Every finding on record at Gainesville Health and Rehab Center

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure one of nine residents in the survey sample was free from abuse, Resident #1. This was cited as past non-compliance. The findings include: For Resident #1 (R1), the facility staff failed to ensure they were free from abuse by a staff member on 5/30/2023. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/28/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 6/7/2023 at 10:30 a.m., an interview was conducted with R1. R1 stated that the previous week they were in the hallway just past the activities door listening to music with another resident who resides on that side of the facility. R1 stated that they always hang out in that area with their girlfriend to listen to music together and talk. R1 stated that CNA (certified nursing assistant) #4 became irritated with them for no apparent reason. R1 stated that CNA #4 started arguing with their girlfriend about them being in the hallway near the unit. R1 stated that they tried to calm the situation but then they became angry and started yelling also. R1 stated that the CNA was yelling at them that they were not allowed there and had to go back to their unit. R1 stated that CNA #4 started pulling his wheelchair backwards so he grabbed the handrail on the wall. R1 stated that CNA #4 kept yanking the wheelchair and taking their hand off the railing. R1 stated that he fell from his wheelchair on their knee and their buttocks. R1 stated that the unit manager had come and assisted him to get back in the wheelchair and he had not been injured. R1 stated that he did not know what upset the CNA so much because they were in the same area that they always hung out in with their friend. R1 stated that the incident made him feel unsafe and it was the first time anything like that had ever happened. R1 stated that they felt safe at the facility now because the facility had handled the situation. The progress notes for R1 documented in part, - 05/30/2023 23:52 (11:52 p.m.) Fall note. Data : At 1945 (7:45 p.m.), the resident fell off from wheelchair. Action : After the fall, resident was assessed for alertness and consciousness. Resident remains to be alert and verbally responsive. Body audit was done no new skin tears, bruises, lump on head were assessed. Assessed for injury all extremities were flexed, and resident c/o (complains of) R (right) knee soreness. Offered to apply ice pack but resident refused. Tylenol 325 mg (milligram), 2 tabs (tablets) were administered prn (as needed) for R knee soreness. ADON (assistant director of nursing) was informed of the incident. [Name of physician] was informed of the incident. Family, [Name of family member] was called but did not answer, a message was recorded for call back. Response : We will continue to monitor the resident closely. - 05/31/2023 11:51 (11:51 a.m.) Psychosocial Visit note. Residents psychosocial concerns discussed (isolation, loneliness, fear, sadness, anxiety) : fear and anxiety. Residents outward appearance (sad, happy, crying, withdrawn, guarded) : happy but guarded. Interventions in place (staff visits, FaceTime visits, window visits, activities of interest) : phone calls with his mom, would like to take with psych services [Name of psychologist], weekly check-ins with social services. Follow up needed (psych referral, SW visits, family FaceTime visits) : psych referral, weekly meeting with SW (social worker). - 06/01/2023 08:42 (8:42 a.m.) Psych note. Note Text : Psychologist met with patient this AM; Discussed his interpretation of recent events involving an employee; Today he reports he feels very safe to be at this facility. His mood is calm. Also discussed recent escalation in aggressive verbal and at times physical behaviors. Patient states he feels his anger is due to not being included by my family in more family things; Encouraged talking to staff when frustrated; identified appropriate staff he can reach out to for support when needed. - 06/05/2023 14:01 (2:01 p.m.) Psychosocial Visit note. Residents psychosocial concerns discussed (isolation, loneliness, fear, sadness, anxiety) : fear and anxiety over prior event. Residents outward appearance (sad, happy, crying, withdrawn, guarded) : Happy - expresses no fear of the event. Interventions in place (staff visits, FaceTime visits, window visits, activities of interest) : weekly visits with SW, Met with Psych services they helped a lot. Follow up needed (psych referral, SW visits, family FaceTime visits) : continued SW visits. The comprehensive care plan for R1 documented in part, (Name of R1) is at risk for or has a history of exhibiting aggressive behaviors that may impact self or others. Contributing factors include: Cognitive impairment, Depression. Date Initiated: 02/11/2022. Revision on: 05/16/2022. Review of the facility synopsis of events final investigation dated 6/6/2023 documented in part, .This letter serves as the final report of an allegation of patient abuse reported to your office on 05/30/2023 .(Name of R1) alleged abuse by CNA (Name of CNA #4). (Name of R1) reported that CNA (Name of CNA #4) pushed or pulled him forcibly resulting in a fall .Based upon the Center's investigation the physical abuse allegation is substantiated due to the CNA attempting to physically remove resident against his will and removing his hand off the handrail to take him back to the Fairview Unit. CNA was terminated related to this allegation and a report will be filed with the Virginia DHP [department of health professions] as required by law . On 6/7/2023 at 10:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that they were working late and were in their office with the door closed on 5/30/2023 when R1 fell out of the wheelchair. LPN #3 stated that R1 and the lady friend were sitting in the hallway just beyond the activities doorway near their office door. LPN #3 stated that everything was quiet and then they heard someone saying loudly through the door to R1 that they were not supposed to be there and needed to be back on their unit. LPN #3 stated that they came out due to the yelling and saw R1 in their wheelchair with CNA #4 pulling them backwards. LPN #3 stated that R1 was holding onto the hand rail on the wall to prevent CNA #4 from moving the wheelchair and he started slipping down in the wheelchair. LPN #3 stated that CNA #4 then removed R1's hand from the hand rail and put their arms underneath R1 and lifted them up when R1 started flailing their arm and cursing. LPN #3 stated that R1 went limp and went down on the floor on their behind at that time. LPN #3 stated that they advised CNA #4 to leave R1 on the floor to be assessed, then at that point the CNA left. LPN #3 stated that they had calmed R1 by telling him that it was not his fault and they would help them back in the chair. LPN #3 stated that once they got R1 back in the wheelchair they had called the evening supervisor to come over to assess R1 and they had found CNA #4 and asked them to go sit in the conference room. LPN #3 stated that R1 had called the police so two police officers had come in and taken statements from the residents, LPN #3 and CNA #4. LPN #3 stated that the police officers had asked R1 if they wanted to press charges against CNA #4 because it was assault, but R1 did not want to do this. LPN #3 stated that they explained the investigation process in the facility to the police and that CNA #4 would be suspended until the investigation was completed and the police relayed this to R1 who was satisfied with this process and did not want to press charges against the CNA. LPN #3 had notified the administrator of the incident when the police had arrived as soon as possible because it all happened so quickly. LPN #3 stated that they took R1 and the girlfriend back to their rooms and made sure they both felt safe. CNA #4 left the building after writing their statement and speaking with the police. LPN #3 stated that they had completed a body audit for R1. LPN #3 stated that there was peace and quiet on the unit and R1 was not doing anything wrong so they did not know why CNA #4 had approached them and that CNA #4 had no reason to come over and start yelling at the resident; and if anything should have used a calm approach to ask them to go back over to their unit. LPN #3 stated that R1 would never have fallen if CNA #4 had left him alone, and they never heard R1 say anything prior to CNA #4 yelling at the resident through their closed door. On 6/7/2023 at 11:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that they had investigated the fall for R1 on 5/30/2023. ASM #2 stated that it happened in the evening and they were all gone for the day. ASM #2 stated that they were informed of the incident the next morning. ASM #2 stated that they had concluded that R1 and their girlfriend were in the hallway when CNA #4 approached them and told them they needed to go back to their unit. ASM #2 stated that R1 did not want to go back to their unit and CNA #4 was holding the wheelchair at the back trying to pull him to take him back to the unit. ASM #2 stated that R1 held on to the hand rail resisting the move, CNA #4 removed R1's hand from the rail and pulled the wheelchair backwards which led to R1 sliding to the floor. ASM #2 stated that the unit manager came out when they heard the noise and witnessed the CNA removing R1's hand from the rail and pulling the wheelchair. ASM #2 stated that some parts of the witness statements were inconsistent but all of the witnesses said they R1 held on to the hand rail and felt that if R1 was holding onto the hand rail they did not want to go and CNA #4 should have left him alone. ASM #2 stated that CNA #4 said he did not take R1's hand off the rail but the other witnesses said he did. ASM #2 stated that their main concern was that CNA #4 physically pushed R1's hand off the rail and pulled him backwards causing the fall and they had substantiated the allegation of abuse based on those findings. ASM #2 stated that nothing was happening to precipitate that incident, that the residents were just in hallway listening to their music. On 6/7/2023 at 11:35 a.m., a review was made of CNA #4's Virginia State Police background check completed upon hire and evidence of abuse and neglect training completed upon hire and current training. There were no concerns identified. The facility policy, Abuse Prevention with a revision date of 10/7/2022 documented in part, Residents should be free from abuse, neglect, corporal punishment, involuntary seclusion and misappropriation of personal property. The Center is committed to maintaining a safe environment for all residents and will appropriately investigate allegations . On 6/7/2023 at 11:49 a.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern. ASM #1 stated that they had put a plan of correction in place and would provide evidence. On 6/7/2023 at 12:02 p.m., ASM #1 provided a binder containing a five point plan of correction regarding the incident on 5/30/2023 between R1 and CNA #4. ASM #1 stated that the date of compliance for the plan of correction was 6/6/2023. Review of the plan of correction documented interventions in place to ensure R1 was monitored and safe, identification of other affected residents, systemic changes put in place and monitoring plans. The plan of correction binder included an identification of all residents being at risk with body audits completed on all residents with a BIMS level of 9 or less and interviews completed for all residents with a BIMS level of 10 or greater. Review of the body audits documented all completed between 5/31-6/1/2023 and all resident interviews completed on 6/1/2023. The binder included evidence of education to all current staff on abuse and managing challenging behaviors and different approaches/intervention strategies completed on 6/1/2023. Sign in sheets for each department were reviewed for completion. The binder documented plan for monitoring to interview 12 alert and oriented residents (10% of current residents) for signs of abuse and review 12 body audits a week (10% of current residents) to ensure no further signs or symptoms of abuse are occurring weekly x 4 weeks and monthly x 2 months. Psychosocial visit completed by social services and will be completed weekly times 4 to ensure residents psychosocial well is being monitored. The audit findings will be reviewed and/or revised in the QAPI with any variances addressed. The binder documented ad hoc QAPI meetings held on 5/31/23 and 6/1/23. Verification of the facility plan of correction was completed by observations, staff interviews and review of the completed documents listed above. No other concerns regarding abuse were identified during the survey. No further information was obtained prior to exit. This was cited at past non-compliance.

Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete dialysis care and services per the comprehensive plan of care for two of 46 residents in the survey sample, Resident #67 and Resident #71. The findings include: 1. For Resident #67, the facility failed to provide communication to the dialysis facility for one of 13 visits in November 2022, 4 of 13, visits in December 2022, 5 of 13, visits in January 2023 and 2 of 12 visits in February 2023. Resident #67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/15/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section O-special procedures/treatments coded the resident as dialysis no. A review of the comprehensive care plan dated 10/17/20, which revealed, FOCUS: The resident has renal disease requiring dialysis 3 times/week. INTERVENTIONS: Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes. A review of physician orders, dated 10/17/20, revealed the following, Hemodialysis on Mon-Wed-Fridays. A review of Resident #67's dialysis communication book revealed missing communication to the dialysis facility for 12 of 51 visits from 11/1/22-2/28/23. An interview was conducted on 2/27/23 at 4:00 PM with Resident #67. When asked if they take their dialysis communication book with them to the dialysis center, Resident #67 stated, Yes, the book goes with me. An interview was conducted on 2/28/23 at 12:45 PM with LPN (licensed practical nurse) #2. When asked what information is provided to the dialysis facility when a resident is sent for hemodialysis, LPN #2 stated, when a resident is going out to dialysis, we take their vital signs, check their weight, give them breakfast and their morning medicines. They take their book with them and we give them a lunch to take with them. When asked if the documentation was complete if missing vital signs and/or weights, LPN #2 stated, no, it is not. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. A review of the facility's Care and Management of a Patient Receiving Hemodialysis policy revised 5/27/22, revealed, The center will coordinate and collaborate with the dialysis center to ensure that there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by the healthcare center and the dialysis center. The licensed nurse will communicate to the hemodialysis center that will include but is not limited to medication administration (initiated, held or discontinued) by the healthcare center, Physician / treatment orders, laboratory values and vital signs. Nutritional/fluid management including documentation of weights, patient compliance with food/fluid restrictions or the provision of meals before, during and/or after hemodialysis and monitoring intake and output measurements as necessary. No further information was provided prior to exit. 42106 2. For Resident #71 (R71), the facility failed to provide communication to the dialysis (1) facility for seven of 25 visits in January/February 2023, on the dates of 1/16/2023, 1/18/2023, 1/20/2023, 1/23/2023 and 2/20/2023. Resident #71 (R71) was admitted to the facility on [DATE] with diagnoses that included but were not limited to ESRD (end stage renal disease) and dependence on renal dialysis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/13/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. Section O documented R71 receiving dialysis while a resident. The comprehensive care plan dated 1/21/2022, documented in part, [Name of R71] has End Stage Renal Disease requiring dialysis. She refuses at times. Date Initiated: 01/21/2022. Revision on: 09/07/2022. Under Interventions/Tasks it documented in part, .Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes. Date Initiated: 12/28/2021 . The physician orders for R71 documented in part, - Monitor PermaCath site for signs of bleeding and infection. Order Date: 1/22/2022. - Dialysis [Name and location of dialysis center] MWFri p/u (pick up) 215pm for 315 chair, return 530pm. Order Date: 1/22/2022. On 2/28/2023 at 8:36 a.m., an interview was conducted with R71 in their room. R71 stated that they went to dialysis three days a week on Monday, Wednesday and Fridays. When asked if a book was sent with them to dialysis, R71 stated that it was and that the book was in the chair in the room in the open duffel bag at the end of their bed. R71 stated that they had gone to dialysis the day before and the book had been there since they got back. On 2/28/2023 at 8:37 a.m., review of the dialysis communication book for R71 failed to evidence communication to the dialysis facility on 1/16/2023, 1/18/2023, 1/20/2023, 1/23/2023 and 2/20/2023. Review of R71's clinical record failed to evidence dialysis communication for the dates listed above or refusal of dialysis on those dates. On 2/28/2023 at 8:39 a.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that prior to R71 going to dialysis they weighed them, obtained vital signs and filled out the dialysis communication form in the book and reviewed the book when they came back for communication from the dialysis center. LPN #6 stated that the dialysis communication form should be completed each time the resident went to dialysis. The facility policy, Care and Management of a Patient Receiving Hemodialysis dated 5/27/22 documented in part, The Center will ensure that each patient receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: 1. The ongoing assessment of the patient's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. 2. Ongoing communication and collaboration with the dialysis center regarding dialysis care and services .3. The licensed nurse will communicate to the hemodialysis center that will include, but is not limited to: a. Medication administration (initiated, held or discontinued) by the healthcare center, b. Physician/treatment orders, laboratory values, and vital signs On 3/01/2023 at 2:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing/infection preventionist and ASM #5, the clinical services specialist were made aware of the findings. No further information was provided prior to exit. Reference: (1) hemodialysis When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called dialysis. There are two main types of dialysis. Both types filter your blood to rid your body of harmful wastes, extra salt, and water.: Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. Peritoneal dialysis uses the lining of your abdomen, called the peritoneal membrane, to filter your blood. This information was obtained from the website: https://medlineplus.gov/dialysis.html

