Every finding on record at Fairmont Crossing Health and Rehab Center

Based on observation, staff interviews, and facility documentation review, the facility staff failed to ensure a clean and sanitary environment in one of two dining rooms within the facility. The findings included:The facility staff failed to ensure a clean environment on the first-floor dining room area.On 4/20/26 at 12:00 pm an observation was conducted in the dining room area on the first floor of the facility. During the observation, there was a light fixture with a bug light underneath, and it was observed that there were cobwebs all over the bottom of the light fixture and top of the bug light. Also, observed were dead bugs on the top and sides of the bug light. There was a resident observed at a table right under the bug light.An interview was conducted with a certified nursing assistant, CNA#1 (CNA1). CNA1 showed the light fixture and bug light, and she said, that looks like it has been there for a while. CNA1 was observed making a disappointed facial expression. CNA1 looked on top of the bug light and said, yeah, it's full of bugs.On 4/21/26 at 2:06 pm an interview was conducted with the housekeeping staff, other staff #3 (OS3). She said, the dining room is deep cleaned by the dietary staff not housekeeping staff.On 4/21/26 at 2:30 pm an interview was conducted with a dietary aide, other staff #1 (OS1). OS1 provided dietary's monthly cleaning list for review and she stated, dietary deep cleans the kitchenette area not the actual dining area, that is done by housekeeping.On 4/21/26 at approximately 2:45 pm an interview was conducted with the housekeeping supervisor, other staff #2 (OS2). OS2 stated that deep cleaning of the dining room is done twice a month by housekeeping but was unable to provide evidence of when it was last completed. He stated he has no record of when it was done last or by who. OS2 stated that he doesn't keep a schedule of who or when the deep cleaning was completed. On 4/21/26 at 3:30 pm, a review of facility documentation was conducted. The facility policy titled, Cleaning and Disinfecting Environmental Surfaces, read in part, . Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for disease Control] recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] bloodborne pathogens standard. 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visible soiled. 10. Environmental surfaces will be disinfected, (or cleaned) on a regular basis(e.g., daily, three times per week) and when surfaces are visibly soiled.On 4/21/26 at 5:00 pm, an end of day meeting was conducted, and the above concerns were discussed with the regional nurse consultant, director of nursing and the administrator. The administrator said, I am aware of how it looked, I have pictures of it. No additional information was provided prior to exit conference.

Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for six of fifteen residents in the survey sample (Residents #106, #109, #111, #113, #114 and #115). The findings include:1. Resident #109's plan of care was not revised regarding Covid-19 infection and discontinued use of enhanced droplet precautions. Resident #109 (R109) was admitted to the facility with diagnoses that included multiple sclerosis, insomnia, hypothyroidism, major depressive disorder and dysphagia. The minimum data set (MDS) dated [DATE] assessed R109 as cognitively intact. Review of R109's clinical record revealed a physician's order dated 2/26/26 for enhanced droplet precautions for seven days due to the resident testing positive for Covid-19. The clinical record documented the order for enhanced droplet precautions was discontinued on 3/5/26. Resident #109's current plan of care (revised 3/2/26) documented the resident had tested positive for Covid-19 and required droplet precautions. Interventions to prevent complications from Covid-19 included, administer oxygen as ordered, use of appropriate personal protective equipment per policy, check oxygen saturation levels as needed, notification to physician of changes in condition, observe for signs/symptoms of respiratory complications related to Covid-19 infection and vital signs as needed. On 4/21/26 at 9:10 a.m., the licensed practical nurse unit manager (LPN #1) caring for R109 was interviewed about the care plan. LPN #1 stated the resident had Covid-19 and was placed on droplet precautions for seven days per the physician. LPN #1 stated the droplet precautions had been discontinued and were no longer in use. LPN #1 stated the Covid-19 droplet precautions should have been removed from the care plan when the precautions were discontinued (3/5/26). On 4/21/26 at 10:35 a.m., LPN #2 responsible for MDS assessments and care planning was interviewed about R109's plan. LPN #2 stated MDS usually completed the initial care plan and that unit managers were typically responsible for updates as needed. LPN #2 stated R109's care plan should have been revised when the droplet precautions for Covid-19 were discontinued. LPN #2 stated that the unit manager would typically update the care plan for discontinued care interventions. The facility's policy titled Care Planning - Comprehensive Person-Centered (undated) documented, .The facility will develop and implement a comprehensive person-centered care plan for each resident , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .When there has been a significant change in the resident's condition .When goals, needs, and preferences change . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 4/21/26 at 4:45 p.m. with no further information presented prior to the end of the survey. 2. Resident #114's plan of care was not revised regarding discontinued contact precautions. Resident #114 (R114) was admitted to the facility with diagnoses that include major depressive disorder, hypertension, atrial fibrillation, liver cirrhosis, diabetes, pediculosis (head lice) and anxiety. The minimum data set (MDS) dated [DATE] assessed R114 as cognitively intact. R114's clinical record documented the resident had been treated prior to admission for head lice. The record documented a physician's order dated 3/17/26 for contact precautions due to head lice. Another treatment was administered on 3/17/26 and the contact precautions were discontinued on 3/20/26. R114's plan of care (revised 4/3/26) documented the resident was on contact isolation due to head lice. Interventions to prevent complications and resolve infestation included personal protective equipment per policy, isolation precautions per order, observation for complications and vital signs as needed. On 4/21/26 at 9:10 a.m., the licensed practical nurse unit manager (LPN #1) caring for R114 was interviewed about the care plan. LPN #1 stated the resident had been treated prior to admission for head lice, received an additional treatment upon admission and that contact precautions were discontinued after the resident had received two showers in the facility. LPN #1 stated R114 was no longer on contact precautions and that the contact precautions should have been removed from the care plan when discontinued. On 4/21/26 at 10:35 a.m., LPN #2 responsible for MDS assessments and care planning was interviewed about R114's plan. LPN #2 stated MDS usually completed the initial care plan and that unit managers were typically responsible for updates as needed. LPN #2 stated R114's care plan should have been revised when the contact precautions were discontinued. The facility's policy titled Care Planning - Comprehensive Person-Centered (undated) documented, .The facility will develop and implement a comprehensive person-centered care plan for each resident , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .When there has been a significant change in the resident's condition .When goals, needs, and preferences change . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 4/21/26 at 4:45 p.m. with no further information presented prior to the end of the survey. 3. Resident #115's plan of care was not revised to include interventions in place for appointment/transportation validation prior to outside appointments. Resident #115 (R115) was admitted to the facility with diagnoses that included schizophrenia, paranoia, osteoarthritis, anemia, hypertension, atrial fibrillation and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R115 as cognitively intact. R115's clinical record documented on 3/18/26 that the resident left the facility for an audiology appointment, asked to instead be transported to a lawyer's office and then ended up at the social services office before being returned to the facility. On 4/21/26 at 9:55 a.m., the director of nursing (DON) was interviewed about the incident. The DON stated social services accompanied the resident back to the facility. The DON stated she was aware the resident left the facility for an appointment, but the resident had not mentioned that she was going to a lawyer's office instead of the appointment. The DON stated that following this incident, staff were now validating all appointments made by the resident and the resident's Medicaid transport service account was modified with instructions to verify with facility staff prior to confirming any transport arrangements for the resident, including the destination. R115's plan of care was revised 4/9/26 regarding the resident making arrangements for an appointment she did not have/attend. The care pan had not been revised to include interventions of validating appointments made by the resident and the modified Medicaid transport service account limiting the resident's ability to make transportation arrangements. On 4/21/26 at 10:00 a.m., the DON was interviewed about R115's plan of care. The DON stated she added the problem of the resident reporting an appointment that she did not have but did not include interventions of validating appointments and the modified Medicaid transportation account instructions to not allow transport services until verified with the facility. The DON stated the interventions should have been added to the care plan. The facility's policy titled Care Planning - Comprehensive Person-Centered (undated) documented, .The facility will develop and implement a comprehensive person-centered care plan for each resident , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .When there has been a significant change in the resident's condition .When goals, needs, and preferences change . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 4/21/26 at 4:45 p.m. with no further information presented prior to the end of the survey. 4. Resident # 111's (R11) care plan was not revised regarding the use of heels up and heel protectors. On 4/21/26 at 10:40 am, an observation was conducted of R111's room. There were no heels up or heel protectors visible in the room or on the bed at the time of observation. On 4/21/26 at 10:47 am, an interview was conducted with a certified nursing assistant, CNA#2 (CNA2). During the interview, CNA2 stated this was the first time taking care of R111. She stated that there were no heels up on his bed or heel protectors on his heels this morning upon her arrival to take care of him today. On 4/21/26 at 10:50 am, an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 stated that his heels up and heel protectors was as tolerated. LPN3 was unable to find any heels up or protectors in his room. She stated she didn't know what happened to the devices. LPN3 stated that R111 refuses the heels up and protectors and provider should be notified when he refuses and maybe something else can be initiated. On 4/21/26 an interview was conducted with the licensed practical nurse, LPN#2 (LPN2), who was one of the MDS (Minimum Data Set) coordinators. She stated that a care plan was updated quarterly, for a decline or changes in resident care. LPN2 stated that the MDS coordinator was responsible to do the initial care plan and the unit managers on the units were responsible to do the updates on the care plans. A review of R11's clinical record was conducted. R11's care plan was revised on 3/30/26 and had to apply heel protectors as tolerated and float heels as tolerated. The care plan section of skin impairment had him with impaired skin integrity left heel, right heel, sacrum and left calf. R11's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed. Section M- Skin Conditions had him coded with a stage 4 pressure ulcer. R11's weekly wound evaluation dated 3/27/26 was reviewed. The wound evaluation had wound location was right heel, Stage 4, wound was unchanged, was to off-load heels and had specialty devices. A review of facility documentation was conducted on 4/21/26. The policy titled, Care Planning-Comprehensive Person-Centered, read in part, 16. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When requested by the resident/resident representative b. When there has been a significant change in the resident's condition; c. When the desired outcome is not met; d. When goals, needs, and preferences change e. When the resident has been readmitted to the facility from a hospital stay; and f. At least quarterly and after each OBRA MDS assessment. On 4/21/26 at 5:00 pm, an end of day meeting was conducted with the director of nursing, administrator and the regional nurse consultant and the above concerns were discussed. No additional information was provided prior to the exit conference. 5. The facility staff failed to update and revise Resident #113's (R113) care plan as his overall health condition began to decline. On 4-20-26 at 3:15 pm, a tour of the second-floor nursing units was conducted. During the tour, observations of R113 were made. The first observation was R113 lying in bed moving around, and the second observation was of him lying in bed with his eyes closed. On 4/21/26 at 3:50 pm, a clinical record review was conducted. During the review, the Physician Assistant's (PA) progress note was reviewed. The progress note dated 4/14/26 read in part, .comfort focused interventions have been initiated including low dose of morphine and lorazepam for symptom management. The PA's progress noted dated 4/15/26 identified changes in R113's overall health condition. R113 was having increased abdominal pain, decreased food and fluid intake, altered level of consciousness, more assistance needed with activities of daily living, general weakness, and decreased mobility. During the review, on 4/17/26 there was a progress note written by the medical doctor. The progress note read in part, .comfort-focused interventions were initiated on 4/14/26 including low-dose morphine concentrate and lorazepam for symptom management. A nursing note by RN#3, dated 4/14/26, was reviewed and read in part, . discussed resident's change in condition with provider. Lack of interest in going to dining room for meals, decrease in appetite and fluid intake, decrease in mobility, and was complaining of chronic abdominal pain. On 4/21/26 at 3:50 pm, an interview was conducted with a licensed practical nurse, LPN #2 (MDS). LPN#2 stated that care plans were updated quarterly when a resident has a decline or a change in status. On 4/21/26 at 4:13 pm, an interview with a Registered Nurse, RN#3 who stated that resident was started on comfort medications, but the facility staff was waiting for resident's representative (RR) to decide if she wanted to put resident on comfort care. A review of facility documentation was conducted on 4/21/26. The policy titled, Care Planning-Comprehensive Person-Centered, read in part, 16. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When requested by the resident/resident representative b. When there has been a significant change in the resident's condition; c. When the desired outcome is not met, d. When goals, needs, and preferences change e. When the resident has been readmitted to the facility from a hospital stay, and f. At least quarterly and after each OBRA MDS assessment. On 4/21/26 at approximately 5:00 pm, an end-of-day meeting was conducted with the administrator, the DON, and the regional nurse consultant and the above concerns were discussed. No additional information was provided at this time. On 4/22/26 at 8:33 am, an interview with the Director of Nursing (DON) was conducted. During the interview, the DON stated that the care plan for R113 was not updated for decline in his overall condition, which included his decrease in appetite, decrease in fluid intake, increase in abdominal pain, decrease mobility, and decrease in socialization. On 4/22/26 at 8:45 am, an interview was conducted with the director of nursing, the regional nurse consultant, and the physician assistant. The regional nurse consultant stated that she understood that the care plan was not updated by the facility staff with R113's overall health decline. The regional nurse consultant said, this was a learning curve for us. The PA, the director of nursing, and the regional nurse consultant, all three acknowledged that R113's care plan was not updated with his overall decline in his health condition for the facility staff to be able to provide care for him daily. No additional information was provided prior to exit conference. 6. Resident #106's care plan had not been revised regarding interventions for pressure ulcer prevention that were no longer in use. Resident #106 (R106) was admitted with diagnoses that included Metabolic Encephalopathy (broad term for brain dysfunction), Type 2 Diabetes Mellitus w/ foot ulcer on left heel, Dementia and Immunodeficiency. Resident #106's Minimum Data Set (MDS), an assessment protocol, dated 4/1/2026 showed Resident #106 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment and required extensive assistance on staff for Activities of Daily Living and care. On 4/21/26 a review of Resident 106's care plan, revised 4/3/2026, revealed the resident had pressure ulcers on the buttock and left heel and was at risk or pressure ulcer development due to Type 2 Diabetes Mellitus. Interventions for pressure ulcer treatment/prevention included applying heel protectors while the resident was in bed and the use of a heels up cushion while in bed, alternating air mattress and pressure reducing mattress. On 4/21/26 at 9:20 AM accompanied by licensed practical nurse (LPN #1), Resident 106 was observed sleeping in bed and a heels up cushion was in place. There were no heel protectors on Resident 106 or visible in the resident's room. A pressure reducing mattress was in use. On 4/21/26 at 9:40 AM an interview was conducted with Unit Manager LPN #1 regarding Resident 106's heel ulcer interventions in the care plan. LPN #1 stated that the heel protectors were no longer in use. LPN #1 said that Resident 106's heel ulcer was healing, and staff only used the heels off cushion. LPN #1 stated the care plan should have been revised to remove the heel protectors and alternating air mattress, as they were no longer in use. On 4/21/2026 at 10:10 AM the Director of Nursing (DON) was interviewed regarding Resident 106's care plan. The DON stated that Resident 106 only used the heels up cushion and required a pressure-reducing mattress. On 4/21/2026 at 10:49 AM an interview with LPN #2, responsible for MDS and care planning, was conducted. LPN #2 reviewed Resident 106's care plan for skin interventions. LPN #2 acknowledged the interventions needed to be clarified. At 11:36 AM LPN #2 confirmed that the current care plan for Resident 106 had not been updated and the resident no longer required heel protectors or alternating air pressure mattress. A review of a facility policy titled, Care Planning-Comprehensive Person-Centered, read in part that the Care Planning/Interdisciplinary team was responsible for the review and updating of care plans. The policy provided examples of when a resident's care plan should be reviewed and updated, which included when there has been a significant change in the resident, when goals, needs and preferences change and when the resident has been readmitted to the facility from a hospital. On 4/21/26 at 4:45 PM an end-of-day meeting with the Administrator, DON and the Regional Nurse Consultant was conducted and the failure to review and revise care plans was discussed with no further information provided prior to the end of the survey.

Based on observation, staff interviews, and facility document review the facility staff failed to ensure that meals were served at palatable temperatures for one of two kitchenettes within the facility. The findings included:The facility staff served residents on the first-floor nursing units (two units) lunch meals at temperatures that were not palatable.On 4/20/26 at 11:45 pm, an observation was made of the kitchenette on the first floor preparing to plate and serve the lunch meal to the residents.The dietary aide, other staff #7 (OS7) was observed obtaining the temperatures of the food from the steam table and the temperatures were as follows:Ham - 100 Puree ham- 90 Sweet potatoes- 110 Grilled chicken- 95 Noodles- 100 Chopped ham - 100 Puree broccoli- 95 Pork chops- 95 Broccoli- 100 Puree bread- 100OS7 was observed shaking her head while obtaining temperatures. OS7 said, it is not reaching the right temperature. OS7 continued to plate the food and was served to the residents on the first-floor of the facility with unsafe temperatures.On 4/20/26 at 2:42 pm, the dietary manager was interviewed. During the interview the dietary manager said, she knew she should have brought the food down to get it to temperature, and I even told her that earlier.On 4/21/26 a review of the facility documentation was conducted. The policy titled, Food temperature control, read in part, .All foods shall be cooked, held, and served at safe temperatures to prevent foodborne illness. Hot foods >135 [degrees Fahrenheit]. Corrective action will be taken immediately for any unsafe reading.A review of the facility documentation titled, Service Line Meal Temperature Monitoring, read in part, .All food temperatures shall be monitored, recorded, and maintained within safe ranges during cooking, holding, and service. Corrective action (reheat, cool, or discard) taken if unsafe range is found.A review of the facility documentation titled, Hot holding temperatures, read in part, All cooked food shall be maintained at proper hot-holding temperatures until service. If food drops below 135 [degrees Fahrenheit], it must be reheated to 165 [degrees Fahrenheit[ for 15 seconds, within 2 hours or discarded.On 4/21/26 at approximately 5:00 pm, an end of day meeting was held with the administrator, the director of nursing, and the regional nurse consultant. During the meeting, the above concerns were discussed. The administrator said, they know what to do, in reference to the dietary staff's actions when unsafe food temperatures were identified during food temperature monitoring. No additional information was provided prior to exit conference.

Based on observation, staff interviews, and facility documentation review the facility staff failed to ensure food items in the walk-in freezer were within expiration dates in the main kitchen. The findings included:The facility staff failed to remove expired yogurt stored in the walk-in freezer.On 4/20/26 at 2:30 pm, an observation of the kitchen was conducted. During the observation, the dietary manager was present. In the walk-in freezer, a case of Dannon yogurt labeled with an expiration date of 4/17/26 was observed stored for use after its expiration date. On 4/20/26 at 2:32 pm, an interview was conducted with the dietary manager. During the interview, the dietary manager picked up the case, reviewed the date, and said, yes, it is expired, then shook his head and stated he does not know how the case was missed. He then reviewed the date on the case beside Dannon yogurt.On 4/21/26 a review of facility policy was conducted. The policy titled, Food storage and labeling, read in part, .All food shall be stored, labeled, and dated to prevent contamination and ensure freshness. Purpose: to maintain safe food storage conditions that comply with CMS [ Centers for Medicare & Medicaid Services] F812 requirements. The Dietary manager will ensure weekly storage inspections.On 4/21/26 at approximately 5:00 pm, an end of the day meeting was conducted with the administrator, the director of nursing, and the administrator. During the meeting, the above concerns were discussed.No additional information was provided prior to exit conference.

Based on observations, staff interviews, resident interviews, and clinical record reviews, the facility staff failed to implement measures to promote healing to pressure ulcers for one resident, Resident #111 (R111) out of a survey sample of 15 residents. The findings included:The heels up and heel protectors (pressure relieving devices) were not available in R111's room to be offered/used for use to promote wound healing.On 4/21/26 at 10:40 am, an observation was conducted of R111's room. There were no heels up or heel protectors visible in the room or on the bed at the time of observation.On 4/21/26 at 10:47 am, an interview was conducted with a certified nursing assistant, CNA#2 (CNA2). During the interview, CNA2 stated this was the first time taking care of R111. She stated that there were no heels up on his bed or heel protectors on his heels this morning upon her arrival to take care of him today.On 4/21/26 at 10:50 am, an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 stated that he had heels up and booties LPN3 was unable to find any heels up or protectors in his room. She stated she didn't know what happened to the devices. LPN3 stated that R111 refuses the heels up and protectors and that the providers should be notified when he refuses and maybe something else can be initiated.On 4/21/26 at 10:50 am, While the nurse was looking through R111's room for the heels up and heel booties she asked him where they were and R111 said, you won't find them anywhere in here y'all took them out a long time ago to give to someone else.A review of R111's clinical record was conducted. R111's care plan section of skin impairment had him with impaired skin integrity to left heel, right heel, sacrum and left calf. R11's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed. Section M- Skin Conditions had him coded with a stage 4 pressure ulcer. R111's weekly wound evaluation dated 3/27/26 was reviewed. The wound evaluation had wound location was right heel, Stage 4, wound was unchanged, and he was to off-load heels and had specialty devices. On 4/21/26 at 5:00 pm, an end of day meeting was conducted with the director of nursing, administrator and the regional nurse consultant and the above concerns were discussed.No additional information was provided prior to the exit conference.

