door to sound when staff opened the door. On 3-6-19 at 10:05 am, administrative staff A stated the facility's front door was never alarmed when anyone went in and out. There was a code panel by the door to open it, but it had never alarmed, as far as he/she knew for as long as he/she had worked here, about 1 ½ years. On 3-6-19 at 3:32 pm, direct care staff E confirmed that he/she was the one that saw the resident outside when looking out a window. He/she had not heard the WanderGuard alarm sound, ran outside to bring the resident back in, who was standing by the road, with a 20 mile per hour limit, in front of the facility. The WanderGuard alarmed when staff brought the resident back inside the front door. The front door did not alarm when someone came in or out, only the WanderGuard alarm sounded if a resident who had the alarm bracelet on was too close to an exit door. The Kansas State Weather data library reported the weather on 3-4-19 at 6:05 pm, was 18.5 Fahrenheit, with wind out of the North at 6.9 miles per hour. On 3-6-19 at 3:52 pm, licensed staff G confirmed that he/she did not see the resident outside when coming to work, clocked in at 6:04 pm, stepped onto unit and did not hear an alarm sounding. Direct care staff E ran past him/her stating resident #133 was outside. He/she was brought back in immediately, was given a snack and staff obtained a set of vital signs. The nursing staff checked the WanderGuard on each shift. The front door had a code pad to go out and would only alarm if a resident with a WanderGuard was near it. He/she checked the expiration date on the WanderGuard and it was good until (MONTH) of this year. The reason the WanderGuard did not sound as the resident went outside was unknown. On 3-6-19 at 5:00 pm, administrative staff A stated he/she lacked knowledge that the front door should alarm. The reason why the WanderGuard alarm did not sound when the resident left the facility was unknown. The facility's undated elopement policy, included the front door was to lock and alarm. The facility failed to provide adequate supervision or devices to prevent this confused/self-ambulatory resident from exiting the facility without staff knowledge, exposing him/her to the elements of cold winter temperatures and placing him/her at risk of harm. The resident left the facility through the front door, with the door alarm turned off, without staff knowledge, in 18.5-degree Fahrenheit weather, and was found by staff when they happened to look out the window. This practice placed the resident in immediate jeopardy. The facility abated the Immediate Jeopardy on 3/8/19 at 11:00 am, by initiating the following: 1.) On 3/4/19 at 6:08 pm, staff checked all exit doors to ensure they were securely closed and the alarm system was functioning. 2.) On 3/4/19 at 6:31 pm, the maintenance director came to the facility and inspected the door closure and receiving transmitter, which functioned appropriately at the time. 3.) On 3/4/19 at 8:00 pm, the administrator started in-service of the staff on duty, related to the facility's elopement policy. The administrator continued with the education for all facility staff, shift by shift, prior to their working, until all but PRN (as needed) staff completed the education. The PRN staff will be in-serviced prior to their return to work. 4.) On 3/5/19, the housekeeping supervisor will continue to check all exit doors daily for 3 weeks and then weekly thereafter. 5.) On 3/6/19 at 10:00 am, the administrator turned back on the second front door exit alarm, so that when the door opened, the triggered alarm would continue to sound until reset by the staff. 6.) On 3/7/18 at 4:00 pm, the facility held a Quality Assurance Meeting related to the resident's elopement and implemented interventions to prevent reoccurrence, with the minutes reviewed by the medical director. The deficient practice remained at a scope and severity of a D.

