Every finding on record at George E. Wahlen Ogden Veterans Home

Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility did not ensure each resident was free from abuse. Specifically, a resident's husband tried to shove a spoon with medication into another resident's mouth. In another incident the same resident's husband shoved her and removed her clothing to change her clothes. There were no interventions to prevent the resident from further abuse. The findings for resident 1 were determined to have resulted in immediate jeopardy. Resident identifiers: 1 and 2. Findings included: NOTICE On 2/26/25 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. This notice was given verbally and in writing to the facility Administrator (ADM), and the Director of Nursing (DON) regarding resident 1. On 2/27/25, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 2/27/25 at 11:59 PM. Removal Plan for Immediate Jeopardy Substandard Quality of Care The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiency. Health and Resident Safety 1. Immediate Action: a. Resident 1 was moved to the secure unit on 2/26/25. Visits in person will be scheduled in advance and supervised. Residents will have the opportunity to stay in contact with use of technology available in the facility. b. Resident 1 will be placed on q [every] shift monitoring to identify behaviors of distress indicating that she is not adjusting to room placement such as but not limited to searching for her husband, lack of appetite, anger/hostility towards others, refusals of care, or inability to be redirected. Resident 1's care plan will be updated with interventions to adjust to change in living condition. c. If Resident 1 does not adjust to her new room placement, she will be returned to her prior living situation with continued 1:1 supervision with staff who have been re-educated on abuse until the spouse receives caregiver burnout counseling and shows an ability to maintain a consistent kind and patient demeanor during care. d. Resident 2 will be placed on q shift monitoring to identify behaviors of distress indicating that he is not adjusting to room placement such as but not limited to, lack of appetite, anger/hostility towards others, refusals of care, or inability to be redirected. Resident 2's care plan will be updated with interventions to adjust to changes in living conditions. 2. Identification of Others At Risk: a. Current residents with a BIMs greater than or equal to 9 will be interviewed by Administrator/designee to screen for signs and symptoms of abuse. Residents with a BIMs less than 9 will have their POA interviewed to identify s/s of abuse. 3. Education: a. DON/Designee will provide Re-education: What is abuse, when to report abuse, and how to report abuse. i. Staff members in the facility on shift will be educated prior to end of day 02/26/2025 ii. Staff members not in the facility will be educated prior to their next shift b. Regional Nurse Consultant will provide re-education of abuse policies. 4. An ad hoc QAPI meeting was held on 2/27/25 to approve the above plan. 5. Alleged Date of Removal a. 2/27/2025 Quality Assurance and Monitoring The DON/Designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The ongoing audits will include random interviews of residents in the facility to identify indications of abuse. Audits will be brought to the QAPI committee by the DON/Designee for three months for tracking, trending, and additional recommendations based on the audit findings with oversight provided by the DON/Designee. On 2/28/25, while completing the complaint survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 2/28/25 at 11:00 AM. Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, muscle weakness and cognitive communication deficit. A continuous observation was conducted on 2/26/25 from 10:44 AM through 11:50 AM for residents 1 and 2. It was observed that no staff entered room [ROOM NUMBER] where both of the residents were located. The residents were observed to be in the same room with both the door and blinds closed. On 1/28/25, a quarterly Minimum Data Set (MDS) documented resident 1 had a brief interview for mental status (BIMS) score of 0 which indicated severe cognitive impairment. A review of resident 1's progress notes revealed the following: a. On 2/23/25 at 8:30 PM, a nursing note documented, [Resident 2] and [Resident 1] who goes by '[name redacted]' are married. The couple each have a private room with a shared bathroom between them. Every evening after dinner the couple enjoy sitting on a small sofa that is located in [resident 1's] room and spend the evening sitting next to each other watching TV and visiting. [Resident 1] has cognitive impairments r/t [related to] her diagnosis and needs prompting and cueing often to help encourage her to allow the staff at the facility to help her with many of her ADLs [activities of daily living]. At 2000 [8:00 PM] on 02/23/2025 the CNA [certified nurse aide] went to help [resident 1] get in her pajamas and get her ready for bed. [Resident 1] was telling the CNA that she was not ready to get ready for bed yet. The CNA waited for a couple for [sic] minutes and then [resident 1] got up with her walker and started to walk around the room. The CNA and [resident 1] were about halfway into the bathroom when [resident 2] got up from the couch and was raising his voice at [resident 1] telling her she needed to get her clothes changed. [Resident 2] shoved her into the bathroom while she did not have a hold of her walker, and she was stumbling. Next [resident 2] grabbed [resident 1's] dress forcing her to change. The CNA stepped in and said that she has it from here. [Resident 2] said no she needs to change and continued to make her take her dress off. [Resident 1] got really flustered and started crying and then could no longer express herself and just kept crying more and more as and [sic] the CNA tried to finish getting her ready for the bed. Nurse came in to give [resident 1] her pills and saw [resident 1] sitting on the toilet just sobbing and trying to understand the CNA. CNA said she needed to talk to the nurse in private later. Nurse shut the door to bathroom and let the CNA console [resident 1]. Nurse gave pills to [resident 2] who was sitting on the sofa and then left the room and would come back later to give [resident 1] her medications. CNA said to [sic] come back in about 15 minutes. Nurse had no idea at the point what had happened. Nurse returned about 15 minutes later. [Resident 1] was sitting next to [resident 2] on the sofa watching TV. When the nurse went back to give [resident 1] her evening medications, she noticed that [resident 1] was still crying a little. Asked what was wrong and she does not have the ability to express herself. Nurse gave the Resident her pills which she held in her hands for a short time and then tried to put them into her mouth. [Resident 1] will not let the nurse help her put the medications into her mouth. [Resident 1] turned to [resident 2] and asked him to help in her own way. [Resident 2] took the pills and dumped them into [resident 1's] mouth and nurse helped her with her water mug that she likes to use. Before the nurse left theroom [sic], [resident 1] was holding [resident 2's] hand and was calming down. When we checked a few minutes later on them, all was well, and [resident 1] was no longer crying. [Resident 2] helped [resident 1] into bed about 2100 [9:00 PM] pm [sic] and then went to his room. [Resident 2] always tucks [resident 1] into bed every night. When CNA checked on [resident 1] later that evening, she was asleep in bed. Around 2015 [8:15 PM], the CNA was finally able to report to floor Nurse what happened, and it was immediately reported to RN Noc Supervisor. RN NOC Supervisor immediately reported it to [Administrator] who is the Administrator at [facility] . Resident relies a lot on her husband for help and support. Resident was comforted by the CNA for a while and then helped into her night clothes. Next, she was escorted back to the sofa where she spent the next hour watching TV with [resident 2] and she and him were holding hands. Resident is unable to explain what happened to the nurse r/t her diagnosis and cognitive impairment. Frequent checks done to make sure things were still okay . Police notified and an officer spoke with the CNA who reported the incident. [Resident 2] is the # [number] 1 Emergency contact for [resident 1]. b. On 2/23/24 at 10:05 PM, a nursing note documented, Incident reported to this supervisor by floor nurse [name redacted] and CNA [name redacted]. It was reported that this resident has been refusing cares and her husband, [resident 2], has been getting frustrated. [Resident 2] got frustrated at her refusal of cares tonight and got pushy with [resident 1]. It was reported that [resident 1] stumbled but did not fall. [Resident 2] forced residents dress off so that she would change into clean pajamas. No physical injury noted. [Resident 1] was tearful after the incident. Resident was frequently checked on by CNA after the incident to ensure she is ok physically and emotionally. Administrator, [name redacted] notified of incident and is reporting to APS [adult protective services] and Dept [department] of Health. This nurse notified [local county dispatch]. Officer [name redacted] with [local police department] called the supervisor phone at 2150 [9:50 PM] for a verbal report. This supervisor answered all questions. Officer [name redacted] and this nurse discussed that residents are both safely in bed in their own rooms at this time. Officer [name redacted] also spoke to CNA [name redacted] for verbal report of incident. NOC staff aware of situation and will monitor residents close through the night and notify supervisor of any changes. Social work will follow up with residents. Officer satisfied to know that our internal social work department will follow up with the situation and happy to be notified that administrator will be in contact with APS and dept of health. Officer asked if we need anything else from him and stated we should call back if anything changes. c. On 2/24/24 at 8:00 AM, a nursing note documented, MD [medical doctor] was notified of resident to resident incident. No injuries were found upon assessment of [resident 1] per the floor nurse at the time of the incident. d. On 2/24/25 at 4:05 PM, a social services note documented, SS [social services] met with [resident 1] r/t the resident to resident altercation with her husband last night. She was able to answer my questions, but could not give more than just a few word answers. She could not recall what happened last night, but reports she feels safe at the facility and with [resident 2], she reports he treats her well and has no concerns. No physical or emotional harm noted. SS discussed with her husband the potential of moving rooms to the memory care unit as the structure and activities may be beneficial to [resident 1]. [Resident 2], her husband, does not want to move rooms at this time, but is open to discussing it again. SS to f/u [follow up] as appropriate. Resident 2 was admitted to the facility on [DATE] with diagnoses of Post-Traumatic Stress Disorder and recurrent severe major depressive disorder. On 2/26/25 at 10:18 AM, an interview was conducted with Resident 2. Resident 2 stated staff were very helpful. Resident 2 stated, on Sunday night staff were getting resident 1 ready for bed and she did not want to take her dress off. Resident 2 stated they got impatient, spoke to resident 1 a little harshly and took her dress off. Resident 2 stated they had not realized they had done anything terribly wrong until staff came in and talked to him the next day. Resident 2 stated they now realized that what they had done to resident 1 was wrong. On 12/30/24, a quarterly MDS documented resident 2 had a BIMS of 15 which indicated resident 2 was cognitively intact. A review of resident 2's progress notes revealed the following: a. On 11/7/24 at 10:34 PM, a progress note documented, [Resident 2] became frustrated when [resident 1] would not willingly take her night medications. He took the spoon and tried to force her to take them. The nurse intervened, taking the spoon away from [resident 2] and stating that it was ok if she did not want to takethe [sic] medications at this time and that I could try again later. He slammed his feet down and told [resident 1] 'Fine, I will see you in a week' and started to stand up. [Resident 1] apologized and took the spoon from the nurse and took her medications. Nurse educated [resident 2] that [resident 1] has the right to refuse medications, and we should not be forcing her to take them if she does not want to. Prior to this, [resident 2] had asked about his antidepressant and if it could be evaluated. He stated he feels 'blank.' . b. On 2/24/25 at 3:56 PM, a social services note documented, SS met with [resident 2] r/t the resident to resident altercation with his wife last night. [Resident 2] reported that he did not intend to hurt his wife in anyway [sic]. He reports he 'flipped' and became frustrated and 'slipped her dress off' as she was resistive to let staff assist her. SS discussed the memory care unit and the potential benefits to his wife moving to that unit. [Resident 2] is hesitant to move her as he feels the change might be too hard on her. Their direct social worker discussed it with them earlier today as well. SS discussed what [resident 2] is doing for self-care and to take breaks. SS invited [resident 2] to Caregiver Support Group, [resident 2] was interested in attending. SS to f/u as appropriate. c. On 2/24/25 at 4:02 PM, a social services note documented, SS discussed with [resident 2] the option of moving [resident 1] to [memory care unit] to help with caregiver burnout, sundowning, increased behaviors from [resident 1] during cares, and incident from last night. [Resident 2] stated that he did not intend to become upset with [resident 1] last night, he was just trying to help her get ready for bed. SS informed [resident 2] of the process and different approaches that staff can make to help [resident 1] with cares and that if she is upset in the moment, they may leave and attempt to care at a later time in a different approach. [Resident 2] appreciated the education on the staff process/approach and stated that he will keep that mind [sic] next time. He stated that at this time, he would like to wait to move [resident 1] to [memory care unit] and does not think 'she is to that point yet.' SS to F/U [follow up] with [resident 2] as needed when a community move/room is recommended in the future. SS WCTM [will continue to monitor]. On 2/26/25 at 8:22 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 1 and resident 2 were a married couple. RN 1 stated resident 1 had dementia, and resident 2 had served as her primary care giver. RN 1 stated that resident 1 depended on resident 2 heavily, experienced frequent mood swings, and refused to get up in the morning unless resident 2 was there. RN 1 stated resident 1 often cried and despite these challenges, resident 2 rarely requested help. RN 1 stated resident 1 and resident 2 spent most of their time together, often watching TV. RN 1 stated she did not know the details of any incidents involving the residents. On 2/26/25 at 8:40 AM, an interview was conducted with CNA 1. CNA 1 stated resident 1 needed help getting dressed and getting out of bed. CNA 1 stated that resident 1 required substantial assistance with all daily activities but could walk independently with her walker. CNA 1 stated resident 1 had dementia and frequently needed reminders, often asking if she needed to use the bathroom. CNA 1 stated that resident 2 stayed with resident 1 most of the time, but did not assist with her personal care. CNA 1 stated that when resident 2 was not around, resident 1 would look for him. CNA 1 stated resident 1 experienced occasional mood swings or behavioral issues but was generally cooperative unless it involved a shower or an activity she did not want to do. CNA 1 stated regarding the incident the other night, the details were unclear. CNA 1 stated the previous shift reported a dispute in which resident 2 was trying to rip off resident 1's clothes, leading to a police intervention. CNA 1 stated despite this, care routines did not seem to have changed, though staff checked on resident 1 more frequently. CNA 1 stated she had not noticed any changes in resident 1's behavior. On 2/26/25 at 8:51 AM, an interview was conducted with RN 2. RN 2 stated that resident 1 had dementia, while resident 2 was cognitively intact. RN 2 stated resident 2 provided significant emotional support, especially when resident 1 exhibited behavioral changes. RN 2 stated resident 1 often became teary and cried in the morning without any apparent reason, sometimes experiencing similar episodes at night. RN 2 stated after breakfast resident 1 and resident 2 sat in resident 1's room watching TV, spending most of the day there before sleeping in separate rooms at night. RN 2 stated resident 1 was able to communicate her needs, though staff monitored her for behavioral issues, particularly angry outbursts when taking her medications. RN 2 stated she was unaware of the incident that occurred on Sunday and had not heard any details about it. RN 2 stated, starting on Tuesday, she was instructed to be more mindful of resident 2's feelings and to observe him to determine if he needed a break. On 2/26/25 at 9:03 AM, an interview was conducted with the Social Services Assistant (SSA). The SSA stated that staff attempted to provide care for resident 1 and get her ready for bed, but she resisted due to her worsening dementia. The SSA stated that resident 2 became upset and took resident 1 into the bathroom to help her change into her pajamas since she was not responding to staff. The SSA stated that she spoke with resident 2 and explained that nursing staff could not force resident 1 to comply with care. The SSA stated that resident 2 responded that he was not trying to harm her but was simply trying to get her ready for bed. Resident 2 admitted to removing her clothes but claimed not to know anything beyond that. The SSA stated she had heard reports of a push during the incident but could not verify it. The SSA stated she was unaware of any other incidents involving the couple but suspected that the situation was likely related to caregiver burnout. The SSA stated that resident 2 did not assist with resident 1's personal care, he spent all of his time with her, focusing on her needs rather than his own. On 2/26/25 at 11:13 AM, an interview was conducted with the Social Services Director (SSD). The SSD stated there was an incident that involved a married couple, resident 1 and resident 2. The SSD stated that resident 1 had dementia and resident 2 had been her caregiver for a long time. The SSD stated when resident 1 was first admitted , she stayed in the memory care unit, but visiting her on that floor became overwhelming for resident 2. The SSD stated resident 2 remained highly attentive to resident 1 as her dementia progressed. The SSD stated resident 1 often resisted care due to confusion and restlessness and became anxious when resident 2 was not nearby. The SSD stated resident 2 stayed with resident 1 unless family members visited to give him a break. The SSD stated resident 1 and resident 2 preferred to spend alone time in their room, where they had two recliners side by side, rather than participating in community activities. The SSD stated that resident 1 had major depression along with her dementia, and her baseline mood was typically tearful. The SSD stated resident 1 had become more emotional over time. The SSD stated resident 1 had also started exhibiting verbal aggression during care, frequently yelling at staff, though she was unsure if she had shown any physical aggression. The SSD stated resident 1 had adjusted well in memory care, and since resident 2 spent so much time there, the facility arranged for them to stay together when two adjoining rooms became available. The SSD stated on Sunday (2/23/25), CNA staff entered resident 1's room to assist resident 1 with changing into her nightclothes and use the restroom. The SSD stated resident 1 and staff were in the bathroom while resident 2 sat in his recliner. The SSD stated resident 1 began resisting care, and staff attempted to talk her through it. The SSD stated resident 2 heard the commotion and became frustrated and stern with resident 1. The SSD stated that staff reassured resident 2 that they had the situation under control and the CNA remained in the bathroom with resident 1 to comfort her while resident 2 returned to his recliner. The SSD stated that according to the nurse's report, the CNA reported that resident 2 bumped into resident 1. The SSD stated she was still in the process of getting interviews with staff. The SSD stated that resident 2 acknowledged that he typically did not react this way but recognized that resident 1's dementia was worsening and he often became frustrated when she resisted care. The SSD stated that she recommended moving resident 1 back to the memory care unit to give resident 2 a break and help prevent his frustration. The SSD stated however, due to an ongoing RSV outbreak in the memory care unit t, they were hesitant to transfer her at this time. The SSD stated resident 2 expressed an interest in attending the facility's monthly caregiver support group. The SSD stated a referral was placed for resident 1 to receive physical therapy services for strengthening, which would also provide resident 2 with some time apart from resident 1. The SSD stated staff were expected to continue their supervision, conducting regular two-hour rounding. The SSD stated when providing care, they were expected to observe resident 2 for signs of frustration or irritability and to ensure he and resident 1 had opportunities for space when needed. The SSD stated staff had been trained on recognizing signs of caregiver burnout in all staff meetings and completed a computer training module. The SSD stated education binders were available in all communities, allowing immediate access to training materials. The SSD stated staff were informed about the incident through verbal reports and through their messaging app. The SSD stated she was unsure of the specific details that were communicated to staff. On 2/26/25 at 11:33 AM, an interview was conducted with CNA 3. CNA 3 stated room [ROOM NUMBER] and 116 had a little situation happen the other day that staff were all aware of. CNA 3 stated resident 1 and resident 2 were married and got in an overheated argument but nothing too extreme. CNA 3 stated they were pretty sure it was just words that were said and maybe a little aggression. CNA 3 stated resident 2 had apparently pushed resident 1 just a little but not enough to cause harm. CNA 3 stated normally resident 2 and resident 1 were really good to each other but resident 1 gave resident 2 a little shove on Sunday. CNA 3 stated staff were checking on resident 1 to make sure they were okay and the checks were mainly occurring at night because that is when a dispute was more likely to occur. CNA 3 stated resident 1 had bad dementia and sometimes they were difficult to work with. CNA 3 stated they were informed of the incident between resident 2 and 1 during shift change on monday and since then, they had been checking on her during each round and doing visuals. CNA 3 stated resident 2 and 1 were good about voicing their needs. On 2/26/25 at 1:03 PM, an interview was conducted with CNA 4. CNA 4 stated she worked the Sunday night shift (2/23/25) from 2:00 PM-10:00 PM. CNA 4 stated while assisting resident 1 in getting ready for bed, she helped her change into pajamas and a new brief. CNA 4 stated resident 1 usually preferred to change in the bathroom and use the toilet. CNA 4 stated on Sunday night she gathered resident 1's pajamas, a new brief and asked resident 1 if she would like to get into her pajamas. CNA 4 stated resident 1 refused to get up and change. CNA 4 stated she reassured resident 1 that it would be quick, but resident 1 had become increasingly difficult to work with due to her dementia, only complying when resident 2 asked her to. CNA 4 stated that resident 1 eventually stood up, walked around the room, and insisted she did not want to get ready for bed. CNA 4 stated resident 1 began to walk into the bathroom and stopped about halfway through the door and repeated that she did not want to get changed. CNA 4 stated that resident 2 raised his voice and told resident 1 she needed to get changed and ready for bed. CNA 4 stated that resident 2 got up from the recliner and pushed resident 1 on her back, making her unsteady and nearly causing her to fall. CNA 4 stated she quickly grabbed onto resident 1 to prevent her from falling. CNA 4 stated that resident 2 then pulled up resident 1's dress to change her, acting aggressively, an unusual behavior from him, as he was not typically aggressive. CNA 4 stated that after resident 2 removed resident 1's dress, he went back to sit in his recliner. CNA 4 stated resident 1 began crying after she was pushed into the bathroom, but never said anything. CNA 4 stated she spent 10-15 minutes in the bathroom with resident 1 afterward, trying to help her calm down because resident 1 seemed extremely upset. CNA 4 stated once resident 1 felt ready they left the bathroom and at that time the nurse was coming into the room to give resident 1 her medications. CNA 4 stated that at that point, resident 1 had stopped crying and was not very expressive-just present but quiet. CNA 4 stated that resident 2 was still in the room, sitting in his recliner. CNA 4 stated resident 2 seemed fine and had calmed down. CNA 4 stated she informed the nurse that she needed to speak with her. CNA 4 stated following the incident she provided a verbal statement to a police officer and an incident report was filed with the nursing supervisor. CNA 4 stated she had recently noticed that resident 1's dementia had worsened, and resident 1 struggled to understand things and seemed more confused. CNA 4 stated over the past couple of weeks, she had observed resident 1's cognitive decline and noted that resident 2 had become increasingly frustrated, especially when resident 1 refused to take her medications. On 2/26/25 at 1:40 PM, a telephone interview was conducted with the RN 3. RN 3 stated they were informed that CNA 4 was encouraging resident 1 to get ready for bed. Resident 1 was refusing and resident 2 then got frustrated with resident 1 and got pushy. RN 3 stated resident 2 pushed resident 1 hard enough to make them stumble. RN 3 stated while resident 1 was sitting on the toilet, resident 2 forcefully took resident 1 ' s dress off which caused resident 1 to become visibly upset and start crying on the toilet. RN 3 stated afterwards resident 1 and resident 2 were observed to be sitting on their couch and holding hands prior to resident 1 going to bed. RN 3 stated thanks to resident 1 ' s diagnosis of dementia, resident 1 had forgotten about the incident pretty quickly. RN 3 stated they notified the police department about the incident. The police department did not arrive on scene because at that time, both residents were separated and in their own rooms sleeping. RN 3 stated the plan was for the CNAs to frequently monitor both residents. On 2/26/25 at 2:01 PM, an interview was conducted with the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN stated that she served as the abuse coordinator, overseeing all abuse allegations and incidents. The ADMIN stated that staff should report any concerns directly to her. The ADMIN stated she handled all the reporting when possible and that the social services director served as her backup. The ADMIN stated that she instructed the nursing supervisor to educate staff Sunday night to ensure resident 1's safety, and conduct frequent rounds to monitor resident 1's emotional state. The ADMIN stated that she typically preferred to have documentation written in the resident's chart but had been occupied with the ongoing complaint survey at the facility. The ADMIN stated that an immediate assessment of resident 1's emotional and physical state was conducted. The ADMIN stated that she decided not to separate resident 1 from resident 2 that night and instead implemented frequent rounding. The ADMIN stated that frequent rounding was not documented, though it should have occurred every 15 to 30 minutes. The ADMIN stated staff had only received verbal instructions to complete checks, and no formal documentation existed to confirm they had been done. The ADMIN stated on Monday morning, the SSD offered to move resident 1 to the memory care unit, but resident 2 requested a few days to reflect on his actions and learn from his mistakes. The ADMIN stated that resident 2 was informed that the recreation therapy team would need to take resident 1 on walks and resident 2 agreed to attend a caregiver support group. The ADMIN stated she classified this incident as a safety check but had used the term frequent rounding. The ADMIN stated that it was reported that resident 1 had been combative, attempting to hit staff, becoming verbally aggressive, and resisting getting dressed. The ADMIN stated that resident 2 overheard the commotion, intervened by pushing resident 1-though she did not fall-and then pulled her dress up off of her. The ADMIN explained that the process required reporting the incident first, followed by an investigation. The ADMIN stated that according to resident 2's account, he did not recall pushing resident 1 but remembered that her dress was pulled up over her head. The ADMIN stated resident 2 entered the bathroom and removed the dress. The ADMIN stated that staff should have documented the incident through occurrence charting, which tracks incidents requiring monitoring for adverse side effects, injuries, behavioral changes, or any new or ongoing concerns. The ADMIN stated staff failed to complete occurrence charting and it was missed. The ADMIN stated to address the situation, staff implemented new interventions such as recreation staff would begin to take resident 1 on walks throughout the day, therapy referrals were made for both residents, and social services conducted daily check-ins. The ADMIN stated that she had not been informed of any incident between the residents in November and only learned about it today from the SSD. The ADMIN stated that if she had known about the previous incident, she would have contacted the corporate office for guidance on handling the situation and determining the appropriate course of action. The ADMIN stated that the facility recently noticed that staff had not always notified management about incidents. The ADMIN stated that to address this issue, management began printing and reviewing notes to identify any necessary follow-ups. The ADMIN stated that knowing about the November incident could have influenced how she handled the recent situation on 2/23/25. The ADMIN stated that it might have changed her opinion and the direction she would have taken. The ADMIN stated that resident 2 was experiencing caregiver burnout and that resident 2 needed breaks and more education about dementia care. The ADMIN stated that the [TRUNCATED]

