Every finding on record at Good Samaritan - Estherville

Based on observations, staff interviews and policy review, the facility failed to store food items according to professional standards and discard food items after product recommended date. The facility identified a census of 46 residents.Findings include: An initial kitchen tour conducted on 1/12/26 at 10:30 AM, of the kitchen revealed the following items were stored in the kitchen's refrigerator ready for service:a. Bag of shredded lettuce- turning brown- dated 1/2/26b. Container of breaded chicken- dated 1/4/26c. Container of fruit cocktail- dated 1/3/26d. Container of tomato sauce-dated 1/2/26e. Container of egg salad- open with used by date of 12/29/25f. Low Fat Cottage Cheese- 5 lbs- use by 11/11/25g. Mildly Thick Orange Juice - open with no lid and not dated. The directions on the container documented after opening may be kept up to 7 days under refrigeration.h. Angel food cake inside a plastic bag- Not datedIn addition, observation revealed a tray of dinner buns on a rack that were not covered.On 1/12/26 at 10:48 AM, the Certified Dietary Manager (CDM) reported left overs are good for 3 days then discarded otherwise they go by the expiration date on the food item. The facility policy titled Food-Supply-Food and Nutrition Services dated 3/7/25 documented the purpose of the policy was to ensure food was stored properly. The policy documented left over food items to be used within 7 days per food code and food items that have a use by date are checked on a regular basis and discarded when expired.

Based on clinical record review and staff interview, the facility failed to complete a gradual dose reduction (GDR) for 1 of 5 residents (Resident #8) reviewed for unnecessary medications. The facility reported a census of 46 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS included diagnosis of non-Alzheimer's dementia, depression, frontotemporal cognitive disorder, adjustment disorder with depressed mood and emotional lability. The MDS documented Resident #8 was taking high risk medication that included antipsychotic and antianxiety medications. The Clinical Record revealed Resident #8 was admitted to the facility on [DATE].The Care Plan with a target date of 3/10/26 revealed Resident #8 was on an antipsychotic medication related to dementia with behavioral symptoms and an antianxiety medication related to adjustment issues and anxiety disorder. The care plan directed staff to consult with pharmacy and health care providers to consider dosage reduction when clinically appropriate.The January 2026 Medication Administration Record (MAR) directed staff to administer the following medications:1. Lorazepam (antianxiety medication) 0.5 mg (milligrams) one tablet one time a day in the morning with a start date of 12/24/24. 2. Lorazepam 0.5 mg one tablet one time a day at bedtime with a start date of 12/27/24.3. Olanzapine (antipsychotic medication) 2.5 mg one tablet two times a day with a start date 11/12/24. Review of the Clinical Record revealed one GDR completed on 9/17/25 for the routine Lorazepam and Olanzapine with no changes being made. The clinical record lacked a second GDR being completed in 2 separate quarters within the first year of admission. On 1/15/26 at 1:30 PM, the Director of Nursing (DON) verified there was only one GDR completed for the Olanzapine and routine Lorazepam on 9/17/25. The DON said she called the pharmacist and the pharmacist could not locate the second GDR. The DON agreed it was an expectation to complete two GDRs within the first year, in two separate quarters with a month in between.