Based on observation, staff interviews, and facility documentation the facility staff failed to ensure appropriate infection control practices for one resident, Resident #111 (R111) out of a survey sample of 15 residents. The findings included:Facility staff failed to ensure R111's nasal cannula tubing and CPAP (continue positive airway pressure) mask were stored appropriately to prevent infection and maintained infection control practices.On 4/20/26 at 2:45 pm, an observation was conducted in R111's room of his nasal cannula tubing and CPAP mask lying on the floor in his room.On 4/20/26 at 2:50 pm, an interview was conducted with the unit manager, registered nurse, RN#2 (RN2). During the interview, RN2 said, I will get another nasal cannula tubing for him, and it should be stored in a bag when not in use.On 4/21/26 at 10:30 am, a second observation was made of R11's room and the nasal cannula tubing and CPAP mask were on the floor. On 4/21/26 at 10:47 am, an interview was conducted with certified nursing assistant, CNA#2, (CNA2). During the interview, CNA2 stated that this was the first time she was R111's caregiver. She stated that the nasal cannula (NC) tubing and CPAP mask were on the floor when she arrived this morning for her shift. CNA2 stated that she had notified the charge nurse and had been asking for a table to place equipment on and for a bag for the NC tubing and CPAP mask to be stored. CNA2 stated she wanted the bag for storage and to keep the NC tubing and CPAP clean.On 4/21/26 at 10:50 am. an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 was the charge nurse on the unit that R111 resided. LPN3 observed the NC tubing and CPAP mask was on the floor. She said, it should not be placed on the floor, it should be put in bags that are properly labeled to keep the tubing and mask clean.On 4/21/26 at approximately 3:30 pm, the director of nursing was providing information concerning R111's oxygen nasal cannula tubing that was observed on the floor in his room two times. The DON stated that R111 was known to remove his oxygen and could have thrown the tubing on the floor. The DON was not aware that he was wearing his oxygen nasal cannula using an E cylinder (E-tank) and that the tubing on the floor was attached to his oxygen concentrator, which staff indicated was used at bedtime. The DON said, oh he had his oxygen on. No additional information was provided.On 4/21/26 a review of facility policy was conducted. The policy titled, Prevention of Infection While Providing Respiratory Care, read in part, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. 1. Respiratory equipment, when not in use by the assigned resident, will be stored in a safe manner to prevent injury and/or contamination. 3. a. oxygen cannulas and tubing will be changed weekly and when soiled; oxygen cannulas and masks will be kept covered when not in use. 5. CPAP/BiPAP or other Mechanical Respiratory Support Devices c. equipment will be cleaned and disinfected between resident use and will be stored in a clean environment. 7. a. When respiratory therapy equipment is cleaned/disinfected between resident use, the equipment will have a label indicating that the machine was cleaned/disinfected and the date. b. when respiratory supplies are changed, the facility will maintain a system for identifying the date that the equipment/supplies were changed and/or the date that the equipment/supplies are to be changed.On 4/21/26 at approximately 5:00 pm an end of date meeting was held to discuss the concerns above with the administrator, the director of nursing, and the regional nurse consultant.No additional information was provided prior to the exit conference.

Based on observation, interview, record review, and review of the facility policy, the facility failed to provide adequate supervision to prevent aspiration for one of three residents (Resident (R) 100 reviewed for aspirations precautions. R100 had physician orders for no straws due to the high risk of aspiration. R100 was observed three times with a cup and straw, and facility staff did not intervene. This failure placed R100 at risk for serious harm, injury, or death. Immediate Jeopardy was identified on 03/03/26 at 6:57PM and was determined to exist on 03/03/26 in the area of F689 Free of Accident Hazards/Supervision/Devices at Scope and Severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on 03/03/26 at 6:57PM. The facility was notified that an acceptable plan of removal had been accepted on 03/04/26 at 1:30 AM. The survey team validated implementation of the removal plan through review of records and documents, staff interviews, and review of resident records. The Immediate Jeopardy was removed on 03/04/26 at 6:03PM. After removal of the Immediate Jeopardy, the deficiency remained at a S/S of D for an isolated deficient practice of no actual harm with potential for more than minimal harm.Findings include:Review of the admission Record found under the Profile tab of the electronic medical record (EMR) revealed R100 was admitted to the facility on [DATE] with a with diagnoses that included cerebral infarction without residual effects, vascular dementia, dysphagia, and aphasia.Review of R100's Physician Orders located in the EMR under the Orders tab, revealed R100 had a physician's order, dated 07/15/25, for no straws due to a high risk for aspiration.Review of R100's Speech Therapy (ST) Treatment Encounter Notes, dated 07/30/25 provided by the ST indicated, Pt [patient] seen for skilled ST to improve swallow function. Pt had MBSS [Modified Barium Swallow Study a 10-15 minute X-ray procedure used to evaluate how a person chews and swallows, typically identifying if food or liquid is entering the airway (aspiration)-] study this morning, SLP [Speech Language Pathology] consulted nursing staff with results of study recommending patient not use straws.Review of the Progress Notes tab of the EMR from July 2025 to present contained no evidence that supervision or redirection of R100's use of a straw had occurred.Review of the annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an assessment reference date (ARD) of 04/03/25 indicated R100 had a Brief Interview for Mental Status (BIMS) score of four out of 15 indicating severe cognitive impairment. Further review of the quarterly MDS with an ARD of 02/13/26, indicated R100 had a BIMS score of three out of 15 indicating severe cognitive impairment.Review of the care plan revealed no documented evidence of a focus with interventions related to the resident's high risk of aspiration when using a straw to drink.During an initial observation on 03/03/26 at 9:10 AM, R100 was seated in the dining room eating his breakfast and had finished a cup of what appeared to be a clear liquid with a straw coming from the cup. During the second observation on 03/03/26 at 10:45 AM, R100 was sitting in the common area in front of the nursing station, seated in his wheelchair holding a cup with what appeared to be a small amount of red liquid, with a straw in it.During the third observation on 03/03/26 at 12:10 PM, R100 was seated at the table in the dining room eating his lunch and had a cup that appeared to be iced tea and had a straw in the top of the cup. The Manager of Sojourner's Way (M)1 validated the observations and said she was not aware that R100 had a physician's order for no straws.Observation 03/03/26 at 12:15 PM of R100's meal card placed on his meal tray, indicated in capital letters, no straws.During an interview on 03/03/26 at 12:52 PM, Certified Nursing Aide (CNA)3 stated she assisted with R100's meals but was not aware that he could not use a straw and was not aware that his meal tray card listed no straws for R100.Interview and observation on 03/03/26 at 2:45 PM, with the Director of Nursing (DON), she stated that it was likely R100 had access to straws when in the dining room. The DON accompanied the surveyor to the dining room, and it was observed that the tables were set up with straws on the dining tables, which would be within the resident's reach.Interview with the Dietary Manager (DM) on 03/03/26 at 3:45 PM revealed she was aware that R100 could not use a straw and that the dining staff did not provide straws on any resident's food tray; however, she stated straws were available to residents in the dining room.Interview with the ST on 03/03/26 at 4:30 PM revealed that on multiple occasions, dates unknown, that she had verbally educated and reminded all nursing staff that R100 was on aspiration precautions and had an order for no use of a straw. ST stated spoke frequently to R100 during speech therapy sessions and he was aware that the use of a straw was not safe for him to use and he would find his own straw and would be visibly upset if his straw was removed from his drink.During an interview on 03/03/26 at 4:50 PM with the DON and the Administrator, they said their expectations were for R100 to be monitored and supervised to provide safety from using a straw and possible aspiration.Review of the facility policy titled, Meal Delivery and Distribution Procedures,indicated, Meals shall be delivered promptly and safely to residents in accordance with temperature and diet standards.Verify tray tickets at point of delivery before serving.

Based on observation, staff interviews, and facility documentation review the facility staff failed to ensure a clean and sanitary environment in one of two dining rooms within the facility. The findings included:Facility failed to ensure a clean environment on the first-floor dining room area.On 4/20/26 at 12:00 pm an observation was conducted in the dining room area on the first floor of the facility. During the observation, there was a light fixture with a bug light underneath, and it was observed that there were cobwebs all over the bottom of the light fixture and top of the bug light. Also, observed were dead bugs on the top and sides of the bug light. There was a resident observed at a table right under the bug light.An interview was conducted with a certified nursing assistant, CNA#1 (CNA1). CNA1 showed the light fixture and bug light, and she said, that looks like it has been there for a while. CNA1 was observed making a disappointed facial expression. CNA1 looked on top of the bug light and said, yeah, it's full of bugs.On 4/21/26 at 2:06 pm an interview was conducted with the housekeeping staff, other staff #3 (OS3). She said, the dining room is deep cleaned by the dietary staff not housekeeping staff.On 4/21/26 at 2:30 pm an interview was conducted with a dietary aide, other staff #1 (OS1). OS1 provided dietary's monthly cleaning list for review and she stated, dietary deep cleans the kitchenette area not the actual dining area, that is done by housekeeping.4/21/26 at approximately 2:45 pm an interview was conducted with the housekeeping supervisor, other staff #2 (OS2). OS2 stated that deep cleaning of the dining room is done twice a month by housekeeping but was unable to provide evidence of when it was last completed. He stated he has no record of when it was done last or by who. OS2 stated that he doesn't keep a schedule of who or when the deep cleaning was completed. On 4/21/26 at 3:30 pm, a review of facility documentation was conducted. The facility policy titled, Cleaning and Disinfecting Environmental Surfaces, read in part, . Environmental surfaces will be cleaned and disinfected according to current CDC [Centers for disease Control] recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] bloodborne pathogens standard. 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visible soiled. 10. Environmental surfaces will be disinfected, (or cleaned) on a regular basis(e.g., daily, three times per week) and when surfaces are visibly soiled.4/21/26 at 5:00 pm, an end of day meeting was conducted, and the above concerns were discussed with the regional nurse consultant, director of nursing and the administrator. The administrator said, I am aware of how it looked I have pictures of it. No new information was provided prior to exit conference.

Based on observation, interview, record review, the facility failed to ensure that Resident (R)100 had a revised/updated care plan after his change in condition physician's order to restrict R100 from using a straw due to aspiration precautions. This failure had the potential to cause harm through improper communication, improper and inconsistent care, and negative resident outcomes by missing important interventions in the care plan needed to address the resident's needs. Refer to F689. Findings include:Review of the admission Record found under the Profile tab of the electronic medical record (EMR) revealed R100 was admitted to the facility on [DATE] with a with diagnoses that included cerebral infarction without residual effects, vascular dementia, dysphagia, and aphasia.Review of R100's Physician Orders located in the EMR under the Orders tab, revealed R100 had a physician's order, dated 07/15/25, for no straws due to a high risk for aspiration. Further review revealed R100 had orders for a regular diet, dysphagia, puree texture, Regular/Thin consistency, no straws. And magic cup nutritional supplement with meals.Review of R100's Speech Therapy (ST) Treatment Encounter Notes, dated 07/30/25 provided by the ST indicated, Pt [patient] seen for skilled ST to improve swallow function. Pt had MBSS [Modified Barium Swallow Study a 10-15 minute X-ray procedure used to evaluate how a person chews and swallows, typically identifying if food or liquid is entering the airway (aspiration)-] study this morning, SLP [Speech Language Pathology] consulted nursing staff with results of study recommending patient not use straws.Record review of the quarterly Minimum Data Set (MDS), in the EMR, under the MDS tab, with an assessment reference date (ARD) of 02/13/26, indicated R100 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the Care Plan located in the EMR under the Care Plan tab, dated 03/03/26 at 9:45 AM, did not reveal an order was received in July 2025 for no straws and did not document any reference for use possible outcome, or intervention for R100 nonuse of a straw. At 2:45 PM, review of R100's care plan had been updated to indicate he had an order for no straws due to high risk of aspiration.Interview on 03/03/26 at 4:30 PM with the Speech Therapist (ST) revealed that on multiple occasions, dates unknown, that she had verbally educated and reminded all nursing staff that R100 was on aspiration precautions and had an order for no use of a straw. ST stated R100 would find his own straw and would be visibly upset if his straw was removed from his drink.During an interview on 03/03/26 at 12:52 PM, Certified Nurse Aide (CNA)3 stated she assisted with R100's meals but was not aware that he could not use a straw and was not aware that his meal tray card listed no straws for R100.During an interview on 03/03/26 at 4:50 PM with the Director of Nursing (DON) and the Administrator, they said their expectations for R100 was to be monitored and supervised to provide safety from using a straw and possible aspiration, and that his care plan should have been updated and revised to indicate a physicians order for no straws, the possible outcome, and the interventions to provide constant supervision of R100's safety from using a straw.

Based on record review, observation and interview, the facility failed to serve food at a preferable temperature (hot foods not served hot) in one of one serving kitchens on one of two floors affecting the second floor affecting 55 out of 108 residents.Findings include:Review of the Resident Council minutes for the last 12 months revealed a series of food complaints including concerns about food temps (temperatures). The facility had no food committee meeting The DM was unaware the food was cold.During observation of the second floor serving area on 03/04/26 at 11:04 AM, the Dietary Manager (DM) described the process by which the food is plated and delivered to the 56 residents on the second floor.1. During an observation of the serving line on the second floor on 03/04/26 at 11:20 AM, Dietary Aide (DA)1 took the temperature of the scalloped potatoes which was 130 degrees Fahrenheit (F). DA1 stated, It is not really hot, and should be over 140 degrees F. I know they been in the oven all day. During an interview with the DM on 03/05/26 at 12:38 PM, stated, I expect the food to be heated to 165 degrees F. There could be bacterial growth if food is served between 41 degrees F and 135 degrees F, which is the danger zone for unsafe food temperatures and the residents could get a foodborne illness.2. During an observation of the serving line on the second floor on 03/04/26 at 11:22 AM, DA1 took the temperature of the carrots and stated this isn't temping right, give me that other thermometer over there. (Never calibrated the thermometer) carrots were 130 degrees F, and a second thermometer reveals the temperature of the carrots was 140 degrees F. During an interview with DT1 stated, They aren't temping very good. During an interview with DM on 03/05/26 at 12:40 PM, stated DA1 should have calibrated the thermometer before using it by using an ice water bath to make sure it is as close to 32 degrees F as possible. DA1 should have reheated the carrots to 165 degrees F. 3. During an observation of the serving line on the second floor on 03/04/26 at 11:25 AM, DA1 took the temperature of the kielbasa (called them hot dogs) revealed the temperature was 120 degrees F. DT1 said I don't know why the temperature is so low. I will have to take it back downstairs to reheat it. During an interview with DM on 03/05/26 at 12:41 PM stated the temperature should be over 135 degrees and DA1 should have taken the cold food downstairs to reheat before serving or the residents could get a foodborne illness from too cold food. 4. During an observation of the serving line on the second floor on 03/04/26 at 11:28 AM, DA1 took the temperature of the pureed carrots which were heated to 135 degrees F. During an interview at that moment, DA1 stated [the pureed carrots] are supposed to be hotter than that. During an interview with DM on 03/05/26 at 12:42 PM stated the temperature should not have been below 135 degrees F or the residents could get a foodborne illness from the food being too cold. DA1 should have heated that one up too before serving it to the residents. 5. During an observation of the serving line on the second floor on 03/04/26 at 11:29 AM, DA1 took the temperature of the ground hamburger in water which read 120 degrees F. DA1 then tried another thermometer which read 130 degrees F. During an interview with DA1 at that moment stated, It's not really a good temperature but served the food to the residents. During an interview with DM on 03/05/26 at 12:43 PM DM stated, DA1 should have reheated the ground hamburger to 165 degrees F to prevent possible food borne illness for the residents. 6. During an observation of the serving line on the second floor on 03/04/26 at 11:31 AM, DA1 took the temperature of the ground kielbasa with the thermometer which read 130 degrees F. At that moment, DA1 stated The food is not temping very well today and served the food to the second-floor residents at that temperature. During an interview with DM on 03/05/26 at 12:43 PM stated, DA1 should have reheated the food to 165 degrees F and not served the food at the cold temperature because the residents are at risk for foodborne illness from cold food. 7. During an observation of the serving line on the second floor on 03/04/26 at 11:36 AM, DA1 took the temperature of the alternate entree which was a hamburger patty that temped at 130 degrees F. At that moment, DA1 stated, That's a normal temperature for those [hamburger patties]. During an interview with DM on 03/05/26 at 12:44 PM stated, I expect the temperature of hamburger patties to be 135 degrees F or higher. DA1 should have reheated the food before serving it to prevent foodborne illness.During an observation of the serving line on the second floor on 03/04/26 at 11:38 AM, DA1 stated, Most of the time we take cold food downstairs, but we only have 20 minutes until service, so I don't have time to do it today. During an interview with DM on 03/05/26 at 12:45 PM stated, My expectation is DA1 should have taken the cold food downstairs and reheated it to proper serving temperatures to prevent foodborne illness.During an interview with DA1, on 03/04/26 at 11:44 AM, said she fills out the temperature logs after she serves the meals. A request for the temperature logs was made but denied by DA1 during the survey.8. During an observation of the serving line on the second floor on 03/04/26 at 12:45 PM, DA1 never took the temperature of the mechanical altered chicken before serving it to the residents. It was in a 1/8 pan not in the steam table well but it was sitting on top of the steam table. During an interview with DM on 03/05/26 at 12:45 PM stated the size of that pan was called a single serve pan, and it should have had the temperature taken it when DA1 was taking the temperatures of all the food on the steam table.A review of the Dietary Services Policy & Procedure Manual - Food Temperature Control indicated, Procedure:1. Hot Foods [greater or equal to]135degrees F . 2. Food temperatures will be taken once cooked, before, during and after service. 4. Reheated foods must reach [greater or equal to] 165 degrees F for 15 seconds.6. Corrective Action will be taken immediately for any unsafe reading.

Based on observation, interview, and policy review, the facility failed to serve food in a safe and sanitary manner in one of one serving kitchens on one of two floors affecting the second floor affecting 55 out of 108 residents and failed to maintain a clean nourishment/Cafe refrigerator in a clean fashion.Findings include:1. During observation of the second floor serving area on 03/04/26 at 11:48 AM, Dietary Aide (DA) 1 plated meals to the 56 residents on the second floor to [NAME] Run and Cedar Ridge. During an observation of DA1 plating the food on 03/04/26 at 11:48 AM, started on Cedar Ridge to plate up the meal trays. DA1 was observed picking up bread with her gloved hands. DA1 did not change gloves after touching utensils and did not use tongs to pick up bread. Then, DA1 used her gloved hands to open the microwave and placed a hamburger bun on the bottom of microwave with no barrier to the bottom of the microwave. DA1 then served a plate of food and then used the same gloves to touch the egg noodles on the plate. DA1 then took the hamburger bun out of the microwave with the same gloved hand and placed the bun on a plate. DA1 did not perform hand hygiene and used no utensils to place the bread on the plates. During an interview with the Dietary Manager (DM) on 03/05/26 at 12:48 PM stated, My expectation was that DA1 should not have touched the food with the same gloves that were on the serving utensils. DA1 should have changed gloves and used tongs for plating the bread. The lack of hand hygiene or lack of changing gloves, or lack of utensils while serving food could result in cross contamination or bacteria and possibly spread foodborne illnesses. 2. During an observation of DA1 on 03/04/26 at 11:53 AM, DA1 touched two plated scalloped potatoes with a scoop spoon and her gloved hands and then touched the carrots with her gloved hand while scooping them and placing them on the residents' plate. During an observation on 03/04/26 at 11:55 AM, DA1 touched the kielbasa on the plate and then moved it around the plate with her same gloved hand, so she could put the peppers and onions on the plate. DA1 then used the same dirty gloved hand to put the bread on the plate. DA1 did not perform handwashing or changing gloves and did not use utensils before touching food, after using utensils, or after touching food on the plate. During an interview with the DM on 03/05/26 at 12:49 PM stated I expect the staff to perform hand hygiene, change gloves and use utensils before and after touching the food to prevent the spread of foodborne illnesses.A record review of the policy titled, Dietary Services Policy & Procedure Manual Policy: indicated, All dietary personnel shall perform effective hand hygiene before, during, and after food handling. Purpose: To prevent contamination and ensure compliance with infection control standards. Procedure: 1. Wash hands with warm water and soap for at least 20 seconds: . Moving from one task to another.3. During an observation on 03/04/26 at 10:47 AM the [NAME] Run Nourishment/Cafe area in the day room refrigerator revealed dirty sticky substance on the two shelves on the door and both drawers had a sticky yellow and brown colored food splatter in the drawers. The shelves had a yellow grey substance stuck on them. The freezer had dirt and food debris scattered on the bottom of the freezer. During an interview on 03/04/26 at 10:53 AM Licensed Practical Nurse (LPN)1 confirmed the dirty sticky substance on the two shelves on the door and stated, It looks like house supplement on both shelves, and both drawers had sticky yellow and brown colored food splatters in the drawers, probably had formula stuck on it. The freezer had dirt and food debris scattered on the bottom of the freezer. During an interview on 03/04/26 at 12:10 PM, Registered Nurse (RN)2 stated, We just learned it is nursing's job to clean the nourishment/Cafe fridge daily or as often and as needed.A review of the facility policy titled, Dietary Services Policy & Procedure Manual -Nutritional Room Procedures Policy indicated, Nourishment rooms shall be maintained in a clean, secure, and sanitary condition at all times. Purpose: To prevent contamination and ensure the safe storage of snacks, supplements and fluids. Procedure: 4. Clean and sanitize shelves, counters, and equipment daily.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents receiving psychotropic medications had the benefits, risks, and available treatment options explained to them or their representatives and that informed consent was obtained prior to administration for one of five residents (Resident (R) 43) reviewed for the right to be informed and to participate in treatment decisions. This deficient practice placed residents at risk for the use of psychotropic medications without informed consent, potential chemical restraint, increased mortality associated with antipsychotic use in elderly residents with dementia, and adverse effects such as excessive sedation, emotional blunting, or worsening cognitive decline.Findings include:Review of R43's Quarterly Minimum Data Set (MDS) located under the MDS tab in the electronic medical record (EMR), with an Assessment Reference Date (ARD) of 02/25/26, revealed an admission date of 12/21/23 with the most recent reentry date of 05/31/25. Diagnoses included Alzheimer's disease with late onset, anxiety, major depressive disorder, insomnia, and dementia in other diseases classified elsewhere, severe, with agitation. The MDS indicated R43's cognitive skills for daily decision making were severely impaired, based on a Staff Assessment for Mental Status. The MDS also reflected routine use of antipsychotic medication during the assessment period.Review of R43's printed Order Summary Report of active medications, dated 03/05/26 and provided by the Director of Nursing (DON), revealed orders for:-Buspirone 5 mg tablet by mouth three times daily for anxiety (start date 01/15/26)-Risperidone 0.5 mg tablet by mouth twice daily for hospice agitation/anxiety (start date 02/10/26)-Sertraline 100 mg, two tablets by mouth daily for depression/anxiety (start date 10/01/25)Additional orders included hospice admission and behavioral monitoring for antidepressants, antipsychotic, and antianxiety medications.Review of R43's printed Consent/Notification of Psychotropic Medication Use, dated 03/02/26 and provided by the DON, reflected the form listed multiple psychotropic medications including Sertraline, Buspirone, Risperdal (Risperidone), and Lorazepam. The form included the signature of Registered Nurse (RN) 2, indicating that informed consent was obtained by telephone from Family Member (FM) 1.During an interview on 03/05/26 at 11:15 AM, the DON stated that medications from different psychotropic classifications should not be combined on the same consent form, as the risks, benefits, and indications differ depending on the medication. The DON further stated that an informed consent must be obtained prior to administration of the medication.During an interview on 03/05/26 at 11:25 AM, RN2 stated she was in training for the Unit Manager position and had been asked by the DON to obtain the informed consent from the family. RN2 stated she could not identify the medication classifications of the medications listed on the consent form and could not explain the risks and benefits associated with the medications. Review of the facility's undated policy titled, Resident's Rights revealed, .31. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice . c. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, staff interviews, and facility documentation the facility staff failed to ensure appropriate infection control practices for one resident, Resident #111 (R111) out of a survey sample of 15 residents. The findings included:Facility staff failed to ensure R111's nasal cannula tubing and CPAP (continue positive airway pressure) mask were stored appropriately to prevent infection and maintained infection control practices.On 4/20/26 at 2:45 pm, an observation was conducted in R111's room of his nasal cannula tubing and CPAP mask lying on the floor in his room.On 4/20/26 at 2:50 pm, an interview was conducted with the unit manager, registered nurse, RN#2 (RN2). During the interview, RN2 said, I will get another nasal cannula tubing for him, and it should be stored in a bag when not in use.On 4/21/26 at 10:30 am, a second observation was made of R11's room and the nasal cannula tubing and CPAP mask were on the floor. On 4/21/26 at 10:47 am, an interview was conducted with certified nursing assistant, CNA#2, (CNA2). During the interview, CNA2 stated that this was the first time she was R111's caregiver. She stated that the nasal cannula (NC) tubing and CPAP mask were on the floor when she arrived this morning for her shift. CNA2 stated that she had notified the charge nurse and had been asking for a table to place equipment on and for a bag for the NC tubing and CPAP mask to be stored. CNA2 stated she wanted the bag for storage and to keep the NC tubing and CPAP clean.On 4/21/26 at 10:50 am. an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 was the charge nurse on the unit that R111 resided. LPN3 observed the NC tubing and CPAP mask was on the floor. She said, it should not be placed on the floor, it should be put in bags that are properly labeled to keep the tubing and mask clean.On 4/21/26 at approximately 3:30 pm, the director of nursing was providing information concerning R111's oxygen nasal cannula tubing that was observed on the floor in his room two times. The DON stated that R111 was known to remove his oxygen and could have thrown the tubing on the floor. The DON was not aware that he was wearing his oxygen nasal cannula using an E cylinder (E-tank) and that the tubing on the floor was attached to his oxygen concentrator, which staff indicated was used at bedtime. The DON said, oh he had his oxygen on. No additional information was provided.On 4/21/26 a review of facility policy was conducted. The policy titled, Prevention of Infection While Providing Respiratory Care, read in part, .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. 1. Respiratory equipment, when not in use by the assigned resident, will be stored in a safe manner to prevent injury and/or contamination. 3. a. oxygen cannulas and tubing will be changed weekly and when soiled; oxygen cannulas and masks will be kept covered when not in use. 5. CPAP/BiPAP or other Mechanical Respiratory Support Devices c. equipment will be cleaned and disinfected between resident use and will be stored in a clean environment. 7. a. When respiratory therapy equipment is cleaned/disinfected between resident use, the equipment will have a label indicating that the machine was cleaned/disinfected and the date. b. when respiratory supplies are changed, the facility will maintain a system for identifying the date that the equipment/supplies were changed and/or the date that the equipment/supplies are to be changed.On 4/21/26 at approximately 5:00 pm an end of date meeting was held to discuss the concerns above with the administrator, the director of nursing, and the regional nurse consultant.No additional information was provided prior to the exit conference.

