Every finding on record at Foothills Transitional Care and Rehabilitation

Based on facility policy review, medical record review, satellite imagery and measurements from Google Earth review, Historic Weather Data from the National Weather Service (NWS) review, Fire Department (FD) record review, Emergency Medical Services (EMS) records review, facility investigation review, hospital documentation reivew, and interviews the facility failed to prevent an elopement of 1 resident, (Resident #7) of 6 residents reviewed. The facility's failure resulted in Harm to Resident #7 when on the evening of 5/26/2024, Resident #7 exited the facility unbeknownst to staff, walked 0.25 miles away from the facility, down the street, fell over the curb into the yard of a private residence, and was found by an off duty law enforcement officer who was passing by. Resident #7 sustained a fractured Humerus (upper long bone of the arm) in the fall, required transportation by EMS to a local hospital for emergent treatment, then later required outpatient surgical treatment to repair the fracture. The facility was cited at F 689 at a Scope and Severity of G (Harm). The facility was cited as past non-compliance. Noncompliance began on 5/26/2024 and continued until 5/31/2024. Noncompliance ended on 6/1/2024. The facility is not required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Elopements and Wandering Residents, dated 5/26/2024, revealed, .The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering . Review of medical records revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Hypertension, Pneumonia, Intracranial Injury with Loss of Consciousness, Urinary Tract Infection, Dementia, Mood Disturbance, Psychotic Disturbance, Anxiety, Seizures, Difficulty Walking, and Muscle Wasting with Atrophy. Review of the care plan for Resident #7 dated 5/17/2024, revealed interventions in place for cognitive impairment and fall risk. Continued review revelaed no documentation the resident was at risk for elopement. Review of the Elopement and Wandering Evaluation dated 5/17/2024 at 6:44 PM (time of admission), revealed Resident #7 was a low risk for elopement. The assessment was revised on 5/17/2024 at 7:32 PM and revealed Resident #7 was changed to at risk for elopement. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Resident #7 used a rolling walker or wheelchair for ambulation and required moderate assistance of 1 person for activities of daily living (ADL). Review of the nursing notes dated 5/19/2024, revealed Resident #7 was placed in a room closer to the nursing station to address behaviors which included arising from bed unattended and pushing his bedside table around his room. Review of overhead satellite imagery and digital measurements taken from Google Earth, revealed the facility was situated atop a hilly terrain, in the rear of a large residential neighborhood, surrounded by homes and side streets on all sides. The road which led to the facility, was moderately sloped to the facility property line and campus entrance. Review of weather data from the National Weather Service (NWS) dated 5/26/2024 at 8:30 PM, revealed for the location of the incident, the temperature was 68 degrees Fahrenheit (F) with no rain. Review of the local Fire Department records dated 5/26/2024, revealed Resident #7 was located laying on the ground, in the yard of a private residence, near the edge of the street, approximately 0.25 miles from the facility near the base of the hillside around 30 meters (98.43 feet) from the intersection of the facility entrance road and an adjacent 2 lane secondary road. Continued review revealed First Responders were summoned by a law enforcement officer who found Resident #7 at approximately 8:24 PM and arrived on scene at 8:35 PM. Continued review revealed .responded to non-emergency to a fall call at the intersection of [named road] and [named road] .Arrived on scene .Found an off duty [Police] .officer standing with a male lying on the ground .Officer .advised he was driving by and saw the gentleman lying there and stopped to render aid .The gentleman seemed very unsure of his location [EMS service] arrived on scene and had primary patient care .The gentleman had a tote bag with him marked [Facility name] .Officer .contacted the facility to advise them of the gentleman's location and to let them know .[EMS] would be transporting to the hospital . Review of EMS records for Resident #7 dated 5/26/2024, revealed EMS arrived to the scene at 8:25 PM and an ambulance arrived at 8:33 PM. Resident #7 was transported to a local hospital at 8:48 PM. Continued review of the EMS record revealed .Dispatched to location for .male that had fallen .Upon arrival .[Resident #7] was found sitting on the ground, conscious, alert and disoriented . The resident was in care by .an off-duty law enforcement officer .[Resident #7] .was able to give his name and date of birth but was disoriented to location and recent events leading up to him being on the ground. He complained only of left arm pain .It was discovered by the officer he was a resident at [the facility] .Upon assessment of the left arm, deformity .was noted .[The facility] was notified by the officer of the situation and that .[Resident #7] . would be transferred to [hospital] .The left arm was stabilized with .splint .transferred to hospital Review of Hospital documentation for Resident #7 dated 5/26/2024, revealed .History of Present Illness .This is a [AGE] year-old male .who lost his balance and fell while walking on the road. EMS was called [Resident #7] with significant deformity to his left elbow and left arm .does have a history of dementia and is slightly confused but states he did not lose consciousness Denies striking his head .denies neck pain .denies any other injury .complaining of pain to left elbow as well as left mid humerus .symptoms moderate intensity . Continued review revealed X ray results as follows: .Findings .Angulated and distracted fracture deformity distal diaphyseal segment left humerus involves the distal component of the operative fixation .with a fixation plate and multiple screws mid diaphyseal segment . [broken bone in the lower part of the upper arm, where the fracture fragments are not only bent at an angle but also pulled apart from each other] distal diaphyseal segment [lower, cylindrical part of the humerus bone, just before it flares out to form the joint surfaces of the elbow] . Further review revealed .[Resident #7] .did receive X rays which showed a previous plating [surgical procedure that involves attaching a plate to the fractured humerus to stabilize it] of the midshaft humerus .Family states this was done [AGE] years ago .also noted was significantly angulated displaced fracture of the distal portion of the humerus .elbow joint appears intact with no signs of fracture to the elbow itself .Discussed case with [orthopedist] .[Resident #7] .was placed in .splint .given a prescription for hydrocodone [opioid medication for pain] and discharged back to his skilled nursing facility in stable condition .follow up with orthopedic surgery in 2 to 3 days .Clinical impression, Acute Fall, Acute left distal humerus fracture . Review of staffing data dated 5/26/2024, revealed there were 13 residents present on Resident #1's unit at the time of the elopement with a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA) assigned full time to the unit. Review of the facility investigation, witness statements, and Interdisciplinary Team Notes dated 5/26/2024 - 5/28/2024, revealed on 5/26/2024 Resident #7 was last seen on the clinical unit, in his room seated in his wheelchair around 7:45 PM prior to the elopement. Resident #7 had not exhibited wandering or exit seeking behaviors prior to the incident. Continued review of the investigation revealed the facility was advised of Resident #7's elopement around 8:40 PM by way of a telephone call from first responders at the scene. Resident #7 returned to the facility from the hospital on 5/27/2024 at 12:44 AM and was transferred to the facility's secure memory care unit. Review of the elopement risk assessment dated [DATE] at 2:42 AM, revealed Resident #7 was considered at high risk for an elopement. Review of the care plan for Resident #7 dated 5/27/2024, revealed additional interventions to monitor behaviors, the resident's injuries, and prevent elopement were added to the care plan. Review of Orthopedic Surgeon Notes and Operative Reports dated 5/30/2024 revealed Resident #7 underwent surgical repair of the fracture without complications. Resident #7 was admitted to the hospital post operatively for monitoring and returned to the facility on [DATE]. During an interview on 2/14/2024 at 1:29 PM, the Police Officer who found Resident #7 on 5/26/2024, stated he lived in the area near the facility. The Police Officer stated he was off duty, and was driving by when he observed Resident #7 lying on his side, face down in the grass of a private residence, with his feet dangling over the curb, and he stopped to render aid. The Police Officer stated Resident #7 was profoundly confused and stated he was walking to a store. The Police Officer stated he observed obvious deformity in Resident #7's left upper arm and elbow and immediately called 911. The Police Officer stated he obtained an air splint from his personal first aid kit, splinted Resident #7's arm and awaited arrival of EMS and the Fire Department. The Police Officer stated he identified Resident #7 as a resident of the facility by a tote bag with the facility name that was on the ground beside Resident #7. The Police Officer stated Resident #7 could only give his name and date of birth. The Police Officer stated he telephoned the facility, advised the staff of the situation, and confirmed Resident #7 was a resident of the facility. The Police Officer stated the facility was not aware of the elopement until his notification. The Police Officer stated he advised the facility Resident #7 was injured and would be transported to the hospital by EMS. The Police Officer stated Resident #7 was dressed in blue jeans, a t-shirt, socks, and tennis shoes, During an interview on 2/18/2025 at 1:30 PM, the Director of Nursing (DON) stated the facility investigation determined at the time of the elopement Resident #7 exited the facility with visitors who did not realize he was a resident. The DON stated at the time of the incident, multiple family members of another resident had entered and left the facility in groups several times per hour throughout the day and evening of 5/26/2024. The DON stated at the time of the elopement a digital keypad was located at the front door and the entry code was posted in view above the door itself, in order to allow visitors to access the front lobby independently. The DON stated Resident #7 was not seen wandering about the facility or in the lobby prior to the incident and was carrying a tote bag given to visitors. The DON stated the facility investigation concluded it was likely a visitor mistook Resident #7 for another visitor and permitted him outdoors via the main entrance door. The DON confirmed the facility failed to prevent elopement of Resident #7 and he was harmed as a consequence. In Response to the incident, the facility implemented corrective actions which were validated onsite by the surveyor between 2/12/2025 and 2/18/2025. 1. On 5/26/2024 around 8:40 PM the facility launched an investigation which included interviews of all staff present in the facility prior to holding an ad hoc Quality Assurance Meeting between the DON, Administrator, and Nursing Supervisors. 2. On 5/26/2024 Resident #7's family along with the medical director were notified of the situation when the facility became aware of the elopement. 3. On 5/26/2024 The facility checked all entry and exit doors to ensure they were operational with no negative findings. The facility implemented door checks every 8 hours with logs on each unit. The door codes posted near the front door were removed. The door code at the front door was changed to a new code. Ad Hoc Quality Assurance review of the incident was initiated at 11:20 PM and included the medical director and corporate consultants. 4. On 5/26-27/2024 immediately upon return to the facility from the hospital, Resident #7 was transferred to a locked secure unit inside the facility for continued care. 5. ON 5/27/2024 staff education began related to the incident which included education that no visitors were permitted door codes, and all visitors were to be escorted in and out via the front door only. Additional education on the facility elopement policies and procedures were provided with attestations required by staff. Staff education was completed by 5/31/2024 with all remaining staff off duty at the time given notice education would be required prior to the next shift. 6. ON 5/27/2024 through 5/28/2024 the facility conducted elopement risk assessments on all residents, and identified increased risk for one elder, whose care plan was adjusted with new interventions and teaching to all staff on those (Resident #15). The facility held additional Quality Assurance (QA) Meetings related to the incident on 5/28/2024 and discussed facility conclusions of its investigation and root cause analysis of the incident, measures being implemented in response to findings, and added the incident to the QA agenda for monthly review to supplement weekly reviews to be performed by the DON, Administrator and ADON (assistant director of nursing). QA oversight of the incident response was monitored by the facility administrator, medical director and DON. The door codes on all doors at the facility were changed 5/28/2024. 7. ON 5/27/2024 Resident #7 was evaluated by the physician and Interdisciplinary team which included mental health services to address his changes in condition. 8. The facility began elopement drills on 5/29/2024 on every shift conducted 5 times weekly for 4 weeks. Then reduced at intervals to 3 times weekly for 4 weeks, then once weekly for 4 weeks. The drills were documented with no negative findings. Random elopement drills continued at the time of the facility investigation and were observed on the afternoon of 2/18/2025 during the onsite survey with no negative findings. Staff located a simulated missing resident in less than 3 minutes when the missing resident code (code pink) was called overhead. The test was initiated by the DON with assistance of a resident who served as the subject of the search at the request of the surveyor with no advance notice to other facility leadership or staff members before the drill began. 9. On 5/30/2024 the administrator completed notifications to all families and responsible parties via phone messages (168 total calls) and a voice mail left on the facility answering machine which advised callers of the new policy related to changed door codes which would no longer be provided them and safe entry and exit to the building via the front lobby entrance only. The facility placed a placard on the front door on both sides, which cautioned visitors to not allow others to follow them out, along with a phone number to call for entry after hours or if the lobby reception desk was unmanned. 10. Additional staff education on the incident and review of all prior education given and all staff attestations were logged into the facility investigation documents contained in a large binder on 5/30/2024. This documentation was preserved for State Agency (SA) review by the DON and presented as requested on 2/10/2024 after the entrance conference. The facility documentation was reviewed throughout the survey with no additions, deletions, or evidence of changes found in it at anytime during the survey as it was reviewed. (the binder was returned to the facility at the conclusion of each survey day 2/10/2025 -2/18/2025) and final copies obtained at conclusion of the survey on 2/18/2025 showed no alterations evident. 11. Monthly QA of the incident, elopement risks for residents, and effectiveness of the interventions continued throughout 2024 and January 2025 with no recurrent elopements or similar incidents. The surveyor validated the corrective actions via observations of the entry and exit procedures throughout the survey which were in place as reported. All door alarms were tested and were functional. 5 families were interviewed and reported they did not have access to door codes and had to be let in and out of the facility by staff. The surveyor was not provided door codes to enter the facility either. In total 10 staff interviews conducted on both shifts on all units which included day and night shift personnel showed all staff were knowledgeable of the elopement policy, facility safeguards to prevent elopement and actions to take to initiate a code pink drill, and steps to take during the drill in their assigned areas. The surveyor executed an unannounced nighttime entry to the facility on the evening of 2/13/2025 at 11:00 PM and remained onsite on 2/14/2024 until 2:30 AM with no breaches in the facility security measures observed. All signage was in place on the front entrance as reported and the phone number used to access the facility after hours was effective. A code pink drill was initiated by the DON at directive of the surveyor on the afternoon of 2/18/2025 with no negative findings. Resident #7 was observed throughout the survey on the secure unit. Resident #7 had fully recovered from his injuries but had no recall of the incident. Resident #7 was observed to be free of exit-seeking on the secure unit and appeared well adjusted to the environment. The surveyor validated all logs of staff training by review of the facility record of it and selected staff for interview from the logs observed. Additionally, the surveyor selected employees hired after the incident for interviews, which showed new hires had been trained on the facility elopement prevention policy and safeguards on hire. The Surveyor also reviewed QA sign in sheets for the period June 2024 to January 2025 and verified monthly QA of the incident remained ongoing at the time of the investigation. Medical record review for Resident #7 showed no recurrent serious behaviors or elopement attempts after the incident and the resident had successfully completed rehabilitation with occupational, physical and speech therapy. Review of facility incident logs showed no similar incidents in the prior year. The incident was appropriately documented in the incident logs and clinical records. The facility report of the incident to required authorities was completed timely in compliance with state and federal law.

Based on facility policy review, observation, and interview the facility failed to maintain a clean and sanitary Kitchen which had the potential to affect 105 of 105 residents of the facility. The findings include: Review of the facility's undated policy titled, Food Safety and Sanitation Policy, revealed .The food and nutrition services department will follow regulations as outlined by other official health agencies .with jurisdiction over the facility .Stored food is handled to prevent contamination and growth of pathogenic organisms .All time, temperature control for safety .foods including leftovers should be labeled, covered and dated when stored .when a food package is opened, the food item should be marked to indicate the open date .This date is used to determine when to discard food . During an observation in the kitchen and interview with the Dietary Manager (DM) on 2/12/2025 at 2:45 PM, during the evening meal preparation revealed the following: The range top was blackened with scattered food particles and residue beneath the burner eyes. The Deep Fryer revealed the appliance was coated with a thin layer of oil, and food debris on the upper deck. The baskets also contained cooked food particles. The deep fryer oil was heavily stained dark brown with floating food particles. The DM stated the device was last cleaned and the oil changed approximately 5 days ago, was supposed to be cleaned after use, and the oil changed once weekly on Fridays. Continued interview revealed the deep fryer cooking was supposed to be changed after fried fish was prepared. The DM confirmed the device was last used to cook fish and the oil was not changed. The 3-compartment sink revealed compartments #1 and #2 had clogged drains. Dirty dish water was pooled in both compartments. The sink had leaked from the clogged floor drain insertion site, flowed into the floor and had pooled in the corner behind and adjacent to the sink where 2 dark discolored grill grates were leaned against the kitchen wall and in contact with the pooled water. The pooled water in the floor was black in appearance and grease floating atop the water which was adjacent to the food preparation area. The DM reported the sink repeatedly had clogged floor drains which had been an ongoing issue for over 3 months. The steam table revealed mashed potatoes and pureed beans leftover from the lunch meal which was stored in tins covered with aluminum foil. The mashed potato temperature measured 136.9 degrees Fahrenheit (F) (safe temp range is 140 degrees). The DM stated the food items had not been removed after lunch service was served. The walk- in refrigerator revealed an aluminum pan covered with foil which contained 5 cooked hamburger patties dated . 1/10 use by 1/13 . [1 month past the expiration date] The DM state the foods were prepared 2 days prior and had been misdated by staff. Continued observations revealed a 32-ounce (oz) container of egg mix open to air, 1/2 full, without a label or open date on the opened container and a 44 oz container of whipped cream with no label of the opened or expiration dates. The DM confirmed the food items were improperly stored and labeled and were available for use. The dish washing area revealed the drain line from the appliance was misaligned with the floor drain and wastewater from the dish washer failed to enter the drain at the end of each cycle which resulted in staff having to stand in the pooled water the dish washer was loaded and unloaded. The DM and kitchen staff who were present during the observation stated the issue had been present as long as they could remember. During interview on 2/12/2025 at 3:45 PM, the DM stated she had made multiple budget requests to the Administrator for needed repairs in the kitchen to maintain compliance with State and Federal Standards for food safety and quality. The DM stated the concerns were discussed with the Administrator 10/2024, and he had informed her the supplemental budget requests couldn't be approved at that time and stated to the DM .I'll take the tag [referring to a cited deficiency by the state agency . During interview on 2/18/2025 at 11:20 AM the Administrator confirmed the facility failed to maintain sanitary conditions and working equipment in the kitchen.

Based on review of resident council minutes and interviews, the facility failed to resolve resident concerns related to food quality for 5 consecutive months from 6/2024 through 11/2024 and were not corrected until 12/2024, 6 months after the initial concerns were lodged during the resident council meetings. The findings include: Review of Resident Council Minutes from 6/2024 revealed .Old Business .Food New Business .Food issues .Dietary .oatmeal needs to be in a bowl .fried potatoes need to be cooked and not hard .want heavier meal at supper time (6 to 2 vote) wanting bigger portions .wanting snacks available .have butter .syrup served with pancakes .hamburger buns .cold food and cold coffee, cold plates, cold eggs, wants snacks around 3:00 PM . Review of Resident Council Minutes for 7/2024 revealed .Dietary .Cold food .not having salad items, sugar for sweet tea, no hamburger buns for hamburgers .wanting whole milk .supply issue . Review of Resident Council Minutes dated 8/2024, revealed .New Business .Residents getting dislikes on their trays .Running out of different condiments and food items .only getting whole milk part of the time .cold food and coffee on trays .want whole milk available all the time .unable to open up juice containers .wanting more fresh fruit .getting dislikes on trays .not getting the food that is posted on the menu .always running out of condiments .or not enough condiments on their trays for all meals . Review of resident council minutes dated 9/2024, revealed the meeting was canceled due to a facility wide Corona Virus, 2019 (COVID-19) outbreak. Review of Resident Council Minutes dated 10/2024, revealed .New Business .Food Issues: cold when receiving on floor and occasionally in dining room, amount of food given is too small @ [at] times .Coffee grounds in the coffee, no creamer or sugar, sweet tea is not sweet enough .Residents stating they are getting their dislike foods on their trays even with the ticket stating they don't like the certain food .coleslaw hot and steamy today (10/11/2024) for lunch .Bread is being put on plate with food which is making it soggy, hard biscuits .Last 2 days .got 1 piece of toast w/o [without] butter and 1 piece of sausage on plate .serving too much chicken .Food cold when served on floor and sometimes in dining room .want the form back that gives .other options they can have if they don't like the main meal . Review of the Resident Council Minutes dated 11/2024, revealed .Old business .cold food when receiving on the floor, amount of food given is small .Residents getting dislikes on trays, food still cold or luke warm .apple/orange juice tasting like its watered down .coffee grounds in the bottom of their cups .not getting all their condiments on their tray . Review of the Resident Council Minutes dated 12/2024, revealed .old business Dietary .getting dislikes on trays .food still cold .Dietary .Needs improvement .some food is good .some is not . During a telephone interview on 1/30/2025 at 1:35 PM, Resident #2's responsible party (RP) stated he had lodged multiple complaints with the Dietary Manager, Administrator, and Director of Nursing (DON) related to the poor food quality being served to Resident #2 and the complaints had gone without resolution during the resident's admission at the facility (8/13/2024-9/11/2024). The RP stated his mother was served runny oatmeal on a plate with other breakfast foods and stated his mother repeatedly voiced dislikes for eggs and was served eggs almost daily. The RP stated Resident #2 was frequently served meals which were refrigerator cold and unpalatable. The RP stated due to the continuous food concerns, Resident #2's inability to eat the unpalatable food, and the facility's failure to correct the dietary issue, he had to collaborate with other family members to bring meals to the facility to ensure his mother received some food and nutrition. The RP stated multiple relatives had also lodged complaints with the facility staff related to the poor food quality which went without resolution. During an observation and interview on 2/12/2025 at 12:15 PM, at Resident #2's residence, with Resident #2 and Resident #2's daughter revealed Resident #2 was alert and oriented in all spheres. Resident #2 produced a notebook and observation revealed documented dates, times, meals provided to the resident, the complaints lodged to the facility, and to whom the complaints were lodged by name and title. The complaints were voiced to the Administrator, the Dietary Manager (DM), a Regional Nurse, to floor staff (nursing staff), and during Resident Council meetings. Resident #2 described food quality at the facility as abysmal (extremely bad). Resident #2 stated throughout her stay at the facility, foods were unpalatable and gave examples of warm food items served cold, oatmeal served on plates instead bowls, dirty or missing utensils, cold foods served lukewarm, missing condiments with nearly every meal, and stated her dietary preferences were frequently ignored. Resident #2 stated she had requested alternatives, but the alternatives were equally unpalatable and gave an example of a chef salad provided to her on 8/18/2024. Observation of Resident #2's notebook revealed on 8/18/2024, the chef salad consisted of a small bowl of lettuce with cheese, no vegetables or fruit, and the lettuce was wilted and brown on the edges with no salad dressing provided. Resident #2 reported most days foods served her were unrecognizable and not what was listed on the menus and when questioned the staff, they stated mystery meat. Resident #2 stated she requested her family members bring fresh fruits, vegetables and whole meals daily to have nutrition. Resident #2 stated during the Resident Council meetings, several other residents and families also voiced concerns related to the poor food quality. Resident #2 stated she complained to the dietary staff about the lack of bowls for such things as oatmeal, she was told no bowls were available in the kitchen. Resident #2 reported on 1 occasion she asked for an alternate meal when cold and hard chicken was served, and she received an overcooked hamburger served between 2 slices of white bread for a bun, covered with a single piece of lettuce and no condiments. Resident #2 stated she and other residents complained again about the food and the kitchen staff told her the facility had run out of hamburger buns due to the number of alternate meals that had been requested that day. Resident #2's daughter was present in the home during the interview and added she had witnessed poor food quality during visits to the facility, 3 to 4 times weekly at various intervals and stated concerns she witnessed included cold foods served warm, warm foods served cold, stale bread items, and inadequate portions, which led her to coordinate delivery of meals with her siblings to the resident. Resident #2's daughter stated she had complained to facility's staff about the foods served and .nothing was done . During an interview on 2/12/2024 at 3:45 PM, the current DM (transferred from a sister facility) stated the former DM was terminated in the fall of 2024 after repeated efforts to counsel her on food quality at the facility and company expectations of the kitchen failed. The current DM stated the former DM had multiple meetings with the Administrator and Corporate staff in response to the multiple resident and family complaints about the poor food quality at the facility. The DM confirmed the reports of poor food quality and oatmeal served on plates had occurred repeatedly, as Resident #2 had stated. The DM confirmed the facility had received multiple complaints from other residents, family members and staff members on behalf of residents, related to poorly cooked foods, issues with food palatability and appearance, missing condiments, cold coffee, lack of certain food items, warm foods served cold, cold foods served warm as documented in the Resident Council Minutes. The DM reported low food quality had occurred frequently throughout the period 6/2024 to 11/2024 with the former DM and since 12/2024, the food quality had improved and no complaints had been lodge since 12/2024. During an interview on 2/18/2024 at 11:20 AM, the Administrator confirmed the facility had implemented a performance improvement plan and was ongoing related to the poor food quality in response to multiple complaints from the resident council meetings. The Administrator stated the former DM was replaced due to failures to resolve consistent complaints related to food quality as reported by the current DM, and as documented in the Resident Council Minutes.