Based on clinic record review, staff interviews, and policy review. The facility failed to develop a care plan to address risk factors and interventions for 2 of 13 residents reviewed. (Residents #7, and #10) for Comprehensive Care Plans. The facility reported a census of 46. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated for 11/3/2025 identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of traumatic brain injury (TBI), hypertension (high blood pressure), and depression. Resident #4's January 2026 MAR's listed the following orders:Oxygen at 4 Liters Per Minute (LPM) per nasal cannula, via O2 concentrator and/or tank. Titrate as tolerates, wean oxygen as patient tolerates tube and O2 sats 90% every shift for hypoxia. The Care Plan with an initiated date of 5/5/25 failed to develop a care plan for oxygen therapy. 2. Resident #10's Minimum Data Set (MDS) assessment dated for 12/8/2025 identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS included diagnoses of hypertension (high blood pressure), renal insufficiency, and diabetes mellitus.Resident #10's January 2026 MAR's listed the following orders:Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 Unit/ML - inject 25 unit subcutaneously two times a day for Diabetes.Insulin Aspart Injection Solution 100 unit/ML - inject 14 unit subcutaneously before meals for Diabetes.Insulin Aspart Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 200 - 250 = 4 units; 251 - 300 = 7 units; 301 - 350 = 10 units; 351 - 400 = 13 units; 401 - 450 = 16 units >451 call Dr. [NAME]., subcutaneously four times a day for DiabetesThe Care Plan with an initiated date of 8/26/25, lacked direction regarding the treatment and management of type 2 diabetes mellitus and insulin usage. The Care Plan lacked risk factors and interventions regarding blood sugar monitoring and parameters on when to report the Physician, signs/symptoms to monitor for related to hyper/hypoglycemia (high/low blood sugars), and potential adverse reactions/complications.The facility policy titled Care Plan - R/S, LTC, Therapy and Rehab with a revised date of 12/1/25 revealed the purpose to develop a comprehensive care plan using an interdisciplinary team approach and to provide guidance to the interdisciplinary team in developing the initial care plan. Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. The comprehensive plan of care will be finalized during an interdisciplinary care team conference no later than seven days after completion of the comprehensive resident assessment. This plan of care will be modified to reflect the care currently required/provided for the resident. The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services.On 1/15/26 at 10:00 a.m. the Director of Nursing acknowledged the care plans did not address the oxygen therapy and lacked treatment and management of diabetic mellitus.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 13 residents reviewed (Resident #2) for Physician orders. The facility reported a census of 46 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #2 was dependent on staff for lower body dressing. The MDS included diagnoses of hypertension (high blood pressure), heart failure (heart does not pump enough blood), chronic kidney disease, type 2 diabetes mellitus, and morbid obesity. The Care Plan with a target date of 2/10/26 revealed Resident #2 had skin integrity issues with open wounds on bilateral lower extremities (BLE) related to a fall. The care plan directed staff to monitor location, size and treatment of the skin injury. The care plan lacked direction regarding ace wraps or compression to lower the BLE. The Progress Note dated 11/12/25 revealed Resident #2 was seen for an initial ET (enterostomal therapy) nurse consultation due to BLE injuries related to a fall on 10/27/25. The ET nurse recommended the following:1. Topical care to the left lower extremity (LLE) wound on bath days and PRN (as needed) with dislodgement or soilage. Cleanse wound and periwound with Vashe (wound cleanser) and gauze. Dry with gauze. Apply Triad (hydrophilic paste) to the wound base. Gently fill depth with a strip of CMC fiber (highly absorbent dressing). Secure with a foam border dressing. 2. Topical care to the right lower extremity (RLE) wound daily and PRN with dislodgement or soilage. Cleanse wound and periwound with Vashe wound cleanser and gauze. Dry with gauze. Apply Triad to wound base. Gently fill depth with a strip of CMC fiber. Secure with a silicone super absorbent dressing. 3. Apply gradual compression to BLE daily (on in the morning and off at bed time). Beginning at base of toes with a 4 inch ace wrap and transition to 6 inch ace wrap to complete wrapping to base of the knees. The Progress Note dated 11/14/25 revealed Resident #2's Physician agreed with the ET Nurse recommendations. The November 2025 Treatment Administration Record (TAR) revealed the treatment order for the RLE was not transcribed correctly to the TAR on 11/14/25. The RLE treatment was transcribed to the TAR to be completed on bath days (Tuesday and Friday) and not daily as the Physician order was written. The TAR revealed the treatment to the RLE was not completed on 11/15 and 11/16. The Clinical Record revealed Resident #2 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The Progress Note dated 12/2/25 revealed the ET Nurse evaluated Resident #2's BLE wounds and recommended to restart the gradual compression to BLE daily (on in the morning and off at bed time). Beginning at base of toes with a 4 inch ace wrap and transition to 6 inch ace wrap to complete wrapping to base of the knees. The Physician agreed with the recommendations on 12/2/25. The December 2025 TAR revealed the ace wraps were not signed off indicating Resident #2 did not wear the ace wraps according to the Physician order on the following dates: 12/8, 12/9, 12/10, 12/13, 12/14, 12/15, 12/16, 12/23 and 12/30. On 1/14/26 at 1:30 PM, the Director of Nursing (DON) and the facility wound nurse acknowledged the daily treatment for the RLE was not transcribed correctly to the November TAR. The DON reported she would expect treatments to be transcribed correctly and implemented per Physician order. The DON reported she would expect staff to follow the physician order for the ace wraps and document the administration or refusals on the TAR. The facility policy titled Physician/Practitioner Orders dated 4/6/25 documented the purpose of the policy was to provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders and to provide a procedure that facilitates the timely and accurate processing of the orders. The policy directed orders must be obtained for wound care including product to be used, when to change and when to reassess.