Based on observations, staff interviews, resident interviews, and clinical record reviews, the facility staff failed to implement measures to promote healing to pressure ulcers for one resident, Resident #111 (R111) out of a survey sample of 15 residents. The findings included:The heels up and heel protectors (pressure relieving devices) were not available in R111's room to be offered/used for use to promote wound healing.On 4/21/26 at 10:40 am, an observation was conducted of R111's room. There were no heels up or heel protectors visible in the room or on the bed at the time of observation.On 4/21/26 at 10:47 am, an interview was conducted with a certified nursing assistant, CNA#2 (CNA2). During the interview, CNA2 stated this was the first time taking care of R111. She stated that there were no heels up on his bed or heel protectors on his heels this morning upon her arrival to take care of him today.On 4/21/26 at 10:50 am, an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 stated that he had heels up and booties LPN3 was unable to find any heels up or protectors in his room. She stated she didn't know what happened to the devices. LPN3 stated that R111 refuses the heels up and protectors and that the providers should be notified when he refuses and maybe something else can be initiated.On 4/21/26 at 10:50 am, While the nurse was looking through R111's room for the heels up and heel booties she asked him where they were and R111 said, you won't find them anywhere in here y'all took them out a long time ago to give to someone else.A review of R111's clinical record was conducted. R111's care plan section of skin impairment had him with impaired skin integrity to left heel, right heel, sacrum and left calf. R11's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed. Section M- Skin Conditions had him coded with a stage 4 pressure ulcer. R111's weekly wound evaluation dated 3/27/26 was reviewed. The wound evaluation had wound location was right heel, Stage 4, wound was unchanged, and he was to off-load heels and had specialty devices. On 4/21/26 at 5:00 pm, an end of day meeting was conducted with the director of nursing, administrator and the regional nurse consultant and the above concerns were discussed.No additional information was provided prior to the exit conference.

Based on observation, interview, and record review, the facility failed to promote care to a resident in a manner that maintains or enhances his dignity and respect for one resident out of a sample total of 26. The Manager of Sojourner's Way (M)1 spoke to Resident (R)100 in a loud, exclamatory manner. This failure had the potential to affect the dignity and psychosocial wellbeing of R100.Findings include:During observation on 03/03/26 at 12:10 PM, R100 was seated at the table in the dining room eating his lunch and had a cup that appeared to be iced tea with a straw coming from the cup. M1 was asked to observe that R100 was using a straw and that R100 had a physician order for no straw to be used , due to his high risk for aspiration. M1 validated the observations and said she was not aware that R100 had a physician's order for no straws. She reacted to the surveyor in a quick manner, reached across the table and suddenly seized the straw from R100's cup and said in an exclamatory voice, You can't have a straw. R100 is non-verbal and appeared to react to M1's exclamatory voice as she suddenly seized the straw, by thrashing his arms at the M1.Review of the admission Record found under the Profile tab of the electronic medical record (EMR) revealed R100 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction without residual effects, vascular dementia, dysphagia, and aphasia.Review of R1's physician orders in the electronic medical record (EMR) under the Orders tab, revealed R100 had a physician's order, dated 07/15/25, for no straws due to a high risk for aspiration. Record review of the Quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an assessment reference date (ARD) of 01/02/26, indicated R100 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Review of the Progress Notes in the EMR, under the Progress Notes tab revealed R100 contained no evidence that supervision or redirection of R100's use of a straw had occurred. Observation 03/03/26 at 12:15 PM of R100's meal card placed on his meal tray, indicated in capital letters, NO STRAWS.During an interview on 03/03/26 at 4:50 PM with the Director of Nursing (DON) and the Administrator, they said their expectations of all staff were to treat residents with dignity and respect at all times. The Administrator and the DON agreed with the surveyor that M1 was inappropriate as she reached across the table and suddenly seized the straw from R100's cup and said in an exclamatory voice, You can't have a straw.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to use a meal ticket that accurately reflected food allergies for one of eleven residents in the survey sample (Resident #3). The findings include: Resident #3 (R3) was admitted to the facility with diagnoses that included hypothyroidism, anemia, gastroesophageal reflux disease, venous insufficiency, depression and neuropathy. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented a physician's order dated 7/27/23 for a regular high protein diet. The clinical record documented R3's food allergies of aspartame and food preservatives. On 6/25/24 at 8:12 a.m., R3 was observed eating breakfast. With the resident's permission, the breakfast meal ticket was reviewed. R3's meal ticket matched the food items served but documented no mention of the resident's allergy and/or intolerance of aspartame and food preservatives. R3 was interviewed at this time about her food allergies. R3 stated she was allergic/intolerant of food preservatives and artificial sweeteners like aspartame. R3 stated she was not aware of being served those items but did not know why the allergies were not listed on the meal ticket. On 6/25/24 at 9:05 a.m., the dietary manager (other staff #5) was interviewed about R3's meal ticket. The dietary manager reviewed the ticket system and stated the resident's allergies of aspartame and food preservatives had not made it to the dining side. The dietary manager stated he was not aware that R3's allergies were missing from the meal tickets. The dietary manager stated R3's food allergies were in the clinical record but had not been entered into the meal ticket system. This finding was reviewed with the administrator, director of nursing and regional consultants during a meeting on 6/25/24 at 12:00 p.m. with no further information provided prior to the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to accommodate food allergies for one of eleven residents in the survey sample (Resident #10). The findings include: Resident #10 (R10) was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, morbid obesity, chronic obstructive pulmonary disease, respiratory failure and dysphagia. The minimum data set (MDS- assessment tool) dated 2/28/24 assessed R10 as cognitively intact. R10's clinical record documented a physician's order dated 2/21/24 for a regular textured diet with food allergies listed as broccoli, cauliflower, carrots, yellow dye, and lemonade. R10's diet was changed on 2/22/24 to a 2-gram sodium diet and then on 2/23/24 to a 2-gram sodium dysphagia diet, advanced texture. Facility menus for February 2024 included at least four meals served with mixed vegetables that included broccoli, cauliflower, and/or carrots. On 6/24/24 at 2:25 p.m., the dietary manager (other staff #5) was interviewed about accommodation of food allergies for R10. The dietary manager stated that on several occasions during the first week or two of R10's stay, R10 was served broccoli, cauliflower, carrots or vegetable mix including those foods. The dietary manager stated the allergies were listed on the meal ticket but the ticket system at that time did not allow a substitute to be listed. The dietary manager stated he did not know why kitchen staff plated/served the allergic food items when they were listed on the ticket as foods not to be served. The dietary manager stated R10 made him aware at the time that the vegetables were served, and the resident did not eat the foods. The dietary manager stated to his knowledge, R10 was not served broccoli, cauliflower or carrots after the resident's first week in the facility. R10's plan of care (initiated 2/28/24) documented the resident had nutrition screening that indicated a risk of malnutrition. Interventions to maintain nutrition included, .Honor food preferences as diet allows .Provide modified textured diet/liquids as ordered . The facility's policy titled Food Allergies and Intolerances (10/01/21) documented, Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s) . Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat . This finding was reviewed with the administrator, director of nursing and regional consultants during a meeting on 6/25/24 at 12:00 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to provide timely toileting assistance for one of eleven residents in the survey sample (Resident #10). The findings include: Resident #10's request for toileting assistance was delayed until after meal trays were delivered to other residents on the living unit. Resident #10 (R10) was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, morbid obesity, chronic obstructive pulmonary disease, respiratory failure, and dysphagia. The minimum data set (MDS - assessment tool) dated 2/28/24 assessed R10 as cognitively intact and as dependent upon staff assistance for toileting and transfers. R10's closed clinical record documented a nursing note dated 3/12/24 stating, .18:00 [6:00 p.m.] resident turned call light, CNA's [certified nurses' aides] were passing trays. Residents CNA checked to see what was needed resident needed to go to the bathroom. CNA told her [R10] she would be able to after dinner (per facility policy) .Resident has done this several times knowing what the policy for is . (sic) R10's plan of care (initiated 2/21/24) documented the resident had a self-care deficit for activities of daily living (ADLs) including toileting and was at risk of falls. Interventions to maintain ADLs and prevent falls included physical assist as needed .resident requires (limited to extensive assistance by staff for toileting .resident requires limited to extensive assistance by staff to move between surfaces .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . (sic) On 6/24/24 at 2:05 p.m., the licensed practical nurse (LPN #3) that wrote R10's nursing note on 3/12/24 was interviewed. LPN #3 stated she routinely cared for R10 on the evening shift (3:00 p.m. to 11:00 p.m.) at least five days each week during her stay. LPN #3 stated on 3/12/24, toileting assistance for R10 was delayed until after the dinner trays had been delivered and residents were fed. LPN #3 stated staff had been told to check call lights but that if the call light request was not an emergency, to wait until trays were delivered to provide assistance. LPN #3 stated it was not sanitary for staff to go from feeding residents to toileting residents and that her unit had multiple residents requiring feeding assistance. When asked what a resident was to do if they needed to use the bathroom at mealtime, LPN #3 stated that lots of the residents wore incontinence briefs. On 6/24/24 at 2:50 p.m., CNA #5 that routinely cared for R10 was interviewed. CNA #5 stated R10 required two staff members for toileting because she required a mechanical lift. CNA #5 stated R10 was incontinent as times but usually let staff know when she needed to go to the bathroom or be changed. CNA #5 stated staff were expected to respond to call lights even during mealtimes. CNA #5 stated if staff members were feeding residents, other staff members on the unit were expected to respond to call lights. On 6/24/24 at 2:55 p.m., CNA #6 that routinely cared for R10 was interviewed. CNA #6 stated R10 required assistance of two staff members for toileting because she required the sit-to-stand lift. CNA #6 stated she responded to call lights and requests for toileting as soon as possible and was not aware of a facility policy that residents were not to be toileted during mealtime. On 6/24/24 at 3:15 p.m., the director of nursing (DON) was interviewed about R10's delayed toileting assistance on the evening of 3/12/24. The DON stated call bells and requests for toileting assistance should be answered/provided promptly by staff members. The DON stated there was no facility policy to not respond or toilet residents during meals. The DON stated staff members should have provided prompt assistance to toilet R10 when requested. This finding was reviewed with the administrator, director of nursing and regional consultants during a meeting on 6/25/24 at 12:00 p.m. with no further information provided prior to the end of the survey.

Based on clinical record review, staff interview and facility document review, the facility staff failed to follow the standards of practice for testing and testing documentation. The facility failed to obtain a physician's order prior to performing a COVID-19 test and then failed to document COVID-19 testing information in the clinical record for one of 5 residents in the survey sample, Resident #1. The facility failed to maintain complete and accurate COVID-19 testing logs for staff, including documentation of each instance of testing with results. Findings include: 1. According to the medical record, Resident #1 was admitted to the facility on [DATE], developed COVID-19, and was discharged to the hospital on 12/03/22. A review of Resident #1's clinical documentation revealed the following: A practitioner note dated 11/30/22 documented, .seen today for refusal of care .feeling weak .refused to go to urology appointment this morning because of having diarrhea .signature of NP (Nurse Practitioner). A practitioner note dated 12/01/22 documented, .chief complaint .presenting problem .COVID .being seen today for new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .he is complaining of a sore throat and nasal congestion .seems a bit more confused today .COVID + .isolation and supportive care .signature of NP. There was no documentation indicating when the COVID-19 test was performed for Resident #1, only that the resident had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented record of the testing for this resident of any kind. A review of resident #1's physician's orders was then completed. No physician order to perform a COVID test on resident #1 was found. On 12/06/22 at approximately 1:00 PM, the administrator was asked about the above information. The administrator stated that they (facility) do obtain physician orders to test resident's for COVID-19. The administrator was made aware that a physician order could not be located for Resident #1 regarding COVID-19 testing and that there was no information regarding the testing, other than the resident having a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At approximately 1:30 PM, the administrator stated that the NP had administered the COVID 19 test to the resident. When asked where was the documentation regarding the testing for Resident #1, the administrator stated that she did not know. When asked, the administrator stated that she wasn't sure why the NP did the test and then did not inform staff for COVID-19 tracking. The facility policy titled, COVID-19 Screening/Testing plan for residents and staff documented, .in general testing is not necessary for asymptomatic people .testing will be met through the use of rapid point of care .devices .resident's attending physician/practitioner will be notified of the presence of symptoms and the facility will follow physician /practitioner orders for care .symptomatic individuals identified .residents, regardless of vaccination status, with signs and symptoms must be tested .A physician/practitioner order (standing order is acceptable) will be obtained prior to administration of test .consent for the testing will be maintained and documented for each resident tested .the facility will document resident testing in the medical record in accordance with protected health information .the facility will maintain compliance with testing requirement by documenting the following .date and time of signs/symptoms date of testing date of results .actions taken by facility based on test results .new COVID-19 case-outbreak with resident or staff . At approximately 2:30 PM, the administrator was made aware of concerns regarding Resident #1 not having a physician's order to be tested for COVID-19, as well as the lack of documentation and tracking information regarding testing for this resident. The administrator stated that she did not know why an order was not obtained and why the information was not documented per the facility policy. No further information and/or documentation was presented prior to the exit conference on 12/06/22 at 3:30 PM. 2. The facility failed to document that testing was completed and/or that the subsequent results were recorded. The facility's COVID-19 testing logs for staff were reviewed from September 2022 to present 12/06/22, which included spaces to document the following: staff name, DOB (date of birth), Date/Time, Result, Lot #/Expiration date, and Completed by. The testing log for September 27, 2022 through October 28, 2022 had 20 staff tests documented. Out of the 20 tests, 13 did not have lot# information or who completed the tests. Three tests did not have a date, only a time stamp. Two tests did not have a date or an actual test result for the test completed. The administrator was asked about the above information and testing logs. The administrator stated that the DON (director of nursing) was out today, and that is who takes care of the tracking information. The administrator stated that she could not answer as to why the COVID-19 testing logs were incomplete and stated that she knew that all of the tests were negative. The facility's policy titled, COVID-19 Screening/Testing plan for residents and staff documented, .the facility will document testing results for staff in a secure manner consistent with requirements specified .the facility will maintain compliance with testing requirement by documenting the following .date and time of signs/symptoms date of testing date of results .actions taken by facility based on test results .new COVID-19 case-outbreak with resident or staff . No further information and/or documentation was presented prior to the exit conference on 12/06/22 at 3:30 PM.

Based on staff interview and facility document review, the facility staff failed to implement an antibiotic stewardship program. The facility's documented program regarding protocols and monitoring of antibiotic use was not implemented. The census in the facility was 111 residents. Findings were: On 06/01/2022 at approximately 1:55 p.m., the interim DON (director of nursing), who also identified herself as the IP (Infection preventionist) was interviewed regarding the antibiotic stewardship program at the facility. She stated, I'm not sure what we have, I will need to look .I've been doing this position less than 24 hours. At approximately 3:00 p.m. she presented a policy and procedure Antibiotic Stewardship Program that contained the following: .The goals of the program include: Ensuring residents .are prescribed the appropriate antibiotic, reducing the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. The Antibiotic Stewardship team will analyze infection data [including type of infection or symptoms being treated, antibiotic utilization, and adverse outcomes, etc.] monthly and feedback will be provided to the QAPI Committee regarding antibiotic stewardship practices . The policy included specific procedure and guidance to be followed for the antibiotic stewardship program The Interim DON was asked if there was documentation regarding the use of antibiotics. She stated, This policy is all we have .the former DON was doing it. I talked to her and she said there is supposed to be a book for tracking and other information but we don't have one. She was asked if the former DON was onsite for interview. She stated, Yes. At approximately 3:15 p.m., the former DON was interviewed. She stated, The former ADON (assistant director of nursing) was doing it .she went out on FMLA in December and then resigned .I can't find any of her books .I took it over in December and I have some tracking back to then, but we really don't have the information that you are looking for. No further information was obtained prior to the exit conference on 06/02/2022.