The facility had a census of 32 residents. The sample of 14 residents included 3 reviewed for accidents. Based on observation, record review and interview, the facility failed to develop and implement timely and effective interventions to prevent falls for 1 (#17) of the 3 residents sampled. Resident #17 had a history of [REDACTED]. Findings included: - Resident #17's, signed physician orders, dated 3/10/18, documented the resident admitted on [DATE], with anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain in unspecified joint, and history of [MEDICAL CONDITION] disease (the reduced supply of blood to the brain). The admission MDS (minimum data set), dated 3/21/18, revealed the resident had hearing with moderate difficulty, hearing aids, clear speech, usually made self understood, understood others, and vision adequate. The resident had a BIMS (brief interview for mental status) score of 0, indicating severely impaired cognition. The resident required extensive staff assistance for bed mobility, and transfers; total staff dependence for locomotion, and toileting. The resident's balance was not steady, with functional limitation in range of motion to upper and lower extremities on both sides, and mobility per walker and wheelchair. The resident had an indwelling catheter, and was frequently incontinent of bowel. The resident received PRN (as needed) pain medication, and did not have pain. The resident had a fall in the last month prior to admission, and a fall within the last 2-6 months prior to admission. The resident received an antianxiety medication. The CAA's (care area assessment), dated 3/30/18, triggered for cognitive loss/dementia and falls lacked an analysis of findings. The admission care plan dated 3/11/18, at 12:52 PM, documented the resident required total assistance with catheter and staff assistance for toileting. The resident required 2 staff assistance for locomotion per wheelchair. The resident required staff assistance of 1 for position change. Supportive devices required were not identified. The resident experienced confusion and was alert. The care plan lacked documentation the resident was a fall risk, or documentation of interventions for prevention of falls. The admission care plan lacked documentation regarding staff assistance for transfers. The fall assessment, dated 3/10/18, documented the resident was a fall risk related to a history of one or more falls, within the last 6 months. The resident scored 22 on the Fall Assessment. A score of over 13 points indicated a high fall risk. The comprehensive care plan for falls, reviewed on 4/26/18, documented the following interventions: --Increased staff supervision with intensity based on the resident's needs, initiated on 3/28/18. --The resident had a fall on 5/16/18, and received a fracture to his/her right hip, scheduled for surgery on 5/17/18, and his/her anticipated return to the facility was unknown at this time. The hospice care plan for fall and safety precautions documented the resident was to use a hi/low bed for safety. The nurses progress note, dated 3/10/18 at 12:36 PM, documented the hospital called with the following discharge information. The staff found the resident after a fall, unresponsive in his/her room at another facility. The resident had a history of [REDACTED]. The resident admitted in (MONTH) (YEAR), for a [MEDICAL CONDITION](([MEDICAL CONDITION]), a stroke caused by the rupture of a blood vessel in or on the surface of the brain with bleeding into the surrounding tissue). The resident had confusion, with worsening in the evenings and night more than during the day. The resident had a skin tear to his/her right shin after attempting to climb over the side rail of a hospital bed. The resident fall event, dated 5/16/18 at 12:35 PM, documented the resident was sitting in his/her recliner in his/her room with legs elevated. The staff walked by and the resident yelled for help. The resident stated he/she was looking for a person and fell . Staff did not witness the fall. The resident had severe pain (a 7 on a scale of 0-10) to his/her left hip. The nurse was unable to determine the injury, however the resident's right foot rotated, with abnormal alignment. The resident was awake, without possible contributing factors, and without restraints. The resident wore shoes. The nurses progress notes, dated 5/16/18 at 12:49 PM, documented at around 10:30 AM, staff reported the resident fell . Upon entering the room, the resident was on his/her back with his/her head toward the door. The resident stated he/she had pain and his/her hand was on his/her right hip area. The resident's right foot noted as abducted (to movement of a limb away from the body). Staff notified the doctor, and the resident was transported by EMS (emergency medical services) to the hospital emergency room . The results of the right hip X-ray obtained on 5/16/18, documented the resident had a displaced fracture (fracture in which the two ends of the broken bone are separated from one another) through the right femoral (thigh bone). On 5/17/18 at 3:22 PM, direct care staff O stated the resident was continent of bladder on the day shift. Staff usually toileted the resident when he/she arose in the morning and after breakfast. The resident would tell the staff if he/she needed to toilet after lunch. The resident required the use of a walker for ambulation (walking) in his/her room and staff O used a gait belt also. Staff O stated the resident was a fall risk, he/she required the use of a floor mat in front of the recliner and bed, and the bed was to be in the lowest position. The resident did not try to climb out of bed, and used his/her call light some of the time. Staff O stated he/she was not aware of the resident trying to climb out of his/her recliner. If a resident fell , he/she would look in the communication book, and the resident's plan of care for any new interventions in place to prevent further falls. On 5/17/18 at 3:40 PM, direct