Based on clinical record reviews, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 2 residents reviewed (Resident #2) for falls. The facility reported a census of 46 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #2 was dependent on staff for all transfers. The MDS included diagnoses of hypertension (high blood pressure), heart failure (heart does not pump enough blood), chronic kidney disease, type 2 diabetes mellitus, and morbid obesity. The Care Plan initiated on 8/11/25 revealed Resident #2 had an Activity of Daily Living (ADL) self care performance deficit related to weakness and limited mobility. The care plan intervention revised on 9/20/25 directed staff to use a mechanical sit to stand lift with assist of 2 with transfers or sit to stand with assist of 2 staff members, walker and gait belt depending on resident's fluctuating level of consciousness. An incident report (IR) titled Resident Event dated 9/20/25 at 10:30 AM revealed Resident #2 had fallen on the floor when one staff member was transferring Resident #2 from the recliner to commode using a mechanical sit to stand lift. The IR documented Resident #2 let go of the bars and slipped out of the sling onto the floor. The clinical record documented the intervention was to use the mechanical sit to stand lift with assistance of 2 staff members instead of one. An IR titled Resident Event dated 10/9/25 documented a Registered Nurse (RN) was called to Resident #2's room due to Resident #2 almost slipped out of the lift. The note documented Resident #2 was readjusted with the lift sling placed correctly and assisted onto the commode. According to the note, the RN told the CNA (Certified Nursing Assistant) not to transfer Resident #2 on her own and to call for help when she was finished on the commode. The RN was called back urgently to Resident #2's room and noted Resident #2 on the floor. The CNA reported when she went to transfer Resident #2, she went limp and was assisted to the ground. On 1/14/26 at 10:45 AM, Staff A, CNA reported she assisted Resident #2 on and off the commode using the mechanical sit to stand lift by herself. Staff A said when she went to get Resident #2 off the commode to go to the wheelchair she went limp and was not standing. She said Resident #2 could not hold onto the bar of the lift. She said she lowered Resident #2 to the floor by putting her hands under her armpits. On 1/14/26 at 11:09 AM, Staff B, RN reported when she entered the room, Resident #2 was on the commode but not safely. She said she had to help reposition Resident #2 so she could go to the bathroom. She said Resident #2's sling was not applied correctly. She said the sling was loose and Staff A was using the blue and green loop. Staff B said she corrected the harness and provided education to Staff A. She said she told Staff A to stay with Resident #2 and not to leave her. Staff B said she told Staff A to radio her when Resident #2 was ready to get off the commode and she would come back to help with the transfer. Staff B said she told Staff A not to get Resident #2 up by herself. Staff B said the next radio contact from Staff A was reporting Resident #2 was on the floor. Staff B said she went to the room and observed Resident #2 was on the floor and Staff A was in a panic. She said Staff A was the only person in the room. She said Staff A reported Resident #2 had gone limp. She said when she got to the room Resident #2 was talking to her. She said she told Staff A not to use the mechanical sit to stand lift again and to use the full body mechanical lift. On 1/14/26 at 1:00 PM, the Director of Nursing (DON) reported the intervention for the fall on 10/9/25 was verbal education with Staff A. The DON reported she did not document the education that was given. The DON reported she would expect the staff to follow the care plan. The facility policy titled Safe Resident Handling Program dated 12/12/25 documented the goal was to maintain a safe living and working environment for residents and employees. The policy directed the caregivers to perform a time out safety stop while the resident is in a sling or harness and still over the surface of the bed or chair to ensure that all straps are secure before moving away from the surface. This was to be completed once the straps are taut, but before the resident leaves a surface. The facility policy titled Care Plan dated 12/1/25 documented the purpose of the policy was to develop a comprehensive care plan using an interdisciplinary approach. The policy documented the plan of care would be modified to reflect the care currently required and provided for the resident. The care plan will address the relationship of items or services required and facility responsibility for providing these services.