Based on staff interview, facility document review, and clinical record review, facility staff failed to ensure 1 one of 25 residents, Resident #88 was free from a significant, medication error, causing harm. The facility implemented a plan of correction for this deficiency and no other issues were identified during the survey. This is cited as past non-compliance. Findings included: Resident #88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/22/2020. Resident #88 was assessed as cognitively intact with a total cognitive score of 13 out of 15. On 03/03/2020 at 2:00 p.m, Resident #88 was observed sitting in a Broda chair watching television, in the day area with other residents. She was alert, but non-verbal. Resident #88's clinical record was reviewed on 03/03/2020 at approximately 2:30 p.m. A clinical note dated 02/07/2020 at 1:12 p.m. included, Charge Nurse made this writer aware that she had administered wrong medication to resident. NP (nurse practitioner) called and made aware at this time. Instructed nurse to assess resident and obtain V/S (vital signs). V/S 195/78, 98.2, 76, 20, 93 Room air. Notified DON (director of nursing) and ADON (assistant director of nursing). Subsequent clinical notes were reviewed and included the following: 02/07/2020 at 1:20 p.m. - Pharmacy called and made them aware, instructed to call MD (physician) or send to (hospital initials) for eval. NP made aware at this time of what Pharmacy recommended. 911 called at this time. 02/07/2020 at 1:25 p.m. - Resident remain alert and talking, neuro check WNL (within normal limits), resident able to move all extremities without any difficulty, she is able to tell me her name, give me her daughters name, and pupils are round and reactive to light. (sic) She is able to squeeze my hand on command. RP (responsible party) called made aware at this time. 02/07/2020 at 1:45 p.m. - Into assess resident at this time, resident remain alert and orient, talking to me. Knows what going on V/s 132/74, 72, 24, O2 sat 93 Room air. (sic) Pupils are not dilating as noted earlier. EMS (emergency medical system) Captain arrived to assess resident at this time. Made us aware that he was going to stay with resident until (Name) Transport arrived they was in route. (sic) Resident remain stable, resident daughter in facility at this time. 02/07/2020 at 2:15 p.m. - (Name) transport in here in facility to transport resident to (hospital initials). Resident noted to drowsy, slow to respond, she is still alert and talking to staff and EMS. (sic) The Administrator was interviewed on 03/03/20 at 03:45 p.m. regarding the above mentioned clinical notes. The Administrator stated, We immediately pulled the nurse from the floor. Gave 1:1 education regarding medication pass and pour. She was then monitored for three med passes before she was allowed to administer meds alone on the floor. All facility nurses received education regarding med pass and the facility policy and procedure. We are currently performing random med pass and pour observations. This is the beginning of week 3 of 4. The resident was admitted to the hospital ICU, but was not placed on a ventilator. She received one dose of [MEDICATION NAME] here at the facility. Received another dose of [MEDICATION NAME] at the hospital and was placed on a [MEDICATION NAME] drip. She had problems with her B/P (blood pressure) being high in the hospital that contributed to her lengthy stay. She is now back at the facility at her baseline. Recognizes family. Was up on the unit walking around today. The facility plan of correction (POC) was requested and received on 03/03/2020 at 3:50 p.m. Included in the POC was a witness statement completed by the nurse that administered the wrong medications. It included, During preparation of medication for resident in (room number) (Name-Resident #23), (Name-Resident #88) approached cart after lunch to receive her medication. I then stopped to prepare (Name) Resident #88's medication. (Name) Resident #88's medication was placed into a medicine cup that already had (Name) Resident #23's medication ([MEDICATION NAME] & [MEDICATION NAME]) inside. (Name) Resident #88 took the pills and swallowed them after I handed her water. Unit manager notified. The POS (physician order [REDACTED].#23 included, .[MEDICATION NAME] ER (extended release) 100 mg (milligrams) tablet, oral, every eight hours .[MEDICATION NAME] 30 mg tablet (1 tab) oral, every six hours . These are the two medications Resident #88 received in error on 02/07/2020. The emergency room note included, .Service Date/Time: 2/7/2020 17:09 (5:09 p.m.) .Chief Complaint: Pt (patient) was given someone elses meds by mistake at nursing home. Pt given 100mg ex release [MEDICATION NAME] and 30 of oxy. Assessment/Plan: 1. Accidental opiate poisoning .Orders: [MEDICATION NAME] 8mg + sodium chloride 0.9% 500 mL .per MD, pt to start at 0.6mg/hr and titrate if needed. Plan to admit .History of Present Illness: Patient presents to the emergency department after she was inadvertently administered another patient's medications at her skilled nursing facility .EMS reports that she received 100 mg of extended release [MEDICATION NAME] p.o. (orally) along with 30 mg [MEDICATION NAME] p.o. around 1 PM. She became less alert within an hour and has required 2 doses of [MEDICATION NAME] (1 mg apiece) prior to arrival to maintain her baseline mental status .She is currently asymptomatic. She has no complaints. Vitals & Measurements: HR: (heartrate) 61 (Monitored). RR: 20. B/P: 150/88. SpO2: 97% .General: Awake, alert, elderly, slow in mentation. Eyes: Pupils round and reactive to light 3-4 mm OU (both eyes) .Cardiac: Normal S1 and S2 .Medical Decision Making: IV [MEDICATION NAME] hung at 0.6mg/hr in concentrated form. Alert and at baseline throughout ED (emergency department) stay. Will need to admit, as meds are long acting . The facility action plan was implemented immediately. Resident was sent to the ER (emergency room ) for evaluation on 2/7/2020. The RN (registered nurse) administering the medications was provided with 1:1 education related to medication pass/pour responsibilities prior to returning to duty. This included, .Dispense meds for one resident at a time only. Follow policy and procedure as it relates to medication administration. Reviewed rights of medication administration and safety checks, completed 2/8/2020. The RN will be observed for three days during a med pass to ensure competency with medication pass/pour responsibilities. Successful completion of the competency will be required prior to being allowed to administer medications independently, completed 2/18/2020. Nursing staff will be re-educated on the policy and procedure for medication pass/pour responsibilities, completed 2/21/2020. Random observations of nurses to be conducted on all three shifts weekly for four weeks to ensure nurses adhering to policy and procedure as it relates to medication administration. This is ongoing and currently in week three of four. Facility policy, Medication Administration Policy, Scope: All Senior Care Services Facilities, Purpose: Is to receive and administer medications in the most accurate and efficient manor (sic) possible .Medication Administration Guidelines, Skill Level: RN, LPN (licensed practical nurse) .Policy: 1. The five rights of medication administration are to be followed. Right drug, Right dose, Right client, Right route, Right time . This incident investigation, education and corrective action plan was discussed with the Administrator, DON (director of nursing), and ADON (assistant director of nursing) during a meeting with the survey team on 03/04/2020 at approximately 2:30 p.m. The Administrator stated, If the nurse had not identified her immediate medication error and quickly responded, the outcome could have been much worse. No further information was received prior to the exit conference on 03/04/2020.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, facility staff failed to ensure one of 25 residents in the survey sample was free of an accident with injury, Resident #84. Facility staff failed to ensure Resident #84 did not sustain first and second [MEDICAL CONDITION] her thighs from spilled coffee on 07/05/2018. Findings included: Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/12/2018. Resident #84 was assessed as severely impaired in her cognitive status with a total cognitive score of three out of 15. Resident #84's clinical record was reviewed on 01/23/19 at 10:00 a.m. During this review a clinical note dated 07/05/18 at 4:46 p.m. included: This morning at breakfast, the resident spilled her cup of coffee in her lap. Resident was heard screaming by staff in the dining room, resident was taken to her room for this nurse to assess. Resident's pants, hipsters and ted hose were removed. Pants and hipsters had coffee on them. Her right thigh was red and left thigh had some redness to it. Resident stated It hurts. ADON (assistant director of nursing) and care coordinator, (Name), came over and helped put the resident in the bed. At that time, it was noted that the resident had blisters on her bilateral inner thighs . A verbal order dated 07/05/2018 included: .Begin Date: 07/05/2018 Wound Care 2 Times Daily for 3 Days burn treatment. Instructions: Apply Silverdene cream [MEDICAL CONDITION] bilateral thighs and cover with xeroform gauze BID (twice daily) x 3 (times three) days then change daily. A nutrition assessment completed on 06/25/18 by the dietary manager included: .Meal Intake/Eating .Ability to Feed Self - Independent, Needs help with tray set up . A monthly nursing summary completed on 07/03/18 by an LPN (licensed practical nurse) included: .Physical Functioning and Structural Problems .Eating Self Performance 1. Supervision . A Quarterly MDS with an ARD of 06/26/18 under Section G, Functional Status, H. Eating was coded as one under self-performance, indicating Supervision-oversight, encouragement or cueing and was coded two under support, indicating One person physical assist. A Comprehensive MDS with an ARD of 09/25/18 and a Quarterly MDS with an ARD of 12/12/18 was coded the same as the MDS dated [DATE]. The DON (director of nursing) was interviewed on 01/23/19 at 4:50 p.m. regarding Resident #84's MDS coding for eating. The DON stated, We set her tray up. (MONTH) have to cue her to eat and if not eating may need to feed her. On 01/24/19 at 8:25 a.m. Resident #84 was observed in the dining room feeding herself breakfast. There was a lid on her coffee cup. Resident denied any complaints. Her hands were steady without any noted tremors. The facility investigation of the accident, witness statements and the facility action plan was reviewed. The OT (occupational therapist) was out sick and unavailable for interview. The person from housekeeping was not working and unavailable for interview. The Dietary Aide was interviewed on 01/24/18 at 9:05 a.m. regarding the accident on 07/05/18 involving Resident #84. Dietary Aide stated, I was working as an aide that day. She started shaking her hands and stating, it hurts, it hurts. I looked at (Name) and said she has spilled her coffee on her. I grabbed a bib and patted her legs. I don't remember anything else. The Maintenance Director was interviewed at 9:50 a.m. He stated, It's been awhile. I help out a lot in the mornings, serving coffee and stuff. I don't remember if I served her coffee that morning or not. I do remember her hollering out and immediately there were aides around her. I didn't see her actually spill the coffee. They took her out of the dining room right away. The action plan included: Immediate removal of Resident #84 from the dining area and removal of wet clothing. A complete nursing assessment of Resident #84 was completed. The physician and responsible party were notified. Treatment orders were obtained from the physician. An Occupational Therapy consult was ordered. All room trays were audited to ensure lids were placed on all hot beverages and cups were only 2/3 full. Staff education was completed regarding serving hot beverages to residents. The beverage system tech was notified to service the hot beverage dispensers in the facility and to adjust the maximum allowed temperature on all dispensers. Hot liquid and adaptive equipment assessments were completed on all residents, and care plans were updated. Random audits were completed for a period of time with a completion date of 09/30/2018. There have been no other accidents with injury in the facility regarding hot beverages since 07/05/18. This will be cited at a harm level, at past non-compliance, with a noted completion date of 09/30/18. This is a complaint deficiency.

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure necessary care and treatment for [REDACTED].# 107. The facility staff failed to obtain a physician's orders [REDACTED]. joy boot) for Resident # 107, as a result the resident developed two pressure related areas from the continued use of the boot and subsequently developed an infection, which required the resident to have a PICC (peripherally inserted central catheter) placed in order to receive prolonged IV (intravenous) antibiotic therapy. Findings include: Resident # 107 was admitted to the facility on [DATE] (Thursday). [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a 5 day admission assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive assistance for transfers, toileting and bathing with at least two staff members. The resident was additionally assessed as requiring limited assistance with dressing and hygiene, with at least one staff member assistance. During a revisit survey conducted on 11/13/17 through 11/14/17, a complaint was investigated concerning Resident # 107. Clinical record review revealed that Resident # 107 had a fall at home prior to admission to the facility, which resulted in surgical intervention at the hospital; the resident was then admitted to the facility for rehab. The complainant alleged that the resident had a soft cast/splint on the right foot upon admission and shortly thereafter, the therapy staff put on an 'orthopedic boot' over top of the soft cast/splint, which resulted in the development of black necrotic tissue to the right ankle. The complainant additionally alleged that the resident developed an infection within the wounds on the right foot, which required the resident to receive IV (intravenous) antibiotics, which the resident is still receiving at this time. A hospital discharge summary dated 09/14/17 and timed 6:58 p.m. documented, Discharge Summary .right trimalleolar comminuted fracture probably due to [MEDICAL CONDITION] after a fall, status [REDACTED].came to the hospital after a fall fracturing her right ankle .surgically repaired .did well in the hospital .on day of discharge labs and vitals are stable .Right ankle xray shows acute horizontal fracture through the medial malleous and posterior malleolus .ACTIVITY: Toe-touch weightbearing on the right. She is a 2 person assist for pivot transfers . The facility admission orders [REDACTED]. No activity orders were found for Resident # 107 and no orders were found for Resident # 107 regarding the application/use of an orthopedic boot. The resident's CCP (comprehensive care plan) was then reviewed and documented, (09/14/17) falls/safety risk related to weakness, impaired mobility recent fall with fracture, weight bearing restrictions .will maintain weight bearing orders .PT (physical therapy) referral .assess resident's footwear for proper fit and non-skid soles .potential for pressure sores .impaired mobility and soft cast with boot .prevent pressure ulcers and skin breakdown .follow facility skin care protocol .preventative measures .report to charge nurse any redness or skin breakdown immediately .(09/15/17) .patient will be seen for therapeutic exercise, OT (occupational therapy) eval . On 11/13/17 at approximately 2:00 p.m., Resident # 107 was interviewed in her room. An IV pole with IV machine was attached was observed next to the resident's bed. The resident was sitting in her w/c (wheelchair), well groomed wearing a sock/shoe on the left foot and a green anti-slip sock on the right. The resident's feet were resting on the floor. The resident was asked about her stay at the facility, since admission. The resident stated (in summary) that when she was admitted to the facility (09/14/17) from the hospital, she had a 'soft cast/splint' on her right foot that went up almost to the knee. The resident went on to explain that it was wrapped with a gauze/bandage type material and that it could not be removed by staff. A tall black orthopedic boot was observed standing on the floor next to the wall, near where the resident was sitting. The resident was asked about the black boot. The resident explained that the tall black boot (orthopedic Don Joy boot) came with her from the hospital, the facility did not provide this boot and did not exchange this boot for another boot. Resident # 107 stated that therapy came in the following day and put the boot on her. The resident then stated that 'they (therapy and nursing staff) insisted' that she keep this boot on all the time. The resident was then asked if staff took off the boot to check her toes/foot or to perform any type of assessment on her ankle or foot in any way. The resident stated, No and stated it (the boot) stayed on pretty much the whole time until I went to my follow up visit with Dr. (name of orthopedic physician) on 09/28/17. The resident stated that, this is how her ankle ended up this way, from the boot rubbing my ankle and further stated that the orthopedic doctor had told her it was from wearing the boot too much. The resident stated that this should have been a 6 week stay for her and now because of this and the fact that the wound has become infected, she had to have a PICC line placed in order to receive antibiotics for an extended amount of time. The resident stated that she didn't think it was written in her discharge instructions from the hospital on how to wear the boot and stated, They (the facility) thought I had to wear it all the time. Clinical record revealed a physical therapy plan of care dated 09/15/17 documented, .referred to skilled care after hospitalization .s/p (status [REDACTED]. She is TTWB (tip-toe weight bearing) on right ankle in 'Don Joy boot' for anticipated 4-6 weeks .Precautions: TTWB right LE (lower extremity), Don Joy boot on right, full code patient is currently unable to ambulate due to TTWB on right LE .unable to maintain TTWB without assistance. She reports pain in right ankle that limits her mobility .alert and oriented, motivated to participate, follows commands . This P(NAME) (plan of care) was not signed by the physician until 09/28/17. The occupation therapy plan of care dated 09/15/17 documented, .fall and requiring an ORIF on R (right) ankle with subsequent TTWB and ortho boot with decline in function TTWB while wearing boot on RLE . This P(NAME) was not signed by the physician until 09/28/17. There were no clear instructions and/or information in the above therapy evaluations on the use application/care instructions for the orthopedic boot. A H&P (history and physical) from the facility physician, dated 09/17/17 was reviewed. The H&P documented, .date of evaluation: 09/17/17 .(name of facility location) .status [REDACTED]. She is nonweightbearing (sic) at this time .knows it is going to be a bit of a slow recovery as she is nonweightbearing for the next 4 weeks .sitting in a wheelchair .her right lower extremity is in a splint/boot .continue nonweightbearing per orthopedics .continue with physical and occupational therapy due to ambulatory dysfunction because of her ankle fracture .will await orthopedics consultation in the next 4-6 weeks for weight bearing status . This H&P was electronically signed on 09/22/17. A nursing note dated 09/28/17 documented that the resident returned from an orthopedic appointment earlier that day with new orders. The orthopedic progress note dated 09/28/17 (Friday) documented, .2 weeks status [REDACTED].has been doing well and non-weight bearing .reports no issues and no calf pain .but unfortunately did come in with her posterior and U splint on with walker boot over top of this .reports that (name of facility) has been very persistent about her wearing her boot over top of the splint .she has a wound pressure ulcer and large eschar over the medial aspect of her incision that incorporated about 80 percent of this. The eschar is stable. There are no signs of drainage or signs of infection. No surrounding [DIAGNOSES REDACTED]. Medial incision now shows that the bottom 5 staples are now buried in the skin these were removed with mild difficulty and no signs of dehiscence .Radiographs: three views of the ankle to be reviewed by the surgeon .return Monday or Tuesday with (name of physician) . A physician's orders [REDACTED].continue strict NWB (non weight bearing)- Boot on only when up - Please remove boot at all other times - No boot needed while in chair, only use for transfers and then remove - when up in boot she should have a small dressing on medial to protect wound. Otherwise, remove and let air when boot is off .please call with concerns of redness or drainage . Resident # 107's nursing notes, MARS (medication administration records) and TARS (treatment administration records) were reviewed from admission to present. No documentation could be found in the clinical record to evidence that the above boot instructions were being followed. No documentation could be found in the clinical record to evidence that at any time a dressing was being applied when the resident's boot was in use or that the wound was left open to air. An orthopedic progress note dated 10/09/17 documented, .doing fairly well, with exception of the poorly healing wound. This is likely due to her instability and skin pressure, but placement of the boot over the splint could have applied additional pressure .I don't think that we can debride this eschar until there is more evidence of healing .the patient appears to be making progress in her healing. She will remain NWB (non weight bearing) but begin to work toe-touch WB. May come out of the boot while NWB presents to the office today for recheck of her right ankle .At (name of facility), the patient reports that the nurses at the facility persisted to wear the boot on top of the stirrup splint .large dry medial eschar, no [MEDICAL CONDITION], lateral wound is healed exception of small distal eschar .return in about 2 weeks . The orthopedic physician's orders [REDACTED].to work on TTWB in boot may be out of boot when in bed or chair PT to work on AAROM (active assist range of motion) ankle leave dressing off if wound dry . An orthopedic progress note dated 10/19/17 documented, .presents in her walking boot and ambulating by wheelchair .points to an area of breakdown to the medial aspect of the ankle which is slow to heal .not currently treating her wound .notes irritation along the lateral ankle .right .medial wound measures 2 cm in width X 3 cm in length. dry eschar .mild [DIAGNOSES REDACTED] .lateral wound measures 5 mm X 5 mm .wound was debrided on the medial aspect .without incision .debrided down through subcutaneous tissue .wound care performed .PLAN: .debrided today without incidence .will start wound care with regular dressing changes and irrigation with sterile saline and santyl cream application daily .provided written orders .status NWB .wound culture was taken . The resident was started on PO (by mouth) antibiotics at this time for a urinary tract infection. An orthopedic progress note dated 10/26/17 documented, .no active drainage, but the cultures were positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). The plain films suggested there may be some osteo[DIAGNOSES REDACTED] along the medial malleolus .the fractures appear to be healing .visit (name of surgeon) in about 2 weeks, specifically for advice on any suggestions for debridement of the wound and or removal of her hardware .consulted .infectious disease and he advised us to have the clinical pharmacist begin [MEDICATION NAME] and he will follow up next week .hope that we can suppress any type of infectious process .concerned about her healing the medial wound without some further intervention .without any significant further surgical procedures . A facility physician's progress note dated 10/26/17 documented, .seen for recert .she has just returned from her appointment with orthopedics .she is quite disappointed that she has an infection in her right ankle . A facility physician's progress note dated 10/29/17 documented, .was seen by orthopedics and at that [MEDICAL CONDITION] infection. She is now currently on IV [MEDICATION NAME]. The past couple of days with the [MEDICATION NAME], she an (sic) acute kidney injury, and [MEDICAL CONDITION] .treated .doing a little better . physician's orders [REDACTED].Diagnosis: [REDACTED].Needs PICC line . According to the clinical record the resident had a peripherally inserted IV to receive the IV antibiotics from approximately 10/26/17 though 11/05/17, at which time the resident had received the PICC line for extended treatment of [REDACTED]. An orthopedic progress note dated 11/09/17 documented, .Based on patient's history and physical examination [REDACTED].she will need hardware out once we have confirmed fractures are healed via CT .hopeful she will not need plastics input but this will be a possibility depending on her wound healing .re-evaluation in 4 weeks . On 11/13/17 at 4:10 p.m., the administrator, DON (director of nursing) and the facility consultant, were made aware in a meeting with the survey team of the concerns regarding harm to Resident # 107 for not having an order for [REDACTED].# 107's activity orders on admission and the physician's orders [REDACTED]. On 11/14/17 at 7:50 a.m., the rehab director was interviewed regarding Resident # 107 and was asked how orders are received for resident's who need therapy. The rehab director stated that an alert email comes from the hospital and tells us (therapy dept) that the resident coming will need either PT/OT or ST (speech therapy) and then we will read over the information, look at the discharge summary and background information. The rehab director then stated that then we look in (name of facility computer system) for orders and based on those orders we start care. The rehab director was asked about Resident # 107's orders for care/treatment, specifically for the use of the orthopedic boot (don joy boot) regarding application/removal, when to wear and for how long. The rehab director stated that information would either come from discharge instructions from the hospital, admission orders [REDACTED]. The rehab director was made aware that the above mentioned locations were reviewed by this surveyor and were not found. The rehab director stated that she would have to look that information up. Once in the computer system, the rehab director stated that she did not see an order for [REDACTED]. The rehab director was asked again, where is the physician's orders [REDACTED].# 107 regarding how to wear the boot. The rehab director stated, We do not have that information. On 11/14/17 at approximately 11:20 a.m., the resident's dressing change was observed with permission from the resident. The right inner (medial) ankle wound was approximately the size of 50 cent piece, the wound bed was open and wet with areas of beefy red tissue, along with yellowish drainage on top and yellowish/dark spots along the lower border of the wound. Skin surrounding the wound had [DIAGNOSES REDACTED] (redness) that extended approximately an inch and half above the wound. The resident stated at this time that she is going to have to have another surgery due to all of this happening to remove the plate inside. The resident stated, It's all uncalled for. On 11/14 17 at approximately 11:45 a.m., the administrator, DON, facility consultant and ADON (assistant director of nursing) were made aware of concerns regarding harm level for Resident # 107 due to the failure to obtain a physician's orders [REDACTED]. The DON stated that those orders should have came from the orthopedic office, but was aware that no one called to clarify the use of the boot for Resident # 107. No further information and/or documentation was presented prior to the exit conference on 11/14/17 at 1:00 p.m. This is a complaint deficiency at harm level.