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide rehabilitation services for one of 46 residents in the survey sample, Resident #261. The findings include: For Resident #261 (R261), the facility staff failed to provide physical and occupational therapy services from 03/18/2022 through 03/23/2022. (R261) was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/11/2022, (R261) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R261) was cognitively intact for making daily decisions. The physician's order sheet dated 03/01/2022 - 04/30/2022 documented in part, PT/OT/ST (Physical therapy/occupational therapy/speech therapy) to eval (evaluate) as indicated. Order Date: 03/04/2022. OT Clarification Order: OT to see 5x/wk x 4 (five times per week times four) weeks .Order Date: 03/07/2022. PT Clarification Order: skilled PT to see 5x a wk for 4 weeks .Order Date: 03/05/2022. The facility's PT Service Log Matrix for (R261) dated March 2022 failed to evidence that (R261) received physical therapy from 03/18/2022 through 03/23/2022. The facility's OT Service Log Matrix for (R261) dated March 2022 failed to evidence that (R261) received occupational therapy from 03/18/2022 through 03/23/2022. The NOMNC (Notice of Medicare Non-Coverage) dated 03/15/2022 documented in part, The Effective Date Coverage of Your Current Skilled Nursing Facility Services Will End: 03/17/2022. Under the statement I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO (Quality Improvement Organization) documented (R261's) signature and dated 3/15/22. The Determination Letter from (Name of QIO) for (R261) dated March 17, 2022 documented in part, Based on the Physical Therapy and Occupational Therapy evaluations, the patient has achieved reasonable goals for intensive therapy. There are no medical issues to support the need for daily skilled nursing care .You were notified by telephone on March 17, 2022 at 2:45 PM (p.m.) Eastern time that the decision to end these services was upheld. These services will no longer be paid for by the Medicare program beginning on March 18, 2022. The Determination Letter from (Name of QIO) for (R261) dated March 17, 2022 documented in part, Thank you for your patience while we completed a thorough review of your provider's decision to end services . You were notified by telephone on March 30, 2022 at 1:50 PM Eastern time that the decision to end these services was upheld. These services will no longer be paid for by the Medicare program. On 02/28/2023 at approximately 11:05 a.m., an interview was conducted with OSM (other staff member) #1, rehabilitation director. When asked about the missing documentation of PT and OT services on the Service Log Matrix from 03/18/2022 through 03/23/2022 OSM #1 stated that on 03/15/2022 a NOMNC (notice of Medicare non-coverage) dated 03/15/2022 was given to (R261) indicating that skilled nursing facility services would be ending on 03/17/2022. OSM #1 stated that they were informed that skilled services would not be cover by (R261's) insurance so they discontinued PT and OT services on March 17, 2022. On 02/28/2023 at approximately 1:15 p.m., an interview was conducted with OSM #9, director of social services. When asked to describe the process of a NOMNC OSM #9 stated that when the resident receives the NOMNC they have the right to appeal it by contacting the QIO and social services receives a letter stating that the resident has made an appeal and the QIO will request documentation from the facility to review the case. A decision is made usually within 48 hours and a determination letter is sent to the resident and social services stating weather or not the appeal was upheld or not. OSM #9 further stated that the resident can file a second appeal. When asked if a second NOMNC is given to the resident for a second appeal OSM #9 stated no, that the resident contacts the QIO directly by telephone. When asked how social services is informed that a resident has filed a second appeal OSM #9 stated that every Thursday at 10:00 a.m., they have a Utilization Review with the facility's interdisciplinary team, which includes the director of rehabilitation and the company's (owner of the nursing facility) case manager to discuss the status of all the facility's residents on managed care. When asked about a resident who may be receiving therapy service and they file an appeal OSM #9 stated therapy services would continue until they received a determination letter. After being informed of the lack of documentation on the March 2022 PT and OT service logs for (R261) from 3/18/2022 through 03/23/2022, OSM #9 stated that services should have continued while the second appeal was being reviewed. On 03/01/2023 at approximately 10:05 a.m. an interview was conducted with ASM (administrative staff member) #1, the administrator regarding therapy services for (R261). ASM #1 stated that an email was sent by the case manager asking if (R261) was going to file a second appeal and (OSM #9), director social services, sent an email to the interdisciplinary team that (R261) was filing a second appeal. ASM #1 provided the surveyor with a copy of the emails. The email dated March 17, 2022 from the case manager to OSM #9 documented in part, Per (Name of QIO) (R261's) appeal was upheld. Is she planning to file a recon (reconsideration? The response email dated March 18, 2022 documented in part, From (OSM #9) to central case management, OSM #1, rehabilitation director, .Subject: (Last Name of R261). She did yesterday. On 03/01/2023 at approximately 10:10 a.m., an interview was conducted with OSM #1. After reviewing the emails dated March 17 and 18, 2022 OSM #1 stated that it was an oversight on their part for not continuing therapy for (R261) during the second appeal process. OSM #1 further stated that they didn't recall seeing the emails. When asked to describe the procedure for a resident receiving therapy when they file an appeal for continued services OSM #1 stated that therapy continues until the resident receives a determination letter and based on the letter therapy will either continue or be discontinued. After reviewing (R261's) PT and OT service logs for March 2022, OSM #1 was asked how many therapy sessions were not provided. OSM #1 stated that there were six PT and six OT sessions were not provided. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for the facility for two of two residents who utilized the dialysis center, Resident #67 and Resident #71. The findings include: The facility failed to evidence a written dialysis agreement for one dialysis center that Resident #67 and Resident #71 received dialysis at. During the entrance conference to the facility on [DATE], a request was made for the dialysis contracts or agreements. On 2/27/23, a review of the dialysis contracts evidenced no contract for the one dialysis company utilized by Resident #67 and Resident #71 On 2/28/23 at approximately 3:23 PM, ASM (administrative staff member) #1, the administrator stated, there was no contract for this dialysis center. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to maintain an complete and accurate clinical record for three of 46 residents in the survey sample, Residents #105, #162, and #261. The findings include: 1. For Resident #105 (R105) the facility staff failed complete the Social Services Admission Assessment upon admission to the facility. R105 was admitted to the facility on [DATE]. The Admission MDS (minimum data set) assessment, with an ARD (assessment reference date) of 2/5/2023 was completed. Review of the clinical record failed to evidence any Social Services Assessments for R105. A request was made for any social services notes or assessments completed for R105. The following documentation was provided. An assessment for the Brief Interview for Mental Status was completed on 1/31/2023. A Patient Mood Interview was presented, dated 1/31/2023. A Room Change Notification note, written by the social services staff, was dated 2/21/2023. On 3/1/2023 at 12:14 p.m., ASM (administrative staff member) #1, the administrator, presented a Social Services Admission assessment dated [DATE]. When asked if this form was in the clinical record, ASM #1 stated, no, it was just completed today. When asked if this assessment should have been completed before 3/1/2023 since the resident was admitted on [DATE], ASM #1 stated, yes. The facility policy, Social Services Periodic Assessment and Documentation documented in part, 2. Initial Psychosocial Assessment and Social History will be completed on each resident within 48- 72 hours after admission using the following sources of information: the resident, the resident family members, friends, caregivers, etc. and the medical record. a. Refer to Social Services Admission Assessment in the EMR (electronic medical record). ASM #1, ASM #2, the director of nursing, ASM #4, the assistant director of nursing, and ASM #5 the clinical services specialist, were made aware of the above findings on 3/1/2023 at 2:38 p.m. No further information was obtained prior to exit. 42183 2. a. The facility staff failed to evidence complete and accurate documentation for incontinence care for Resident #162. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/27/21, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as being totally dependent for bathing and requiring extensive assistance for bed mobility, transfer, locomotion, dressing, eating and hygiene. A review of the comprehensive care plan dated 4/6/21, which revealed, FOCUS: The resident had an actual fall and remains at risk for falls related to difficulty walking, dementia. Skin integrity issue present on admission. Current reopening of Pressure injury to sacrum. Remains at risk for further skin breakdown r/t decreased mobility .Observe for moisture and incontinence issues and provide care as indicated. A review of Resident #162's TAR (treatment administration record) for August 2021, revealed, no incontinence care was documented for day shift on 8/31; none documented for evening shifts on 8/5, 8/6, 8/10, 8/11, 8/22, 8/29 and 8/31 and none documented on night shift on 8/18 and 8/21. A review of Resident #162's TAR for September 2021, revealed no incontinence care was documented for evening shift on 9/4, 9/11, 9/18 and 9/25; and none documented for night shift on 9/10 and 9/14. A review of Resident #162's TAR for October 2021, revealed, no incontinence care was documented for day shift on 10/19 and 10/21; none documented for evening shift on 10/9, 10/15, 10/16, 10/18 and 10/31; and none documented for night shift on 10/14 and 10/17. A review of Resident #162's TAR for November 2021, revealed no incontinence care was documented for day shift on 11/2, all incontinence care was documented for evening and night shifts. An interview was conducted on 2/28/23 at 1:40 PM with CNA (certified nursing assistant) #1. When asked what is means if there are blanks/holes in incontinence care documentation, CNA #1 stated, it just was not documented. An interview was conducted on 2/28/23 at approximately 2:00 PM with LPN (licensed practical nurse) #2. When asked what is means if there are blanks/holes in incontinence care documentation, LPN #2 stated, it would mean that the care was not documented. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. A review of the facility's Documentation in Medical Record policy, dated 6/1/21, revealed, Each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. No further information was provided prior to exit. 2. b. The facility staff failed to evidence complete and accurate documentation for feeding assistance for Resident #162. A review of Resident #162's TAR (treatment administration record) for August 2021, revealed, no feeding assistance was documented for day shift on 8/31; none documented for evening shift on 8/31; and none documented on night shift on 8/29 and 8/31. Resident was coded on the MDS as requiring extensive assistance for eating on 8/28/21. A review of Resident #162's TAR for September 2021, revealed all feeding assistance was documented for day shift and evening shift; no feeding assistance was documented for night shift on 9/4, 9/11, 9/18 and 9/25. A review of Resident #162's TAR for October 2021, revealed no feeding assistance was documented for day shift on 10/19 and 10/21; none documented for evening shift on 10/19 and 10/21; and none documented for night shift on 10/1, 10/9, 10/15, 10/16, 10/18 and 10/31. A review of Resident #162's TAR for November 2021, revealed, no feeding assistance was documented for day and evening shift on 11/2. An interview was conducted on 2/28/23 at 1:40 PM with CNA (certified nursing assistant) #1. When asked what is means if there are blanks/holes in incontinence care documentation, CNA #1 stated, it just was not documented. An interview was conducted on 2/28/23 at approximately 2:00 PM with LPN (licensed practical nurse) #2. When asked what is means if there are blanks/holes in incontinence care documentation, LPN #2 stated, it would mean that the care was not documented. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. A review of the facility's Documentation in Medical Record policy, dated 6/1/21, revealed, Each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. No further information was provided prior to exit. 29843 3. For Resident #261 (R261), the facility staff failed to complete the eMAR (electronic medication administration record) for the administration of levothyroxine (1) on 03/15/2022 and 03/16/2022. (R261) was admitted to the facility with diagnoses that included but were not limited to hypothyroidism (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/11/2022, (R261) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R261) was cognitively intact for making daily decisions. The physician's order sheet for (R261's) dated 03/01/2022 - 04/30/2022 documented in part, Levothyroxine Sodium Tablet 150 MCG (micrograms). Give 2 (two) tablet [sic] by mouth one time a day for low thyroid hormone. Order Date: 03/04/2022. Start Date: 03/05/2022. The eMAR for (R261) dated March 2022 documented the physician's order as stated above. Further review of the eMAR revealed blanks for the dates 03/15/2022 and 03/16/2022 for the medication levothyroxine. On 03/01/2023 at approximately 11:02 a.m., an interview was conducted with RN (registered nurse) #1. After reviewing the March 2022 eMAR for the administration of levothyroxine on 03/15/2022 and 03/16/2022, RN #1 was asked to interpret the dates being blank. RN #1 stated that two things could have occurred, one, that the medication was administered but the nurse failed to check it off on the eMAR or the nurse failed to administer the medication. When asked to speak with the nurse who administered medications to (R261) on 03/15/2022 and 03/16/2022, surveyor was informed that the nurse no longer worked at the facility. On 03/01/2023 at approximately 12:16 p.m., an interview was conducted with LPN (licensed practical nurse) #3. After reviewing the March 2022 eMAR for the administration of levothyroxine on 03/15/2022 and 03/16/2022, RN #1 was asked to interpret the dates being blank. LPN #3 stated the nurse gave the medication and forgot to check it off or the medication was not given. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the website: Levothyroxine: MedlinePlus Drug Information (2) Not enough thyroid hormone to meet your body's needs. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/hypothyroidism.html.

Based on observations, staff interview, clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for four of 46 residents in the survey sample, Resident #15, Resident #11, Resident #80 and Resident #67. The findings include: 1. For Resident #15 (R15), facility staff failed to implement the comprehensive care plan for the use of fall mats and positioning the bed in a low position. (R15) was admitted to the facility with a diagnosis that included but was not limited to epilepsy (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/19/2023, (R15) was coded as having both short- and long-term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. On 02/27/2023 at approximately 12:25 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. On 02/27/2023 at approximately 2:45 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. On 02/27/2023 at approximately 3:34 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. On 02/28/2023 at approximately 8:50 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. The comprehensive care plan for (R15) dated 06/19/2021 documented in part, Focus. (Name of (R15) has had actual falls r/t (related to) Traumatic brain injury sustained during a motorcycle accident. Hemiparesis r/t past CVA (cerebral vascular accident - stroke) /balance problems and impulsivity. Has extensive fall history. Date Initiated: 06/19/2021. Under Interventions / Tasks it documented in part, Fall/floor mats at bedside while in bed. Revision on: 03/16/2021, Low bed. Revision on: 03/16/2021. On 02/28/23 at approximately 2:00 p.m., an interview and observation of (R15's) room was conducted with LPN (licensed practical nurse) #3, unit manager. LPN #3 stated that the fall mats were discontinued. After reviewing (R15's) comprehensive care plan LPN #3 stated that the care plan was not accurate for the use of the fall mats. When asked about the height of the bed, LPN #3 stated that the bed did not look low and could be lowered. After measuring the height of the bottom of the mattress from the floor using a standard carpenter's ruler with the surveyor, LPN #3 confirmed that the height was 16 inches from the floor. LPN #3 lowered the bed to its lowest position using the bed remote control and reading the ruler again confirmed that the height was lowered to 10 inches from the floor. When asked if the bed had been placed in the lowest position LPN #3 stated no. When asked if the care plan was followed for placing the bed in a low position LPN #3 stated no. On 03/01/2023 at approximately 2:38 p.m., a request was made to ASM (administrative staff member) #1, administrator, for evidence that the fall mats for (R15) were discontinued. At 4:45 p.m., ASM #1 provided a copy of the facility's Edit Intervention for (R15's) comprehensive care plan dated 02/28/2023. The form documented in part, Status: Resolved. Description: Fall/floor mats at bedside while in bed. When asked if the care plan was being followed for the use of the fall mats prior to the revision of the care plan ASM #1 stated no. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit 2 a. For Resident #11 (R11), facility staff failed to implement the comprehensive care plan for the administration of oxygen at two liters per minute according to the physician's orders. Resident #11 was admitted to the facility with diagnoses that included but were not limited to: congestive heart failure (1). On 02/27/2023 at approximately 12:39 p.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. On 02/27/2023 at approximately 3:52 p.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. On 02/28/2023 at approximately 8:54 a.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. The physician's order for (R11) dated 01/17/2023 documented, O2 (oxygen) at 2(two) L/min (liters per minute) via nasal cannula continually. The comprehensive care plan for (R11) dated 11/15/2021 documented in part, Focus. (Name of R11) has respiratory problem(s) related to acute illness Spine surgery . Date Initiated: 11/15/202. Under Interventions / Tasks it documented in part, Provide oxygen as ordered. Date Initiated: 11/15/2021. On 02/28/2023 at approximately 2:20 p.m., an observation of (R11's) oxygen flow rate on the oxygen concentrator was conducted with RN (registered nurse) #3. After reading the flow meter RN#3 stated that it was about three and a half liters per minute. When asked what the flow rate should be RN #3 stated that they needed to check the physician's orders. After looking up the physician's order in (R11's) EHR (electronic health record) RN #3 stated that the flow rate was ordered for two liters per minute. When asked to describe how to read the oxygen flow rate on an oxygen concentrator RN #3 stated that the liter line should pass through the middle of the float ball inside the flow meter. When asked if the comprehensive care plan for (R11) was being followed for the administration of oxygen RN #3 stated no. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit 2.b For (R11), facility staff failed to develop a care plan for hospice services. Resident #11 was admitted to the facility with diagnoses that included but were not limited to: breast cancer. The physician's order for (R11) dated 02/19/2023 documented, Hospice orders per the following: Hospice agency (Name of Hospice Agency and Phone Number). Review of (R11's) comprehensive care plan dated 11/15/2021 failed to evidence hospice services. On 03/01/2023 at approximately 9:55 a.m., an interview was conducted with OSM (other staff member) #5, MDS coordinator and OSM #6, regional corporate reimbursement specialist. When asked about (R11's) comprehensive care plan dated 11/15/2021 addressing hospice services, OSM #5 and OSM #6 reviewed the care plan. After reviewing the care plan OSM #5 and OSM #6 stated that the care plan did not address hospice services for (R11). When asked to describe the procedure for completing the care plan accurately OSM # 5 stated that they follow the resident assessment instrument (RAI) manual. The facility's policy Comprehensive Care Planning Process documented in part, The facility must develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. An interdisciplinary assessment team shall develop a comprehensive assessment and care plan for each patient based on outcomes of assessments and input from the patient, family, and interdisciplinary team members. The team serves as the authority for overseeing patient care services. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit. 3. For Resident #80 (R80) the facility staff failed to implement the comprehensive care plan for the quarterly review of the advance directive. The facility's Social Services Quarterly Review for (R80) dated 02/16/2022 failed to evidence a review of an advance directive. The physician's order for (R80) documented, Full code. Order Date: 09/03/2022. The comprehensive care plan for (R80) dated 10/21/2021 documented in part, Focus. (Name of (R80)) has a full code status. Will review status during stay. Revision on: 12/30/2022. Under Interventions / Tasks it documented in part, Review code status upon admission, quarterly and as needed with resident/POA/RP (power of attorney/responsible party). Date Initiated: 10/21/2021. On 03/01/2023 at approximately 9:30 a.m., an interview was conducted with OSM (other staff member) #11, assistant director of social services. When asked about the procedure for reviewing a resident's advance directive OSM #11 stated that the review is conducted quarterly. After reviewing the Social Services Quarterly Review for (R80) OSM #11 stated that the review was not conducted. After informed of the information as stated above on the comprehensive care plan for (R80), OSM # 11 was asked if the care plan was being followed for the quarterly review of the advance directive. OSM #11 stated the care plan was not followed. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit 42183 4. The facility staff failed to implement the comprehensive care plan for dialysis communication for Resident #67. Resident #67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/15/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section O-special procedures/treatments coded the resident as dialysis no. A review of the comprehensive care plan dated 10/17/20, which revealed, FOCUS: The resident has renal disease requiring dialysis 3 times/week. INTERVENTIONS: Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes. A review of physician orders, dated 10/17/20, revealed the following, Hemodialysis on Mon-Wed-Fridays. A review of Resident #67's dialysis communication book revealed missing communication to the dialysis facility for 12 of 51 visits from 11/1/22-2/28/23. An interview was conducted on 2/27/23 at 4:00 PM with Resident #67. When asked if they take their dialysis communication book with them to the dialysis center, Resident #67 stated, Yes, the book goes with me. An interview was conducted on 2/28/23 at 12:45 PM with LPN (licensed practical nurse) #2. When asked what information is provided to the dialysis facility when a resident is sent for hemodialysis, LPN #2 stated, when a resident is going out to dialysis, we take their vital signs, check their weight, give them breakfast and their morning medicines. They take their book with them and we give them a lunch to take with them. When asked if the documentation was complete if missing vital signs and/or weights, LPN #2 stated, no, it is not. When asked if there are blanks on the dialysis communication sheets, is the care plan intervention to provide regular pretreatment notes being followed, LPN #2 stated, no. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. A review of the facility's Comprehensive Care Planning Process policy dated 2017, revealed, The facility must develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. No further information was provided prior to exit.

Based on observations, staff interview, clinical record review, it was determined that the facility staff failed to implement fall interventions for one of 46 residents in the survey sample, Resident #15. The findings include: For Resident #15 (R15), the facility staff failed to place the bed in a low position while (R15) was lying in their bed. (R15) was admitted to the facility with a diagnosis that included but was not limited to epilepsy (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/19/2023, (R15) was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. On 02/27/2023 at approximately 12:25 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. On 02/27/2023 at approximately 2:45 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. On 02/27/2023 at approximately 3:34 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. On 02/28/2023 at approximately 8:50 p.m., (R15) was observed lying in their bed. There were no fall mats next to the bed and the bed was not in a low position. Using a standard carpenter's ruler, a measurement taken from the bottom of the mattress to the floor revealed the bed was 16 inches from the floor. The comprehensive care plan for (R15) dated 06/19/2021 documented in part, Focus. (Name of (R15) has had actual falls r/t (related to) Traumatic brain injury sustained during a motorcycle accident. Hemiparesis r/t past CVA (cerebral vascular accident - stroke) /balance problems and impulsivity. Has extensive fall history. Date Initiated: 06/19/2021. Under Interventions / Tasks it documented in part, Fall/floor mats at bedside while in bed. Revision on: 03/16/2021, Low bed. Revision on: 03/16/2021. On 02/28/23 at approximately 1:50 p.m., an interview and observation of (R15's) room was conducted with LPN (licensed practical nurse) #2. When asked about fall mats and the bed being in a low position for (R15), LPN #2 stated that they were new and just started a month ago and did not know if (R15) needed fall mats or if the bed needed to be in a low position. LPN #2 stated that they would get their supervisor. On 02/28/23 at approximately 2:00 p.m., an interview and observation of (R15's) room was conducted with LPN (licensed practical nurse) #3, unit manager. LPN #3 stated that the fall mats were discontinued. After reviewing (R15's) comprehensive care plan LPN #3 stated that the care plan was not accurate for the use of the fall mats. When asked about the height of the bed, LPN #3 stated that the bed did not look low and could be lowered. After measuring the height of the bottom of the mattress from the floor using a standard carpenter's ruler with the surveyor, LPN #3 confirmed that the height was 16 inches from the floor. LPN #3 lowered the bed to the lowest position using the bed remote control and reading the ruler again confirmed that the height was lowered to 10 inches from the floor. When asked if the bed had been placed in the lowest position LPN #3 stated no. When asked if the care plan was followed for placing the bed in a low position LPN #3 stated no. When asked why it was important to place the bed in a low position LPN #3 stated that it helped prevent an injury if the fell out of bed. On 03/01/2022 at approximately 2:38 p.m., ASM #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. A request was made to ASM (administrative staff member) #1, administrator, for evidence that the fall mats for (R15) were discontinued. At 4:45 p.m., ASM #1 provided a copy of the facility's Edit Intervention for (R15's) comprehensive care plan dated 02/28/2023. The form documented in part, Status: Resolved. Description: Fall/floor mats at bedside while in bed. No further information was provided prior to exit. References: (1) A brain disorder that causes people to have recurring seizures. This information was obtained from the website: https://medlineplus.gov/epilepsy.html.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to conduct a periodic review of an advance directive for one of 46 residents in the survey sample, Resident # 80 (R80). The finding include: For (R80), the facility staff failed to evidence a quarterly review for an advance directive. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/06/2023, (R80) scored three out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The facility's Social Services Quarterly Review for (R80) dated 02/16/2022 failed to evidence a review of an advance directive. The physician's order for (R80) documented, Full code. Order Date: 09/03/2022. On 03/01/2023 at approximately 9:30 a.m., an interview was conducted with OSM (other staff member) #11, assistant director of social services. When asked about the procedure for reviewing a resident's advance directive OSM #11 stated that the review is conducted quarterly. After reviewing the Social Services Quarterly Review for (R80) OSM #11 stated that the review was not conducted. The facility's policy Advance Directives documented in part, 10. Educational information concerning Advance Directives will be provided to residents and legal representatives on a periodic basis. On 03/01/2022 at approximately 2:38 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to notify the responsible party (RP) of a change in condition for one of 46 residents in the survey sample, Resident #162. The findings include: The facility failed to notify the RP of Resident #162's new medication order for Depakote (1). Resident #162 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia, idiopathic hydrocephalus, and adjustment disorder with anxiety. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/27/21, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the physician orders dated 4/9/21, revealed, Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (milligram), Give 1 capsule by mouth two times a day for mood disorder. A review of the physician orders dated 5/5/21, revealed, Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG, Give 1 capsule by mouth at bedtime for mood disorder for 3 Days. A review of Resident #162's April and May MAR (medication administration record) revealed, the medication administered as ordered. A review of the progress notes did not reveal the Responsible Party was notified of the start of Depakote. An interview was conducted on 2/28/23 at 8:00 AM with LPN (licensed practical nurse) #3, the unit manager. When asked who notifies the RP if there is a change in medication, LPN #3 stated, Nursing notifies the RP and we write a note in the chart. When asked what it means if there is no note documenting the notification, LPN #3 stated if it is not documented, then it is not done. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. A review of the facilities' Notification of Changes policy dated 5/27/22, revealed the following: The purpose of this policy is to ensure the Center promptly informs the patient, consults the patient's physician/physician extender; and notifies, consistent with his or her authority, the patient's legal representative when there is a change requiring notification. Circumstances that require a need to alter treatment. This may include new treatment. No further information was provided prior to exit. Reference: (1) Depakote is used to treat complex partial seizures, simple and complex absence seizures, as well as acute manic symptoms in patients with bipolar disorder. https://www.depakote.com/about-depakote#:~:text=Depakote%20is%20one%20of%20the,125%20mg