Based on record review and staff interview, the facility failed to report an allegation of abuse to the State Survey and Certification Agency/Department of Inspections, Appeals and Licensing (DIAL) for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 50 residents.Findings include:According to the Minimum Date Set (MDS) assessment dated [DATE] Resident #3 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required assist with toileting, bathing and transfers. The residents diagnoses included an (ankle) fracture.The Progress Notes dated 9/24/25 at 3:06 a.m. documented the resident screamed, waking residents up, self transferring , and making false accusations of being hit by the nurse while the nurse had been at the nurse station charting.On 10/29/25 at 2 p.m. the Administrator stated the resident's son came in, and the police officer came late that afternoon. That was how/when they found out about the allegation made about the night nurse. She said they didn't self-report it because the police had already looked at the video of that night. She said the night nurse was on contract at the time. On 10/30/25 at 8:25 a.m. The administrator and the Director of Nursing (DON) both agreed Staff A Licensed Practical Nurse (LPN) documented about the resident's allegation. The Administrator stated if they had been notified, they would have self-reported to state. On 11/6/25 at 9:42 a.m. Staff A Licensed Practical Nurse (LPN) stated she was at the nurses station when she heard the resident screaming in the hall. She wasn't sure where the CNA was. She walked down the hall and the resident said she threw a flashlight at her. Staff A stated she didn't get close to the resident because she made that allegation. She said she notified the supervisor, but she couldn't remember who. She said that was her last shift there. During interview with the Administrator shown an undated report that documented the Administrator has reported a total of 8 self-reports in the past year for this location and understands the need to report when needed. However, the police had conducted a thorough investigation and deemed that there was nothing that occurred. Therefore the Administrator considered this case closed. The son had reported it therefore both family and local police were notified. The resident sustained no injury or any trauma that was ever identified. This allegation by a disgruntled family member was deemed by the local police as unfounded and therefore no further actions were taken. This agency nurse has not worked in the center since that time as the center has not needed agency assistance since that time.The facility Abuse and Neglect policy reviewed/revised 4/7/27 documented alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin would be reported immediately to the administrator. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.). If the alleged perpetrator is one's supervisor or department manager, notify his/her supervisor. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency (DIAL). If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident/client property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. If there is an allegation that does not involve abuse and there is no serious bodily injury, then it will be reported not later than 24 hours after the allegation is made.

Based on the Center for Medicare and Medicare Services (CMS) PBJ (Payroll Based Journal) Staffing Data Report for April 1 - June 30, 2024 report, facility schedules, and staff interview, the facility failed to submit complete and accurate staffing information to CMS. The facility reported a census of 51 residents. Findings include: The CMS PBJ Staffing Data Report for April 1 - June 30, 2024 indicated the facility triggered for investigation of staffing. The Facility Schedule for May 4th, 2024 showed Staff E Agency Certified Nursing Assistant (CNA) worked 6 p.m. to 6:15 a.m. (May 5th). A facility PBJ report lacked hours for Staff E on May 5th. On 10/30/24 at 9:34 a.m. Staff D who now does scheduling, and did it at one time before, looked at May 4-5 weekend and a Staff E CNA who worked 6 p.m. to 6 a.m. was inputted into the wrong day on the PBJ report. She actually worked 5/4/24 6 p.m. to May 5th 6 a.m., but her information was put in on 4/28/24, a day she did not work. On 10/30/24 at 10:30 a.m. the Administrator confirmed Staff E was put in on the PBJ report 4/28/24 a day she did not work, and not on 5/5/24 (a day she worked 12 a.m. to 6 a.m.). The information was put in wrong. On 10/31/24 at 10:26 a.m. the Administrator obtained additional information that PBJ did not always include agency staff. She said they did not accurately input the information into the PBJ report.