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure necessary care and treatment for [REDACTED].# 107. The facility staff failed to obtain a physician's orders [REDACTED]. joy boot) for Resident # 107, as a result the resident developed two pressure related areas from the continued use of the boot and subsequently developed an infection, which required the resident to have a PICC (peripherally inserted central catheter) placed in order to receive prolonged IV (intravenous) antibiotic therapy. Findings include: Resident # 107 was admitted to the facility on [DATE] (Thursday). [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a 5 day admission assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive assistance for transfers, toileting and bathing with at least two staff members. The resident was additionally assessed as requiring limited assistance with dressing and hygiene, with at least one staff member assistance. During a revisit survey conducted on 11/13/17 through 11/14/17, a complaint was investigated concerning Resident # 107. Clinical record review revealed that Resident # 107 had a fall at home prior to admission to the facility, which resulted in surgical intervention at the hospital; the resident was then admitted to the facility for rehab. The complainant alleged that the resident had a soft cast/splint on the right foot upon admission and shortly thereafter, the therapy staff put on an 'orthopedic boot' over top of the soft cast/splint, which resulted in the development of black necrotic tissue to the right ankle. The complainant additionally alleged that the resident developed an infection within the wounds on the right foot, which required the resident to receive IV (intravenous) antibiotics, which the resident is still receiving at this time. A hospital discharge summary dated 09/14/17 and timed 6:58 p.m. documented, Discharge Summary .right trimalleolar comminuted fracture probably due to [MEDICAL CONDITION] after a fall, status [REDACTED].came to the hospital after a fall fracturing her right ankle .surgically repaired .did well in the hospital .on day of discharge labs and vitals are stable .Right ankle xray shows acute horizontal fracture through the medial malleous and posterior malleolus .ACTIVITY: Toe-touch weightbearing on the right. She is a 2 person assist for pivot transfers . The facility admission orders [REDACTED]. No activity orders were found for Resident # 107 and no orders were found for Resident # 107 regarding the application/use of an orthopedic boot. The resident's CCP (comprehensive care plan) was then reviewed and documented, (09/14/17) falls/safety risk related to weakness, impaired mobility recent fall with fracture, weight bearing restrictions .will maintain weight bearing orders .PT (physical therapy) referral .assess resident's footwear for proper fit and non-skid soles .potential for pressure sores .impaired mobility and soft cast with boot .prevent pressure ulcers and skin breakdown .follow facility skin care protocol .preventative measures .report to charge nurse any redness or skin breakdown immediately .(09/15/17) .patient will be seen for therapeutic exercise, OT (occupational therapy) eval . On 11/13/17 at approximately 2:00 p.m., Resident # 107 was interviewed in her room. An IV pole with IV machine was attached was observed next to the resident's bed. The resident was sitting in her w/c (wheelchair), well groomed wearing a sock/shoe on the left foot and a green anti-slip sock on the right. The resident's feet were resting on the floor. The resident was asked about her stay at the facility, since admission. The resident stated (in summary) that when she was admitted to the facility (09/14/17) from the hospital, she had a 'soft cast/splint' on her right foot that went up almost to the knee. The resident went on to explain that it was wrapped with a gauze/bandage type material and that it could not be removed by staff. A tall black orthopedic boot was observed standing on the floor next to the wall, near where the resident was sitting. The resident was asked about the black boot. The resident explained that the tall black boot (orthopedic Don Joy boot) came with her from the hospital, the facility did not provide this boot and did not exchange this boot for another boot. Resident # 107 stated that therapy came in the following day and put the boot on her. The resident then stated that 'they (therapy and nursing staff) insisted' that she keep this boot on all the time. The resident was then asked if staff took off the boot to check her toes/foot or to perform any type of assessment on her ankle or foot in any way. The resident stated, No and stated it (the boot) stayed on pretty much the whole time until I went to my follow up visit with Dr. (name of orthopedic physician) on 09/28/17. The resident stated that, this is how her ankle ended up this way, from the boot rubbing my ankle and further stated that the orthopedic doctor had told her it was from wearing the boot too much. The resident stated that this should have been a 6 week stay for her and now because of this and the fact that the wound has become infected, she had to have a PICC line placed in order to receive antibiotics for an extended amount of time. The resident stated that she didn't think it was written in her discharge instructions from the hospital on how to wear the boot and stated, They (the facility) thought I had to wear it all the time. Clinical record revealed a physical therapy plan of care dated 09/15/17 documented, .referred to skilled care after hospitalization .s/p (status [REDACTED]. She is TTWB (tip-toe weight bearing) on right ankle in 'Don Joy boot' for anticipated 4-6 weeks .Precautions: TTWB right LE (lower extremity), Don Joy boot on right, full code patient is currently unable to ambulate due to TTWB on right LE .unable to maintain TTWB without assistance. She reports pain in right ankle that limits her mobility .alert and oriented, motivated to participate, follows commands . This P[NAME] (plan of care) was not signed by the physician until 09/28/17. The occupation therapy plan of care dated 09/15/17 documented, .fall and requiring an ORIF on R (right) ankle with subsequent TTWB and ortho boot with decline in function TTWB while wearing boot on RLE . This P[NAME] was not signed by the physician until 09/28/17. There were no clear instructions and/or information in the above therapy evaluations on the use application/care instructions for the orthopedic boot. A H&P (history and physical) from the facility physician, dated 09/17/17 was reviewed. The H&P documented, .date of evaluation: 09/17/17 .(name of facility location) .status [REDACTED]. She is nonweightbearing (sic) at this time .knows it is going to be a bit of a slow recovery as she is nonweightbearing for the next 4 weeks .sitting in a wheelchair .her right lower extremity is in a splint/boot .continue nonweightbearing per orthopedics .continue with physical and occupational therapy due to ambulatory dysfunction because of her ankle fracture .will await orthopedics consultation in the next 4-6 weeks for weight bearing status . This H&P was electronically signed on 09/22/17. A nursing note dated 09/28/17 documented that the resident returned from an orthopedic appointment earlier that day with new orders. The orthopedic progress note dated 09/28/17 (Friday) documented, .2 weeks status [REDACTED].has been doing well and non-weight bearing .reports no issues and no calf pain .but unfortunately did come in with her posterior and U splint on with walker boot over top of this .reports that (name of facility) has been very persistent about her wearing her boot over top of the splint .she has a wound pressure ulcer and large eschar over the medial aspect of her incision that incorporated about 80 percent of this. The eschar is stable. There are no signs of drainage or signs of infection. No surrounding [DIAGNOSES REDACTED]. Medial incision now shows that the bottom 5 staples are now buried in the skin these were removed with mild difficulty and no signs of dehiscence .Radiographs: three views of the ankle to be reviewed by the surgeon .return Monday or Tuesday with (name of physician) . A physician's orders [REDACTED].continue strict NWB (non weight bearing)- Boot on only when up - Please remove boot at all other times - No boot needed while in chair, only use for transfers and then remove - when up in boot she should have a small dressing on medial to protect wound. Otherwise, remove and let air when boot is off .please call with concerns of redness or drainage . Resident # 107's nursing notes, MARS (medication administration records) and TARS (treatment administration records) were reviewed from admission to present. No documentation could be found in the clinical record to evidence that the above boot instructions were being followed. No documentation could be found in the clinical record to evidence that at any time a dressing was being applied when the resident's boot was in use or that the wound was left open to air. An orthopedic progress note dated 10/09/17 documented, .doing fairly well, with exception of the poorly healing wound. This is likely due to her instability and skin pressure, but placement of the boot over the splint could have applied additional pressure .I don't think that we can debride this eschar until there is more evidence of healing .the patient appears to be making progress in her healing. She will remain NWB (non weight bearing) but begin to work toe-touch WB. (MONTH) come out of the boot while NWB presents to the office today for recheck of her right ankle .At (name of facility), the patient reports that the nurses at the facility persisted to wear the boot on top of the stirrup splint .large dry medial eschar, no [MEDICAL CONDITION], lateral wound is healed exception of small distal eschar .return in about 2 weeks . The orthopedic physician's orders [REDACTED].to work on TTWB in boot may be out of boot when in bed or chair PT to work on AAROM (active assist range of motion) ankle leave dressing off if wound dry . An orthopedic progress note dated 10/19/17 documented, .presents in her walking boot and ambulating by wheelchair .points to an area of breakdown to the medial aspect of the ankle which is slow to heal .not currently treating her wound .notes irritation along the lateral ankle .right .medial wound measures 2 cm in width X 3 cm in length. dry eschar .mild [DIAGNOSES REDACTED] .lateral wound measures 5 mm X 5 mm .wound was debrided on the medial aspect .without incision .debrided down through subcutaneous tissue .wound care performed .PLAN: .debrided today without incidence .will start wound care with regular dressing changes and irrigation with sterile saline and santyl cream application daily .provided written orders .status NWB .wound culture was taken . The resident was started on PO (by mouth) antibiotics at this time for a urinary tract infection. An orthopedic progress note dated 10/26/17 documented, .no active drainage, but the cultures were positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). The plain films suggested there may be some osteo[DIAGNOSES REDACTED] along the medial malleolus .the fractures appear to be healing .visit (name of surgeon) in about 2 weeks, specifically for advice on any suggestions for debridement of the wound and or removal of her hardware .consulted .infectious disease and he advised us to have the clinical pharmacist begin [MEDICATION NAME] and he will follow up next week .hope that we can suppress any type of infectious process .concerned about her healing the medial wound without some further intervention .without any significant further surgical procedures . A facility physician's progress note dated 10/26/17 documented, .seen for recert .she has just returned from her appointment with orthopedics .she is quite disappointed that she has an infection in her right ankle . A facility physician's progress note dated 10/29/17 documented, .was seen by orthopedics and at that [MEDICAL CONDITION] infection. She is now currently on IV [MEDICATION NAME]. The past couple of days with the [MEDICATION NAME], she an (sic) acute kidney injury, and [MEDICAL CONDITION] .treated .doing a little better . physician's orders [REDACTED].Diagnosis: [REDACTED].Needs PICC line . According to the clinical record the resident had a peripherally inserted IV to receive the IV antibiotics from approximately 10/26/17 though 11/05/17, at which time the resident had received the PICC line for extended treatment of [REDACTED]. An orthopedic progress note dated 11/09/17 documented, .Based on patient's history and physical examination [REDACTED].she will need hardware out once we have confirmed fractures are healed via CT .hopeful she will not need plastics input but this will be a possibility depending on her wound healing .re-evaluation in 4 weeks . On 11/13/17 at 4:10 p.m., the administrator, DON (director of nursing) and the facility consultant, were made aware in a meeting with the survey team of the concerns regarding harm to Resident # 107 for not having an order for [REDACTED].# 107's activity orders on admission and the physician's orders [REDACTED]. On 11/14/17 at 7:50 a.m., the rehab director was interviewed regarding Resident # 107 and was asked how orders are received for resident's who need therapy. The rehab director stated that an alert email comes from the hospital and tells us (therapy dept) that the resident coming will need either PT/OT or ST (speech therapy) and then we will read over the information, look at the discharge summary and background information. The rehab director then stated that then we look in (name of facility computer system) for orders and based on those orders we start care. The rehab director was asked about Resident # 107's orders for care/treatment, specifically for the use of the orthopedic boot (don joy boot) regarding application/removal, when to wear and for how long. The rehab director stated that information would either come from discharge instructions from the hospital, admission orders [REDACTED]. The rehab director was made aware that the above mentioned locations were reviewed by this surveyor and were not found. The rehab director stated that she would have to look that information up. Once in the computer system, the rehab director stated that she did not see an order for [REDACTED]. The rehab director was asked again, where is the physician's orders [REDACTED].# 107 regarding how to wear the boot. The rehab director stated, We do not have that information. On 11/14/17 at approximately 11:20 a.m., the resident's dressing change was observed with permission from the resident. The right inner (medial) ankle wound was approximately the size of 50 cent piece, the wound bed was open and wet with areas of beefy red tissue, along with yellowish drainage on top and yellowish/dark spots along the lower border of the wound. Skin surrounding the wound had [DIAGNOSES REDACTED] (redness) that extended approximately an inch and half above the wound. The resident stated at this time that she is going to have to have another surgery due to all of this happening to remove the plate inside. The resident stated, It's all uncalled for. On 11/14 17 at approximately 11:45 a.m., the administrator, DON, facility consultant and ADON (assistant director of nursing) were made aware of concerns regarding harm level for Resident # 107 due to the failure to obtain a physician's orders [REDACTED]. The DON stated that those orders should have came from the orthopedic office, but was aware that no one called to clarify the use of the boot for Resident # 107. No further information and/or documentation was presented prior to the exit conference on 11/14/17 at 1:00 p.m. This is a complaint deficiency at harm level.

Based on staff interview, clinical record review, and in the course of a complaint investigation, facility staff failed to follow standard of professional practice for one of 22 residents in the survey sample, Resident #22. Facility staff failed to transcribe a physician order [REDACTED]. Findings included: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Fib.), Cardiac Pacemaker, Asthma and Hypertension. Resident #22's most recent MDS (minimum data set) was an incomplete initial assessment with an ARD of 09/17/17. Her cognitive BIMS score was incomplete, but nursing progress notes described Resident #22 as Alert and Oriented x4. Resident #22's clinical record was reviewed on 09/27/17 starting at 2:55 p.m. During this review, it was noted Resident #22 was admitted to the facility on [DATE] and sent out to the hospital on [DATE], and was subsequently discharged from the facility. The Transfer Summary dated 09/10/2017, sent from the hospital to the facility for Resident #22 included: .Admission Diagnoses: [REDACTED]. Chronic [MEDICAL CONDITION], on [MEDICATION NAME] for anticoagulation .Discharge Diagnoses: [REDACTED]. Did receive 1 (one) unit of fresh frozen plasma before surgery .7. Chronic [MEDICAL CONDITION], again on [MEDICATION NAME] for anticoagulation .Discharge medications: [REDACTED].Discharge Instructions: The patient will be going to (Facility Name) for strengthening and conditioning .Recommend that she has a PT ([MEDICATION NAME]) and INR on Monday .Laboratory Results and Diagnostics: .Her PT is 28.1. Her INR on admission was 2.71 .was asked to transfuse some fresh frozen plasma so that they could do her surgery. On 09/07, her PT is 13.5, her INR is 1.06 .On 09/10, PT is 14.9, INR is 1.20. Reason for Admission: .She is on [MEDICATION NAME] for [MEDICAL CONDITION]. Her INR is 2.7 .Objective: .I do recommend that she has PT and INR on Monday . Medication Orders dated 09/10/2017, sent from the hospital to the facility, included the following: .[MEDICATION NAME] 5mg (milligram) tablet, 5 mg Oral Every day; changes as needed, Confirm Date 09/10/2017 10:31 . September 2017 Physician order [REDACTED]. This was the transcribed order sheet at the facility. The facility History and Physical completed by the Medical Director included the following: .Date of Evaluation: 09/11/2017 .Past Medical History: 1. [MEDICAL CONDITION], on [MEDICATION NAME] .Current medications: [REDACTED]. 2. [MEDICATION NAME] 10 mg daily. 3. [MEDICATION NAME] 300 mg b.i.d. (twice daily). 4. [MEDICATION NAME] 40 mg daily. 5. Breo Ellipta 1 (one) puff daily. 6. Vitamin D2, 50,000 units every 2 (two) weeks. 7. [MEDICATION NAME] 25 mg daily. 8. [MEDICATION NAME] 5 mg daily .Laboratory Data: Reviewed from the hospital. Her INR currently is 1.20 .Initial Assessment: .5. Coagulopathy secondary to [MEDICATION NAME], secondary to [MEDICAL CONDITION]. 6. [MEDICAL CONDITION] .Assessment/Plan: .2. Coagulopathy secondary to [MEDICATION NAME]. Her INR is subtherapeutic at 1.20. We will repeat a level this Thursday. We will try to get her goal INR between 2 and 3 . As noted above, [MEDICATION NAME] was not listed as one of Resident #22's current medications on her admission H&P to the facility. Review of Resident #22's MAR (medication administration sheet) from 9/10/2017 through 9/17/2017 did not include any documentation that she received any [MEDICATION NAME] while at the facility. Review of Clinical Notes Report dated 09/17/2017 01:49 PM included: Residents husband came to nurses station and stated that he thought she had a stroke. I went to room and observed resident staring blankly, eyes were glassy. Resident would not respond to me. V/S (vital signs) obtained BP 99/53 P 70 R 16 O2 94% T 97.7. BS 165 .EMT called. MD made aware. This note was signed by the LPN (licensed practical nurse). A second note dated 09/17/2017 01:50 PM included: Report was called to ER at 1330. (1:30 p.m.) This note was also signed by the LPN. Results of Resident #22's CT Scan of her head and neck at the hospital on [DATE] included: .Clinical Indication: Found Unresponsive Slumped Over In Wheelchair, AMS (altered mental status), Last Seen Normal at 12PM .Date: 9/17/2017 2:12 PM .Findings: .Left Carotids: .There is complete occlusion of the left internal carotid artery (ICA) beginning approximately 1.5 cm (centimeters) above the bifurcation. There is recanalization of the distal most aspect of the intracranial ICA via collateral flow .Impression: 1. There is a long segment occlusion of the left internal carotid artery originating approximately 1.5 cm above the bifurcation. There is reconstitution of flow in the intracranial ICA via collateral flow. 2. Vague decreased attenuation in the left frontal lobe is noted suggesting recent infarction . A physician progress notes [REDACTED].#22 is seen in [MEDICATION NAME] followup after the thrombectomy. She presented with symptoms of decreased responsiveness, left gaze deviation, global [MEDICAL CONDITION], and weakness of her right upper extremity. She underwent an emergent endovascular thrombectomy, proximal left ICA was recanalized, but there was persisting clot in the terminal ICA, and we tried 2 solitaire stent retriever passes followed by Trevo stent retriever pass without recanalization of periophthalmic segment occlusion. Postprocedure, the patient was withdrawing in the upper extremities .She continues to be globally aphasic. She was intubated prior to the procedure because of her deterioration, from a respiratory standpoint, she became hypotensive during the procedure, requiring IV fluid boluses as well as starting her on [MEDICATION NAME] .I discussed the findings of thrombectomy with the family and explained that she most likely will have in (sic) significant stroke involving left hemisphere and we will continue the supportive care . Administration #1 (Admin #1), Admin #2 and Admin #3 were all interviewed regarding the above incident with Resident #22 on 09/27/17 at 4:30 p.m. This surveyor and all three Admin personnel discussed Resident #22 and the missed [MEDICATION NAME] medication order. Admin #3 stated, It is exactly as you said. It was missed in transcription. The [MEDICATION NAME] was not transcribed on admission from the hospital discharge orders. According to Fundamentals of Nursing, 6th Edition, on pages 846-847; Correct Transcription and Communication of Orders. The nurse .writes the prescriber's complete order on the appropriate medication form, the MAR. The transcribed order includes the client's name .medication name, dose, frequency, and route of administration .A registered nurse checks all transcribed orders against the original order for accuracy and thoroughness . (1) Admin #3 stated, It was missed several times by the nurse and the doctor. It is being investigated by our Risk Management Team. This surveyor interviewed the Medical Director via telephone on 09/27/17 at 5:00 p.m. His admission H&P was discussed and the noted subtherapeutic INR of 1.2. Why was the [MEDICATION NAME] not ordered at that time? The Medical Director stated, I thought she was already on [MEDICATION NAME]. I know when her medicines came from pharmacy [MEDICATION NAME] was included, but was sent back. It was my understanding it wasn't on the EMR (electronic medical record) so it was sent back. I know she was on 5mg in the hospital. I also know Risk Management is looking into it. On 09/28/2017 at 8:30 a.m., Admin #3 was interviewed on the process of ordering medications from the discharge hospital list and the facility list. Admin #3 stated, We have an outpatient pharmacy. The orders are usually faxed simultaneously to the pharmacy and the facility because it is usually late in the day. Any adjustments are made either later in the day or the next day. The nurse has to transcribe the physician orders [REDACTED]. The [MEDICATION NAME] was missed. The results of the complaint investigation were discussed with the Administrative team during a meeting with the survey team on 09/28/17 at approximately 10:00 a.m. No further information was received by the survey team prior to the exit conference on 09/28/17. (1) Potter, Patricia A. and Perry, Anne G. Fundamentals of Nursing. St. Louis: Mosby, 2005. This is a complaint deficiency.