Based on observation, interview and record review it was determined, for 1 of 9 sampled residents, that the facility did not ensure all alleged violations involving abuse were reported immediately to the State Survey Agency. Specifically, it was not reported to the State Survey Agency when a resident's husband tried to shove a spoon with medication into her mouth. The findings for resident 1 were determined to have resulted in immediate jeopardy. Resident identifiers: 1 and 2. Findings included: NOTICE On 2/26/25 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. This notice was given verbally and in writing to the facility Administrator (ADM), and the Director of Nursing (DON) regarding resident 1. The facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 2/27/25 at 11:59 PM. Removal Plan for Immediate Jeopardy Substandard Quality of Care The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiency. Health and Resident Safety 1. Immediate Action: a. Resident 1 was moved to the secure unit on 2/26/25. Visits in person will be scheduled in advance and supervised. Residents will have the opportunity to stay in contact with use of technology available in the facility. b. Resident 1 will be placed on q [every] shift monitoring to identify behaviors of distress indicating that she is not adjusting to room placement such as but not limited to searching for her husband, lack of appetite, anger/hostility towards others, refusals of care, or inability to be redirected. Resident 1's care plan will be updated with interventions to adjust to change in living condition. c. If Resident 1 does not adjust to her new room placement, she will be returned to her prior living situation with continued 1:1 supervision with staff who have been re-educated on abuse until the spouse receives caregiver burnout counseling and shows an ability to maintain a consistent kind and patient demeanor during care. d. Resident 2 will be placed on q shift monitoring to identify behaviors of distress indicating that he is not adjusting to room placement such as but not limited to, lack of appetite, anger/hostility towards others, refusals of care, or inability to be redirected. Resident 2's care plan will be updated with interventions to adjust to changes in living conditions. 2. Identification of Others At Risk: a. Current residents with a BIMs greater than or equal to 9 will be interviewed by Administrator/designee to screen for signs and symptoms of abuse. Residents with a BIMs less than 9 will have their POA interviewed to identify s/s of abuse. 3. Education: a. DON/Designee will provide Re-education: What is abuse, when to report abuse, and how to report abuse. i. Staff members in the facility on shift will be educated prior to end of day 02/26/2025 ii. Staff members not in the facility will be educated prior to their next shift b. Regional Nurse Consultant will provide re-education of abuse policies. 4. An ad hoc QAPI meeting was held on 2/27/25 to approve the above plan. 5. Alleged Date of Removal a. 2/27/2025 Quality Assurance and Monitoring The DON/Designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with the plan. The ongoing audits will include random interviews of residents in the facility to identify indications of abuse. Audits will be brought to the QAPI committee by the DON/Designee for three months for tracking, trending, and additional recommendations based on the audit findings with oversight provided by the DON/Designee. On 2/28/25 at 11:00 AM, while completing the complaint survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy removal. The surveyors determined that the Immediate Jeopardy was removed. Resident 2 was admitted to the facility on [DATE] with diagnoses of Post-Traumatic Stress Disorder and recurrent severe major depressive disorder. On 12/30/24, a quarterly Minimum Data Set (MDS) documented resident 2 had a brief interview for mental status (BIMS) of 15 which indicated resident 2 was cognitively intact. A review of resident 2's progress notes revealed the following: a. On 11/7/24 at 10:34 PM, a progress note documented, [Resident 2] became frustrated when [resident 1] would not willingly take her night medications. He took the spoon and tried to force her to take them. The nurse intervened, taking the spoon away from [resident 2] and stating that it was ok if she did not want to takethe [sic] medications at this time and that I could try again later. He slammed his feet down and told [resident 1] 'Fine, I will see you in a week' and started to stand up. [Resident 1] apologized and took the spoon from the nurse and took her medications. Nurse educated [resident 2] that [resident 1] has the right to refuse medications, and we should not be forcing her to take them if she does not want to. Prior to this, [resident 2] had asked about his antidepressant and if it could be evaluated. He stated he feels 'blank.' . Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, muscle weakness and cognitive communication deficit. A continuous observation was conducted on 2/26/25 from 10:44 AM through 11:50 AM for residents 1 and 2. It was observed that no staff entered room [ROOM NUMBER] where both of the residents were located. The residents were observed to be in the same room with both the door and blinds closed. On 1/28/25, a MDS documented resident 1 had a BIMS score of 0 which indicated severe cognitive impairment. The incident was not documented in resident 1's medical record. On 2/26/25 at 2:01 PM, an interview was conducted with the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN stated that she served as the abuse coordinator, overseeing all abuse allegations and incidents. The ADMIN stated that staff should report any concerns directly to her. The ADMIN stated she handled all the reporting when possible and that the social services director served as her backup. The ADMIN stated that she had not been informed of any incident between the residents in November and only learned about it today from the Social Service Director. The ADMIN stated that if she had known about the previous incident, she would have contacted the corporate office for guidance on handling the situation and determining the appropriate course of action. The ADMIN stated that the facility recently noticed that staff had not always notified management about incidents. The ADMIN stated that knowing about the November incident could have influenced how she handled the recent situation on 2/23/25.

Based on observation, interview or record review it was determined, for 2 of 9 sampled residents, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered plan, the residents' goals and preferences. Specifically, residents on oxygen were using empty oxygen tanks. Resident identifier: 7 and 8. Findings Included: 1. Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic systolic congestive heart failure. On 2/25/25 at 1:32 PM, an observation was made of resident 7's portable oxygen tank while in use. The oxygen tank indicator was observed in the red refill area. Resident 7's medical records were reviewed on 2/25/25. A care plan focus area initiated 9/9/24 documented resident 7 had altered respiratory status and required supplemental oxygen to maintain oxygenation saturation. The facility grievances were reviewed from December to current. There were 5 documented grievances about residents having low or no oxygen in the portable oxygen tanks while in use. 2. Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and chronic obstructive pulmonary disease. On 2/25/25 at 12:45 PM, an observation was made of resident 8's portable oxygen tank. The indicator was observed to be on the number 0 in the red area. Resident 8 was immediately interviewed and stated they needed to be on oxygen due to shortness of breath. Resident 8's medical records were reviewed on 2/25/25. Resident 8's physician orders were reviewed and documented resident 8 had an order for oxygen due to acute respiratory failure. On 2/25/25 at 12:48 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was observed to look at resident 8 ' s portable oxygen tank and stated they were going to get resident 8 a new portable oxygen tank because the indicator was getting close to the red area. On 2/25/25 at 12:50, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated when the oxygen tank indicator was close to red, the portable oxygen tank needed to change. CNA 5 stated staff checked the portable oxygen tanks pretty frequently including prior to resident use. On 2/27/25 at 12:08 PM, an interview was conducted with the Licensed Practical Nurse (LPN). The LPN stated portable oxygen tanks were checked every shift by the CNAs. The LPN stated the portable oxygen tanks needed to be changed if the indicator was in the red which indicated the tank was low on oxygen. The LPN stated staff have been provided education on oxygen such as making sure residents were switched back from the portable oxygen tanks to the concentrators. On 2/28/25 at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated portable oxygen tanks needed to be checked when they were initially put into use and checked at least every hour if they were in use. The DON staff needed to check and see how much oxygen was left in the tank and if the indicator was in the red then it needed to be changed because the oxygen would be running out soon. The DON stated they hoped staff would be proactive in switching out the portable oxygen tanks before they became empty.