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to conduct an accurate MDS (minimum data set) assessment for two out of 46 residents in the survey sample, Residents #67 and #110. The findings include: 1. The facility staff failed to complete an accurate annual assessment MDS to include dialysis for Resident #67. Resident #67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal disease, peripheral vascular disease, atrial fibrillation and cardiomegaly. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/15/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section O-special procedures/treatments coded the resident as dialysis no. A review of the comprehensive care plan dated 10/17/20, which revealed, FOCUS: The resident has renal disease requiring dialysis 3 times/week. INTERVENTIONS: Coordinate with Dialysis center for dialysis treatments as ordered. Communicate with dialysis provider regularly via pre/post treatment notes. On 2/27/23 at approximately 4:00 PM, Resident #67 was observed returning from dialysis. A review of physician orders, dated 10/17/20, revealed the following, Hemodialysis on Mon-Wed-Fridays. On 2/28/23 at 4:35 PM, an interview was conducted with OSM (other staff member) #4, the MDS manager, OSM #5, the MDS coordinator and OSM #6, the regional corporate reimbursement specialist. When asked to review the 12/15/22 MDS Section O (special treatments and procedures): 0100. J dialysis, OSM #5 stated, It is coded no. That was my mistake. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. 2. The facility staff failed to complete an accurate MDS for Resident #110. Resident #110 was coded as discharged to an acute hospital in error. During the closed record review, Resident #110 was identified as 'hospitalized '. Resident #67 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes, dementia, Alzheimer's Disease and osteoarthritis. The most recent MDS (minimum data set) assessment, a discharge return not anticipated assessment, with an ARD (assessment reference date) of 2/6/23, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. Section A: Identification Information was coded- A.2100 Discharge Status: acute hospital. A review of the nursing progress note, dated 2/6/23 at 10:30 AM, revealed, Resident to discharge to assisted living facility (ALF), vital signs are stable upon discharge, morning medications were given. Husband was educated on diagnoses and medications. ALF was sent medications as well as scripts sent with the husband. Resident left the facility with all personal belongings and husband had no further questions at this time. On 3/1/23 at 1:35 PM, an interview was conducted with OSM (other staff member) #4, the MDS manager. When asked to review the 2/6/23 MDS Section A (identification information): A.2100-discharge status-acute hospital, OSM #4 stated, it is coded acute hospital. When asked to review the progress note dated 2/6/21, OSM #4 stated, The resident went to an ALF, it should not have been coded as acute hospital. We will modify that. On 3/1/23 at approximately 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing and ASM #5, the clinical services specialist was made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to revise the comprehensive care plan for one of 46 residents on the survey sample, Resident #165 (R165). The findings include: The facility staff failed to revise the care plan for the use of a PICC line (peripherally inserted central catheter) (1) and for the administration of TPN (total parenteral nutrition) (2) for R165. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/22/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. A significant change MDS assessment was in progress. On 2/27/2023 at approximately 12:30 p.m. R165 was observed in bed with TPN solution being administered through the PICC line. The Nutritional Care Plan dated 10/5/2022 and revised on 1/5/2023, failed to evidence documentation of R165 receiving TPN. The comprehensive care plan dated, 10/5/2022 and last revised on 2/23/2023, failed to evidence documentation for the use and care of a PICC line. An interview was conducted with OSM (other staff member) #12, the dietitian, on 2/28/2023 at 2:10 p.m. When asked who is responsible for updated the care plan for TPN, OSM #12 stated either herself or nursing. When asked if it is expected to see TPN on a care plan, OSM #12 stated, yes, her readmission assessment is not due yet but she is doing it today. An interview was conducted with LPN (licensed practical nurse) #1, on 2/28/2023 at 2:25 p.m. When asked who updated the care plans, LPN #1 stated if the resident is gone from the facility for more than 24 hours, they would do an actual admission care plan. She further stated, even though the resident is a readmission, we would reenter everything in the system, batch orders and care plans, they would pick what areas are appropriate for that resident. When asked if a resident with a PICC line and TPN should have these things addressed on the care plan, LPN #1 stated, absolutely. When asked the purpose of the care plan, LPN #1 state it's the goals for that patient, what they, the facility staff, are going to do for them. The facility policy, Comprehensive Care Planning Process failed to evidence anything related to reviewing and revising the care plan. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing, and ASM #5 the clinical services specialist, were made aware of the above findings on 3/1/2023 at 2:38 p.m. No further information was obtained prior to exit. (1) Peripherally inserted central catheter is a long-line catheter made of soft silicone or Silastic material that is placed peripherally but delivers medications and solutions centrally. Lippincott, [NAME] & Wilkins, Fundamental of Nursing, 5th edition, 2007, page 1423. (2) Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein provides most of the nutrients the body needs. The method is used when someone can't or shouldn't receive feedings or fluids by mouth. https://medlineplus.gov/ency/patientinstructions/000177.htm

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice for medication administration and monitoring, for one of 46 residents in the survey sample, Resident #163. The findings include: 1.a. For Resident #163 (R163), the facility staff failed to transcribe a telephone order for Tums (1). On the most recent MDS (minimum data set) assessment, a five day admission assessment, with an assessment reference date of 11/15/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. The assessment documented R163 receiving hemodialysis. The SBAR (situation, background, assessment, recommendation) Communication Form for R163 dated 11/13/2022 documented in part, .NP (nurse practitioner) notified of patients complaint of heartburn new orders received for Tums 500mg (milligram) q4h (every four hours) PRN (as needed). Patient and RP (responsible party) notified . The physician orders dated 11/10/2022-11/16/2022 failed to evidence an order for Tums. The eMAR (electronic medication administration record) dated 11/1/2022-11/30/2022 failed to evidence an order for Tums. On 2/28/2023 at 2:07 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that R163 had complained of heart burn on 11/13/2022 and they had contacted the nurse practitioner because there was nothing ordered at the time. LPN #1 stated that the nurse practitioner had ordered as needed Tums for R163 to take and as far as they knew R163 had received them. LPN #1 stated that they did not recall a delay in getting the medication however they did not keep a stock supply of the medication and may have had to wait for the medication to come from the pharmacy. LPN #1 stated that when they received a telephone order they entered the new order into the electronic medical record which sent it directly to the pharmacy to be processed and automatically put it on the eMAR after it was verified by the pharmacy. LPN #1 reviewed R163's physician orders dated 11/10/2022-11/16/2022 and eMAR dated 11/1/2022-11/30/2022 and stated that they did not know why the Tums were not on there. On 2/28/2023 at approximately 5:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the Tums order being transcribed and/or administered for R163's complaints of heart burn on 11/13/2022. On 3/1/2023 at approximately 8:00 a.m., ASM #4, the assistant director of nursing/infection preventionist stated that they did not have any evidence of the Tums being transcribed or administered on 11/13/2022 for R163. The facility policy, Guidelines for Medication Orders dated 6/21/2017 documented in part, .New Verbal Orders: The nurse documents a complete order received by telephone or in person on the appropriate pharmacy approved form (physician's order sheet, Interim Order Form, Telephone order form or approved electronic order entry system). Documentation must include T.O. for telephone orders, V.O. for verbal orders or other indication in electronic order entry system. The nurse must indicate the prescriber's name giving the order and the licensed nurse accepting/recording the order. The nurse will sign the order in the appropriate space on the verbal order form. Verbal orders must be signed by the prescriber within the timeframe required by State and Federal regulations .Facility staff transcribes newly prescribed medications on the Medication Administration Record (MAR/TAR). When a new order changes the dosage of a previously prescribed medication, staff discontinues the previous entry by writing DC'd and the date and yellowing through the entry. Enter the new order on the MAR/TAR . On 2/27/2022 during survey entrance, ASM (administrative staff member) #1, the administrator stated that the facility followed Lippincott as their nursing standard of practice and provided a copy of the cover of Lippincott Manual of Nursing Practice, 10th Edition. According to Fundamentals of Nursing Lippincott [NAME] and Wilkins, 2007 pages 167-168 it documented in part, .anytime you accept a verbal order, it's your responsibility to ensure the accuracy of the communication .afterward write and sign the order that was given to you verbally by the prescriber and have the prescriber sign your written copy as soon as possible . On 3/1/2023 at approximately 2:38 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing/infection preventionist and ASM #5, the clinical services specialist were made aware of the findings. No further information was provided prior to exit. (1) Tums Calcium carbonate also is used as an antacid to relieve heartburn, acid indigestion, and upset stomach. It is available with or without a prescription .This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601032.html 1.b. For Resident #163 (R163), the facility staff failed to reassess the blood pressure after administration of Midodrine (1) on 11/15/2022 at 11:06 a.m. prior to the resident being sent to the emergency room at 1:00 p.m., and failed to notify the nurse practitioner of the need for a dose of Midodrine on 11/15/2022 due to continued hypotension and it being on a non-dialysis day. On the most recent MDS (minimum data set) assessment, a five day admission assessment, with an assessment reference date of 11/15/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. The assessment documented R163 received hemodialysis. The physician orders for R163 documented in part, Midodrine HCl (hydrochloride) Tablet 10 MG (milligram) Give 1 tablet by mouth as needed for Hypotension (low blood pressure). On dialysis day. If Systolic less than 100. Order Date: 11/11/2022. The physician orders further documented, Dialysis days Monday, Wenesday [sic], and Fridays At [Name of dialysis center]. Order Date: 11/12/2022. The eMAR (electronic medication administration record) dated 11/1/2022-11/30/2022 for R163 documented Midodrine 10 mg administered on 11/15/2022 at 8:58 a.m. for a blood pressure of 90/58 and at 11:06 a.m. for a blood pressure of 88/54. The SBAR (situation, background, assessment, recommendation) Communication Form for R163 dated 11/15/2022 documented in part, .Vital Signs: BP (blood pressure): 88/54 .Primary Care Clinician Notified: Yes, Date: 11/15/2022; Time: 8:00 AM; Recommendations of Primary Clinicians (if any): Midodrine 10 mg (milligram) as needed . The progress notes for R163 documented in part, - 11/15/2022 08:58 (8:58 a.m.) eMAR Administration Note. Note Text: Midodrine HCL Tablet 10mg Give 1 tablet by mouth as needed for Hypotension on dialysis day if systolic less than 100. - 11/15/2022 11:06 (11:06 a.m.) eMAR Administration Note. Note Text: Midodrine HCL Tablet 10mg Give 1 tablet by mouth as needed for Hypotension on dialysis day if systolic less than 100. - 11/15/2022 12:06 (12:06 p.m.) eMAR Administration Note. Note Text: Midodrine HCL Tablet 10mg Give 1 tablet by mouth as needed for Hypotension on dialysis day if systolic less than 100. PRN administration was Ineffective. - 11/15/2022 12:07 (12:07 p.m.) eMAR Administration Note. Note Text: Midodrine HCL Tablet 10mg Give 1 tablet by mouth as needed for Hypotension on dialysis day if systolic less than 100. PRN administration was Effective. - 11/15/2022 18:58 (6:58 p.m.) Transfer Out (Acute/Emergency) Reason for transfer and requires higher level of care (describe): Abnormal vital sign/Low blood pressure 88/54. Symptoms exhibited: anxiety, n/v (nausea/vomiting), Current TX (treatment) (if applicable): Midodrine 10mg PRN .daughter called 911 . The SNF/NF (skilled nursing facility/nursing facility) to hospital transfer form for R163 dated 11/15/2022 documented in part, .Reason(s) for transfer: Abnormal vital signs (low/high BP, high respiratory rate) .Vital signs BP 88/54 11/15/2022 11:06 (11:06 a.m.) .Date of Transfer: 11/15/2022 13:00 (1:00 p.m.) . The blood pressure summary for R163 documented blood pressures on 11/15/2022 as 121/79 at 2:03 a.m., 90/58 at 8:40 a.m. and 88/54 at 11:06 a.m. Review of R163's clinical record failed to evidence a blood pressure taken after the administration of the Midodrine on 11/15/2022 at 11:06 a.m. or notification of the physician/nurse practitioner of the continued low blood pressure after administration of the Midodrine at 8:58 a.m. and need for second dose of Midodrine at 11:06 a.m. On 2/28/2023 at 3:01 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated that R163 had been sent to the emergency roiagnom on [DATE] for unstable vital signs. LPN #4 stated that R163's blood pressure had been low when they had checked it that morning and they had rechecked it and it was still low so they had called the nurse practitioner who had told them to administer the as needed Midodrine. LPN #4 stated that R163 was a dialysis resident but did not go that day [it was a Tuesday]. LPN #4 stated that R163's blood pressure was still low when they rechecked it a couple of hours later and they complained of weakness so they administered a second dose of Midodrine. LPN #4 stated that they did not recall calling the nurse practitioner but thought that they were in the building and saw the resident. LPN #4 stated that R163's daughters arrived to the facility and wanted the resident to go to the emergency room and called 911. LPN #4 stated that they did not recall checking the blood pressure before they went out to the emergency room and thought that they went out before lunch. LPN #4 stated that it was their normal practice to go back and recheck the blood pressure when it was running low. On 2/28/2023 at approximately 5:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the blood pressure being re-checked after administration of the Midodrine 10mg on 11/15/2022 at 11:06 a.m. or evidence that the medication was effective as documented in the progress note dated 11/15/2022 at 12:07 a.m. On 3/1/2023 at approximately 8:00 a.m., ASM #1, the administrator provided a written statement from LPN #4 which stated that that they had mistakenly documented the Midodrine 10mg as being effective on 11/15/2022 at 12:07 a.m. On 3/1/2023 at 1:43 p.m., an interview was conducted with LPN #3. LPN #3 stated that when Midodrine was administered to residents for low blood pressure they would follow up with a blood pressure recheck in an hour to see if the medication was effective. LPN #3 stated that the eMAR prompted them to go back to recheck the blood pressure and enter the results and effective or ineffective. LPN #3 stated that they would also document a progress note regarding the medication and whether or not the medication worked. LPN #3 stated that if the blood pressure continued to be low they would call the physician to notify them for further orders or evaluation. LPN #3 stated that orders for as needed Midodrine on dialysis days were for those days only and should be clarified with the physician if needed on non-dialysis days. The manufacturers product instructions for use for Midodrine Hydrochloride Tablets documented in part, .Doses may be given in 3-hour intervals, if required, to control symptoms, but not more frequently . The supine and standing blood pressure should be monitored regularly, and the administration of Midodrine hydrochloride tablets should be stopped if supine blood pressure increases excessively . The facility policy, Medication Monitoring dated 6/1/21 documented in part, .Licensed nurses, with periodic oversight by nurse managers, shall: .b. Adhere to facility policies and current standards of practice for administration and monitoring of medications . According to the facility provided Lippincott Manual of Nursing Practice, 10th Edition. Lippincott Procedures page 556, it documented in part, .Oral Drug Administration .Verify the order on the patient's medication record by checking it against the practitioner's order .Assess the patient's condition to determine the need for medication and the effectiveness of previous therapy . On 3/1/2023 at approximately 2:38 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing/infection preventionist and ASM #5, the clinical services specialist were made aware of the findings. No further information was provided prior to exit. (1) Midodrine Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a616030.html

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 46 residents in the survey sample, Resident #11. The findings include: For Resident #11 (R11), the facility staff failed to maintain the physician ordered oxygen flow rate at two liters per minute. Resident #11 was admitted to the facility with diagnoses that included but were not limited to: congestive heart failure (1). On 02/27/2023 at approximately 12:39 p.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. On 02/27/2023 at approximately 3:52 p.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. On 02/28/2023 at approximately 8:54 a.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. The physician's order for (R11) dated 01/17/2023 documented, O2 (oxygen) at 2(two) L/min (liters per minute) via nasal cannula continually. The comprehensive care plan for (R11) dated 11/15/2021 documented in part, Focus. (Name of R11) has respiratory problem(s) related to acute illness Spine surgery . Date Initiated: 11/15/202. Under Interventions / Tasks it documented in part, Provide oxygen as ordered. Date Initiated: 11/15/2021. On 02/28/2023 at approximately 2:20 p.m., an observation of (R11's) oxygen flow rate on the oxygen concentrator was conducted with RN (registered nurse) #3. After reading the flow meter RN#3 stated that it was about three and a half liters per minute. When asked what the flow rate should be RN #3 stated that they needed to check the physician's orders. After looking up the physician's order in (R11's) EHR (electronic health record) RN #3 stated that the flow rate was ordered for two liters per minute. When asked to describe how to read the oxygen flow rate on an oxygen concentrator and how often a resident's oxygen flow rate should be checked RN #3 stated that the liter line should pass through the middle of the float ball inside the flow meter and the flow rate should be checked at the beginning of each shift and whenever the nurse goes into the room. On 03/01/2022 at approximately 2:38 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing and ASM #3, assistant director of nursing and ASM #5, clinical services specialist, were made aware of the above findings. No further information was provided prior to exit. References: (1) A condition in which the heart can't pump enough blood to meet the body's needs. This information was obtained from the website: https://medlineplus.gov/heartfailure.html

Based on resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as needed pain medications for one of 46 residents in the survey sample, Resident #58. The findings include: For Resident #58 (R58), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of the as needed pain medication, Percocet (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/15/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section J documented R58 receiving as needed pain medications and not receiving non-medication interventions for pain. Section N documented R58 receiving Opioid medications 2 of the 7 days during the assessment period. On 2/27/2023 at 2:04 p.m., an interview was conducted with R58 in their room. R58 stated that they had frequent pain and took pain medications as needed. When asked if the staff attempted non-pharmacological interventions prior to administering the medication, R58 stated, Sometimes they do, it depends on the nurse. The physician order's for R58 documented in part, - Percocet Tablet 5-325 MG (milligram) (oxyCODONE Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain. Order Date: 09/07/2022. - NON-PHARMACOLOGICAL INTERVENTION and OUTCOME during your shift that were attempted prior to medication being administered: A) Non-Pharmacological Intervention: 0= No Pain Issues Observed 1= Reposition 2= Massage 3= Music/TV (distraction) 4= Warm Compress 5= Therapy Pain Management B) Outcome: 0= No pain 1= Intervention Effective 2= Intervention NOT Effective requires pharmacological intervention (medication, etc ) every shift for pain management Document the corresponding code associated with intervention initiated or attempted. Order Date: 09/08/2022. The eMAR (electronic medication administration record) dated 1/1/2023-1/31/2023 documented the Percocet was administered to R58 on 1/9/2023 for a pain level of five, on 1/17/2023 for a pain level of zero, on 1/25/2023 at 12:05 a.m. for a pain level of five, on 1/25/2023 at 1:23 p.m. for a pain level of six, and 1/29/2023 for a pain level of seven. The eMAR failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of Percocet on 1/25/2023 at 1:23 p.m. The eMAR dated 2/1/2023-2/28/2023 documented the Percocet administered to R58 on 2/1/2023 at 7:34 p.m. for a pain level of eight, on 2/2/2023 at 9:47 p.m. for a pain level of eight, on 2/11/2023 at 10:23 p.m. for a pain level of six, on 2/19/2023 at 7:47 p.m. for a pain level of eight, on 2/21/2023 at 9:31 p.m. for a pain level of seven, on 2/22/2023 at 1:24 p.m. for a pain level of five and 2/25/2023 at 5:08 p.m. for a pain level of six. The eMAR failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of Percocet on 2/19/2023 at 7:47 p.m., 2/21/2023 at 9:31 p.m. or 2/22/2023 at 1:24 p.m. The progress notes for R58 failed to evidence documentation of non-pharmacological interventions attempted or offered prior to the administration of the Percocet on the dates and times listed above. The comprehensive care plan for R58 dated 9/2/2022 documented in part, [Name of R58] has pain or potential for pain. Date Initiated: 09/07/2022. Revision on: 09/08/2022 . On 2/28/2023 at approximately 5:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of non-pharmacological interventions being provided for 1/25/2023, 2/19/2023, 2/21/2023 and 2/22/2023 prior to the administration of Percocet as documented above. On 3/1/2023 at approximately 8:00 a.m., ASM #1 stated that they did not have evidence of non-pharmacological interventions being provided for the dates requested. On 3/1/2023 at 11:16 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that when a resident complained of pain they assessed the pain location and level and attempted non-pharmacological interventions prior to administering ordered as needed pain medications. RN #1 stated that they attempted to reposition residents, provide music or a snack and if the interventions were not effective they administered the medication. RN #1 stated that they documented the non-pharmacological interventions on the eMAR or in the progress notes each time an as needed pain medication was administered. The facility policy Pain Management dated 5/27/22 documented in part, .The Center must ensure that pain management is provided to patients who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the patients ' goals and preferences .Non-pharmacological interventions will include but are not limited to: a. Environmental comfort measures (e.g., adjusting room temperature, smoothing linens, comfortable seating or assistive devices) b. Loosening any constrictive bandage, clothing, or device c. Applying splinting (e.g., pillow or folded blanket) d. Physical modalities (e.g., cold compress, warm shower/bath, massage, turning and repositioning) e. Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobility f. Cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the patient coping techniques and education about pain) . On 3/1/2023 at approximately 2:38 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing/infection preventionist and ASM #5, the clinical services specialist were made aware of the findings. was made aware of the concern. No further information was provided prior to exit. Reference: (1) Percocet Oxycodone is used to relieve moderate to severe pain. Oxycodone extended-release tablets and extended-release capsules are used to relieve severe pain in people who are expected to need pain medication around the clock for a long time and who cannot be treated with other medications. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow the assessment for the use of side rails for one of 46 residents in the survey sample, Resident #165. The findings include: For Resident #165 (R165), the facility staff had side rails up while the resident was in bed, however the bed/side rail evaluation indicated no bed rails were required. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/22/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, R165 was coded as requiring extensive assistance of one staff member for moving in the bed and extensive assistance of two staff member for transfers. On 2/27/2023 at approximately 12:00 p.m. R165 was observed in their bed with both side rails up at that time. A second observation was made on 2/27/2023 at 3:12 p.m. R165 was in bed with bilateral bed side rails up. The clinical record was reviewed. The most recent Bed Rail Evaluation, dated, 2/22/2023, documented, NO bed rails required. Review of the physician orders failed to evidence a physician order for the use of side rails. The comprehensive care plan dated, 11/30/2022, documented in part, Focus: (R165) demonstrates the need for ADL (activities of daily living) assistance r/t (related to) decreased mobility and generalized weakness. The Interventions documented in part, Bed rails as ordered. An interview was conducted with LPN (licensed practical nurse) #6, the unit manager, on 3/1/2023 at 8:20 a.m. The above bed rail assessment and observation was reviewed with LPN #6. When asked if the resident should have side rails on their bed, LPN #6 stated there should be another assessment completed. The facility policy, Proper Use of Side Rails documented in part, It is the policy of this Center to utilize a person-centered approach when determining the use of side rails, also known as bed rails. Alternative approaches are attempted prior to installing a side or bed rail. If used, the Center ensures correct installation, use, and maintenance of the rails. Policy Explanation:1. As part of the patient's comprehensive assessment, the following components will be considered when determining the patient's needs, and whether or not the use of side/bed rails meets those needs: a. Medical diagnosis, conditions, symptoms, and/or behavioral symptoms. b. Size and weight, c. Sleep habits, d. Medication(s), e. Acute medical or surgical interventions, f. Underlying medical conditions, g. Existence of delirium, h. Ability to toilet self safely, i. Cognition, j. Communication, k. Mobility (in and out of bed), and/or l. Risk of falling .g. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side/bed rail. h. Obtain physician/physician extender orders for the use of side/bed rails. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing, and ASM #5 the clinical services specialist, were made aware of the above findings on 3/1/2023 at 2:38 p.m. No further information was obtained prior to exit.