Based on staff interview, clinical record review and complaint investigation, the facility staff failed to ensure safety during incontinence care for one of 22 residents in the survey sample. Resident #21, assessed as totally dependent upon staff for bed mobility and with no range of motion in her right elbow, was turned in bed during incontinence care with the assistance of one person and fell off the opposite side of the raised bed. The resident experienced a fractured right distal femur, fractured left hip and fractured right tibia and fibula (harm) as a result of the fall. The resident was not a candidate for surgery, was placed on hospice care and died in the facility 14 days after the fall. The findings include: Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #21 with severely impaired cognitive skills, as totally incontinent of bowel and bladder and with functional limitations of her upper extremity on one side. MDS assessments dated [DATE] and [DATE] assessed Resident #21 as totally dependent upon two people for bed mobility, transfers and toileting. Resident #21's clinical record documented a nursing note dated [DATE] stating, Nurse was called into the resident's room at 2200 (10:00 p.m.) by CNA (certified nurses' aide). Resident was observed llying (lying) on the floor in her room between the bed and the wall. Staff CNA reported that she was in the process of changing the residents; incontinent wear and turned the resident to her left side, She then reached to grabbed (grab) the cleaning cloths and resident just slid off of the bed to the floor. Staff member stated that she (CNA) did attempt to catch her (Resident #21) but was unable to hold onto her. Resident had no complaints of any pain or discomfort and no wounds were noted. Staff, however will do the Neuro (neurological) check protocol because resident could not let staff know if she had hit her head or not . (sic) A nursing note dated [DATE] at 7:30 a.m. documented, Resident assessed before going to radiology appointment for barium swallow test. Resident has swelling to the right hip and bruising to the right leg also. Resident also has bruising to the right arm. On call doctor called and would like to have the right arm and shoulder and right hip and knee xray to be done at appointment at radiology . Resident #21's x-ray report of the right knee dated [DATE] documented, There is a slightly angulated/displaced fracture of the distal femur .Impression: There is a fracture of the distal femur. An x-ray report of the left leg revealed, There is a left femoral neck fracture with a possible nondisplaced fracture of the greater trochanter (left hip). An x-ray report of the right ankle dated [DATE] documented, There are slightly laterally angulated fractures of the distal fibula and tibia. A nondisplaced posterior malleolar (ankle) fracture is also suspected. The clinical record documented the resident remained at the facility following the fall/fractures. A physician's progress note dated [DATE] documented the resident had difficulty swallowing and eating and had declined prior to the fall. The note documented a discussion with the family that stated, We talked about osteoporosis and the recent fracture that happened. It is nonoperative at this point .I did not know if it would heal and she would be able to sit up in a wheelchair whereas she is just lying in the bed . I said regardless prior to fracture, (Resident #21) was declining and was not doing well and at this standpoint, even with that, it would probably be the same path . The note stated the family desired no aggressive treatment of [REDACTED]. The facility's investigation of Resident #21's fall of [DATE] documented the resident slid off side of bed during ADL's (activities of daily living) with one CNA assisting the resident during a brief change due to incontinence. A written statement dated [DATE] from CNA #1 with Resident #21 at the time of the fall documented, I was doing my rounds before end of shift and was changing resident as I was reaching for the cloth turned resident Slide off the side of the raised bed onto the floor, I tried to grab her but her shoulders slid through my hands, I immediately called for the nurse. The fall investigation documented interventions implemented to prevent further falls as, Staff educated - two person assist with ADL care, concave mattress . Resident #21's clinical record documented the resident had no range of motion in her right elbow and required specialized seating for proper positioning when up in a chair. The record documented physician orders [REDACTED]. no range of motion right elbow . J-back wheelchair with bilateral leg rests, pommel cushion and right and side bilateral support . pressure relief mattress . Fall precautions . elevate right arm - no range of motion with right elbow, up with assist hoyer lift . Turn and reposition . every 2 hours . Resident #21's plan of care (effective [DATE] to present) prior to the fall did not specify the assistance required during activities of daily living including incontinence care. The care plan documented the resident was at risk for falls due to poor safety awareness. Interventions to prevent falls included, remind resident to use call bell, transfers with the assistance of two people using Hoyer lift, clutter free environment, bed at appropriate height, keep family and physician informed, encourage activities, instruct resident on safety measures and proper lighting. The care plan documented the resident required assistance with ADL's due to severe dementia, cognitive impairment and expected decline in function. Interventions for assistance with ADL's included to turn the resident every two hours, remind resident to use call bell, two person assist for transfers with Hoyer lift, clutter free environment, bed appropriate height and instruct resident on safety measures. The care plan listed the resident had potential for fractures due to osteoporosis. Interventions to prevent fractures included medications as ordered, labs as ordered, light in room, proper fitting shoes, assistance with proper body alignment, call bell in reach and activity as tolerated. The care plan was revised after the resident's fall on [DATE] to include use of a concave mattress and a requirement for two people to assist for bed mobility and ADL care. In the week prior to the fall on [DATE], Resident #21's ADL records ([DATE] through [DATE]) documented the resident was provided incontinence care with the assistance of two people at times and at other times was assisted with one person. Resident #21's undated care card used as a guide by the CNA's listed the resident required the use of one person for bathing and required two people for transfers with use of a Hoyer lift. The card did not specify assistance required for activities of daily living other than bathing. On [DATE] at 3:10 p.m. CNA #1 with Resident #21 when she fell on [DATE] was interviewed. CNA #1 stated on [DATE] she was making last rounds for the shift and was changing Resident #21's brief when the fall occurred. CNA #1 stated the resident had loose stool everywhere including her legs and on the bed. CNA #1 stated she got wet wash cloths and raised the resident's bed. CNA #1 stated she raised the bed above my waist level, removed her brief and asked her if she could turn. CNA #1 stated she assisted the resident to turn onto her left side away from her with the resident facing the opposite side of the bed. CNA #1 stated the resident's hand was on the grab bar. CNA #1 stated with her hand on the resident, she reached for the wash cloths and the resident's right foot went over the left foot and the resident rolled toward the other side of the bed. CNA #1 stated she tried to hold the resident's shoulders but was unable to keep the resident in bed. CNA #1 stated the resident hit the floor after rolling off the opposite side of the bed. CNA #1 stated, I probably had the bed a little high. CNA #1 was asked about the resident's abilities to assist with turning in bed and the care required for the resident. CNA #1 stated Resident #21 couldn't turn without assistance. CNA #1 described the resident as totally dependent for care needs. CNA #1 stated the resident was able to hold on to the grab bar when turned but was not able to pull or move herself in bed. CNA #1 stated the resident required a Hoyer lift for transfers. When asked how she knew the assistance required for Resident #21's incontinence care, CNA #1 stated she went by what the senior aides told her. CNA #1 stated she usually provided incontinence care to Resident #21 without assistance. CNA #1 stated the care card for Resident #21 listed the resident was a Hoyer lift but did not include assistance required for turning and brief changes. On [DATE] at 4:10 p.m. the director of nursing (DON) was interviewed about Resident #21's fall from bed during incontinence care on [DATE]. The DON stated the care cards were supposed to be updated daily as needed by the unit managers depending on the resident's condition. When asked about the how the aides knew when to use one person or two people for assistance with Resident #21, the DON stated it was up to the CNA's. The DON stated, They (CNA's) do what they feel like they can do, what they are comfortable with. When asked what interventions were put in place after the fall, the DON stated, We made her (Resident #21) a two person assist. These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 10:00 a.m. This was a complaint deficiency.

Based on staff interview, clinical record review, and in the course of a complaint investigation, facility staff failed to ensure one of 22 residents in the survey sample was free from a significant medication error resulting in harm, Resident #22. Facility staff failed to transcribe a physician order [REDACTED]. Findings included: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Fib.), Cardiac Pacemaker, Asthma and Hypertension. Resident #22's most recent MDS (minimum data set) was an incomplete initial assessment with an ARD of 09/17/17. Her cognitive BIMS score was incomplete, but nursing progress notes described Resident #22 as Alert and Oriented x4. Resident #22's clinical record was reviewed on 09/27/17 at 2:55 p.m. During this review, it was noted Resident #22 was admitted to the facility on [DATE] and sent out to the hospital on [DATE], and was subsequently discharged from the facility. The Transfer Summary dated 09/10/2017, sent from the hospital to the facility for Resident #22 included: .Admission Diagnoses: [REDACTED]. Chronic [MEDICAL CONDITION], on [MEDICATION NAME] for anticoagulation .Discharge Diagnoses: [REDACTED]. Did receive 1 (one) unit of fresh frozen plasma before surgery .7. Chronic [MEDICAL CONDITION], again on [MEDICATION NAME] for anticoagulation .Discharge medications: [REDACTED].Discharge Instructions: The patient will be going to (Facility Name) for strengthening and conditioning .Recommend that she has a PT ([MEDICATION NAME]) and INR on Monday .Laboratory Results and Diagnostics: .Her PT is 28.1. Her INR on admission was 2.71 .was asked to transfuse some fresh frozen plasma so that they could do her surgery. On 09/07, her PT is 13.5, her INR is 1.06 .On 09/10, PT is 14.9, INR is 1.20. Reason for Admission: .She is on [MEDICATION NAME] for [MEDICAL CONDITION]. Her INR is 2.7 .Objective: .I do recommend that she has PT and INR on Monday . Medication Orders dated 09/10/2017, sent from the hospital to the facility, included the following: .[MEDICATION NAME] 5mg (milligram) tablet, 5 mg Oral Every day; changes as needed, Confirm Date 09/10/2017 10:31 . September 2017 Physician order [REDACTED]. This was the transcribed order sheet at the facility. The facility History and Physical completed by the Medical Director included the following: .Date of Evaluation: 09/11/2017 .Past Medical History: 1. [MEDICAL CONDITION], on [MEDICATION NAME] .Current medications: [REDACTED]. 2. [MEDICATION NAME] 10 mg daily. 3. [MEDICATION NAME] 300 mg b.i.d. (twice daily). 4. [MEDICATION NAME] 40 mg daily. 5. Breo Ellipta 1 (one) puff daily. 6. Vitamin D2, 50,000 units every 2 (two) weeks. 7. [MEDICATION NAME] 25 mg daily. 8. [MEDICATION NAME] 5 mg daily .Laboratory Data: Reviewed from the hospital. Her INR currently is 1.20 .Initial Assessment: .5. Coagulopathy secondary to [MEDICATION NAME], secondary to [MEDICAL CONDITION]. 6. [MEDICAL CONDITION] .Assessment/Plan: .2. Coagulopathy secondary to [MEDICATION NAME]. Her INR is subtherapeutic at 1.20. We will repeat a level this Thursday. We will try to get her goal INR between 2 and 3 . As noted above, [MEDICATION NAME] was not listed as one of Resident #22's current medications on her admission H&P to the facility. Review of Resident #22's MAR (medication administration sheet) from 9/10/2017 through 9/17/2017 did not include any documentation that she received any [MEDICATION NAME] while at the facility. Review of Clinical Notes Report dated 09/17/2017 01:49 PM included: Residents husband came to nurses station and stated that he thought she had a stroke. I went to room and observed resident staring blankly, eyes were glassy. Resident would not respond to me. V/S (vital signs) obtained BP 99/53 P 70 R 16 O2 94% T 97.7. BS 165 .EMT called. MD made aware. This note was signed by the LPN (licensed practical nurse). A second note dated 09/17/2017 01:50 PM included: Report was called to ER at 1330. (1:30 p.m.) This note was also signed by the LPN. Results of Resident #22's CT Scan of her head and neck at the hospital on [DATE] included: .Clinical Indication: Found Unresponsive Slumped Over In Wheelchair, AMS (altered mental status), Last Seen Normal at 12PM .Date: 9/17/2017 2:12 PM .Findings: .Left Carotids: .There is complete occlusion of the left internal carotid artery (ICA) beginning approximately 1.5 cm (centimeters) above the bifurcation. There is recanalization of the distal most aspect of the intracranial ICA via collateral flow .Impression: 1. There is a long segment occlusion of the left internal carotid artery originating approximately 1.5 cm above the bifurcation. There is reconstitution of flow in the intracranial ICA via collateral flow. 2. Vague decreased attenuation in the left frontal lobe is noted suggesting recent infarction . A physician progress notes [REDACTED].#22 is seen in [MEDICATION NAME] followup after the thrombectomy. She presented with symptoms of decreased responsiveness, left gaze deviation, global [MEDICAL CONDITION], and weakness of her right upper extremity. She underwent an emergent endovascular thrombectomy, proximal left ICA was recanalized, but there was persisting clot in the terminal ICA, and we tried 2 solitaire stent retriever passes followed by Trevo stent retriever pass without recanalization of periophthalmic segment occlusion. Postprocedure, the patient was withdrawing in the upper extremities .She continues to be globally aphasic. She was intubated prior to the procedure because of her deterioration, from a respiratory standpoint, she became hypotensive during the procedure, requiring IV fluid boluses as well as starting her on [MEDICATION NAME] .I discussed the findings of thrombectomy with the family and explained that she most likely will have in (sic) significant stroke involving left hemisphere and we will continue the supportive care . Administration #1 (Admin #1), Admin #2 and Admin #3 were all interviewed regarding the above incident with Resident #22 on 09/27/17 at 4:30 p.m. This surveyor and all three Admin personnel discussed Resident #22 and the missed [MEDICATION NAME] medication order. Admin #3 stated, It is exactly as you said. It was missed in transcription. The [MEDICATION NAME] was not transcribed on admission from the hospital discharge orders. It was missed several times by the nurse and the doctor. It is being investigated by our Risk Management Team. This surveyor interviewed the Medical Director via telephone on 09/27/17 at 5:00 p.m. His admission H&P was discussed and the noted subtherapeutic INR of 1.2. Why was the [MEDICATION NAME] not ordered at that time? The Medical Director stated, I thought she was already on [MEDICATION NAME]. I know when her medicines came from pharmacy [MEDICATION NAME] was included, but was sent back. It was my understanding it wasn't on the EMR (electronic medical record) so it was sent back. I know she was on 5mg in the hospital. I also know Risk Management is looking into it. On 09/28/2017 at 8:30 a.m., Admin #3 was interviewed on the process of ordering medications from the discharge hospital list and the facility list. Admin #3 stated, We have an outpatient pharmacy. The orders are usually faxed simultaneously to the pharmacy and the facility because it is usually late in the day. Any adjustments are made either later in the day or the next day. The nurse has to transcribe the physician orders [REDACTED]. The [MEDICATION NAME] was missed. The results of the complaint investigation were discussed with the Administrative team during a meeting with the survey team on 09/28/17 at approximately 10:00 a.m. No further information was received by the survey team prior to the exit conference on 09/28/17. This is a complaint deficiency.

Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure necessary care and treatment for [REDACTED].# 107. The facility staff failed to obtain a physician's orders [REDACTED]. joy boot) for Resident # 107, as a result the resident developed two pressure related areas from the continued use of the boot and subsequently developed an infection, which required the resident to have a PICC (peripherally inserted central catheter) placed in order to receive prolonged IV (intravenous) antibiotic therapy. Findings include: Resident # 107 was admitted to the facility on [DATE] (Thursday). [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a 5 day admission assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive assistance for transfers, toileting and bathing with at least two staff members. The resident was additionally assessed as requiring limited assistance with dressing and hygiene, with at least one staff member assistance. During a revisit survey conducted on 11/13/17 through 11/14/17, a complaint was investigated concerning Resident # 107. Clinical record review revealed that Resident # 107 had a fall at home prior to admission to the facility, which resulted in surgical intervention at the hospital; the resident was then admitted to the facility for rehab. The complainant alleged that the resident had a soft cast/splint on the right foot upon admission and shortly thereafter, the therapy staff put on an 'orthopedic boot' over top of the soft cast/splint, which resulted in the development of black necrotic tissue to the right ankle. The complainant additionally alleged that the resident developed an infection within the wounds on the right foot, which required the resident to receive IV (intravenous) antibiotics, which the resident is still receiving at this time. A hospital discharge summary dated 09/14/17 and timed 6:58 p.m. documented, Discharge Summary .right trimalleolar comminuted fracture probably due to [MEDICAL CONDITION] after a fall, status [REDACTED].came to the hospital after a fall fracturing her right ankle .surgically repaired .did well in the hospital .on day of discharge labs and vitals are stable .Right ankle xray shows acute horizontal fracture through the medial malleous and posterior malleolus .ACTIVITY: Toe-touch weightbearing on the right. She is a 2 person assist for pivot transfers . The facility admission orders [REDACTED]. No activity orders were found for Resident # 107 and no orders were found for Resident # 107 regarding the application/use of an orthopedic boot. The resident's CCP (comprehensive care plan) was then reviewed and documented, (09/14/17) falls/safety risk related to weakness, impaired mobility recent fall with fracture, weight bearing restrictions .will maintain weight bearing orders .PT (physical therapy) referral .assess resident's footwear for proper fit and non-skid soles .potential for pressure sores .impaired mobility and soft cast with boot .prevent pressure ulcers and skin breakdown .follow facility skin care protocol .preventative measures .report to charge nurse any redness or skin breakdown immediately .(09/15/17) .patient will be seen for therapeutic exercise, OT (occupational therapy) eval . On 11/13/17 at approximately 2:00 p.m., Resident # 107 was interviewed in her room. An IV pole with IV machine was attached was observed next to the resident's bed. The resident was sitting in her w/c (wheelchair), well groomed wearing a sock/shoe on the left foot and a green anti-slip sock on the right. The resident's feet were resting on the floor. The resident was asked about her stay at the facility, since admission. The resident stated (in summary) that when she was admitted to the facility (09/14/17) from the hospital, she had a 'soft cast/splint' on her right foot that went up almost to the knee. The resident went on to explain that it was wrapped with a gauze/bandage type material and that it could not be removed by staff. A tall black orthopedic boot was observed standing on the floor next to the wall, near where the resident was sitting. The resident was asked about the black boot. The resident explained that the tall black boot (orthopedic Don Joy boot) came with her from the hospital, the facility did not provide this boot and did not exchange this boot for another boot. Resident # 107 stated that therapy came in the following day and put the boot on her. The resident then stated that 'they (therapy and nursing staff) insisted' that she keep this boot on all the time. The resident was then asked if staff took off the boot to check her toes/foot or to perform any type of assessment on her ankle or foot in any way. The resident stated, No and stated it (the boot) stayed on pretty much the whole time until I went to my follow up visit with Dr. (name of orthopedic physician) on 09/28/17. The resident stated that, this is how her ankle ended up this way, from the boot rubbing my ankle and further stated that the orthopedic doctor had told her it was from wearing the boot too much. The resident stated that this should have been a 6 week stay for her and now because of this and the fact that the wound has become infected, she had to have a PICC line placed in order to receive antibiotics for an extended amount of time. The resident stated that she didn't think it was written in her discharge instructions from the hospital on how to wear the boot and stated, They (the facility) thought I had to wear it all the time. Clinical record revealed a physical therapy plan of care dated 09/15/17 documented, .referred to skilled care after hospitalization .s/p (status [REDACTED]. She is TTWB (tip-toe weight bearing) on right ankle in 'Don Joy boot' for anticipated 4-6 weeks .Precautions: TTWB right LE (lower extremity), Don Joy boot on right, full code patient is currently unable to ambulate due to TTWB on right LE .unable to maintain TTWB without assistance. She reports pain in right ankle that limits her mobility .alert and oriented, motivated to participate, follows commands . This P[NAME] (plan of care) was not signed by the physician until 09/28/17. The occupation therapy plan of care dated 09/15/17 documented, .fall and requiring an ORIF on R (right) ankle with subsequent TTWB and ortho boot with decline in function TTWB while wearing boot on RLE . This P[NAME] was not signed by the physician until 09/28/17. There were no clear instructions and/or information in the above therapy evaluations on the use application/care instructions for the orthopedic boot. A H&P (history and physical) from the facility physician, dated 09/17/17 was reviewed. The H&P documented, .date of evaluation: 09/17/17 .(name of facility location) .status [REDACTED]. She is nonweightbearing (sic) at this time .knows it is going to be a bit of a slow recovery as she is nonweightbearing for the next 4 weeks .sitting in a wheelchair .her right lower extremity is in a splint/boot .continue nonweightbearing per orthopedics .continue with physical and occupational therapy due to ambulatory dysfunction because of her ankle fracture .will await orthopedics consultation in the next 4-6 weeks for weight bearing status . This H&P was electronically signed on 09/22/17. A nursing note dated 09/28/17 documented that the resident returned from an orthopedic appointment earlier that day with new orders. The orthopedic progress note dated 09/28/17 (Friday) documented, .2 weeks status [REDACTED].has been doing well and non-weight bearing .reports no issues and no calf pain .but unfortunately did come in with her posterior and U splint on with walker boot over top of this .reports that (name of facility) has been very persistent about her wearing her boot over top of the splint .she has a wound pressure ulcer and large eschar over the medial aspect of her incision that incorporated about 80 percent of this. The eschar is stable. There are no signs of drainage or signs of infection. No surrounding [DIAGNOSES REDACTED]. Medial incision now shows that the bottom 5 staples are now buried in the skin these were removed with mild difficulty and no signs of dehiscence .Radiographs: three views of the ankle to be reviewed by the surgeon .return Monday or Tuesday with (name of physician) . A physician's orders [REDACTED].continue strict NWB (non weight bearing)- Boot on only when up - Please remove boot at all other times - No boot needed while in chair, only use for transfers and then remove - when up in boot she should have a small dressing on medial to protect wound. Otherwise, remove and let air when boot is off .please call with concerns of redness or drainage . Resident # 107's nursing notes, MARS (medication administration records) and TARS (treatment administration records) were reviewed from admission to present. No documentation could be found in the clinical record to evidence that the above boot instructions were being followed. No documentation could be found in the clinical record to evidence that at any time a dressing was being applied when the resident's boot was in use or that the wound was left open to air. An orthopedic progress note dated 10/09/17 documented, .doing fairly well, with exception of the poorly healing wound. This is likely due to her instability and skin pressure, but placement of the boot over the splint could have applied additional pressure .I don't think that we can debride this eschar until there is more evidence of healing .the patient appears to be making progress in her healing. She will remain NWB (non weight bearing) but begin to work toe-touch WB. (MONTH) come out of the boot while NWB presents to the office today for recheck of her right ankle .At (name of facility), the patient reports that the nurses at the facility persisted to wear the boot on top of the stirrup splint .large dry medial eschar, no [MEDICAL CONDITION], lateral wound is healed exception of small distal eschar .return in about 2 weeks . The orthopedic physician's orders [REDACTED].to work on TTWB in boot may be out of boot when in bed or chair PT to work on AAROM (active assist range of motion) ankle leave dressing off if wound dry . An orthopedic progress note dated 10/19/17 documented, .presents in her walking boot and ambulating by wheelchair .points to an area of breakdown to the medial aspect of the ankle which is slow to heal .not currently treating her wound .notes irritation along the lateral ankle .right .medial wound measures 2 cm in width X 3 cm in length. dry eschar .mild [DIAGNOSES REDACTED] .lateral wound measures 5 mm X 5 mm .wound was debrided on the medial aspect .without incision .debrided down through subcutaneous tissue .wound care performed .PLAN: .debrided today without incidence .will start wound care with regular dressing changes and irrigation with sterile saline and santyl cream application daily .provided written orders .status NWB .wound culture was taken . The resident was started on PO (by mouth) antibiotics at this time for a urinary tract infection. An orthopedic progress note dated 10/26/17 documented, .no active drainage, but the cultures were positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). The plain films suggested there may be some osteo[DIAGNOSES REDACTED] along the medial malleolus .the fractures appear to be healing .visit (name of surgeon) in about 2 weeks, specifically for advice on any suggestions for debridement of the wound and or removal of her hardware .consulted .infectious disease and he advised us to have the clinical pharmacist begin [MEDICATION NAME] and he will follow up next week .hope that we can suppress any type of infectious process .concerned about her healing the medial wound without some further intervention .without any significant further surgical procedures . A facility physician's progress note dated 10/26/17 documented, .seen for recert .she has just returned from her appointment with orthopedics .she is quite disappointed that she has an infection in her right ankle . A facility physician's progress note dated 10/29/17 documented, .was seen by orthopedics and at that [MEDICAL CONDITION] infection. She is now currently on IV [MEDICATION NAME]. The past couple of days with the [MEDICATION NAME], she an (sic) acute kidney injury, and [MEDICAL CONDITION] .treated .doing a little better . physician's orders [REDACTED].Diagnosis: [REDACTED].Needs PICC line . According to the clinical record the resident had a peripherally inserted IV to receive the IV antibiotics from approximately 10/26/17 though 11/05/17, at which time the resident had received the PICC line for extended treatment of [REDACTED]. An orthopedic progress note dated 11/09/17 documented, .Based on patient's history and physical examination [REDACTED].she will need hardware out once we have confirmed fractures are healed via CT .hopeful she will not need plastics input but this will be a possibility depending on her wound healing .re-evaluation in 4 weeks . On 11/13/17 at 4:10 p.m., the administrator, DON (director of nursing) and the facility consultant, were made aware in a meeting with the survey team of the concerns regarding harm to Resident # 107 for not having an order for [REDACTED].# 107's activity orders on admission and the physician's orders [REDACTED]. On 11/14/17 at 7:50 a.m., the rehab director was interviewed regarding Resident # 107 and was asked how orders are received for resident's who need therapy. The rehab director stated that an alert email comes from the hospital and tells us (therapy dept) that the resident coming will need either PT/OT or ST (speech therapy) and then we will read over the information, look at the discharge summary and background information. The rehab director then stated that then we look in (name of facility computer system) for orders and based on those orders we start care. The rehab director was asked about Resident # 107's orders for care/treatment, specifically for the use of the orthopedic boot (don joy boot) regarding application/removal, when to wear and for how long. The rehab director stated that information would either come from discharge instructions from the hospital, admission orders [REDACTED]. The rehab director was made aware that the above mentioned locations were reviewed by this surveyor and were not found. The rehab director stated that she would have to look that information up. Once in the computer system, the rehab director stated that she did not see an order for [REDACTED]. The rehab director was asked again, where is the physician's orders [REDACTED].# 107 regarding how to wear the boot. The rehab director stated, We do not have that information. On 11/14/17 at approximately 11:20 a.m., the resident's dressing change was observed with permission from the resident. The right inner (medial) ankle wound was approximately the size of 50 cent piece, the wound bed was open and wet with areas of beefy red tissue, along with yellowish drainage on top and yellowish/dark spots along the lower border of the wound. Skin surrounding the wound had [DIAGNOSES REDACTED] (redness) that extended approximately an inch and half above the wound. The resident stated at this time that she is going to have to have another surgery due to all of this happening to remove the plate inside. The resident stated, It's all uncalled for. On 11/14 17 at approximately 11:45 a.m., the administrator, DON, facility consultant and ADON (assistant director of nursing) were made aware of concerns regarding harm level for Resident # 107 due to the failure to obtain a physician's orders [REDACTED]. The DON stated that those orders should have came from the orthopedic office, but was aware that no one called to clarify the use of the boot for Resident # 107. No further information and/or documentation was presented prior to the exit conference on 11/14/17 at 1:00 p.m. This is a complaint deficiency at harm level.