Based on observation, interview and record review, for 2 of 38 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choice. Specifically, a resident was administered medications by the nurse after he was unable to put them in his own mouth and was experiencing confusion, having difficulty staying awake, had gurgling sounds when breathing, and difficulty keeping oxygen saturation above 90 percent. No monitoring was documented for his change in condition. The resident was discharged to the hospital with an overdose. In addition, a resident was experiencing low oxygen levels in the evening and was not monitored throughout the night to ensure it was above 90 percent after the resident was provided increased oxygen. Resident identifiers: 67 and 77. Findings include: 1. Resident 67 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included type 2 diabetes with polyneuropathy, Post Traumatic Stress Disorder (PTSD), asthma, respiratory failure with hypoxia, fluid overload, dependence on renal dialysis, metabolic encephalopathy, congestive heart failure (CHF), and ischemic cardiomyopathy. On [DATE] at 9:29 AM, an interview was conducted with resident 67 who stated he had gone to the hospital as a result of an accidental overdose. Resident 67's medical record was reviewed between [DATE] and [DATE]. An annual Minimum Data Set (MDS) revealed resident 67 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident 67's physician's orders included: a. Melatonin Tablet 3 MG (milligrams) Give 9 mg by mouth at bedtime for insomnia. Start date [DATE]; Discontinued [DATE]. b. Potassium Tablet (Potassium) Give 20 mEq (Miliequivalents) by mouth two times a day for supplement. Start date [DATE]; Discontinued [DATE]. c. Prazosin HCI (Hydrogen chloride) Capsule Give 2 mg by mouth two times a day for nightmares related to Post Traumatic Stress Disorder, Chronic. Start date [DATE]; Discontinued [DATE]. d. Furosemide Oral Tablet (Furosemide) Give 60 mg by mouth three times a day for Edema. Start date [DATE]; Discontinued [DATE]. e, Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain. Start date [DATE]; Discontinued [DATE]. f. Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 8 hours for pain for 2 days. Start Date [DATE]. g. Naloxone HCI Nasal liquid 4 mg/0.1 ml(milliliters); 1 spray in nostril as needed for suspected overdose, if no response in 3 minutes repeat. Start date [DATE]; Discontinued [DATE]. h. Resident may have a RUM shot (Captain [NAME] kept in back med room) or Scotch ([NAME] Whiskey) can have 100 ml po (by mouth) BID (twice daily), PRN (as needed). Administration to be visualized by staff, do not leave in room per POA (Power of Attorney) request. Must choose which one he would like, he cannot have both at same time, as needed BID (twice daily) PRN (as needed). Start date [DATE]; Discontinued [DATE]. (It should be noted that 100 ml of rum is two-1.5 ounces or approximately 3.4 ounces) Resident 67's care plan included: a. [Resident 67] has altered cardiovascular status r/t (related to) pulmonary hypertension due to left heart disease, hypertension due to left heart disease, hyperlipidemia, hypertensive heart and chronic kidney disease without heart failure, hypertension. The goal was, [Resident 67] will be free from untreated complications of cardiac problems through the review date. Interventions included, .Assess for shortness of breath and cyanosis as needed .Obtain vital signs per facility protocol. Notify MD [Medical Doctor] of significant abnormalities .Oxygen settings: O2 [oxygen] via nasal cannula per MD orders. b. [Resident 67] has end stage renal disease and received renal dialysis r/t DM [diabetes mellitus] type 2 with diabetic polyneuropathy, DM type 2 with diabetic foot ulcer, fluid volume overload, Chronic kidney disease [CKD]. The goal was, [Resident 67] will have no untreated s/sx [signs or symptoms] of complications related to fluid overload through the review date. Interventions included, .Encourage [Resident 67] to limit fluids to 1L [liter] QD [once daily] r/t dialysis. [Resident 67] is typically noncompliant with this .Fluids as ordered. Restrict or give as ordered .Monitor vital signs per facility protocol. Notify MD of significant abnormalities. A review of resident 76's Medication Administration Record (MAR) for [DATE] revealed: a. Potassium Tablet (Potassium) Give 20 mEq by mouth two times a day for supplement. Administered on [DATE] at 9:13 PM. b. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain. Administered on [DATE] at 9:14 PM. c. Melatonin Tablet 3 MG Give 9 mg by mouth at bedtime for insomnia. Administered on [DATE] at 9:13 PM. d. Prazosin HCI Capsule Give 2 mg by mouth two times a day for nightmares related to Post Traumatic Stress Disorder, Chronic. Administered on [DATE] at 9:14 PM. e. Furosemide Oral Tablet (Furosemide) Give 60 mg by mouth three times a day for edema. Administered on [DATE] at 9:14 PM. f. Morphine Sulfate Oral Tablet 15 MG (Morphine Sulfate) Give 1 tablet by mouth every 8 hours for pain for 2 days. Administered on [DATE] at 9:15 PM. g. Gabapentin Capsule 300 MG Give 1 capsule by mouth three times a day for nerve pain. Administered on [DATE] at 10:06 PM. It should be noted that 2 doses of Gabapentin were administered within 52 minutes of each other. Resident 67's vital signs were reviewed. On [DATE] at 11:34 PM, resident 67's oxygen was documented to be 92% via nasal cannula. On [DATE] at 5:44 AM, resident 67's oxygen was documented to be 77% nasal cannula. Resident 67's progress notes revealed: a. On [DATE] at 2:45 AM, Resident was not able to hold his pills or put them in his mouth. Nurse had to put pills in Resident's mouth this evening. He was having difficulty staying awake, his appearance was gray, skin was cold and clammy, confusion, gurgling sound when breathing, and had trouble keeping O2 sats (saturation) above 90%. MD called, and orders given to hold morning morphine to see if Resident wakes up and is more responsive. b. On [DATE] at 4:37 AM, Occurrence Report; Vitals; [blood pressure] ,d+[DATE], [heart rate] 62, [respirations] 18, [temperature] 98.9, [saturations] 100% RA [room air]. Resident is on occurrence charting for UWF [Unwitnessed Fall] with no injuries and change in condition r/t pain. Resident continues with c/o [complains of] pain with a ,d+[DATE], PRN pain medications have been effective. Resident has no new injures [sic] noted. He is asleep and call light is within reach. c. On [DATE] at 6:58 AM, Follow-up on [Resident 67's] condition: The CNA's [Certified Nursing Assistant] went into Resident's room to move him from the recliner to his bed to change him. Nurse called in and resident was more awake but unable to voice his needs. He has SOB [shortness of breath], sats were 72% via NC on 2L, skin color was gray with blue around the lips, extreme weakness, loud gurgling, and loud moaning. Skin was clammy and cool to the touch. Resident was suctioned to help him breath. Turned O2 up and called MD. MD said to send to [Hospital name redacted] ER [emergency room ]. Handed to the EMS [emergency medical services] transportation people. d. On [DATE] at 7:18 AM, This nurse assisted NOC [night] floor nurse with sending [resident 67] out to hospital. Floor nurse reported [resident 67] was having increased confusion, SOB and was desating [sic]. [Resident 67] had audible secretions and day shift nurse was assisting with suctioning him. [Resident 67] is a full code per his POSLT [Physician's Order for Life Sustaining Treatment] and NP [Nurse Practitioner] [Name redacted] ordered for [resident 67] to be sent out. [Resident 67] wished to be sent to [hospital name redacted] ER. NOC floor nurse attempted to reach family and left VM[voice mail]. POLST, SBAR [Situation, Background, Assessment, Recommendation], Transfer form, NP order, infection form was sent out with res [resident] and faxed to [hospital name redacted] ER. [Resident 67] was transported by EMS at approximately 0630 [6:30 AM]. Bed hold policy was verbally explained to [resident 67] but he was unable to sign it. Will go over when we are able to get in contact with family. NOC floor nurse gave report to ER. DON [Director of Nursing] notified. On [DATE], the hospital history and physical revealed, Chief complaint: pt [patient] found with altered LOC [level of consciousness], hypoxia, overdose, narcan given en route, placed on bipap via ems from [facility name redacted]. History of present illness: Was here in our ED [emergency department] 2 days ago for back pain and got prescribed hydrocodone 5 mg QID (four times daily) PRN. Reportedly he's already getting morphine at [facility name redacted] nursing home. Today he was found by staff and thought to be dead but he was revived with oxygen and Naloxone and brought to the ED. He got very agitated with the 2 mg of Naloxone give by EMS. So on arrival he got 25 mcg [micrograms] of fentanyl. He got 4 mg of IV [Intravenous] morphine for his MRI [Magnetic Resonance Imagine]. Since then he's had some restlessness but more recently he's gotten progressively lethargic. He has been very gurgly and required a lot of suctioning. He can't provide history .Vitals & Measurements: T [temperature] 36.9 [36XXX,d+[DATE].3] HR [heart rate] 79 [,d+[DATE]] BP [Blood Pressure],d+[DATE] [100-,d+[DATE]-110] RR [respiratory rate] 7 [,d+[DATE]] O 2 sat 96 6L Nasal cannula (,d+[DATE]) .General: Obtunded but then suddenly wakes up and stares speechless, obese, disheveled .Assessment/plan: 1. Opioid poisoning-Appears to have taken more than opioid and in the setting of severe renal disease he didn't clear it well and thus #2. Start Naloxone drip to titrate to acceptable balance of agitation and sedation. Monitor closely for complications. 2. Toxic metabolic encephalopathy-Due to #1 and #3 and #6. Hold sedating meds [medications] and try to improve renal function. 3. Acute hypercapnic respiratory failure-Likely due to #1 combined with #19. Given his low GCS [glascow coma scale] NIPPV [Noninvasive positive pressure ventilation] would be unsafe. If his airway cannot be made safe with Naloxone then intubation will be needed .6. Acute nontraumatic kidney injury-Suspect poor oral intake in setting of #1 and #2 on top of ACEI [angiotensin-converting enzyme inhibitors] and diuretic use. IV hydration and hold ACEI and diuretic .19. Morbid obesity-Increases risk of respiratory failure .Two Midnight Documentation (inpatients only)-This patient requires inpatient admission in pursue urgent management of new severe, life threatening condition complicated by chronic comorbidities that require close monitoring and IV fluids and airway/respiratory support. This is expected to require that the patient stay at least 2 nights in the hospital (including ED time) to ensure sufficient improvement in mental status and renal function to permit discharge. On [DATE] at 1:44 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1 who stated resident 67 was A/O (alert and oriented) x 4 (person, place time and situation). LPN 1 stated resident 67 got alcohol 5 days per week (Saturday, Sunday, Monday, Tuesday, and Wednesday). LPN 1 stated resident 67 often asked for the alcohol. LPN 1 stated resident 67 had to wait 2 hours after consuming alcohol before he could take his medications. When asked what the signs and symptoms of an opioid medication overdose were, LPN 1 stated the resident would get despondent, rock back and forth, and it would not be clear about what he was saying. LPN 1 stated there would be breathing changes, oxygen saturation would fall, and the resident would not make sense. When asked about Morphine, LPN 1 stated, Morphine helps with breathing. LPN 1 stated alcohol relaxed someone. LPN 1 stated resident 67 was also taking Ativan and that was why he took his drugs 2 hours from consuming alcohol. LPN 1 stated resident 67 would frequently leave the facility with family and come back intoxicated. LPN 1 stated a few month prior, resident 67 was drinking more and more. LPN 1 stated she was unsure if morphine decreased the respiratory drive. LPN 1 was asked about the progress note she had written on [DATE] at 2:45 AM, about putting pills in the resident's mouth. LPN 1 stated resident 67 had been out with his son and been drinking alcohol. LPN 1 stated by the evening, resident 67 could not put pills in his mouth or walk to his room. LPN 1 stated resident 67 told her he felt really woozy. LPN 1 stated she had to put the pills in his mouth to help him get them down. LPN 1 stated she did not know if morphine was included in the pills that were given. LPN 1 stated she would say resident 67 was having a change in his condition. LPN 1 stated after she assisted resident 67 in taking his pills she checked his vital signs because he was taking heart medication. LPN 1 stated she wanted to be sure resident 67's oxygen level was above 90%. LPN 1 stated resident 67 had standing orders for oxygen and to elevate his legs if his oxygen was below 90%. LPN 1 was asked about the the progress note written on [DATE] at 6:58 AM. LPN 1 stated she did not know how much additional oxygen resident 67 was given. LPN 1 stated she thinks she would have documented it and it would be in a progress note. LPN 1 stated the resident's oxygen should be checked every 15 minutes after turning the oxygen up and the oxygen level should be documented in a progress note or in the vital signs. LPN 1 stated if a resident had a change in condition she should notify the doctor and the night supervisor. LPN 1 stated resident 67 was his own responsible party so he would let them know if they should notify his family. On [DATE] at 3:12 PM, an interview was conducted with LPN 4 who stated on the morning of [DATE], she had just come on shift and did not know resident 67's baseline. LPN 4 stated she was told resident 67's oxygen was low. LPN 4 stated she remembered that resident 67 was not typically on oxygen. LPN 4 stated resident 67 had a change in his level of consciousness. LPN 4 stated resident 67 was lethargic and tired, had changed a narcotic he was taking and she thought he had taken too much. LPN 4 stated she was not told about resident 67 having any alcohol intake. LPN 4 stated LPN 1 told her she gave resident 67 his night medications and he was able to answer questions. LPN 4 stated providing medications was unsafe if the resident could not answer questions, stay awake, continue a sentence or follow a simple command. LPN 4 stated if a resident had a change in condition she would take the resident's vital signs, look to see if the resident was being treated for an infection, look at the medications they were taking, look to see if there had been a medication change or if the resident had been given a PRN dose of a medication. LPN 4 stated any time a resident had a change in condition the physician should be notified. LPN 4 stated if she did not feel it was safe to administer medications, she would notify the provider that she was holding the medications. LPN 4 stated when she arrived to work it was already a hectic situation. LPN 4 stated she was a supervisor and did not know the resident. LPN 4 stated she was helping with the paperwork and the day nurse was with resident 67. LPN 4 stated the night nurse had already called 911 because she felt there was not time to wait and that resident 67 should get to the hospital. LPN 4 stated resident 67's eyes were open and he was able to answer questions. LPN 4 stated she vaguely remembered being told that resident 67 had to be suctioned so he could breathe. LPN 4 stated that morphine can be given when a resident was on hospice and it would help with shortness of breath. LPN 4 stated receiving too much morphine could suppress the respiratory system, and if overdosed, breathing would be much less. LPN 4 stated if respirations dropped below 8 the staff would intervene. LPN 4 stated if a resident had a change in condition, the nurse would write a progress note and do an evaluation. LPN 4 stated there was an SBAR, emergency room transfer form, and an e-interact form to document the resident's baseline. LPN 4 stated sometimes that does not always happen. On [DATE] at 3:30 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated the facility did not have a policy and procedure regarding resident overdose. On [DATE] at 1:15 PM, an interview was conducted with Unit Manager (UM) 1 who stated if a resident took pills while in an altered condition they could choke. UM 1 stated resident 67 had been put on morphine for pain related to a previous fall. UM 1 stated resident 67 had been given 2 administrations of rum on [DATE], but had not been given any on [DATE]. UM 1 stated most nurses document when a resident takes a leave of absence (LOA). UM 1 stated LOA forms were scanned into the resident electronic medical record. UM 1 stated she remembered resident 67 would go out and drink with his son, come back drunk, and then want more rum. UM 1 stated LPN 1 should have used her nursing skills and not provided medication to resident 67. UM 1 stated if resident 67 was provided medications as the orders were written he should not have overdosed. UM 1 stated she did not know how alcohol and Morphine interact. UM 1 stated resident 67 had crappy kidneys and was preparing to go on dialysis. On [DATE] at 6:28 AM, a second interview was conducted with LPN 1. LPN 1 stated resident 67 could not put the pills in his mouth so she put them in and gave him some water. LPN 1 stated often, resident 67 would talk with the staff in the evenings. LPN 1 stated resident 67 had been out with his son and he told her that he had a couple more drinks. LPN 1 stated the doctor had told the staff that if resident 67 asks for a drink they should give it to him. LPN 1 stated resident 67 said he was not feeling the best. LPN 1 stated resident 67's vital signs were normal and he wanted to go and lay down. LPN 1 stated during the night of [DATE], resident 67 tanked and they sent him out. LPN 1 stated resident 67 had the ability to sign himself out. LPN 1 stated resident 67 would meet his son at the front door. LPN 1 stated staff were not supposed to ask if a resident had been drinking. LPN 1 stated resident 67 had been telling her what a good time he had with his son. LPN 1 stated if they were aware that a resident had been drinking staff should wait 2 hours before providing pills. LPN 1 stated if resident 67 has taken his medication, he will ask for the alcohol later. LPN 1 was asked if a resident had more to drink than usual, if the 2 hour window was still appropriate. LPN 1 stated it should have been a longer window. LPN 1 stated she would go by the time the resident returned to the facility. LPN 1 stated resident 67's kidney function could have had an effect on processing his medication as it was compromised. LPN 1 stated after resident 67 went to the hospital the doctor told him he should not drink. LPN 1 stated nobody told her the outcome of resident 67's hospitalization on [DATE]. LPN 1 was asked if it was safe to put pills in resident 67's mouth if he had been drinking. LPN 1 stated resident 67 said he still wanted the medications. LPN 1 stated the resident has the right to take his medication. LPN 1 stated resident 67 normally took his medications, but in this occasion he stated he needed help putting the pills in his mouth. LPN 1 stated resident 67 took Melatonin, Prazosin, and one other medication at night. LPN 1 stated she had no other recollections about additional information related this occurrence. LPN 1 stated they did not do a change in condition because it was a new process that was put in place to correct something. LPN 1 stated there was a paper for occurrence charting and another for a change in condition monitoring. LPN 1 stated the change took place last year and it was just a note. On [DATE] at 12:12 PM, a follow-up interview was conducted with UM 1 who stated she thought LPN 1 had mis-remembered about resident 67 going out drinking with his son because there was no documentation that he had signed out of the building. UM 1 stated staff should be making sure that residents sign out if they were leaving the facility. UM 1 stated staff were educated after this event occurred. UM 1 stated a progress note on [DATE] clearly stated that resident 67 was intoxicated and he should have been monitored. UM 1 stated resident 67 had an unwitnessed fall on [DATE] and was screaming in pain, so neuro checks were started, vital signs were taken, resident 67 rated his pain as ,d+[DATE] and was unable to sit up or transfer back to bed. UM 1 stated resident 67 had a small abrasion on his head. UM 1 stated the NP was contacted and gave an order to send resident 67 to the ER. UM 1 stated resident 67's son was also notified. UM 1 stated information was sent with the paramedics. UM 1 stated resident 67 returned from the ER with orders for Morphine. UM 1 stated resident 67 continued to complain of pain in both hips so x-rays were ordered, and an EKG (Electrocardiogram). UM 1 stated resident 67 received a shot of rum at 3:08 PM on [DATE], and a second shot at 9:45 PM. UM 1 stated the MD saw resident 67 on [DATE] at 9:42 AM and reviewed his medications, his stage 5 kidney disease, and addressed his hip and flank pain. UM 1 stated at that time, resident 67's vital signs were stable, he was alert and in no distress. UM stated resident 67 was having a good response to his pain medications and the provider gave an order to decrease the morphine from TID (three times daily) to BID after the TID order expired on [DATE]. UM 1 stated it was possible that resident 67 took a leave of absence and did not sign out. UM 1 stated she provided training because she was unable to complete write-ups on staff. UM 1 stated there should have been more documentation of monitoring resident 67's change in condition. UM 1 stated nurses should not be putting medications into resident's mouths. 2. Resident 77 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included paroxysmal atrial fibrillation, paranoid schizophrenia, metabolic encephalopathy, acute respiratory failure with hypoxia, major depressive disorder, other mixed anxiety disorders, type 2 diabetes, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. Resident 77's medical record was reviewed between [DATE] through [DATE]. A Quarterly MDS revealed resident 77 had a BIMS score of 13, indicating the resident was cognitively intact. Physician orders included, 02 via nc at ,d+[DATE] lpm (liters per minute) to keep sats >90%. A radiology report signed on [DATE] at 4:12 AM revealed, CHEST 1 VIEW; chest, single view .Findings: The cardiomediastinal silhouette is mildly prominent. Pulmonary vascularity is unremarkable. There is opacification of bilateral hemidiaphragms with moderate predominantly bibasilar patchy densities, left greater than right, compatible with pneumonia. There is blunting of bilateral costophrenic angles with small pleural effusions. The bony mineralization is mildly decreased. Mild degenerative changes are noted in the gleno-humeral joints. IMPRESSION: 1. Opacification of bilateral hemidiaphragms with moderate patchy predominantly bibasilar densities, left greater than right, compatible with pneumonia. Small bilateral pleural effusions. Follow up CXR suggested. 2. Mild cardiomegaly. 3. Mild osteopenia, 4. Mild osteoarthritis demonstrated. Resident 77's care plan included: a. [Resident 77] has altered cardiovascular status r/t paroxysmal atrial fibrillation, acute respiratory failure with hypoxia, chronic kidney disease stage 2, chronic obstructive pulmonary disease, long term use of anticoagulants, type 2 diabetes mellitus with other specified complication. The goal was, [Resident 77] will be free from untreated complications of cardiac problems through the review date. Interventions included, Administer cardiac medications as ordered .Monitor/document/report PRN any s/sx of CAD [coronary artery disease]: chest pain or pressure especially with activity, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema, changes in cap [capillary] refill, color/warmth of extremities .Obtain vital signs per facility protocol and record. Notify MD of significant abnormalities, Oxygen settings O2 via nasal cannula as prescribed and PRN. Date initiated [DATE]. b. [Resident 77] has respiratory alterations r/t paroxysmal atrial fibrillation, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and Gastroesophageal Reflux Disease [GERD] without esophagitis. The goal was, [Resident 77] not experience any untreated s/sx of poor oxygen absorption through the review date. Interventions included, Encourage or assist with locomotion as indicated .[Resident 77] is on oxygen per NC [nasal cannula] as prescribed .Monitor for s/sx of respiratory distress and report to MD PRN: Respiration; increased heart rate; diaphoresis; headaches; lethargy; atelectasis; hemoptysis; cough; pleuritic pain; accessory muscle usage; skin color changes .Promote lung expansion and improve air exchange by positioning with proper body alignment. Encourage head of bed to be elevated to 30 to 45 degrees .Refer to MD as needed. Progress notes revealed: a. On [DATE] at 7:04 PM, Called into room by CNA who indicated that the resident did not look good. O2 sat checked- on 3 L only at 84%. Increased O2 to 5L and O2 only increased to 85%. Breathing treatment given per schedule and an additional prn dose also given. The resident remained on 5L n/c after the treatment and was only sating ,d+[DATE]%. Dr. [physician name removed] notified and received order for stat [without delay] CXR [chest x-ray] and a dose of Lasix 40 mg x1. Changed out the resident's concentrator as the other had a faulty filter. Information given to night nurse and supervisor. It should be noted that when the medical record was reviewed on [DATE] at 8:15 AM, there was no additional documentation after the [DATE] 7:00 PM entry in resident 77's progress notes. b. On [DATE] at 8:50 AM, STAT CXR results received this morning. Results: impression: 1. Opacification of bilateral hemidiaphragms with moderate patchy predominantly bibasilar densities, left greater than right, compatible with pneumonia. Small bilateral pleural effusions. Follow up CXR suggested. 2. Mild cardiomegaly. 3. Mild osteopenia. 4. Mild osteoarthritis demonstrated. Electronically signed by [physician name redacted] [DATE] 0412 [4:12 AM]. MD notified of results, gave new order for Levaquin 500 mg QD [daily] x 7 days. Order for acidophilus 1 capsule TID x 10 days also implemented per facility protocol. Resident is his own responsibility party and was notified of CXR results and new abx [antibiotic] order. First dose pulled from Omnicell and given at 0910 [9:10 AM]. Infection prevention RN [registered nurse] notified. Floor nurse notified to start resident on infection charting. TO: [treatment order]: Levaquin Oral Tablet 500 mg [Levofloxacin] Give 500 mg PO [by mouth] one time only for pneumonia for 1 day AND Give 500 mg PO QD for Pneumonia for 6 Administrations. TO: Acidophilus Oral Capsule (Lactobacillus) Give 1 capsule PO TID for Abx Use for 30 Administrations. On [DATE] at 8:41 AM, an interview was conducted with Licensed Practical Nurse (LPN) 5 who stated resident 77 was doing better. LPN 5 stated the STAT x-ray was completed at about 11:00 PM on [DATE]. LPN 5 stated resident 77's change in condition was happening about the time of shift change on [DATE] so she stayed to help prepare paperwork. LPN 5 stated the night nurse should have written a progress note after the x-ray was completed and what the result was. On [DATE] at 9:24 AM, an interview was conducted with Certified Nursing Aide 1 who stated resident 77's cognition was gradually decreasing and he was pretty sleepy a lot of the time. CNA 1 stated in the mornings, the nurse on duty completed vital signs on the resident. CNA 1 stated CNA's could complete vital signs if requested. CNA 1 stated for the afternoon shift, the CNA's checked resident vital signs as soon as they came on shift. CNA 1 stated resident 77's oxygen has been low recently. CNA 1 stated resident 77 required an increase in oxygen to keep his saturations above 90 percent. CNA 1 stated he learned of resident 77's drop in oxygen level this morning when he arrived at work. CNA 1 stated if he noticed a resident's oxygen saturations were low, he would notify the nurse before making a change to the oxygen. CNA 1 stated if a resident has had lower oxygen levels, the nurse would request the CNA check saturations more frequently. On [DATE] at 12:57 PM, an interview was conducted with UM 1 who stated a change in condition could be anything that was completely different from the resident's normal behavior or level of cognition. UM 1 stated lethargy was something staff looked for. UM 1 stated if the oxygen saturation was consistently low, it could be a change in condition. UM 1 stated if there was a respiratory problem, that could be a change in condition. UM 1 stated if there was concern for a change in condition, the nurse should do a full assessment and try to determine why the oxygen saturation was low. UM 1 stated a respiratory assessment should also be conducted if the resident was using oxygen. UM 1 stated the medical provider should be contacted for guidance. UM 1 stated the facility had focused assessment guidance for what to do and what kind of information the provider would need. UM 1 stated that with each assessment, the nurse should take the next steps in contacting the physician. UM 1 stated that during the night her expectation would be that the nurse on duty should check on the resident. UM 1 pulled up resident 77's medical record and acknowledged that there was no documentation stating that resident 77's oxygen level had improved with the interventions in place. UM 1 stated it appeared that no follow-up had been done during the night on resident 77 and the nurse on duty should document what was monitored. On [DATE] at 6:23 AM, an interview was conducted with LPN 1 who stated she got a report on resident 77 and a chest x-ray was ordered. LPN 1 stated radiology did not come until almost midnight. LPN 1 stated resident 77 was monitored through the night on [DATE]. LPN 1 stated the staff put resident 77 on an oxygen tank and a nasal cannula because his oxygen concentrator was not working correctly. LPN 1 stated she did not document in the resident's medical record the monitoring that was done. LPN 1 stated she was not told to document the resident's vital signs in the computer. LPN 1 stated resident 77's last oxygen reading was 97% at 5:00 AM. LPN 1 stated there was no order from the doctor to monitor resident 77's oxygen levels. LPN 1 stated the process for a change in condition was there was a paper that was supposed to be filled out. LPN 1 stated the nurse on duty before her had a paper, and she was told to check resident 77's oxygen a few times during the night to make sure it was above 90%. LPN 1 stated the nurse on duty was supposed to put in a progress note. LPN 1 stated she usually put one in, especially if there was a change in condition. LPN 1 stated she would probably have considered the incident on [DATE] a change in condition.