Based on observations and interviews the facility failed to maintain all kitchen equipment in a safe and operable condition. The findings include: During observations in the dietary department and interview with the Dietary Manager (DM) on 2/12/2025 at 2:45 PM, during evening meal preparation, revealed the following: 1. The ice maker was inoperable. The DM stated the ice maker had been out of service for 2 months and not repaired. The DM stated the kitchen staff were required to use an ice maker at an adjacent nursing station to obtain ice for kitchen several times daily. 2. The Convection Oven #1 was inoperable. The DM stated the Convection Oven replacement parts were not unavailable and had been inoperable for 5 months. 3. The plate warming system revealed 1 of 3 plate warmers inoperable. The DM stated the facility administrator was made 10/2024 and had not been repaired or replaced. 4. The 3-compartment sink revealed compartments #1 and #2 had clogged drains. Dirty dish water was pooled in both compartments. The DM stated the sink repeatedly had clogged floor drains which had been an ongoing issue for over 3 months. Continued observation revealed water from the sink had leaked from the clogged floor drain insertion site, flowed into the floor and had pooled in the corner behind and adjacent to the sink. 2 dark and discolored grill grates were leaned against the kitchen wall and in contact with the pooled water which was dark in color and had grease floating atop the water. 5. The dish washing area revealed the drain line from the dish washer was misaligned with the floor drain. Waste water from the dish washer failed to enter the drain at the end of each cycle as water pressure decreased and pooled in the floor of the dish washing area where staff had to stand in it as they loaded and unloaded the machine. The DM and kitchen staff present said the observed misalignment had been present as long as they could remember. During interview on 2/12/2025 at 3:40 PM the Maintenance Director stated the problems with the 3- compartment sink drainage system had been recurrent for several months despite multiple prior repairs. The maintenance director stated he was not aware of the misaligned floor drain in the dish washer area and the ice maker could not be repaired due to lack of available replacement parts and confirmed the device had been inoperable for several months. During interview on 2/12/2025 at 3:45 PM, the DM reported she had assumed oversight of the facility kitchen in October 2024 as replacement for the prior DM who was let go due to multiple issues related to food quality and management of the kitchen. The DM reported she had made multiple budget requests to the Administrator for needed repairs in the kitchen which included replacement of inoperable equipment in the kitchen to maintain compliance with State and Federal Standards for food safety and quality. The DM reported when she discussed her concerns with the Administrator sometime in October 2024, he informed her the supplemental budget requests couldn't be approved at that time and stated to the DM .I'll take the tag .

Based on resident council minutes review, medical record review, and interview the facility failed to provide palatable, temperature appropriate, and sufficient meals for 1 resident (Resident #2) of 5 residents reviewed for dietary services. The facility was cited as Past Non-Compliance at F-804 at a Scope and Severity of D. Non-compliance began on 6/1/2024 and ended on 12/10/2024. The facility is not required to submit a Plan of Correction. The findings include: Review of Resident Council Minutes dated 7/2024, revealed .Dietary .Cold food .not having salad items, sugar for sweet tea, no hamburger buns for hamburgers .wanting whole milk .supply issue . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Lumbosacral Spondylosis, Diabetes, Chronic Kidney Disease, Acute Kidney Failure, Chronic Back Pain, Muscle Wasting Multiple Sites, and Depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 15 on the Brief Interview of Mental Status (BIMS) assessment which indicated Resident #2 was cognitively intact. Resident #2 was on a no added salt, regular texture diet, with thin liquids and bowls only for oatmeal. Resident #2 completed rehabilitation and discharged home on 9/11/2024. Review of Resident Council Minutes dated 8/2024, revealed .New Business .Residents getting dislikes on their trays .cold food and coffee on trays .wanting more fresh fruit .not getting the food that is posted on the menu board or not getting what they ordered . Continued review revealed Resident #2 was present during the resident council meeting. Review of resident council minutes dated 9/2024, revealed the meeting was canceled due to a facility wide Corona Virus 2019 ( COVID-19) outbreak. Review of Resident Council Minutes dated 10/2024, revealed .New Business .Food Issues: cold when receiving on floor and occasionally in dining room, amount of food given is too small @ [at] times .Coffee grounds in the coffee, no creamer or sugar, sweet tea is not sweet enough .Residents stating they are getting their dislike foods on their trays even with the ticket stating they don't like the certain food .coleslaw hot and steamy today (10/11/2024) for lunch .Bread is being put on plate with food which is making it soggy, hard biscuits .Last 2 days .got 1 piece of toast w/o [without] butter and 1 piece of sausage on plate .serving too much chicken .Food cold when served on floor and sometimes in dining room .want the form back that gives .other options they can have if they don't like the main meal . Review of the Resident Council Minutes dated 11/2024, revealed .Old business .cold food when receiving on the floor, amount of food given is small .Residents getting dislikes on trays, food still cold or luke warm .apple/orange juice tasting like its watered down .coffee grounds in the bottom of their cups .not getting all their condiments on their tray . Review of the Resident Council Minutes dated 12/2024, revealed .old business Dietary .getting dislikes on trays .food still cold .Dietary .Needs improvement .some food is good .some is not . During a telephone interview on 1/30/2025 at 1:35 PM, Resident #2's responsible party (RP) stated he had lodged multiple complaints with the facility's leadership which included the Dietary Manager, Administrator, and Director of Nursing (DON) related to the poor food quality being served to Resident #2 and the complaints had gone without resolution during the resident's admission at the facility. The RP stated his mother was served runny oatmeal on a plate with other breakfast foods and stated his mother repeatedly voiced dislikes for eggs and was served eggs almost daily. The RP stated Resident #2 was frequently served meals which were refrigerator cold and unpalatable. The RP stated due to the continuous food concerns, Resident #2's inability to eat the unpalatable food, and the facility's failure to correct the dietary issue, he had to collaborate with other family members to bring meals to the facility to ensure his mother received some food and nutrition. The RP stated multiple relatives had also lodged complaints with the facility staff related to the poor food quality which went without resolution. During an observation and interview on 2/12/2025 at 12:15 PM, at Resident #2's residence, with Resident #2 and Resident #2's daughter revealed Resident #2 was alert and oriented to person, place, and time. Resident #2 produced a notebook and observation revealed documented dates, times, meals provided to the resident, the complaints lodged to the facility, and to whom the complaints were lodged by name and title. The complaints were voiced to the Administrator, the Dietary Manager (DM), a Regional Nurse, to floor staff (nursing staff), and during Resident Council meetings. Resident #2 described food quality at the facility as abysmal (extremely bad). Resident #2 stated throughout her stay at the facility, foods were unpalatable and gave examples of warm food items served cold, oatmeal served on plates instead bowls, dirty or missing utensils, cold foods served lukewarm, missing condiments with nearly every meal, and stated her dietary preferences were frequently ignored. Resident #2 stated she had requested alternatives, but the alternatives were equally unpalatable and gave an example of a chef salad provided to her on 8/18/2024. Observation of Resident #2's notebook revealed on 8/18/2024, the chef salad consisted of a small bowl of lettuce with cheese, no vegetables or fruit, and the lettuce was wilted and brown on the edges with no salad dressing provided. Resident #2 reported most days foods served her were unrecognizable and not what was listed on the menus and when questioned the staff, they stated mystery meat. Resident #2 stated she requested her family members bring fresh fruits, vegetables and whole meals daily to have nutrition. Resident #2 stated during the Resident Council meetings, several other residents and families also voiced concerns related to the poor food quality. Resident #2 stated she complained to the dietary staff about the lack of bowls for such things as oatmeal, she was told no bowls were available in the kitchen. Resident #2 reported on 1 occasion she asked for an alternate meal when cold and hard chicken was served, and she received an overcooked hamburger served between 2 slices of white bread for a bun, covered with a single piece of lettuce. Resident #2 stated she and other residents complained again about the food and the kitchen staff told her the facility had run out of hamburger buns due to the number of alternate meals that had been requested. Resident #2's daughter was present in the home during the interview and added she had witnessed poor food quality during visits to the facility, 3 to 4 times weekly at various intervals and stated concerns she witnessed included cold foods served warm, warm foods served cold, stale bread items, and inadequate portions, which led her to coordinate delivery of meals with her siblings to the resident. Resident #2's daughter stated she had complained to facility's staff about the foods served and .nothing was done . During an interview on 2/12/2024 at 3:45PM, the current Dietary Manager (DM) (transferred from a sister facility) stated the former DM was terminated in the fall of 2024 after repeated efforts to counsel her on food quality at the facility and company expectations of the kitchen failed. The current DM stated the former DM had multiple meetings with the Administrator and Corporate staff in response to the multiple resident and family complaints about the poor food quality at the facility. The DM confirmed the reports of poor food quality and oatmeal served on plates had occurred repeatedly, as Resident #2 had stated. The DM confirmed the facility had received multiple complaints from other residents, family members and staff members on behalf of residents, related to poorly cooked foods, issues with food palatability and appearance, missing condiments, cold coffee, lack of certain food items, warm foods served cold, cold foods served warm as documented in the Resident Council Minutes. The DM reported poor food quality had occurred frequently throughout the period 6/2024 to 11/2024 with the former DM and since 12/2024, the food quality had improved and no complaints had been lodge since the former DM was terminated. During an interview on 2/18/2024 at 11:20 AM, the Administrator confirmed the facility failed to provide palatable foods on multiple occasions as documented in the resident council minutes in 8/2024 for Resident #2 and further confirmed the complaints related to dietary services were frequent between 6/2024 and 11/2024 as reported in the Resident Council Meeting minutes. The facility implemented a Performance Improvement Plan (PIP) and corrective actions to address the food quality on 12/10/2024. The interventions were validated onsite by the surveyor from 2/10/2025 to 2/18/2025. The findings were as follows: 1. On 12/10/2024, The Administrator (Adm or designee and social service worker began audits for all residents related to perceptions of food quality by interview and observations. All concerns were to be documented in the grievance log and immediately addressed. All findings were reported daily to the Dietary Services Manager (DSM), Adm and interdisciplinary team. (IDT) This was completed on 1/13/2025. 2. The Adm/Designee (Director of Nursing (DON), Social Worker) reviewed all grievances related to food quality with the facility IDT which includes all department heads daily during stand up/clinical meeting. Issues addressed in the daily meeting were addressed by the Adm for immediate correction. (Ongoing). 3. By 1/31/2025 the Adm/Designee will re-educate the DSM and all kitchen staff on facility standards regarding the provision of safely serving quality foods that meets the expectations of the residents. Adm/designee will re-educate IDT including the social worker on addressing resident concerns about food quality by immediately resolving the concerns and/or completing a grievance form that is shared with the IDT in daily stand-up meetings, what actions taken, and resolution shared with the resident with concerns. The Staff Development Coordinator (SDC) will re-educate staff to report concerns regarding food quality to resolve issues, report it to supervisor or complete a grievance form. Newly hired staff shall receive this education during the orientation process and at least annually. This was completed by the Social Worker and SDC on 1/11/2025. 4. The Adm will randomly sample 2 test trays (one lunch, and one dinner) weekly for 8 weeks to ensure food quality and initiate appropriate actions, provide feedback, to the DSM, and IDT as necessary. (Ongoing at time of survey). Surveyor observation verified the audits were continued and the meals were sampled. 5. The Adm and IDT team will review compliance with the corrective actions in the morning meeting, Monday Through Friday. Issues are immediately reviewed by the IDT for appropriate corrective action. The Adm reports the results of the audits to the Quality Assurance Performance Improvement Committee (QAPI). The QAPI committee consists of all department heads, Adm, Medical Director and members of the medical staff. (Ongoing at time of survey). The surveyor validated the facility corrective actions by observations of meal trays served between 2/10/2025 and 2/18/2025 at various meals. Photographs of the meals as plated were documented. All trays prepared were of suitable appearance and texture with condiments, utensils etc. present and on clean dinnerware. Foods were readily identifiable and of pleasant smell and appearance. The surveyor also observed tray passes of multiple meals on each clinical unit daily during the investigation. No excessive delays in tray distribution were observed. The surveyor interviewed 8 residents at various intervals throughout the survey who reported no concerns with the meals served and 1 resident (Resident #14) who had lived at the facility for an extended period reported food quality though poor for several months during a period of change in ownership of the facility in 2024 had markedly improved by 12/2024, and was actually superior now to what it was under the prior facility management in 2023 and most of 2024. All residents interviewed reported no problems with breakfast meals since December 2024. Food temperatures were measured at the end of tray preparation during the meal service on the afternoon of 2/12/2025 at dinner, and all foods sampled were of safe temperatures, appropriate appearance, matched the menu, and were palatable. The surveyor observed alternate foods available for use which were also palatable. The surveyor observed facility stocks of snacks and alternates which were observed to be sufficient. The facility also observed the facility dish supply which was adequate to meet demands of the kitchen at the time of the survey. Observations of utensils and dish storage areas revealed no concerns. Resident council minutes for 1/2025 were reviewed with no recurrent issues with dietary services noted. Additional interviews with multiple staff members conducted on all units and shifts during the survey included interviews with overnight shift personnel who reported no further issues with food quality in the morning after 12/2024. Multiple personnel interviewed reported they again ate meals at the facility themselves with no new concerns since the new DSM assumed management of the kitchen.

Based on facility policy review, observations, and interviews, the facility failed to ensure kitchen cooking/ serving/ storage equipment was maintained in a sanitary condition, which had the potential to affect 95 of 95 residents, and failed to ensure expired thickened liquids were discarded. The findings include: Review of the facility's policy titled, Cleaning & Sanitation, dated [DATE], showed .ensure that equipment and utensils are properly cleaned and sanitized .Keep all containers used to store utensils (drawers, shelves, bus/ utility bins) clean and free of all debris . Review of the facility's policy titled, Receiving and Storage Standards and Procedures dated [DATE], showed .Discard out-of-date products .Keep all equipment .in good repair, free of defects, cracks, or breaks .clean and free of visible residue buildup . During an observation of the cooking and food preparation area with the Certified Dietary Manager (CDM) on [DATE] at 9:40 AM, showed the following: 1. Eleven 8-inch plate warming bases had multiple pieces broken off, of various sizes, from the anterior perimeter of the base. 2. Gas stove ranges had dried, black greasy food debris present on surface and inner area 3. Deep fryer had dried, brown, food debris with brown grease-like residue present on the perimeter surface 4. Double welled plate warmer had multiple areas of brown, rust-like substance to both inner well areas During an observation of the dry storage room with the CDM on [DATE] at 9:45 AM, showed one 46-ounce (oz) carton of honey thickened apple juice had expired on [DATE]. During an observation of the clean dish storage area with the CDM on [DATE] at 9:50 AM, showed the following: 1. One 24-welled steel mini muffin pan with dried, yellowish-brown food debris present in 8 muffin wells 2. One metal serving spoon with dried, yellow food debris 3. One plastic storage bin, which housed the lids for the storage containers and the cooking pans, had a brown-sticky jelly-like substance in the bottom of the bin During an interview on [DATE] at 9:50 AM, the CDM confirmed the plate warming bases need replaced, expired thickened apple juice had not been discarded, the gas stove/ deep fryer/ lid storage bin/ muffin pan/ serving spoon had not been maintained in a sanitary condition.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide privacy for 1 resident (Resident #8) of 95 residents reviewed for resident dignity. The findings include: Review of the facility policy titled, Resident Rights, revised 3/22/2022, showed .The resident has the right to a dignified existence, self-determination, and communication and access to persons and service inside and outside the facility . Resident #8 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Peripheral Vascular Disease, Restless Leg Syndrome, Major Depressive Disorder, Muscle Wasting and Atrophy with Physical Debility. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15. Which indicated the resident was cognitively intact. Review of Resident #8's comprehensive care plan last revised 12/27/2023, showed the resident had vision loss and had mobility decline. During an observation on 1/8/2024 at 11:50 AM, Resident #8 was observed lying in the bed closest to the door of a two-person room. The resident was wearing an orange t-shirt, had an incontinence brief in place, and was not covered with a sheet or blanket. The door to the room was open, and the resident was visible from the hallway. During an observation on 1/8/2024 at 3:00 PM, Resident #8 was observed lying in bed closest to the door of a two-person room. The resident was wearing an orange t-shirt, had an incontinence brief in place, and was not covered with a sheet or blanket. The door to the room was open, and the resident was visible from the hallway. During an observation and interview on 1/8/2024 at 3:35 PM, Certified Nursing Assistant (CNA) #2 stated Resident #8 preferred to lay in the bed uncovered without pants. The CNA also stated it was difficult to keep the resident covered because the resident kicked the cover off. An observation showed a privacy curtain was available and not in use. Resident #8 stated .privacy curtain would be ok . CNA #2 confirmed the privacy curtain was not in use. During an observation on 1/10/2024 at 8:52 AM, Resident #8's room door was open, and the resident was observed from the hallway lying in bed uncovered wearing an incontinence brief and t-shirt. During observation and interview on 1/10/2024 at 8:56 AM, in Resident #8's room with Licensed Practical Nurse (LPN) #2, showed the resident was observed lying in bed uncovered wearing an incontinence brief and t-shirt without the privacy curtain in use. The LPN #2 stated she was familiar with Resident #8, cared for the resident routinely, and the resident did not like to wear pants. The LPN also stated .we try to keep the door closed, but the roommate's spouse goes in and out of the room and does not close the door . LPN #2 confirmed it was a dignity issue for the resident to lay in bed uncovered wearing only a incontinence brief and t-shirt and be visible from the hallway. During an interview on 1/10/2024 at 9:28 AM, the Social Worker (SW) stated it was a dignity issue for Resident #8 to be visible from the hallway when he was wearing an incontinence brief and not wearing pants. The SW stated she was unaware of any discussion regarding the use of a privacy curtain. During an interview on 1/10/2024 at 1:40 PM, the Director of Nursing (DON) stated it was not acceptable for Resident #8 to be seen from the hallway with an incontinence brief, uncovered with no pants in place. The DON confirmed yes, it is a dignity issue.

Based on facility policy review, facility document review, medical record review and interview, the facility failed to ensure 1 resident (Resident #76) acknowledged having, was educated on or offered information regarding advance directives of 26 advanced directives reviewed. The findings include: Based on the facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 1/2023, showed .It is the policy of this facility to support and facilitate a resident's right to request .to formulate an advance directive .'Advance directive' is a written instruction, such as a living will or durable power of attorney for healthcare .relating to the provision of healthcare when the individual is incapacitated .The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive . Review of a facility document titled, Admissions Agreement, dated 11/23/2022, showed .Page 7 of 21 .Advance Directive .Please check the box if an advance directive exists [box not checked] .Right to Refuse Treatment .Resident has the right to refuse medical treatment as defined by law .Resident/Sponsor acknowledges that they have been informed of Resident's right to prepare a written advance directive concerning Resident's medical treatment .Resident Signature .[no signature] .Sponsor Signature .[no signature] . Resident #76 was admitted to the facility on [DATE] with diagnoses including Dementia, Hyperlipidemia and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. During a telephone interview on 1/10/2024 at 4:30 PM, Resident #76's spouse stated she had not received information regarding advance directives or how to formulate an advance directive. During a telephone interview on 1/10/2024 at 4:40 PM, Resident #76's family member stated he had signed some of the resident's admission paperwork. He also stated he does not recall being provided information regarding advance directives or how to formulate an advance directive. He stated if they (the facility) had, he would have referred them to the resident's spouse because he did not feel comfortable making those decisions. During an interview on 1/10/2023 at 6:00 PM, the Director of Nursing confirmed resident #76 or the resident's representative had not been provided education to formulate an advance directive.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to maintain a safe, clean, homelike environment in 3 resident (Residents #30, #3, and #8) rooms of 66 rooms observed. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, revised 3/23/2022, showed .It is the policy of this facility to ensure the provision of routine cleaning .in order to provide a safe, sanitary environment .'Cleaning' .refers to the removal of visible soil from objects and surfaces . Review of the facility's policy titled, Safe and Homelike Environment, undated, showed .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment .'Environment' refers to any environment in the facility that is frequented by residents, including .the residents' rooms .'Sanitary' includes .keeping resident .equipment clean .equipment includes .equipment used in the completion of the activities of daily living . Resident #30 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Ischemic Cardiomyopathy (the heart's decreased ability to pump blood properly), Type 2 Diabetes Mellitus, and Dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. During an observation on 1/8/2024 at 10:50 AM, in Resident #30's room, showed the resident's bedside table had a dried, crusty, white debris caked on the left outer edge, and down the side, and bottom of the metal base. During an observation on 1/9/2024 at 2:00 PM, in Resident #30's room, showed the resident's bedside table had a dried, crusty, white debris caked on the outer left edge, and down the side, and bottom of the metal base. During an observation on 1/10/2024 at 8:00 AM, in Resident #30's room, showed the resident's bedside table had a dried, crusty, white debris caked on the outer left edge, and down the side, and bottom of the metal base. During an interview on 1/10/2024 at 11:10 AM, Housekeeper #1 stated resident rooms are cleaned daily. During daily cleaning the furniture was .wiped down .floors are swept and mopped .and walls are spot cleaned . During an interview on 1/10/2024 at 11:15 AM, the Environmental Service Director stated resident rooms were cleaned daily which included .the bedside tables are wiped down everyday . During an observation and interview on 1/10/2024 at 11:23 AM, with the Environmental Service Director in Resident #30's room, showed the resident's bedside table had a dried, crusty, white debris caked on the left outer edge, and down the side and bottom of the metal base. The Environmental Service Director stated the resident spits, and the dried white crusty debris was spit, and her expectation was for the bedside table to be cleaned daily. The Environmental Service Director confirmed Resident #30's bedside table had not been cleaned and a homelike environment was not maintained. Resident #3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Dementia, Difficulty Walking, and Generalized Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], showed Resident #3 had a BIMS score of 1 which indicated the resident had severe cognitive impairment. During an observation on 1/8/2024 at 11:00 AM, in the resident's room, showed 3 smears of a brown substance on the wall next to the bed. During an observation and interview on 1/10/2024 at 11:27 AM, with the Environmental Service Director in Resident #3's room, showed 3 smears of a brown substance on the wall next to the bed. The Environmental Service Director stated .I know what that is [brown substance] she [resident] spits and confirmed the wall had not been cleaned. Resident #8 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Visual Impairment, and Generalized Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], showed Resident #8 had a BIMS score of 15 which indicated the resident was cognitively intact. During an observation on 1/8/2024 at 11:50 AM, in the resident's room, showed a dark brown substance on the side rail next to the wall. During an observation and interview on 1/10/2024 at 11:30 AM, with the Environmental Service Director in Resident #8's room, showed a dark brown substance on the side rail next to the wall. The Environmental Service Director confirmed Resident #8's side rail had not been cleaned. During an interview on 1/10/2024 at 2:25 PM, the Director of Nursing stated it was the facility's expectation for Resident rooms to have a clean homelike environment.