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to provide supervision during toileting, which resulted in a left hip fracture, for one of 24 residents in the survey sample, Resident #22. The findings included: Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/7/11 was a quarterly assessment. The resident was assessed as a 15 for cognitive (no memory impairments and independent in decision-making skills). Under section E. "Behavior," the resident was assessed as not exhibiting behavioral symptoms. Under Section G. 0110 "Functional Status, (I). Toilet Use-how the resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy care or catheter; and adjust clothes..." the resident was assessed as a 3/2 (requiring extensive assistance with one person for physical assist). Under Section G 0300 "Balance during transitions and walking" the resident was coded as (2) Not steady, only able to stabilize with human assistance, for the areas: "A. Moving from seated to standing position...D. Moving on and off toilet...E. Surface-to-surface transfer (transfer between bed and chair or wheelchair). Resident #22 was discharged home on[DATE] was reviewed as a closed clinical. On 5/17/12 at approximately 10:40 a.m., a Facility Reported Incident was reviewed to include the following: "7/22/11...On, Sunday, July 10, 2011 (resident named) experienced a witnessed fall while in her bathroom. Nurse Aide (named) was in the bathroom with her and turned around to obtain a washcloth necessary for incontinence care and during this motion the resident attempted to rise and fell to the floor before the nurse aide could stop the fall. The resident's legs were crossed at the ankles and she (the resident) had toilet paper in her hand when she fell . Later that afternoon when the family arrived they expressed concern that the roommate had stated that (resident named) was left alone in the bathroom...The roommate was present in the room, the bathroom door was pulled shut leaving only a crack in the door...The roommate is not a good historian, was not hollering out for help because of resident (named) fall, nor was the call bell being rung. The nurse entered the room because the nurse aide came to get her..." On 5/17/12 at approximately 10:45 a.m., the following notes were reviewed in Resident #22's electronic medical records (EMRs): An admission assessment with an ARD of 4/19/12, cognitive was coded a 12 (no memory impairments and independent in decision-making skills). Section E. Behaviors; no behaviors present. Under Section G. 0110 "Functional Status, (I). Toilet Use-how the resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy care or catheter; and adjust clothes..." the resident was assessed as a 3/3 (requiring extensive assistance with two person for physical assist). Under Section G 0300 "Balance during transitions and walking" the resident was coded as (2) Not steady, only able to stabilize with human assistance, for the areas: "A. Moving from seated to standing position...D. Moving on and off toilet...E. Surface-to-surface transfer (transfer between bed and chair or wheelchair). A care plan updated and reviewed on 4/29/11 and again on 5/4/11 included: "4. Problem: At risk for falling r/t weakness, unsteady balance, impulsive-poor safety awareness, Fall...Goal: Min A ADLs (activity of daily living) and mobility bed to wheelchair to toilet with DME (durable medical equipment) to R (right) side...Will have no significant injury from falls over the next 90 days...Approach: 16. Assist with toileting/provide incontinence care frequently and prn...17. Hoyer lift for transfers-x2 assist for transfers." An admission assessment recorded on 4/12/11 was reviewed to include: "Musculoskeletal: (1) Flaccid Left side. Neurological/Mental Status: Alert/Oriented...Health Conditions: (L) Unsteady gait flaccid left side..." A Morse Fall Risk Assessment recorded on 4/12/11 was reviewed to include the following: "History of falls: Scale: Yes Points: 25 Patients points: 25, Secondary diagnosis; Scale: Yes. Points: Yes, Patients points: 15, Gait/Transferring: Scale: Impaired, Points: 20, Patients Points: 20...Total Score: 60..." Resident #22 was coded a 60 on the assessment (High risk=51 or higher). On 5/17/12 at approximately 10:47 a.m., the following nursing notes were reviewed to include the following: "7/10/11, 1200 (12:00 p.m.) Resident observed by CNA (certified nursing assistant) on commode attempting to get up unassisted lost balance, CNA unable to catch, struck head on wheelchair. Small scratch noted to L (left) side of nose. Neuro checks WNL (within normal limits) VSS (vital signs stable). RP (responsible person/party) named made aware." "7/10/11, 1830 (6:30 p.m.) Family, son (named), expressing concerns about fall she (resident) experienced today. Expressing concern about her being left in the bathroom alone, concerns about future safety. Expressed concern about if roommate had not seen her fall how long would she have been in the floor. After this discussion resident received a very thorough physical and neuro assessment, chair alarm placed in w/c (wheelchair), sign placed in bathroom stating do not leave, resident (named), alone in the bathroom. Info (information) passed on to the other shifts in huddle." 7/11/11, 0030 (3:00 a.m.) ...continues to c/o (complain of) left arm and leg pain medicated with prn (as need/necessary) Tylenol..." 7/11/11, 1445 (2:45 p.m.) Resident in therapy, A & O (alert and oriented) MD (physician/doctor) in to evaluate per son's request. Resident c/o left hip pain since fall...New orders L (left) hip Xray..." 7/11/11, 1830 (6:30 p.m.) MD in and reviewed chart. New order for CT (computed tomography) to r/o (rule out) femoral neck fracture..." 7/12/11, 1250, (12:50 p.m.) per DON (named): Resident to hospital (named) for CT scan..." The next documented nursing note in the EMR (electronic medical record) was a readmission back to the facility in 7/15/11 at 2030 (8:30 p.m.). On 5/17/12 at approximately 10:50 a.m., a History and Physical dated 7/12/11 was reviewed to include the following: Chief Complaint: Left hip fracture: History of present illness: Resident (named)...has a history of stroke secondary to right middle cerebral artery distribution infarct in April of this year. She has been at facility (named) since then, working with strengthening. She was on the commode Sunday. She pulled the cord to ask the aid to come help her get up and pulling the cord caused her to fall of (sic) the commode onto the floor...Laboratory data: CT scan of the left hip showed impacted, nondisplaced subcapital femoral neck fracture...Assessment/Plan: Hip fracture. Will go ahead and admit her..." On 5/17/12 at approximately 10:52 a.m., the following Physical therapy notes were reviewed to include the following: 7/8/11...transfers with minimal assist of 1 from w/c (wheelchair) to reg (regular) chair stood at wall bal (balance) x3 with CGA (contact guard assist)..." On 5/17/12 at approximately 1:55 p.m., CNA #10, who was assisting the resident in the toilet on 7/10/11, was interviewed regarding the resident's fall in the bathroom. CNA #10 stated that she put the resident on the commode with the assistance of another staff person. When asked about the staff person, CNA #10 stated, "I don't know who helped me but I remember getting help." CNA #10 stated that after the resident was seated on the commode, "I turned around towards the sink to get a towel off the rack. As soon as I turned my back, she (Resident #22) slid over to the left side and slid onto the floor." After several minutes into the interview CNA #10, recalled the other staff person that assisted the resident onto the commode. CNA #10 stated, "She (the other staff person) did not stay in the bathroom she left after the resident was on the commode." CNA #10 stated that some commodes had a raised toilet seat with bars on both sides for the residents to hold on to. When asked if Resident #22 had that type of commode, CNA #10 stated, "No, she had a regular commode." CNA #10 was then asked if the resident attempted to stand. CNA #10 stated, "No, she did not stand, she leaned to the left side. When asked how the resident was transferred, CNA #10 stated, "We was using a Hoyer prior to the fall due to safety issues but then we started doing 2 person assist. She was a 2 person assist for transfers." On 5/17/12 at approximately 2:30 p.m., the rehab manager (Other 4) and the physical therapy assistant (PTA-Other 5) were interviewed regarding the resident's ability to ambulate, transfer and balance self. The PTA stated that the resident, in therapy, was "one person contact guard assist," for transfers and balance. When asked the meaning of CGA, the PTA stated, "We do not physically help you do anything but my hand is on you for balance and she (Resident #22) was such that you had to do that." The PTA stated that the resident had good trunk balance seated but if she moved "side to side she was unable to catch herself using her left side." The PTA also stated that the resident could sit on the edge of the bed but if you "pushed her over to her left side, as I often would do with her, or if she leaned over to the left side she could not catch herself and you had to help her back over." The PTA was asked if the resident had a tendency to lean to her weaker side. The PTA stated, "Oh yes definitely." The PTA further stated that she had taken the resident to the bathroom but "I never left her, if you told her to hang on (to the rail in the bathroom, located on the right side of the commode) she would but sometimes she would let it go." On 5/17/12 at approximately 2:35 p.m., the witness statements were requested and reviewed. The witness statement from the CNA assisting with toileting documented, "On 7/10/11 resident (named) ask if she could be put on commode so I did to have a BM (bowel movement) after finishing she need to be clean up. I turn around to get wash cloth and towel on the hamper when turning back around pt (patient) fell over the side on floor, when call for nurse to check her over, she had both foot cross over the other c (with) toilet paper in hand...(sic)." The witness statement from staff assessing the resident after the fall documented: "CNA came to nurse's station to ask nursing staff for assistance with resident. Nursing staff ask what was wrong says that she had "lowered resident to floor." Says resident was attempting to stand to clean self up after toileting and CNA was unable to hold on to her and lowered her to the bathroom floor...(sic)." The witness statement from staff nurse on duty on 7/10/11 (LPN #1) documented: "I was told in the break room by the LPN in charge of resident (named) incident occurring in her bathroom. Where I was told she was lowered to the floor during a transfer from the toilet to wheelchair and had a small superficial scratch to her nose...I wasn't present when it occurred and the staff involved had left for the day...We then checked ROM (range of motion) to legs resident did state some discomfort but when asked where she stated "what are going to do about my still arm" grabbing and pulling at it. I repeated the question and she put her right hand above her left knee and pointed downwards towards her foot and said 'all that'...(sic)." The witness statement from the Nursing supervisor that was on duty on 7/10/11 documented: "At about 630 pm, I was called on the phone by one of the CNA's on SW (the unit where Resident #22 resided) to come and talk with a family member. She had requested to speak to the "supervisor"...I went to SW. A woman was standing at the nurses desk when I arrived. After she introduced herself, she immediately stated that she was concerned about Resident #22. She sad there were different stories about Resident #22's falling and she wanted to see my report. I stated I was not aware of a fall, that I did not have information about a fall. (I was told by LPN #1) it was a near miss)...In the hallway, almost to the lobby I had a conversation with this female and her husband (named). They both stated that resident (named) was in her right mind and she knows what she is talking about. They stated that resident (named) was left alone in the bathroom, she tried to wipe herself and fell off the toilet. They also said that resident (named) roommate had to call for help, using her own call bell...They kept saying, "She should never have been left in the bathroom alone."...Meanwhile resident (named) was sitting in the lobby...and stated that her leg was hurting. S he said, "My leg feels like it's broke."...Several safety measures were taken after this incident. A sign was placed by me, in the bathroom, stating do not leave resident (named) alone in the bathroom. A chair alarm was placed in her wheelchair. I instructed all staff on SW not to leave her in the bathroom alone and ask them to be sure to tell others during huddle...(sic)." On 5/17/12 at approximately 2:45 p.m., this surveyor and another surveyor on the team went to the room where Resident #22 had resided to interview the resident's roommate and to assess the bathroom. Resident #22's former roommate (who was listed in the survey sample as Resident #7) was interviewed regarding Resident #22 falling in the bathroom on 7/10/11. Resident #7 was assessed on her most recent annual MDS with an ARD of 4/12/12 as a 14 for cognitive skills (no memory impairments and independent in decision-making skills). Resident #7 stated, "I remember her falling and I remember ringing the call bell for help. I think somebody came in and helped her, I don't remember." After the interview with Resident #7 and obtaining permission, the bathroom where the incident occurred was observed. The following observation of the bathroom was made: At the entrance of the bathroom were two clothes hampers, approximately 2-3 feet and in front of the hamper was the commode, when seated on the commode, a grab bar was noted to the right of the commode and the sink was to the left and less than one foot away from the commode. On 5/17/12 at approximately 2:50 p.m., the licensed practical nurse (LPN #1), who was on duty when Resident #22 complained of falling in the bathroom, was interviewed regarding the incident. LPN #1 stated, "She was taken to the bathroom by the CNA working with her. The CNA came out and yelled for help. We went in there and got her (the resident) back up. I went in the room with nurse (named), who was the supervisor, we put the resident back to bed and did an assessment." LPN #1 was made aware that the interview given was not the same as the written statement. LPN reviewed the written statement and stated, "What I wrote in the statement is what happened." When LPN #1 was asked if he went into the room to assist the resident, the CNA and the supervisor, LPN #1 stated, "No." LPN #1 was interviewed regarding the incident and if the physician was made aware. LPN #1 stated, "I did not call the doctor." When interviewed regarding the facility's protocol for physician notification, LPN #1 stated, "After the resident is assessed and the family is notified, we notify the physician. Anytime someone touches the floor it's a fall and the doctor is notified." On 5/17/12 at approximately 3:15 p.m., the administrator #1, #2 and the director of nursing (DON) were made aware that the written statements and interviews from CNA #10 and LPN #1 were inconsistent. Administrator #2 stated, "I see that they are, but I do not have any doubt that CNA #10 is not telling the truth, she is one of the better CNA's and we have not have any complaints regarding her care." On 5/17/12 at approximately 3:34 p.m., the interim administrator #2 and the director of nursing (DON) was interviewed regarding the documentation that the resident's physician was made aware of the fall from the toilet on 7/10/11. The administrator #2 stated that the facility documented the physician notification on the SBAR form (a form used by the facility to track incidents and the findings are reported to the physician) and "I will check and see if one was done." On 5/17/12 at approximately 4:10 p.m., administrator #2 was interviewed regarding the physician notification on the SBAR form; administrator #2 stated, "I don't know if we notified the doctor but we are still looking." No further information was received during the course of the survey, that the physician was made aware of the fall resulting in a left hip fracture on 7/10/11. On 5/17/12 at approximately 4:52 p.m., the DON stated, "Do you want to hear the story about the resident being found with toilet paper in her hand?" This surveyor agreed to hear the story and CNA #10 was called back to the conference room by the DON. CNA # 10 stated, "She did that all the time (sat on the commode with toilet paper in her hand). That was a norm for her. She would try to wipe herself." CNA #10 demonstrated how the resident wiped using a front to back motion with her hand and slightly leaning to the side. CNA #10 stated, "She wiped from front to back and she would lean to the side. She did not lean forward or else she would have fallen on her face." CNA #10 was asked if the resident had a tendency to lean to her left side when toileted. CNA #10 stated, "Yes, she would lean and sometimes she could help herself up and sometimes she couldn't and I had to help her."