Based on resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to store medications in a secure manner for one of 46 residents in the survey sample, Resident #71. The findings include: The facility failed to secure medications for Resident #71 (R71). On 2/28/2023 at 8:36 a.m., three Midodrine 2.5 mg tablets (1) were observed unsecured in R71's dialysis communication book in the residents room in an open duffel bag. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/13/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. Section O documented R71 receiving dialysis while a resident. The physician orders for R71 documented in part, - Midodrine HCl (hydrochloride) Tablet 10 MG (milligram) Give 1 tablet by mouth every day shift every Mon, Wed, Fri for Hypotension. Send 1 tab (tablet) with pt (patient) to dialysis every M,W,F. Order Date: 12/15/2022. On 2/28/2023 at 8:36 a.m., an interview was conducted with R71 in their room. R71 stated that they went to dialysis three days a week on Monday, Wednesday and Fridays. When asked if a book was sent with them to dialysis, R71 stated that it was and that the book was in the chair in the room in the open duffel bag at the end of their bed. R71 stated that they had gone to dialysis the day before and the book had been there since they got back. On 2/28/2023 at 8:37 a.m., a review of the dialysis communication book for R71 was conducted. Observation of the dialysis communication book revealed three tablets in separate packaging labeled Midodrine tab 2.5 mg in a plastic sleeve inside the binder. R71 stated that the medicine went with them to dialysis each time. On 2/28/2023 at 8:39 a.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that prior to R71 going to dialysis they weighed them, obtained vital signs and filled out the dialysis communication form in the book. LPN #6 stated that they sent the book and the Midodrine with R71 each time they went to dialysis. LPN #6 stated that the nurses should get the book back when the resident returned to the facility to read any communication the dialysis center sent back and store the book at the nurses station. LPN #6 stated that R71 went to dialysis the day before and normally came back to the facility between 3-4 p.m. LPN #6 stated that the dialysis book was normally kept at the nurses station and the medication should not be kept in the binder in the residents room unsecured. LPN #6 stated that any resident could go into the room and pick it up and it needed to be locked up. The facility policy, Medication Storage dated 7/23/2019 documented in part, .Only licensed nurses, the Consultant Pharmacist, and those authorized to administer medications (e.g. medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access . On 3/01/2023 at 2:38 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the assistant director of nursing/infection preventionist and ASM #5, the clinical services specialist were made aware of the findings. No further information was provided prior to exit. Reference: (1) Midodrine Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a616030.html

Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for three of 31 residents in the survey sample, Resident's # 35, #10, and #32. The facility staff failed to develop Resident # 35's comprehensive care plan to address the care needs and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] # 10's physician ordered fluid restriction and failed to implement Resident #2's comprehensive care plan, for the use of non-pharmacological interventions prior to the administration of as needed pain medication. The findings include: 1. Resident # 35 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 35's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 07/10/2021, coded Resident # 35 as scoring an 11 on the brief interview for mental status (BIMS) of a score of 0 - 15, 11 - being moderately impaired of cognition for making daily decisions. Section I Active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] or [CONDITION(S)]. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 [one] tablet by mouth two times a day for Treat [treatment] seizures. Order Date: 7/3/2021 and [MEDICATION(S)] [3] Tablet Delayed Release 250 MG. Give 1 tablet by mouth two times a day for Treat [treatment] [CONDITION(S)] / [CONDITION(S)] [4] disorder. Order Date: 7/3/2021. The comprehensive care plan for Resident # 35 dated 07/04/2021 failed to evidence a care plan to address Resident # 35's care needs for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/15/21 at 3:58 p.m., an interview was conducted with RN [registered nurse] # 2, MDS coordinator. After RN #1 reviewed Resident # 35's care plan dated 07/04/2021, RN # 2 stated that there was no evidence a care plan to address Resident # 35's [CONDITION(S)]. When asked how the comprehensive care plan is developed, RN # 2 stated that they take information from CAAs [care assessment area] of the MDS, from the interim care plan and the resident's diagnoses. The facility's policy Comprehensive Care Planning Process documented in part, The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. An interdisciplinary assessment team shall develop a comprehensive assessment and care plan for each resident based on outcomes of assessments and input from the resident, family and interdisciplinary team members. The team serves as the authority for overseeing resident care services. On 09/14/2021 during the entrance conference at approximately 11:00 a.m., ASM [administrative staff member] # 1, administrator, was asked what professional standard the nursing staff flows. ASM # 1 stated Lippincott. According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . Fundamentals of Nursing Lippincott Williams & Wilkins 2007 Lippincott Company Philadelphia pages 65-77. On 09/16/2021 at approximately 3:35 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, director of operations and ASM # 4, clinical service specialist, were made aware of the above findings. No further information was provided prior to exit. References: [1] A brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness. This information was obtained from the website: https://medlineplus.gov/[CONDITION(S)].html. [2] Used alone and along with other medications to control partial-onset seizures (seizures that involve only one part of the brain) in adults, children, and infants 1 month of age or older. [MEDICATION(S)] is in a class of medications called anticonvulsants. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 9.html. [3] [MEDICATION(S)] [[MEDICATION(S)]] is used alone or with other medications to treat certain types of seizures. [MEDICATION(S)] is in a class of medications called anticonvulsants. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 2.html. 2. The facility failed to implement the comprehensive care plan for Resident # 10's physician ordered fluid restriction. Resident # 10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/13/2021, coded Resident # 10 as scoring a three [3] on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 10 for [CONDITION(S)] while a resident. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 420 cc provided by nursing as follows: 7-3 [7:00 a.m. - 3:00 p.m.] can give 180 cc; 3-11 [3:00 p.m. - 11:00 p.m.] can give 180 cc; 11-7 [11:00 p.m. - 7:00 a.m.] can give 60 cc. Start Date: 3/3/2021. The comprehensive care plan for Resident #10's dated 10/17/2020 documented in part, Focus: [Resident # 10] is nutrition at risk [sic] for weight fluctuation r/t [related to] dx [diagnosis] of moderate protein-calorie malnutrition w/increased [with increased] need secondary to [CONDITION(S)] [end stage renal disease] on HD [hemodialysis] 3x/week [three times per week]. R [right] leg BKA [below the knee amputation] and hx [history] of pressure ulcer (now resolved), hx of refusing to go to [CONDITION(S)], w/need for protein supplementation, therapeutic diet and fluid restriction. Date Initiated: 10/20/2020. Under Interventions it documented in part, Fluid restriction as ordered. Date Initiated: 3/3/2021. Review of one day of meal tickets for Resident # 10 was conducted. The meal ticket documented, Only 4.5oz [ounces] of fluid allowed for each of the three meals, breakfast, lunch and dinner. The POC (point of care) documentation, recorded by the staff after meal intake, for September 2021 was reviewed with the following fluid totals: 09/01/2021=1300cc [cubic centimeter], 09/05/2021=1240cc, 09/07/2021=1550cc, 09/11/2021=1300cc and 09/14/2021=1340cc. Review of the eMAR [electronic medication administration record] for Resident # 10 dated September 2021 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] =240cc with a total of 1540 cc of fluid for the day, 09/05/2021=420cc with a total of 1600 cc of fluid for the day, 09/07/2021=420cc with a total of 1950 cc of fluid for the day, 09/11/2021=540ccs with a total of 1840 cc of fluid for the day and 09/14/2021=420cc with a total of 1760cc of fluid for the day. On 09/16/2021 at 11:41 a.m., an interview was conducted with ASM [administrative staff member] # 2, director of nursing, regarding the monitoring of Resident # 10's fluid restrictions and Resident # 10's comprehensive care plan. When asked if the physician prescribed fluid restrictions for Resident # 10, are being monitored if the daily intake totals of fluid were over the physician ordered amount, ASM # 2 stated, No. When asked if the comprehensive care plan was being implemented ASM # 2 stated no. On 09/16/2021 at approximately 3:35 p.m., ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, ASM # 3, director of operations and ASM # 4, clinical service specialist, were made aware of the above findings. No further information was provided prior to exit. 3. The facility staff failed to implement Resident #2's comprehensive care plan, for the use of non-pharmacological interventions prior to the administration of as needed pain medication. Resident #32 was admitted to the facility on [DATE] with a recent readmission on 6/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/9/2021, coded Resident #32 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for most of her activities of daily living. Resident #32 was coded as requiring supervision after set up assistance was provided for eating. In Section J - Health Conditions, the resident was coded as receiving as needed pain medications for occasional pain. The comprehensive care plan dated, 6/22/2021, documented, Focus: (Resident #32) has pain or potential for pain. The Interventions documented, Administer pain medications as ordered. Report s/s (signs and symptoms) potential negative side effects. Assess pain level q (every) shift and PRN (as needed) and apply interventions as needed. Assist with alternate positioning and other diversional activities to relieve pain. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 MAR (medication administration record) for Resident #32 documented the above physicians order for Tylenol and documented the Tylenol was administered on the following dates and times for the following documented pain levels: 8/18/2021 at 5:20 a.m., and 8/20/2021 at 5:50 a.m. - for pain levels of 5. 8/20/2021 at 9:10 p.m. - pain level of 7. 8/25/2021 at 5:25 a.m., 8/26/2021 at 6:20 a.m., and 8/28/2021 at 12:30 a.m. - pain levels of 5. 8/29/2021 at 1:45 p.m. - pain level of 6. Review of the nurses noted for the dates above revealed the following documentation: - 8/18/2021 at 5:20 a.m. documented, Resident c/o (complained of) pain to lower abdomen, resident denies spastic pain. Pain level 5/10 (five out of a pain scale of 0 -10, ten being the worse pain ever in and zero meaning no pain). There was no documentation of non-pharmacological interventions provided or offered. - 8/20/2021 at 5:50 a.m. documented, Resident c/o minor body aches, afebrile, and encouraged to drink fluids. Pain level 5/10. There was no documentation of non-pharmacological interventions provided or offered. - 8/20/2021 at 9:10 p.m. documented, Tylenol 2 tabs (tablets) for headache, pain level of 7/10. There was no documentation of non-pharmacological interventions provided or offered. - 8/25/2021 at 5:25 a.m. documented, Resident c/o pain to sacrum. Pain level 5/10. There was no documentation of non-pharmacological interventions provided or offered. - 8/26/2021 at 6:20 a.m., and 8/28/2021 at 12:30 a.m., both entries documented, Resident c/o pain to sacrum, pain level 5/10. - 8/29/2021 at 1:45 p.m. failed to document the location of the pain or non-pharmacological interventions offered. The September 2021 MAR for Resident #32 documented the above physicians order for Tylenol and documented the Tylenol was administered on the following dates and times for the following documented pain levels: 9/2/2021 at 12:24 p.m. and 9/3/2021 at 9:31 a.m. - pain levels of 6. 9/4/2021 at 9:28 p.m. and 9/14/2021 at 12:16 p.m. - pain levels of 5. 9/6/2021 at 12:08 p.m., 9/7/2021 at 8:26 a.m., 9/10/2021 at 1:41 p.m., and 9/12/2021 at 8:20 p.m. - pain levels of 6. Review of the nurse's notes for the dates above revealed the following: 9/2/2021 at 12:24 p.m., 9/3/2021 at 9:31 a.m., 9/4/2021 at 9:28 p.m.,9/6/2021 at 12:08 p.m.,9/10/2021 at 1:41 p.m., 9/7/2021 at 8:26 a.m., 9/12/2021 at 8:20 p.m., all failed to evidence documentation of the location of the pain and if non-pharmacological interventions were attempted or offered. The nurse's note dated, 9/14/2021 at 12:16 p.m. documented, Resident complained of pain to right knee. On the pain scale of 1 -10, she stated it is a 5/10. There was no documentation if non-pharmacological interventions were offered. An interview was conducted with LPN (licensed practical nurse) #1, on 9/16/2021 at 10:30 a.m. When asked the purpose of the care plan, LPN #1 stated it's for us to have interventions for the resident. When asked if the care plan should be followed, LPN #1 stated, yes. ASM #1, the administrator, ASM #2, the director of nursing, ASM # 4, the clinical services specialist and ASM #3, the director of operations, were made aware of the above concern on 9/16/2021 at 3:33 p.m. No further information was provided prior to exit. References: (1) Pneumonia: An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. This information was obtained from the following website: https://medlineplus.gov/pneumonia.html. (2) Asthma: respiratory disorder characterized by recurrent episodes of difficulty in breathing, wheezing, cough, and thick [MEDICATION(S)] production, caused by inflammation of the bronchi. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 51. (3) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 4.html