Based on facility policy review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 3 residents (Residents #48, #42, and #30) of 29 residents reviewed for MDS assessments. The findings include: Review of the facility's policy titled, RAI [resident assessment instrument] Assessment - MDS 3.0 Completion, dated 3/23/2022, showed .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State . Resident #48 was admitted to the facility on [DATE] with diagnoses including Dementia, Difficulty in Walking, Lack of Coordination, and Muscle Weakness. Review of the medical record showed Resident #48 had a witnessed fall on 12/16/2023. Resident #48 sustained a skin tear to the right arm from the fall. Review of the admission MDS assessment dated [DATE], showed Resident #48 had 1 fall with no injury and 1 fall with injury. During an interview on 1/10/2024 at 11:31 AM, the Director of Nursing (DON) stated Resident #48 was admitted to the facility on [DATE]. Resident #48 fell on [DATE] and got a skin tear to the right arm from the fall. The DON stated Resident #1 had no other falls. The DON confirmed Resident #48's admission MDS assessment dated [DATE] showed the resident had 1 fall with injury and 1 fall without injury. The DON confirmed the MDS assessment was not accurate. 48100 Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Gastrostomy (opening in the skin and abdominal wall that delivers artificial nutrition via tube), Epilepsy, and Dysphasia (difficulty swallowing). Review of a significant change MDS assessment dated [DATE], showed Resident #42 had a memory problem, received tube feeding and a mechanically altered diet, had weight loss, and was on a physician-prescribed weight-loss regimen. Review of Resident #42's comprehensive care plan revised on 12/20/2023, showed .requires .tube feeding r/t [related to] weight loss and decreased ability to consume foods .had a significant weight loss . Review of the physician recapitulation orders dated 1/9/2024, showed .Enteral Feeding .at Rate 40ml/hr [milliliters/hour] for 24 hrs/day .Hydration: Provide 25 ml/hr water via pump . Review of the medical record showed Resident #42 had a significant weight loss of 15.95% in 6 months, which showed the following weight values: 116 pounds on 7/12/2023; 102.5 pounds on 10/10/2023; and 97.5 pounds on 1/2/2024 Review of a progress note dated 10/27/2023, showed .weight this week is 101.2 .Resident has a consult for a peg [percutaneous enteric gastric] tube placement .Multiple interventions have been put in place with no positive effects .Weight continues to decrease despite interventions due to medical condition .RD [Registered Dietitian] aware and following .Weekly weights continue at this time . During an interview on 1/10/2024 at 1:34 PM, the Registered Nurse (RN) MDS Coordinator stated Resident #42 had significant weight loss and had not been on a physician prescribed weight loss program. The RN MDS Coordinator confirmed the MDS assessment had not been coded accurately to reflect the resident's current condition. 49792 Resident #30 was admitted to the facility on [DATE] with diagnoses including Chronic Heart Failure with Atrial Fibrillation, Chronic Respiratory Failure, Dementia, and Anxiety. Review of a physician order dated 8/7/2020, showed .Admit to [named hospice company] hospice . Review of a quarterly MDS assessment dated [DATE], showed Resident #30 had a BIMS score of 6 which indicated the resident had severe cognitive impairment. Further review showed the resident was not receiving hospice services. During an interview on 1/10/2024 at 2:55 PM, the RN MDS Coordinator, confirmed Resident #30 received hospice services and the quarterly MDS assessment dated [DATE] was inaccurate.

Based on facility policy review, medical record review, observation, and interviews the facility failed to implement the care plan for 1 resident (Resident #84) of 29 care plans reviewed. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 8/30/2022, showed .It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions . Resident #84 was admitted to the facility on [DATE] with diagnoses including Hypertension, Anxiety Disorder, Dementia, and Repeated Falls. Review of Resident #84's comprehensive care plan dated 6/16/2023, and revised 7/27/2023, showed .Bed alarm . as a fall intervention. Review of the recapitulation orders showed .Start Date .7/27/2023 .Bed alarm . During an observation on 1/10/2024 at 7:45 AM in Resident #84's room, showed the resident lying in bed on her right side. Further observation showed the resident did not have a bed alarm in place. During an interview and observation on 1/10/2024 at 7:46 AM, Certified Nursing Assistant (CNA) #1 stated Resident #84 was supposed to have a bed alarm in place. Observation showed the resident did not have a bed alarm in place. CNA #1 confirmed the resident did not have a bed alarm in place. During an interview on 1/10/2024 at 7:48 AM, the Central Supply Clerk stated the resident was supposed to have a bed alarm in place. During an interview on 1/10/2024 at 7:55 AM, Licensed Practical Nurse (LPN) #1 confirmed the resident had a physician order for a bed alarm. Review of the medical record showed Resident #84 had not sustained any falls after the bed alarm was ordered on 7/27/2023. During an interview on 1/10/2024 at 2:19 PM, the Director of Nursing confirmed it was the facility's expectation for the comprehensive care plan interventions to be implemented for Resident #84.

Based on medical record review, observation, and interviews the facility failed to follow physician orders for 1 resident (Resident #84) of 29 residents reviewed. The findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses including Hypertension, Anxiety Disorder, Dementia, and Repeated Falls. Review of the recapitulation orders showed the resident had a bed alarm ordered on 7/27/2023 for a fall intervention. During an observation on 1/10/2024 at 7:45 AM in Resident #84's room, showed the resident lying in bed on her right side. Further observation showed the resident did not have a bed alarm in place. Review of the medical record showed Resident #84 had not sustained any falls after the bed alarm was ordered on 7/27/2023. During an interview and observation on 1/10/2024 at 7:46 AM, Certified Nursing Assistant (CNA) #1 stated Resident #84 was supposed to have a bed alarm in place. Observation showed the resident did not have a bed alarm in place. CNA #1 confirmed Resident #84 did not have a bed alarm in place. During an interview on 1/10/2024 at 7:48 AM, the Central Supply Clerk, stated the resident was supposed to have a bed alarm in place. During an interview on 1/10/2024 at 7:55 AM, Licensed Practical Nurse (LPN) #1 confirmed the resident had a physician order for a bed alarm.

Based on facility policy review, medical record review, observation and interview, the facility failed to secure dental services for 1 resident (Resident #8) of 29 residents reviewed for dental services. The findings include: Review of the facility's policy titled, Dental Services, revised 3/14/2023, showed .The dental needs of each resident are identified through the physical assessment and MDS [minimum data set] Assessment processes and addressed in each resident's plan of care .Item 1b .Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care . Resident #8 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Anoxic Brain Damage, and Cervical Disc Disorder. The resident's quarterly MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 15. Which indicated the resident was cognitively intact. Review of a dental visit Summary Report, dated 8/3/2021, showed Resident #8 had missing and chipped teeth. The dentist recommended an oral surgery referral for the extraction of teeth #4, #5, #18, and #21. Review of the medical record showed no additional dental visit notes were available. During an interview on 1/8/2024 at 11:50 AM, Resident #8 stated he had missing and broken teeth and would like to see a dentist. Resident #8 denied oral pain or discomfort. During an interview on 1/10/2024 at 9:28 AM, the Social Worker (SW) stated there was no evidence of a dental follow-up since 8/3/2021. During an observation and interview on 1/10/2024 at 2:25 PM, with Licensed Practical Nurse [LPN] #2 in Resident #8's room showed the resident lying in bed. The oral cavity was assessed by LPN #2 and showed the left lower canine tooth was broken off at the gum line. During an interview on 1/10/2024 at 5:20 PM, LPN #2 stated she cared for the Resident #8 routinely, and the resident had not requested to see a dentist or complained of oral pain. During a telephone interview on 1/10/2024 at 6:18 PM, Resident #8's responsible party stated he visited the resident weekly, and the resident had not informed him to be evaluated by the dentist. He also stated the resident had not complained of oral pain or broken teeth. During an interview on 1/10/2024 at 6:34 PM, the Director of Nursing (DON) stated she had worked at the facility for 3 years, and Resident #8 had not requested to see the dentist nor had she received resident complaints of oral pain. The DON confirmed Resident #8 was evaluated by a dentist on 8/3/2021, was referred to an oral surgeon, and the facility failed to follow up with the referral. During a telephone interview on 1/10/2024 at 6:43 PM, LPN #5 stated she cared for Resident #8 routinely, the resident had not requested to see a dentist and had not complained of problems with his teeth.

Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 1 of 1 dumpster. The findings include: Review of the facility's undated policy titled, Food-Related Garbage and Rubbish Disposal, showed .Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter . During an observation on 1/8/2024 at 10:32 AM, of the outside dumpster area with the Certified Dietary Manager (CDM), showed 3 plastic medication cups, 4 used disposable gloves, 2 milk cartons, and multiple paper straw wrappers on the ground surrounding the dumpster. The area adjacent to the dumpster had 3 large pieces of wet, decayed wooden debris with 2 large sheets of disintegrating cardboard lying on the ground, exposed to the elements. During an interview on 1/8/2024 at 10:35 AM, the CDM stated the trash debris, which included plastic medication cups, used disposable gloves, milk cartons, straw wrappers, and wood/cardboard debris, should not be present on the ground around the dumpster area. The CDM confirmed the area adjacent to the dumpster and surrounding area had not been maintained in a good sanitary order.

Based on observations and interviews, the facility failed to provide hand hygiene assistance for residents prior to the meal on 1 of 4 hallways observed for meal tray distribution. The findings include: During an observation and interview on 1/8/2024 at 12:26 PM, Licensed Practical Nurse (LPN) #3 delivered the lunch tray to a resident, assisted the resident to set up the meal tray, and exited the room. The LPN did not offer hand hygiene assistance to the resident. LPN #3 stated residents were to be offered hand hygiene assistance with either a wash cloth or hand sanitizer prior to meals. LPN #3 confirmed he had not offered hand hygiene assistance to the resident. During an observation on 1/8/2024 at 12:28 PM, LPN #4 delivered the lunch meal tray to a resident, assisted the resident to set up the meal tray, and exited the room. The LPN did not offer hand hygiene assistance to the resident. During an observation and interview on 1/8/2024 at 12:29 PM, LPN #4 delivered the lunch meal tray to another resident room, assisted the resident to set up the tray, and exited the room. The LPN did not offer hand hygiene assistance to the resident. LPN #4 stated hand sanitizer was to be offered to residents prior to meals. The LPN confirmed she had not offered hand hygiene assistant to the residents. During an interview on 1/8/2024 at 2:39 PM, the Infection Preventionist (IP) confirmed it was the expectation of the facility that residents were assisted with hand hygiene prior to meals. During an interview on 1/8/2024 at 3:14 PM, the IP stated the facility did not have a policy that addressed hand hygiene assistance of residents prior to meals. The IP confirmed it was the expectation of the facility hand hygiene assistance was provided or offered to residents prior to meals. During an interview on 1/10/2024 at 3:23 PM, the Director of Nursing (DON) confirmed staff were to assist residents with hand hygiene prior to meals.

Based on facility policy review, medical record review, and interview the facility failed to ensure 1 resident (Resident #64) was assessed for pneumococcal immunization of 5 residents reviewed for vaccinations. The findings include: Review of the facility's policy titled, Pneumococcal Vaccine (Series), revised on 3/23/2022, showed .Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received .Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized . Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Alzheimer's Disease, and Chronic Kidney Disease. Review of the medical record showed no evidence Resident #64's pneumococcal vaccination status had been assessed. During an interview on 1/10/2024 at 8:29 AM, the Infection Preventionist (IP) stated it was the expectation of the facility that residents were assessed for pneumococcal vaccination on admission and entered into the medical record. Immunization information was to be obtained from the resident and/or resident representative, medical records, and the Tennessee state immunization registry website. Resident immunization information was to be documented in the medical record and residents were to be screened, educated and provided vaccinations if eligible. The IP confirmed Resident #64 had not been assessed for pneumococcal vaccination and he was unaware if the resident had been offered the pneumococcal vaccine.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure 1 resident's (Resident #8) call light was within reach out of 95 residents observed. The findings include: Review of the facility policy titled, Call Lights: Accessibility and Timely Response, revised 8/30/2022, showed .Staff will ensure the call light is within reach of each resident and secured . Resident #8 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Cervical Disc Disorder, Muscle Wasting and Atrophy, and Unspecified Physical Debility. Review of a quarterly Minimum Data Set (MDS) dated [DATE] showed the resident has a Brief Interview for Mental Status (BIMS) of 15. Which indicated the resident was cognitively intact. The MDS showed the resident required substantial/maximal assist with eating, toileting, and was dependent with upper and lower body dressing. Review of Resident #8's comprehensive care plan, last revised 12/27/2023, showed Resident #8's call light needed to be within reach and encourage Resident #8 to use it. During an observation on 1/8/2024 at 11:50 AM, in the resident's room, showed Resident #8's call light cord was wrapped around the right side rail next to the wall. The resident was lying on his right side towards the wall. The call light button could not be seen. The resident was asked to put the call light on. The resident was not able to reach the call light cord or find the call light button to push it. During an observation on 1/8/2024 at 3:00 PM, Resident #8 was observed lying on his right side facing the wall. The call light cord was wrapped around the right side rail. Resident #8 was asked if he could turn the call light on, and the resident was unable to reach the call cord on the side rail or find the call light button. During an observation and interview on 1/8/2024 at 3:45 PM, in Resident #8's room, Certified Nursing Assistant (CNA) #2 stated the call light cord was wrapped around the right side rail next to the bed and confirmed the call light was not within the resident's reach. During an interview on 1/10/2024 at 6:10 PM, the Director of Nursing (DON) stated the expectation was for call lights to be placed within residents' reach.

Based on facility policy review, record review, document review, observation, and interviews, the facility failed to ensure 1 resident (Resident #10) of 3 residents was safely transferred using a mechanical lift. Specifically, Resident #1 had paralysis and weakness to the left side of the body. The facility failed to assess Resident #10 for the appropriate type of mechanical sling/lift pad to prevent the resident from leaning to the left side. On 11/30/2022 and 01/14/2023, while utilizing a bariatric sized four-point sling, Resident #10 began to lean toward the left side and fell to the floor from the sling. This failure resulted in a left shoulder fracture as a result of the 11/30/2022 fall, a left elbow fracture as a result of the fall on 01/14/2023, and resulted in Resident #10 being fearful of getting out of bed with a mechanical lift. The facility's failure resulted in actual Harm to Resident #10. Findings included: A review of the [Name of the Mechanical Lift] User Manual with a copyright date of 2014 revealed WARNING Visibly inspect sling prior to each use to ensure sling is the correct type, size and design to handle lifting. The manual indicated Most accidents occur from wrong sling size or type. Make certain you understand how to select, attach, inspect and test slings. According to the manual, In addition, ensure slings are sized appropriately and attached correctly to the patient and lift. Failure to follow these instructions could result in serious injury. A review of the facility's policy, titled, Safe Resident Handling/Transfers, initiated on 01/02/2020, indicated, 8. The facility will ensure that there are appropriate amounts of varying slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing. 9. Ensure that an appropriate sling is utilized. The policy further indicated 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. A review of an undated document titled, Choosing the Proper Sling for Your Residents revealed Sling size and fit can vary significantly depending on resident weight, girth and shape. Ensure sling is properly fitted before performing any lift. - Resident being lifted will feel safe, dignified and comfortable - Will increase caregiver confidence and lift efficiency - Maximize resident and caregiver safety As prescribed by company policy, a therapist or nurse should provide sling sizing and style selection. A review of a Resident Face Sheet for Resident #10 revealed the facility admitted the resident on 06/11/2019 with diagnoses to include Hemiplegia(paralysis) and Hemiparesis (muscle weakness) following a stroke affecting the left non-dominant side, Morbid Obesity, Muscle Weakness, Generalized Anxiety Disorder, and Unspecified Intellectual Disabilities. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/01/2022, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated Resident #10 required extensive assistance of two plus persons for transfers, which occurred only once or twice during the assessment period. The MDS indicated Resident #10's height was 66 inches tall. A review of Resident #10's Weights and Vitals Summary, revealed on 11/01/2022, the resident weighed 326 pounds. A review of Resident #10's care plan initiated on 05/09/2018 and revised on 06/30/2022, indicated Resident #10 was at risk for falls related to decreased mobility. A review of Resident #10's care plan initiated on 05/09/2018, indicated the resident had a activities of daily living self-care performance. An intervention revised on 10/14/2021, instructed the staff that Resident #10 required total assistance of two people for transfers using a mechanical lift. A review of a Kardex Report [a care guide for Certified Nursing Assistants (CNAs)] as of 11/10/2022, revealed Resident #10 required total assistance of two people for transfers using a mechanical lift. During an observation on 08/10/2023 at 10:00 AM, the surveyor observed the available facility mechanical lift sling pads were medium with a maximum weight of 450 pounds, large with maximum weight of 600 pounds and bariatric size with a maximum weight of 700 pounds. During an interview on 08/11/2023 at 9:32 AM, the Director of Nursing (DON) stated all the facility slings could accommodate up to 450 pounds and they had no residents that were greater than 450 pounds. The DON stated the CNAs used their judgement based on resident girth and shape for sizing. A review of the facility Incidents by Incident Type report revealed Resident #10 sustained a fall on 11/14/2022. A review of Resident #10's Progress Notes, dated 11/14/2022 at 4:40 PM, revealed while being transferred from a shower chair to bed by way of a bariatric mechanical lift, the lift pad underneath the resident tilted to the left side and the resident slipped/assisted by staff to the floor landing on their back and the back of the head. The note indicated the resident had left shoulder and left hip pain and a physician's order was obtained for x-rays of the left shoulder and left hip. The Progress Notes indicated an immediate intervention put in place was to use a bariatric lift pad during transfers. A review of Resident #10's Radiology Report dated 11/15/2022, revealed the resident had an acute, comminuted (broken in at least two places) fracture of the proximal left humerus (shoulder). A review of Resident #10's ED [Emergency Department] General Adult Worksheet with an admitted [DATE], revealed the resident presented to the ED with complaints of left shoulder pain status post fall. The document revealed, the resident was being lifted with a mechanical lift and fell on to their left shoulder. Resident #10 was informed of the results which demonstrated a nonoperative, proximal humerus fracture. Resident #10's arm was placed in a sling and the resident was discharged back to the facility. A review of CNA #9's handwritten statement dated 11/15/2022, revealed she assisted CNA #17 with the transfer of Resident #10. According to CNA #9's statement, she was on Resident #10's right side and CNA #17 was on the resident's left, paralyzed side. CNA #9 indicated she turned around and noticed Resident #10 was about to fall. CNA #9 reached for the resident to catch the resident and lowered the resident to the ground on their back. During an interview on 08/10/2023 at 9:41 AM, CNA #9 stated she, CNA #17, and LPN #10 transferred Resident #10 into bed with the mechanical lift when the resident fell . CNA #9 stated she was on one side and CNA #17 was on the other side of the resident. CNA #9 stated they instructed Resident #10 to hold on to their left paralyzed arm with the right arm, but Resident #10 released the left arm, but when the resident dropped their arm, all their weight went to one side. CNA #9 stated she was on the left side of Resident #10 but could not hold the resident up due to the resident's weight. CNA #9 stated she and the resident both fell to the ground. CNA #9 stated the slings could hold up to 450 pounds, but some were wider than others and they used the wider, bariatric one for Resident #10. CNA #9 further stated Resident #10 no longer wanted to get out of bed. A review of CNA #17's handwritten statement dated 11/15/2022, revealed on 11/14/2022, CNA #17 got assistance from CNA #9 to transfer Resident #10 back to bed. CNA #17 indicated as the staff were about to lift the resident, she noticed the resident was crooked, so the resident was placed back down into the shower chair to reposition Resident #10. According to CNA #17's handwritten statement, Licensed Practical Nurse (LPN) #10 helped the CNAs by moving the chair, while CNA #9 operated the controls. CNA #17 indicated as the staff were about to place Resident #10 in bed, the resident slipped from the mechanical lift pad and fell to the floor. During a telephone interview on 08/10/2023 at 10:28 AM, CNA #17 stated she and CNA #9 positioned Resident #10 on the sling but then Resident #10 started to lean to one side and they could not keep the resident from falling. CNA #17 stated she had training on the proper use of the mechanical lift and slings and stated they used a bariatric sling and lift for Resident #10. CNA #17 stated she thought the sling just was not positioned correctly on the resident. During an interview on 08/10/2023 at 12:30 PM, LPN #10 stated she was present when Resident #10 fell in November 2022. LPN #10 stated the CNAs had gotten the resident up for a shower without incident, but then upon transferring the resident back to bed, the resident started leaning to one side and fell . During an interview on 08/09/2023 at 2:31 PM, the Occupational Therapist (OT)/Director of Rehabilitation (DOR) stated Resident #10 had used a mechanical lift since admission to the facility. The OT/DOR stated she evaluated Resident #10 following the fall in November 2022 for proper positioning and a shoulder immobilizer but did not assess the type of sling after the November fall. The DOR stated Resident #10 had used a 4-point sling since admission without any incidents, but due to Resident #10's weight and hemiparesis, if the resident was not perfectly aligned in the sling, the resident could lean to the left, causing the sling to be off balance. A review of the Facility Event Summary Report revealed Resident #10 had a fall on 01/30/2023. A review of Resident #10's Resident Progress Notes dated 01/30/2023 at 11:55 AM revealed LPN #19 documented she observed the resident lying face down on the floor next to the bathroom door. The note indicated CNAs had used a bariatric lift and bariatric lift pad. The resident had a bruise to the right arm above the elbow and a slight raised area on the left cheek that was pink in color. The note indicated the facility notified the family and the nurse practitioner. On 01/30/2023 at 1:07 PM, the note indicated a new order was received to x-ray to the resident's left shoulder, left forehead, left wrist, left hand, and left facial with attention to the nose and left maxilla (jaw). A review of an Event Report for Resident #10 dated 02/10/2023, revealed the resident had a fall on 01/30/2023. The report indicated the resident was lowered to the ground from a mechanical lift as the resident was sliding out. The facility's intervention to prevent further falls was to provide a six-point lift pad and therapy to educate staff on usage. A review of Resident #10's Radiology Report dated 02/10/2023, revealed the resident had a minimally displaced and angulated fracture of the left elbow that was not included on the prior field of view (dated 01/30/2023). During an interview on 08/10/2023 at 1:13 PM, LPN #19 stated she worked when Resident #10 fell on [DATE]. LPN #19 stated Resident #10 was on the floor when she came in, and she did not witness the fall. LPN #19 stated the sling with the resident's name on it was underneath the resident on the floor. LPN #19 stated the resident was large and flaccid on the left side. LPN #19 stated the staff would remind the resident to hold their left paralyzed arm with the right arm during transfers, but sometimes the resident would release the left arm, causing the resident to lean to the left. During an interview on 08/10/2023 at 2:38 PM, CNA #20 stated she and CNA #21 got Resident #10 up in a bariatric mechanical lift with the bariatric sling for a shower. CNA #20 stated Resident #10 leaned to the left, so they tried to hold up that side. CNA #20 stated she assisted Resident #10 with transfers multiple times without incident. CNA #20 stated she knew to use the bariatric lift and sling and had crossed it under the resident's legs, but it did not keep the resident from leaning to the left, and Resident #10 fell . During an interview on 08/10/2023 at 2:49 PM, CNA #21 stated she and CNA #20 got Resident #10 up with the large bariatric lift. CNA #21 stated Resident #10 was weak on the left side and started leaning to the left. CNA #21 stated both she and CNA #20 tried to keep Resident #10 from falling but the resident was too heavy. CNA #21 stated the sling was already under Resident #10 when she came in the room to assist. During an interview on 08/09/2023 at 2:31 PM, the OT/DOR stated after the second fall in January 2023, nursing realized the problem had not been resolved and reached out to therapy to evaluate the sling. The OT/DOR stated at that time she recommended the six-point harness sling because it provided additional lateral support (more support to each side of the resident). During an interview on 08/08/2023 at 2:34 PM, Resident #10 stated they did not get out of bed because of a broken elbow and did not want to fall out of the lift. Resident #10 stated their left arm was heavy and caused them to lean that way, which caused them to fall. Resident #10 pointed to a six-point bariatric sling in the room with the resident's name on it. During a follow-up interview on 08/11/2023 at 7:02 PM, Resident #10 stated they did not want to use the mechanical lift. Resident #10 stated they used to get up for showers and sometimes for bingo prior to the falls. Resident #10 stated they would prefer to get a shower over a bed bath. Resident #10 stated they would like to get up again but did not trust the CNAs and had not allowed anyone to work with the resident on getting up. During an interview on 08/10/2023 at 12:00 PM, the Assistant Director of Nursing (ADON) stated Resident #10's fall in January 2023 had been discussed in the weekly Interdisciplinary Team (IDT) Clinical At-Risk meetings (CAR). The ADON stated Resident #10 tended to lean to one side. The ADON stated if a resident was above 450 pounds or wider staff should use a bariatric sling. During an interview on 08/11/2023 at 9:32 AM, the DON stated during the facility's IDT meeting regarding Resident #10's November 2022 fall, they discussed the root cause and felt it may have been caregiver error, as the resident had recently moved halls, so they did in-service training with the staff. The DON also stated even though Resident #10 was not technically heavy enough to require a bariatric sling, given the resident's girth and short height, Resident #10 was appropriate for a bariatric sling. Per the DON, the facility ordered a bariatric sling with the resident's name on it to keep in the resident's room. The DON stated Resident #10 had never gotten up much but did get up for showers. The DON confirmed the facility had not consulted with therapy to assess the sling at that time. According to the DON, after the second fall in January 2023, the staff reached out to therapy to assess the sling and therapy determined it was not the size of the sling, but the resident needed more lateral support. During a follow-up interview on 08/11/2023 at 2:58 PM, the DON stated after a fall, the IDT met and discussed what happened and put appropriate interventions in place. The DON stated the facility provided staff training following Resident #10's fall on 11/14/2022. However, it was not specific to Resident #10 and was a general training and staff demonstration on proper use of mechanical lifts. The DON stated her expectation was that staff would follow the care plan to ensure safety when transferring residents. During an interview on 08/11/2023 at 3:51 PM, the Executive Director (ED) stated she expected staff to know how a resident was supposed to be transferred and follow the resident's plan of care.