Based on interview and record review it was determined, for 2 of 38 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident was unable to provide verbal pain scores. The resident sustained a fall and an x-ray was not obtained for 15 days with revealed the resident sustained an L2 fracture. In addition, another resident had pain medication that was documented as ineffective and there was no follow-up. Resident identifiers: 77 and 78. Findings include: 1. Resident 78 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to occlusion or stenosis of small artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, dementia, stable burst fracture of second lumbar vertebra, and spinal stenosis. On 7/29/24 at 11:17 AM, an interview was conducted with resident 78's family member. Resident 78's family member stated resident 78 sustained falls prior to admission. Resident 78's family member stated the only issue with the facility was resident 78 fell in the bathroom. Resident 78's family member reported the fall was reported to them immediately and staff reported resident 78 did not have pain. Resident 78's family member stated when they came to the facility and resident 78 complained of pain in his right hip and was rubbing it with some grimacing. Resident 78's family member stated the next day it was reported that resident 78 was complaining of back pain. Resident 78's family member stated about a week later they got a call that resident 78 was being aggressive and they wanted to try a mood stabilizer. Resident 78's family member stated they asked the staff to obtain an x-ray and a urine analysis. Resident 78's family member stated resident 78 had x-ray and he had something wrong with his spine. Resident 78's family member stated they talked with Unit Manager (UM) 1 about resident 78 not getting an x-ray sooner and UM 1 stated that was a mistake by the facility. Resident 78's medical record was reviewed 7/29/24 through 8/7/24. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 78 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. The MDS revealed resident 78 was administered scheduled and as needed pain medication. The MDS revealed that resident 78 was not provided non-pharmalogical interventions for pain. The MDS further revealed that a resident pain interview was conducted. The next section revealed resident 78 was unable to answer if he had the presence of pain. The MDS revealed resident had a fall since admission with an injury. A care plan dated 11/30/23 revealed [Resident 78] has UNDESIRABLE BEHAVIORS as evidenced by wandering, verbal and physical aggression, rejection of cares r/t [related to] Moderate dementia with agitation, MDD [major depressive disorder], insomnia, anxiety disorder 1/12/24 - Resident to Resident Altercation 1/27/24 - Resident to resident altercation 2/8/24 - Resident to Resident altercation 3/6/24 - Resident to Resident Altercation 6/20/24 - Resident to Resident Altercation The goals were [Resident 78's] safety will be maintained daily and he will not experience elopement through the next review and [Resident 78] will not harm others or be harmed by others QD [every day] TNR [through next review] One of the interventions dated 1/29/24 revealed, Ensure pain is addressed. Another care plan dated 11/14/23 revealed [Resident 78] is at RISK for UNCONTROLLED PAIN r/t Cerebral infarction, Moderate dementia with agitation, pain, migraines, old myocardial infarction, MDD, insomnia, anxiety disorder. The goal was [Resident 78] will not have an interruption in normal activities due to pain through the review date. Interventions included Administer analgesia as per orders; Anticipate [resident 78's] need for pain relief and respond immediately to any complaint of pain; Monitor/record pain Severity (1 to 10 scale) every shift and PRN [as needed]; Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment; Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; and Offer and assist with non-pharmacological interventions for complaints of pain (ie: rest/reposition, heat/ice, massage, sensory stimulation, distraction, etc.). Resident 78's progress notes revealed on 1/25/24 at 1:58 PM, Initial occurrence VS [vital signs] 97.4 [temperature], 51 [heart rate], 18 [respirations], 108/68 [blood pressure]. This nurse was called into residents' room by CNA [Certified Nursing Assistant]. Per CNA resident was being assisted with a shower, as she was finishing and drying the floor resident had his crocs on, attempted to stand and hit a wet spot before CNA could get to that area, resident fell on his behind falling against the plastic shower chair. Back and lower back of his head hit shower chair. When this nurse arrived CNAs had gotten resident up and was ambulating back to his bed. [NAME] [sic] was steady with no issues or pain noted. Assessed for pain or injuries once in bed, ROM [range of motion] is intact per baseline. Assessed leg length, no issues. No injuries present, some redness to bottom however likely due to sitting on shower chair due to area forming a circular design similar to shower chair. Hand grasps equal, A/O [alert and oriented] per baseline. L [left] pupil is reactive, R [right] pupil is enlarged and sluggish. Contacted POA [power of attorney] regarding fall and pupil, per POA pupil to L eye occurred following most recent stroke. Hospital was aware and assessed, nothing new came of it. Placed on NPs [Nurse Practitioner] list to be assessed Friday due to POA having concern that this may not be a normal stroke occurrence. Stated she was OK to wait until NP comes in due to having this issue upon arrival with no changes noted. No further concerns present. Will follow up as needed [POA name removed] aware, MD aware, placed on incident charting as well as neuro checks. No further issues noted, will follow up as needed. A progress note dated 1/26/24 at 8:51 AM, Resident complains of lower back pain. New order per house standing orders: Acetaminophen 650mg [miligrams] PO [orally] Q [every] 6 hrs [hours] PRN [as needed] NTE [not to exceed] 3G [grams] in 24 hours. A physician's order dated 1/26/24 and discontinued on 2/8/24 revealed Acetaminophen Oral tablet 650 mg by mouth every 6 hours as needed for pain. Resident 78's January 2024 Medication Administration Record (MAR) revealed on 1/26/24 at 9:00 AM resident had a pain score of 8 out of 10, on 1/26/24 at 4:36 PM a pain score of 6 and on 1/27/24 at 7:21 AM pain score of 5. A progress note dated 1/26/24 at 5:28 PM, .He has complaints of some back pain today. PRN Acetaminophen administered with reported good effect . A progress note dated 1/27/24 at 10:42 AM, .Resident stating that PRN APAP [acetaminophen] has not been managing pain effectively. New order Ibuprofen 400 mg Q 8h PRN for pain. POA and MD notified. A progress note dated 1/27/24 at 2:02 PM, Dietary staff was standing at door to res [resident] room when this nurse walked by. res was standing near his bed and res2 was on floor by the door. This nurse stood by res to keep him away from res2 and noticed bld [sic] on res left hand. Res yelling at res 2. Res stated that res 2 was standing in door and wouldn't let res out of room. res stated res 2 was yelling at res so res hit res 2. Res has cut to left forth finger and bruise to left 3rd finger. Cut cleansed and bandage applied. A progress note dated 1/27/24 at 2:51 PM, .Resident on charting for witnessed fall on 1/25. Resident has been endorsing back pain this shift unrelieved by APAP. No other s/s [signs and symptoms] injury observed. New order for ibuprofen added. Shoes or nonskid socks on AAT [at all times]. Ensuring pain is managed and needs are met. A progress note dated 2/2/24 at 3:17 PM, [Resident 78's] fall on 1/25 was reviewed in antigravity on 1/30/24. [Resident 78] was in the shower, assisted by CNA. He slipped on a wet spot on the floor standing up from the shower chair. No injuries noted at the time of occurrence, but [resident 78] later c/o [complained of] of [sic] back pain. PRN Ibuprofen was given over the course of 5-7 days. Staff reports it was effective with pain management and that he no longer has complaints of back pain. Grip tape was place [sic] in bathroom outside of shower. A progress note dated 2/2/24 at 4:06 PM, This am at breakfast res starting yelling and swearing at male residents at a different table. Res was taken into the dayroom by RNA [Restorative Nurses Aide] who had res sit at table for breakfast. Once res sat down he flipped off the res at the other table. RNA stayed with res until he calmed down. Will continue to monitor behaviors. A progress note dated 2/3/24 at 3:17 PM, Refused 2 or more meals in the day. Nurse to document and start supplements. If continues, consult Registered Dietitian. Res ate snacks and is able to let staff know when he is hungry. A progress note dated 2/8/24 at 10:19 AM, Occurrence charting Physical aggression received. This nurse heard res yelling in dining room. This nurse and CNA split residents apart and had res leave dining room. Res 2 was going into dining room to sit at his normal table where Res was sitting sideways in a chair. Res 2 pushed res chair to the side and toward table. This upset res who stood up and slapped res 2 in face. Res 2 stated that it didn't hurt, he was fine and didn't really feel anything. Res stated that Res 2 pushed him, so res stood up and hit res 2. This nurse talked with res about what happened and asked that if res has something happen that he doesn't like to come to a staff member. Dgtr [daughter] [name removed] notified who stated she would talk with SSW [Social Service Worker] next week at the res care conference. A progress note dated 2/8/24 at 11:36 AM, This nurse spoke with [physician name removed]. [Physician's name] regarding [resident 78]'s recent mood swings from very happy to very angry rapidly that resulted in a few resident to resident occurrences and regarding possible unaddressed pain due to [resident 78] not always being able to communicate his needs effectively. [Physician's name] recommended changing PRN acetaminophen to 650mg PO BID [twice daily] for pain and starting Depakote125 mg PO BID to help with mood swings. This nurse spoke with daughter [name removed] regarding MD recommendations. [Name removed] is agreeable to scheduling acetaminophen. She would like to have some time to research possible adverse effects of Depakote as to make an educated decision regarding a mood stabilizer medication for her dad. She has had issues with prior facilities and administering medications without notifying her of adverse reactions that have occurred. This nurse educated [name removed] regarding facility psychotropic protocol including monitors each shift for possible adverse effects of medications and quarterly psychotropic meetings . No further concerns at this time. New order: Acetaminophen 650mg PO BID for pain. Keep PRN dose as ordered. Resident 78's February 2024 MAR revealed a physician's order for Acetaminophen give 650 mg by mouth two times a day related to pain. In addition, Acetaminophen 650 mg administer every 6 hours as needed for pain was administered on 2/9/24 with a pain score of 7 and it was ineffective. A social services note dated 2/8/24 at 3:19 PM, .[Family member] then went on to discuss Depakote, pain,and [resident 78's] aggression She also requested that [resident 78] be tested for a UTI [urinary tract infection] and get an xray of the hip he most recently fell on to rule out infection and fracture as the causes of aggression . A progress note dated 2/8/24 at 3:32 PM, This nurse spoke with [name of physician] regarding Daughter [name removed] request for an x-ray and UA [urine analysis]. [Name of Physician] is agreeable to x-ray and UA. New orders: 1- Lumbar x-ray 2-AP and Lateral Pelvis x-rays 3-UA with culture and sensitivity if indicated . A progress note dated 2/9/24 at 1:46 AM, X-ray results of lumbar spine show compression fracture of T10, T9, and L2. On call NP notified by floor nurse at approx 0135 [1:35 PM] of results, NP ordered a referral to neuro surgeon. Rn supervisor notified Administrator of new fx [fracture] findings at 0137 [1:37 AM]. Daughter notified of xray result at 0145 [1:45 AM] by night floor nurse, answering questions and educating her on process for setting up appt [appointment] for referral. res has been denying pain, but does groan and grimace when getting self from lying to standing position. res has prn Tylenol and ibuprofen for treatment of pain. res has been ambulatory without assistance. res was offered pain meds tonight but refused them. will cont to monitor. A nursing note dated 2/9/24 at 5:18 AM, .Resident on charting d/t [due to] being recipient of physical aggression from another resident. Resident responded with aggression himself. Resident has been in good mood this shift. No agitation or aggression noted this shift. Resident denies pain but s/sx of 2/10 pain noted while this nurse was assessing resident. Resident was moaning as he lifted self from laying to sitting position. Resident had x-ray results returned this shift . A nursing note dated 2/9/24 at 3:44 PM, NP [name removed] ordered the following. 1- tramadol 50mg PO TID [three times a day] PRN as needed for pain 2- Thoracic and lumbar spine MRI without contrast related to fractures Residents daughter notified of new orders. A Physician/Practitioner note dated 2/13/24 at 12:39 PM, Asked to see patient to evaluate his lumbar compression fractures. Patient has had recurrent falls both before he was admitted and has had some since. Patient states that he has had chronic back pain. He states that his pain is no worse now than it was before. It is been well managed. He has had x-ray that show compression fractures of unknown age and recommend CT scan .Musculoskeletal: Some mild tenderness with percussion of his thoracic and lumbar spine. Assessment/plan Compression fractures: Patient has had x-rays showing age indeterminate compression fractures. These could be from prior to admission or since admission. He has not noticed any change in his pain. He has had falls. Will obtain a CT scan for better evaluation. Will also get a DEXA bone scan. By a definition with compression fractures he does. Have some osteoporosis if were osteopenia at least. A nursing progress note dated 2/13/24 at 2:44 PM, TO [telephone order]: CT [computed tomography] for thoracic, lumbar spine. Per [Physician's name],MD. for compression fractures to T9, T10, L2. Signed order, facesheet faxed to [local hospital] Imaging on 2/13/24. Appointment was then scheduled for Wednesday,February 21, 2024 at 3:30pm . On 7/31/24 at 9:38 AM, an interview was conducted with CNA 2. CNA 2 stated she was assisting resident 78 with a shower on 1/25/24 when he dropped a rag and stepped on to the floor and fell down. CNA 2 stated she was in resident 78's room to grab his clothing because resident 78 was able to shower independently. CNA 2 stated resident 78 has a shower bench but refuses to sit when showers. CNA 2 stated she was able to see resident 78 but was unable to get to resident quick enough before he fell backwards into a sitting position. CNA 2 stated resident 78 hit the lower back on the ground. CNA 2 stated resident complained of pain to his privates. CNA 2 stated there were no increased complaints of pain that day. CNA 2 stated with resident 78's personality, she was not sure if he would ever tell staff he was in pain. CNA 2 stated resident 78 had the tough guy personality and it was tough to know when he was in pain. CNA 2 stated when resident 78 was in pain, he slept more or laid down more. On 7/31/24 at 9:07 AM, an interview was conducted with LPN 7. LPN 7 stated resident 78 would not tell staff if something hurts or if he was in pain. LPN 7 stated staff ask him daily about pain. LPN 7 stated each resident has a pain evaluation completed daily. LPN 7 stated resident 78 had complained of his back being sore. LPN 7 stated that if staff ask resident 78 if he is in pain he will say no, but if staff ask about a specific area of his body he will report pain. On 7/31/24 at 9:19 AM, an interview was conducted with RN 4. RN 4 stated staff tried to manage resident 78's pain and he had as needed Tramadol and Tylenol with scheduled Ibuprofen. RN 4 stated she watched resident for non-verbal cues of pain. On 8/1/24 at 10:15 AM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated pain was monitored daily with vital signs for each resident. UM 2 stated after resident 78 sustained a fall on 1/25/24 and then a resident to resident altercation on 1/27/24, resident was started on as needed pain medication. UM 2 stated staff were monitoring to see if the aggression was from increased pain or aggression with dementia. UM 2 stated if staff asked resident 78 if he was in pain, he would say he was fine. UM 2 stated staff were to use a non-verbal pain scare for resident 78 because he moaned and groaned when he was moving but when asked would say he was fine. UM 2 stated as needed Tylenol seamed to work really well. UM 2 stated some nursing staff were recording resident 78's pain as no pain but other staff members were observing non-verbal pain. UM 2 stated resident 78 was cranky, aggressive, moaned, groaned and winced to show he was in pain. UM 2 stated that resident 78 was having pain probably for less than a month after his fall. UM 2 stated the numerical pain scale was not appropriate to use for him. UM 2 stated the she was not not sure if there was education to nurses regarding using the non-verbal pain scale. UM 2 stated CNA's were good at alerting UM's about resident 78's non-verbal pain. UM 2 stated resident 78's pain was discussed in a clinical meeting and an x-ray was ordered after about a week because his pain was not improving. UM 2 stated the clinical meeting would have been documented in the progress notes. UM 2 stated she was unable to find notes about the clinical meeting but the progress notes revealed resident 78's pain was not controlled. UM 2 stated that staff were to get x-rays within 24 to 48 hours after a fall. UM 2 stated resident 78's x-rays were delayed because resident 78 had a history of back pain. UM 2 stated the x-rays should have been completed sooner. On 8/5/24 at 9:00 AM, an interview was conducted with the Administrator. The Administrator stated that resident 78 did not have increased complaints of pain after the fall. The Administrator stated that she was sure the x-ray would come back negative because resident 78 did not appear to be in pain. The Administrator provided pain scores for resident 78. The form revealed that staff were using a numerical system to determine pain verses PAINAD (non-verbal). The form revealed pain from 0 to 8 reported between 1/25/24 through 2/9/24. 43212 2. Resident 77 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which consisted of CHF(congestive heart failure), morbid obesity, PTSD (post traumatic stress disorder), palliative care, insomnia, metabolic disorder, suicide attempt, hypokalemia, obstructive uropathy, anxiety disorder, MDD (Major Depressive Disorder), fusion of spine, pain, HTN (Hypertension), BPH (Benign Prostatic Hypertrophy), and OSA (Obstructive Sleep Apnea). On 7/30/24 at 7:48 AM, an interview was conducted with resident 77. Resident 77 stated he had pain in both knees and he thought the left knee might be broken. Resident 77 stated he had pain in the back and shoulders also. Resident 77 stated that his current level of pain was 8/10. Resident 77 stated that his pain medication did not alleviate his pain. Resident 77 stated that nothing made the pain more tolerable. Resident 77 stated that the facility had tried everything to decrease his pain. Resident 77 stated that he had worked with physical therapy to improve his strength. Resident 77's medical record was reviewed between 7/29/24 and 8/7/24. Resident 77's physician's orders revealed: a. On 5/13/24, Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Milligram per milliliter) (Morphine Sulfate) Give 1 ml by mouth every 1 hours as needed for Pain or SOB (shortness of breath) b. On 3/7/24, Gabapentin Oral Tablet 600 MG (Gabapentin) Give 600 mg by mouth three times a day for chronic pain related to other idiopathic peripheral autonomic neuropathy. c. On 2/20/24, Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth two times a day related to other chronic pain d. On 8/22/23, Acetaminophen Oral Tablet (Acetaminophen) Give 1000 mg by mouth three times a day for pain related to pain. e. On 9/27/22, Question resident about presence of pain or burning including pressure points. Monitor for pain using 0-10 scale. 0 for no pain, 10 for worst pain possible. If resident is not able to answer, use painad scale. Review of the July 2024 MAR revealed that all scheduled pain medication was documented as administered per the physician orders. The as needed Morphine was documented as administered 12 times for the month. It should be noted that the Morphine was ordered Q (every)1 hr as needed. On 7/1/24 at 10:10 PM and on 7/3/24 at 10:28 AM the administration was documented as ineffective. Review of the MAR progress notes revealed the following: a. On 7/1/24 at 12:50 AM, an administration progress note revealed, Note Text: Morphine Sulfate (concentrate) Oral Solution 20 MG/ML(milligrams per milliliter); Give 1 ml by mouth every 1 hours as needed for pain or SOB; PRN Administration was : Ineffective; resident stated pain is still bad; Follow-up Pain Scalel was: 7. It should be noted that no additional doses of pain medication were documented as administered for the ineffective pain relief. b. On 7/3/24 at 10:28 AM, an administration progress note revealed, Note Text: Morphine Sulfate (concentrate) Oral Solution 20 MG/ML; Give 1 ml by mouth every 1 hours as needed for pain or SOB. Reports 10/10 generalized pain. It should be noted that additional doses of pain medication were not administered until 2 hours after the initial administration. c. On 7/3/24 at 12:31 PM, an administration progress note revealed, Note Text: Morphine Sulfate (concentrate) Oral Solution 20 MG/ML; Give 1 ml by mouth every 1 hours as needed for pain or SOB. PRN administration was: Ineffective; Follow-up pain scale was: 10; First dose not effective. Another dose administered. Resident 77's Care Plan revealed, [Resident's name redacted] has a TERMINLA PROGNOSIS r/t CHF, metabolic disorder; Date initiated: 3/8/2024, Revision on: 3/8/2024. The goals were: [Resident 77] comfort will be maintained through the review date. Date initiated: 3/8/2024; Revision on: 3/8/2024; Target Date: 9/2/2024. Interventions included: a. Adjust provision of ADLS [Activities of Daily Living] to compensate for [Resident 77] changing abilities. Encourage participation to the extent [Resident 77] wishes to participate; Date Initiated: 03/08/2024 b. Assess [Resident's name redacted] coping strategies and respect [Resident's name redacted] wishes; Date Initiated: 03/08/2024 c, Contact [Hospice company] @ [phone number]; Date Initiated: 03/08/2024 d. Encourage family and [Resident's name redacted] to attend and participate in IDT [interdisciplinary team] meetings; Date Initiated: 03/08/2024 e. Encourage support system of family and friends; Date Initiated: 03/08/2024 f. Encourage to follow homelike routine, encourage family to provide personal items to increase comfort; Date Initiated: 03/08/2024 g. Encourage visits from family and friends; Date Initiated: 03/08/2024 h. Ensure [Resident 77] comfort and quality of life is met at the highest potential daily; Date Initiated: 03/08/2024 i. Evaluate the need for support services and assist with referral PRN; Date Initiated: 03/08/2024 j. [Resident 77] is on Hospice; Date Initiated: 03/08/2024; Revision on: 03/08/2024 k. [Resident 77] is under the care of Bristol Hospice Services; Date Initiated: 03/08/2024 l. Nursing staff monitor and manage symptoms r/t end of life care and notify hospice when noted. Symptoms such as: changes in pain, nausea, agitation, respiratory concerns, lethargy, vertigo, skin is [resident's name redacted], or infections in order to keep [resident's name redacted] comfortable. Date Initiated: 03/08/2024 m. Observe (Resident 77) closely for signs of pain, administer pain medications as ordered, and notify physician if interventions are unsuccessful or if current complaint is a significant change from [resident's name redacted] past experience of pain. Date Initiated: 03/08/2024 n. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Date Initiated: 03/08/2024 o. Refer to Hospice MD (Medical Doctor) PRN; Date Initiated: 03/08/2024 p. Refer to Social Services PRN; Date Initiated: 03/08/2024 q. The [Name of facility redacted] and [Name of Hospice redacted] will coordinate (Resident 77) cares, medications, and treatments. On 8/7/24 at 8:54 AM, an interview was conducted with LPN 3 who stated resident 77 complained of generalized pain. LPN 3 stated resident 77 had scheduled Morphine and Tylenol. LPN 3 stated depending on his pain, resident 77 had prn morphine also. LPN 3 stated that sometimes resident 77 forget that he had been given his morphine and asked for it again. LPN 3 stated, For the most part his pain is controlled. LPN 3 stated resident 77's hospice provider came to see him, but he did not know how often, maybe every 2 days. LPN 3 stated the hospice RN was at the facility every other day as well. LPN 3 stated that after providing Morphine, the nurse would ask about resident 77's pain, and if the pain medication was not effective they could offer an additional dose. LPN 3 stated if resident 77 was sleeping and comfortable, the pain medication would be considered effective. On 8/7/24 at 1:19 PM, an interview was conducted with LPN 4 who stated she had taken care of resident 77 since he was signed on to hospice services. LPN 4 stated sometimes resident 77 had to take a few doses before the Morphine became effective. LPN 3 stated there were a few times when resident 77 refused his pain medication. LPN 4 stated if resident 77's pain medication was ineffective, she would give a second dose of morphine. LPN 4 stated she remembered there were a couple of times that the dose of Morphine was not effective. LPN 4 stated she would check with resident 77 after half an hour to see if his pain medication was effective.