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and revise the care plan for three of 31 residents in the survey sample, Residents #64, #297, and #63. 1. The facility staff failed to revise the comprehensive care plans for Residents #64 and #297 following a resident to resident incident between them on 5/8/21. 2. The facility staff failed to revise Resident #63's care plan when he began taking an antidepressant medication. The findings include: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/3/21, Resident #64 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having demonstrated no mood disorder symptoms, no [CONDITION(S)], no behaviors toward himself or others, no rejection of care, and no wandering. He was coded as being independent in all ADLs (activities of daily living), as having no functional limitations with range of motion in upper or lower extremities, and as always continent of both bladder and bowel. He was coded as using a wheelchair for locomotion during the look back period. Resident #297 no longer resides in the facility. She was admitted on [DATE] and discharged on [DATE]. She was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS, an admission assessment with an ARD of 4/26/21, she was coded as being severely cognitively impaired for making daily decisions, having scored seven out of 15 on the BIMS. She was coded as being completely dependent on facility staff for all ADLs, and as using a wheelchair for locomotion. A review of Resident #64's clinical record revealed the following progress notes: 5/8/2021 12:31 (12:31 p.m.) *Behavior Note Behavior Observed (Onset and Duration): Resident walked out of the facility in the morning without using wheel-chair, he came back with signs of being intoxicated. At around 1030 (10:30 a.m.), resident noted with extreme agitation, tried to hit staff and the writer. Writer tried to calm resident down and redirect him, but resident was not cooperative, writer called 911 for help. Police officer stayed with resident for about 45 minutes and recommended writer to call family and MD (medical doctor) for a quick discharge, because of safety concerns of the staff and other employees. Police officers told writer that resident stated: 'I don't want to be here.' Family and MD notified. 5/8/2021 13:09 (1:09 p.m.) Social Services Note Late Entry: Note Text: 05/08/2021, at approximately 9:30 p.m. [local police department] arrived to serve ECO (emergency custody order) which was approved by magistrate. Resident completed a virtual evaluation with [local CSB (community services board) Representative with [local police department] present. 05/08/2021 at approximately 9:50 p.m. SS [social services] Care Coordinator (SSCC) spoke with [name CSB representative]. SSCC provided [CSB representative] with a hx (history) of Resident's behavior and actions on 05/08/2021 along with a hx of his medical condition, mental illness, and suspected substance abuse. [CSB representative] shared that during the evaluation, Resident denied having a mental illness dx (diagnosis) and denied substance abuse. [CSB representative] shared that she would have her Supervisor review her evaluation and give SSCC a call back. 05/08/2021 at approximately 11 p.m. SSCC received phone call from [CSB representative]. She shared that her Supervisor determined that Resident does not meet ECO criteria. 5/8/2021 16:14 (4:14 p.m.) *Behavior Note Behavior Observed (Onset and Duration): Cna (certified nursing assistant) reported to writer that she observed resident slamming his wheelchair into the same resident [Resident #297] wheelchair multiple times. Cna also stated resident had enough room to pass around the resident without slamming the wheelchair. A review of Resident #64's comprehensive care plan dated 7/25/18 and most recently updated 8/16/21 revealed no evidence of this incident. A review of Resident #297's comprehensive care plan dated 4/20/21 revealed no evidence of this incident. On 9/15/21 at 1:58 p.m., ASM (administrative staff member) #1, the administrator, and ASM #4, the clinical services specialist, were interviewed. ASM #1 stated there was no evidence of updates to either resident's care plan following the incident. On 9/16/21 at 9:51 a.m., ASM #1, ASM #3, the clinical services specialist, and ASM #4, director of operations, were informed of these concerns. On 9/16/21 at 10:31 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked the purpose of a care plan, she stated the care plan is in place to have interventions to meet the residents' needs. When asked who is responsible for updating the care plan as changes develop with residents, she stated it is primarily the nursing staff - unit supervisor, assistant director of nursing or director of nursing. She stated a resident to resident incident should be added to both residents' care plans. On 9/16/21 at 11:41 a.m., ASM #2 was interviewed. When asked the purpose of a care plan, he stated the care plan is a guide to help staff take care of a resident with their own specific problems and interventions. He stated the care plan is an ongoing document and involves all disciplines who provide care and services for the resident. He stated a resident to resident incident should be included on the care plan for both residents involved. A review of the facility policy, Comprehensive Care Planning Process, revealed, in part: Duties and responsibilities of the Care Planning/Interdisciplinary Team include, but are not limited to: Reviewing care plans to assure that: They reflect the resident's medical and nursing assessment; They attempt to manage risk factors. No further information was provided prior to exit. (1) [CONDITION(S)] (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. This information is taken from the website https://www.nimh.nih.gov/health/topics/[CONDITION(S)]-disorder/index.shtml. (2) The epilepsies are a spectrum of brain disorders ranging from severe, life-threatening and disabling, to ones that are much more benign. In [CONDITION(S)], the normal pattern of [CONDITION(S)] activity becomes disturbed, causing strange sensations, emotions, and behavior or sometimes convulsions, muscle spasms, and loss of consciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/[CONDITION(S)]-Information-Page. (3) [CONDITION(S)], or [CONDITION(S)], is a progressive disease that makes it hard to breathe. Progressive means the disease gets worse over time. [CONDITION(S)] can cause coughing that produces large amounts of a slimy substance called [MEDICATION(S)], wheezing, shortness of breath, chest tightness, and other symptoms. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/[CONDITION(S)]. 2. Resident #63 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/2/21, Resident #63 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having received an antidepressant on all seven days of the look back period. A review of Resident #64's physician orders revealed the following order: [MEDICATION(S)] (4) Tablet 7.5 MG (milligrams). Give 1 tablet by mouth at bedtime for Depression. Start Date 06/03/2021. A review of Resident #63's MARs (medication administration records) from 6/4/21 through 9/14/21 revealed he had received the [MEDICATION(S)] as ordered. A review of Resident #63's comprehensive care plan, dated 4/26/21 and revised 7/16/21, revealed no evidence that it had been updated to include Resident #63's receiving the [MEDICATION(S)]. On 9/16/21 at 10:31 a.m., LPN (licensed practical nurse) #1 was interviewed. When asked the purpose of a care plan, she stated the care plan is in place to have interventions to meet the residents' needs. When asked who is responsible for updating the care plan as changes develop with residents, she stated it is primarily the nursing staff - unit supervisor, assistant director of nursing or director of nursing. She stated a resident's care plan should be updated when the resident begins receiving an antidepressant. On 9/16/21 at 11:41 a.m., ASM #2 was interviewed. When asked the purpose of a care plan, he stated the care plan is a guide to help staff take care of a resident with their own specific problems and interventions. He stated the care plan is an ongoing document and involves all disciplines who provide care and services for the resident. He stated a resident's care plan should be updated to include the resident's receiving an antidepressant. On 9/16/21 at 9:51 a.m., ASM (administrative staff member) #1, he administrator, ASM #3, the director of operations, and ASM #4, the clinical services specialist, were informed of these concerns. No further information was provided prior to exit. (1) Heart failure is a condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body .As the heart's pumping becomes less effective, blood may back up in other areas of the body. Fluid may build up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called [CONDITION(S)]. This information is taken from the website https://medlineplus.gov/ency/article/ 8.htm (2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (3) [CONDITION(S)] (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. This information is taken from the website https://www.nimh.nih.gov/health/topics/[CONDITION(S)]-disorder/index.shtml. (4) [MEDICATION(S)] tablets are indicated for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .nlm.nih.gov/dailymed/drugInfo.cfm?setid=0039f505-7cd0-4d79-b5dd-bf2d 1a0.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to promote a safe environment for three of 31 residents in the survey sample, Residents #64, #297, and #35. 1. Resident #64 was repeatedly allowed to leave the facility unsupervised without being assessed for safety to do so, and without being educated by the facility regarding the risks of suffering a serious injury while out of the facility without supervision. On 5/8/21, Resident #64 rammed his wheelchair into Resident #297's wheelchair multiple times while Resident #297 was seated in her wheelchair. The facility failed to assess Resident #297 for injury, and failed to implement interventions to ensure a safe environment and the safety of Resident #297. The facility failed to perform urine and/or blood screening tests for alcohol and illegal drugs on Resident #64 on multiple occasions when the resident displayed symptoms of impairment, despite having entered into an agreement with the resident to do so. 2. The facility staff failed to wrap Resident # 35's right and left bedrails with a towel for [CONDITION(S)] precautions according to the physician's orders. The findings include: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses including a femur fracture, [CONDITION(S)] (1), [CONDITION(S)] (2), alcohol abuse, and [MEDICATION(S)] dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/3/21, Resident #64 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having demonstrated no mood disorder symptoms, no [CONDITION(S)], no behaviors toward himself or others, no rejection of care, and no wandering. He was coded as being independent in all ADLs (activities of daily living), as having no functional limitations with range of motion in upper or lower extremities, and as always continent of both bladder and bowel. He was coded as using a wheelchair for locomotion during the look back period. Resident #297 no longer resides in the facility. She was admitted on [DATE] and discharged on [DATE]. She was admitted with diagnoses including urinary tract infection, [CONDITION(S)] (3), and anxiety disorder. On the most recent MDS, an admission assessment with an ARD of 4/26/21, she was coded as being severely cognitively impaired for making daily decisions, having scored seven out of 15 on the BIMS. She was coded as being completely dependent on facility staff for all ADLs, and as using a wheelchair for locomotion. On 9/15/21 at 8:30 a.m., Resident #64 was observed standing in the hallway near the nurses' desk. He walked from the nurses' desk through the day room, and stepped out into the courtyard. On 9/15/21 at 11:22 p.m., Resident #64 was observed sitting in the day room in a wheelchair. A review of Resident #64's physician's orders revealed the following order: 7/25/18 Topiragen Tablet ([MEDICATION(S)]) 50 mg. Give 3 tablets by mouth two times a day for Seizures. A review of Resident #64's clinical record revealed the following progress notes: 4/18/2021 17:15 (5:15 p.m.) *Behavior Note Behavior Observed (Onset and Duration): At 1610 (4:10 p.m.), resident was verbally abusive and yelling at high volume at the writer, threatening to break and entering the writer's office by force. Resident entered the office and he was instructed to get out of the office. Writer told resident that his behavior was not acceptable. Resident appeared more drunk (sic), he had a bottle in his jacket which he could not (sic) writer to see what was in the bottle. 4/19/2021 23:50 (11:50 p.m.) Health Status Note Text: Nurse writing this report was called CNA in [Resident #64's room] and found resident sitting on the floor closed to his bed seizuring (sic) .continuing monitoring resident for [CONDITION(S)] precaution. 4/28/2021 00:09 (00:09 a.m.) Health Status Note Text: Resident went out for dental appt (appointment) today, when he came back around 1800 (6:00 p.m.) smell like a alcohol (sic) from him. I didn't saw (sic) him to drink but just smell like a alcohol. No other episode observed other than smell. 5/1/2021 13:12 (1:12 p.m.) Health Status Note Text: resident signed out @ (at) 08:45 am and came back @ 10:00 am. couple hour later resident was smelling (like) alcohol and became talkative, bothering everyone in the unit. witness fall in [unit name] living room by students CNA. Resident refused to be assess by nurse. 5/1/2021 23:06 (11:06 p.m.) *Behavior Note Behavior Observed (Onset and Duration): resident had alcohol smell all over today after coming back for his shopping at [local grocery store]. Was talkative and provoking staff members. 5/8/2021 12:31 (12:31 p.m.) *Behavior Note Behavior Observed (Onset and Duration): Resident walked out of the facility in the morning without using wheel-chair, he came back with signs of being intoxicated. At around 1030 (10:30 a.m.), resident noted with extreme agitation, tried to hit staff and the writer. Writer tried to calm resident down and redirect him, but resident was not cooperative, writer called 911 for help. Police officer stayed with resident for about 45 minutes and recommended writer to call family and MD (medical doctor) for a quick discharge, because of safety concerns of the staff and other employees. Police officers told writer that resident stated: 'I don't want to be here.' Family and MD notified. 5/8/2021 13:09 (1:09 p.m.) Social Services Note Late Entry: Note Text: 05/08/2021, at approximately 9:30 p.m. [local police department] arrived to serve ECO (emergency custody order) which was approved by magistrate. Resident completed a virtual evaluation with [local CSB (community services board) Representative with [local police department] present. 05/08/2021 at approximately 9:50 p.m. SS (social services) Care Coordinator (SSCC) spoke with [name CSB representative]. SSCC provided [CSB representative] with a hx (history) of Resident's behavior and actions on 05/08/2021 along with a hx of his medical condition, mental illness, and suspected substance abuse. [CSB representative] shared that during the evaluation, Resident denied having a mental illness dx (diagnosis) and denied substance abuse. [CSB representative] shared that she would have her Supervisor review her evaluation and give SSCC a call back. 05/08/2021 at approximately 11 p.m. SSCC received phone call from [CSB representative]. She shared that her Supervisor determined that Resident does not meet ECO criteria. 5/8/2021 16:14 (4:14 p.m.) *Behavior Note Behavior Observed (Onset and Duration): Cna (certified nursing assistant) reported to writer that she observed resident slamming his wheelchair into the same resident [Resident #297] wheelchair multiple times. Cna also stated resident had enough room to pass around the resident without slamming the wheelchair. A review of Resident #64's comprehensive care plan dated 7/25/18 and most recently updated 8/16/21 revealed, in part: Resident #64 is at risk of a change/decline in his mood and/or psychosocial status d/t (due to) continuing ETOH abuse, [MEDICATION(S)] dependence, hx of aggressive/intimidating behavior toward elderly residents, being younger than the general population .Encourage and allow to ventilate feelings .Mental Health Consult . The care plan did not evidence any documentation regarding or addressing the incident with Resident #297 on 5/8/21. A review of Resident #297's clinical record revealed no evidence of documentation regarding this incident, and no evidence that Resident #297 was assessed for injury following this incident. A review of Resident #297's comprehensive care plan dated 4/20/21 revealed no evidence of this incident, or any interventions for ensuring a safe environment and Resident #297's safety from Resident #64. Further review of Resident #64's clinical record revealed the following progress notes: 5/8/2021 18:32 (6:32 p.m.) Social Services Note Text: 05/08/2021, 5:15 p.m. SS Care Coordinator met with magistrate at Prince [NAME] County Adult Detention Center in Manassas, VA. SSCC submitted a petition for ECO (Emergency Custody Order) for Resident, [name of Resident #64] due to his attempt to physically harm staff members and other elderly residents at the center on the morning of 05/08/2021. Center awaits magistrate's decision to deny or grant the ECO. 05/08/2021, 6:15 p.m. SSCC arrived at the center to assess the situation in regard to Resident's behavior. Resident prompted conversation with SSCC. Resident was noted to have dilated pupils, unable to finish his thoughts, repeating himself often, and easily distracted. Resident rambled on about the events that occurred earlier in the day; however, Resident's thoughts remained scattered. Staff will continue to monitor Resident closely due his unpredictable and abrasive/threatening behavior and demeanor. 5/12/2021 20:05 (8:05 p.m.) Fall Note Data: Resident complained of pain in his left shoulder and left side of his chest, when i (sic) asked what happened he says 'I fell down early Tuesday from the bed.' Action: Did assessment, resident has cut on his scalp behind left ear, can't fully lift his left hand. Resident doesn't remember exact time when it happened because he was dreaming. Neurocheck initiated .Notified, MD, got orders for chest x-ray and Left shoulder x-ray. 5/12/2021 20:23 (8:23 p.m.) Health Status Note Text: Resident stated that he fell down from his bed on Tuesday early morning, was complaining on pain in his left side of chest, left shoulder and cut on his head. 5/14/2021 11:30 (11:30 a.m.) Social Services Note Late Entry: Note Text: IDT (interdisciplinary team) conducted Care Plan Meeting with Resident to discuss behavior management. IDT Members present for meeting include: Administrator, DON (director of nursing), ADON (assistant director of nursing), SS (social services) Care Coordinator, Psych (psychiatry) NP (nurse practitioner), and Psychologist. Resident denied being verbally or physically aggressive toward staff or other residents on 05/08/2021. When asked why the police were called on [5/8/21], Resident stated it was because he and ADON do not get along; then he changed the subject. Resident denied consuming alcohol and denied using any other substances. When asked why his behavior and overall demeanor are significantly different after he returns from LOA, Resident could not provide an answer. When asked why he smells of alcohol and has increase in falls after returning from LOA, Resident could not provide an answer. At the conclusion of the meeting, Resident agreed to the following: -Allowing staff to search his room and personal belongings at any time as long as he is present. -Providing blood or urine for toxin screen to be completed. -Going on LOA only during Monday through Friday between the hours of 8 a.m. to 4 p.m. 5/14/2021 13:26 (1:26 p.m.) Psych (psychiatry) Note Late Entry: Note Text: Psychiatric Progress Note Chief Complaint: Patient seen to evaluate mental status and adjust medications for behavioral disturbance Chief Complaint Comments: Care plan meeting with the patient relating his escalated behavior issues History of Present Illness [Resident #64] is seen on 5/14/2021 for care plan meeting regarding patient escalated behavior issues recently. The meeting was held in conference room with the patient in presence of this provider, psychologist, SW (social service care coordinator), DON, ADON, and facility administrator. The patient has shown behavior concern especially in the weekend for past couple of weeks. Per staff notes he goes out of the facility and when he comes back to the facility Resident was noted to have dilated pupils, unable to finish his thoughts, repeating himself often, and easily distracted. Reported he has agitated behavior towards the staff and other resident in the facility. Patient denied being intoxicated with any alcohol or substance abuse while he is in the facility. Upon asking about cause of his agitation he talks about random things and avoided conversation focused on alcohol intake or substance use (patient has a history of alcohol abuse, crystal meth and cocaine use). He is noted to be defensive for any questions asked and had a perseverative thoughts. Per staffs he has been refusing medical services including outpatient referrals and lab [laboratory] works. At the end of the meeting patient agreed to comply with the purposed facility protocol, and agreed with lab works. No overt symptoms suggestive of depression, SI/HI [suicidal ideation/homicidal ideation], and hallucination noted. He reported having a fair appetite and sleep at night. Chart and medication reviewed. Pt has Hx of ETOH abuse and may possibly be buying ETOH. Discussed risks of using ETOH with pt. Mental Status Exam Attitude: Defensive, Guarded Appearance: Appropriate, Thin Habitus Behavior: Intrusive Speech: Hyperverbal Gait: Wheel Chair but walks, says uses w/c d/t [wheel chair due/to] [CONDITION(S)] concerns Mood: Irritable Affect: Labile Thought process: Circumstantial Thought Content: No hallucinations, grandiose delusions Suicidality: None/denies Homicidality: None/denies Insight/Judgement: Poor Diagnosis Substance Induced Mood Disorder - F19.94 [CONDITION(S)] ' Mixed ' Unspecified - F31.6 Anxiety Disorder Secondary to Medical Conditions - F06.4 Alcohol abuse uncomplicated- F10.10 [MEDICATION(S)] Dependence unspecified-F17.200 Treatment Plan / Recommendations Plan: Supportive therapy provided. Psychiatric team will monitor mood and behavior, Performance measures Neuropsychiatric symptoms reviewed, Patient is encouraged to participate in activities on the unit Continue psychotherapy Patient motivated to verbalized any concerns at any time with the staffs Will continue to monitor his mood and behavior. This note was signed by OSM #6, the psychiatric NP (nurse practitioner). 6/17/2021 15:49 (3:49 p.m.) Health Status Note Text: 06/17/21 at 1549 (3:49 p.m.) Resident started episode of [CONDITION(S)] near nursing station during this shift put resident safe position with blanket under head side lying position and ends at 1600 (4:00 p.m.). 7/22/2021 15:37 (3:37 p.m.) Fall Note Data: At 1506 (3:06 p.m.) resident was in courtyard when he had [CONDITION(S)] and fell down from his wheelchair and hit his head on concrete (other resident witnessed the fall) .His mother and MD was informed, got order to send to ER (emergency room ) for evaluation. Called 911. 7/22/2021 19:27 (7:27 p.m.) Health Status Note Text: At 1506 (5:06 pm) resident was found in courtyard lying on the ground having [CONDITION(S)]. Other resident saw him how he fell down from the wheelchair and hit his head, there was loud sound .Got report from morning nurse that resident was out earlier in the [local convenience store], when he came back, she smelled alcohol. His mother and MD was notified. Got order to send to ER for evaluation. 7/22/2021 19:36 (7:36 p.m.) Health Status Note Text: At 18.45 (6:45 p.m.) got report from (local hospital) that patient going back, he has Aberration of Left hand, contusion of Left hand, head injury .bloodwork for alcohol and drugs was negative. 8/2/2021 16:52 (4:52 p.m.) Health Status Note Text: Resident face is red, flashed when he was passing me by. i (sic) smelled alcohol from him. Morning nurse gave me report that earlier in the morning he was out. 8/2/2021 20:43 (8:43 p.m.) Health Status Note Text: At 18.50 (6:50) pm resident was cursing calling me '[OBSCENITY] ' he would come into nursing station, aggressive and yelling, supervisor asked him to leave area, he got up from his wheelchair and started going onto him, repeating 'What's you gonna do' threatening him. So supervisor told me to call 911. When later at 19.15 policemen came they talked to me, to resident and supervisor. 9/16/2021 01:48 1:48 a.m.) Health Status Note Text: Noted resident to smell heavily of alcohol, face is red, speech is slurred, pupils dilated, and resident is rambling loudly and rapidly in incoherent speech. Resident has been going in and out of his room, then outside to the courtyard. When he comes back in building, his behavior is escalated. Resident refuses to allow staff to search his room. Unable to redirect. Further review of Resident #64's clinical record failed to reveal any evidence that he had been assessed for safety to leave the facility unsupervised, given his history of seizures and falls. The review failed to reveal evidence that the facility had put interventions in place to protect the resident from injury when he left the facility unsupervised. The review failed to reveal any evidence that the facility staff had educated Resident #64 on the risks for falls and seizures occurring out in the community when he left the facility unsupervised. The review failed to reveal evidence that Resident #64 had received further psychological/psychiatric services after 5/14/21, prior to 9/15/21. The review failed to reveal any evidence that the facility had chosen to [MEDICATION(S)] on the verbal agreement made between the facility and the resident subsequent to the 5/14/21 IDT meeting, other than a urine and blood screening performed by an outside hospital when the resident was sent to the emergency room for a possible fracture on 7/22/21. Further review of Resident #64's comprehensive care plan dated 7/25/18 and most recently updated 8/16/21 revealed, in part: [Resident #64] has had actual falls with injuries noted, and remains at risk of falling in the future d/t (due to) disease process/[CONDITION(S)] diagnosis. Resident non-compliant (with) safety measures .Continue with rounding frequently to check on resident and offer help as needed .Anticipate and meet needs as possible .[Resident #64] has seizures r/t (related to) [CONDITION(S)] .Give [CONDITION(S)] medication as ordered by doctor .observe for [CONDITION(S)] activity and report to MD .[CONDITION(S)] PRECAUTIONS Do not leave resident alone during a [CONDITION(S)], protect from injury, if resident is out of bed, help to the floor to prevent injury. Remove or loosen tight clothing, don't attempt to restrain resident during a [CONDITION(S)] as this could make the convulsions more severe. Protect from onlookers, draw curtains. On 9/15/21 at 1:58 p.m., ASM (administrative staff member) #1, the administrator, and ASM #4, the clinical services specialist, were interviewed. When asked if the facility had submitted a FRI (facility reported incident) regarding the 5/8/21 altercation between Resident #64 and Resident #297, ASM #1 stated there were no FRIs related to that incident. When asked to provide additional information regarding Resident #64's stay at the facility, ASM #4 stated the psychologist has documented the resident likely has [CONDITION(S)] (post-traumatic stress disorder) (5), [CONDITION(S)] and a mood disorder. She stated the resident is resistant to care and support, that he is independent, and he is able to provide his own care. ASM #4 stated the staff has been working with Resident #64 on medication management and verbal communication rather than aggression. ASM #1 stated the facility attempted to issue the resident a 30-day discharge notice, as the facility staff does not feel like the resident is appropriate for nursing home-level care. She stated Resident #64 appealed the discharge, and his appeal was granted. ASM #1 stated the regulating entity ruled that the facility did not have an acceptable discharge plan for the resident. When asked if Resident #64 has been assessed to be able to leave the facility unsupervised, given his history of falls and seizures, ASM #4 stated: No, we do not have a form for that. She stated the facility bases the decision to allow Resident #64 to leave the facility unsupervised on his BIMS score (15 out of 15), and that he is his own RP (responsible party). When asked to provide evidence that the facility staff had educated the resident on the risks of leaving the facility unsupervised, given his history of seizures and falls, ASM #4 stated she would have to look. She stated Resident #64 attends appointments with his mother from time to time. ASM #4 stated, A formalized assessment for his safety does not exist in our system. When asked who else is aware that Resident #64 leaves the building unsupervised, she stated the social worker, the administrator, the nursing staff, and the psychologist are aware. When asked where Resident #64 goes when he leaves the building, ASM #4 stated, I don't know exactly. He is not forthcoming with that information when he leaves. ASM #1 was asked to provide copies of the sign-out sheets for the last six months for Resident #64. She provided a document with six entries, dating from 8/17/21 through 9/14/21. Each entry contained off prop (property) in the destination column. ASM #1 stated she was unable to locate any sign-out information prior to August 2021. She added the facility has no evidence to prove what Resident #64 does when he leaves the facility, other than those times he has a scheduled doctor's appointment. ASM #1 stated the smell of alcohol on the resident's breath is not evidence that he has been ingesting alcohol - that it is only a suspicion. She stated when the resident returns and is agitated, No one can get near him. On 9/15/21 at 2:21 p.m., ASM #2, the DON (director of nursing) joined the conversation. When asked if he is aware where Resident #64 goes when he leaves the facility unsupervised, ASM #2 stated he does not know for sure. He stated the resident goes out and walks down the street and comes back later. He stated staff have reported that they think they smell alcohol, but that is not definitive. ASM #1 stated Resident #64 avoids staff so no one can physically get close enough for a determination. When asked who is responsible for Resident #64's safety when he leaves the facility unsupervised, ASM #1 stated, Himself. ASM #2 stated, He is his own RP. When asked what interventions the facility has put in place to provide for Resident #64's safety when he leaves the building unsupervised, there was no answer. When asked why an FRI was not submitted for the 5/8/21 incident, ASM #1 stated: It was a resident-to-resident incident. A FRI should have been submitted. When asked to provide evidence of what was done to protect and esnure a safe enviorment for Resident #297 after the incident, ASM #1 stated, We don't have any. She stated Resident #64 was already on one-to-one supervision for his seizures, but there was no documentation. She stated there was no evidence of assessments for Resident #297, or of updates to either resident's care plan following the incident. On 9/15/21 at 3:46 p.m., OSM #6, the psychiatry NP, was interviewed. She stated she has not seen Resident #64 since May 2021. When asked why she has not seen Resident #64 since 5/14/21, OSM #6 stated when the resident does not have anything particular happening, she does not see him formally. She stated she will sometimes have a conversation in the hallway, but has not had any billable visits since 5/14/21. OSM #6 stated Resident #64 refuses all services and medications she offers. When asked if she documented any offers and refusals, she stated she has not. OSM #6 stated the resident leaves the building, and the facility staff has tried to set limits. She stated the resident had an incident in May 2021 that resulted in a contract between the resident and the facility. When asked if she was aware of any occasion, other than the 7/22/21 trip to the emergency room , where the facility attempted to test Resident #64's urine or blood for alcohol or drugs, she stated she was not. When asked if Resident #64 is safe to leave the building unsupervised, given his history of falls and seizures, she stated he could be. When asked if other residents are safe when Resident #64 leaves the building unsupervised and comes back altered, OSM #6 stated, It is totally unsafe for other residents. OSM #6 stated, It is really difficult to determine his safety. She stated staff has documented that when he returns from his unsupervised time out of the facility, frequently he has dilated pupils and is clearly altered. OSM #6 stated,We need to assess him for mental capacity. On 9/16/21 at 9:21 a.m., OSM #7, the psychologist, was interviewed. When asked about Resident #64, she stated he is sometimes totally alert and oriented, and capable of caring for himself. She stated at other times, he is, in her opinion, under the influence of some type of psychoactive substance. OSM #7 stated, He turns into a monster. She stated he cannot find his words, and he becomes belligerent and paranoid. When asked if she was aware Resident #64 was leaving the facility unsupervised, she stated she was not aware he was leaving the facility other than with his mother. OSM #7 stated she was not aware the resident had ever suffered a [CONDITION(S)]. When asked if other facility residents are safe when he is allowed to leave unsupervised, OSM #7 stated they are not. When asked why she has not seen Resident #64 since 4/8/21, she stated it is because he will not talk to her. She stated the team has offered Resident #64 a medication to treat [CONDITION(S)], but he has repeatedly refused, as documented multiple times in the clinical record. The facility provided a note from 5/19/21 documenting the resident's refusal of the medication to treat [CONDITION(S)]. No further documentation was provided. On 9/16/21 at 8:02 a.m., 8:55 a.m., 9:16 a.m., and 10:55 a.m., Resident #64 was observed in the day room, accompanied by CNA #7. On 9/16/21 at 9:16 a.m., CNA #7 stated she was assigned to be one on one with Resident #7 for her entire shift that day. A review of the staff schedule for 9/16/21 and 9/17/21 revealed a CNA scheduled to accompany Resident #64 on all shifts. On 9/16/21 at 9:51 a.m., ASM #1, the administartor, ASM #3, the clinical services specialist, and ASM #4 the clinical services specialist, were informed of these concerns. ASM #3 stated before the team left the faciity on [DATE], they initiated 15 minute safety checks on Resident #64 for the safety of Resident #64 and for safety of other residents in the facility. ASM #3 stated he had an incident between midnight and 1:00 a.m., making verbal outbursts, cursing, and yelling at other residents and staff. She stated there was suspicion of the smell of alcohol, and the resident repeatedly went out into the courtyard and came back in. ASM #1 stated the staff searched his room and the courtyard, but found nothing unusual. She stated the resident was put on one-to-one supervision. ASM #1 stated they called OSM #7 to come in that morning, and before she arrived, Resident #64 became violent toward a staff member. ASM #1 stated she has called the local police, the ombudsman, and the local community services board. She stated the local community services board has refused to come to the facility to assess the resident because he is already in a medical facility, on one-to-one supervision. ASM #1 stated the facility is initiating a five day discharge notice to Resident #64. She stated as of that morning, Resident #64 is no longer allowed to leave the facility unsupervised. ASM #4 stated the other residents are safe from Resident #64 now that he is on one-to-one supervision, and is not allowed to leave the facility unsupervised. ASM #1 stated the facility does not have any documentation regarding an assessment of Resident #297 for the 5/8/21 incident. She stated she should have been assessed, and interventions should have been put in place and added to the care plan. When asked to provide evidence that the facility attempted to test Resident #64's urine and blood for foreign substances, per the resident's agreement with the facility, following any of the documented occasions where he showed evidence of having consumed alcohol or was altered in any way, ASM #1 stated there was no evidence. She referred back to the 7/22/21, emergency room screening that was performed when the resident was diagnosed with the fractured clavicle. ASM #1 stated she could not provide any evidence that Resident #64 had been educated regarding the risks of leaving the facility unsupervised, given his history of seizures and falls. A review of the facility policy, Accidents and Supervision, revealed, in part: Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: Identifying hazards and risks. Evaluating and analyzing hazards and risks. Implementing interventions to reduce hazards and risks. Monitoring for effectiveness and modifying interventions when necessary .The facility should make a reasonable effort to identify the hazards and risk factors for each resident .Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk .Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. No further information was provided prior to exit. REFERENCES (1) [CONDITION(S)] (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. This information is taken from the website https://www.nimh.nih.gov/health/topics/[CONDITION(S)]-disorder/index.shtml. (2) The epilepsies are a spectrum of brain disorders ranging from severe, life-threatening and disabling, to ones that are much more benign. In [CONDITION(S)], the normal pattern of [CONDITION(S)] activity becomes disturbed, causing strange sensations, emotions, and behavior or sometimes convulsions, muscle spasms, and loss of consciousness. This information is taken from the website https://www.ninds.nih.gov/Disorders/All-Disorders/[CONDITION(S)]-Information-Page. (3) [CONDITION(S)], or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. Progressive means the disease gets worse over time. [CONDITION(S)] can cause coughing that produces large amounts of a slimy substance called [MEDICATION(S)], wheezing, shortness of breath, chest tightness, and other symptoms. This information is taken from the website https://www.nhlbi.nih.gov/health-topics/[CONDITION(S)]. (4) [MEDICATION(S)] is used alone or with other medications to treat certain types of seizures including primary generalized tonic-clonic seizures (formerly known as a grand mal [CONDITION(S)]; [CONDITION(S)] that involves the entire body) and partial onset seizures (seizures that involve only one part of the brain). [MEDICATION(S)] is also used with other medications to control seizures in people who have Lennox-Gastaut syndrome (a disorder that causes seizures and developmental delays). [MEDICATION(S)] is also used to prevent migraine headaches but not to relieve the pain of migraine headaches when they occur. [MEDICATION(S)] is in a class of medications called anticonvulsants. It works by decreasing abnormal excitement in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a 2.html. (5) Post-traumatic stress disorder ([CONDITION(S)]) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event .Those who continue to experience problems may be diagnosed with [CONDITION(S)]. People who have [CONDITION(S)] may feel stressed or frightened, even when they are not in danger. This information is taken from the website https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-[CONDITION(S)]. 2. The facility staff failed to wrap Resident # 35's right and left bedrails with a towel for [CONDITION(S)] precautions according to the physician's orders. Resident # 35 wa