Based on facility policy review, record review, document review, and interviews, the facility failed to report an allegation of abuse in a timely manner for 1 (Resident #1) of 4 abuse allegations reviewed. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed/revised 08/30/2022, revealed, VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A review of Resident #1's Resident Face Sheet revealed the facility admitted the resident on 11/11/2016 with diagnoses that included Bipolar Disorder, Anxiety Disorder, Recurrent Depressive Disorders, and Seizures. A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/06/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. A review of a nursing Progress Note, dated 06/16/2023 at 4:55 PM and written by the Assistant Director of Nursing (ADON), revealed Resident #1 reported to the dayshift certified nursing assistant (CNA) during their bath that a nighttime CNA slapped the resident's right leg and called them a baby the other day. The Progress Note indicated the Executive Director (ED) was notified and an investigation was initiated. A review of an Investigation Staff to Resident form, dated 06/16/2023, revealed Resident #1 reported a CNA slapped the resident on the thigh and called them a baby during a bed bath but could not remember what day or what time it happened. The form identified CNA #8 as the alleged perpetrator. A review of the Tennessee Adult Protective Services report indicated the facility successfully submitted the initial report regarding Resident #1's allegation on 06/16/2023 at 8:11 PM. During an interview on 08/11/2023 at 2:48 PM, the Director of Nursing (DON) stated abuse allegations must be reported within two hours. She stated she came into the facility and started the report on Resident #1 before the time it was due and got all the way through it, and before she could save it, the system kicked her out, and she had to put the information back into the system. She said it took so long to re-enter the information, it made the report was late. During an interview on 08/11/2023 at 3:50 PM, the ED stated abuse allegations needed to be reported within two hours. The ED indicated she did not work at the facility at the time of Resident #1's allegation.

Based on facility policy review, record reviews, document reviews, and interviews,the facility failed to ensure 3 residents (Residents #6, #7, and #8) of 6 residents reviewed for abuse were free from physical abuse. On 12/26/2022, Resident #5 hit Resident #6 and on 01/07/2023, Resident #7 and Resident #8, both hit each other. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, with a reviewed/revised date of 08/30/2022, indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy specified, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy further indicated Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. A review of Resident #5's Resident Face Sheet revealed the facility admitted Resident #5 on 01/25/2022 with diagnoses that included Bipolar Disorder, Delusional Disorder, Dementia, Psychotic Disturbance, and Muscle Weakness. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/03/2022, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A review of Resident #5's Care Plan, dated 11/19/2022, indicated Resident #5 had the potential to display inappropriate social coping behaviors. Interventions included instructions for staff to intervene as necessary to protect the rights and safety of others, divert the resident's attention, and remove the resident from the situation and take to an alternate location as needed. The Care Plan also indicated Resident #5 had the potential to be physically aggressive related to dementia and poor impulse control with a goal the resident would not harm themself or others. Interventions included instructions for staff to intervene before agitation escalated and guide the resident away from the source of distress. A review of Resident #6's Resident Face Sheet revealed the facility admitted Resident #6 on 11/04/2022 with diagnoses that included Dementia, Cataract, and Weakness. A review of an admission MDS, with an ARD date of 11/11/2022, revealed Resident #6 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. A review of the Incident Reporting System, revealed on 12/26/2022 Resident #6 entered Resident #5's room on 12/26/2022. When the nurse removed Resident #6 from Resident #5's room, Resident #6 stated Resident #5 had hit them with a shoe. Resident #5 then confirmed Resident #6 entered their room, and Resident #5 hit Resident #6 with a shoe. Resident #6 was noted with a small abrasion above their eye. No witnesses were identified. Neither resident could recall the incident later in the day. During an interview on 08/09/2023 at 2:00 PM, Certified Nursing Assistant (CNA) #23 stated Resident #6 would occasionally walk into other residents' rooms, but not on purpose. Per CNA #23, the resident never had any alterations since they had been on the memory care unit. During an interview on 08/09/2023 at 2:06 PM, Registered Nurse (RN) #24 stated Resident #6 had poor eyesight and that was why Resident #6 sometimes wandered into other residents' rooms. During an interview on 08/10/2023 at 9:49 AM, CNA #9 stated whenever Resident #5 was out of their room, staff kept an eye on the resident due to resident's potential to become aggressive. During an interview on 08/10/2023 at 3:20 PM, RN #22 stated staff kept a close eye on Resident #5 and that Resident #5 would yell at people. During an interview on 08/11/2023 at 9:45 AM, the Director of Nursing (DON) stated Resident #5 was not aggressive toward other residents unless they intruded on Resident #5's space. The DON stated staff knew Resident #5 and were able to identify and redirect the resident when the resident was agitated. During a follow-up interview on 08/11/2023 at 3:15 PM, the DON stated it was her expectation that staff would intervene to prevent any altercations between residents or escalation of behaviors. During an interview on 08/11/2023 at 3:53 PM, the Executive Director (ED) stated her expectation was that staff would separate residents involved in an altercation. The ED stated staff should understand what triggered the behavior so they could put interventions in place to prevent it from happening again. 2. A review of Resident #7's Resident Face Sheet revealed the facility admitted Resident #7 on 01/03/2022 with diagnoses that included Schizophreniform Disorder, Anxiety Disorder, Dementia, and Cognitive Communication Deficit. A review of the annual MDS, with an ARD date of 12/06/2022, revealed Resident #7 had a BIMS score of 8, which indicted the resident had moderate cognitive impairment. A review of Resident #8's Resident Face Sheet revealed the facility admitted Resident #8 on 07/19/2021 with diagnoses that included Dementia, Schizophrenia, and Generalized Anxiety Disorder. A review of the quarterly MDS, with an ARD date of 12/12/2022, revealed Resident #8 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. A review of the Incident Reporting System, revealed on 01/07/2023, a nurse witnessed an altercation between Resident #7 and Resident #8 and intervened as Resident #8 hit Resident #7 on their leg. There was no physical or mental harm caused. Neither resident had any marks on them during a completed skin assessment following the altercation. It was also noted, neither resident recalled the altercation when asked about it. Both residents reside in the memory care unit of the facility. A review of Resident #7's Progress Notes dated 01/07/2023 at 2:01 PM, revealed Resident #7 hit another resident with an open hand four times on the head. A review of Resident #8's Progress Notes dated 01/07/2023 at 2:04 PM, revealed Resident #8 was hit on the head by another resident with an open hand four times and Resident #8 proceeded to hit the other resident's leg with an open hand three times. During an interview on 08/09/2023 at 8:44 AM, the Director of Nursing (DON) stated Resident #8 would try to boss other residents around in the memory care unit. The DON stated staff redirected Resident #8 or would sit and talk to the resident when Resident #8 started to boss others around. During an interview on 08/09/2023 at 10:59, CNA #23 stated Resident #8 would frequently say they disliked Resident #7. CNA #23 stated staff kept the two residents separated. CNA #23 stated Resident #8 frequently sat in the doorway and staff tried to keep other residents from the area to avoid any confrontations. CNA #23 stated when Resident #7 became agitated, staff would take Resident #7 out to smoke to allow everyone to calm down. During an interview on 08/09/2023 at 11:00 AM, RN #24 stated Resident #8 would become annoyed when other residents got in Resident #8's doorway, so staff made sure that did not happen. RN #24 reported, staff would separate Resident #8 from other residents if Resident #8 started to become agitated. RN #24 stated Resident #7 and Resident #8 did not get along. According to RN #24, Resident #8 would frequently yell out which caused other residents to get agitated. RN #24 stated staff would keep Resident #7 busy with activities in the dining room because Resident #8 did not go in the dining room. During a follow-up interview on 08/09/2023 at 4:25 PM, the DON stated Resident #8 would sit in their doorway and make comments to the other residents in the hall, so staff would intervene. The DON reported, staff would take Resident #7 outside to smoke to calm the resident down. During an interview on 08/10/2023 at 11:03 AM, Licensed Practical Nurse (LPN) #26 stated Resident #8 would sit in the doorway and talk bad about other residents, and occasionally Resident #7 and Resident #8 would yell at each other over the television remote control. LPN #26 stated after the incident, staff kept the residents separated. LPN #26 reported, staff would keep Resident #7 and Resident #8 on opposite sides of the nurses' station and there were no additional incidents. During an interview on 08/11/2023 at 9:51 AM, the DON stated on the day of the altercation, Resident #7 and Resident #8 were seated in the hallway with no indication that anything would happen.

Based on medical record review, observation, review of facility policy, review of medication variance report worksheet, review of performance improvement form, and interview, the facility failed to follow facility policy and physician's orders [REDACTED].#6) of eighteen residents reviewed. The facility's failure to ensure the scheduled medications were administered resulted in unmanaged pain and anxiety for resident #6 (Actual Harm). The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of seven out of a possible fifteen (with zero being the lowest and fifteen the highest). Continued review revealed the resident received scheduled and as needed (PRN) pain medications during the last five days, and experienced no pain or hurting during the last five days. Medical record review of the March 2014 Physician's Recapitulation Orders revealed, "[MEDICATION NAME] (narcotic pain medication) 7.5 MG (milligrams) 1 (one) Tab (tablet) PO (by mouth) Q (every) 8 (eight) HRS (hours) DX: (diagnosis) [MEDICATION NAME] ([MEDICATION NAME]) (anti-anxiety medication) 0.5 MG 1 Tab PO Q 8 HRS DX: Anxiety/Excessive [MEDICATION NAME] 7.5 MG PO Q 4 (four) HRS PRN DX: Pain..." Medical record review of the Care Plan dated March 11, 2014, revealed the resident had Chronic Pain and Anxiety, and approaches (interventions) included, "...Administer...routine (scheduled)...PRN pain medications...([MEDICATION NAME])" and "...Administer...medication as prescribed by the physician...([MEDICATION NAME])..." Medical record review of the Nurse Practitioners' (NP) Progress Notes dated January 20, February 25, and March 21, 2014, (no time) revealed the resident required scheduled and PRN [MEDICATION NAME] for Chronic Back Pain and [MEDICAL CONDITION]. Continued review confirmed the resident required scheduled [MEDICATION NAME] for Anxiety. Observation on March 24, 2014, at 7:25 a.m., in the hallway outside of resident #6's room, confirmed the resident's call light was on and Certified Nursing Assistant (CNA) #1 entered the room to assist the resident. Continued observation confirmed the resident was lying on the bed in a fetal position on the left side, with facial grimacing, and was moaning and crying aloud; and stated to CNA #1, "Would you please get the nurse and tell (nurse) I need my pain medicine...it was due at 6:00 (a.m.) and I haven't gotten it yet...(nurse) is late...I'm hurting...I'm hurting so bad...." CNA #1 left the room and notified the Licensed Practical Nurse (LPN) #1. Continued observation at approximately 7:26 a.m., confirmed LPN #1 proceeded to the resident's room and verified the resident's request for pain medication and assessed the resident's pain. The resident continued in the fetal position, with moaning and facial grimacing. Continued observation confirmed LPN #1 lightly touched and attempted to assist the resident to stretch out the legs for positioning, and the resident cried out, "I can't, I'm hurting too bad...please just give me my pain medicine." LPN #1 obtained the resident's vital signs and stated, "...blood pressure is 140/80; it's up (elevated)." Continued observation confirmed LPN #1 reviewed the resident's March 2014 Medication Administration Record [REDACTED]. Continued observation confirmed the resident's Controlled Substance Records and actual count of the resident's [MEDICATION NAME] (twenty-five remaining) and [MEDICATION NAME] (zero remaining) were accurate. LPN #1 reviewed the count sheets for the [MEDICATION NAME] and [MEDICATION NAME], and stated, "The last [MEDICATION NAME] and [MEDICATION NAME] administered to the resident was last night (March 23, 2014) at 10:00 (p.m.)." Medical record review of the Nurses' Notes dated November 12, 2014, revealed the following: 7:30 p.m., LPN #1 notified the Physician of the omitted [MEDICATION NAME] and [MEDICATION NAME]; the Physician gave a Telephone Order which stated, "May give 0600 (6:00 a.m.) [MEDICATION NAME] and [MEDICATION NAME] now." 7:40 a.m., LPN #2 assessed the resident's pain and administered the resident's 6:00 a.m., [MEDICATION NAME] (7.5 mg). LPN #2 used a pain scale of 0-to-10 (with 0 being no pain and 10 being severe pain). The resident remained in a fetal position, and was moaning with facial grimacing, and had a pain level of "10." 8:00 a.m., LPN #2 had retrieved [MEDICATION NAME], 0.5 mg, from the Emergency Back-Up Drug Kit located in the facility and administered it to the resident. The resident stated a pain level of "10" continued and requested more pain medication. LPN #2 explained it was too soon with the [MEDICATION NAME] administered at 7:40 a.m., and the [MEDICATION NAME] at 8:00 a.m.; but to give the medication a few more minutes and (LPN #2) would check back with the resident. The resident stated, "Ok (okay)." 8:30 a.m., the resident remained in pain with a pain score of "10." 8:35 a.m., LPN #2 notified the NP of the resident's continued pain and "No new orders received." 9:00 a.m., the resident was "resting quietly with eyes closed." Review of the 2014 Nursing Drug Handbook, (Lippincott, Williams, and Wilkins), revealed, "...Nursing Considerations...For full [MEDICATION NAME] effect, give drug before patient has intense pain..." Review of facility policy, Pain Management, dated August 31, 2013, (revised), page one and two, revealed, "...Policy...(Facility) recognizes a patient's right to be free of pain and promotes pain relief...Components...11. Pain control measures are implemented before pain becomes severe. 12...This includes pharmacological..." Review of facility policy, 6.0 General Dose Preparation and Medication Administration, dated January 1, 2013, (revised), page two, revealed, "...5 During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following...5.4 Administer medications within timeframes..." Review of facility worksheet, Medication Variance Report, dated March 24, 2014, at 8:00 a.m., revealed LPN #3 omitted the resident's scheduled [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 0.5 mg, on March 24, 2014, at 6:00 a.m. Review of a performance improvement form dated March 24, 2014, completed by the Director of Nursing (DON), revealed LPN #3 had omitted the resident's scheduled [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 0.5 mg, on March 24, 2014, at 6:00 a.m. Interview with LPN #1 on March 24, 2014, at 10:30 a.m., in the Conference Room, confirmed the resident was not administered [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. LPN #1 confirmed the resident was in pain, was in a fetal position with facial grimacing, crying, moaning aloud, and anxious. LPN #1 confirmed, "I touched (resident) and (resident) told me to stop; it was painful. This was not like (resident)...generally smiles and talks to me, but...didn't this morning because (resident) was obviously in severe pain and needed (resident's) [MEDICATION NAME] and [MEDICATION NAME]. Continued interview with LPN #1 confirmed the failure to administer the medications as scheduled resulted in the resident experiencing anxiety and severe pain. Interview with LPN #2 on March 24, 2014, at 10:45 a.m., in the Conference Room confirmed the resident was not administered [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. LPN #2 confirmed the resident was in severe pain with a pain level of 10. LPN #2 confirmed the resident was moaning and grimacing, and couldn't be repositioned because "(resident) couldn't stand to be touched due to pain." LPN #2 confirmed the [MEDICATION NAME] was administered at 7:40 a.m., and the [MEDICATION NAME] at 8:00 a.m., and the (resident) did not evidence pain relief until 9:00 a.m. Continued interview with LPN #2 confirmed the failure to administer the medications as scheduled resulted in the resident experiencing severe pain and anxiety. Interview with CNA #1 on March 24, 2014, at 3:00 p.m., in the Conference Room, confirmed, "It is rare that (resident's) call light is on in the mornings. Usually if it is, (resident) is asking about the heat. It was unusual for (resident) to be asking for medicine that early. (Resident) told me...had been waiting on it ([MEDICATION NAME]) for a while...since 6:00 (a.m.) and it was 7:25 (a.m.) when I answered...call light. (Resident's) knees were drawn up (fetal position)...it was obvious (resident was in pain...usually (resident's) legs are stretched out when...lying in bed, but not this morning." Interview with the NP on March 24, 2014, at 3:20 p.m., in the Conference Room, confirmed the resident does require routine (scheduled) anxiety and pain medications, and has the availability for [MEDICATION NAME] PRN, for breakthrough pain. The NP confirmed, "The resident does have Chronic Pain, [MEDICAL CONDITION], and Anxiety. The omission of the [MEDICATION NAME] on top of the [MEDICATION NAME] served to further compound the resident's pain. It's not good for the resident to just stop these medications, or not give as ordered." Telephone interview with LPN #3 on March 24, 2014, at approximately 8:38 p.m., confirmed, "I didn't realize the medications had been omitted. I just overlooked them on the MAR's." Continued interview confirmed LPN #3 failed to administer the resident's [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. Interview with the District Director of Clinical Operations (DDCO) on March 25, 2014, at 11:40 a.m., in the Conference Room, confirmed the reconciliation of the Controlled Substance Records and count of the [MEDICATION NAME] and [MEDICATION NAME] confirmed the resident did not receive the [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. Continued interview with the DDCO confirmed the facility's failure to administer the [MEDICATION NAME] and [MEDICATION NAME] as scheduled resulted in the resident having severe pain and anxiety.

Based on medical record review, observation, review of professional reference material, review of facility policy, review of medication variance report worksheet, review of performance improvement form, and interview, the facility failed to follow facility policy and physician's orders [REDACTED].#6) of eighteen residents reviewed. The facility's failure to ensure the scheduled medications were administered resulted in a significant medication error for resident #6 (Actual Harm). The findings included: Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident received scheduled and as needed (PRN) pain medications during the last five days, and experienced no pain or hurting during the last five days. Medical record review of the March 2014 Physician's Recapitulation Orders revealed, "[MEDICATION NAME] (narcotic pain medication) 7.5 MG (milligrams) 1 (one) Tab (tablet) PO (by mouth) Q (every) 8 (eight) HRS (hours) DX: (diagnosis) [MEDICATION NAME] ([MEDICATION NAME]) (anti-anxiety medication) 0.5 MG 1 Tab PO Q 8 HRS DX: Anxiety/Excessive [MEDICATION NAME] 7.5 MG PO Q 4 (four) HRS PRN DX: Pain..." Medical record review of the Nurse Practitioners' (NP) Progress Notes dated January 20, February 25, and March 21, 2014, (no time) revealed the resident required scheduled and PRN [MEDICATION NAME] for Chronic Back Pain and [MEDICAL CONDITION]. Continued review confirmed the resident required scheduled [MEDICATION NAME] for Anxiety. Observation on March 24, 2014, at 7:25 a.m., in the hallway outside of resident #6's room, confirmed the resident's call light was on and Certified Nursing Assistant (CNA) #1 entered the room to assist the resident. Continued observation confirmed the resident was lying on the bed in a fetal position on the left side, with facial grimacing, and was moaning and crying aloud; and stated to CNA #1, "Would you please get the nurse and tell (nurse) I need my pain medicine...it was due at 6:00 (a.m.) and I haven't gotten it yet...(nurse) is late...I'm hurting...I'm hurting so bad...." Continued observation at approximately 7:26 a.m., confirmed LPN #1 proceeded to the resident's room and verified the resident's request for pain medication and assessed the resident's pain. The resident continued in the fetal position, with moaning and facial grimacing. Continued observation confirmed LPN #1 lightly touched and attempted to assist the resident to stretch out the legs for positioning, and the resident cried out, "I can't, I'm hurting too bad...please just give me my pain medicine." LPN #1 obtained the resident's vital signs and stated, "...blood pressure is 140/80; it's up (elevated)." Continued observation confirmed LPN #1 reviewed the resident's March 2014 Medication Administration Record [REDACTED]. Continued observation confirmed the resident's Controlled Substance Records and actual count of the resident's [MEDICATION NAME] (twenty-five remaining) and [MEDICATION NAME] (zero remaining) were accurate. LPN #1 reviewed the count sheets for the [MEDICATION NAME] and [MEDICATION NAME], and stated, "The last [MEDICATION NAME] and [MEDICATION NAME] administered to the resident was last night (March 23, 2014) at 10:00 (p.m.)." Medical record review of the Nurses' Notes dated November 12, 2014, revealed the following: 7:30 p.m., LPN #1 notified the NP of the omitted [MEDICATION NAME] and [MEDICATION NAME]; the NP gave a Telephone Order (TO), "May give 0600 (6:00 a.m.) [MEDICATION NAME] and [MEDICATION NAME] now." 7:40 a.m., LPN #2 assessed the resident's pain and administered the resident's 6:00 a.m., [MEDICATION NAME]. LPN #2 used a pain scale of 0-to-10 (with 0 being no pain and 10 being severe pain). The resident remained in a fetal position, and was moaning with facial grimacing, and had a pain level of "10." 8:00 a.m., LPN #2 had retrieved [MEDICATION NAME], 0.5 mg, from the Emergency Back-Up Drug Kit located in the facility and administered it to the resident. The resident stated a pain level of "10" continued and requested more pain medication. LPN #2 explained it was too soon with the [MEDICATION NAME] administered at 7:40 a.m., and the [MEDICATION NAME] at 8:00 a.m.; but to give the medication a few more minutes and (LPN #2) would check back with the resident. The resident stated, "Ok (okay)." 8:30 a.m., the resident remained in pain with a pain score of "10." 8:35 a.m., LPN #2 notified the NP of the resident's continued pain and "No new orders received." 9:00 a.m., the resident was "resting quietly with eyes closed." Review of the 2014 Physician's Desk Reference (PDR), 68th Edition, eBook, at www.pdr.net revealed elimination half-life of [MEDICATION NAME] following administration is 12 hours and [MEDICATION NAME] is 3.5 to 4 hours. Review of the 2014 Nursing Drug Handbook, (Lippincott, Williams, and Wilkins), revealed, "...Nursing Considerations...For full [MEDICATION NAME] effect, give drug before patient has intense pain..." Review of facility policy, 6.0 General Dose Preparation and Medication Administration, dated January 1, 2013, (revised), page two, revealed, "...5 During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following...5.4 Administer medications within timeframes..." Review of facility worksheet, Medication Variance Report, dated March 24, 2014, at 8:00 a.m., revealed LPN #3 omitted the resident's scheduled [MEDICATION NAME] 7.5 mg and [MEDICATION NAME] 0.5 mg, on March 24, 2014, at 6:00 a.m. Review of a performance improvement form dated March 24, 2014, completed by the Director of Nursing (DON), revealed LPN #3 had omitted the resident's scheduled [MEDICATION NAME] 7.5 mg, and [MEDICATION NAME] 0.5 mg, on March 24, 2014, at 6:00 a.m. Interview with LPN #1 on March 24, 2014, at 10:30 a.m., in the Conference Room, confirmed the resident was not administered [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. LPN #1 confirmed the resident had not received [MEDICATION NAME] or [MEDICATION NAME] since March 23, 2014, at 10:00 p.m.; and was in a fetal position in pain, with facial grimacing, crying, moaning aloud, and anxious. Continued interview with LPN #1 confirmed the failure to administer the medications as scheduled resulted in the resident experiencing anxiety and severe pain. Interview with LPN #2 on March 24, 2014, at 10:45 a.m., in the Conference Room, confirmed the resident was not administered [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. LPN #2 confirmed the resident was in severe pain with a pain level of 10. LPN #2 confirmed the resident was moaning and grimacing, and couldn't be repositioned because "(resident) couldn't stand to be touched due to pain." Continued interview with LPN #2 confirmed the failure to administer the medications as scheduled resulted in the resident experiencing severe pain and anxiety. Interview with CNA #1 on March 24, 2014, at 3:00 p.m., in the Conference Room, confirmed, "It is rare that (resident's) call light is on in the mornings. Usually if it is, (resident) is asking about the heat. It was unusual for (resident) to be asking for medicine that early. (Resident) told me...had been waiting on it ([MEDICATION NAME]) for a while...since 6:00 (a.m.) and it was 7:25 (a.m.) when I answered...call light. (Resident's) knees were drawn up (fetal position)...it was obvious (resident was in pain...usually (resident's) legs are stretched out when...lying in bed, but not this morning." Interview with the NP on March 24, 2014, at 3:20 p.m., in the Conference Room, confirmed the resident does require routine (scheduled) anxiety and pain medications, and has the availability for [MEDICATION NAME] PRN, for breakthrough pain. The NP confirmed, "The resident does have Chronic Pain, [MEDICAL CONDITION], and Anxiety. The omission of the [MEDICATION NAME] on top of the [MEDICATION NAME] served to further compound the resident's pain. It's not good for the resident to just stop these medications, or not give as ordered." Telephone interview with LPN #3 on March 24, 2014, at approximately 8:38 p.m., confirmed, "I didn't realize the medications had been omitted. I just overlooked them on the MAR's." Continued interview confirmed LPN #3 failed to administer the resident's [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. Interview with the District Director of Clinical Operations (DDCO) on March 25, 2014, at 11:40 a.m., in the Conference Room, confirmed the reconciliation of the Controlled Substance Records and count of the [MEDICATION NAME] and [MEDICATION NAME] confirmed the resident did not receive the [MEDICATION NAME] and [MEDICATION NAME] on March 24, 2014, at 6:00 a.m., as scheduled. Continued interview with the DDCO confirmed the facility's failure to administer the [MEDICATION NAME] and [MEDICATION NAME] as scheduled resulted in the resident having severe pain and anxiety.