Based on observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 2 of 8 residents reviewed (Residents #27, and #43). The facility reported a census of 51 residents. Findings include: 1. Review of Resident #27 ' s Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Interview on 10/28/24 at 12:02 PM with Resident #27 revealed that she eats in her room and that the food is often cold when it is delivered. 2. Review of Resident #43 ' s MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. Interview on 10/28/24 at 1:17 PM with Resident #43 revealed that food is often cold when it should be hot. During continuous observation on 10/30/24 at 1:32 PM the last room trays were sent out of the kitchen to be delivered to the residents. Observation on 10/30/24 at 1:47 PM a temperature was obtained on the last room tray delivered. The ham and beans was revealed to be 126 degrees and the mashed potatoes were noted to be 122 degrees. Interview on 10/30/24 at 1:53 PM with the Certified Dietary Manager (CDM) revealed her expectations are for food to be served at the appropriate temperatures. Review of a facility provided policy titled, Food Temperature Monitoring with a review date of 12/21/23 documented: a. Hot foods should be served at 135 degrees Fahrenheit or higher.

Based on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 51 residents. Findings include: During continuous observation on 10/30/24 from 12:25 PM until 12:41 PM Staff A was observed to make extra servings of pureed brownie without completing hand hygiene. Staff A was then observed touching door jams, then preparing room trays, handling spatulas, touching plates for service, and handling bowls for lunch service. At 12:41 PM Staff A then completed hand hygiene. Interview on 10/30/24 at 1:53 PM with the Certified Dietary Manager (CDM) revealed her expectations are for hand hygiene to be completed at the appropriate times. Review of a facility provided policy titled, Hand Washing and Glove Usage-Food Nutrition Services with a review date of 6/13/24 revealed: a. Employees involved in food preparation, distribution and serving must consistently utilize good hygienic practices and techniques.

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to treat residents with dignity, and respect throughout cares provided for 2 of 5 residents reviewed (Resident #2, and #43). The facility reported a census of 51 residents. Findings include: 1. Review of Resident #2 ' s Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnosis of cancer, renal insufficiency, anxiety, and diabetes mellitus. Interview on 10/29/24 at 8:07 AM with Resident #2 revealed that Staff B Certified Nursing Assistant (CNA) had told her that she would get to her when she had time, and to not keep using the call light. Resident # 2 then revealed that Staff B had never cursed at her, but was just rude and waved her finger at Resident #2. Review of a facility provided investigation dated 9/22/24 revealed an interview with Resident #2 documenting that Resident #2 reported a concern that Staff B had pointed at Resident #2 and told the resident to not put on the call light, and that Staff B would get to the resident when Staff B had time. This document further revealed that Staff B was put on suspension on 9/23/24 at 11:11 AM. 2. Review of Resident #43 ' s MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. The MDS further revealed diagnosis of heart failure, and diabetes mellitus. Interview on 10/28/24 at 1:12 PM with Resident #43 stated that Staff B CNA was very barky, and rude. Resident #43 further revealed that Staff B does not work here anymore. Resident #43 stated that there was a meeting and he brought up the fact that Staff B was rude. Resident #43 revealed he was relieved when Staff B was not here anymore. Resident #43 stated Staff B would talk very disrespectfully to him, and other residents. Interview on 10/30/24 at 7:49 AM with Staff C Registered Nurse (RN) revealed that she had heard reports from residents that Staff B was rude to them. Staff B stated that residents had told her that Staff B was never rough with them, but it was just the tone of her voice, and that Staff B wasn't talking to them in a respectful way. Staff C then revealed that she would notify the Director of Nursing (DON) when the complaints were reported to her. Interview on 10/30/24 at 10:54 AM with the DON revealed her expectation would be for staff to treat the residents with dignity and respect. The DON further revealed that she will not tolerate any issues of residents being treated without respect or dignity. Interview on 10/30/24 at 11:06 AM with the Administrator revealed that her expectations are for residents to be treated with respect and dignity at all times. Review of facility provided policy titled, Resident Dignity with a review date of 11/16/23 revealed: a. Addressing residents as individuals when providing care and services.