care staff P stated the resident required help with ADL's (activities of daily living). The resident ambulated with 1 staff assistance, was fairly steady once the resident walked. He/she was told the resident was a fall risk, checked on the resident every 30 minutes, floor mats in place, low bed, and used a call light. The resident was continent and the only time he/she would try to get up was when he/she had to go to the bathroom. Staff P stated he/she would look at the resident's care plan for interventions for falls. On 5/17/18 at 4:35 PM, direct care staff L stated the resident required assistance for ambulation, would tell the staff when he/she required the bathroom. The resident used a walker for ambulation with a gait belt. The resident's balance was not steady. The resident used a fall mat, placed by the bed and the recliner. The staff had an intervention book at the desk, and if a resident did have a fall then he/she would look in the communication book for the new intervention to prevent further falls. On 5/21/18 at 11:53 AM, direct care staff BB stated the day the resident fell , the resident had a fall mat under his/her chair, and staff checked on the resident as often as possible. The resident's family member advised the staff the resident did scoot out of his/her recliner or bed. The resident also had a high/low bed. On 5/21/18 at 2:10 PM, direct care staff N stated he/she came down the hall with direct care staff H and saw the resident on the floor. The resident stated he/she broke his/her hip. Staff N stated he/she took a resident on this hall to a doctor's appointment. He/she did quite a few appointments that day, which left only 3 CNA's (certified nurse aides) on the floor, however everyone worked together to provide care for the residents. Staff N advised the resident was a fall risk. He/she had to check on the resident because the resident would try to get out of his/her chair. The resident's blue mat needed to be placed beside the bed or the chair, and the bed was supposed to be in the lowest position when the resident was in bed. On 5/21/18 at 2:30 PM, direct care staff H stated he/she and direct care staff N were going down the hallway, heard a noise and observed the resident on the floor, somewhere between the bed and the recliner. He/she stopped licensed nursing staff E and staff E left to obtain his/her treatment cart with equipment staff E required. When staff asked the resident what happened, the resident stated to find Carl. When the resident asked if he/she had pain, the resident grabbed at his/her right hip. On 5/21/18 at 9:30 AM, direct care staff Q stated he/she did not know of the fall until after it happened. The resident ate breakfast in the dining room and when he/she came back, to the dining room the resident was gone. When he/she went to the nurses desk, he/she heard the nurse calling for an ambulance. The resident had a blue fall mat , and the bed was in the lowest position. That morning the resident tried to climb over the foot of his/her recliner, and when he/she asked the resident what was wrong, the resident stated he/she needed to go to the bathroom. The resident's walker was beside the recliner, which staff Q did not put there, and the blue floor mat was in place. He/she then took the resident to the bathroom, dressed the resident, and took the resident to breakfast. Staff Q always put the resident's walker by the closet, not by the recliner. Staff Q was unaware of why the walker was by the closet and not beside the recliner. On 5/21/18 at 10:56 AM, licensed nursing staff D stated the resident was in the dining room, and hospice personnel took the resident to his/her room. The hospice staff transferred the resident to his/her recliner. The staff observed the resident on the floor around 10:30 AM. The resident was a fall risk, and usually was good about using his/her call light. He/she did know that at night the resident was on a check schedule of every 15-20 minutes because the resident would try to climb out of the bed. Staff D reviewed the care plan and stated the care plan lacked interventions for falls. However, staff D stated the resident may have had a fall mat, but he/she was not sure, and the bed placed in the low position. On 5/21/18 at 11:33 AM, licensed staff E stated the hospice staff advised him/her the resident asked for an unknown person frequently. He/she believed the resident was in his/her room alone for about 30 minutes, and the call light was within reach. The resident crawled over the bottom of the recliner. On 5/21/18 at 1:43 PM, licensed nursing staff F stated the resident was a fall risk on admission. The staff needed to check on him/her at least every 2 hours, however he/she told staff to check more frequently. He/she placed a fall mat beside the recliner and bed, and a low bed. On 5/22/18 at 8:56 AM, administrative nursing staff B stated he/she expected the base line care plan to reflect the resident's needs and how much assistance the resident required. For the comprehensive care plans, he/she expected the care plan to also address the resident's needs, and to have appropriate interventions. Staff B was aware the interventions on the care plan did not flow to the CNA's Kardex (electronic care plan for the CNA's). Neither staff B nor staff C were aware there was a button required to push before the information flowed to the Kardex to update it. The resident used a low bed and fall mat in place, but these interventions were never added to the care plan. The resident was a fall risk since admission. The facility policy for falls and fall prevention dated 1/11/16, documented, staff were to develop a individualized plan of care. The falls assessment was to be completed on admission, quarterly, and with any change in condition. The facility failed to provide adequate fall interventions and interventions that the direct care staff could access and implement and prevent a fall. The resident's fall resulted in a [MEDICAL CONDITION].