Based on medical record review, review of facility policies, review of facility records, and interview, the facility failed to immediately notify the physician of a change in resident condition, failed to notify the Physician of a delay in administering intravenous fluids, failed to notify the Physician of not administering the ordered amount of intravenous fluids, failed to notify the Physician of uncompensated fluid loss, and failed to notify the Physician of the inability to safely swallow medications due to sedation for one resident (#1), of thirty-two residents reviewed. The facility's failure resulted in resident (#1) with a history of Acute [MEDICAL CONDITION] developing an exacerbation secondary to severe dehydration. The facility's failure resulted in the resident's transfer to the hospital emergency room for evaluation and admission to the Trauma Intensive Care Unit for Dehydration and fluid resuscitation. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Quality Specialist, District Director of Clinical Operations, and Corporate Registered Nurse (RN) were informed of the Immediate Jeopardy in the Conference Room on September 11, 2013, at 3:05 p.m. The findings included: Resident #1 was admitted to the facility from the local hospital on December 14, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated December 14, 2012, with the fax header dated December 14, 2012, at 1:50 p.m., revealed, "..XXX[AGE] year-old...with a history of [MEDICAL CONDITION] status [REDACTED]. This hospital course is complicated mostly by [MEDICATION NAME] fistula with secondary complications due to such fistula. The patient [MEDICAL CONDITION] stents replaced without any complications and since that time period...acute [MEDICAL CONDITION] has resolved...creatinine has returned to normal/baseline...no other issues with...ileal conduit since that [MEDICATION NAME] fistula...repaired on 11/8/12 (November 8, 2012) and...had no further recurrence of [MEDICATION NAME] fistula, most notably by no stool (feces) per vagina. To address...ostomy, the patient has a high output [MEDICAL CONDITION] (an artificial opening created in the Ileum and brought to the surface of the abdomen for the purpose of evacuating feces) which subsequently had complication of an [MEDICATION NAME] fistula (a cutaneous fistula connecting the body surface and some parts of the intestine) coming through the midline incision. The incision was opened, it was irrigated and replaced with a negative pressure [DEVICE] which is still currently being used today...To address the ileocutaneous fistula...stent was placed...on 12/5/12 (December 5, 2012) and then replaced on 12/10/12 (December 10, 2012) which covered the fistula. Since that time there has been no further leakage from this fistula into the midline incision...To address...urinary output...patient has also required a one liter (1000 milliliters or 1000 cubic centimeters) normal saline infusion (intravenously) over 8 (eight) hours each day to maintain an adequate urinary output...due to...high output ostomy...is not able to maintain p.o. (by mouth) fluid well enough to keep up with...ostomy output. The patient will be discharged with instructions to maintain or continue a one liter normal saline infusion...per day...will be discharged to a skilled nursing facility...I would not anticipate any further problems at this moment..." Medical record review of a hospital laboratory report dated December 12, 2012, revealed a Creatinine level (measures kidney function) of 0.76 (normal reference range: 0.60-1.30); and a Sodium level (an electrolyte in the blood) of 136 (normal reference range: 136-147). Medical record review of the hospital's discharge Physician orders [REDACTED]." Medical record review of a Physician's Telephone Order (TO) dated December 14, 2012, (no time), revealed, "Clarification order NS...IV Q (every) day @ (at) 100 ml (milliliters)/ (per) hour x 14 days." Continued review revealed the Assistant Director of Nursing (ADON) signed in validation of the TO being written and correctly transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Medical record review of the December 2012 MAR indicated [REDACTED]." Continued review revealed Registered Nurse (RN) #1 incorrectly transcribed the rate as 40 cc's per hour instead of 100 cc's per hour, which equated to an amount of 960 cc's per day instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Continued review revealed the IV was administered at 40 cc's per hour from December 15, 2012, until sometime on December 19, 2012. Further review revealed on December 19, 2012, the IV order was re-transcribed; a line was struck through the 40 cc's with "error" written below the 40 cc's and 100 cc's written above the erroneous 40 cc's. Medical record review of the Nurse's Notes (NN) revealed the resident was admitted to the facility on [DATE], at 7:00 p.m. (five hours and ten minutes after the resident's Discharge Summary was sent to the facility). Continued review revealed the IV was not started until December 15, 2012, at 10:50 a.m., and was set to be administered at 40 cc's per hour, which equated to an approximate amount of 520 cc's on December 15 instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Medical record review of a Physician's TO dated December 15, 2012, at 2:25 p.m., revealed a PRN (as needed) order for IV [MEDICATION NAME] (for nausea and vomiting) and [MEDICATION NAME] (for pain). Medical record review of the MAR indicated [REDACTED]#1 on August 29, 2013, at 6:10 p.m., in the Conference Room, confirmed the Physician's TO dated December 15, 2012, at 2:25 p.m., for the PRN IV [MEDICATION NAME] and [MEDICATION NAME] was incorrectly dated for December 15, which should have been dated December 16, 2012, at 2:25 p.m.) Medical record review of the NN's revealed the resident became nauseous and vomited on December 15, 2012, at 3:00 p.m. Continued review revealed RN #1 gave [MEDICATION NAME], a medication for the nausea, as ordered on the admission Physician orders. Continued review of the NN's dated December 15, and 16, 2012, at 10:00 p.m., and 4:00 a.m., respectively, revealed RN #2 continued to administer the IV at 40 cc's per hour. Medical record review of the NN's dated (Sunday) December 16, 2012, completed by RN's #1 and #2 revealed: (RN #1) 4:25 p.m. "...having nausea and vomiting x2 today...Crying...tearful...c/o (complaint of) n/v (nausea and vomiting)...not knowing why...so sick...Called doctor o/c (on-call)...new orders...IV [MEDICATION NAME] (for nausea and vomiting)..." (RN #1) 9:45 p.m. "...Constantly tearful and speaks in whine-voice (long, high-pitched complaining cry)..." (RN #2) 10:00 p.m. "...Resident tearful stated very nauseated..." Medical record review of a NN completed by the ADON, dated December 19, 2012, at 10:15 a.m., revealed, "...liquid...stool...IV fluids running (administered) @ 40 cc/hr..." Medical record review of a NN completed by RN #1 dated December 20, 2012, revealed: 7:45 a.m. "...pt (patient) in bed [MEDICAL CONDITION] and [MEDICATION NAME] (urine) appliances leaking...n/v..." 8:00 a.m. "...med (medicated) with [MEDICATION NAME] n/v." 10:00 a.m. "Wound dsg (dressing) changed for a second time. Canister (container to hold drainage from wound) changed out...was full (one canister holds 1000 cc's)." 12:00 p.m. "Pt weeping...talks with whine. Stating wants to see MD (Medical Doctor)/NP (Nurse Practitioner) because...is concerned about how much n/v...is having. Increased anxiety. Med (Medicated) with [MEDICATION NAME] (antianxiety) 0.5 mg (milligrams)." 2:00 p.m. "(NP) came ex (examined) pt. Discussed n/v...New orders noted..." Medical record review of a TO written by the NP, dated December 20, 2012, revealed, "Give [MEDICATION NAME] 0.5 mg p.o. (by mouth) q (every) 6 (six) hr & (and) one q 6 hr prn anxiety..." Medical record review of a NN completed by RN #1 dated December 21, 2012, at 8:20 p.m., revealed, "...Canister changed x2 (twice) today due to being full..." Medical record review of a Physical Therapy Assistant Weekly Progress Report, reporting period dated December 15 to December 21, 2012, revealed, "...Clinical Summary: Pt has had increased nausea and vomiting...and unable to tolerate increased movement...decrease treatment time as pt unable to tolerate a complete session..." Medical record review of a Physical Therapy Discharge Summary dated December 22, 2012, revealed, "In the weeks pt received P.T. (physical therapy) rx (treatment), (resident) was quite ill and did not tolerate rx very well..." Medical record review of a NN completed by Licensed Practical Nurse (LPN) #1 dated December 22, 2012, at 4:00 p.m., revealed, "Pt quite sedated and sleeping until 3:00 p.m...Did not take AM (morning) or noon meds..." Medical record review revealed no documentation the Physician was notified of the uncompensated fluid loss from the resident's wound on December 20 and 21, 2012, or of the resident being sedated and unable to take routine medications on December 22, 2012. Medical record review of a NN dated December 22, 2012, at 8:45 p.m., revealed the resident's Responsible Party (RP) was concerned and called the facility. Continued review revealed, "...(RP) yelled and said, 'You're killing (resident)...(Resident) used to be able to have full good conversations and now (resident) can't pick up the phone'...(RP) demanding (resident) go to the (hospital) ER (emergency room )...Spoke to (ADON)...explained situation. (ADON) said to ask res (resident). Resident fairly lethargic but stated, 'Well I don't feel good.' ADON said to go ahead and send (resident)." Continued review revealed the resident left the facility by EMS (Emergency Medical Services) at 9:45 p.m. Review of facility policy, Notifications, original date September 23, 2003 and release date April 28, 2013, revealed, "...Staff informs the patient, consults with their attending physician, and notifies the patient's surrogates when...A significant change occurs in the patient's physical, mental...status..." Review of facility policy, Fluid Intake and Output Measurement, revised October 31, 2006, revealed, "...Intake and output (I&O) measurement is recorded for residents according to the following criteria: Residents identified as at high risk for dehydration...Residents receiving intravenous therapy for duration of treatment...Documentation Guidelines: 1. Record the shift, type, and amount of both intake and output; Significant variations in intake and output, as well as: a. Date and time of physician notification..." Medical record review of the emergency room Nurse's Notes dated December 22, 2012, (time illegible), revealed, "...To (room number) via EMS, lethargic. Cries when moved...(urinary device) with thick urine...11:10 p.m., urine collected...foul odor noted...11:28 p.m., Critical (life-threatening) Values: Na (Sodium) 117 (normal reference range: 136-147)..." Medical record review of a hospital History and Physical dated December 22, 2012, revealed the patient had been at the nursing home for the past eight days. Continued review revealed the patient's creatinine was 6.83 (normal reference range: 0.60-1.30), and sodium was 117 on hospital readmission on December 22, 2012. Assessment and plan revealed, "This is a [AGE] year-old...with likely [DIAGNOSES REDACTED] as well as acute [MEDICAL CONDITION] and [MEDICAL CONDITION]...1. The patient will be admitted to the trauma ICU (Intensive Care Unit)...2. (Patient) will receive IV fluid resuscitation with normal saline at 110 mL (milliliters)/hour and will probably increase as needed to obtain adequate urinary output until the patient is properly resuscitated. Continued review of the hospital Discharge Summary dated January 18, 2013, revealed the Acute [MEDICAL CONDITION] resolved and the patient was discharged to another skilled nursing facility on January 18, 2013. Interview with the ADON, in the presence of the Administrator, on August 22, 2013, at 1:25 p.m., in the Conference Room, confirmed the hospital Discharge Summary dated December 14, 2012, was received by the facility from the hospital hours prior to the resident's admission to the facility. The ADON confirmed the resident was at high risk for Dehydration, and due to the resident's inability to meet the high output of the ostomies with oral intake, one liter of Normal Saline IV was required daily for hydration. Continued interview with the ADON confirmed the order was received for the Normal Saline 1000 cc's daily at 100 cc's per hour and was transcribed to the MAR by the admitting Nurse (RN #1) at 40 cc's per hour versus 100 cc's per hour. The ADON confirmed failed to follow through and review the MAR for accuracy and failed to notify the Physician of the IV rate transcription and validation error. A second interview with the ADON in the presence of the Administrator on August 29, 2013, at 4:00 p.m., in the conference room confirmed the IV rate on the MAR indicated [REDACTED]'s, not 100 cc's per hour. Continued interview confirmed the resident vomited on December 15, 16, and 20, 2012, and the Physician was not notified until December 16, 2012, and stated, "December 16, 2012 was on a Sunday and the on-call Physician was notified, who didn't know anything about the resident." The ADON confirmed further unmonitored and uncompensated fluid loss from the Negative Pressure [DEVICE] without Physician notification; in which the NN's revealed the canister was so full it had to be changed out once on December 20, and twice on December 21, 2012. The ADON stated, "We (facility) failed to notify the Physician of a change in condition." Interview with RN #1 in the presence of the Administrator on August 29, 2012, at 6:10 p.m., in the conference room confirmed RN #1 was on duty December 15, 2012 and knew the resident was medically and post-operatively complex. RN #1 stated, "I have never taken care of a patient with this degree of sickness...the huge wound in (resident's) abdomen, all the tubes coming from (resident's) abdomen" and "I knew (resident) had problems with maintaining...fluids, but I didn't realize to what extent...I realized the IV of NS was to ensure (resident) maintained adequate hydration in addition to P.O. fluids..." RN #1 stated, "I start work on the dayshift at approximately 6:45 a.m., to 6:50 a.m., receives report for the resident's for whom RN #1 is "responsible" for, and is normally through with report at approximately 7:45 a.m. Continued interview confirmed RN #1 could not recall why (RN #1) waited so long to start the IV fluids on December 15, 2012, at 10:50 a.m. RN #1 confirmed, "When I saw the order for the IV of NS, I miscalculated the rate to be 40 cc's an hour, which was 960 cc's per day and 40 cc's short of the ordered 1000 cc's per day." RN #1 confirmed the resident began vomiting on December 15, 2012, at 3:00 p.m., and RN #1 administered [MEDICATION NAME], P.O. RN #1 confirmed the order for the IV [MEDICATION NAME] and [MEDICATION NAME] was not obtained on December 15, and stated "I wrote the wrong date on the TO...I called the on-call Doctor on December 16th, not the 15th...the resident was not nauseous and/or vomiting on the December 14...began vomiting on the 15th and I gave [MEDICATION NAME] next day (16th)...vomiting again and (resident) told me [MEDICATION NAME] worked better. I called the on-call Doctor and told...resident said [MEDICATION NAME] worked better...was having pain...(Physician) asked if (resident) was on fluids (intravensously)...'yes' and I got the order for the [MEDICATION NAME] and [MEDICATION NAME] the [MEDICATION NAME] and [MEDICATION NAME](resident) was sick and crying...'wailing'...I didn't give the (on-call) Doctor any history or information on the resident other than (resident) was vomiting, having pain, and that [MEDICATION NAME] worked better..." Continued interview confirmed on December 16, 2012, the resident was in bed, crying, and vomiting (at 8:00 a.m.), and the wound canister, which held 1000 cc's, was full (at 10:00 a.m.); and on December 21, 2012, the canister was full twice on RN #1's shift. RN #1 confirmed the I&O Record for both intake and output contained multiple blanks and stated, "I was negligent in monitoring the resident's intake and output consistently...failed to notify the Doctor of the delay in starting the IV on December 15...failed to notify the Doctor when (resident's) change in condition began on December 15, 2012...and failed to notify the Doctor on December 20 and 21, 2012, when the wound canisters were full." Interview with Licensed Practical Nurse (LPN) #1 on August 30, 2013, at 10:00 a.m., in the Conference Room confirmed LPN #1 was assigned to the resident on December 22, 2012, on the first shift (7:00 a.m. to 7:00 p.m.), and stated, "On December 22, 2012, the resident was too sedated to take any medications or liquids by mouth until 3:00 p.m...was a very sick (resident)...we were unable to provide the level of care this resident needed." Continued interview confirmed LPN #1 did not notify the Physician of the resident's inability to take medications or fluids by mouth on December 22, 2012. Interview with the NP on August 30, 2013, at 1:10 p.m., in the Conference Room, confirmed the NP recalled the resident, who was a "very sick individual." Continued interview confirmed the IV of NS was to be administered at 100 cc's per hour and the rate of 40 cc's per hour did not get the resident the required total of 1000 cc's needed per day, and stated, "I wasn't informed of this." Continued interview confirmed when the resident had the change in condition on December 15, 2012, and began vomiting, the nurse did not call (the NP), "but should have." Continued interview confirmed the NP was not notified of the delay in starting the IV fluids on December 15, 2012. Further interview with the NP confirmed, "I did not receive notification from the facility on December 20, 2012, of the (resident) vomiting or any issues regarding output. I was told (upon arriving at the facility) the resident was anxious and 'a bundle of nerves' and that's why I wrote the order for the [MEDICATION NAME]. I saw Anxiety and wasn't informed of the vomiting." Interview with the Attending Physician on August 30, 2013, at approximately 4:15 p.m., in the Conference Room, confirmed the Physician did not receive any calls from the facility regarding this resident. Interview with the Administrator on September 11, 2013, at approximately 2:30 p.m., in the Conference Room, confirmed the facility failed to ensure policies were followed and notify the Physician of the resident's change in condition, the delay in administering intravenous fluids, not administering the correct amount of fluids, uncompensated fluid loss, and inability to safely swallow medications due to sedation. In summary, the facility failed to notify the Physician of a change in resident #1's condition; inability to swallow medication; failed to notify the Physician of the error of administering IV fluids at a rate and amount less than ordered by the Physician, and failed to notify the Physician of the intake and output/loss of uncompensated fluids. On December 20, the resident was vomiting (more uncompensated fluid loss) and the surgical wound drainage filled a 1000 cc canister (more uncompensated fluid loss); and the Physician was not notified. RN #1 documented the resident was "weeping" and talked with a "whine" due to "concern" over "how much nausea and vomiting" (resident) was having; and the Physician was not notified. On December 21, the surgical wound drainage filled two canisters, for a total of 2000 cc's of fluid loss (more uncompensated fluid loss); and the Physician was not notified. It was on December 22, 2012, that the resident's RP "demanded" the resident be transferred to the hospital. The facility did transfer the resident back to the same hospital, where just two days prior to admission to the facility, the resident's creatinine and sodium levels were normal. Upon evaluation in the hospital ER, the resident had a critical (life-threatening) sodium level of 117 (normal reference range: 136-147), and the creatinine was 6.83 (normal reference range: 0.60-1.30). The resident was in Acute [MEDICAL CONDITION] secondary to severe dehydration, and was admitted to the hospital's Trauma ICU. The Immediate Jeopardy was effective from December 14, 2012, through September 12, 2013, and was removed on September 13, 2013. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on September 13, 2013. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure all staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Fluid Intake and Output (I&O) Measurement (revised) b. IV Therapy (re-educated) c. Condition Change of Resident (re-educated) d. Procedure for Verbal/Telephone and Physician order [REDACTED]. e. 24-Hour Report of Resident Change in Condition (re-educated) f. Clinical Daily Rounds (newly implemented) g. Negative Pressure Wound Therapy and Devices (newly implemented education and competency) 2. Conduced interviews with licensed nursing staff, to include six Registered Nurses and fifteen Licensed Practical Nurses for a total of twenty-one of thirty-one licensed nurses on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Fluid Intake and Output, IV Therapy, Condition Change of Resident, Procedure for Verbal/Telephone and Physician Orders, 24-Hour Report of Resident Change in Condition, Clinical Daily Rounds; and Negative Pressure Wound Therapy and Devices" to ensure staff recognize and respond to the following: a. The rationale for monitoring bodily orifice output that may warrant Physician notification and intervention. Including but not limited to: [MEDICAL CONDITION], negative pressure wound therapy and devices, indwelling urinary catheters, emesis, and new onset of runny stools. The interviews included a verbal explanation of who may require I&O monitoring and measurement; what is considered fluid intake and output; when and by whom is the fluid intake and output obtained and what is the significance; and when, where and by whom is the intake and output measured and documented. The Comprehensive Intake-Output Record and Intake/Output Worksheet coexist and are required in accordance with the Fluid Intake and Output Measurement Policy. b. The facility's procedural requirement for all new IV therapy orders, which must be clarified and validated by two licensed nurses, to ensure accuracy of flow rate, type of solution, time, dose and resident receiving IV therapy. The interviews included the process for validation; and a written dosage and calculation test (using pen and paper only) to ensure comprehension in calculating a flow rate per hour, drops per minute, and hours of administration. c. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. d. The facility's policy and procedural requirement for verbal/telephone and Physician orders, and ensuring clarification. Interviews included a verbal explanation on how to write verbal and telephone orders and ensure accuracy when transcribing all orders to the Medication Administration. e. The facility's policy and guidelines for use of the 24-Hour Report. Interviews ensured the understanding and use of the 24-Hour Report, 24-Hour Report Change in Condition Book with Protocols for Physician Notification and Care Path Algorithms. The 24-Hour Report, 24-Hour Report Change in Condition Book with Protocols for Physician Notification and Care Path Algorithms coexist and are required in accordance with the Condition Change of Resident Policy. e. The process of the facility's required Clinical Daily Rounds. Interviews included what the rounds are, what is to be accomplished with rounds, who participates, how often, and what follow-up is required. f. The rationale for Negative Pressure Wound Therapy and Devices to ensure competent use. Interviews included why the system is used, how it works, monitoring and measuring of output; and the accurate application and dressing changes. 3. Review of Dehydration Risk Assessments with 34 resident's requiring I&O monitoring (including intake, or output, or both). 4. Review of IV orders and Peripheral IV Documentation Forms was not conducted; no residents were receiving IV therapy at the time of review. 5. Review of the active 24-Hour Report and Nurse's Notes related to changes in residents' condition. 6. Review of Verbal/Telephone and Physician orders. IV therapy orders were not reviewed; no residents were receiving IV therapy at the time of the review. 7. Review of an emergency Quality Assurance/Performance Improvement Committee Meeting was held on September 11, 2013, with the Administrator, Medical Director, Director of Nursing, Registered Dietician, Housekeeping/Laundry Staff; Environmental Services Director, District Director of Clinical Services, and Case Management. Based upon the compliant survey initiated on August 20, 2013, the Committee discussed the areas of concern and corrective actions as identified in the Allegation of Compliance. Non-compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. C/O #