Based on clinical record review, staff interview, and policy review the facility failed to update the resident's care plan to accurately reflect the resident for 1 of 3 residents reviewed (Resident #200). The facility reported a census of 51 residents. Findings include: Review of Resident #200 ' s Minimum Data Set (MDS) dated [DATE] revealed Resident #200 was admitted on [DATE] from a critical access hospital. The MDS further revealed diagnosis of depression, and psychotic disorder. Review of Resident #200 ' s Electronic Healthcare Record (EHR) page titled, Physician ' s orders revealed an order for alprazolam (an antianxiety medication) 0.5 mg oral tablet, give 0.5 mg by mouth every 8 hours as needed for agitation. Review of Resident #200 ' s Care Plan with a printed date of 10/30/24 lacked any documentation of antianxiety medication usage. Interview on 10/30/24 at 10:51 AM with the Director of Nursing (DON) confirmed Resident #200 does have an order for alprazolam, and her expectation would be for antianxiety medications to be on the Resident ' s care plan. Review of a facility provided policy titled, Care Plans with a revision date of 11/1/23 revealed: a. The plan of care will be modified to reflect the care currently required/provided for the resident.

Based on observation, record review, and staff interview, the facility failed to have sufficient nursing staff to complete individualized restorative nursing plans for 4 of 4 residents reviewed (Resident #1, #3, #4, and #7). The facility reported a census of 53 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had no functional limitation in range of motion (ROM). The resident had diagnoses including Myasthenia Gravis (weakness and rapid fatigue of muscles under voluntary control). The Care Plan identified the resident had a need for restorative intervention due to limited physical mobility related to Myasthenia Gravis evidenced by weakness, initiated 5/28/19. The interventions included: a. Passive (P)ROM to fingers and wrists of left and right extremities, 5 to 8 repetitions as tolerated 3 x week. b. Active (A)ROM: to complete RNA program 3 x/week of the following: hamstring and calf stretching 3x30 seconds bilateral, seated active assisted (AA)ROM, hip flexion, minimum resistance hip abduction and hamstring curl each 3x10. With AAROM, have resident initiate the movement and then assist her to complete the entire movement. The October 2023 Restorative sign off sheets lacked any signatures the resident's restorative plan was completed. The November 2023 Restorative sign off sheets lacked any signatures the resident's restorative plan was completed. 2) According to the MDS assessment dated [DATE] Resident #3 scored 11 on the BIMS indicating moderate cognitive impairment. The resident had no functional limitation in ROM. The resident had diagnoses including hemiplegia (paralysis) following intracerebral hemorrhage (stroke) affecting the right dominant side. The Care Plan identified the resident had a need for restorative intervention due to limited physical mobility related to a history of a stroke evidenced by activity intolerance, initiated 9/22/22. Interventions included: a. AROM, ambulation x 50 feet with gait belt and front wheeled walker (FWW) 2-3 x week. b. NuStep level 4 x 12 minutes 2-3 x week. c. Pull to stand using side rail 2 x 10 reps. 2-3 x week. The October 2023 Restorative sign off sheets lacked any signatures the resident's restorative plan was completed. The November 2023 Restorative sign off sheets lacked any signatures the resident's restorative plan was completed. 3) According to the MDS assessment dated [DATE] Resident #4 demonstrated long and short term memory problems and severely impaired skills for daily decision making. The resident had no functional limitation in ROM. The resident's diagnoses included Alzheimer's disease and osteoporosis. The Care Plan identified the resident had a need for restorative intervention due to limited physical mobility related to a right hip fracture evidenced by weakness, revised on 6/21/23. Interventions included PROM to all extremities, 5 reps of 10, 2-3 x/week. The October 2023 Restorative sign off sheets lacked any signatures the resident's restorative plan was completed. The November 2023 Restorative sign off sheets lacked any signatures the resident's restorative plan was completed. 4) According to the MDS assessment dated [DATE] Resident #7 scored 15 on the BIMS indicating no cognitive impairment. The resident had a functional limitation in ROM of both lower extremities. The resident had contractures of the left shoulder, left upper arm, left hand and left forearm. The Care Plan identified the resident had a need for restorative intervention due to limited physical mobility related to contractures evidenced by weakness, revised 6/4/21. The interventions included: a. AROM both upper extremities and lower extremities all joint in all available planes sitting or supine. (Have resident demonstrate proper wrist/hand ROM/stretching that she needs to do 4<>8 x day by herself), 2-3 x week. b. Resident to self propel in wheelchair to all activities/meals daily to maintain strength/endurance maximize resident independence. c. PROM left upper extremity all joints and bilateral lower extremities hamstring/ankle x 2 set x 20 -30 second stretch, 2-3 x week. The resident sign off sheet for October 2023 showed staff usually signed off for the resident propelling self to all activities and meals 3 times a day. The other restorative directives were not signed off. The resident sign off sheet for November 2023 showed staff usually signed off for the resident propelling self to all activities and meals 3 times a day. The other restorative directives were not signed off. On 11/30/23 at 2:02 p.m. Resident #7 stated she had contractures of her left arm and hand. She can do some exercises herself but not like the girls used to do. She was told in September Staff D RN was going to do restorative. That has not happened. She does not want to lose the movement she has left (in feet). The resident was able to move the toes on her right foot, but could not on her left. On 11/21/23 at 3:20 p.m. Staff A Registered Nurse (RN) stated restorative is not getting done. They don't have the time to do it. They have to take care of the residents other needs. They used to have a restorative aide but they don't have the staff to do it. On 11/28/23 at 9:16 a.m. Staff B CNA stated the residents are not getting restorative because they are short staffed. On 11/28/23 at 9:32 a.m. Staff C Licensed Practical Nurse (LPN) stated they planned to get to restorative when they had the staff to do it. The facility Restorative policy revised 11/8/23 identified the purpose to provide appropriate restorative nursing care to each resident. The goal of restorative nursing care was to attain and maintain the maximum possible independence and/or prevent rapid declines through their interventions for each resident.