Based on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: The facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses, Certified Nurses Aides, and the resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Findings include: On 7/29/24 at 8:05 AM, an observation was made of the nursing staff posting which was located inside the facility entry area across from the reception desk. There were 2 days of postings observed: One of the postings was dated 7/14/24, the other was dated 7/15/24, with the 5 being difficult to read legibly. On 8/7/24 at 8:15 AM, an observation was made of the nursing staff posting. One of the postings was dated 8/4/24, the other was dated 8/5/24. On 8/7/24 at 10:53 AM, an interview was conducted with the Certified Nursing Aide Coordinator (CNAC) who stated the night supervisor in the building was responsible for posting the nursing hours. The CNAC stated the information on the postings was different every day based on who was scheduled to work.

Based on observation, interview and record review it was determined that the facility did not ensure that the medication error rates was not 5 percent or greater. Observations of 35 opportunities revealed 2 medication errors which resulted in a 5.71 percent medication error rate. Specifically, a resident was administered thyroid medication not on an empty stomach and an apical pulse was not obtained prior to administering Digoxin. Resident identifier: 24. Findings included: On 7/31/24 at approximately 8:25 AM, an interview was conducted with resident 24. Resident 24 was being administered his morning medication by Licensed Practical Nurse (LPN) 2. Resident 24 stated that he had just finished breakfast and it was his favorite, biscuits and gravy. LPN 2 was observed to administer all morning medications to the resident 24 which included Digoxin tablet 125 micrograms (mcg) by mouth one time a day for atrial fibrillation and Levothyroxine tablet 75 mcg by mouth one time a day for hypothyroidism. Resident 24's physician's orders were reviewed and revealed no supplemental information or hold parameters that were specific to a pulse. The Levothyroxine order documented an administration time of 6:00 AM. On 7/31/24 at 8:31 AM, an interview was conducted with LPN 2. LPN 2 stated that she obtained resident 24's vital signs with the machine and the heart rate was 87. LPN 2 stated that it was safe to administer the medication because the HR was above 60 beats per minute. LPN 2 stated no apical pulse was obtained for the Digoxin. LPN 2 stated that the order did not have instructions to obtain an apical pulse. LPN 2 stated that she should double check with an apical pulse. LPN 2 stated that the Levothyroxine was scheduled to be administered at 6:00 AM, and was administered late. Registered Nurse (RN) 2 stated she was the supervising RN. RN 2 stated that the Levothyroxine should be administered 30 minutes to 1 hour before any other medications or food for better absorption because if it was administered with food or other medication it became less effective. On 7/31/24 at 10:35 AM, an interview was conducted with RN 1. RN 1 stated with Digoxin staff should take an Apical pulse prior to administration. RN 1 stated that the pulse should be checked prior to administration because it lowers the heart rate and the order should say to hold if heart rate is less than 60. RN 1 stated it should be noted that the order did not contain parameters to hold the medication. RN 1 stated that the radial pulse could be different, and apical pulse was more accurate. RN 1 stated that it was a nursing standard of practice to obtain an apical pulse prior to administration of Digoxin. RN 1 stated that the physician ordered the Digoxin because 24 was having his Metoprolol held due to hypotension. On 8/1/24 at 8:39 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that staff should be giving scheduled medication within an hour of the administration time unless a resident requested not to have it at that time. UM 1 stated Levothyroxine should be administered 30 to 60 minutes prior to meals and be given on an empty stomach. UM 1 stated what was why it was scheduled at 6:00 AM and could be administered as late as 7:00 AM. UM 1 stated that resident 24 liked to have all his medication together in the dining room, and it should be on his care plan. UM 1 reviewed the care plan and stated no documentation could be found of the resident preferences with regards to medication administration. The Levothyroxine order was reviewed by UM 1 and she stated that it did not state to administer with other medication. UM 1 stated that the medication should be given on an empty stomach. UM 1 stated that nurses should be taking apical pulse for 30 seconds to 1 minute prior to administration of the Digoxin. UM 1 stated staff were looking for any abnormal or low heart rate prior to administration and if it was within the parameters to administer. Review of the Nursing 2022 Drug Handbook documented that prior to oral administration of Digoxin the nurse was to take a apical-radial pulse for 1 minute. The guidance further stated to notify the prescriber of any significant changes such as sudden increase or decrease in pulse rate, pulse deficit, or irregular beats. Wolter Kluwer. 42nd Edition Nursing 2022 Drug Handbook. 2022, Philadelphia, pp. 436-440.

Based on observation, interview and record review it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, a medication cart was left unlocked and unattended. In addition, medication was available for use past the expiration date. Resident identifiers: 60. Findings include: 1. On 7/31/24 at 7:36 AM, an observation was made of the 200 hallway. Registered Nurse (RN) 6 was observed with a medication cart. RN 6 was observed to unlock her medication cart and walk away from the cart leaving it unattended. RN 6 was interviewed and stated she could not believe she left the cart unlocked and unattended. 2. On 7/31/24 at 9:19 AM, an observation was made of the 200 hallway medication cart. There was a Basaglar kwikpen with an open date of 6/29/24 that was available for use and was labeled for resident 60. Licensed Practical Nurse (LPN) 3 was interviewed and stated the medication should have been discarded. LPN 3 stated the medication was good for 28 days from the time that it was opened. On 8/1/24 at 8:30 AM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated that if a staff member stepped away from the medication cart they should lock the medication cart and lock the computer screen, and no medications should be left sitting out. UM 1 stated the process for checking for expired medications was done by the nurses. UM 1 stated the leadership team conducted random audits. UM 1 stated insulin pens were only good for 28 days from the date of open. UM 1 stated she reminded the staff to check their medication cart monthly for any expired medications, and the central supply staff rotated the over the counter stock. UM 1 stated the Central Supply Clerk should notify the nursing staff of any expired medication in the central supply.

Based on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 7/29/24 at 9:14 AM, an interview was conducted with the DM who stated she was in the middle of getting her certification to serve as the DM. The DM stated she had been doing the job as a DM for [AGE] years, and had been employed at the facility for 2 years. The DM stated another full time kitchen employee ([NAME]) had completed the certification for DM, but was not working in that role. On 8/7/24 at 11:04 AM, a follow-up interview was conducted with the DM who stated it was her understanding that having 2 years of experience as the DM met the requirement to serve as the DM. The DM stated she was taking the required courses, but had to obtain an extension due to a medical concern, and had not yet completed the course. The DM stated the RD conducted a kitchen audit once per month and shared her findings with the DM, the Administrator, the infection control coordinator, and the corporate Dietitian. The DM stated the RD also conducted an audit of one kitchenette area out of the four each month and rotated between them. The DM stated if the RD had findings she would provide her with recommendations. On 8/7/24 at 11:05 AM, an interview was conducted with the [NAME] who stated she had been working at the facility for [AGE] years, but was no longer certified to be a dietary manager.

Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were open to air. Findings include: On 7/29/24 at 9:14 AM, an initial kitchen tour was conducted. In the walk-in freezer a box of peanut butter cookie dough was open to air, a box with egg patties was open to air, a box containing corn on the cob was open to air, a box containing breaded chicken was open to air, and a box containing corn dogs was open to air. On 8/7/24 at 11:04 AM, a follow-up kitchen tour was conducted. In the walk-in refrigerator, a bag of parmesan cheese was open to air. In the walk-in freezer a box of peanut butter cookie dough was open to air, a box with sausage links was open to air, a box with frozen cut corn was open to air, a box with frozen peas was open to air, a box with chicken fried beef patties was open to air, and a box containing corn dogs was open to air. On 8/7/24 at 11:18 AM, an interview was conducted with the Dietary Manager (DM) who stated if food items in the freezer were taken from a box and the box was not emptied, it would be returned to the freezer. The DM stated if there was very little food from that box left it would be wrapped and dated and returned to the freezer or thrown away. The DM stated items in the refrigerator and freezer were checked every day. The DM stated the morning managers checked items in the refrigerator and freezer in the mornings. The DM stated the cooks should be aware if the food items were stored properly. The DM stated that the Registered Dietitian (RD) came to the facility on ce per week, and conducted a kitchen audit once per month. The DM stated if the RD had concerns she would share them with the DM, the administrator, the Infection Control coordinator and the corporate dietitian. The DM stated items left open to air in the refrigerator or freezer could result in freezer burn or contamination and all items should be sealed and dated whether inside the box or outside of the box.

Based on interview and record review it was determined, for 1 of 38 sampled residents, the facility did not ensure each resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident rolled out of a high bed and hit his head on a feeding tube pump. In addition, a family member noticed the change in condition and transported the resident to the hospital. Resident identifier: 119. Findings include: Resident 119 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, Parkinson's disease with dyskinesia, acute kidney failure, dysphagia, muscle weakness, muscle wasting and atrophy, and traumatic subdural hemorrhage without loss of consciousness. Resident 119's medical record was reviewed 7/29/24 through 8/7/24. An admission Minimum Data Set (MDS) dated [DATE] revealed that resident 119 had short and long term memory problems. Resident 119 had severe cognitive impairment with making decisions regarding tasks of daily living. Resident 119 had altered level of consciousness. Resident 119 was dependent which meant helper did all of the effort for rolling left to right, lying to sitting on side of the bed, siting to standing, chair/bed to chair transfer and wheeling 50 feet with two turns. A care plan dated 4/4/24 revealed [Resident 119] is at RISK for FALLS r/t [related to] Metabolic encephalopathy, Parkinson's disease with dyskinesia with fluctuations, dehydration, severe protein calorie malnutrition, severe dementia, personal history of TIA [Transient ischemic attack] , cachexia, hypovolemia, sarcopenia. The goal was [Resident 119] will be free of untreated injury r/t falls through the review date. Interventions dated 4/4/24 were anticipate and meet needs; be sure call light is within reach and encourage resident to use it for assistance as needed and resident needed prompt response to all requests for assistance; educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; ensure appropriate footwear prior to ambulating; physical therapy evaluate and treat as ordered and as needed; and review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary Team as to cause. Interventions developed on the care plan 4/30/24 were bed in lowest position while occupied, fall mat at bedside while occupied, one hour safety checks and use a Call, don't fall sign in room. A nursing progress note on 4/26/24 at 4:22 AM revealed, Initial incident: This nurse was called into room after CNA [Certified Nursing Assistant] witnessed resident fall to floor hitting his head on pole holding kangaroo bags. Neurological observations initiated. Skin tear to right knee, lacerations to right brow and scalp noted. Orders placed to treat wounds. MD [Medical Doctor] and family notified. Resident later sent to [local hospital] ER [emergency room ] for evaluation. [Name removed], his son, took resident to hospital at 23:30 [11:30 PM]. The incident report dated 4/25/24 at 8:20 PM revealed the same progress note. The resident description was resident 119 said he was getting up. Resident was not taken to the hospital and was alert and oriented to person. Resident 119 had a laceration to the top of his scalp and face with a skin tear to right knee. A nursing progress note dated 4/27/24 at 1:32 PM revealed, resident 119 remained at the hospital. A form titled NSG (nursing) Neurological Observation revealed on 4/25/24 at 8:20 PM the incident happened. The form had the time, temperature, heart rate, respirations, blood pressure, loss of consciousness, pupils, hand grasps, physician notification of change, and comments. Resident 119's blood pressures were documented: a. Initial blood pressure was 160/72. b. At 8:35 PM, 156/70 c. At 8:50 PM, 160/62 d. At 9:05 PM, 142/69 e. At 9:35 PM, 150/67 f. At 10:05 PM, 99/59 g. At 11:05 PM, 93/53 h. At 12:05 AM, admitted to hospital. According to the form 358 submitted to the State Survey Agency (SSA) resident 119 was admitted to the ER after a fall. Resident 119 was assessed after the fall and had a skin tear to right knee, laceration to right eyebrow and laceration to scalp. The resident's family member noticed a change in cognition and transported resident 119 to the hospital. It was documented by the Administrator that It was determined the bed was in normal position, not low to the ground. The form 359 revealed that resident 119 returned back to the facility and was not a candidate for surgery due to the brain bleed. There was a form title Performance Documentation Form for the nurse that was on shift the night resident 119 fell . The issue was not notifying the MD of the fall and complications within limit of major incident. The Incident Management -Falls form revealed required tasks for nurses. The tasks were assess for injuries before moving, assess for injures after moving, possible signs and symptoms of fracture, notify family or responsible party within one hour of incident, notify MD within 1 hour, complete the first responder packet, write treatment order, place resident on 72 -hour charting, implement a new intervention to prevent future falls and complete incident report. A form title 5-Why's revealed resident was lying be bed, bed height in normal position, not low to the ground. Resident was attempting to get out of bed before staff assisted. Call light at 7:56 PM went off for 4 min and 33 seconds. The root cause was resident 119 did not wait for assistance. According to the form titled Investigation Summary dated 4/30/24 there was a fall with an injury. The summary of events or allegation revealed that staff went in to answer resident 119's call light. As staff were entering they saw resident 119 roll out of bed, hit his head on the tube feeding pole and floor. Resident 119 was sent to the hospital later that night with his son to the ER. Resident 119's physical condition was a brain bleed that was diagnosed by the hospital. Summary of Employee Witness Sweeps revealed that resident 119 was not normally in highest position in his bed. Resident 119's History and Physical Reports from the hospital dated 4/26/24 revealed This is an elderly male with severe dementia fell out of bed and presents to the emergency room with interfalcine hemorrhage. This is a nonsurgical medical condition . The Assessment and Plan revealed .1. Subdural hematoma. 2. Scalp Laceration. On 8/6/24 at 3:18 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated if a change in condition was observed or reported she would take down all the information, notify the physician, notify the family and notify the MDS coordinator or Unit Manager (UM). RN 3 stated the nurse was to complete alert charting every shift. RN 3 stated she had only cared for resident 119 once or twice but was a supervisor during the night shift. RN 3 stated she helped nursing staff with cares for resident if there was a concern. RN 3 stated she had assessed residents, contact the physician and notify the administration when there was a concern. RN 3 stated she was supervising the nurses the night resident 119 fell . RN 3 stated she was not notified of the fall until later. RN 3 stated she was told neurological checks were stated and later in the shift resident 119's blood pressure dropped. RN 3 stated the son was at the facility and the son took the resident to the hospital. RN 3 stated she was not sure why the son took the resident instead of calling for an ambulance. RN 3 stated if she had been made aware of resident 119's fall and blood pressure decrease she would have contacted the physician, obtain physician's orders, and made sure that resident did not have a brain bleed. RN 3 stated she thought that resident 119 was diagnosed with a brain bleed at the hospital. On 8/6/24 at 3:32 PM, an interview as conducted with UM 2. UM 2 stated if a resident sustained a fall, a nurses should respond to fall, assess the resident and check for injuries. UM 2 stated after the assessment, as long as CNA's were able to help get the resident up, then the resident was moved. UM 2 stated the physician and family were notified. UM 2 stated the nurse then completed a risk management/incident report and a nurses note. UM 2 stated if there was an injury the MD was notified for new orders and instructions. UM 2 stated resident 119 sustained a fall and the son was notified. UM 2 stated the son came to the facility immediately and felt there was a change in condition. UM 2 stated the physician was notified and the family member felt resident 119's cognition was changing. UM 2 stated the staff notified the physician about the residents change and the resident was taken to the hospital by his family member. UM 2 stated resident 119 had a gash in his head and was bleeding. UM 2 stated she could not remember what his diagnoses at the hospital was but thought it was a brain bleed. On 8/7/24 at 12:38 PM, a follow-up interview was conducted with Unit Manager (UM) 2. UM 2 stated neurological checks were completed after resident 119 fell . UM 2 stated resident 119's systolic blood pressure was averaging 120 to 130 before he fell . UM 2 stated resident 119's blood pressure dropped and his family member took him to the hospital. UM 2 stated the nurse should have documented more monitoring of residents condition. UM 2 stated the RN supervisor on shift was not notified of the blood pressure decreasing. The Fall Prevention Program dated 4/19 and revised on 2/2020 revealed the following: Intent: The Fall Prevention Program is designed to provide a safe environment for residents. Each resident will be evaluated upon admission, quarterly and, as needed to assess his/her individual level of risk. The Interdisciplinary Team will review fall risk assessments completed by the nursing department. Program Goals: 1. To identify residents at risk in a timely manner. 2. To gather accurate, objective and consistent data for the purpose of implementing an individualized, person-centered care plan designed to meet the resident's needs. 3. To provide consistency in the implementation of preventive measures to assist with reduction of falls. 4. To evaluate outcomes. Guidelines: 1. Upon admission, residents will be considered at risk for falls and general precautions will be implemented. 2. The Fall Risk Assessment will be completed within 24 hours of admission to determine the resident's fall risk factors. 3. The Fall Risk Assessment will be completed on admission, quarterly, and if the resident experiences a significant change of condition. 4. The results of the Fall Risk Assessment will be scored to identify the resident's risk category. 5. Fall committee meeting weekly to build upon interventions as needed. 6. The identified interventions will be implemented and added to the resident's person- centered care plan. 7. Resident falls will be tracked using the Fall Tracking Log. 8. Each resident fall will be thoroughly investigated. 9. Implementation of interventions will be monitored by nursing staff on a routine basis. 10. The 4 P's Rounding program will be a part of the Falls Program. 11. Falls will be reviewed for trends and patterns routinely during a Fall Committee Meeting. Recommendations will be made by the committee, as appropriate. 12. The Falls Committee meeting is held routinely, preferably weekly. 13. Fall trends and patterns will be reported to the QAPI Committee on a monthly basis.