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to have a complete pain management program for two of 31 residents in the survey sample, Resident #32 and Resident #63. 1. The facility staff failed to offer non-pharmacological interventions prior to the administration of an as needed pain medication and failed to document the location of Resident #32's pain. 2. The facility staff failed to document the location of Resident #63's pain on multiple occasions in September 2021 when administering an as-needed pain medication to him. The findings include: 1. Resident #32 was admitted to the facility on [DATE] with a recent readmission on 6/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/9/2021, coded Resident #32 as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for most of her activities of daily living. Resident #32 was coded as requiring supervision after set up assistance was provided for eating. In Section J - Health Conditions, the resident was coded as receiving as needed pain medications for occasional pain. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 MAR (medication administration record) for Resident #32 documented the above physicians order for Tylenol and documented the Tylenol was administered on the following dates and times for the following documented pain levels: 8/18/2021 at 5:20 a.m., and 8/20/2021 at 5:50 a.m. - for pain levels of 5. 8/20/2021 at 9:10 p.m. - pain level of 7. 8/25/2021 at 5:25 a.m., 8/26/2021 at 6:20 a.m., and 8/28/2021 at 12:30 a.m. - pain levels of 5. 8/29/2021 at 1:45 p.m. - pain level of 6. Review of the nurses noted for the dates above revealed the following documentation: · 8/18/2021 at 5:20 a.m. documented, Resident c/o (complained of) pain to lower abdomen, resident denies spastic pain. Pain level 5/10 (five out of a pain scale of 0 -10, ten being the worse pain ever in and zero meaning no pain). There was no documentation of non-pharmacological interventions provided or offered. · 8/20/2021 at 5:50 a.m. documented, Resident c/o minor body aches, afebrile, and encouraged to drink fluids. Pain level 5/10. There was no documentation of non-pharmacological interventions provided or offered. · 8/20/2021 at 9:10 p.m. documented, Tylenol 2 tabs (tablets) for headache, pain level of 7/10. There was no documentation of non-pharmacological interventions provided or offered. · 8/25/2021 at 5:25 a.m. documented, Resident c/o pain to sacrum. Pain level 5/10. There was no documentation of non-pharmacological interventions provided or offered. · 8/26/2021 at 6:20 a.m., and 8/28/2021 at 12:30 a.m., both entries documented, Resident c/o pain to sacrum, pain level 5/10. · 8/29/2021 at 1:45 p.m. failed to document the location of the pain or non-pharmacological interventions offered. The September 2021 MAR for Resident #32 documented the above physicians order for Tylenol and documented the Tylenol was administered on the following dates and times for the following documented pain levels: 9/2/2021 at 12:24 p.m. and 9/3/2021 at 9:31 a.m. - pain levels of 6. 9/4/2021 at 9:28 p.m. and 9/14/2021 at 12:16 p.m. - pain levels of 5. 9/6/2021 at 12:08 p.m., 9/7/2021 at 8:26 a.m., 9/10/2021 at 1:41 p.m., and 9/12/2021 at 8:20 p.m. - pain levels of 6. Review of the nurse's notes for the dates above revealed the following: 9/2/2021 at 12:24 p.m., 9/3/2021 at 9:31 a.m., 9/4/2021 at 9:28 p.m.,9/6/2021 at 12:08 p.m.,9/10/2021 at 1:41 p.m., 9/7/2021 at 8:26 a.m., 9/12/2021 at 8:20 p.m., all failed to evidence documentation of the location of the pain and if non-pharmacological interventions were attempted or offered. The nurse's note dated, 9/14/2021 at 12:16 p.m. documented, Resident complained of pain to right knee. On the pain scale of 1 -10, she stated it is a 5/10. There was no documentation if non-pharmacological interventions were offered. The comprehensive care plan dated, 6/22/2021, documented, Focus: (Resident #32) has pain or potential for pain. The Interventions documented, Administer pain medications as ordered. Report s/s (signs and symptoms) potential negative side effects. Assess pain level q (every) shift and PRN (as needed) and apply interventions as needed. Assist with alternate positioning and other diversional activities to relieve pain. An interview was conducted with LPN (licensed practical nurse) #1 on 9/16/2021 at 10:30 a.m. LPN #1 administered the Tylenol in September on several occasions. When asked about the process staff follows for resident complaints of pain, LPN #1 stated. She first asks the resident to rate the pain level, where it is, and what makes it better or worse. LPN #1 stated, she then tries a distraction, ice or hot compress, if that doesn't work, I look at the orders to give them pain medications. When asked where the distractions, location of pain and the pain scale rating is documented, LPN #1 stated it's on the computer as soon as you pull up the pain medication. When shown the some of the above times and dates when she administered the Tylenol, LPN #1 stated she failed to document a note under the section in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with ASM (administration staff member) #2, the director of nursing, on 9/16/2021 at 11:41 a.m. When asked the process for giving an as needed pain medication, ASM #2 stated the nurse should document that it was given, the location of the pain, the level of pain, any non-pharmacological interventions provided and a follow up to determine if it was effective. When asked where it was documented, ASM #2 stated in a nurse's note. The facility policy, Pain Management documented in part, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (nurse, practitioners, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information as applicable to the resident: History of pain, asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual description that is appropriate and referred by the resident, Reviewing the resident's current medical conditions, identifying key characteristic of the pain, obtaining descriptors of the pain, identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain, current prescribed pain medications, dosage and frequency .Non-pharmacological interventions will include but are not limited to: environmental comfort measures, loosening any constrictive bandage, clothing or device, applying splinting, physical modalities such as cold compress, warm shower/bath, exercised to address stiffness and prevent contractures, cognitive/behavioral interventions .Facility staff will reassess resident's pain management for effectiveness and/or adverse consequences. ASM #1, the administrator, ASM #2, the director of nursing, ASM # 4, the clinical services specialist and ASM #3, the director of operations, were made aware of the above concern on 9/16/2021 at 3:33 p.m. No further information was provided prior to exit. References: (1) Pneumonia: An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. This information was obtained from the following website: https://medlineplus.gov/pneumonia.html. (2) Asthma: respiratory disorder characterized by recurrent episodes of difficulty in breathing, wheezing, cough, and thick [MEDICATION(S)] production, caused by inflammation of the bronchi. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 51. (3) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. This information was obtained from the following website: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a 4.html 2. The facility staff failed to assess/document the location of Resident #63's pain on multiple occasions in September 2021 when administering an as-needed pain medication to the resident. Resident #63 was admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/2/21, Resident #63 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as frequently experiencing pain, and as having received an opioid pain medication on three days of the look back period. A review of Resident #63's clinical record revealed the following physician order: [MEDICATION(S)] [[MEDICATION(S)]] (4) Tablet 5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 05/18/2021. A review of Resident #63's MARs (medication administration records) for September 2021 revealed that he received Oxycodone 5 mg by mouth on the following dates and times: 9/3/21 at 8:00 a.m., 9/6/21 at 8:03 a.m., 9/7/21 at 11:03 a.m., 9/8/21 at 7:58 a.m., and 9/9/21 at 8:00 a.m. Further review of Resident #63's MARs and progress notes revealed no documentation of the location of Resident #63's pain for any of these administrations. A review of Resident #63's comprehensive care plan, dated 4/26/21 and revised 7/16/21, revealed, in part: [Resident #63] has pain or potential for pain .Administer pain medication as ordered. On 9/16/21 at 10:31 a.m., LPN (licensed practical nurse) #1 was interviewed, regarding the process staff follows when administering an as needed pain medication to a resident. LPN #1 stated she asks the resident to rate the pain, describe the location, and to tell her if anything makes the pain better or worse. She stated these items should all be documented in the nurse's note. On 9/16/21 at 11:41 a.m., ASM #2 was interviewed. When asked what documentation should accompany the administration of an as needed pain medication to a resident, he stated the nurse should document that the medication was actually given, the location of the pain, the pain level, non-pharmacological interventions attempted, and a follow-up to document whether the medication was effective. On 9/16/21 at 9:51 a.m., ASM (administrative staff member) #1, the administrator, ASM #3, the director of operations, and ASM #4, the clinical services specialist, were informed of these concerns. No further information was provided prior to exit. (1) Heart failure is a condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body .As the heart's pumping becomes less effective, blood may back up in other areas of the body. Fluid may build up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called [CONDITION(S)]. This information is taken from the website https://medlineplus.gov/ency/article/ 8.htm (2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (3) [CONDITION(S)] disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. This information is taken from the website https://www.nimh.nih.gov/health/topics/[CONDITION(S)]-disorder/index.shtml. (4) Oxycodone is used to relieve moderate to severe pain . Oxycodone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a 2.html.

Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility staff failed to provide adequate supervision, and failed to implement interventions to prevent falls with injury for four of 34 residents in the survey sample, Residents # 9, 29, 6 and 17. 1. The facility staff failed to implement fall prevention interventions for Resident #9 and failed provide supervision to reduce the risk of falls with injury. Resident #9 sustained 14 falls from 1/17/14 through 10/2/14. Four falls with major injury, lacerations to the head requiring transport to a local emergency room for sutures or staples. 2. On 5/16/14 Resident #29 was identified as being at moderate risk for falls. The facility staff failed to implement fall prevention interventions and the resident fell on [DATE]. 3. For Resident #6, the facility staff failed to implement interventions after falls and the resident continued to have falls. 4. The facility staff failed to implement fall prevention interventions for Resident # 17 following the falls on 12/22/13, 1/8/14, 2/15/14, 2/19/14, 2/20/14, 2/21/14, 3/5/14, 4/17/14, 7/11/14, and 10/1/14. The findings include: 1. Resident #9 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 9/4/14. Resident #9 was coded on the MDS as having a BIMS (Brief Interview for Mental Status) score of 15 out of 15, indicating that the resident's cognition was intact. In Section C (Cognitive Patterns) the resident was coded as having inattention and disorganized thinking. Section G (Functional Status), G , of the MDS coded the resident as requiring supervision without physical assistance for walking and locomotion on and off unit. Section G, G0300, coded the resident as not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfer. According to previous quarterly MDS assessments with assessment reference dates of March 5, 2014 and June 5, 2014, Resident #9 was coded as requiring supervision with ambulation, and physical assistance with transfers. The resident was also coded as not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfer. A review of the clinical record revealed facility fall assessments documented that Resident #9 was a high risk for falls on 1/17/14, 3/3/14, 8/23/14, 9/2/14, 9/26/14, 9/28/14 and 10/2/14. Further review of the clinical record revealed Interdisciplinary Therapy Screen notes that documented, in part, the following: ? 12/2/13 - "Patient has had recent falls - secondary to poor recall - requires verbal cues for directions, safety and initiation of ADLs (activities of daily living), meals. No change - not in need." ? 1/1/14 - 1/24/14: On physical therapy caseload ? 1/15/14 - " Treatment Encounter Note (TEN): Provided neuro (neurological) re-education techniques to promote improved static standing balance techniques." On 1/17/14 Resident #9 fell , this fall was not addressed by therapy and an evaluation was not conducted as indicated in the care plan. ? 1/22/14 - "TEN: Cues to keep cane with her at all times vs. (versus) hanging or placing out of reach. Cues to increase to L (left) side in congested areas." ? 1/24/14 - "Discharge summary: PT (physical therapy) recommends constant supervision during transfers and ambulation as pt (patient) unable to demonstrate correct carryover of safety techniques. Pt (patient) demonstrates fair safety awareness during tx (treatment) session but unable to demonstrate carryover of safety information after tx session and at next tx session." A review of the physician orders did not reveal specific interventions related to Resident #9's falls. A psychiatric evaluation was completed on 1/17/14 and documented that the resident was "Cooperative" and did not speak to falls. The clinical record further revealed that Resident #9 fell on 14 occasions from 1/17/14 through 10/2/14: 1. 1/17/14 - fell in hallway 2. 2/16/14 - fell by nurses ' station 3. 3/15/14 - fell in hallway 4. 4/10/14 - Found on floor in another resident's room 5. 4/20/14 - fell in room 6. 5/3/14 - fell coming out of room 7. 5/24/14 - fell in hallway 8. 5/27/14 - fell in hallway 9. 7/24/14 - fell in hallway 10. 8/20/14 - fell in hallway 11. 8/23/14 - fell in living room area 12. 9/26/14 - fell in bathroom 13. 9/28/14 - fell in dining room 14. 10/2/14 - fell in hallway Review of the clinical record, the facility incident reports and the facility fall investigations revealed that Resident #9 had four falls that occurred on 2/16/14, 4/10/14, 5/24/14, and 8/20/14 that resulted in lacerations injuries requiring transport to a local emergency room and sutures or staples to Resident #9's head. A review of the clinical record revealed the following documentation in regards to the falls with injury: Review of the nurse's notes for 2/16/14 at 1448 (2:48 p.m.) revealed that Resident #9 was walking by the nurses' station, "Lost her balance and fell on the floor landing on her left side and hit her head on the floor. Noted bleeding, pressure and ice applied. 911 called to transport to ER for evaluation." The ER report dated 2/16/14 documented: "Fall -laceration/puncture L (left) side temple." A CT (computerized tomography) scan was completed and found to be negative; three sutures were applied to the wound on the head. A therapy screen dated 2/17/14 documented: "Patient lost balance and fell to floor per NSG (nursing) note. Returned from ER with sutures to scalp. Patient recently on PT (physical therapy); improved balance. Recommend S (supervision) with amb (ambulation)/transfer due to impaired safety awareness and behavior. No (symbol for change) in function." The care plan was not revised to include new interventions and the PT recommendation for supervision with ambulation and transfers dated 1/24/14 was not initiated or implemented. The PT recommendations for supervision with ambulation dated 2/17/14 and 3/17/14 were not initiated or implemented. A therapy screen dated 3/17/14 documented: "Pt (patient) is mod (moderately) ind (independent) with transfers. PT recommended supervision with ambulation." Prior to the falls with injury that occurred on 2/16/14, 4/10/14, 5/24/14 and 8/20/14, the care plan had been revised with interventions twice: On 1/27/14: ? "Remind (name of resident) to use her cane for walking and to keep it on the ground instead of using it to gesture with." - created 1/27/14; initiated 1/17/14 ? "Staff to remind (name of resident) to wait for a clear path when navigating on and off of the unit." - created 1/27/14; initiated 1/17/14 ? "Staff to remind (name of resident) to call for assistance as needed." - created 1/27/14; initiated 1/17/14 ? "Therapy to evaluate and treat as needed due to fall with injury." - created 1/27/14 A nurse's progress note dated 4/10/14 at 10:45 a.m. documented, in part: "Resident came out of the shower and walked into another resident's room and looking for her glasses. She was heard screaming and found her sitting on the floor yelling. Found blood dripping down her neck and applied direct pressure to stop the bleeding. 911 was called. She was sent to the hospital for more observation." The ER record dated 4/10/14 documented a "scalp laceration." The head wound was closed with three staples and the resident was returned to the facility. A Fall Investigation was completed on 4/10/14. Under the heading "Care Plan Review" there was a check mark beside "Current Plan is effective to prevent recurrent falls/injury." There were no recommended interventions documented. Resident #9's care plan was updated on 4/21/14 and documented, "Ensure resident wears non skid socks when in bed." A nurse's progress note dated on 5/24/14 at 7:58 a.m. documented, in part: "fell after loosing (sic) balance. Sustained a 3 cm (centimeter) lateral cut on occipitus (back of the head*). Transferred to ER for evaluation." The ER report dated 5/24/14 fall documented the reason for visit as "Head injury, scalp abrasion." The discharge instructions documented: "Please assist patient when out of bed (e.g. to the bathroom, walking, going to lunch, etc.). This patient has a significant fall risk." The care plan documented that it was revised on 5/27/14. The care plan was not revised to include new interventions and the PT recommendations for supervision with ambulation dated 3/17/14 and 5/7/14 were not initiated or implemented. In addition further review of the care plan, failed to reveal any identification or documentation of non compliance for Resident #9. A fall investigation dated 5/24/14 was completed. Under the heading "Care Plan Review" nothing was checked. In the box for recommendations the following was documented: "Pt (patient) is non compliant and sometimes very aggressive towards staff and other residents." There were no recommendations for interventions and as stated above no care plan documenting this. A nurse's progress note dated on 8/20/14 at 22:05 (10:05 p.m.) documented, in part: "6:50 p.m. pt was observed on the floor, from apparent fall, she was noted with open area to her left cranium, bleeding noted when she fell and hit her head on the floor on hallway by cart 1 on Clairmont nursing station. MD notified and an order to transfer her to ER for eval (evaluation) and treatment. 911 called." The ER report dated 8/20/14 documented, in part, "Head injury. Scalp lac (laceration) with staples." A Fall Investigation was completed on 8/22/14. Under the heading "Care Plan Review" there was no check mark. Documented in the box for recommendations: "Possible helmet for resident?" Other than an entry on the care plan as documented below, no further documentation was found regarding this proposed intervention. Review of Resident #9's care plan revealed a problem: "(Name of resident) has had actual falls r/t (related to) [DIAGNOSES REDACTED]/hemiparesis r/t past CVA (cerebral vascular accident), gait/balance problems and impulsivity and refuses to wear helmut (sic) for protection. Frequently gets out of bed with no socks and ambulates in hallway." Dated 8/23/13. The care plan was reviewed and revised on 8/25/14 with the following intervention: "Encourage resident to wait for staff to assist her with getting changed for bed after dinner and engage her in activities if possible." An interview was conducted on 10/8/14 at 11:20 a.m. with Resident #9. The resident was asked if she remembered falling a lot. Resident #9 responded, "Yes and I cut my head. They want to put me in a wheelchair but I can walk by myself." The resident was asked if she was offered help, the resident responded, "Yes they ask me if I need help and I tell them no and to go away." Resident #9 was asked whether or not she was asked if she needed help when she left the activities room immediately prior to this interview, Resident #9 stated, "Yes." This surveyor had observed Resident #9 as she left the activities room immediately prior to the interview. Resident #9 had stood up unassisted, turned and left the room. The staff member in the room did not acknowledge that the resident was preparing to leave and did not approach Resident #9 to offer assistance. Resident #9 indicated that she had difficulty remembering things, "I had a brain injury; I fell off a motorcycle." A review of the clinical record did not reveal that this resident had refused/or had been resistant to care or assistance. A nurse's note dated 4/22/14 documented: "Resident states' will never use a w/c' and also states' no helmet.' There was no documentation evidencing a discussion with Resident #9 offering a helmet or wheelchair as an intervention and no documentation evidencing Resident #9 was educated and understood the risk of not using a helmet and wheelchair. On 10/7/14 at 4:00 p.m. RN (registered nurse) #4, the unit manager, was asked to provide the documentation that demonstrated the care plan was reviewed and revised with new interventions following each fall, and to demonstrate what was done to reduce the risk of injury for Resident #9. RN #4 reviewed the documentation on the computer with this surveyor and was unable to speak to each occurrence. RN #4 asked to be given some time to do some research and collect the paperwork to demonstrate what was being done. On 10/8/14 at 8:40 a.m. RN #4 was asked to provide the documentation that had been requested regarding Resident #9's falls. RN #4 had created a timeline of all the falls for Resident #9 and then proceeded to explain each fall but was unable to provide the evidence that the care plan had been reviewed and that interventions had been put into place to ensure the safety of the resident. RN #4 stated, "There is not much we can do, she is so impulsive and so quick." RN #4 was asked about the recommendation made by physical therapy for supervision of Resident #9 with ambulation, RN #4 stated, "She is difficult to watch, she is so quick. We have asked for another evaluation to be done, I asked on 9/26/14 and then asked again on 9/28/14. I still don't have it." On 10/8/14 at 1:47 p.m. an interview was conducted with ASM (administrative staff member) #2, the director of nursing, with ASM #1, the administrator in attendance. ASM #2 was asked what was being done by the facility to keep Resident #9 safe from falls with injuries. ASM #2 responded, "We have engaged a psychiatrist to help us with her medications." ASM #2 was asked when the resident last saw the psychiatrist, ASM #2 stated, "January." ASM #1 and ASM #2 were advised that all of the falls and investigations had been reviewed and revealed that interventions were not put into place or implemented for all of Resident #9's falls to prevent Resident #9 from falling and sustaining injuries. ASM #2 stated, "What else can we do, she (Resident #9) is impulsive." ASM #1 and ASM #2 were shown the therapy recommendation for supervision while ambulating, which had been provided on three different dates. ASM #2 stated, "We all supervise her (Resident #9) all of the time. We watch her when she's moving around, she's always moving around. We would have to get her a one to one sitter to watch her all the time." This surveyor advised ASM #2 that observations had been made of Resident #9 during the survey process and there had not been any supervision whenever the resident was observed ambulating. At this time ASM #2 provided copies of the facility's internal fall investigation reports for Resident #9's falls. They were reviewed with ASM #2 and ASM #1 but did not provide evidence that any interventions had been implemented prior to Resident #9's fall with injuries. At this time this surveyor expressed concern for harm for Resident #9. Resident #9 was observed on the following dates and times: ? 10/7/14 at 1:00 p.m. - lying in the bed. When this surveyor entered the room the resident attempted to get up to sit on the side of the bed. This took a lot of effort as Resident #9 had no movement in her left arm and limited mobilization of the left leg. ? 10/8/14 at 11:15 a.m. - Resident #9 walked from the dining room into the activities room and then to her room. The resident did not have any supervision while walking down the hallway and no staff member was observed to approach Resident #9 to offer assistance or to supervise ambulation. Resident #9 was observed as being slow with an unstable gait. The resident walked with left side forward, unable to bend left knee though was able to pick the left foot off of the floor and move it forward. The resident was using a cane with her right hand; her left arm was bent and held against her body. As the resident passed by the nurses' station a nurse reminded Resident #9 to keep her cane on the floor, no staff offered Resident#9 assistance or supervision with ambulation. ? 10/8/14 at 12:30 p.m. - Resident #9 was observed walking using her cane down the hallway. There was no supervision and staff was not close by to offer assistance or supervision. ? 10/8/14 at 3:15 p.m. - Resident #9 was observed walking, with a cane, from the activities room where she had participated in a group activity, she was one of the last residents to leave and the activities staff member was still in the room. The resident was not supervised, and no staff member approached Resident #9 to offer assistance or supervision. When the resident reached the nurses' station she stated she was going to the bathroom, there were staff members at the nurses' station. The resident went into the bathroom unassisted and without supervision. No staff members followed the resident into her room to supervise or assist during this time. ? 10/8/14 at 5:00 p.m. - Resident #9 was observed standing in the hallway waiting to go into the dining room. There were wheelchairs noted around her and there were no staff members present to provide supervision. ? 10/9/14 at 8:40 a.m. - Resident #9 was observed walking to her room from the dining room without supervision and no staff member offered assistance or supervision during the observation. On 10/8/14 at 4:40 p.m. OSM #8, the facility physical therapist, was asked to define "Supervision" as documented in the physical therapy notes. OSM #8 stated, "Supervision is for someone who needs watching, needs verbal cueing but does not need physical assistance. The distance would be side by side but no touching." OSM #8 was asked if the definition for the term "supervision" was consistent among all physical therapists. OSM #8 stated, "Yes." OSM #8 was asked whether or not she was familiar with Resident #9 and what type of care she needed to help prevent falls. OSM #8 responded, "She needs supervision, she can walk fairly independently but she needs cueing to guide her around obstacles. She doesn't require physical assistance just someone beside her to walk with her." OSM #8 was asked about the evaluations that had been requested to be done on Resident #9 on 9/26/14 and again on 9/28/14. OSM #8 stated, "We don't have them, we changed therapy services on 10/1/14 and we don't have the evaluation requests for 9/26/14 and 9/28/14. We only have what is in the record." A review of the facility policy titled: "SAFETY FALLS - INITIAL STEPS TO FOLLOW IF A RESIDENT FALLS OR IS FOUND ON THE FLOOR." Documented, in part, the following: "STEPS: 6. The fall must be documented thoroughly in the EMR (electronic medical system) under Interdisciplinary Notes. Include all details of the fall, not just "resident found on the floor " or "resident eased to the floor by the CNA." Also, include the results of your full body assessment, not just "not (sic) apparent injury. Complete the "Fall Assessment" after each fall in the EMR under the User Defined Assessment. Update the careplan as appropriate." A review of the clinical record failed to reveal fall assessments were completed after the following falls: 2/16/14, 3/15/14, 4/10/14, 4/20/14, 5/3/14, 5/24/14, 5/27/14, 7/24/14, and 8/20/14. On 10/9/14 at approximately 10:00 a.m. , ASM # 1 and ASM #2 were told that there was insufficient documentation for Resident #9 to evidence that interventions had been implemented prior to each fall with injury. ASM #1 and ASM #2 were advised that there was a continued concern for harm for Resident #9. This surveyor requested any further documentation that would provide evidence that interventions were implemented prior to Resident #9 falling and sustaining injuries. ASM #1 and ASM #2 were unable to provide any further documentation prior to survey exit. 2. On 5/16/14 Resident #29 was identified as being at moderate risk for falls. The facility staff failed to implement fall prevention interventions and the resident fell on [DATE]. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. Section C "Cognitive Patterns" of Resident #29's five day Medicare MDS assessment was unable to be completed prior to discharge. Section G coded the resident as requiring extensive assistance of one staff with bed mobility and transfers, and as requiring limited assistance of one staff with walking. Section J documented Resident #29 had one fall with injury (except major). The resident's admission assessment dated [DATE] documented the resident was oriented to self, oriented to time and able to follow directions. Review of Resident #29's clinical record revealed a fall risk assessment dated [DATE] that documented the resident as being at moderate risk for falls. The assessment further documented the resident had fallen within the last six months, displayed agitated behavior daily or more, and was confined to a chair and oriented. Further review of Resident #29's clinical record failed to reveal the development of an interim care plan to address the resident's fall risk and failed to reveal any interventions were implemented to prevent falls. A nurse's note dated 5/17/14 documented, "Fall precautions in place..." but failed to document any further information. A nurse's note dated 5/19/14 at 2:39 a.m. documented the resident was observed on the bathroom floor at 7:45 p.m. (5/18/14) after calling for help. The resident stated he had slipped on the floor when trying to exit the bathroom. The resident sustained [REDACTED]. On 10/8/14 at 5:18 p.m., an interview was conducted with LPN (licensed practical nurse) #7, the nurse responsible for completing Resident #29's fall risk assessment. LPN #7 stated residents who are newly admitted and identified as being at risk for falls are checked on every 15 to 30 minutes. When asked what interventions were implemented to prevent Resident #29 from falling, LPN #7 stated "We monitored." LPN #7 stated she asked the CNAs (certified nursing assistants) to go in and check on the resident every 30 minutes. When asked if she could provide documentation of Resident #29 being monitored, LPN #7 stated she only completed the admission process and didn't know if the other nurses documented anything. On 10/8/14 at approximately 5:30 p.m., an interview was conducted with LPN #8, the nurse who documented the note regarding Resident #29's fall. LPN #8 stated she remembered Resident #29's name but not much else. When asked what fall interventions were in place to prevent the resident from falling, LPN #8 stated fall mats and a low bed. When asked to provide documentation of this, LPN #8 stated there should have been a physician's order. When told Resident #29's clinical record did not contain a physician's order for fall mats or a low bed, LPN #8 stated the mats and low bed were part of the fall protocol. On 10/8/14 at 7:05 p.m., the Administrator and Director of Nursing were made aware of the above concern. The facility policy titled "SAFETY: FALLS-INITIAL STEPS TO FOLLOW IF A RESIDENT FALLS OR IS FOUND ON THE FLOOR" failed to document any information regarding fall prevention. The facility policy titled "CARE PLANS - PRELIMINARY" documented, "Policy: A preliminary plan of care shall be developed for each resident admitted . Procedure: 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan is developed upon admission. 2. The interdisciplinary team reviews the attending physician's order (e.g., diet, medications, treatment, etc.), and implements a nursing care plan to meet the resident's immediate care needs. 3. Preliminary care plans are used until the comprehensive care plan has been completed. No further information was presented prior to exit. In "Fundamentals of Nursing" 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates." * This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/Occipitus COMPLAINT DEFICIENCY 3. For Resident #6, the facility staff failed to implement interventions after falls and the resident continued to have falls. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/18/14, coded the resident as being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive to being dependent of one or two staff members for all of her activities of daily living. The resident was coded in Section J - Health Conditions as having had two falls with no injury since the prior assessment. Review of the clinical record revealed Resident #6 had suffered 15 falls since her admission on 1/17/14. The resident suffered falls on 2/23/14, 3/17/14, 4/7/14, 4/23/14. 4/27/14, 5/8/14 (sent to ER for hematoma), 5/14/14, 5/18/14, 6/9/14, 6/14/14, 7/15/14, 7/17/14, 8/10/14, 9/8/14, and 9/22/14. The resident's fall risk assessments for 1/17/14 documented her to be a "9" a high risk for falls. A nurse's note dated, 2/23/14, documented, "Resident found on floor in front of her wheelchair. No injury noted. ROM (range of motion) wnl (within normal limits). Neuro (neurological checks) initiated and WNL for resident. Therapy notified. Husband (name of husband) notified. MD (medical doctor) notified. Will continue neuro checks per policy." The care plan dated, 2/6/14, documented, "Focus: (Resident #6 has actual falls r/t (related to) confusion and poor safety awareness from dementia." The "Interventions" dated, 2/6/14, documented, "Anticipate and meet needs. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. Follow facility fall protocol if resident should fall. Monitor labs (laboratory tests) per MD (medical doctor) orders. Provide rest periods as needed and or tolerated. PT (physical therapy) evaluate and treat as ordered or PRN (as needed)." The next revision to the care plan was dated, 4/6/14, and then again on 4/7/14 after the resident had a fall on that date. An interview was conducted with RN (registered nurse) #4, on 10/8/14 at 11:32 a.m. When asked what new interventions were put in place after the fall on 2/23/14, RN #1 stated, "She wasn't on my unit at that time so I don't know what happened."When asked if she saw any updates or revisions to the care plan and any new interventions put in place for the 2/23/14 fall, RN #4 stated, "No, I don't see any." An interview was conducted with administrative staff member (ASM) #2, the director of nursing, on 10/9/14 at 10:15 a.m. When asked what new interventions were put in place after the 2/23/14 fall, ASM #2 stated, "We continued to monitor as there were already things in place. We continued the current plan of care." When asked if the care plan was reviewed and revised, ASM #2 stated, "It's not on the care plan. We didn't change anything. We didn't realize that it (the computer) didn't time stamp when we reviewed a care plan. We review all falls in the morning clinical meeting." The physical therapy discharge summary dated, 3/12/14, documented, "Patient has reached optimal functional level and will continue with Restorative Nursing Program. Restorative Nursing Program has been established and all caregivers have been trained and demonstrated 100% carry over. Pt is mod (moderate) < > max (maximum) a (assist) x2 (with two persons) with transfers, able to stand in the parallel bars with max a with max VC (verbal cues) for correct posture and weight bearing through RLE (right lower extremities). Pt has underlying dementia which impairs pt's performance and ability to follow directions during transitional movements." The fall risk assessment dated , 4/11/14 documented the resident's fall risk score as a "19" indicating a high risk for falls. A nurse's note dated, 4/23/14 at 9:45 a.m., documented, "Resident was found laying (sic) on left side on floor in TV room with w/c (wheelchair) tipped upward. ROM within normal range, voices no c/o (complaints of pain). RP (responsible party) and (Name of doctor) notified." The care plan dated, 2/6/14, documented, "Focus: (Resident #6 has actual falls r/t (related to) confusion and poor safety awareness from dementia." The new interventions documented on 4/7/14 after the residet fell on that date, documented, "Fall mats beside bed when patient is in bed. Keep resident in hallway or where she can be directly supervised when up in wheelchair. Provide pain medication per order. Provide alarm device as appropriate." An interview was conducted with RN #4, on 10/8/14 at 11:32 a.m. When asked what new interventions were put in place after the fall on 4/23/14, RN #4 stated, "I did review the care plan but we didn't realize it (the computer) didn't time stamp when we reviewed the care plan. There were no updates to the care plan." An interview was conducted with ASM #2 on 10/9/14 at 10:15 a.m. When asked what new interventions were put in place after the fall of 4/23/14, ASM #2 stated, "We didn't have any new interventions to add." A nurse's note dated, 4/27/14 at 10:45 a.m. documented, "Resident was reaching for something on the floor by nurse station and slided (sic) out of w/c landing on buttock. ROM WNL. Voices no c/o pain at this time." The care plan did not document any new interventions or new dates of review. An interview was conducted with RN #4, on 10/8/14 at 11:32 a.m. When asked what new interventions were put in place after the fall on 4/27/14. RN #4 reviewed the care plan and stated, "I don't see anything." An interview was conducted with ASM #2 on 10/9/14 at 10:15 a.m. When asked what new interventions were put in place after the fall of 4/27/14, ASM #2 stated, "We didn't have any new interventions to add." The resident was started on physical therapy services from 5/6/14 through 5/30/14. The resident did not improve her bed mobility. She remained a maximal assistance from 5/6/14 through 5/30/14. She improved her sitting balance from poor sitting balance on 5/6/14 to being fair sitting balance and able to tolerate 15 mins (minutes). The physical therapy discharge summary dated, 5/30/14 documented, "Pt is discharged as achieved max (maximum) rehab (rehabilitation) potential. Pt is a max a (assist) with transfers and bed mobility. Pt has underlying dementia which limits her full participation." A nurse's note dated, 5/8/14 at 11:41 p.m. documented, "Pt (patient) was sent to the ER (emergency room ) for further eval (evaluation) due to fall and hematoma to left frontal lobe at 4:30 p.m. and returned back to the facility at 8:00 p.m. X-ray was negative and all tests done were negative. No complains (sic) of pain or discomfort from fall." The hospital records dated, 5/8/14, documented, "Diagnosis: [REDACTED]." No new medications were ordered per the hospital record. An interview was conducted with RN #4, on 10/8/14 at 11:32 a.m. When asked what new interventions were put in place after the fall on 5/8/14, RN #4 stated, "I don't see anything added and I don't see a note that I reviewed the care plan." A nurse's notes dated, 5/14/14 at 5:19 p.m. documented, "Pt was