The facility identified a census of 42 residents. The sample included 6 residents. Based on record review and interview, the facility failed to identify constipation (difficulty passing stools) and intervene in a timely fashion to avoid a fecal impaction (an accumulation of hardened feces in the rectum that the individual is unable to move) for the 1 resident (#31) sampled for fecal impaction. The facility also failed to notify the physician of the length of time of constipation, that interventions were ineffective, that the resident's abdomen was firm and distended or that the resident experienced black tarry stool. Findings included: - The physician orders [REDACTED]. The admission MDS (minimum data set), dated [DATE], revealed the resident with a BIMS (brief interview for mental status) score of 9, moderately impaired cognition. The resident identified as always continent of bowel with no constipation present, no dehydration noted and required extensive assist of 1 staff for toileting. The CAAS (care area assessment summary), for the MDS admitted d [DATE], revealed the following identified care areas: Dementia: Resident had a [DIAGNOSES REDACTED]. The resident required assistance of 1 with most cares. Dehydration: Resident admitted to the facility with UTI (urinary tract infection) and did not have any signs or symptoms of dehydration at this time. The discharge return expected MDS, dated [DATE], revealed the resident with acute onset of mental status change, always incontinent of bowel, and required total dependence of staff for toileting. The admission care plan, last updated on [DATE], lacked any documentation regarding constipation. The Physician order [REDACTED]. 1.) Milk of Magnesia (MOM) with ordered on [DATE] and end date [DATE]: 30 ml (milileters) oral PRN (as necessary) for constipation. Per DSO (Doctor Standing Orders), call physician if condition does not resolve. 2.) [MEDICATION NAME] powder, 17 gram 1 cap, with 8 ounces of water, once a day, PRN for constipation, ordered by the physician on [DATE]. 3.) Senna Plus tablet 8XXX,[DATE] mg (miligrams), 2 tablets oral BID (twice daily), for constipation, ordered on [DATE]. DSO dated [DATE] documented PRN Constipation: MOM 30 cc PO daily PRN Ducolax suppository, 1 rectally every 3rd day, if no BM (bowel movement) after MOM. Fleets enema, 1 PRN, if no relief from ducolax suppository. Call Physician if conditions do not resolve. The Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 1.) MOM administered [DATE] at 12:18 PM, result not effective. 2.) MOM administered [DATE] at 10:28 AM, result not effective. 3.) Ducolax suppository administered [DATE] at 1:16 PM, result not effective. 4.) Fleet enema administered [DATE] at 10:01 AM, result not effective. 5.) MOM administered [DATE] at 10:26 AM, result not effective. 6.) Ducolax suppository administered [DATE] at 6:38 AM, result effective with medium BM. 7.) MOM administered [DATE] at 1:43 PM, result effective with medium BM. The eMAR, from [DATE] to [DATE], lacked any documentation of administration of the Senna or [MEDICATION NAME]. Review of the medical record vital sign output tracking documented the resident without bowel movements from [DATE] to [DATE], a total of 10 days; without bowel movement from [DATE] to [DATE], a total of 5 days; and without bowel movement from [DATE] to [DATE], when the resident expired, a total of 4 days. The record also documented a loose, liquid, black/tarry stool on [DATE]. (The hospital) Physician Entered Orders dated and electronically signed by the physician on [DATE] at 3:19 PM, documented Diagnoses: [REDACTED]. Nursing order: soap suds enema (the introduction of a solution into the rectum for cleansing or therapeutic purposes). (The hospital) Diagnostic Imaging Report dated [DATE] at 2:54 PM, documented findings: colon with a moderate amount of fecal material throughout the colon. Impression: Bowel distension with findings suggestive of constipation, clinical correlation is advised. Review of the Discharge Summary from (the Hospital) emergency room (ER), dated [DATE], documented (Physician O) performed a rectal exam on the resident on [DATE] at 3:18 PM, diagnosed the resident with fecal impaction at 3:19 PM, and ordered the resident to be admitted to the hospital and be administered a soap suds enema at that time. Review of the Electronic Medical Record at the hospital revealed two enemas given, with result of 1 small bowel movement. Review of (Physician O) History and Physical, dated [DATE], documented the resident with abdominal pain, diminished bowel sounds in all quadrants, mild abdominal tenderness in the suprapubic area (area below the belly button), right and left lower quadrants. Review of the laboratory tests, dated [DATE] at 3:09 PM, documented red blood cells 3.95 low (4.2000 - 5.4000) and Hematocrit 36.3 low (37XXX,[DATE].0), which could indicate internal bleeding. Review of the Nurses notes documented the following: On [DATE] at 6:12 AM, the resident had an x-large