Based on interview and record review it was determined, for 2 of 38 sampled resident, that the facility did not ensure each resident was free of any significant medication errors. Specifically a resident was administered pain medication and anti-anxiety medications not according to physician's orders. In addition, another resident had a blood thinner held longer than 7 days. Resident identifiers: 50 and 119. Findings include: 1. Resident 50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, anxiety disorder, chronic kidney disease, major depressive disorder and osseous stenosis ofneural canal ofcervical region. Resident 50's medical record was reviewed 7/29/24 through 8/7/24. Resident 50's physician's orders revealed the following orders: a. On 5/23/24 Methadone HCl (hydrochloride) Oral Tablet 10 MG (milligrams) (Methadone HCl). Give 30 mg by mouth two times a day related to vertebrogenic low back pain; other chronic pain; Watch dose Give with breakfast and lunch. b. On 5/23/24, Methadone HCl Oral Tablet 10 MG (Methadone HCl) Give 40 mg by mouth at bedtime related to Vertebrogenic low back pain; other chronic pain *watch dose*. c. On 5/2/23 and discontinued on 5/20/24 Methadone HCL Oral Tablet 10 MG (Methadone HCL) Give 30 mg by mouth two times a day related to other chronic pain and give 40 mg by mouth at bedtime related to other chronic pain. d. On 10/31/23 and discontinued on 11/14/23, Xanax Oral Tablet 0.25 MG (Alprazolam) Give 0.25 mg by mouth as needed for Anxiety/restlessness related to anxiety disorder . BID (twice daily) PRN [as needed]. Progress notes, incident reports and narcotic records were reviewed and revealed the following: a. On 4/19/23 at 4:27 PM, Occurrence Charting VS [vital signs]: [Temperature] 97.9, [heart rate] 63, [respirations] 16, [blood pressure] 144/76, [saturations] SpO2 97% on 3LPM [liters per minute] via NC [nasal cannula] This nurse administered 10mg of methadone this AM [morning] instead of the prescribed 30mg as ordered. [Physician's name removed] notified no new orders at this time. No s/o [sic] [signs and symptoms] if increased pain this shift. [Name removed], Resident's daughter notified via telephone by this nurse, verbalized understanding. Call light within reach. On 4/19/23 at 7:23 AM, the incident report documented, This nurse administered only one tab instead of three as ordered of his methadone. Resident did not say anything about pain until afternoon. Narcotic record for Methadone HCL 10 MG tablets revealed resident was administered 1 tablet on 4/19/23 at 7:23 AM. b. On 11/5/23 at 6:55 PM, During Shift count it was noted that res this shift has been given Xanax rather than methadone. MD, res [resident] and family was notified. No new orders other than to monitor res. This nurse did move prn narcotics behind scheduled ones. This nurse will continue to review orders and ensure correct medication is to be given. res did report he was a little more tired than usual. res is scheduled for a shower today however res requesting to be have shower changed until tomorrow evening. Res and staff to help with cares and transfers as res may be needing more assistance. On 11/5/23 at 6:00 PM, an incident report documented the same note as above and Res did report that he was a little more tired. Immediate action taken was Notification to supervisor, MD, res and family done. Res prn narcotics moved to behind scheduled ones. Res shower moved to tomorrow to monitor res. The incident report was prepared by Licensed Practical Nurse (LPN) 8. Resident 50's Narcotic Record for November 2023 revealed Methadone was administered on 11/3/24 at 8:00 PM 3 tablets that were 10 mg each. Alprazolam 0.25 mg tablets on 11/4/24 at 3:45 PM 1 tablet was administered with 12 tablets left and then on 11/5/23 it was documented that count was corrected with 5 tablets left. c. On 3/27/24 at 1:39 PM, Occurrence Charting- Med Error VS; 175/84, 76, 18, 97.9, 91% RA This nurse was going through the narcotics book and on his page noticed that he had been given 10 mg of methadone last shift instead of 40 mg. Supervisor and resident notified (res his own POA). Resident said that he had noticed there was only to spoonful last night instead of the usual three or four and he hadn't been able to sleep last night or get comfortable. Resident rated pain 6/10 this morning before he knew about the error. Resident frustrated and said that he didn't think he would have to count his pills like he did when he was at home. On 3/27/24 at 10:30 AM, an incident report documented, Nurse was going through narcotics record book and discovered that resident was given 10 mg of methadone instead of 40 mg in the shift before. Resident rated pain 6/10 that morning before error was discovered. The resident description was I guess that explains why I didn't sleep well last night. I couldn't get comfortable. I noticed that the nurse only gave me two spoonfuls of medication instead of three or four like usual. That nurse doesn't work over here often does she? I guess I'll need to count my pills like I did at home. I didn't think I would have to here. The Immediate Action Taken was RN [Registered Nurse] supervisor and resident notified. Daughter came in for a visit and nurse talked about it with her as well. Vital signs are WNL [within normal limits], pain was rated 4/10 later in the day after methadone doses were given in the morning and afternoon of the shift. No change in LOC [loss of consciousness]. The nurse documenting the incident report was RN 5. A review of resident 50's Narcotic Record for March 2024 revealed on 3/26/24 at 10:45 PM 1 tablet was administered. On 8/1/24 at 12:12 PM, an interview was conducted with LPN 8. LPN 8 stated that she was proctoring a student nurse on 11/5/24. LPN 8 stated that the she overlooked the medication dose while talking to the student. LPN 8 stated that she thinks that she dispensed the medication and administered it and not the student nurse. LPN 8 stated resident 50 was a new admission and she was not familiar with his medication. LPN 8 stated resident 50 was supposed to have 30 mg or three tablets and he received 10 mg or one tablet. LPN 8 stated that she could not recall how she identified the error. LPN 8 stated that she notified the supervisor, family and the MD and he was monitored for 72 hours post incident and they conducted a full set of VS per shift. LPN 8 stated there was no worsening or increased complaints of pain with the medication omission. LPN 8 stated the family was worried that resident 50 might have increased pain and the methadone was the only medication that helped. LPN 8 stated the physician stated to monitor resident 50. LPN 8 stated she did not administer the additional dose at the time of the identification of the error. LPN 8 stated that when dispensing they should be looking for the right patient, right dose and right route for administration. On 8/1/24 at 12:26 PM, an interview was conducted with RN 5. RN 5 stated that she was familiar with resident 50, but that she had not cared for resident 50 in a couple of months. RN 5 stated that when she pulled the morning dose on 3/27/24 she identified that the previous shift had given him only one 10 mg tablet instead of 40 mg tablet. RN 5 stated that the nurse who made the error was another nurse. RN 5 stated that she texted the supervisor and notified the MD. RN 5 stated she then went in and told the resident and the daughter what had happened. RN 5 stated that she checked the residents VS and asked him if he was in any pain. RN 5 stated that resident 50 took his medication in applesauce and that was what he meant by spoonfuls. RN 5 stated resident 50 usually rated his pain high even without the medication error and he always said he could not sleep. RN 5 stated that she recalled that resident 50 did report more pain that day. RN 5 stated that she administered resident 50's scheduled methadone and monitored the effectiveness. RN 5 stated that after the resident was informed of the dosage error he rated his pain higher. RN 5 stated the MD instructed her to monitor his pain level but no further orders were provided. RN 5 stated that she was not aware if resident 50 had any additional PRN pain medication. RN 5 stated that she did not administer any additional pain medication to resident 50. On 8/1/24 at 1:10 PM, an interview was conducted with Unit Manager (UM) 2. UM 2 stated staff should look for any PRN medication, notify the MD, and conduct an assessment for any change in condition or complaints of pain. UM 2 stated resident 50 had a recent order for the Xanax. UM 2 stated in the narcotic book the medication was separated by resident and resident 50 had scheduled methadone and she popped the Xanax instead of the methadone. UM 2 stated the nurse did not verify the medication blister pack with the narcotic count and MAR. UM 2 stated the nurse didn't notice that she had done it until she reconciled with the next shift. UM 2 stated that she did not know if the Xanax and methadone looked alike. UM 2 stated staff should be verifying the 5 to 7 rights of medication administration, verifying right drug, right patient, right dose, right route, right time. UM 2 stated the nurse should have looked at the MAR, the narcotic sheet and the narcotic blister card. UM 2 stated resident 50's did not complain of any increased pain. UM 2 stated resident 50 did not have any noticeable side effects. UM 2 stated resident 50 reported the next morning that he was more tired and asked his shower to be changed. UM 2 stated resident 50 had asked staff for help with care and transfers. 2. Resident 119 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, Parkinson's, acute kidney failure, and dysphagia, traumatic subdural hemorrhage without loss of consciousness, fall on same level. Resident 119's medical record was reviewed from 7/29/24 through 8/7/24. Progress notes revealed the following: Resident 119's progress notes revealed the following: a. On 4/25/24 at 11:00 PM, T.O. [telephone order] Send to [local hospital] ER [emergency room ] for evaluation r/t [related to] fall with head injury. b. On 4/25/24 at 11:48 PM, 2305 [11:05 PM]: Son told floor nurse who then relayed info to this RN supervisor that 'Per his Cardiologist,[Name and clinic name removed] he can't have any Beta Blockers or Blood Thinners d/t [due to] his fall with head injury.' This RN placed an order to hold Plavix [Clopidogrel Disulfate] x7 days with info to f/u [follow up] as instructed by son at [phone number removed] to have it stopped, with any Beta Blockers. MD notified. Floor nurse aware. It should be noted that the progress note was a created on 4/26/24 at 4:51 PM. c. On 5/29/24 at 4:44 PM, Orders - Administration Note Plavix is currently on HOLD (x7 days). Per son, f/u [follow up] with Cardiologist, .to have it stopped *And any Beta Blockers* d/t fall with head injury. D/C ORDER AND PUT IN A NURSES NOTE ONCE COMPLETED. every shift for Son's Request. Order reinstated. d. On 5/29/24 at 5:44 PM a nursing note revealed, This nurse was notified by floor nurse that [resident 119's] order for Plavix was still on hold. Resident had a previous fall w/ [with] head injury and on 4/26 his neurologist requested that Plavix be held x 7 days and should have been restarted on 5/3/24. [Resident 119] has not shown any adverse side effects during this time. [Physician's name removed] was contacted, and stated 'OK, no problem'. Plavix was restarted today. Voicemail was left for son to call UM back. WCTM [will continue to monitor]. A physician's order dated 3/16/24 revealed Clopidogrel Disulfate Oral Tablet 75 MG. Give 1 tablet via NG [nasogastric]-tube one time a day related to Atherosclerotic heart disease of native coronary artery without angina pectoris. According to the April 2024 Medication Administration Record (MAR) the last dose of Clopidogrel Bisulfate was administered between 6:00 AM and 10:00 AM was on 4/24/24. According to the May 2024 MAR Clopidogrel Bisulfate was administered on 5/30/24 and 5/31/24. Resident 119 was not provided the blood thinner from 4/24/24 until 5/30/24. On 8/6/24 at 3:18 PM, a phone interview was conducted with RN 3. RN 3 stated resident 119 sustained a fall and hit his head. RN 3 stated she was not sure which physician had staff hold resident 119's blood thinner. RN 3 stated she clarified orders as part of her supervising position. RN 3 stated she was not aware that the blood thinner was held longer than 7 days. On 8/6/24 at 3:32 PM, an interview was conducted with UM 2. UM 2 stated resident 119 sustained a fall and had a gash in his head from hitting his head. UM 2 stated that a family member took resident 119 to the hospital and had contacted resident 119's specialist to let them know about the fall. UM 2 stated the family member told the nurse at the facility to hold the blood thinner incase there was a brain bleed according to the specialist. UM 2 stated staff were waiting for the family member to contact the facility to restart the blood thinner instead of contacting the physician. UM 2 stated the facility physician was notified when it was found that resident 119 was not receiving his blood thinner. UM 2 stated the risks of not having the blood thinner could be another stroke.

Based on observation, interview and record review, the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, hand hygiene was not performed prior to entering and exiting resident rooms, including an isolation room. Additionally, gloves and gown were not donned prior to entering isolation rooms. Resident identifiers: 2 and 4. Findings include: 1. On 11/16/20 at 1:14 PM, room [ROOM NUMBER] was observed to have a stop sign on the door, which instructed those that wanted to enter room [ROOM NUMBER] to see the nurse first. room [ROOM NUMBER] was also observed to have a cart outside the room with Personal Protective Equipment (PPE) in it for donning prior to entrance. On 11/16/20 at 1:26 PM, an observation was made of the Recreation Aide. The Recreation Aide was passing snacks to the residents on the 100 pod. The Recreation Aide was observed to leave room [ROOM NUMBER] and enter room [ROOM NUMBER] without performing hand hygiene. The Recreation Aide was also observed to enter room [ROOM NUMBER] without donning a gown or gloves. The Recreation Aide then provided the resident in room [ROOM NUMBER] a snack at his bedside, coming within 6 feet of the resident. The Recreation Aide was wearing a mask and face shield throughout the facility. The Recreation Aide was later observed to exit room [ROOM NUMBER] and enter room [ROOM NUMBER] without conducting hand hygiene in between rooms. 2. On 11/16/20 at 1:40 PM, an observation was made of the Recreation Aide. The Recreation Aide was observed to enter room [ROOM NUMBER] without donning a gown or gloves. room [ROOM NUMBER] was observed to have a stop sign on the door and a cart with PPE outside the room. On 11/16/20 at 1:14 PM, an interview was conducted with Registered Nurse (RN 1). RN 1 stated that room [ROOM NUMBER] was on contact and droplet precautions due to going out of the facility for wound care, therefore the resident was treated as a suspected Covid-19 case. RN 1 stated that the facility had implemented universal mask and eye protection for all staff while they were in the building. On 11/16/20 at 1:30 PM, an interview was conducted with the Recreation Aide. The Recreation Aide stated that she had worked at the facility for 5 years. The Recreation Aide stated that room [ROOM NUMBER] was on isolation due to leaving the facility for appointments. The Recreation Aide stated that she did not gown and glove when she went into the room because she was told that she could go into the room up to a certain point without donning PPE. The Recreation Aide could not state what that point in the room was. On 11/16/20 at 11:42 PM, a follow up interview was conducted with RN 1. RN 1 stated that everyone was required to donn a gown and gloves prior to entering an isolation room such a room [ROOM NUMBER]. RN 1 stated that there were no exceptions if the person was only going part way into the room. RN 1 stated that room [ROOM NUMBER] was on contact and droplet isolation related to exposure to another resident that was Covid-19 positive as well as having left the facility for surgery and was readmitted . Record review revealed that room [ROOM NUMBER] was occupied by resident 4. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 11/18/20. A review of resident 4's care plan documented (Resident 4) is at risk for infection r/t (related to) COVID-19 due to ongoing wound care appointments outside the facility. The following intervention was initiated on 6/30/20 Contact/Droplet Precautions per facility protocol related to ongoing outside the facility appointments. Record review revealed that room [ROOM NUMBER] was occupied by resident 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 11/18/20. A physician's orders [REDACTED]. On 11/16/20 at 1:52 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated that residents on isolation were on contact and droplet precautions which required that anyone entering the room must perform hand hygiene and donn a mask, face shield, gown, and gloves. The IP stated that everyone had to donn the required PPE when they entered the room, and stated there were no exceptions. The IP stated that staff were required to perform hand hygiene before and after they entered any resident rooms, as well as while in the resident room in-between tasks. The Centers for Disease Control and Prevention guidelines found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html state Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. HCP (health care providers) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents.