Based on medical record review, review of educational article, review of employee files, review of training records, review of facility policies, review of facility records, review of facility investigation, and interview, the facility neglected to notify the physician of a change in resident condition, neglected to administer intravenous fluids as ordered by the Physician, neglected to monitor and manage the intake and output; and neglected to ensure training and competency of nursing staff for negative pressure wound therapy for one resident (#1), and failed to prevent misappropriation of narcotics for three residents (#18, #19, #20) of thirty-two residents reviewed. The facility's negligence resulted in resident (#1) with a history of Acute [MEDICAL CONDITION] developing an exacerbation secondary to severe dehydration and placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Quality Specialist, District Director of Clinical Operations, and Corporate Registered Nurse (RN) were informed of the Immediate Jeopardy in the Conference Room on [DATE], at 3:05 p.m. F224 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated [DATE], with the fax header dated [DATE], at 1:50 p.m., revealed, "..XXX[AGE] year-old...with a history of [MEDICAL CONDITION] status [REDACTED]. This hospital course is complicated mostly by [MEDICATION NAME] fistula with secondary complications due to such fistula. The patient [MEDICAL CONDITION] stents replaced without any complications and since that time period...acute [MEDICAL CONDITION] has resolved...creatinine has returned to normal/baseline...no other issues with...ileal conduit since that [MEDICATION NAME] fistula...repaired on [DATE] ([DATE]) and...had no further recurrence of [MEDICATION NAME] fistula, most notably by no stool (feces) per vagina. To address...ostomy, the patient has a high output [MEDICAL CONDITION] (an artificial opening created in the Ileum and brought to the surface of the abdomen for the purpose of evacuating feces) which subsequently had complication of an [MEDICATION NAME] fistula (a cutaneous fistula connecting the body surface and some parts of the intestine) coming through the midline incision. The incision was opened, it was irrigated and replaced with a negative pressure [DEVICE] which is still currently being used today...To address the ileocutaneous fistula...stent was placed...on [DATE] ([DATE]) and then replaced on [DATE] ([DATE]) which covered the fistula. Since that time there has been no further leakage from this fistula into the midline incision...To address...urinary output...patient has also required a one liter (1000 milliliters or 1000 cubic centimeters) normal saline infusion (intravenously) over 8 (eight) hours each day to maintain an adequate urinary output...due to...high output ostomy...is not able to maintain p.o. (by mouth) fluid well enough to keep up with...ostomy output. The patient will be discharged with instructions to maintain or continue a one liter normal saline infusion...per day...will be discharged to a skilled nursing facility...I would not anticipate any further problems at this moment..." Medical record review of a hospital laboratory report dated [DATE], revealed a Creatinine level (measures kidney function) of 0.76 (normal reference range: 0XXX,[DATE].30); and a Sodium level (an electrolyte in the blood) of 136 (normal reference range: ,[DATE]). Medical record review of the hospital's discharge Physician orders [REDACTED]." Medical record review of a Physician's Telephone Order (TO) dated [DATE], (no time), revealed, "Clarification order NS...IV Q (every) day @ (at) 100 ml (milliliters)/ (per) hour x 14 days." Continued review revealed the Assistant Director of Nursing (ADON) signed in validation of the TO being written and correctly transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Medical record review of the [DATE] MAR indicated [REDACTED]." Continued review revealed Registered Nurse (RN) #1 incorrectly transcribed the rate as 40 cc's per hour instead of 100 cc's per hour, which equated to an amount of 960 cc's per day instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Continued review revealed the IV was administered at 40 cc's per hour from [DATE], until sometime on [DATE]. Further review revealed on [DATE], the IV order was re-transcribed; a line was struck through the 40 cc's with "error" written below the 40 cc's and 100 cc's written above the erroneous 40 cc's. Medical record review of the Nurse's Notes (NN) revealed the resident was admitted to the facility on [DATE], at 7:00 p.m. (five hours and ten minutes after the resident's Discharge Summary was sent to the facility). Continued review revealed the IV was not started until [DATE], at 10:50 a.m., and was set to be administered at 40 cc's per hour, which equated to an approximate amount of 520 cc's on [DATE] instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Medical record review of a Physician's TO dated [DATE], at 2:25 p.m., revealed a PRN (as needed) order for IV [MEDICATION NAME] (for nausea and vomiting) and [MEDICATION NAME] (for pain). Medical record review of the MAR indicated [REDACTED]#1 on [DATE], at 6:10 p.m., in the Conference Room, confirmed the Physician's TO dated [DATE], at 2:25 p.m., for the PRN IV [MEDICATION NAME] and [MEDICATION NAME] was incorrectly dated for [DATE], which should have been dated [DATE], at 2:25 p.m.) Continued review of the NN's revealed the resident became nauseous and vomited on [DATE], at 3:00 p.m. Continued review revealed RN #1 gave [MEDICATION NAME], a medication for the nausea, as ordered on the admission Physician orders. Continued review of the NN's dated [DATE], and 16, 2012, at 10:00 p.m., and 4:00 a.m., respectively, revealed RN #2 continued to administer the IV at 40 cc's per hour. Medical record review of the NN's dated (Sunday) [DATE], completed by RN's #1 and #2 revealed: (RN #1) 4:25 p.m. "...having nausea and vomiting x2 today...Crying...tearful...c/o (complaint of) n/v (nausea and vomiting)...not knowing why...so sick...Called doctor o/c (on-call)...new orders...IV [MEDICATION NAME] (for nausea and vomiting)..." (RN #1) 9:45 p.m. "...Constantly tearful and speaks in whine-voice (long, high-pitched complaining cry)..." (RN #2) 10:00 p.m. "...Resident tearful stated very nauseated..." Medical record review of a NN completed by the ADON, dated [DATE], at 10:15 a.m., revealed, "[MEDICAL CONDITION] (an artificial opening created in the large intestine and brought to the surface of the abdomen for the purpose of evacuating feces)...liquid...stool...IV fluids running (administered) @ 40 cc/hr..." Medical record review revealed the resident had an [MEDICAL CONDITION] (in the Ileum of the small intestines, which produces liquid stool), not a [MEDICAL CONDITION] (in the Colon of the large intestines, which produces formed stool). Review of an educational article at www.cc.nih.gov, the National Institutes of Health Clinical Center, revealed, "...Broken-down food mixes with digestive juices and moves through the small and large intestines. The small intestine digests and absorbs nutrients. The large intestine stores undigested food and absorbs liquid..." Medical record review of a NN completed by RN #1 dated [DATE], revealed: 7:45 a.m. "...pt (patient) in bed [MEDICAL CONDITION] and [MEDICATION NAME] (urine) appliances leaking...n/v..." 8:00 a.m. "...med (medicated) with [MEDICATION NAME] n/v." 8:15 a.m. "wound dsg (dressing) changed, [MEDICAL CONDITION] and [MEDICATION NAME] appliances completely changed..." 9:00 a.m. "Wound dsg lost suction...attempted to reinforce dsg." 10:00 a.m. "Wound dsg changed for a second time. Canister (container to hold drainage from wound) changed out...was full (one canister holds 1000 cc's)." 12:00 p.m. "Pt weeping...talks with whine. Stating wants to see MD (Medical Doctor)/NP (Nurse Practitioner) because...is concerned about how much n/v...is having. Increased anxiety. Med (Medicated) with [MEDICATION NAME] (antianxiety) 0.5 mg (milligrams)." 2:00 p.m. "(NP) came ex (examined) pt. Discussed n/v...New orders noted..." Medical record review of a TO written by the NP, dated [DATE], revealed, "Give [MEDICATION NAME] 0.5 mg p.o. (by mouth) q (every) 6 (six) hr & (and) one q 6 hr prn anxiety..." Medical record review of a NN completed by RN #1 dated [DATE], at 8:20 p.m., revealed, "...Canister changed x2 (twice) today due to being full..." Medical record review of a Physical Therapy Assistant Weekly Progress Report, reporting period dated [DATE] to [DATE], revealed, "...Clinical Summary: Pt has had increased nausea and vomiting...and unable to tolerate increased movement...decrease treatment time as pt unable to tolerate a complete session..." Medical record review of a Physical Therapy Discharge Summary dated [DATE], revealed, "In the weeks pt received P.T. (physical therapy) rx (treatment), (resident) was quite ill and did not tolerate rx very well..." Medical record review of a NN completed by Licensed Practical Nurse (LPN) #1 dated [DATE], at 4:00 p.m., revealed, "Pt quite sedated and sleeping until 3:00 p.m...Did not take AM (morning) or noon [MEDICAL CONDITION] intact..." Continued review revealed no documentation the Physician was notified the resident was sedated and unable to take routine medications. Medical record review of a NN dated [DATE], at 8:45 p.m., revealed the resident's Responsible Party (RP) was concerned and called the facility. Continued review revealed, "...(RP) yelled and said, 'You're killing (resident)...(Resident) used to be able to have full good conversations and now (resident) can't pick up the phone'...(RP) demanding (resident) go to the (hospital) ER (emergency room )...Spoke to (ADON)...explained situation. (ADON) said to ask res (resident). Resident fairly lethargic but stated, 'Well I don't feel good.' ADON said to go ahead and send (resident)." Continued review revealed the resident left the facility by EMS (Emergency Medical Services) at 9:45 p.m. Medical record review of the [DATE] Comprehensive Intake-Ouput (I&O) Record revealed the following intake and/or output was not measured for monitoring of hydration status: [DATE], Output: [MEDICAL CONDITION], Negative Pressure [DEVICE]-no documentation (resident admitted to the facility at 7:00 p.m.; IV fluids were administered at the hospital prior to discharge); [DATE], Intake: PO, IV, H2O (water) with meds-no documentation; Output: [MEDICAL CONDITION], Negative Pressure [DEVICE], Emesis (vomit)-no documentation; [DATE], Intake: PO, IV, H2O (water) with meds-no documentation; Output: [MEDICAL CONDITION], Negative Pressure [DEVICE], Emesis (vomit)-no documentation; [DATE], Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; [DATE], Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; [DATE], Intake: IV-no documentation (except on nightshift); Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; [DATE], No documentation for any intake and/or output (except IV on nightshift); [DATE], No documentation for any intake and/or output; [DATE], No documentation for any intake and/or output (except urine on nightshift). Review of facility Intake/Output Worksheets (facility records) revealed three worksheets dated [DATE], and 19, 2012, was completed for urine output only on day and night shifts. Continued review revealed no worksheets were available for [DATE], 16, 20, 21, and 22, 2012. Review of facility employee files and training records of four RN's and one LPN, including the ADON, RN #1 and #2, and LPN #1, revealed no documentation of education and/or competency-based skills on Negative Pressure Wound Therapy. Review of facility policy, Notifications, original date [DATE] and release date [DATE], revealed, "...Staff informs the patient, consults with their attending physician, and notifies the patient's surrogates when...A significant change occurs in the patient's physical, mental...status..." Review of facility policy, Hydration, revised [DATE], revealed, "...Each resident is to be provided sufficient fluid to maintain hydration and health. Definition: Sufficient Fluid: The amount of fluid needed to prevent dehydration (fluid output far exceeds fluid intake) and maintain health. The amount needed...fluctuates as the resident's condition fluctuates. Compliance Guidelines: 1. Residents shall be assessed for risk of dehydration and/or dehydration...with significant change or more frequently if needed. 2. Clinicians consider the following when assessing risk for and presence of dehydration: a. Clinical conditions commonly associated with inadequate fluid intake; b. Presence of factors that increase the risk of dehydration; c. Clinical presentation of hydration deficits; d. Indirect signs/symptoms of fluid deficit..." Review of facility policy, IV Therapy, revised [DATE], revealed, "...A Skilled Nursing Center is responsible for the care of the residents receiving IV therapy...Compliance Guidelines...2. IV solutions are administered according to the prescriber orders..." Review of facility policy, Fluid Intake and Output Measurement, revised [DATE], revealed, "...Intake and output (I&O) measurement is recorded for residents according to the following criteria: Residents identified as at high risk for dehydration...Residents receiving intravenous therapy for duration of treatment...Definitions: Fluid Intake: All fluid entering the resident's body, including beverages, foods that are liquid at room temperature...and I.V. fluids. Fluid Output: All fluid that leaves the resident's body, including urine, loose stools, vomitus...and drainage from surgical drains...Procedure: 1. During each shift, measure fluid taken in by the resident; 2. Record amount of intake...Fluid Output...13. Record amount of output...Documentation Guidelines: 1. Record the shift, type, and amount of both intake and output; Significant variations in intake and output, as well as: a. Date and time of physician notification..." Review of facility policy, Abuse, original date [DATE], released date [DATE], revealed, "...neglect of the patient...(is) strictly prohibited...Patients have the right to be free of...neglect..." Medical record review of the emergency room Nurse's Notes dated [DATE], (time illegible), revealed, "...To (room number) via EMS, lethargic. Cries when moved...(urinary device) with thick urine...11:10 p.m., urine collected...foul odor noted...11:28 p.m., Critical (life-threatening) Values: Na (Sodium) 117 (normal reference range: ,[DATE])..." Medical record review of a hospital History and Physical dated [DATE], revealed the patient had been at the nursing home for the past eight days and had subsequently become debilitated. The patient presented with increased pain to the lower right quadrant, right flank and back with extreme tenderness to palpitation, and stated that the ileostomies were not having the output they once did when (patient) was in the hospital previously. Continued review revealed the patient's creatinine was 6.83 (normal reference range: 0XXX,[DATE].30), and sodium was 117. Assessment and plan revealed, "This is a [AGE] year-old...with likely [DIAGNOSES REDACTED] as well as acute [MEDICAL CONDITION] and [MEDICAL CONDITION]...1. The patient will be admitted to the trauma ICU (Intensive Care Unit)...2. (Patient) will receive IV fluid resuscitation with normal saline at 110 mL (milliliters)/hour and will probably increase as needed to obtain adequate urinary output until the patient is properly resuscitated. Continued review of the hospital Discharge Summary dated [DATE], revealed the Acute [MEDICAL CONDITION] resolved and the patient was discharged to another skilled nursing facility on [DATE]. Interview with the ADON, in the presence of the Administrator, on [DATE], at 1:25 p.m., in the Conference Room, confirmed the hospital Discharge Summary dated [DATE], was received by the facility from the hospital hours prior to the resident's admission to the facility. The ADON confirmed the resident was at high risk for Dehydration, and due to the resident's inability to meet the high output of the ostomies with oral intake, one liter of Normal Saline IV was required daily for hydration. Continued interview with the ADON confirmed the order was received for the Normal Saline 1000 cc's daily at 100 cc's per hour and was transcribed to the MAR by the admitting Nurse (RN #1). The ADON confirmed admission orders [REDACTED]. After the ADON confirmed this, the surveyor showed the MAR indicated [REDACTED]. The ADON confirmed neglected to follow through and review the MAR for accuracy in transcribing the order. Telephone interview with the Surgical Oncologist on [DATE], at approximately 2:51 p.m., confirmed, "...(Patient) left the hospital on [DATE], in stable condition...and (resident's) creatinine and sodium were normal...(patient) was not nauseous or vomiting when discharged from the hospital...(facility) should have called upon the initial vomiting to determine the cause (of the vomiting)...when (patient) returned (to the hospital on [DATE])...the creatinine was 6.83 and sodium was 117 (critical level)...(Patient) was severely Dehydrated and Hyponatremic and in Acute [MEDICAL CONDITION] levels are not compatible with life to sustain for a period of time...(patient) was at risk for death, no doubt about it. You don't get to those levels in 24-hours...you get there in days. This was negligent and unacceptable..." A second interview with the ADON in the presence of the Administrator on [DATE], at 4:00 p.m., in the conference room confirmed the IV rate on the MAR indicated [REDACTED]'s, not 100 cc's per hour. Continued interview confirmed the resident vomited on [DATE], and 20, 2012, and the Physician was not notified until [DATE], and stated, "[DATE] was on a Sunday and the on-call Physician was notified, who didn't know anything about the resident." The ADON confirmed further unmonitored and uncompensated fluid loss from the Negative Pressure [DEVICE]; in which the NN's revealed the canister was so full it had to be changed out on [DATE], and twice on [DATE]. Continued interview confirmed resident was transferred to the hospital on [DATE], per the RP's demand. Continued interview confirmed Negative Pressure Wound Therapy education had not been provided and skill competency had been validated for the nurses in providing Negative Pressure Wound Therapy. The ADON stated, "This (resident) was...a very sick (resident). (Resident) needed the IV (fluids) to compensate for...inability to take in enough P.O. fluids to cover (resident's) ostomy output, emesis, and wound drainage loss. We (facility) failed to monitor and manage the resident's I&O, to notify the Physician of a change in condition, and neglected the resident." Interview with RN #1 in the presence of the Administrator on [DATE], at 6:10 p.m., in the conference room confirmed RN #1 was on duty [DATE] and knew the resident was medically and post-operatively complex. RN #1 stated, "I have never taken care of a patient with this degree of sickness...the huge wound in (resident's) abdomen, all the tubes coming from (resident's) abdomen" and "I knew (resident) had problems with maintaining...fluids, but I didn't realize to what extent...I realized the IV of NS was to ensure (resident) maintained adequate hydration in addition to P.O. fluids..." RN #1 stated, "I start work on the dayshift at approximately 6:45 a.m., to 6:50 a.m., receives report for the resident's for whom RN #1 is "responsible" for, and is normally through with report at approximately 7:45 a.m. Continued interview confirmed RN #1 could not recall why (RN #1) waited so long to start the IV fluids on [DATE], at 10:50 a.m. RN #1 confirmed, "When I saw the order for the IV of NS, I miscalculated the rate to be 40 cc's an hour, which was 960 cc's per day and 40 cc's short of the ordered 1000 cc's per day." RN #1 confirmed the resident began vomiting on [DATE], at 3:00 p.m., and RN #1 administered [MEDICATION NAME], P.O. RN #1 confirmed the order for the IV [MEDICATION NAME] and [MEDICATION NAME] was not obtained on [DATE], and stated "I wrote the wrong date on the TO...I called the on-call Doctor on [DATE]th, not the 15th...the resident was not nauseous and/or vomiting on the [DATE]...began vomiting on the 15th and I gave [MEDICATION NAME] next day (16th)...vomiting again and (resident) told me [MEDICATION NAME] worked better. I called the on-call Doctor and told...resident said [MEDICATION NAME] worked better...was having pain...(Physician) asked if (resident) was on fluids (intravensously)...'yes' and I got the order for the [MEDICATION NAME] and [MEDICATION NAME] the [MEDICATION NAME] and [MEDICATION NAME](resident) was sick and crying...'wailing'...I didn't give the (on-call) Doctor any history or information on the resident other than (resident) was vomiting, having pain, and that [MEDICATION NAME] worked better..." Continued interview confirmed on [DATE], the resident was in bed, crying, and vomiting (at 8:00 a.m.), and the wound canister, which held 1000 cc's, was full (at 10:00 a.m.); and on [DATE], the canister was full twice on RN #1's shift. RN #1 confirmed the I&O Record for both intake and output contained multiple blanks and stated, "I was negligent in monitoring the resident's intake and output consistently...failed to notify the Doctor of the delay in starting the IV on [DATE]...failed to notify the Doctor when (resident's) change in condition began on [DATE]...and failed to notify the Doctor on [DATE] and 21, 2012, when the wound canisters were full." Interview with Licensed Practical Nurse (LPN) #1 on [DATE], at 10:00 a.m., in the Conference Room confirmed LPN #1 was assigned to the resident on [DATE], and stated, "On [DATE], the resident was too sedated to take any medications or liquids by mouth until 3:00 p.m...was a very sick (resident)...we were unable to provide the level of care this resident needed." Continued interview confirmed LPN #1 did not notify the Physician of the resident's inability to take medications or fluids by mouth on [DATE]. A third interview with the ADON in the presence of the Administrator on [DATE], at 11:30 a.m., confirmed the ADON was responsible for the oversight and review of the Intake/Output Worksheets. The ADON confirmed nursing has two 12-hour shifts (1st shift is days and 2nd shift is nights). At the end of second shift, the worksheets are turned in to the ADON for review. The ADON confirmed to review the worksheets during normal work days Monday through Friday, and upon the day of return to work after any time off (weekends, holidays, etc.) for the period of time elapsed while off. When the surveyor reviewed the Intake/Output Worksheets dated [DATE], and 19, 2012, with the ADON, the ADON confirmed the worksheets were not completed on [DATE], 16, 20, 21, and 22, 2012. Further interview confirmed the ADON failed to follow up when worksheets were not submitted, and neglected to determine if the resident's intake and/or output was being monitored. Interview with the NP on [DATE], at 1:10 p.m., in the Conference Room, confirmed the NP recalled the resident, who was a "very sick individual" and was unaware of the resident's fragile hydration needs "because the facility doesn't routinely get the Discharge Summaries from the hospital...I wish I would have known there was a Discharge Summary; they have such valuable information," and confirmed no recall of the summary being in the resident's chart. Continued interview confirmed the IV of NS was to be administered at 100 cc's per hour and the rate of 40 cc's per hour did not get the resident the required total of 1000 cc's needed per day. Continued interview confirmed when the resident had the change in condition on [DATE], and began vomiting, the nurse did not call (the NP), "but should have." Continued interview confirmed the NP was not notified of the delay in starting the IV fluids on [DATE]. Further interview with the NP confirmed, "I did not receive notification from the facility on [DATE], of the (resident) vomiting or any issues regarding output. I was told (upon arriving at the facility) the resident was anxious and 'a bundle of nerves' and that's why I wrote the order for the [MEDICATION NAME]. I saw Anxiety and wasn't informed of the vomiting." Interview with the Attending Physician on [DATE], at approximately 4:15 p.m., in the Conference Room, confirmed, "This resident was too sick to be admitted to this facility...This is not an ICU (Intensive Care Unit)." Continued interview confirmed the Physician did not receive any calls from the facility regarding this resident. Interview with RN #2 in the presence of the Administrator on [DATE], at 10:25 p.m., in the Conference Room, confirmed, "I didn't realize why the resident was getting daily IV's. " After reviewing the order for the IV of NS, MAR, NN's, and I&O Record, RN #2 confirmed, "I took care of this resident when I worked (second shift on [DATE], 17, 20, and 21, 2012)...(resident) was on my hall...I, along with other Nurses neglected to administer the correct amount of IV fluids, and neglected to monitor the intake and output. I had no training or experience working with (negative pressure wound therapy) prior to working here. I started here in [DATE], and this resident may have been my first one...my education (by the facility) consisted of a Nurse taking me in the room, showed me how to hook it up and put the dressing on, and that was it. It (education) wasn't good enough and I didn't feel good about it. I asked for additional education on (negative pressure wound therapy) (unable to recall who), but wasn't given any. Upon the surveyor asking how RN #2 determined the (negative pressure wound therapy) was functioning properly, RN #2 stated, "I know it's okay if there's 'stuff' going through the tube." Interview with the Administrator on [DATE], at approximately 2:30 p.m., in the Conference Room, confirmed the facility failed to ensure policies were followed; failed to administer the correct amount of IV fluids; failed to notify the Physician of the resident's change in condition, delay in administering IV fluids, loss of uncompensated fluids, and the resident's inability to safely swallow medications due to sedation; and failed to ensure the resident's hydration and intake and output status was monitored and managed, resulting in neglect of the resident. Interview with the District Director of Clinical Operations on [DATE], at 9:00 p.m., in the Conference Room, confirmed the facility failed to ensure licensed nursing staff were educated with competency validated on Negative Pressure Wound Therapy. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE], secondary to multiple comorbidities. Medical record review of a Physician's Telephone Order dated [DATE], and the [DATE] Medication Administration Records revealed the order for [MEDICATION NAME] (narcotic pain medication) 20 milligrams P.O. (by mouth) every eight hours, had been discontinued. Review of a facility investigation dated [DATE], revealed one (1) of the discontinued [MEDICATION NAME] tablets was missing and not available for destruction. Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE], secondary to multiple comorbidities. Medical record review of the [DATE] Physician's Recapitulation Orders and Medication Administration Records revealed an order for [REDACTED]. (by mouth) every eight hours. Review of a facility investigation dated [DATE], revealed two (2) of the [MEDICATION NAME]/[MEDICATION NAME] tablets were missing and not available for destruction. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE], and expired on [DATE], secondary to Pneumonia. Medical record review of the [DATE] Physician's Recapitulation Orders and Medication Administration Records revealed an order for [REDACTED]. Review of a facility investigation dated [DATE], revealed two (2) of the [MEDICATION NAME]es were missing and not available for destruction. Review of a facility investigation dated [DATE], at 7:00 a.m., revealed one (1) [MEDICATION NAME] tablet, two (2) [MEDICATION NAME] tablets, and two (2) [MEDICATION NAME]es were missing. Continued review of the investigation revealed Licensed Nurses were interview