Based on observation, menu review and staff interview, the facility failed to serve the menu as written for 4 of 4 meals observed. The facility reported a census of 53 residents. Findings include: 1) The menu for the noon meal 11/21/23 included grilled chicken chef salad, potato salad and a garlic buttered breadstick. On 11/21/23 at 11:30 a.m. Staff H Cook stated they were having a chicken patty, carrots, and potato salad. Staff H served the aforementioned. 2) The menu for the noon meal 11/27/23 included French style green beans. On 11/27/23 at 9:50 a.m. Staff E Cook, stated serving what's on the menu except wax beans. On 11/27/23 at 12:30 p.m. residents received wax beans instead of green beans. 3) The noon menu for 11/28/23 included buttered cauliflower. On 11/28/23 at 11:54 a.m. Staff H served lunch including mixed vegetables. At 1:50 p.m. Staff H stated they didn't serve cauliflower because they didn't have any. 4) The noon menu for 11/29/23 included coffee cake. On 11/29/23 at 12:10 p.m. residents received a cookie with lunch, not coffee cake. The facility policy Menu Requirements- Food and Nutrition Services revised 1/24/23 documented menus were prepared at least one week in advance of when the menu was served. Temporary menu changes should be kept to a minimum.

Based on observation and staff interview, the facility failed to assure meals were served at regular times comparable to normal mealtimes in the community. The facility reported a census of 53 residents. Findings include: On 11/27/23 at 3:20 p.m. Staff A Registered Nurse (RN) stated there had been times when residents did not receive breakfast. There had been times when lunch was served as late as 2 p.m. On 11/28/23 at 8:40 a.m. Resident #2 stated she hadn't received her breakfast yet. Resident #2's husband arrived at 9:15 a.m. and she still had not had breakfast. At 9:45 a.m. the resident and her husband stated she just finished breakfast. On 11/29/23 at 9:20 a.m. room trays were not out yet. A resident came to the 400/500 hall nurses station to ask about breakfast. Staff A told her they not brought trays out yet. On 11/29/23 at 9:45 a.m. breakfast trays were delivered by Staff G Dietary Aide. On 11/29/23 at 9:47 a.m. Resident #2 stated she thought she would be getting breakfast earlier. Her husband stated they were late for some reason. On 11/29/23 at 9:51 a.m. Resident #3 stated she ate in the dining room for breakfast. She said they had forgotten to bring her a tray 1 time when she stayed in her room. On 11/29/23 at 10:00 a.m. Staff E, cook stated trays were late this morning. They don't get those ready until they have served everyone in the dining room. She did feel that was late to be getting breakfast. On 11/29/23 at 10:02 a.m. Staff A came to the dining room and asked for a breakfast tray for a new resident admitted yesterday. Staff E stated she didn't know about that, there was no dietary card for the resident. On 11/29/23 at 11:45 a.m. Resident #2 sat in the dining room for lunch with her husband. When asked if she was ready for lunch, she said not really, she ate not too long ago (breakfast trays served at 9:45 a.m.). On 11/29/23 at 4:30 p.m. the Administrator stated meal times were 7:30 a.m., 11:30 a.m. and 5:30 p.m The facility policy Frequency of Meals and Snacks- Food and Nutrition Services documented the purpose to ensure scheduled meals were consistent with normal meal times in the community.