Based on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise. Specifically, one resident's weight continued to trend down while the facility did not change or add interventions. Another resident had a decrease in weight of 12% over one month and did not have adequate calories and protein estimates based on his condition. Resident identifiers: 17 and 111. Finding include: 1. Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 4/23/19, resident 17's medical record was reviewed. The following weight trends were revealed: (Note: All weights are in pounds.) a. 3/3/16, 197 b. 5/17/18, 194 (Note: weights were stable from 3/3/16 until this date.) c. 6/21/18, 192 d. 7/19/18, 191 e. 8/16/18, 186 f. 9/6/18, 187 g. 9/13/18, 184 h. 9/20/18, 184 i. 9/27/18, 184 j. 10/19/18, 179 k. 11/15/18, 173 (Note: resident had a 11% weight loss over 6 months.) l. 12/21/18, 166 m. 12/27/18, 165 n. 1/3/19, 167 o. 1/10/19, 163 p. 1/17/19, 161 q. 1/24/19, 163 r. 1/31/19, 166 s. 2/7/19, 169 t. 2/15/19, 166 u. 2/21/19, 164 v. 2/28/19, 161 (Note: resident had a 7% weight loss over 3.5 months.) w. 3/7/19, 158 x. 3/14/19, 157 y. 3/21/19, 156 z. 3/28/19, 156 aa. 4/5/19, 154 (Note: resident had a 4.4% weight loss over approximately 1.5 months.) bb. 4/12/19, 155 cc. 4/18/19, 155 Resident 17's physician's orders [REDACTED]. a. Start date 9/11/18, Boost breeze two times a day, offer 236 mls (milliliters) PO (by mouth), document mls accepted. (discontinue date 12/23/18). b. Start date 10/24/18, Regular diet, Mechanical soft texture, thin consistency. (active at the time the survey was conducted). c. Start date 12/23/18, Boost breeze three times a day, offer 236 mls PO, document mls accepted. (active at the time the survey was conducted). Resident 17's nursing progress notes were reviewed and revealed the following: a. On 12/22/18, Skin & (and) weight-(resident 17) is being added to weekly weights due to weight loss. He is triggering for a monthly weight loss of 4.0%, and three month weight loss of 9.8%, and a six month weight loss of 13.1%. (Resident 17) is eating 0-25% of his meals on a mechanical soft diet and accepting 88% of his boost breeze BID (twice per day). MD (physician) notified, new order to increase boost breeze to 236 mL PO TID (three times per day). Current BMI (body mass index) of 23.1 is within ideal range. Treatment orders are in place for scratches to the left buttocks. Skin is otherwise intact but (Resident 17) is at high risk for skin breakdown due to limited mobility. He is currently working with PT/OT (physical therapy and occupational therapy). Left message for family to update on weight and supplement orders. Will continue to monitor weight weekly until stable. b. On 1/21/19, Skin & weight-(resident 17) continues to be monitored on weekly weights due to weight loss. He is triggering for a monthly weight loss of 3.0%, a three month weight loss of 10.1%, and a six month weight loss of 13.4%. (Resident 17) is eating 26-50% of his meals on a mechanical soft diet and accepting 89% of his booth breeze TID. Intake is noted to be increased with this assessment There are no changes to the P[NAME] (plan of care) at this time. Will continue to monitor weight weekly until stable. c. On 2/25/19, Skin & weight-(resident 17) continues to be monitored on weekly weights due to weight loss. He is triggering for a six month weight loss of 12.3%. (Resident 17) is eating 51-75% of his meals on a mechanical soft diet and accepting 86% of his boost breeze TID. Intake continues to increase There are no changes to the P[NAME] at this time. Will continue to monitor weight weekly until stable. d. On 3/11/19, .Resident is on incident charting for teeth extractions. He continues to complain of 8/10 pain to mouth. No redness, swelling or drainage is noted. PRN (as needed) [MEDICATION NAME] given and effective. He has had no bleeding noted this shift. He is encouraged to eat small amounts of food during meals. e. On 3/26/19, Skin & weight-(resident 17) continues to be monitored on weekly weights due to weight loss. He is triggering for a one month weight loss of 6.0% and three month weight loss of 7.7% and a six month weight loss of 15.2%. (Resident 17) is eating 26-50% of his meals on a mechanical soft diet and accepting 100% of his boost breeze TID. His BMI of 21.8 is within ideal range .There are no changes to the P[NAME] at this time. Will continue to monitor weight weekly until stable. f. On 4/22/19, Skin & weight- (resident 17) continues to be monitored on weekly weights due to weight loss. He is triggering for a three month weight loss of 8.3% and a six month weight loss of 10.4%. (Resident 17) is eating 51-75% of his meals on a mechanical soft diet and accepting 90% of his boost breeze TID. Intake is noted to be improved with this assessment Will continue to monitor weight weekly until stable. Within Resident 17's medical record were evaluations titled nutrition evaluation. They were performed on 9/6/18, 2/5/19, and 2/20/19. They were nutrition assessments performed by the facility Registered Dietitian (RD). They revealed the following: a. On 9/6/18, the following was documented: i. Height 71 in (inches) ii. Most recent weight 187 iii. BMI 26 iv. Usual weight 193 v. Ideal body weight 172 vi. Estimated energy requirements: 2125-2550 kcals (kilocalories). Method 25-30 cal/kg (calories per kilogram) vii. Protein 85-102 gm (grams). Method 1-1.2 gm/kg (gram per kilogram). viii. In a section of free text space the RD documented, readmitted after hospital tx (treatment) r/t (related to) [MEDICATION NAME], aspiration pneumonia, [MEDICAL CONDITION]. current wt (weight) of 186# (pounds) is stable from last month but is down 5#/2.6% from 2 mots (sic) ago. His usual wt has been about 193#. He stated that he can chew meat OK as long as it is cut up; he is missing some teeth. ST (speech therapy) has worked with him r/t swallowing and he is using compensatory strategies for safe swallowing. Meal intake has been averaging 50-75% since returning. This does not meet his estimated needs. Boost Breeze to be given 8 oz (ounces) BID (480 Cal (calories), 20 gm Pro (protein) daily) to help meet estimated needs. Addition of MVI (multivitamin)/mineral will also help insure that RDI's (recommended daily intakes) are met. IV (intravenous) ABX (antibiotics) continue at this time. Weekly wt to be monitored until stable (over) 4 weeks. Will continue to eval (evaluate) wt and PO intake PRN. b. On 2/5/19, the following was documented: i. Most Recent Weight 166 (Note: this weight was measured on 1/31/19.) ii. BMI 23 iii. Usual weight 190 iv. Estimated energy requirements1875-2250 kcals. Method 25-30 cal/kg (Note: Despite weight loss, resident 17's estimated needs were calculated using his current body weight and the same factors or methods) v. Protein 75-90 gm. Method 1-1.2 gm/kg vi. In a section of free text space the RD documente, Nutrition assessment: Current wt of 166# is in a desirable range with BMI of 23. Resident stated that he would like to be at about 170#. Weight is up slightly in last 2 weeks but he has had an overall wt loss of 8% in last 6 months. Weight has remained at 161-167# for past month so has stabilized. Boost Breeze TID was added in (MONTH) to prevent further wt loss. Meal intake is variable averaging 50% or more for breakfast and lunch; he often refuses dinner. He said that he usually is just not hungry for dinner. He has also had some difficulty with chewing due to lower teeth in poor condition. He has had dental appointments to address this and may have teeth extracted soon. He is satisfied with Mech (mechanical) soft texture diet at this time and likes Boost Breeze (takes nearly 100%). With wt stable and skin intact, no new changes recommended. Staff will prompt and monitor as needed in dining room to promote the best meal intake. (Note: despite a weight loss of 8% in the last 6 months and the resident expressing a desire to weigh more, there were no additional interventions implemented. From 2/5/19, resident 17 continued to lose weight. Resident 17's weights trended down 6.7% over approximately two and a half months. There were no further RD assessments.) Resident 17's care plan was reviewed and revealed the following: a. Focus (Resident 17) has potential nutritional problems r/t h/o (history of)[MEDICAL CONDITION](cardiovascular accident) and weakness; h/o dysphagia. Meal intake may not always meet estimated needs with decreased appetite following pneumonia. 12/22/18-(Resident 17) is triggering for a significant weight loss b. Goal: (resident 17) will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx (signs or symptoms) of malnutrition through review date. Date initiated 10/26/18, Revision on 2/7/19, Target date 7/17/19 . c. Interventions .RD to evaluate and make diet change recommendations PRN. On 4/24/19 at 10:58 AM, an interview was conducted with the RD. The RD stated that she would typically add an additional supplement if a resident's weight continued to trend down. Resident 17's weight trends were described to the RD. When asked if the Boost Breeze provided to resident 17 three times per day was adequate in meeting his nutritional needs in combination with his oral intake, the RD stated that obviously Boost isn't doing the trick. The RD stated that resident 17 was not triggering on a computerized report generated by the charting software the facility utilized. The RD stated we need to look at him. The RD acknowledged in her note that resident 17 desired to be around 170 pounds. The RD stated that the Boost was not doing what we need. When asked why no other interventions were tried, the RD stated if the supplement was the same and had not changed for months, and his weight was trending down he would need something else done. On 4/24/19 at 1:17 PM, an interview was conducted with the director of nursing (DON). The DON stated she had just spoken with resident 17. The DON stated that resident 17 confirmed he would like to weigh 170 pounds. The DON stated resident 17 declined any more clear Boost (Boost Breeze) and did not want any regular Boost. The DON stated resident 17 told her you're doing all you can and I'm doing all I need. The DON provided a document with nursing notes from (YEAR). On 2/18/16 at 8:01 AM, the note documented (Resident 17) states that he has recently been started on MedPass, and he does not enjoy the taste or texture. MD notified D/C (discontinue) medpass .Boost breeze 8 oz (236 mL) PO BID. (Note: There was no other documentation of other supplements being trialed or of any alteration to resident 17's diet to enhance calories and protein.) 2. Resident 111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/23/19, resident 111's medical record was reviewed. The following weight trends were revealed: (Note: All weights are in pounds.) a. 3/7/19, 194 (Note: resident 111's weight had been stable for nearly one year up to this date.) b. 3/25/19, 179 (Note: resident has a 7.2% weight loss in two and a half weeks.) c. 3/29/19, 177 (Note: resident had a 8.8% weight loss in three weeks.) d. 4/4/19, 175 (Note: resident had a 9.8% weight loss in four weeks.) e. 4/12/19, 172 (Note: resident had a 12% weight loss in 5 weeks.) Resident 111's progress notes were reviewed. They revealed that resident 111 had been discharged to the hospital on [DATE] and returned on 3/25/19. The following was identified: a. On 3/18/19 at 11:27 PM, resident began to feel nauseous and started vomiting at 1240 (12:40 AM). MD notified of nausea and vomiting and ordered [MEDICATION NAME] 8 mg (milligrams) PO q (every) hours PRN. b. On 3/19/19 at 2:58 AM, Resident has had nausea and vomiting this shift, he has vomited 3 times .Dr. called and one time order given for ondanestron HCl ([MEDICATION NAME]) 8 mg PO one time only for vomiting. c. On 3/19/19 at 3:40 AM, (resident 111) is very weak with a very unsteady gait. d. On 3/19/19 at 5:27 AM, (resident 111) has been nauseous and vomiting .last emesis around 0210 (2:10 AM) . e. On 3/19/19 at 11:22 AM, Today he .developed nausea, projectile vomiting, fever. He has not been feeling very well at all. f. On 3/19/19 at 4:01 PM, Minimal emesis of clear fluid with slight yellow noted, resident ate soup for lunch and yogurt for breakfast. g. On 3/20/19 at 2:05 AM, Resident has had some nausea and vomiting this shift . h. On 3/20/19 at 3:10 PM, Resident alerted nurse to episode of vomiting. Emesis noted to be mostly clear yellow/green liquid. i. On 3/21/19 at 6:34 AM, .Nausea and vomiting this shift . j. On 3/22/19 at 4:10 PM, (resident 111) c/o (complains of) nausea and was just very tired. [MEDICATION NAME] given and resident was resting when his daughter came to visit. He was [MEDICAL CONDITION] at 114 CMP (complete metabolic panel) results back with abnormals as follows: .BUN (blood uria nitrogen) 71, creatinine high at 2.39, and GFR (glomerular filtration rate) low at 25 daughter .wanted him sent to ER (emergency room ) .Resident sent to .(the) hospital ER per non emergent transport at about 1:20 PM. k. On 3/23/19 at 12:59 AM, Resident .was sent to the hospital .for nausea, confusion, weakness and diarrhea. Resident was admitted .for dehyhdration and [MEDICAL CONDITION]. l. On 3/25/19 at 5:12 PM, Res (resident) was readmitted from .hospital . m. On 3/27/19 at 10:48 AM, Res states he is feeling weak and nauseous, [MEDICATION NAME] given. Res reports having a poor appetite and has been eating less than 25 percent of his meals. Supplement drinks and gatorade given. n. On 3/27/19 at 6:59 PM, Resident reported feeling increasingly weak. Res did not eat breakfast or lunch. Res reported to feel nauseous . o. On 3/28/19 at 12:59 AM, Stated he ate some crackers, denied wanting to eat at this time . p. On 3/29/19 at 12:55 AM, Resident refused to eat dinner this evening but he did drink a boost drink. He states he still isn't hungry at this time. q. On 3/29/19 at 3:22 PM, a Physician's progress note documented I was asked to see (resident 17) due to his daughter's concerns regarding nausea and vomiting. They state that he has had some nausea, he has had some diarrhea, and they feel that he is doing very poorly in would like him sent to the hospital. He has been to the hospital once and they found nothing emergent and recommended he follow up with his GI (gastrointestinal) doctor. He has an appointment but is not for a couple months r. On 4/1/19 at 11:32 AM, a Skin & Weight note documented (resident 111) is being added to weekly weights following recent readmission for long-term care s/p (status [REDACTED]. He is eating 26-50% of his meals on a mechanical soft diet. Boost breeze was just recently started QID (four times daily) to help supplement nutrition. (Resident's) BMI of 24.0 is within ideal range. He has no alterations in skin integrity and he is at low risk for skin breakdown. (Resident) is currently working with therapy. There are no changes to the P[NAME] at this time. Will continue to monitor weight weekly to establish a new baseline. s. On 4/4/19 at 1:21 AM, Resident through (sic) up a scant amount of vomit this evening . t. On 4/5/19 at 1:00 PM, He has had some periods of nausea . u. On 4/6/19 at 2:36 AM, Resident refused shower this shift, stated he was too tired .Resident stated had some N/V (nausea and vomiting) earlier today . v. On 4/6/19 at 1:36 PM, Pt states he is not feeling well after taking his meds, educated could be potential that ABX are making him feel sick (resident) stated that .he had thrown up . w. On 4/9/19 at 11:30 AM, .It was noted this shift that resident has lost 19 pounds from 03/07 to 04/04. Res has been eating less than 25% of his meals or refusing to eat .states he does not have an appetite .Res reports feeling 'weak.' x. On 4/9/19 at 12:05 PM, a Physician/Practitioner Note documented Asked to see patient due to continued weight loss, and fatigue. Patient states his diarrhea has resolved. He still has some nausea. He has no appetite. He has lost close to 20 lb (pounds) Nausea: patient has persistent nausea .Unintentional weight loss: partially due to his nausea. He also has no appetite. Will start him on [MEDICATION NAME] 7.5 mg at bedtime. y. On 4/9/19 at 2:27 PM, .Res states feeling weak and has been eating less than 25% of his meals or refusing them. z. On 4/9/19 at 2:52 PM, SLP (speech language pathologist) clarification- patient seen for dysphagia .Recommended nutritional supplements to be offered like magic cups, boost and med pass. SLP services will target increased oral intake . aa. On 4/11/19 at 6:56 AM, .continuous yellow bile-colored emesis. bb. On 4/11/19 at 7:56 AM, threw (antinausea medication) up right after administering. cc. On 4/11/19 at 11:47 AM, .Resident is pale, weak, and has malaise. Threw up prn [MEDICATION NAME] (sic) and [MEDICATION NAME] right after being administered dd. On 4/11/19 at 3:48 PM, .Appears pale and weak, malaise con't (continued) . ee. On 4/14/19 at 1:32 AM, .Resident did state he had N/V episodes this shift . ff. On 4/16/19 at 5:38 PM, .(resident) visited (hospital) radiology for MBS (modified [MEDICATION NAME] swallow) swallow study due to decrease appetite, profuse vomiting, and needing IV fluids. Hx (history) [MEDICAL CONDITION] strictures that has been stretched at the VA. Meds need to be crushed. Lost almost 30 lbs in the last month was reason for visit. Physician's finding .no aspiration. [MEDICAL CONDITION] stricture about 13 mm (millimeters) . gg. 4/19/19 3:27 PM .Reports having a 'better appetite compare (sic) to last week.' A hospital history and physical dated 3/22/19, documented (resident 111) is brought in for diarrhea and vomiting .He was here on Sunday .sent back to the (Name of facility) .and family says that ever since then he has not done well with ongoing non-bloody emesis and diarrhea .Is able to eat and drink just doesn't keep it down well. Had some abd (abdominal) pain .Wt 88 kg (killograms) (193.6 pounds) .BUN: 82 mg/dL (milligrams per deciliter) High, Creatinine level: 2.18 mg/dL High .Assessment/Plan: 1. AKI (acute kidney injury) .7. Acute diarrhea. Resident 111 had the following laboratory data within his record: a. 3/22/19, [MEDICATION NAME] 3.9 g/dL (grams per deciliter) (reference range: 3.5-5.2) b. 4/11/29 [MEDICATION NAME] 3.6 g/dL (reference range: 3.5-5.2) A Speech Therapy evaluation dated 4/9/19, documented Clinical impressions: Pt (patient) benefited from offering enticing food, chocolate and vanilla magic cup. (Physician) is recommending appetite stimulant to further assist in increasing pt's intake. Within Resident 111's medical record were evaluations titled nutrition evaluation. They were performed on 7/31/18, 3/28/19, and 4/19/19. They were nutrition assessments performed by the facility RD. They revealed the following: a. On 7/31/18 the following was documented: i. Diet: Regular, mechanical soft ii. Height 72 inches iii. Most recent weight 196 (Note: this weight was measured on 7/5/18.) iv. BMI 27 v. Ideal body weight 178 vi. Estimated energy needs 2225-2670 Cal. Method 25-30 Cal/kg Estimated protein requirements 89-98 gm. Method 1-1.1 gm/kg. vii. In a section of free text space the RD stated: Quarterly nutrition review .Resident wt has increased over the past year but is not stabilizing over the last few months at (approximately) 195#. At current wt of 196# BMI =26.6 and is at upper end of desirable range. b. On 3/28/19 the following was documented: i. Most recent weight 179.6 (Note: this was recorded on 3/25/19.) ii. Body mass index 24 iii. Estimated energy requirements 2050-2460 Cal. Method 25-30 cal/kg. Estimated protein requirements 82-98 gm Pro Method 1-1.2 gm/kg. iv. To the question What is the resident's average meal intake? The RD had marked 0-24.9% v. To the question :What is the resident's average food intake over the past 7 days? The RD had marked 0-24.9% vi. In the free text space the RD stated Nutrition assessment: readmitted from hospital after tx r/t AKI, metabolic [MEDICAL CONDITION], dehydration. Meal intake prior to hospitalization was (less than) 25% for about 5 days and he had IV fluids prior to hospital stay. Since returning, meal intake has remained (less than) 25%. Mech soft diet provided r/t h/o chewing & swallowing difficulty with [MEDICAL CONDITION] obstruction. He had been eating 75-100% of meals with stable weight until 2-3 weeks ago. current wt of 179.6# is still in desirable range with BMI of 24 but is down 14# 7.4% from 3 weeks ago. He has continued to have diarrhea. Nurse contacting MD. Recommend adding boost Breeze 8 oz QID until he is able to eat more PO. POLST (Physician order [REDACTED]. Weekly wt to be monitored. Will eval wt and PO intake PRN. (Note: the next assessment was performed on 4/19/19. Between 3/28/19 and 4/19/19, resident 111's weight had trended down from 179 on 3/25/19 to 177 on 3/29/19 to 175 on 4/4/19 to 172 on 4/12/19.) c. On 4/19/19 the following was documented: i. Most recent weight 172 (Note: measurement was recorded on 4/12/19.) ii. Body mass index 23 iii. Estimated energy requirements: 1950-2340 Cal. Method 25-30 Cal/kg. Estimated Protein requirements 78-94 gm. Method 1-1.2 gm/kg. (Note: this was a 13% decrease in calories and protein from the (MONTH) (YEAR) assessment. The estimated needs were calculated utilizing the resident's curent body weight and the same factors or methods.) iv. To the inquiry What is the resident's average meal intake? The RD marked 25-49.9% v. To the inquiry What is the resident's average food intake over the last 7 days? The RD marked 25-49.9% vi. In the free text space the RD stated: Nutrition assessment: Weight has decreased slightly since readmission last month, down 7#/4% x 3 weeks to 172%. Wt is still in desirable range with BMI of 23. Wt is also down about 20#/10%in last 1-2 months. He has been eating only 25-50% of meals on Reg (regular) mech soft diet. MBS done showing narrowing of distal esophagus which may be affecting PO intake. Speech therapy notes from swallow study ahve been requested which should have diet texture recommendation. He has taken 75-100% of Boost Breeze QID (960 cal, 40 gm Pro daily). He also take a magic cup daily (300 Cal, 10 gm Pro). Intake of meals plus supplements does meet most of his estimated nutrition needs. Skin intact. Will continue to eval wt and PO intake PRN. On 4/24/19 at 9:10 AM, an interview was conducted with the DON. The DON stated that resident's got put on weekly weights and were monitored for 4 weeks when they were newly admitted , including readmissions from the hospital. The DON stated that if a resident triggered for significant weight change, then they would stay on the weekly weight program. The DON stated those residents were reviewed in skin and weight meetings and had a skin and weight evaluation completed each month. The DON stated that a significant weight change was 3% in 1 week, 5% in a month, and 7.5% in 3 months and 10% in 6 months. The DON stated that if a resident were to discharge and return, then their charting system still tracked a resident from their previous weights. The DON stated weekly weights were taken on Thursday. The DON was asked why resident 111 was not weighed on 4/18/19. The DON was observed to open the skin and weight tracking book and discovered that his weight had been recorded, but not put in the computer. The DON stated and showed that the weight recorded for resident 111 was 177 pounds. On 4/24/19 at 10:58 AM, an interview was conducted with the RD. The RD stated she would review residents at readmissions, changes of condition, or if their weight history triggered an assessment for her. The RD stated that for the skin and weight meetings, the process was driven by nursing staff. The RD stated I hope they will let me know everybody who triggers. The RD stated I know nursing will sometimes address it (weight change) with a supplement or other intervention that they feel are appropriate. The RD stated that the nursing staff would inform her of resident's to assess based on their judgement. The RD stated that sometimes residents would not eat well the first three to five days after being at the hospital. The RD stated I want to see what their weight will do. The RD stated she might not have recommended more at the time of the assessment on 3/28/19. The RD stated that adding supplements was a common intervention. The RD stated that when she calculated estimated energy needs and protein needs, she would always use the current weight. The RD stated she would just increase the amount (of calories and protein) if they were trending down. The RD stated that a 25-30 calorie per kilogram factor was standard. The RD stated that she would sometimes use a factor up to 35 if a resident had wounds or was needing more. The RD stated that the factor she used to calculate protein was 1-1.2 grams per kilogram to start, then higher for wounds or terrible labs. The RD stated that malnutrition has a lot to do with their BMI. The RD then stated and probably the amount they've been eating if that's declined a lot. The RD stated she might also use labs or changes to a resident's physical appearance. The RD stated that if a resident looked really thin and gaunt that would be an indication of malnutrition. The RD stated if a resident had malnutrition, she would recommend some supplements. The RD stated that they're probably not wanting to eat much. The RD stated that they would be placed on weekly weights and would try to follow up on them a little more often. The RD stated that occasionally she would request a [MEDICATION NAME] if an [MEDICATION NAME] or total protein was low. When asked if a [DIAGNOSES REDACTED]. If I'm told this patient was really declining and they are thinking about hospice, then I would not increase their calories a lot. If I went to 35 (calories per kilogram) then I would still have a bigger range for them of 25-35 (calories per kilogram). If we want them to gain, we could go up to 35 (calories per kologram). If the resident was not considering hospice then I would go up to 35 kcals/kg then I would give them as much to eat as we could. We will give them larger portions and supplements no top of that. When the RD was referred to resident 111 and explained about the trending weights, the RD stated it might be worth looking into a tube feed. The RD stated she thought resident 111 may not have liked what he was getting to eat since it had to be altered for his chewing or swallowing function. The RD stated if resident 111's weight was stabilizing she could see why I wasn't more aggressive. The RD stated that resident 111 may have benefitted from that estimate (of calories) being higher.