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional standards of practice for the transcription of physician medication orders and the documentation of medications when not given for three of seven residents in the survey sample, Residents #1, #2, and #6. 1.a. The facility staff failed to transcribe the physician medication order for [MEDICATION NAME] (an antidiabetic medication) accurately, which resulted in Resident #1 receiving four extra doses of the medication the resident subsequently experienced [DIAGNOSES REDACTED] (too low blood sugar) as a result of these errors and was transferred to a local hospital and admitted to the critical care unit. 1.b. The facility staff documented administering medications to Resident #1 that had not been given. 2. The facility staff failed to transcribe the admission medication orders accurately for Resident #2. 3. The facility staff failed to transcribe the admission medication orders accurately for Resident #6. The findings include: 1.a. Resident #1 was admitted to the facility on [DATE] with a readmission on 5/2/14 with [DIAGNOSES REDACTED]. The most recent completed MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 5/9/14, coded the resident as scoring an eight on the brief interview for mental status indicating the resident was moderately impaired to make cognitive daily decisions. The resident was coded as having periods of inattention and disorganized thinking that were present and fluctuated. Resident #1 was coded as having verbal behaviors directed towards others and other behaviors not directed toward others that occurred one to three days of the look back period. Review of the hospital discharge physician orders [REDACTED]. "Glimepiride (used to treat diabetes (1)) 4 MG (milligrams); commonly known as [MEDICATION NAME]. Instructions: Take 4 mg by mouth every morning before breakfast. In addition the hospital discharge physician orders [REDACTED]. ? [MEDICATION NAME] (used to treat diabetes (2)) 500 MG; commonly known as [MEDICATION NAME]. Instructions: Take 1000 mg by mouth 2 (two) times daily with meals. ? Sitaglip (used to treat diabetes (3)) 100 MG tablet; commonly known as [MEDICATION NAME]. Instructions: Take 100 mg by mouth daily." Administrative staff member (ASM) #3, the assistant director of nursing, signed and dated the orders on 4/24/14 at 1458 (2:58 p.m.). A Review of the facility physician orders [REDACTED]. The Medication Administration Record [REDACTED]. In addition the MAR indicated [REDACTED] ? "[MEDICATION NAME] Tablet 4 mg; Give 4 mg by mouth before meals related to DIAB W/O COMP Type II not stated UNCNTRL." The scheduled time for administration was documented as 6:00 a.m., 11:30 a.m. and 5:00 p.m. (A total dose of 12 mg in 24 hours). The medication was documented as having been administered on 4/25/14 at 6:00 a.m. and 5:00 p.m. All doses were documented as given on 4/26/14 and 4/27/14. On 4/28/14, only the 6:00 a.m. dose and 11:30 a.m. dose were documented as given. The following drug information was provided by the facility pharmacy via an email from the pharmacy information system. Glimepiride is a once-daily oral suflonulurea (antidiabetic medication) Glimepiride is used as an adjunct to diet to lower blood sugar in patients with type 2 diabetes mellitus. Glimepiride may be used in combination with insulin or [MEDICATION NAME]..Glimepiride is long-acting (roughly 24 hours)...Pharmacokinetics: Glimepiride is completely metabolized following oral administration and has a half-life about 5 hours initially, but increased to roughly 9 hours after multiple dosing.....Maximum Dosage Limits: Adults - 8 mg/day PO (by mouth). Elderly - 8 mg/day. (1) The review of the nurse's notes dated 4/28/14 at 6:44 a.m. revealed, "Patient awake most of the shift and yelling out and ringing call light. Patient given snack and fluids and incont (incontinent) care and continues to yell out. Attempted to get out of bed with legs hanging off bed and lower body hanging off bed. Patient encouraged to put lower body back on bed. Daughter called and stated that her mother had left 6 voice messages. This writer ensured (sic) daughter that staff was available for her mother the entire shift. Patient is sleeping at this time." The nurse's note dated 4/28/14 at 15:34 (3:34 p.m.) documented, "Resident noted to be alert and oriented x 1 (to self only). At the beginning of the shift, resident yelling and stating that she was sick. Upon assessment, resident noted to be diaphoretic, blood sugar was check (sic), it was 41. resident alert and verbalizing. Was offered orange juice and breakfast, blood sugar was rechecked, was 62. md (medical doctor) notified, new order for cbc (complete blood count) cmp (complete metabolic panel), Mag (magnesium) level and accu checks (fingerstick blood sugars) ac and hs (before meals and at bedtime), and hs (bedtime) snacks was received and noted by unit manager. Resident has good appetite, frequent snacks offered. Denies pain or discomfort. Assisted with adls (activities of daily living), dressed in bed during shift. No acute distress noted." On 4/28/14 at 4:00 p.m. the nurse documented, "Pt (patient) confused, blood sugar was 36, im (intramuscular) [MEDICATION NAME] (a rapid glucose/sugar solution used to raise very low blood sugar levels (4)) given, md made aware. New orders to dc (discontinue) all po (oral/by mouth) antidiabetic agents, [MEDICATION NAME] and [MEDICATION NAME] dc'd (discontinued). will continue to monitor." At 4:40 p.m. the nurse documented, "pt blood sugar rechecked after [MEDICATION NAME], blood sugar was 53. pt has some improvement in yelling out." On 4/28/14 at 5:44 p.m. the nurse documented, "pt blood sugar checked again at this time pt is 41. md made aware of this result and previous result. new orders for accucheck ac & (and) hs with humalog (5) (quick acting insulin) sliding scale and md made sure antidiabetic meds were not given and were dc'd (discontinued). will continue to monitor pt blood sugar. pt not yelling out as much but is still confused." At 6:40 p.m. the nurse documented, "pt blood sugar checked this time and was 42, md in building and made aware. will see pt. pt still presenting with confusion. pt dinner tray in front of pt and pt has consumed all dinner. will continue to monitor pt." At 6:50 p.m. the nurse documented, "was called to pt room by cna (certified nursing assistant) who stated pt was on the floor, entered pt room to find pt on far side of bed and in front of bedside table with bedside table tilted toward her. pt sitting upright, pt was positioned with sheet underneath her and will (sic) assistance of staff assisted back to bed. no complaints of pain were voiced at this time however pt was still confused and yelling out frequently while we were trying to position her. pt md was in building at this time and will round on pt. pt r/o (responsible party) was in room after pt fell to visit and was made aware." On 4/28/14 at 7:40 p.m. the nurse documented, "pt blood sugar at this time was 44. md ordered pt to be sent out for [DIAGNOSES REDACTED]. vitals were 164/86 (blood pressure), 95.6 A (axillary temperature), 20 (respirations), 71 (heart rate), 92% on oxygen per order. daughter present and aware of new orders to send pt to ER (emergency room ) to be evaluation (sic) for [DIAGNOSES REDACTED]. report called to (name of ER nurse) at (name of ER). pt transferred out via squad." At 8:00 p.m. the nurse documented, "pt discharged out of building in care of squad (rescue squad)." This paragraph is written as it was documented in the clinical record. The resident was admitted to the hospital on [DATE] and discharged on [DATE]. The hospital discharge summary dated, 5/2/14, documented, "Apparently, the patient has been at (name of nursing facility) since being discharged from (name of hospital). According to the daughter, the patient was apparently on [MEDICATION NAME] and this was being given to her at (name of nursing facility) three times a day, instead of her usual dose of once a day. Blood sugars have been noted to be low at (name of facility), apparently sugar got as low as 25. The patient was treated with D50 ([MEDICATION NAME] 50 [MEDICATION NAME] Injection (6)), and was brought into the emergency room at (name of hospital) secondary to her altered mental status and subsequent fall. On arrival to the emergency room , the patient's blood sugar was noted to be 53, and was treated with an amp ([MEDICATION NAME]) of D50, and was also given D ([MEDICATION NAME])5 half normal saline (Intravenous solutions containing [MEDICATION NAME] and sodium chloride (7) ). Her sugars were continuously low, and for that reason she was admitted to the critical care unit and started on a D10 (concentrated [MEDICATION NAME] in water (8)) infusion. Her blood sugars initially were monitored every hour until it was more stabilized. ....As the patient's blood sugar continued to improve so did her altered mental status. She was able to come off her D10 drip on the morning of 4/30, and her oral hypoglycemics were continued to be held....Discharge Instructions and Disposition: Given that there were no other accepting facilities or beds available at other facilities that the patient's daughter looked at, she will be returning to (name of nursing home) for the time being." An interview was conducted with administrative staff member (ASM) #3, the assistant director of nursing (ADON) on 5/13/13 at 5:02 p.m. When asked what occurred on 4/24/14 in regards to Resident #1's admission orders [REDACTED]. We were starting a new process." When asked about the start date of the new process, ASM #3 stated, "April 24th." ASM #3 continued to state, "The management team is now getting the information from the admission orders [REDACTED]. We, the management team, place them in the cue until the patient arrives, then another nurse verifies the orders." When asked who verified of the orders for Resident #1, ASM #3 stated, "(Name of RN (registered nurse) #3) came on duty and I handed him the chart. He had already received the education on the new process and verbalized he was the second nurse check. He signed and verified the orders. Every hospital has a different way of sending us orders. The orders come to the admissions office and we use those orders. Sometimes additional papers and orders come with the resident and the nurse who receives the resident is responsible to review any new orders that come with the resident." When asked what went wrong with the orders for Resident #1, ASM #3 stated, "(RN#3) should have signed the orders from the hospital next to my orders. He didn't do that." When asked how Resident #1's [MEDICATION NAME] order went from once a day to three times a day, ASM #3 stated, "There is a drop down box for orders, I made the mistake, I clicked on before meals and it auto generated the TID (three times a day) dosing." When asked if any other nurse questioned the order, ASM #3 stated, "No." ASM #3 stated, "The only thing I can add is that I was entering the orders while sitting at the nurse's station and I got interrupted several times, I know it's not an excuse but I believe it didn't help me." During an interview conducted with RN #3 on 5/14/14 at 9:50 a.m., RN #3 was asked to describe the new process used by the facility for new admission orders [REDACTED]. It takes two nurses now. The first nurse puts the orders into the computer and the second nurse verifies the orders are correct." When asked if the nurse sign's anything indicating they have verified the orders the first nurse entered, RN #3 stated, "Yes, you are supposed to sign next to or under the nurse's signature that entered the orders. I didn't sign these orders. I never saw the paper with the discharge orders. What I did was to review the orders in the computer in draft form. If I had seen the paper, it would have had my signature on it." RN #3 was asked if he questioned the [MEDICATION NAME] TID order when he completed the review of the orders, RN #3 stated, "It didn't occur to me. I didn't know the resident. It was my first encounter with her that evening." An interview was conducted with ASM #2, the director of nursing (DON) on 5/14/14 at 11:45 a.m. When asked to explain the new process for the transcription of admission orders [REDACTED]. The leadership team will enter the orders into the computer. The second nurse will verify the orders. We had a breakdown in the process. We are going [MEDICATION NAME] so we now take the orders from the hospital, write directly on that piece of paper and verify the orders with the physician. We write any new orders, such as lab work orders, directly on the hospital order sheet. The orders get put directly into (name of computer system). A second nurse has to verify the orders. Once confirmed in the computer, the nurse signs electronically that they reviewed the orders." When asked what happened with Resident #1, ASM #2 stated, "The first breakdown was the transcription of the order in (name of computer program). The second breakdown was the second nurse was to verify the orders. He didn't have a clean understanding of his role. He didn't see the orders in the chart to verify them. The third breakdown in our process was the pharmacy, they never questioned the dose. And the fourth breakdown was the nurses giving the medication; they didn't question the dosage of the [MEDICATION NAME]." The facility policy, "Process for Entering New admission orders [REDACTED]. Upon receiving discharge orders from the hospital, a nurse (UM (unit manager)/ADON/DON/Supervisor) should go to the waiting list view and select the applicable resident by clicking on their name. (click on "residents" in gold bar, click on "waiting list", then click "all" to display entire waiting list). 2. Once the chart is opened, go to the Medical [DIAGNOSES REDACTED]. Nurse must also enter allergies [REDACTED]. A medical dx (diagnosis) or indication for use is required for all pharmacy orders when entering them. (reminder; if dx are entered under med (medical) dx tab first, it will expedite the process when entering the pharmacy orders). 3. Then go to the orders tab and begin entering the diet and medication orders placing them in the queue, adding schedules as indicated per orders. For medication orders, nurse must select the total dose of medication instead of specific # (number) of tablets/capsules. (ex: if order from hospital says ([MEDICATION NAME] 100 mg give 4 tablets (25 mg) BID (twice a day), the nurse would need to enter it in (name of software program) by selecting "[MEDICATION NAME] tab" from (name of computer program) library and then identify the 100 mg total dose when creating the schedule so it will not conflict with how the pharmacy will dispense the med). When finished entering all of the pharmacy orders, they are to be left in the queue until the resident arrives. Check to see if medications are available in (name of pharmacy backup system in facility) if applicable to your center. 4. Nurse should then go to "batch update" and select "add order group." Select the order groups that are applicable to that resident by clicking on the + to collapse the applicable order group. Nurse must select the group "ADMISSION/READMISSION -all residents" to put all of those orders over for all new admissions. Other order groups are to be selected as applicable to the resident, such as: foley, oxygen, behavior monitoring and side effects monitoring as indicated by applicable medication orders, tube feedings, etc. 5. Once the selected orders are placed in the queue, the nurse will review the queue, clicking only on the orders in the queue that need schedules to be added so the nurse can sign off in eMAR. Once a schedule is created on an order, nurse will click on "update queue" and continue to the next order. When finished adding all applicable schedules, leave orders in the queue with the pharmacy orders until resident arrives. (reminder: orders just sitting in queue are not active orders). 6. The center nurse should receive verbal report from the hospital nurse. At that time, the center nurse should question the transferring nurse regarding medication orders and verify last administration times. Any medication(s) due in next 4 hours - center nurse to request hospital to administer, or to send dose(s) with resident for us to administer. IF resident is on inhaler(s), center nurse request that hospital send inhaler(s) with the resident. 7. When the resident arrives, the center nurse will verify the orders with the MD, (nurse to refer to available medication list from (name of pharmacy backup system in facility), if applicable to you center, and discuss possible substitutions with MD, if necessary, based on availability of specific medications). 8. Once the orders are verified with MD, nurse to complete the quick ADT process to admit resident into (name of computer program). 9. The nurse will then need to open the orders queue and reconcile the verified orders with the ones that were previously placed in the queue prior to arrival. Any changes/additional orders will need to be completed while the orders are still in the queue. Verify schedules. Once all orders have been verified /reconciled, the nurse will "save queued orders." 10. Once all orders are reconciled and active in (name of computer program), the nurse MUST then PRINT the order summary report, FAX the order summary report to (name of pharmacy), AND CALL (name of pharmacy) to alert them of the new admission orders [REDACTED]. Nurse will communicate the specified times to (name of pharmacy) that the medications are needed. Verify "next run" arrival time/ "stat" arrival time/ or the need to use back-up pharmacy to ensure medications are available. The use of the back-up pharmacy should be a rare occasion as we have/Omnicell/E-kits/back up boxes that should be customized for your center." This policy is dated, 4/17/14. According to Perry & Potter's Fundamentals of Nursing, 6th edition, page 419, "The physician should write all orders, and the nurse must make sure that they are transcribed correctly." The administrative staff members, #1, (the administrator) #2 and #5 (the clinical consultant) were made aware of the concern for harm on 5/15/14 at 12:45 p.m. No further information was provided prior to exit. COMPLAINT DEFICIENCY References: (1) www.clinical <http://www.clinical> pharmacology (2) [MEDICATION NAME] is used alone or with other medications, including insulin, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). [MEDICATION NAME] is in a class of drugs called biguanides. [MEDICATION NAME] helps to control the amount of glucose (sugar) in your blood. <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 5.html> (3) Sitagliptin is used along with diet and exercise and sometimes with other medications to lower blood sugar levels in patients with type 2 diabetes (condition in which blood sugar is too high because the body does not produce or use insulin normally). <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 3.html> (4) [MEDICATION NAME] is a hormone produced in the pancreas. [MEDICATION NAME] is used to raise very low blood sugar. [MEDICATION NAME] is usually given by injection beneath the skin, in the muscle, or in the vein. It comes as a powder and liquid that will need to be mixed just before administering the dose. Instructions for mixing and giving the injection are in the package. [MEDICATION NAME] should be administered as soon as possible after discovering that the patient is unconscious from low blood sugar. After the injection, the patient should be turned onto the side to prevent choking if they vomit. Once the [MEDICATION NAME] has been given, contact your doctor. It is very important that all patients have a household member who knows the symptoms of low blood sugar and how to administer [MEDICATION NAME]. If you have low blood sugar often, keep a [MEDICATION NAME] kit with you at all times. You should be able to recognize some of the signs and symptoms of low blood sugar (i.e., shakiness, dizziness or lightheadedness, sweating, confusion, nervousness or irritability, sudden changes in behavior or mood, headache, numbness or tingling around the mouth, weakness, pale skin, sudden hunger, clumsy or jerky movements). Try to eat or drink a food or beverage with sugar in it, such as hard candy or fruit juice, before it is necessary to administer [MEDICATION NAME]. <http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 0.html> (5) HUMALOG? (insulin [MEDICATION NAME] injection, USP (rDNA origin)) is a rapid-acting human insulin analog used to lower blood glucose. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=C8ECBD7A-0E22-4FC7-A503-FAA58C1B6F3F#nlm -3 <http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=C8ECBD7A-0E22-4FC7-A503-FAA58C1B6F3F> (6) 50% [MEDICATION NAME] Injection is indicated in the treatment of [REDACTED]. <http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id= > (7) [MEDICATION NAME] 5 and half normal saline - Intravenous solutions containing [MEDICATION NAME] and sodium chloride are indicated for [MEDICATION NAME] of fluid, minimal carbohydrate calories, and sodium chloride as required by the clinical condition of the patient. <http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=6926> (8) [MEDICATION NAME] 10 - 10% [MEDICATION NAME] Injection, USP (concentrated [MEDICATION NAME] in water) in a partial-fill container is indicated for admixture with amino acids or dilution with other compatible IV fluids to provide a 5% final [MEDICATION NAME] concentration for intravenous infusion in patients whose condition requires [MEDICATION NAME] nutrition. <http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=60e6d95d-b3f4-47fb-5abe-c772f 91> 1.b. The facility staff documented administering medications to Resident #1 that had not been given. The facility physician orders [REDACTED]. The Medication Administration Record [REDACTED] "[MEDICATION NAME] Tablet 4 mg; Give 4 mg by mouth before meals related to DIAB W/O COMP Type II not stated UNCNTRL." The scheduled time for administration was documented as 6:00 a.m., 11:30 a.m. and 5:00 p.m. (A total dose of 12 mg in 24 hours). The medication was documented as having been administered on 4/25/14 at 6:00 a.m. and 5:00 p.m. All doses were documented as given on 4/26/14 and 4/27/14. On 4/28/14, only the 6:00 a.m. dose and 11:30 a.m. dose were documented as given. During an interview conducted with ASM #2, the DON, on 5/14/14 at 4:12 p.m. ASM #2 stated, "The resident did not receive the medication as documented. During our investigation we discovered that the nurses documented on 4/25/14 at the 6:00 a.m. and the 5:00 p.m. doses and on 4/26/14 at 6:00 a.m. dose that they administered the medication. Through the investigation, it was discovered, the medication was not delivered until 4/26/14 between 5:00 a.m. and 6:00 a.m. The nurse on 4/26/14 stated that he didn't take the time to go through the medications that were delivered to get the [MEDICATION NAME] out; he just signed it out as having been administered when it wasn't. All nurses have been disciplined for documenting when they did not administer a medication. The medication was not available in the (name of pharmacy backup system in facility) or stat boxes. The nurse on 4/25/14, morning shift, documented that she had called the pharmacy regarding this resident's medications and correctly documented that she did not administer the medication. ASM #2 stated, "Through our investigation, we discovered that not all of the documented doses of medication had actually been administered. Of the 10 doses documented as administered only seven doses were administered. The three doses were her normal once a day medication. There were four extra doses above what the doctor ordered. The resident didn't receive any doses on 4/25/14. She did receive two doses on 4/26/14. She received three doses on 4/27/14 and two doses on 4/28/14 before being transferred to the hospital." When asked if these were given in addition to her other anti diabetic oral agents, ASM #2 stated, "Yes, they were given per the physician orders." The facility policy, "General Guidelines for Medication Administration" documented, "15. Return to the medication cart and document medication administration with initials on the Medication Administration Record [REDACTED]." According to Perry & Potter, Fundamentals of Nursing 6th edition, page 843, "Right Documentation: After the nurse administers the medications, the medications administration record (MAR) is completed per agency policy to verify that the medication was given as ordered. Accurate documentation serves as a way for health care providers to communicate with each other. The following quotation is found in Potter and Perry's Fundamentals of Nursing 6th edition (2005, p. 477): "Documentation is anything written or printed that is relied on as record or proof for authorized persons. Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. Information in the client record provides a detailed account of the level of quality of care delivered to the clients." Potter and Perry (2005) also includes the following information: "As members of the health care team, nurses need to communicate information about clients accurately and in a timely, effective manner." The administrative team was made aware of these findings on 5/15/14 at 12:45 p.m. 2. The facility staff failed to transcribe the admission medication orders accurately for Resident #2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment dated , 5/13/14, documented the resident to be alert and oriented to self, time, and place. The resident was able to follow directions. Resident #2 was documented as having an unsteady gait. Review of the hospital discharge medication orders dated 5/12/14, revealed, "Aspirin EC ([MEDICATION NAME] coated) 81 MG (milligrams) tablet; take 1 tablet (81 mg) by mouth daily." [MEDICATION NAME] coated refers to a pill or tablet; covered with an outer layer of film that does not dissolve until the medication reaches the small intestine. AS a result, the lining of the stomach is not exposed to the underlying medication. [MEDICATION NAME] coating is commonly used to reduce stomach inflammation from known irritants, such as aspirin. (1) The facility physician orders [REDACTED]." The MAR (medication administration record) documented, "Aspirin Tablet 81 MG; give 81 mg by mouth in the morning related to UNSPECIFIED ESSENTIAL HYPERTENSION." The Aspirin was documented as administered on 5/13/14 and 5/14/14. An interview was conducted with LPN (licensed practical nurse) #3 on 5/14/14 at 1:16 p.m. When asked to review the medications for Resident #2 in the medication cart, LPN #3 showed the surveyor that the resident was receiving the Aspirin 81 mg, chewable type, not [MEDICATION NAME] coated. An interview was conducted with RN (registered nurse) #1, the unit manager on 5/14/14 at 1:12 p.m. When shown the orders from the hospital and the physician orders [REDACTED].#1 was asked where the double check system for verifying orders was. RN #1 stated, "I'll get back with you." On 5/14/14 at 1:55 p.m., RN #1 stated, "Only two nurses have to check the orders." When asked about the management team entering the orders into the computer, RN #1 stated, "If an admission comes in after the management team leaves for the day, then the charge nurses can enter the orders as long as a second nurse verifies the orders." On 5/14/14 at 5:15 p.m., ASM #2 was asked how soon after an admission should the orders be double checked by a second nurse. ASM #2 stated, "Either the same shift or the next shift." During an interview on 5/15/14 at 12:45 p.m. with administrative staff member (ASM) #2, the director of nursing, ASM #2 showed this surveyor the corrective action that the facility had put in place for admission orders [REDACTED]. It was the only one without a signature indicating that it had not been checked. The resident was admitted on [DATE]. The survey team arrived on 5/13/14 at 9:45 a.m. The clinical record could not be located on 5/13/14. The clinical record was not reviewed until 5/14/14 at 8:00 a.m. by the surveyor. The administrative team was made aware of these findings on 5/15/14 at 12:45 p.m. (1) Barron's Dictionary of Medical Terms for the Non Medical Reader; Rothenberg and Chapman, page198 3. The facility staff failed to transcribe the admission medication orders accurately for Resident #6. Resident #6 was admitted to the facility on [DATE] with two readmissions, the last being on 5/2/14 with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], depression,[MEDICAL CONDITION], and malnutrition. The most recent completed MDS (minimum data set) assessment, a discharge assessment, with an assessment reference date of 4/30/14, coded the resident with short term memory difficulties and being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive to full assistance from one or two staff members for all of her activities of daily living. Review of the physician order [REDACTED]." A review of the facility physician orders [REDACTED]. The nurse's note dated, 4/8/14 at 10:23 a.m. documented, "Resident observed in bed at the beginning of shift, awakens to verbal stimuli and touch. Took am (morning) medications without difficulty. While writer was still taking over from off going nurse, with nursing cart in front of resident's door, heard resident scream and saw resident start to have a [MEDICAL CONDITION], lasted 45 seconds, stayed with resident, after [MEDICAL CONDITION], resident's VS (vital signs) 89/57 (blood pressure), 63 (pulse), 14 (respirations), 99.9 (temperature), O2 (oxygen saturation) 96% on room air. MD (medical doctor) notified, order was received to send resident out to the ER (emergency room ) for observation, RP (responsible part