Based on observations, staff interview and clinical record review, the facility staff failed for three of 14 residents in the survey sample to ensure safety alarms were properly connected and functioning for fall interventions; Residents #101, #102 and #114. The findings include: 1. Resident #102 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set with an Assessment Reference Date of 6/23/12 was a admission assessment. The resident's cognitive status was assessed as a 15 per the MDS coordinator. On 7/3/12 at approximately 8:00 a.m., Resident #102 was observed coming out of his room, self propelling in a wheelchair. As this surveyor was walking behind Resident #102, it was observed that the resident had a chair alarm attached to the right side of the wheelchair and a cord, similar to a telephone cord, was dangling in the back of the wheelchair and not connected to the alarm box. This surveyor followed Resident #102 from his room, past the nursing station and approximately 3 feet from the dining room when the resident stopped to receive a hug from the physical therapy assistant (PTA). On 7/3/12 at approximately 8:08 a.m., the PTA was interviewed regarding the resident's chair alarm. The PTA stated, "He tries to get up." The PTA was made aware of the cord dangling from the back of the wheelchair and not connected to the alarm box. The PTA stated, "I noticed this morning it (the cord to the box) was broken." The PTA lifted the cord, pointed to the end and stated, "See the hook is broken it will not stay in." The PTA was asked about who got the resident in the chair. The PTA stated, "CNA (certified nursing assistant) named and called the CNA to the come over to the resident's chair. As CNA #3 came closer to Resident #102's wheelchair she stated, "His alarm is not hooked." The PTA inserted the end of the cord into the bottom of the box of the alarm and stated, "I don't know how long it's going to stay." The PTA was asked if anyone was made aware that the cord was broken, the PTA stated, "I have not had time to let anyone know." The PTA pushed resident #102 into the dining room and up to a table near a window towards the back of the dining room and proceeded to help pass breakfast trays. On 7/3/12 at approximately 8:10 a.m., this surveyor entered the dining room and observed several residents with alarms attached to the back of their wheelchairs and a green light was flashing under the "In use" label. This surveyor went over to Resident #102's wheelchair and observed that the alarm was not flashing green under the "In use" label. The PTA was called over to the resident's chair and interviewed regarding the functioning of the resident's alarm. The PTA lifted the alarm box, looked underneath and stated, "It's not turned on," and slid the tab to the right side of the box, turning the alarm on, at this time the alarm flashed green under the "in use" label. On 7/3/12 at approximately 8:16 a.m., CNA #3 was interviewed regarding the resident's alarm observed not being turned on. CNA #3 stated, "I thought it was a push button." At this time the PTA walked up and stated, "Not the one on his chair, in his room, is but not that (the one on the wheelchair) one." The CNA stated, "Registered nurse named (RN #1) is going upstairs to see if she can find another pad." On 7/3/12 at approximately 8:26 a.m.. the care coordinator (RN #1) was interviewed regarding Resident #102's alarm not functioning properly. RN #1 stated, "Yeah, I heard PTA named say to you that she noticed the alarm was broke this morning but did not tell anyone." RN #1 was also made aware that the resident's alarm was not turned on. RN #1 stated, "It defeats the purpose of the alarm if it is not turned on." On 7/3/12 at approximately 10:09 a.m., RN #1 was interviewed regarding a physician's orders [REDACTED]. RN #1 stated, "There isn't an order for [REDACTED]." On 7/3/12 at approximately 10:10 a.m., Resident #102's care plan was also reviewed to include: Under the heading of "At Risk for Falling" interventions that included "Bed/Chair Alarm." 2. Resident #114 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) was a significant change assessment. The resident was assessed as having short and long-term memory impairments and severely impaired in decision-making skills. On 7/3/12 at approximately 11:00 a.m., Resident #114 was observed sitting in a wheelchair, parked with the back to the nursing station. The resident was observed with a baby doll in her right hand and rocking back and forth attempting to get up, using her left hand. Resident #114 was observed several times attempting to get up from the wheelchair by sliding close to the edge of the chair and by rocking back and forth. This surveyor observed an alarm attached to the left side of the resident's wheelchair. This surveyor observed that the alarm was not flashing a green light under the "In use" label. This surveyor got up from the nursing station and walked over to the resident's wheelchair and observed that the cord to the alarm was not connected to the base of the alarm box. On 7/3/12 at approximately 11:15 a.m., the care coordinator, who was a licensed practical nurse (LPN) #2, and the medication nurse, LPN #5 were called over the the resident's wheelchair and interviewed regarding the resident's alarm. LPN #5 stated, "She (the resident) attempts to stand up." LPN #2 and LPN #5 were asked to assist the resident to a standing position. Resident #114 was slightly lifted off the alarm pad in the chair; the alarm did not sound. LPN #2 looked at the alarm box and stated, "The cord is not plugged in to the box." LPN #2 inserted the cord into the box, the alarm beeped and the green light flashed indicating that the alarm was in use. On 7/3/12 at approximately 11:20 a.m., CNA #2 (certified nursing assistant) who assisted the resident in the wheelchair was interviewed regarding the resident's alarm observed not on. CNA #2 stated, "The alarm was on when I took her (the resident) to the bathroom. I must have unplugged it, but not on purpose. It's my fault I should have double checked it to make sure it was working." CNA #2 was asked about the time the resident was taken to the bathroom. CNA #2 stated, "I took her (the resident) at 9:00 (a.m.) and brought her back at 10:00 (a.m.)." Resident #114's alarm was not connected for approximately one hour and fifteen minutes based on the time that the CNA stated the resident was brought back from the bathroom. On 7/3/12 at approximately 11:22 a.m., LPN #2 was interviewed regarding how the CNA's were made aware of what interventions the resident were supposed to have. LPN #2 stated that the CNA's looked at the Resident's "411 sheet (a form located in a binder at the nurse ' s station with information on each residents)." A copy of Resident #114's 411 sheet was reviewed to include: Under "Fall Risk," the interventions were "bed and chair alarms." On 7/3/12 at approximately 11:23 a.m., Resident #114's care was reviewed to include under "Safety"..."Has hx of falls." Under interventions the following was included: "Bed & chair alarms." On 7/3/12 at approximately 2:45 p.m., administrator #1 and administrator #2 and the director of nursing were made aware of the above findings. 3. Resident #101 was admitted to the facility on [DATE] with a readmission on 6/20/12, with [DIAGNOSES REDACTED]. Resident #101's most recent MDS (minimum data set) was a quarterly with an assessment reference date of 5/21/12. Resident #101 was assessed as being cognitively intact with a score of 14 out of 15. On 7/3/12 at 8:10 a.m. during initial tour of the facility, Resident #101 was observed in a common area across from the nurses station. At this time a chair alarm was observed attached to Resident #101's wheel chair. Upon closer observation the chair alarm was not blinking to indicate the alarm was turned on. At this time licensed practical nurse (LPN #1) was asked to observe the chair alarm. LPN #1 looked at the alarm and verbalized that the alarm was not turned on. LPN #1 then turned the alarm on and checked to make sure it was working by asking Resident #101 to raise up from the chair. On 7/3/12 at 8:15 a.m. Resident #101's certified nursing assistant (CNA #1) was interviewed concerning the above finding. CNA #1 verbalized that she had gotten Resident #101 up earlier and had forgotten to turn the alarm on. Resident 101's clinical record was then reviewed and revealed a "Fall Risk Assessment" dated 6/5/12 that indicated Resident #101 was a high risk for falls with a total score of 60 (any greater than 51 was considered high risk). Resident #101's care plan was also reviewed and revealed, under the heading of "At Risk for Falling" interventions that included "Bed/Chair Alarm." Further review of Resident #101's nurses notes, indicated that Resident #101 was found on the floor on 5/3/12 and lowered to the floor on 6/30/12. On 7/3/12 at 11:20 a.m. LPN #1 was again interviewed concerning how CNA's received information in order to ensure that residents needed alarms. LPN #1 verbalized that an information sheet called a "411 sheet" was updated and put into a CNA book kept at the nurses station. LPN #1 showed this surveyor the CNA book and revealed Resident #101 was to have a bed and chair alarm. On 7/3/12 during an end of day facility staff/surveyor meeting the above information was presented to the administrator and director of nursing. No other information was provided concerning the above finding prior to exit conference on 7/3/12.

Based on observation, staff interview, resident interview, family interview, and clinical record review, the facility staff failed to provide appropriate treatment and services to ensure the highest practicable level of mental and psychosocial well-being for one of 23 residents in the survey sample, Resident #10. Resident #10 made repeated suicidal statements in addition to ongoing aggression with verbal/physical abuse of other residents and staff without any ongoing assessment/treatment by a mental health professional. The findings include: Resident #10 was originally admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/1/11 was a quarterly assessment. The resident was assessed with [REDACTED]. Further review of the MDS assessment was reviewed to include the following: Section D200, Resident Mood Interview, not completed. Section D0350, Safety Notification not completed. Information for the above two sections are obtained via interview with the resident. Section D500 J. Being short-tempered, easily annoyed, symptom presence and frequency was coded as "0." Section E0200, Behavior Symptom-Presence and Frequency; B. verbal behavioral symptoms directed towards others (e.g. threatening others, screaming at others, cursing others.) C. other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The above sections were coded as "1," behavior of this type occurred 1 to 3 days. Information for the above sections D and E are obtained via staff assessment and observations. The following individuals at the facility were interviewed regarding the above findings: the resident, the resident's spouse, the administrator, the director of nursing (DON), a licensed practical nurse (LPN#3), and the physician that was currently providing care to the resident. On 4/12/11 at approximately 8:45 a.m., Resident #10's clinical record was reviewed to include the following nursing notes: ? "12/28/10, 2100 (9:00 p.m.) Resident alert with confusion...refused to eat wanted to go to her room. Put her at @ nurses station started using foul language raising her voice took her to her room called nurse all kinds of names cussing. Stated, she as soon be dead to get away her life "If I had a knife to cut my wrists and bleed to death. Took her out in hallway and let her propel in w/c (wheelchair) in hallway for 30 min then she was put to bed finally went to sleep (sic)." ? "12/29/10 10:00 a.m. ...Resident not cooperating in PT (physical therapy)- told husband to, "just shoot me in the ass and be down with it." Husband asked me to give her something to calm her down that he could "take this much more...(sic)." ? "12/29/10 2030 (8:30 p.m.) Telling roommate to shut up..." ? "1/17/11 1530 (3:30 p.m.) ...Observed resident throwing banana to window- want a gun to kill her husband- thought her husband was cheating on her..." ? "1/28/11 2100 (9:00 p.m.) ...verbally abusive to staff-resident want her (explicit language) to pick her up -"if she had a gun would kill entire staff-she stated she would blow all of our (explicit language) brains out-resident was observed striking arm on side rail of bed causing a skin tear to Rt (right) forearm-area 2.5 x [MEDICATION NAME] and prn [MEDICATION NAME] given-resident @nurse's station(sic)." ? "2/25/11 1845 (6:45 p.m.) Resident very unpleasant this evening verbally abusive to staff and other residents-want to get to the door so she could get the (explicit language) out of here-wanted to sue writer and staff want to cut writers (explicit language) guts out-if other residents in here way would push the into walls-constantly in and out of other residents rooms-pulling on there covers and call bell. CNA provide 1:1 taking resident to fireplace-gave snacks c (with) no change-..."want to go home damn it" she cont. (continue) to yell resident at 2000 (8:00 p.m.) requested to go to bed resident was transferred bed in low position...became verbally abusive c (with) roommate-resident stated she paid all the bills so cut off the lights and that damn TV roommate very complainant turned off lite and TV...(sic)." ? "3/17/11 1900 (7:00 p.m.) Resident is aggitated and cursing at other residents and staff. Resident redirected several times(sic)." ? "3/23/11 1715 (5:15 p.m.) Resident aggitation increased. Ran into and physically fought with another resident. Cussed at nurse and CNA. Hit nurse with WC (wheelchair) and smacked medications off the med cart. Increase of [MEDICATION NAME] did not seem to help residents aggitation tonight...(sic)." ? "3/25/11 1730 (5:30 p.m.) Resident aggitation increased. Struck another resident tonight and kicked another resident for not getting "out of her (explicit language) way." Redirected resident multiple times. Had to move other residents to safety...(sic)." ? "3/28/11 1945 (7:45 p.m.) Resident slightly less aggitated tonight. Verbally abusive to other residents and staff. Observed by writer rolling a little in wc (wheelchair) then throwing her left leg into cafe wall, repeatedly...(sic)." ? 3/28/11 2000 (8:00 p.m.) Resident less aggitated tonight. Verbally abusive to staff. Not as abusive to other residents...(sic)." ? "3/30/11 1615 (4:15 p.m.) Resident c (with) new order to D/C (discontinue) prn and [MEDICATION NAME] BID (two times a day). New order [MEDICATION NAME] 3 times daily for 1 week then ask for reorder...(sic)." ? "4/3/11 11:45 a.m. Resident very agitated propelling self in w/c (wheelchair) in H/W (hallway) she went by another resident and pulled her hair she was told not to do that any more (sic)." ? "4/7/11 1430 (2:30 p.m.) Resident with new order for [MEDICATION NAME] 100 mg (milligrams) po (by mouth) TID (three times a day)." ? "4/11/11 2000 (8:00 p.m.) Verbally abusive to staff and residents... Further review of the Resident #10's clinical record revealed a Psychological Evaluation that was dated 12/22/10 to include the following: ? "Chief Complaint: acting out behaviors-hitting, biting, throws objects ? History of Present Illness: 3 weeks ? severity: moderate, duration: 3 weeks, timing: rehab, modifying factors: moderate dementia ? Medications: [MEDICATION NAME] ? History: No known psyc (psychiatric) history... ? Psychiatric/Mental Status: Affect: flat ? Orientation: person, Abstract reasoning: impaired, Judgment: impaired, Fund of Knowledge: impaired, Memory: STM impaired. ? Findings/ICD [DIAGNOSES REDACTED]. ? Plan/Recommendation: She may be a candidate for counseling re: adjustment issues if LTC (long-term care) is the plan. Family may benefit from end of care counseling re: eating issues vs (verses) tube feeding etc." There were no other psychological evaluations or consults ordered for Resident #10 after 12/22/10. On 4/12/11 on the above date and time the March and April 2011 Physician order [REDACTED]. ? "1/19/11 [MEDICATION NAME] 25 mg (milligrams) po (by mouth) qhs (at bedtime or hour of sleep) prn (as needed)." ? "2/5/11 [MEDICATION NAME] 25 mg (milligrams) po (by mouth) bid (twice daily)." ? "3/23/11 D/C (discontinue) [MEDICATION NAME] F/C 25 mg (milligrams) po (by mouth) at bedtime prn (as needed/necessary)." ? "3/30/11 D/C [MEDICATION NAME] 25 mg po bid (twice a day) and daily prn order. [MEDICATION NAME] F/C 25 mg po three times a daily for 1 week." ? "4/7/11 [MEDICATION NAME] 100 mg po TID (three times a day)." 1a. "[MEDICATION NAME]- (1).treatment of [REDACTED]. Short-term treatment of [REDACTED]. treatment of [REDACTED]." Special Concerns: (2). Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major [MEDICAL CONDITION] and other psychiatric disorders...Closely observe clients who are started on therapy for clinical worsening, suicidality, or unusual changes in behavior..." b. "[MEDICATION NAME]-In adults, management of post-herpetic neuralgia or pain in the area affected by the [MEDICAL CONDITION] after treating the disease. Investigational: Neuropathic pain, [MEDICAL CONDITION] disorder...Side effects: CNS (central nervous system)...anxiety, hostility, hallucinations, agitation, suicidal tendencies, psychoses..." On 4/12/11 on the above date and time a Care Plan (CP) updated on 12/30/10 was reviewed to include the following: ? "Problem: I become very upset easily when I want something, when I feel ignored, or at any particular time. I may cuss, throw things, threaten to hurt myself, want to be dead at times. ? "Goal: I will have less than 3 episodes of verbal and/or physical aggression per week over the next review." ? "Approach: Allow to vent feelings, SW (social worker) involvement, remove objects from reach, remove from situation as able, MH (mental health) consult, and Suicide Assessment and intervention." On 4/12/11 at 9:59 a.m., LPN #3, the charge nurse on the Cedar Ridge unit was interviewed regarding the documentation in the nursing notes and the psychological consult. LPN #3 stated that the resident does become "agitated" at times and have to be placed at the nurse's station. When asked if the resident had any other evaluations by the psychologist other than 12/22/10, LPN #3 stated, "Psychologist named came to see her but she has not been back. You have to request her to come if someone needs to be seen." LPN #3 was asked if Resident #10's social worker (SW) notes could be reviewed, according to the SW tab in the clinical record, the notes were available in the computer. On the above date and time LPN #3 retrieved Resident #10's SW's notes in the computer. The SW notes were reviewed to include the following: ? "3/9/11 10:43 a.m. Res. (resident) easily upset when husband leaves facility was recently started on [MEDICATION NAME] which appears to be helping with this behavior...SW will monitor moods and behaviors as needed." On 4/12/11 at approximately 10:10 a.m., the SW was interviewed regarding Resident #10's behaviors. The SW stated, "I am new. The only behaviors I was aware of were the ones she haves when her husband leaves." The SW went on to say that the resident was on [MEDICATION NAME] for this behavior and "it appeared to be helping." When interviewed and asked if the resident had been assessed to see if the medication was effective, the SW stated, "I am not sure, but I haven't." On 4/12/11 at approximately 10:19 a.m., the DON was interviewed regarding the documentation in the nurse's notes related to Resident #10's verbal and physical behaviors. The DON stated that when the resident becomes agitated, "we try to move her from the situation to decrease the distractions, sometimes it works and sometimes it doesn't; the family does not want to increase her meds." The DON further stated, "We try to manage her medication piece as well as working with her (Resident #10)." The DON was made aware of the documentation in the clinical record of the resident making statements of wanting to die, wanting to kill staff and spouse, wanting to cut her wrist, and being verbally and physically abusive to residents and staff. When interviewed on the above date and time and asked of her expectations regarding the role of the nursing staff in a situation of this nature, the DON stated, "I would expect to see a suicide assessment and the resident placed on every fifteen (15) minute checks." During the interview the DON was asked of the location of the suicide assessment and the 15 minute checks. The DON stated, "It should be in the clinical record but I do not see it. I have to look and see where it could be." The DON was asked if the resident had been re-evaluated for the above mentioned behaviors. The DON stated that she would have to look through the clinical record and see if there was an assessment performed. On 4/12/11 at approximately 4:33 p.m., during the end of the day meeting with the survey team, the administrator and the DON were made aware of the above findings. The administrator and the DON stated that the resident's family did not want Resident #10 sent out for an evaluation because they felt there was nothing that could be done for her due to her [DIAGNOSES REDACTED]." The administrator was asked if she thought Resident #10's condition was an "as needed" case. The administrator stated, "We have interventions in place, when she is agitated we place her at the nurse's station, we provide her with snacks, and we try to protect the residents by redirecting her (Resident #10's ) behaviors. The administrator and the DON further stated that the resident's behaviors were unpredictable and there were no specific triggers for the resident's behaviors. The administrator stated that the resident's physician was in the facility and she would get her to "take a look at her and see what she thinks." On 4/13/11 at approximately 8:15 a.m. during a morning meeting with the administrator and the DON, the administrator stated, Resident #10 was seen by the physician and a mental health consult was ordered and her medications were adjusted." On 4/13/11 at approximately 10:20 a.m., Resident #10 was observed sitting in a wheelchair at the nursing station approximately 4-6 feet from Resident #20, a resident in which she had a physical altercation with on 3/23/11. Resident #10 was observed at 10:22 a.m. and again at 10:35 a.m. without staff present and in view. Resident #10 was overheard by this surveyor stating, "this is nuts" as she wheeled in her wheelchair from the nursing station to the cafe area (adjacent from the nursing station) without difficulties. Resident #10's spouse was in to visit at approximately 10:45 a.m. Resident #10's was wheeled down to the lobby via her spouse. On 4/13/11 at approximately 11:50 a.m. Resident #10's spouse was interviewed. Resident #10's spouse was interviewed regarding the resident's recurrent thoughts of suicide and wishes to die and if he was aware; Resident #10's spouse stated, "Oh yeah, she is like that now. She was asking me if I knew of a way she could cut herself right here (pointing to his wrist) and 'make myself bleed to death.' Resident #10's spouse was asked if anyone talked to him or his son regarding a consult for Resident #10 to have a psychiatric evaluation. Resident #10's spouse stated, "The nurse called me this morning and said that the doctor had changed her medicines and wanted her (Resident #10) to be evaluated by someone at mental health." When asked if anyone had talked to him or his son regarding a mental health consult in the past Resident #10's spouse stated, "No, I can't recall. I know they have changed her medicines several times but it does not seem to be helping." Resident #10's spouse further stated, "I don't come as often as I did because I think my visits makes her act out. I just wish she was calmer." On 4/13/11 at approximately 3:15 p.m., Resident #10 was sitting at the nurse's station amongst other residents, she was asked if an interview could be conducted with her in her room for privacy, Resident #10 stated, "Sure, I don't have nothing but time." Resident #10 was taken to her room to interview her and in the presence of another surveyor. Resident #10 was interviewed regarding her spouse's visit to the facility and if she remembered the conversation she had with him regarding being unhappy and wanting to hurt herself. Resident #10 stated that she was unsure if her spouse was there but went on to say, "He knows I am unhappy but he said he was going to make me happy and I believe him. When asked if she talked to him regarding harming herself, Resident #10 stated, "I probably did but I say that all the time. When asked if she thought of harming herself often, Resident #10 stated, "It stays in the back of my mind all the time, mostly just talk but I don't think about it all the time. Resident #10 was asked if she ever thought of ways to harm herself she stated, "Oh good Lord no. I am too big of a coward for that. I just say that when I am mad at the kids. We all say things when we are upset. I am sure you have said things when you are mad." At this point the Resident #10 became agitated and the interview was ended. On 4/13/11 at approximately 3:30 p.m., LPN #3 was interviewed and asked if she was aware that Resident #10 was agitated during her spouse's visit and that she was asking for ways to cut her wrist. LPN #3 stated, "Yes I was aware that she was upset but he (Resident #10's spouse) did not say anything about her wanting to hurt herself; we brought her to the nurse's station after he left to watch her." On 4/13/11 at approximately 3:45 p.m., during the end of the day meeting with the survey team, the administrator and the DON were made aware of the above findings. The DON was interviewed and asked if the suicide assessment had been located. The DON stated, "Not yet, we are still looking." On 4/14/11 at approximately 8:30 a.m., during the morning meeting with the survey team, the administrator presented to this surveyor "Every 15 minutes Round Checks for Resident #10." The assessment was dated 12/31/10, two days after the resident made a statement regarding harming herself, through 1/1/11. There were no further 15 minutes checks forms presented during the time of the survey. The DON was interviewed and asked if the suicide assessment had been located the administrator stated, "The nurse's note cannot be found. The DON helped the nurse write the note and we know it was done but we cannot find it." The administrator further stated that the nursing staff did voice their concerns to dietary regarding the resident behaviors and plastic utensils were ordered as an intervention. A copy of the Dietary Assessment was presented to this surveyor. The Dietary Assessment note was reviewed to include the following: "1/3/11 15:48 Assessment Notes-nursing staff requesting plastic utensils as rsd (resident) throwing flatware at this time." On 4/14/11 at approximately 9:55 a.m., Resident #10's physician was interviewed regarding her behaviors and recurrent thoughts of suicide. The physician stated that Resident #10 was fairly new to her and she was asked to evaluate the resident regarding the above mentioned concerns. The physician stated she was informed that the resident's behaviors were increased midday around 2:00 p.m. and it was believed that the other medications the resident was taking were making her behaviors worse. The physician stated, "A person with [MEDICAL CONDITION], some of the medications given can make the symptoms worse but without a mental health consult and a [DIAGNOSES REDACTED]." The physician was interviewed regarding a resident repeatedly stating they wanted to die and her expectations. The physician stated that if it was a new resident and statement that she would send them to the hospital for further evaluation and assessment, if the resident was "familiar" to her she would keep a close watch on them unless she felt the threats were "heartfelt." The physician stated that she interviewed the resident on 4/12/11 and she was not exhibiting any behaviors but she was not sure of how much "she's connecting." The physician was made aware that the resident made repeated threats of suicide since 12/28/10, and that a mental health consult was performed on 12/22/10; without a further assessment documented in the clinical record since. The physician stated that she was given the impression that the resident was experiencing improvements with the changes in medication doses and that was the reason "I increased her [MEDICATION NAME] around midday." The physician further stated, "I agree with you. My expectation is, if someone said they wanted to kill themselves; I would send them out for help." The physician stated that "anybody with signs of depression or is acting out needs a mental health consult," and that Resident #10 should have had a mental health consult when her behaviors first started in December. 1(a)(b) George R. Spratto PhD, and Adrienne L. Woods MSN, ARNP, NP-C. "Nurse's Drug Handbook," 2009. Clifton, Park, New York; Delmar, Cengage Learning Ltd, 2009.