Based on observation, interview and record review it was determined for 6 of 26 sample residents, that the facility did not ensure that the resident was free from physical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Specifically, a resident with a self-releasing belt could not demonstrate the ability to release her seatbelt; a resident's bed was moved against the wall of his dominant side; and four residents with a history of falls had audible pressure alarms in use. None of the residents had comprehensive assessments to show medical necessity for pressure alarms or the self-releasing belt. Resident identifiers: 23, 52, 53, 81, 108, and 112. Findings Include: 1. Resident 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/29/18 at 11:21 AM, resident 112 was observed to be in an activity in the common room. Resident 112 was observed to be in her wheelchair with a seat belt on. On 1/31/18, a review was completed of resident 112's medical record. An informed consent for Physical Restraints, dated 12/8/14, was completed for resident 112 for an alarming self-releasing seatbelt in wheelchair. Resident 112's care plan included the following related to falls: a. Alarming self-releasing belt (SRB) while in wc (wheelchair). Remove q (every) 2 hours and PRN (as needed) for toileting, repositioning, dining. Observe at least q 30 minutes when SRB is in place. b. Resident 112 is at risk for potential entrapment hazards r/t (related to) use of alarming self-releasing belt while in wheelchair. apply alarming self-releasing belt to wheelchair. Check every 30 mins and release CNA, every 2 hours for cares. Document restraint use and release as per facility protocol. Daughter has been educated and continues to decline trial DC (discontinuing) of alarming SRB., Discuss and record with the resident/family/caregivers, the risks and benefits of the alarming SRB, when it should/will be applied, routines while it is in place and any concerns or issues regarding SRB use. c. Monitor/document/report PRN any changes regarding effectiveness of alarming SRB, less restrictive device, if appropriate; any negative or adverse effects noted, including: decline in mood, change in behavior, decrease in adl (Activities of Daily Living) self performance, decline in cognitive ability or communication, contracture formation, skin breakdown, s/sx (signs and symptoms) of [MEDICAL CONDITION], falls/accidents/injuries, agitation, weakness. A review of resident 112's Annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed that a Brief Interview for Mental Status (BIMS) could not be completed for resident 112 because she was rarely/never understood. No evaluations demonstrating medical necessity or assessments demonstrating resident 112's ability to remove her seatbelt could be found in resident 112's medical record. On 1/30/18 at 10:40 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 112 had a SRB when in her wheelchair as a fall precaution. RN 1 stated that resident 112 was unable to stand up on her own but she had a tendency to lean forward in her wheelchair. RN 1 stated that she was unsure if resident 112 could comprehend most of the time during conversation. RN 1 stated that resident 112 would not be able to unfasten her SRB if asked directly. RN 1 stated that resident 112 had on occasion released her SRB. On 1/30/18 at 2:05 PM, Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated resident 112 wore a SRB when in her wheelchair. CNA 1 stated that resident 112 has some moments of lucidity and would communicate through gesturing but was not able to express her needs verbally. CNA 1 stated that at times resident 112 would pull at her SRB. When it appeared to be bothering her, CNA 1 stated that he would release the SRB and stay with resident 112 until she was calm again. CNA 1 stated that resident 112 would not be able to release her SRB if asked to. On 1/30/18 at 2:30 PM, the Director of Nursing (DON) was interviewed. The DON stated that resident 112 had not had any falls in the last year. The DON stated that resident 112 was the only resident in the facility that they did not perform weekly assessments to ensure that she could release her SRB. The DON stated that they did not perform the weekly assessments due to the fact that resident 112 was unable to stand up on her own anyway. The DON stated that the SRB was still used for resident 112 due to resident 112's family's insistence. The DON stated that the staff had attempted to educate that family however the family refused and stated they would take the resident to another facility if the SRB was removed. 2. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/31/18, a review was completed of resident 23's medical record. Resident 23's care plan revealed that resident 23 uses Alarm to bed/WC/recliner at all times. Resident 23's admission progress note dated 10/28/17 at 3:00 PM, revealed that .Daughter .stated rsd (resident) has had approximately 5 falls in the past 2 days, therefore, resident is a high fall risk. Bed alarm, lowest bed position and Posey pads will be placed for protection. A review of resident 23's Admission MDS from 11/3/17 revealed that resident 23 was unable to complete a BIMS triggering the completion of a Staff Assessment for Mental Status (SAMS). The SAMS revealed that resident 23 appeared to have short-term and long-term memory problems. Resident 23 was unable to recall the current season, location of own room, staff names and faces or that he was in a nursing home. The SAMS revealed that resident 23's cognitive skills for daily decision making were severely impaired and that he never/rarely made decisions. No evaluations demonstrating medical necessity or assessments demonstrating effectiveness of resident 23's pressure alarms could be located in resident 23's medical record. On 1/30/18 at 2:05 PM, CNA 1 was interviewed. CNA 1 stated that resident 23 used a pressure alarm on his wheelchair and when in bed. CNA 1 stated that the monitor hung outside the door and alarmed when resident 23 attempted to get up. CNA 1 stated that the alarm was very loud, and audible throughout the unit and resident 23's room. CNA 1 stated that resident 23 could get up on his own, but not safely. On 1/31/18 at 9:16 AM, the DON was interviewed. The DON confirmed there were no evaluations demonstrating medical necessity or assessments demonstrating effectiveness for resident 23's pressure alarms. 3. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 52's care plan revealed the following related to the use of alarms: a. Education provided to ensure pressure alarm to bed is in place and functioning properly Q shift and PRN. b. Resident 52 uses alarming floor mat next to bed while occupied. c. Resident 52 uses fall prevention device: Pressure alarm to bed at all times while occupied. Check proper placement and function Q shift. A review of resident 52's Quarterly MDS dated [DATE] revealed that a BIMS could not be completed for resident 52 because he was rarely/never understood. No evaluations demonstrating medical necessity or assessments demonstrating effectiveness of resident 52's pressure alarms could be located in resident 52's medical record. On 1/31/18 at 8:35 AM, CNA 2 was interviewed. CNA 2 stated that resident 52 used Posey pads, a floor mat, and a floor alarm for fall prevention. CNA 2 stated that resident 52 had a bed pressure alarm recently but that he had not seen it that day. CNA 2 stated that resident 52 could not stand on his own, but that resident 52 would roll and kick himself out of bed. On 1/31/18 at 9:16 AM, the DON was interviewed. The DON confirmed there were no evaluations demonstrating medical necessity or assessments demonstrating effectiveness of resident 52's pressure alarms. 4. Resident 81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/30/18, resident 81's medical record was reviewed. A progress note dated 11/27/17 at 12:23 AM, revealed the following On this shift this nurse was called into resident's room, on entering resident was laying on his back on the floor to the right of the bed, When asked resident what had happened resident stated he, rolled over in his bed and rolled to far falling out of his bed, landed on his knees next to the bed with his top half upright, CNA who found him stated when she entered residents room she witnessed him roll from his knees to laying flat on his back. Resident stated only his knees were a nit (sic) painful due to the floor being so hard. On assessment noted legs to be even lengths, no bruising at this time to knees however, redness noted, possible bruise in the future. Resident stated he did not hit his head however neuros (neurological checks) were started. On new skin issues or ASE (adverse side effects) to the fall. On this shift this nurse also was able to contact her POA (power of attorney) .WCTM (Will continue to Monitor) A progress note dated 11/28/17 at 4:41 PM, revealed that a pressure alarm was now in place for resident 81. (Note: This was resident 81's first fall in the facility.) Resident 81's care plan revealed the following related to the use of alarms, Alarming floor mat next to bed while occupied. Check placement and function Q shift and PRN. A review of resident 81's Significant Change MDS dated [DATE] revealed that resident 81 had a BIMS of 6. A BIMS between 0-7 indicated that resident 81 was severely cognitively impaired. No evaluations demonstrating medical necessity or assessments demonstrating effectiveness of resident 81's alarming floor mat could be located in resident 81's medical record. On 1/30/18 at 2:05 PM, CNA 1 was interviewed. CNA 1 stated that resident 81 had a pressure alarm under his bed. CNA 1 stated that the monitor hung outside the door and alarmed when resident 81 attempted to get up. CNA 1 stated that the alarm was very loud, and audible throughout the unit and resident 81's room. On 1/31/18 at 9:16 AM, the DON was interviewed. The DON confirmed there were no evaluations of the alarms for resident 81. 5. Resident 53 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 1/29/18 at approximately 9:38 AM, a cordless pressure alarm monitor was observed to be secured to the doorway of resident 53's room. A light on the surface of the monitor was blinking to indicate that the system was functioning. Resident 53's medical record was reviewed on 1/30/18. A review of resident 53's Nursing Progress Notes revealed the following entry: a. On 11/2/17, Per floor nurse: Resident son called stated (sic) that the resident had a fall. He lost his balance and fell backwards while he was out at (name of clinic) appt (appointment). He has a fractured left hip. He is currently at (name of hospital) and they are keeping him overnight. They are discussing options there. Will cont. (continue) to monitor. A review of resident 53's MDS Assessment from 11/27/17 revealed that the resident had scored 6 out of 15 on the BIMS. A BIMS score of 0 - 7 indicates severe cognitive impairment. A review of resident 53's current Care Plan revealed the following entries related to falls: a. (Resident 53) is at risk for FALLS r/t (related to) poor safety awareness, impaired balance and making impulsive decisions. Date Initiated: 09/30/2016. Revision on: 9/30/2016. b. Alarming floor mat next to bed while occupied. Check placement and function (once per) shift. Date initiated: 11/09/2017. Revision on: 11/11/2017. c. (Resident 53) has been educated about increased risk for falls r/t health status and chemo treatments. Risk vs. benefits in place r/t refusal of pressure alarm placement. Upon re-entry to facility after re-hospitalization , (Resident 53) agreed to implementing alarming floor mat placement. Date initiated: 12/28/2016. Revision on: 11/30/2017. On 1/30/18 at 10:30 AM, the DON was interviewed. The DON stated that the facility staff were unsure how to interpret the use of sounding pressure alarms under the new regulations regarding physical restraints. The DON stated that evaluations of these alarms as restraints had not been completed. On 1/31/18 at 8:58 AM, CNAs 3 and 4 were interviewed. CNA 3 stated that resident 53 had a floor alarm that goes off when he steps on it. CNA 3 stated that the resident had experienced a fall out of the facility a few months prior, and that the alarm was put into place following the incident to prevent future falls. Additionally, CNA 3 stated that resident 53 had a pressure alarm on his bed which would sound if the resident got out of bed. CNA 4 stated that resident 53 was alert but confused, and that conversations with him didn't stay on track. CNA 3 further stated that resident 53 asked her name multiple times during the same conversation. 6. Resident 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/29/18 at 2:43 PM, resident 108 was observed to be lying in his bed. Resident 108's bed was observed to be up against the wall with the right side of his body closest to the wall. The left side of resident 108's body was observed to be open to the room. A fall mat was observed to be on the floor next to resident 108's bed. On 1/30/18, resident 108's medical record was reviewed. Review of the medical record revealed the following Nursing Note entries: a. 12/30/2017 17:27 (5:27 PM) Nursing Note Note Text: New Admit. Resident arrived via w/c (wheel chair) at facility at 1045 (10:45 AM) transported by our staff from (name of different Long-Term Care facility). Res. (resident) admitted to facility [MEDICAL CONDITION] with L (left) sided weakness, dysphagia and J (Jejunostomy) tube management. Resident has a history [MEDICAL CONDITION](hypertension), pain, DMII (diabetes mellitus type II), gout, [MEDICAL CONDITION]. Recent history of superficial [MEDICAL CONDITION] to BUE (bilateral upper extremities), aspiration PNA (pneumonia), depression, and is [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) carrier. Res. is a falls risk, fall mat in place and family is aware. b. 1/1/2018 23:00 (11:00 PM) Nursing Note Note Text: Occurrence:Vitals- BP (Blood Pressure) 128/64 Pulse 80 Resp (Respirations) 16 Temp (Temperature) 97.6 At approx. (approximately) 2130 (9:30 PM) CNAs observed resident to be on floor on right side of resident's bed. CNAs notified this nurse to come to resident's room. This nurse entered resident's room, observed resident to be on floor and assessed resident for pain, range of motion, injury, . Resident denied any pain. Small abrasion noted to resident's left shoulder(rear). Range of motion intact on resident's right side. Left sided paresis noted which is within resident's baseline. Neurological checks implemented. Neuro checks within resident baseline. Wife (name) notified. NP (Nurse Practitioner) (name) notified, no new orders. Resident's bed moved next to wall and fall mattress placed on floor of free side. All needs met at this time. Will continue to monitor. Review of the medical record revealed an Admission MDS assessment dated [DATE]. Facility staff assessed resident 108 as requiring extensive assist with a two person physical assist with bed mobility. Review of the care plan revealed the following care plan dated 12/30/17: (Resident 108) has fall secondary to [MEDICAL CONDITION], weakness and poor safety awareness. Goal: (Resident 108) will not sustain serious injury related to fall through the review date. Interventions: . Room rearranged and bed moved against the wall and wing tipped APP (Alternating Pressure Pad) mattress with bilateral positioning bars as least restrictive positioning device. No documentation could be found to show that facility staff assessed resident 108 and the use of the bed against the wall with his dominant side closest to the wall as a restraint. On 1/30/18 at approximately 10:30 AM, the facility DON was interviewed. The DON stated that the facility had not assessed resident 108 and the placement of his mattress against the wall as a type of restraint. The DON stated that the bed had been placed against the wall as an intervention for falls. The DON further stated that the facility staff had not been assessing alarms (tab and bed) as restraints.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food under sanitary conditions. Specifically, there was food not labeled and dated in the refrigerator, equipment was soiled and staff were touching the rims of cups. Findings include: 1. On 6/22/15 at 7:13 AM, an initial kitchen tour was conducted and the following observations were made: a) There were four food carts that were soiled. b) There was liquid egg open to air with no open date in the walk in refrigerator. c) There were 3 cups with a green substance with no date or label. d) There were crumbs on the floor in the freezer and a brown substance on the floor. 2. On 6/22/15 at 7:45 AM, the following observations were made in the 200 hall dining room: a) There was an open container labeled Med Pass with no open date in the refrigerator. b) There was salsa dated 6/12/15 and 6/14/15. c) The steam table had crumbs and was soiled. 3. On 6/22/15 at 8:30 AM, the following observations were made in the 300 hall dining room: a) There were 3 cups with a brown substance in the freezer that did not have a date or label. In addition, the 3 cups had overflowed causing brown substance in the freezer. 4. On 6/22/15 at 7:34 AM, an observation was made of staff members touching resident cups around the rim. Residents were observed placing their mouths on the rims to drink. 5. On 6/25/15 at 7:30 AM, an observation was made of the steam table in the 200 hall dining room. The steam table was observed to be soiled and had crumbs on the lids. 6. On 6/25/15 at 7:45 AM, an observation was made of the meal carts. The meal carts were observed to be soiled. The meal carts were observed to have liquid on the sides and inside the carts. On 6/25/15 at 9:40 AM, an interview was conducted with Cook 1. Cook 1 stated that meal carts were cleaned after each meal and pressure washed every night. Cook 1 stated that the steam table was cleaned after lunch and dinner and wiped after each meal. On 6/25/15 at 10:40 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the steam tables were deep cleaned on Saturdays and sanitized after each meal. The DM stated that the food carts finish was removed.

Based on interview, observation, and record review, it was determined that the facility did not ensure that 1 of 18 sample residents were free of unnecessary physical restraints. Specifically, 1) the resident could not release the self releasing seat belt, 2) the residents family was not educated regarding the use of a restraint and 3) there was no documentation that the device used was the least restrictive device. Resident identifiers: 102. Findings include: Resident 102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/22/15 during initial tour resident 102 was observed to have a seat belt in place while he was in his wheelchair. A physician order [REDACTED]. verify function/placement Q (every) shift and PRN (as needed). Res (resident) able to remove independently. On 6/23/15 at 1:05 PM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that resident 102 required 2 staff member to assist with transfer. RN 1 further stated that resident 102 was unable to stand on his own. RN 1 further stated that resident 102 tried to walk on his own which was unsafe. RN 1 stated that the purpose of seat belt was to prevent resident 102 from standing by himself. RN 1 further stated that the seat belt helped resident 102 to remember not to stand without assistance. RN 1 stated that the seatbelt was not a restraint because resident 102 was able to release it. On 6/23/15 at 1:12 PM, resident 102 was observed with RN 1 present. RN 1 was observed to cue resident 102 to release the seat belt. RN 1 then placed resident 102's hand on the seat belt and asked him to release it. Resident 102 was observed to not be able to release it. RN 1 then released the seat belt and put it back on and cued resident 102 to release the seat belt. At 1:23 PM, resident 102 released the seat belt after being assisted and cued by RN 1 for 11 minutes. No documentation could be found in resident 102's medical record to verify that risks versus benefits were communicated with resident 102's family. In addition, there was no documentation that the self releasing seat belt was the least restrictive device. On 6/25/15 at approximately 10:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that the seat belt would be a restraint if the resident was unable to release it. The DON stated she was aware that resident 102 had difficulty releasing the seat belt independently.

Based on observation and interview, it was determined that the facility did not maintain a sanitary environment. Specifically, the floors in each of the dining room were unsanitized and sticky. Findings include: On 6/22/15 at approximately 8:00 AM, observations were made during the initial dining observation. The 100 hall dining room floor was sticky and had a cloudy film. On 6/22/15 at 7:13 AM, an observation was made of the dining room floor in the 200 hall. The floor was sticky. On 6/24/15 at 11:30, an additional observation was made of the floor in the dining room of the 100 hall. The floor was observed to be sticky. At 12:20 Registered Nurse (RN) 1 was telling another staff member that the floors were sticky. On 6/25/15 at 9:10 AM, the dining room floor in the 100 hall was observed to be sticky. An interview was immediately conducted housekeeper 1. Housekeeper 1 stated that the floors had been very sticky lately. Housekeeper 1 stated that the facility changed cleaning products 3 weeks prior. Housekeeper 1 stated the the floors were increasingly sticky after the new product was started. On 6/25/15 at 9:30 AM, housekeeper 2 was interviewed. Housekeeper 2 stated that the facility started using a different floor cleaner about 2-3 weeks ago. Housekeeper 2 stated that the floors were increasingly sticky since changing the cleaning product. On 6/25/15 at 10:40 AM, an interview was conducted with the Dietary Manager (DM). The DM stated housekeeping department changed floor cleaners about a month ago. The DM stated that resident families had complained about the floors in the dining rooms being sticky. On 6/25/15 at approximately 11:00 AM, the Housekeeping Supervisor (HS) was interviewed. The HS stated that the facility recently changed cleaning products for the floors of the dining rooms. The HS stated that the new product made the floors sticky.

Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the Alzheimer's unit was observed to have areas of disrepair such as furniture, flooring, and resident equipment. Resident identifier: 83. Findings include: On 6/12/13 an intial tour was done of the facility Alzheimer's unit at 8:00 AM. The following items were noted: a) A white stain noted on the back of a blue couch in the day room. The stain was approximately 18 inches long, in the shape of an arch. b) A hole was noted to be in the dining room floor. The hole was approximately 2 inches by four inches in size. c) The dining room refrigerator was noted to contain a half-full soda. The soda was not labeled or dated. d) The piano bench in the day room was noted to have a gold cushion on top of it. The cushion had several areas that were worn, threadbare, and torn. e) A black recliner in the day room was noted to have large tears on the arms. The tears were approximately 3 inches by five inches in size. f) Several chairs in the day room were noted to have crusted debris on the seats. g) Resident 83's wheelchair and accompanying equipment were observed. The lap buddy and wheelchair arm rests were noted to be damaged. The armrests and lap buddy were torn in many areas, exposing the underlying material and rendering them unsanitizable. h) Incontinence odors were present in the day room. These odors were present later that day at 1:00 PM, as well as on 6/13/13 at 2:00 PM. On 6/17/13 at 8:00 AM, an interview was conducted with the Housekeeping Director (HD). The HD stated that the chairs were continuously being cleaned, but that the residents had incontinent episodes and/or spilled drinks frequently. The HD stated that they cleaned the chairs three times a day.

Based on observation and interview it was determined that the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, a Registered Nurse (RN) was observed to place a medication into a medication cup with bare hands, a Certified Nursing Assistant (CNA) attempted to feed a resident with bare hands and another CNA carried dining plates against her clothes as she walked down the hallway. Findings include: 1. On 6/12/13 at 10:24 AM, in the 300 hall, was a medication capsule, unsecured, sitting on top of the medication cart. There was no facility staff nearby. When RN 2 was located, she was asked about a pill left on the medication cart. RN 2 stated that this did not normally happen. RN 2 compared the capsule to other capsules contained in a bubble pack for the resident in room [ROOM NUMBER] and then placed it in a resident's cup with her bare hands. When asked what she would do with the medication, she stated she was going to give it to the resident because she was "100 percent" sure of whom it belonged to. On 6/12/13 at 10:26 AM, RN 2 was observed to go into 328 and administer the medication. 2. On 6/12/13 at 12:35 PM, Certified Nurse Assistant (CNA) 2 was observed while assisting resident 122 to eat his noon meal. Resident 122 attempted to spit out a piece of a bread stick, which CNA 2 caught with his ungloved fingers. CNA 2 then attempted to place the breadstick back in resident 122's mouth. 3. On 6/12/13 at 12:45 PM, a kitchen aide was observed while walking down the hallway carrying approximately five uncovered plates that were resting against her clothes. The kitchen aide entered the kitchen area on the 100 hall and gave the plates to the cook. The cook then began plating additional meals to be served to the residents.