BM, abdomen was still rounded and slightly firm at this time. On [DATE] at 2:56 PM, the resident's abdomen was firm and rounded at this time. On [DATE] at 8:57 PM, the resident was incontinent of bowel and bladder and the abdomen was rounded and firm at this time. On [DATE] at 9:34 AM, the resident did not want to eat or drink, mouth was dry and cracked, poor skin turgor (a sign commonly used by health care workers to assess the degree of fluid loss or dehydration). At 9:59 AM, EMS (emergency medical service) transported the resident to the hospital. On [DATE] at 3:25 PM, staff called to check on the resident in the ER (emergency room ), spoke with ER doctor who reported the resident admitted to the hospital with [REDACTED]. On [DATE] at 5:06 PM, the resident had a vagal episode (usually occur when the person is exposed to a specific trigger prior to loss of consciousness, the individual frequently experiences early signs of lightheadedness, nausea, the feeling of being extremely hot or cold, feelings of passing out), while the CNAs (certified nursing assistants) were getting the resident ready for supper. The resident lost consciousness for roughly 15 seconds. On [DATE] at 7:32 AM, Direct care staff D stated the resident was pretty constipated. I chart the BM with size and description, it goes in the computer. It should be charted as it happens. On [DATE] at 7:42 AM, Direct care staff S stated the resident was constipated pretty much the whole time (he/she) was in the facility. Before the resident went to the hospital (he/she) wasn't eating and wasn't really (him/herself) and would not talk or respond to you. When we are caring for a resident that has a BM, we go into the computer immediately afterwards and chart the time, and everything about it, size, color, consistently. On [DATE] at 2:38 PM, Direct care staff T stated, I check the message board (computerized list of messages about the residents for nursing staff information) myself when I first come on shift, if the computer says a resident didn't have a BM for 3 days then I give MOM, I follow up by checking the CNA charting for any BM result and verbal communication for a BM. If no result by the end of my shift, I will ask the nurse if I can give something else and do a second intervention before I leave, usually a [MEDICATION NAME] suppository. If there is no result from that after about 8 hours, they will get an enema. On [DATE] at 9:21 AM, Licensed nursing staff H stated I know we had continual problems with the resident and constipation, it was an ongoing problem. We should have followed standard protocol, from DSO which is if no BM for 3 days, administer MOM, if no result, on day 4 administer [MEDICATION NAME] suppository, if no result, on day 5 give fleets enema. At that point, staff should have notified the doctor for further orders. The only place staff document BMs is on EMR (electronic medical record) under vitals and outputs. Every single day should have something charted in output even if it is "none", then we know they didn't have a BM. If there is nothing there, it would also mean that the resident had no BM. On [DATE] at 3:07 PM, Administrative nursing staff B stated, the day the resident went to the hospital (he/she) wasn't eating or responding well and called the DPOA (durable power of attorney) who asked to send the resident to the hospital. The resident was pretty much unresponsive and the hospital called and said the resident admitted with fecal impaction. We had a [DIAGNOSES REDACTED]. On [DATE] he/she had [MEDICATION NAME], and on [DATE] had MOM. The resident went from [DATE] to [DATE] with no BM, which was 10 days and staff B reported they had no idea that happened. I would expect that a charge nurse would have called the doctor sooner about no BM. Protocol would be that the resident's 3rd day of no BM would be [DATE] and the first dose of MOM given, then [MEDICATION NAME] the next day and fleet the next day, by [DATE]. Apparently we didn't even follow our standing order protocol properly. On [DATE] on 9:00 AM, Physician office staff U stated that the clinic, primary care physician and ARNP (advanced registered nurse practitioner), were not aware of the resident being constipated or having extensive periods without a BM. Staff U reviewed both the physician records and the ARNP records at the clinic from [DATE] to [DATE] for any communication from the nursing facility to the clinic about constipation and stated their record lacked any communication about constipation, his/her abdomen being distended or any black/tarry stool. Staff U reported there were several communications in regards to urinary tract infections and pneumonia, increased weakness and general decline, but nothing about constipation. The facility failed to provide timely and effective interventions for constipation, notify the physician of extended periods of constipation, round firm abdomen, or black tarry stools, resulting in hospitalization of the resident for fecal impaction.