Based on medical record review, review of educational article, review of employee files, review of training records, review of facility policies, review of facility records, and interview, the facility failed to notify the physician of a change in resident condition, failed to administer intravenous fluids as ordered by the Physician, and failed to prevent neglect by not following facility policies for resident change in condition, not monitoring the intake and output; and not ensuring training of nursing staff for negative pressure wound therapy for one resident (#1), of thirty-two residents reviewed. The facility's failure resulted in resident (#1) with a history of Acute [MEDICAL CONDITION] developing an exacerbation secondary to severe dehydration. The facility failed to ensure policies were followed and intake and output was monitored for residents #24 and #29. The facility's failure to notify the Physician of a change in condition, follow policies, ensure training, and monitor resident #1's hydration status resulted in resident's transfer to the hospital emergency room for evaluation and admission to the Trauma Intensive Care Unit for Dehydration and fluid resuscitation. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Quality Specialist, District Director of Clinical Operations, and Corporate Registered Nurse (RN) were informed of the Immediate Jeopardy in the Conference Room on September 11, 2013, at 3:05 p.m. F309 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on December 14, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated December 14, 2012, with the fax header dated December 14, 2012, at 1:50 p.m., revealed, "..XXX[AGE] year-old...with a history of [MEDICAL CONDITION] status [REDACTED]. This hospital course is complicated mostly by [MEDICATION NAME] fistula with secondary complications due to such fistula. The patient [MEDICAL CONDITION] stents replaced without any complications and since that time period...acute [MEDICAL CONDITION] has resolved...creatinine has returned to normal/baseline...no other issues with...ileal conduit since that [MEDICATION NAME] fistula...repaired on 11/8/12 (November 8, 2012) and...had no further recurrence of [MEDICATION NAME] fistula, most notably by no stool (feces) per vagina. To address...ostomy, the patient has a high output [MEDICAL CONDITION] (an artificial opening created in the Ileum and brought to the surface of the abdomen for the purpose of evacuating feces) which subsequently had complication of an [MEDICATION NAME] fistula (a cutaneous fistula connecting the body surface and some parts of the intestine) coming through the midline incision. The incision was opened, it was irrigated and replaced with a negative pressure [DEVICE] which is still currently being used today...To address the ileocutaneous fistula...stent was placed...on 12/5/12 (December 5, 2012) and then replaced on 12/10/12 (December 10, 2012) which covered the fistula. Since that time there has been no further leakage from this fistula into the midline incision...To address...urinary output...patient has also required a one liter (1000 milliliters or 1000 cubic centimeters) normal saline infusion (intravenously) over 8 (eight) hours each day to maintain an adequate urinary output...due to...high output ostomy...is not able to maintain p.o. (by mouth) fluid well enough to keep up with...ostomy output. The patient will be discharged with instructions to maintain or continue a one liter normal saline infusion...per day...will be discharged to a skilled nursing facility...I would not anticipate any further problems at this moment..." Medical record review of a hospital laboratory report dated December 12, 2012, revealed a Creatinine level (measures kidney function) of 0.76 (normal reference range: 0.60-1.30); and a Sodium level (an electrolyte in the blood) of 136 (normal reference range: 136-147). Medical record review of the hospital's discharge Physician orders [REDACTED]." Medical record review of a Physician's Telephone Order (TO) dated December 14, 2012, (no time), revealed, "Clarification order NS...IV Q (every) day @ (at) 100 ml (milliliters)/ (per) hour x 14 days." Continued review revealed the Assistant Director of Nursing signed in validation of the TO being written and correctly transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Medical record review of the December 2012 MAR indicated [REDACTED]." Continued review revealed Registered Nurse (RN) #1 incorrectly transcribed the rate as 40 cc's per hour instead of 100 cc's per hour, which equated to an amount of 960 cc's per day instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Continued review revealed the IV was administered at 40 cc's per hour from December 15, 2012 until sometime on December 19, 2012. Further review revealed on December 19, 2012, the IV order was re-transcribed; a line was struck through the 40 cc's with "error" written below the 40 cc's and 100 cc's written above the erroneous 40 cc's. Medical record review of the Nurse's Notes (NN) revealed the resident was admitted to the facility on [DATE], at 7:00 p.m. (five hours and ten minutes after the resident's Discharge Summary was sent to the facility). Continued review revealed the IV was not started until December 15, 2012, at 10:50 a.m., and was set to be administered at 40 cc's per hour, which equated to an approximate amount of 520 cc's on December 15 instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Medical record review of a Physician's TO dated December 15, 2012, at 2:25 p.m., revealed a PRN (as needed) order for IV [MEDICATION NAME] (for nausea and vomiting) and [MEDICATION NAME] (for pain). Medical record review of the hospital's discharge Physician orders [REDACTED]." Medical record review of a Physician's Telephone Order (TO) dated December 14, 2012, (no time), revealed, "Clarification order NS...IV Q (every) day @ (at) 100 ml (milliliters)/ (per) hour x 14 days." Continued review revealed the Assistant Director of Nursing (ADON) signed in validation of the TO being written and correctly transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Medical record review of the NN's revealed the resident became nauseous and vomited on December 15, 2012, at 3:00 p.m. Continued review revealed RN #1 gave [MEDICATION NAME], a medication for the nausea, which was a part of the admission Physician orders. Continued review of the NN's dated December 15, and 16, 2012, at 10:00 p.m., and 4:00 a.m., respectively, revealed RN #2 continued to administer the IV at 40 cc's per hour. Medical record review of the NN's dated (Sunday) December 16, 2012, completed by RN's #1 and #2 revealed: (RN #1) 4:25 p.m. "...having nausea and vomiting x2 today...Crying...tearful...c/o (complaint of) n/v (nausea and vomiting)...not knowing why...so sick...Called doctor o/c (on-call)...new orders...IV [MEDICATION NAME] (for nausea and vomiting)..." (RN #1) 9:45 p.m. "...Constantly tearful and speaks in whine-voice (long, high-pitched complaining cry)..." (RN #2) 10:00 p.m. "...Resident tearful stated very nauseated..." Medical record review of a NN completed by the ADON, dated December 19, 2012, at 10:15 a.m., revealed, "[MEDICAL CONDITION] (an artificial opening created in the large intestine and brought to the surface of the abdomen for the purpose of evacuating feces)...liquid...stool...IV fluids running (administered) @ 40 cc/hr..." Review of the medical record revealed the resident had an [MEDICAL CONDITION] (in the Ileum of the small intestines, which produces liquid stool), not a [MEDICAL CONDITION] (in the Colon of the large intestines, which produces formed stool). Review of an educational article at www.cc.nih.gov, the National Institutes of Health Clinical Center, revealed, "...Broken-down food mixes with digestive juices and moves through the small and large intestines. The small intestine digests and absorbs nutrients. The large intestine stores undigested food and absorbs liquid..." Medical record review of a NN completed by RN #1 dated December 20, 2012, revealed: 7:45 a.m. "...pt (patient) in bed [MEDICAL CONDITION] and [MEDICATION NAME] (urine) appliances leaking...n/v..." 8:00 a.m. "...med (medicated) with [MEDICATION NAME] n/v." 8:15 a.m. "wound dsg (dressing) changed, [MEDICAL CONDITION] and [MEDICATION NAME] appliances completely changed..." 9:00 a.m. "Wound dsg lost suction...attempted to reinforce dsg." 10:00 a.m. "Wound dsg changed for a second time. Canister (container to hold drainage from wound) changed out...was full (one canister holds 1000 cc's)." 12:00 p.m. "Pt weeping...talks with whine. Stating wants to see MD (Medical Doctor)/NP (Nurse Practitioner) because...is concerned about how much n/v...is having. Increased anxiety. Med (Medicated) with [MEDICATION NAME] (antianxiety) 0.5 mg (milligrams)." 2:00 p.m. "(NP) came ex (examined) pt. Discussed n/v...New orders noted..." Medical record review of a TO written by the NP, dated December 20, 2012, revealed, "Give [MEDICATION NAME] 0.5 mg p.o. (by mouth) q (every) 6 (six) hr & (and) one q 6 hr prn anxiety..." Medical record review of a NN completed by RN #1 dated December 21, 2012, at 8:20 p.m., revealed, "...Canister changed x2 (twice) today due to being full..." Medical record review of a Physical Therapy Assistant Weekly Progress Report, reporting period dated December 15 to December 21, 2012, revealed, "...Clinical Summary: Pt has had increased nausea and vomiting...and unable to tolerate increased movement...decrease treatment time as pt unable to tolerate a complete session..." Medical record review of a Physical Therapy Discharge Summary dated December 22, 2012, revealed, "In the weeks pt received P.T. (physical therapy) rx (treatment), (resident) was quite ill and did not tolerate rx very well..." Medical record review of a NN completed by Licensed Practical Nurse (LPN) #1 dated December 22, 2012, at 4:00 p.m., revealed, "Pt quite sedated and sleeping until 3:00 p.m...Did not take AM (morning) or noon [MEDICAL CONDITION] intact..." Continued review revealed no documentation the Physician was notified the resident was sedated and unable to take routine medications. Medical record review of a NN dated December 22, 2012, at 8:45 p.m., revealed the resident's Responsible Party (RP) was concerned and called the facility. Continued review revealed, "...(RP) yelled and said, 'You're killing (resident)...(Resident) used to be able to have full good conversations and now (resident) can't pick up the phone'...(RP) demanding (resident) go to the (hospital) ER (emergency room )...Spoke to (ADON)...explained situation. (ADON) said to ask res (resident). Resident fairly lethargic but stated, 'Well I don't feel good.' ADON said to go ahead and send (resident)." Continued review revealed the resident left the facility by EMS (Emergency Medical Services) at 9:45 p.m. Medical record review of the December 2012 Comprehensive Intake-Ouput (I&O) Record revealed the following intake and/or output was not measured for monitoring of hydration status: December 14, Output: [MEDICAL CONDITION], Negative Pressure [DEVICE]-no documentation (resident admitted to the facility at 7:00 p.m.; IV fluids were administered at the hospital prior to discharge); December 15, Intake: PO, IV, H2O (water) with meds-no documentation; Output: [MEDICAL CONDITION], Negative Pressure [DEVICE], Emesis (vomit)-no documentation; December 16, Intake: PO, IV, H2O (water) with meds-no documentation; Output: [MEDICAL CONDITION], Negative Pressure [DEVICE], Emesis (vomit)-no documentation; December 17, Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; December 18, Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; December 19, Intake: IV-no documentation (except on nightshift); Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; December 20, No documentation for any intake and/or output (except IV on nightshift); December 21, No documentation for any intake and/or output; December 22, No documentation for any intake and/or output (except urine on nightshift). Review of facility Intake/Output Worksheets (facility records) revealed three worksheets dated December 17, 18, and 19, 2012, was completed for urine output only on day and night shifts. Continued review revealed no worksheets were available for December 14, 15, 16, 20, 21, and 22, 2012. Review of facility employee files and training records of four RN's and one LPN, including the ADON, RN #1 and #2, and LPN #1, revealed no documentation of education and/or competency-based skills on Negative Pressure Wound Therapy. Review of facility policy, Notifications, original date September 23, 2003 and release date April 28, 2013, revealed, "...Staff informs the patient, consults with their attending physician, and notifies the patient's surrogates when...A significant change occurs in the patient's physical, mental...status..." Review of facility policy, Hydration, revised October 31, 2010, revealed, "...Each resident is to be provided sufficient fluid to maintain hydration and health. Definition: Sufficient Fluid: The amount of fluid needed to prevent dehydration (fluid output far exceeds fluid intake) and maintain health. The amount needed...fluctuates as the resident's condition fluctuates. Compliance Guidelines: 1. Residents shall be assessed for risk of dehydration and/or dehydration...with significant change or more frequently if needed. 2. Clinicians consider the following when assessing risk for and presence of dehydration: a. Clinical conditions commonly associated with inadequate fluid intake; b. Presence of factors that increase the risk of dehydration; c. Clinical presentation of hydration deficits; d. Indirect signs/symptoms of fluid deficit..." Review of facility policy, IV Therapy, revised January 15, 2010, revealed, "...A Skilled Nursing Center is responsible for the care of the residents receiving IV therapy...Compliance Guidelines...2. IV solutions are administered according to the prescriber orders..." Review of facility policy, Fluid Intake and Output Measurement, revised October 31, 2006, revealed, "...Intake and output (I&O) measurement is recorded for residents according to the following criteria: Residents identified as at high risk for dehydration...Residents receiving intravenous therapy for duration of treatment...Definitions: Fluid Intake: All fluid entering the resident's body, including beverages, foods that are liquid at room temperature...and I.V. fluids. Fluid Output: All fluid that leaves the resident's body, including urine, loose stools, vomitus...and drainage from surgical drains...Procedure: 1. During each shift, measure fluid taken in by the resident; 2. Record amount of intake...Fluid Output...13. Record amount of output...Documentation Guidelines: 1. Record the shift, type, and amount of both intake and output; Significant variations in intake and output, as well as: a. Date and time of physician notification..." Review of facility policy, Abuse, original date May 15, 2003, released date August 31, 2012, revealed, "...neglect of the patient...(is) strictly prohibited...Patients have the right to be free of...neglect..." Medical record review of the emergency room Nurse's Notes dated December 22, 2012, (time illegible), revealed, "...To (room number) via EMS, lethargic. Cries when moved...(urinary device) with thick urine...11:10 p.m., urine collected...foul odor noted...11:28 p.m., Critical (life-threatening) Values: Na (Sodium) 117 (normal reference range: 136-147)..." Medical record review of a hospital History and Physical dated December 22, 2012, revealed the patient had been at the nursing home for the past eight days and had subsequently become debilitated. The patient presented with increased pain to the lower right quadrant, right flank and back with extreme tenderness to palpitation, and stated that the ileostomies were not having the output they once did when (patient) was in the hospital previously. Continued review revealed the patient's creatinine was 6.83 (normal reference range: 0.60-1.30), and sodium was 117. Assessment and plan revealed, "This is a [AGE] year-old...with likely [DIAGNOSES REDACTED] as well as acute [MEDICAL CONDITION] and [MEDICAL CONDITION]...1. The patient will be admitted to the trauma ICU (Intensive Care Unit)...2. (Patient) will receive IV fluid resuscitation with normal saline at 110 mL (milliliters)/hour and will probably increase as needed to obtain adequate urinary output until the patient is properly resuscitated. Continued review of the hospital Discharge Summary dated January 18, 2013, revealed the Acute [MEDICAL CONDITION] resolved and the patient was discharged to another skilled nursing facility on January 18, 2013. Interview with the ADON, in the presence of the Administrator, on August 22, 2013, at 1:25 p.m., in the Conference Room, confirmed the hospital Discharge Summary dated December 14, 2012, was received by the facility from the hospital hours prior to the resident's admission to the facility. The ADON confirmed the resident was at high risk for Dehydration, and due to the resident's inability to meet the high output of the ostomies with oral intake, one liter of Normal Saline IV was required daily for hydration. Continued interview with the ADON confirmed the order was received for the Normal Saline 1000 cc's daily at 100 cc's per hour and was transcribed to the MAR by the admitting Nurse (RN #1) at 40 cc's per hour versus 100 cc's per hour. The ADON confirmed failed to follow through and review the MAR for accuracy and failed to notify the Physician of the IV rate transcription and validation error. Telephone interview with the Surgical Oncologist on August 28, 2013, at approximately 2:51 p.m., confirmed, "...(Patient) left the hospital on December 14, 2012, in stable condition...and (resident's) creatinine and sodium were normal...(patient) was not nauseous or vomiting when discharged from the hospital...(facility) should have called upon the initial vomiting to determine the cause (of the vomiting)...when (patient) returned (to the hospital on December 22)...the creatinine was 6.83 and sodium was 117 (critical level)...(Patient) was severely Dehydrated and Hyponatremic and in Acute [MEDICAL CONDITION] levels are not compatible with life to sustain for a period of time...(patient) was at risk for death, no doubt about it. You don't get to those levels in 24-hours...you get there in days. This was negligent and unacceptable..." A second interview with the ADON in the presence of the Administrator on August 29, 2013, at 4:00 p.m., in the conference room confirmed the IV rate on the MAR indicated [REDACTED]'s, not 100 cc's per hour. Continued interview confirmed the resident vomited on December 15, 16, and 20, 2012, and the Physician was not notified until December 16, 2012, and stated, "December 16, 2012 was on a Sunday and the on-call Physician was notified, who didn't know anything about the resident." The ADON confirmed further unmonitored and uncompensated fluid loss from the Negative Pressure [DEVICE] without Physician notification; in which the NN's revealed the canister was so full it had to be changed out once on December 20, and twice on December 21, 2012. Continued interview confirmed the resident was transferred to the hospital on December 22, 2012, per the RP's demand. Continued interview confirmed Negative Pressure Wound Therapy education had not been provided and skill competency had not been validated for the nurses in providing Negative Pressure Wound Therapy. The ADON stated, "This (resident) was...a very sick (resident). (Resident) needed the IV (fluids) to compensate for...inability to take in enough P.O. fluids to cover (resident's) ostomy output, emesis, and wound drainage loss. We (facility) failed to monitor and manage the resident's I&O, to notify the Physician of a change in condition, and neglected the resident." Interview with RN #1 in the presence of the Administrator on August 29, 2012, at 6:10 p.m., in the conference room confirmed RN #1 was on duty December 15, 2012 and knew the resident was medically and post-operatively complex. RN #1 stated, "I have never taken care of a patient with this degree of sickness...the huge wound in (resident's) abdomen, all the tubes coming from (resident's) abdomen" and "I knew (resident) had problems with maintaining...fluids, but I didn't realize to what extent...I realized the IV of NS was to ensure (resident) maintained adequate hydration in addition to P.O. fluids..." RN #1 stated, "I start work on the dayshift at approximately 6:45 a.m., to 6:50 a.m., receives report for the resident's for whom RN #1 is "responsible" for, and is normally through with report at approximately 7:45 a.m. Continued interview confirmed RN #1 could not recall why (RN #1) waited so long to start the IV fluids on December 15, 2012, at 10:50 a.m. RN #1 confirmed, "When I saw the order for the IV of NS, I miscalculated the rate to be 40 cc's an hour, which was 960 cc's per day and 40 cc's short of the ordered 1000 cc's per day." RN #1 confirmed the resident began vomiting on December 15, 2012, at 3:00 p.m., and RN #1 administered [MEDICATION NAME], P.O. RN #1 confirmed the order for the IV [MEDICATION NAME] and [MEDICATION NAME] was not obtained on December 15, and stated "I wrote the wrong date on the TO...I called the on-call Doctor on December 16th, not the 15th...the resident was not nauseous and/or vomiting on the December 14...began vomiting on the 15th and I gave [MEDICATION NAME] next day (16th)...vomiting again and (resident) told me [MEDICATION NAME] worked better. I called the on-call Doctor and told...resident said [MEDICATION NAME] worked better...was having pain...(Physician) asked if (resident) was on fluids (intravensously)...'yes' and I got the order for the [MEDICATION NAME] and [MEDICATION NAME] the [MEDICATION NAME] and [MEDICATION NAME](resident) was sick and crying...'wailing'...I didn't give the (on-call) Doctor any history or information on the resident other than (resident) was vomiting, having pain, and that [MEDICATION NAME] worked better..." Continued interview confirmed on December 16, 2012, the resident was in bed, crying, and vomiting (at 8:00 a.m.), and the wound canister, which held 1000 cc's, was full (at 10:00 a.m.); and on December 21, 2012, the canister was full twice on RN #1's shift. RN #1 confirmed the I&O Record for both intake and output contained multiple blanks and stated, "I was negligent in monitoring the resident's intake and output consistently...failed to notify the Doctor of the delay in starting the IV on December 15...failed to notify the Doctor when (resident's) change in condition began on December 15, 2012...and failed to notify the Doctor on December 20 and 21, 2012, when the wound canisters were full." Interview with LPN #1 on August 30, 2013, at 10:00 a.m., in the Conference Room confirmed LPN #1 was assigned to the resident on December 22, 2012, on the first shift (7:00 a.m. to 7:00 p.m.), and stated, "On December 22, 2012, the resident was too sedated to take any medications or liquids by mouth until 3:00 p.m...was a very sick (resident)...we were unable to provide the level of care this resident needed." Continued interview confirmed LPN #1 did not notify the Physician of the resident's inability to take medications or fluids by mouth on December 22, 2012. A third interview with the ADON in the presence of the Administrator on August 30, 2012, at 11:30 a.m., confirmed the ADON was responsible for the oversight and review of the Intake/Output Worksheets. The ADON confirmed nursing has two 12-hour shifts (1st shift is days and 2nd shift is nights). At the end of second shift, the worksheets are turned in to the ADON for review. The ADON confirmed to review the worksheets during normal work days Monday through Friday, and upon the day of return to work after any time off (weekends, holidays, etc.) for the period of time elapsed while off. When the surveyor reviewed the Intake/Output Worksheets dated December 17, 18, and 19, 2012, with the ADON, the ADON confirmed the worksheets were not completed on December 14, 15, 16, 20, 21, and 22, 2012. Further interview confirmed the ADON failed to follow up when worksheets were not submitted, and neglected to determine if the resident's intake and/or output was being monitored. Interview with the NP on August 30, 2013, at 1:10 p.m., in the Conference Room, confirmed the NP recalled the resident, who was a "very sick individual" and was unaware of the resident's fragile hydration needs "because the facility doesn't routinely get the Discharge Summaries from the hospital...I wish I would have known there was a Discharge Summary; they have such valuable information," and confirmed no recall of the summary being in the resident's chart. Continued interview confirmed the IV of NS was to be administered at 100 cc's per hour and the rate of 40 cc's per hour did not get the resident the required total of 1000 cc's needed per day. Continued interview confirmed when the resident had the change in condition on December 15, 2012, and began vomiting, the nurse did not call (the NP), "but should have." Continued interview confirmed the NP was not notified of the delay in starting the IV fluids on December 15, 2012. Further interview with the NP confirmed, "I did not receive notification from the facility on December 20, 2012, of the (resident) vomiting or any issues regarding output. I was told (upon arriving at the facility) the resident was anxious and 'a bundle of nerves' and that's why I wrote the order for the [MEDICATION NAME]. I saw Anxiety and wasn't informed of the vomiting." Interview with the Attending Physician on August 30, 2013, at approximately 4:15 p.m., in the Conference Room, confirmed, "This resident was too sick to be admitted to this facility...This is not an ICU (Intensive Care Unit)." Continued interview confirmed the Physician did not receive any calls from the facility regarding this resident. Interview with RN #2 in the presence of the Administrator on September 9, 2013, at 10:25 p.m., in the Conference Room, confirmed, "I didn't realize why the resident was getting daily IV's. " After reviewing the order for the IV of NS, MAR, NN's, and I&O Record, RN #2 confirmed, "I took care of this resident when I worked (second shift on December 15, 16, 17, 20, and 21, 2012)...(resident) was on my hall...I, along with other Nurses neglected to administer the correct amount of IV fluids, and neglected to monitor the intake and output. I had no training or experience working with (negative pressure wound therapy) prior to working here. I started here in August 2012, and this resident may have been my first one...my education (by the facility) consisted of a Nurse taking me in the room, showed me how to hook it up and put the dressing on, and that was it. It (education) wasn't good enough and I didn't feel good about it. I asked for additional education on (negative pressure wound therapy) (unable to recall who), but wasn't given any. Upon the surveyor asking how RN #2 determined the (negative pressure wound therapy) was functioning properly, RN #2 stated, "I know it's okay if there's 'stuff' going through the tube." Interview with the Administrator on September 11, 2013, at approximately 2:30 p.m., in the Conference Room, confirmed the facility failed to ensure policies were followed; failed to administer the correct amount of IV fluids; failed to notify the Physician of the resident's change in condition, delay in administering IV fluids, loss of uncompensated fluids, and the resident's inability to safely swallow medications due to sedation; and failed to ensure the resident's hydration and intake and output status was monitored and managed, resulting in neglect of the resident. Interview with the District Director of Clinical Operations on September 15, 2013, at 9:00 p.m., in the Conference Room, confirmed the facility failed to ensure licensed nursing staff was educated with competency validated on Negative Pressure Wound Therapy. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's Telephone Orders (TO's) revealed: May 9, 2013, "Neg. (negative) pressure (wound) device to LL (left lower) abdominal wound (surgical wound)...Monitor, drain, and measure drainage from (closed-suction drain with bulb)..." May 14, 2013, revealed, "Measure, describe fluid drainage in (closed-suction drain with bulb) Q (every) shift, empty Q shift." May 17, 2013, "DC (discontinue) (closed-suction drain with bulb)...DC (negative pressure wound device)..." Medical record review revealed no documentation the output from the (closed-suction drain with bulb) was monitored, measured, and described on 1st shift on May 12, 13; and 2nd shift on May 10, 11, 12, and 16, 2013. Continued review revealed no documentation the output from the negative pressure wound device was monitored and measured on 1st and 2nd shifts on May 9, 10, 11, 12, and 16; and 2nd shift on May 16, 2013. Medical record review revealed the resident was discharged to the hospital on June 21, 2013, secondary to Pneumonia and was eventually discharged to another facility. Interview with the Director of Nursing (DON) on September 10, 2013, at 6:40 p.m., in the Conference Room confirmed the facility failed to ensure consistent monitoring and management of the resident's intake and output. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].

Based on medical record review, review of educational article, review of facility policies, review of facility records, and interview, the facility failed to follow policies and provide hydration, failed to administer intravenous fluids as ordered by the Physician, and failed to monitor the intake and output for one resident (#1), of thirty-two residents reviewed. The facility's failure resulted in resident (#1) with a history of Acute [MEDICAL CONDITION] developing an exacerbation secondary to severe dehydration. The facility's failure to ensure policies were followed and notify the Physician of a change in condition resulting in the loss of uncompensated fluids and monitor resident #1's hydration status resulted in the medically and post-operatively complex resident's transfer to the hospital emergency room for evaluation and admission to the Trauma Intensive Care Unit for Dehydration and fluid resuscitation. The facility's failure placed resident #1 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Quality Specialist, District Director of Clinical Operations, and Corporate Registered Nurse (RN) were informed of the Immediate Jeopardy in the Conference Room on September 11, 2013, at 3:05 p.m. F327 resulted in Substandard Quality of Care. The findings included: Resident #1 was admitted to the facility from the local hospital on December 14, 2012, with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Summary dated December 14, 2012, with the fax header dated December 14, 2012, at 1:50 p.m., revealed, "..XXX[AGE] year-old...with a history of [MEDICAL CONDITION] status [REDACTED]. This hospital course is complicated mostly by [MEDICATION NAME] fistula with secondary complications due to such fistula. The patient [MEDICAL CONDITION] stents replaced without any complications and since that time period...acute [MEDICAL CONDITION] has resolved...creatinine has returned to normal/baseline...no other issues with...ileal conduit since that [MEDICATION NAME] fistula...repaired on 11/8/12 (November 8, 2012) and...had no further recurrence of [MEDICATION NAME] fistula, most notably by no stool (feces) per vagina. To address...ostomy, the patient has a high output [MEDICAL CONDITION] (an artificial opening created in the Ileum and brought to the surface of the abdomen for the purpose of evacuating feces) which subsequently had complication of an [MEDICATION NAME] fistula (a cutaneous fistula connecting the body surface and some parts of the intestine) coming through the midline incision. The incision was opened, it was irrigated and replaced with a negative pressure [DEVICE] which is still currently being used today...To address the ileocutaneous fistula...stent was placed...on 12/5/12 (December 5, 2012) and then replaced on 12/10/12 (December 10, 2012) which covered the fistula. Since that time there has been no further leakage from this fistula into the midline incision...To address...urinary output...patient has also required a one liter (1000 milliliters or 1000 cubic centimeters) normal saline infusion (intravenously) over 8 (eight) hours each day to maintain an adequate urinary output...due to...high output ostomy...is not able to maintain p.o. (by mouth) fluid well enough to keep up with...ostomy output. The patient will be discharged with instructions to maintain or continue a one liter normal saline infusion...per day...will be discharged to a skilled nursing facility...I would not anticipate any further problems at this moment..." Medical record review of a hospital laboratory report dated December 12, 2012, revealed a Creatinine level (measures kidney function) of 0.76 (normal reference range: 0.60-1.30); and a Sodium level (an electrolyte in the blood) of 136 (normal reference range: 136-147). Medical record review of the hospital's discharge Physician orders [REDACTED]." Medical record review of a Physician's Telephone Order (TO) dated December 14, 2012, (no time), revealed, "Clarification order NS...IV Q (every) day @ (at) 100 ml (milliliters)/ (per) hour x 14 days." Continued review revealed the Assistant Director of Nursing (ADON) signed in validation of the TO being written and correctly transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Medical record review of the December 2012 MAR indicated [REDACTED]." Continued review revealed Registered Nurse (RN) #1 incorrectly transcribed the rate as 40 cc's per hour instead of 100 cc's per hour, which equated to an amount of 960 cc's per day instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Continued review revealed the IV was administered at 40 cc's per hour from December 15, 2012, until sometime on December 19, 2012. Further review revealed on December 19, 2012, the IV order was re-transcribed; a line was struck through the 40 cc's with "error" written below the 40 cc's and 100 cc's written above the erroneous 40 cc's. Medical record review of the Nurse's Notes (NN) revealed the resident was admitted to the facility on [DATE], at 7:00 p.m. (five hours and ten minutes after the resident's Discharge Summary was sent to the facility). Continued review revealed the IV was not started until December 15, 2012, at 10:50 a.m., and was set to be administered at 40 cc's per hour, which equated to an approximate amount of 520 cc's on December 15 instead of 1000 cc's per day, as ordered by the Physician to meet the resident's hydration needs. Medical record review of a Physician's TO dated December 15, 2012, at 2:25 p.m., revealed a PRN (as needed) order for IV [MEDICATION NAME] (for nausea and vomiting) and [MEDICATION NAME] (for pain). Medical record review of the MAR indicated [REDACTED]#1 on August 29, 2013, at 6:10 p.m., in the Conference Room, confirmed the Physician's TO dated December 15, 2012, at 2:25 p.m., for the PRN IV [MEDICATION NAME] and [MEDICATION NAME] was incorrectly dated for December 15, which should have been dated December 16, 2012, at 2:25 p.m.) Continued review of the NN's revealed the resident became nauseous and vomited on December 15, 2012, at 3:00 p.m. Continued review revealed RN #1 gave [MEDICATION NAME], a medication for the nausea, as ordered on the admission Physician orders. Continued review of the NN's dated December 15, and 16, 2012, at 10:00 p.m., and 4:00 a.m., respectively, revealed RN #2 continued to administer the IV at 40 cc's per hour. Medical record review of the NN's dated (Sunday) December 16, 2012, completed by RN's #1 and #2 revealed: (RN #1) 4:25 p.m. "...having nausea and vomiting x2 today...Crying...tearful...c/o (complaint of) n/v (nausea and vomiting)...not knowing why...so sick...Called doctor o/c (on-call)...new orders...IV [MEDICATION NAME] (for nausea and vomiting)..." (RN #1) 9:45 p.m. "...Constantly tearful and speaks in whine-voice (long, high-pitched complaining cry)..." (RN #2) 10:00 p.m. "...Resident tearful stated very nauseated..." Medical record review of a NN completed by the ADON, dated December 19, 2012, at 10:15 a.m., revealed, "[MEDICAL CONDITION] (an artificial opening created in the large intestine and brought to the surface of the abdomen for the purpose of evacuating feces)...liquid...stool...IV fluids running (administered) @ 40 cc/hr..." Review of the medical record revealed the resident had an [MEDICAL CONDITION] (in the Ileum of the small intestines, which produces liquid stool), not a [MEDICAL CONDITION] (in the Colon of the large intestines, which produces formed stool). Review of an educational article at www.cc.nih.gov, the National Institutes of Health Clinical Center, revealed, "...Broken-down food mixes with digestive juices and moves through the small and large intestines. The small intestine digests and absorbs nutrients. The large intestine stores undigested food and absorbs liquid..." Medical record review of a NN completed by RN #1 dated December 20, 2012, revealed: 7:45 a.m. "...pt (patient) in bed [MEDICAL CONDITION] and [MEDICATION NAME] (urine) appliances leaking...n/v..." 8:00 a.m. "...med (medicated) with [MEDICATION NAME] n/v." 8:15 a.m. "wound dsg (dressing) changed, [MEDICAL CONDITION] and [MEDICATION NAME] appliances completely changed..." 10:00 a.m. "Wound dsg changed for a second time. Canister (container to hold drainage from wound) changed out...was full (one canister holds 1000 cc's)." 12:00 p.m. "Pt weeping...talks with whine. Stating wants to see MD (Medical Doctor)/NP (Nurse Practitioner) because...is concerned about how much n/v...is having. Increased anxiety. Med (Medicated) with [MEDICATION NAME] (antianxiety) 0.5 mg (milligrams)." 2:00 p.m. "(NP) came ex (examined) pt. Discussed n/v...New orders noted..." Medical record review of a TO written by the NP, dated December 20, 2012, revealed, "Give [MEDICATION NAME] 0.5 mg p.o. (by mouth) q (every) 6 (six) hr & (and) one q 6 hr prn anxiety..." Medical record review of a NN completed by RN #1 dated December 21, 2012, at 8:20 p.m., revealed, "...Canister changed x2 (twice) today due to being full..." Medical record review of a NN dated December 22, 2012, at 8:45 p.m., revealed the resident's Responsible Party (RP) was concerned and called the facility. Continued review revealed, "...(RP) yelled and said, 'You're killing (resident)...(Resident) used to be able to have full good conversations and now (resident) can't pick up the phone'...(RP) demanding (resident) go to the (hospital) ER (emergency room )...Spoke to (ADON)...explained situation. (ADON) said to ask res (resident). Resident fairly lethargic but stated, 'Well I don't feel good.' ADON said to go ahead and send (resident)." Continued review revealed the resident left the facility by EMS (Emergency Medical Services) at 9:45 p.m. Medical record review of the December 2012 Comprehensive Intake-Ouput (I&O) Record revealed the following intake and/or output was not measured for monitoring of hydration status: December 14, Output: [MEDICAL CONDITION], Negative Pressure [DEVICE]-no documentation (resident admitted to the facility at 7:00 p.m.; IV fluids were administered at the hospital prior to discharge); December 15, Intake: PO, IV, H2O (water) with meds-no documentation; Output: [MEDICAL CONDITION], Negative Pressure [DEVICE], Emesis (vomit)-no documentation; December 16, Intake: PO, IV, H2O (water) with meds-no documentation; Output: [MEDICAL CONDITION], Negative Pressure [DEVICE], Emesis (vomit)-no documentation; December 17, Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; December 18, Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; December 19, Intake: IV-no documentation (except on nightshift); Output: [MEDICAL CONDITION], Negative Pressure [DEVICE] -no documentation; December 20, No documentation for any intake and/or output (except IV on nightshift); December 21, No documentation for any intake and/or output; December 22, No documentation for any intake and/or output (except urine on nightshift). Review of facility Intake/Output Worksheets (facility records) revealed three worksheets dated December 17, 18, and 19, 2012, was completed for urine output only on day and night shifts. Continued review revealed no worksheets were available for December 14, 15, 16, 20, 21, and 22, 2012. Review of facility policy, Hydration, revised October 31, 2010, revealed, "...Each resident is to be provided sufficient fluid to maintain hydration and health. Definition: Sufficient Fluid: The amount of fluid needed to prevent dehydration (fluid output far exceeds fluid intake) and maintain health. The amount needed...fluctuates as the resident's condition fluctuates. Compliance Guidelines: 1. Residents shall be assessed for risk of dehydration and/or dehydration...with significant change or more frequently if needed. 2. Clinicians consider the following when assessing risk for and presence of dehydration: a. Clinical conditions commonly associated with inadequate fluid intake; b. Presence of factors that increase the risk of dehydration; c. Clinical presentation of hydration deficits; d. Indirect signs/symptoms of fluid deficit..." Review of facility policy, IV Therapy, revised January 15, 2010, revealed, "...A Skilled Nursing Center is responsible for the care of the residents receiving IV therapy...Compliance Guidelines...2. IV solutions are administered according to the prescriber orders..." Review of facility policy, Fluid Intake and Output Measurement, revised October 31, 2006, revealed, "...Intake and output (I&O) measurement is recorded for residents according to the following criteria: Residents identified as at high risk for dehydration...Residents receiving intravenous therapy for duration of treatment...Definitions: Fluid Intake: All fluid entering the resident's body, including beverages, foods that are liquid at room temperature...and I.V. fluids. Fluid Output: All fluid that leaves the resident's body, including urine, loose stools, vomitus...and drainage from surgical drains...Procedure: 1. During each shift, measure fluid taken in by the resident; 2. Record amount of intake...Fluid Output...13. Record amount of output...Documentation Guidelines: 1. Record the shift, type, and amount of both intake and output; Significant variations in intake and output, as well as: a. Date and time of physician notification..." Medical record review of the emergency room Nurse's Notes dated December 22, 2012, (time illegible), revealed, "...To (room number) via EMS, lethargic. Cries when moved...(urinary device) with thick urine...11:10 p.m., urine collected...foul odor noted...11:28 p.m., Critical (life-threatening) Values: Na (Sodium) 117 (normal reference range: 136-147)..." Medical record review of a hospital History and Physical dated December 22, 2012, revealed the patient had been at the nursing home for the past eight days and had subsequently become debilitated. Continued review revealed the patient's creatinine was 6.83 (normal reference range: 0.60-1.30), and sodium was 117. Assessment and plan revealed, "This is a [AGE] year-old...with likely [DIAGNOSES REDACTED] as well as acute [MEDICAL CONDITION] and [MEDICAL CONDITION]...1. The patient will be admitted to the trauma ICU (Intensive Care Unit)...2. (Patient) will receive IV fluid resuscitation with normal saline at 110 mL (milliliters)/hour and will probably increase as needed to obtain adequate urinary output until the patient is properly resuscitated. Continued review of the hospital Discharge Summary dated January 18, 2013, revealed the Acute [MEDICAL CONDITION] resolved and the patient was discharged to another skilled nursing facility on January 18, 2013. Interview with the ADON, in the presence of the Administrator, on August 22, 2013, at 1:25 p.m., in the Conference Room, confirmed the Discharge Summary dated December 14, 2012, was received by the facility from the hospital hours prior to the resident's admission to the facility. The ADON confirmed the resident was at high risk for Dehydration, and due to the resident's inability to meet the high output of the ostomies with oral intake, one liter of Normal Saline IV was required daily for hydration. Continued interview with the ADON confirmed the order was received for the Normal Saline 1000 cc's daily at 100 cc's per hour. The ADON clarified the order was transcribed incorrectly, at 40 cc's per hour versus 100 cc's per hour. Telephone interview with the Surgical Oncologist on August 18, 2013, at approximately 2:51 p.m., confirmed, "...(Patient) left the hospital on December 14, 2012, in stable condition...and (resident's) creatinine and sodium were normal...(patient) was not nauseous or vomiting when discharged from the hospital...(facility) should have called upon the initial vomiting to determine the cause (of the vomiting)...when (patient) returned (to the hospital on December 22)...the creatinine was 6.83 and sodium was 117 (critical level)...(Patient) was severely Dehydrated and Hyponatremic and in Acute [MEDICAL CONDITION] levels are not compatible with life to sustain for a period of time...(patient) was at risk for death, no doubt about it. You don't get to those levels in 24-hours...you get there in days. This was negligent and unacceptable..." A second interview with the ADON in the presence of the Administrator on August 29, 2013, at 4:00 p.m., in the conference room confirmed the IV rate on the MAR indicated [REDACTED]'s, not 100 cc's per hour. Continued interview confirmed the resident vomited on December 15, 16, and 20, 2012, and the Physician was not notified until December 16, 2012, and stated, "December 16, 2012 was on a Sunday and the on-call Physician was notified, who didn't know anything about the resident." The ADON confirmed further unmonitored and uncompensated fluid loss from the Negative Pressure [DEVICE] without Physician notification; in which the NN's revealed the canister was so full it had to be changed out once on December 20, and twice on December 21, 2012. Continued interview confirmed the resident was transferred to the hospital on December 22, 2012, per the RP's demand. The ADON stated, "This (resident) was...a very sick (resident). (Resident) needed the IV (fluids) to compensate for...inability to take in enough P.O. fluids to cover (resident's) ostomy output, emesis, and wound drainage loss. We (facility) failed to monitor and manage the resident's I&O..." Interview with RN #1 in the presence of the Administrator on August 29, 2012, at 6:10 p.m., in the conference room confirmed RN #1 was on duty December 15, 2012 and confirmed to know the resident was medically and post-operatively complex. RN #1 stated, "I have never taken care of a patient with this degree of sickness...the huge wound in (resident's) abdomen, all the tubes coming from (resident's) abdomen" and "I knew (resident) had problems with maintaining...fluids, but I didn't realize to what extent...I realized the IV of NS was to ensure (resident) maintained adequate hydration in addition to P.O. fluids..." RN #1 confirmed to start work on dayshift at approximately 6:45 a.m., to 6:50 a.m., receives report for the resident's for whom RN #1 is "responsible" for, and is normally through with report at approximately 7:45 a.m. Continued interview confirmed RN #1 could not recall why (RN #1) waited so long to start the IV fluids on December 15, 2012, at 10:50 a.m. RN #1 confirmed, "When I saw the order for the IV of NS, I miscalculated the rate to be 40 cc's an hour, which was 960 cc's per day and 40 cc's short of the ordered 1000 cc's per day." RN #1 confirmed the resident began vomiting on December 15, 2012, at 3:00 p.m., and RN #1 administered [MEDICATION NAME], P.O. RN #1 confirmed the order for the IV [MEDICATION NAME] and [MEDICATION NAME] was not obtained on December 15, and stated "I wrote the wrong date on the TO...I called the on-call Doctor on December 16th, not the 15th...the resident was not nauseous and/or vomiting on the December 14...began vomiting on the 15th and I gave [MEDICATION NAME] next day (16th)...vomiting again and (resident) told me [MEDICATION NAME] worked better. I called the on-call Doctor and told...resident said [MEDICATION NAME] worked better...was having pain...(Physician) asked if (resident) was on fluids...'yes' and I got the order for the [MEDICATION NAME] and [MEDICATION NAME] the [MEDICATION NAME] and [MEDICATION NAME](resident) was sick and crying...'wailing'...I didn't give the Doctor any history or information on the resident other than (resident) was vomiting, having pain, and that [MEDICATION NAME] worked better..." Continued interview confirmed on December 16, 2012, the resident was in bed, crying, and vomiting (at 8:00 a.m.), and the wound canister, which held 1000 cc's, was full (at 10:00 a.m.); and on December 21, 2012, the canister was full twice on RN #1's shift. RN #1 confirmed the I&O Record for both intake and output contained multiple blanks and stated, "I was negligent in monitoring the resident's intake and output consistently, and failed to notify the Doctor when (resident's) change in condition began on December 15, 2012...and failed to notify the Doctor on December 20 and 21, 2012, when the wound canisters were full." Interview with Licensed Practical Nurse (LPN) #1 on August 30, 2013, at 10:00 a.m., in the Conference Room confirmed LPN #1 was assigned to the resident on December 22, 2012, on the first shift (7:00 a.m. to 7:00 p.m.), and stated, "On December 22, 2012, the resident was too sedated to take any medications or liquids by mouth until 3:00 p.m...was a very sick (resident)...we were unable to provide the level of care this resident needed." Continued interview confirmed LPN #1 did not notify the Physician of the resident's inability to take medications or fluids by mouth on December 22, 2012. A third interview with the ADON in the presence of the Administrator on August 30, 2012, at 11:30 a.m., confirmed the ADON was responsible for the oversight and review of the Intake/Output Worksheets. The ADON confirmed nursing has two 12-hour shifts (1st shift is days and 2nd shift is nights). At the end of second shift, the worksheets are turned in to the ADON for review. The ADON confirmed to review the worksheets during normal work days Monday through Friday, and upon the day of return to work after any time off (weekends, holidays, etc.) for the period of time elapsed while off. When the surveyor reviewed the Intake/Output Worksheets dated December 17, 18, and 19, 2012, with the ADON, the ADON confirmed the worksheets were not completed on December 14, 15, 16, 20, 21, and 22, 2012. Further interview confirmed the ADON failed to follow up when worksheets were not submitted, and neglected to determine if the resident's intake and/or output was being monitored. Interview with the NP on August 30, 2013, at 1:10 p.m., in the Conference Room, confirmed the NP recalled the resident, who was a "very sick individual" and was unaware of the resident's fragile hydration needs "because the facility doesn't routinely get the Discharge Summaries from the hospital...I wish I would have known there was a Discharge Summary; they have such valuable information," and confirmed no recall of the summary being in the resident's chart. Continued interview confirmed the IV of NS was to be administered at 100 cc's per hour and the rate of 40 cc's per hour did not get the resident the required total of 1000 cc's needed per day. Continued interview confirmed when the resident had the change in condition on December 15, 2012, and began vomiting, the nurse did not call (the NP), "but should have." Continued interview confirmed the NP was not notified of the delay in starting the IV fluids on December 15, 2012. Further interview with the NP confirmed, "I did not receive notification from the facility on December 20, 2012, of the (resident) vomiting or any issues regarding output. I was told (upon arriving at the facility) the resident was anxious and 'a bundle of nerves' and that's why I wrote the order for the [MEDICATION NAME]. I saw Anxiety and wasn't informed of the vomiting." Interview with RN #2 in the presence of the Administrator on September 9, 2013, at 10:25 p.m., in the Conference Room, confirmed, "I didn't realize why the resident was getting daily IV's. " After reviewing the order for the IV of NS, MAR, NN's, and I&O Record, RN #2 confirmed, "I took care of this resident when I worked...(resident) was on my hall...I, along with other Nurses neglected to administer the correct amount of IV fluids, and neglected to monitor the intake and output." Interview with the Administrator on September 11, 2013, at approximately 2:30 p.m., in the Conference Room, confirmed the facility failed to ensure policies were followed; failed to administer the correct amount of IV fluids; and failed to ensure the resident's hydration and intake and output status was monitored and managed, resulting in neglect of the resident. In summary, the facility failed to ensure the hydration required for resident #1 upon being made aware of the resident's medically and post-operatively complex condition. The resident was at high risk for Dehydration due to the resident's inability to intake enough oral fluids to compensate for the high output from the ostomies. To manage this risk of potential Dehydration, the Physician outlined a discharge plan in the resident's Discharge Summary dated December 14, 2012, and gave written orders for one-liter of Normal Saline to be administered intravenously, daily. Upon admission to the facility, the order for the IV fluids was clarified, with a specific rate of administration ordered of 100 cc's per hour. RN #1 confirmed "miscalculated" the rate and inaccurately transcribed the rate to read 40 cc's per hour instead of the ordered rate of 100 cc's per hour. The ADON confirmed the facility failed to administer the ordered amount of fluids from December 15, until December 19, 2012; it wasn't until December 19, that the rate was corrected on the Medication Administration Record, [REDACTED]. On December 15, RN #1 neglected to start the IV until 10:50 a.m., and at an incorrect rate of 40 cc's an hour, which only provided 520 cc's (initial uncompensated fluid loss) for the day instead of the ordered and necessary fluids of 1000 cc's. On December 15, the resident had a change in condition and began vomiting (more uncompensated fluid loss) and RN #1 neglected to notify the Physician of this change in the resident's condition. On December 16, the resident continued vomiting (more uncompensated fluid loss) and the on-call Physician, with no knowledge of the medically and post-operatively complex resident, was called by RN #1. RN #1 confirmed communication with the on-call Physician consisted of reporting the resident's pain and vomiting and that [MEDICATION NAME] worked better for the resident (than [MEDICATION NAME]). On December 20, the resident was vomiting (more uncompensated fluid loss) and the surgical wound drainage filled a 1000 cc canister (more uncompensated fluid loss). RN #1 documented the resident was "weeping" and talked with a "whine" due to "concern" over "how much nausea and vomiting" (resident) was having. On December 21, the surgical wound drainage filled two canisters, for a total of 2000 cc's of fluid loss (more uncompensated fluid loss). Further, the fluid loss from the resident's [MEDICAL CONDITION] was not monitored. On December 22, 2012, the resident's RP "demanded" the resident be transferred to the hospital. The facility did transfer the resident back to the same hospital, where just two days prior to admission to the facility, the resident's creatinine and sodium levels were normal. Upon evaluation in the hospital ER, the resident had a critical (life-threatening) sodium level of 117 (normal reference range: 136-147), and the creatinine was 6.83 (normal reference range: 0.60-1.30). The resident was in Acute [MEDICAL CONDITION] secondary to severe dehydration, and was admitted to the hospital's Trauma ICU. The Immediate Jeopardy was effective from December 14, 2012, through September 12, 2013, and was removed on September 13, 2013. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on September 13, 2013. The surveyor verified the allegation of compliance by: 1. Reviewing the facility's in-service records to ensure all staff were educated or re-educated regarding changes to and implementation of the facility's following policies: a. Fluid Intake and Output (I&O) Measurement (revised) b. IV Therapy (re-educated) c. Condition Change of Resident (re-educated) d. Procedure for Verbal/Telephone and Physician order [REDACTED]. e. 24-Hour Report of Resident Change in Condition (re-educated) f. Clinical Daily Rounds (newly implemented) g. Negative Pressure Wound Therapy and Devices (newly implemented education and competency) 2. Interviews conducted with licensed nursing staff, to include six Registered Nurses and fifteen Licensed Practical Nurses for a total of twenty-one of thirty-one licensed nurses on staff to determine the level of comprehension gained through in-service education conducted regarding changes to and implementation of the facility's policies, "Fluid Intake and Output, IV Therapy, Condition Change of Resident, Procedure for Verbal/Telephone and Physician Orders, 24-Hour Report of Resident Change in Condition, Clinical Daily Rounds; and Negative Pressure Wound Therapy and Devices" to ensure staff recognize and respond to the following: a. The rationale for monitoring bodily orifice output that may warrant Physician notification and intervention. Including but not limited to: [MEDICAL CONDITION], negative pressure wound therapy and devices, indwelling urinary catheters, emesis, and new onset of runny stools. The interviews included a verbal explanation of who may require I&O monitoring and measurement; what is considered fluid intake and output; when and by whom is the fluid intake and output obtained and what is the significance; and when, where and by whom is the intake and output measured and documented. The Comprehensive Intake-Output Record and Intake/Output Worksheet coexist and are required in accordance with the Fluid Intake and Output Measurement Policy. b. The facility's procedural requirement for all new IV therapy orders, which must be clarified and validated by two licensed nurses, to ensure accuracy of flow rate, type of solution, time, dose and resident receiving IV therapy. The interviews included the process for validation; and a written dosage and calculation test (using pen and paper only) to ensure comprehension in calculating a flow rate per hour, drops per minute, and hours of administration. c. What constitutes a change in a resident's condition and what is required when a change in a resident's condition occurs. Interviews included a verbal explanation of prompts notifications, who is notified and by whom, how soon, and required documentation. d. The facility's policy and procedural requirement for verbal/telephone and Physician orders, and ensuring clarification. Interviews included a verbal explanation on how to write verbal and telephone orders and ensure accuracy when transcribing all orders to the Medication Administration. e. The facilit