Based on observation, schedule review, and staff interview, the facility failed to assure sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. The facility reported a census of 53 residents. Findings include: During an observation on 11/21/23 at 11:30 a.m. Staff H Cook was in kitchen. At 11:45 a.m. Staff I working as a dietary aide (DA), stated she normally worked in housekeeping, but was helping out in dietary. Staff G Dietary Aide (DA), and Staff J DA were also working. The Dietary Department schedule for November 21st showed Staff H, Staff G and Staff J scheduled. Staff I was not scheduled in dietary. On 11/21/23 at 3:20 p.m. Staff A Registered Nurse (RN) stated she had seen families serving breakfast. On 11/27/23 at 12:10 p.m. Staff F RN stated the Dietary Supervisor resigned before she went on maternity leave. Sometimes there are only 2 staff in the kitchen and they need 3. She has seen family members try to help with meal service and it's really not a good idea, they could serve a resident the wrong plate. The Dietery Department Schedule showed 3 staff scheduled in the kitchen daily from 10/29/23 to 12/2/23. On 11/27/23 at 2:45 p.m. Staff E Cook stated the meal service was going slow and Resident #8's family member would come for breakfast to sit with Resident #8. One day the cook didn't have an assistant, and Staff G Dietary Aide (DA) was there but he was still in training. The meal service was going very slowly and the family member was trying to get things for the residents, but she didn't know the resident's diets. They told her not to do that and she did not comply. On 11/28/23 at 12:29 p.m. Resident #8's family member stated there was a problem with the kitchen. She said one staff member retired and another left. They got Staff H and she left between 7:30 and 8:30 a.m. to take her son somewhere. Staff G was new and had only been there 2 days. He didn't know what to do. So she started helping so the residents could get their breakfast. Another family member also assisted with serving the residents. This went on for awhile. She then called the corporate office and after that they said she couldn't help. They brought in people from housekeeping to help in dietary. On 11/21/23 at 1:27 p.m. Resident #7's family member stated he went out to have breakfast with his mother. There was no one there to get the residents their food. He spent 2 hours taking orders from the residents and then took the food to them. This went on for about 2 weeks. On 11/29/23 at 8:58 a.m. Staff I stated Staff H did leave at 7:30 a.m. to take her son to school. She said she got back around 8 a.m. She said when that happened she or Staff G, or whoever worked could serve residents. On 11/29/23 at 4:30 p.m. the Administrator stated they had the staff necessary to run the dietary department. They did not ask family to help.

Based on observation, facility policy, admission packet, resident interviews, and staff interviews, the facility failed to provide a way for residents to submit an anonymous grievance. The facility reported a census of 46 residents. Findings include: Observation on 8/27/23 at 2:33 PM of the entry area of the facility revealed: 1. Bulletin board with the Grievance Policy and information about grievances. The information revealed that the Grievance Officer was the Social Worker and that forms were available from her for residents to complete and submit to her. 2. There was no information available about how to file an anonymous grievance. 3. Grievance forms were not available in the entry area either on or near the bulletin board, an open window to the office, or a table in the entry that contained information for residents. In an interview on 8/27/23 at 11:18 AM, Resident #25 reported that she knows that she can file a grievance at the facility, but does not know where grievance forms are located in the facility or that she could file an anonymous grievance. In an interview on 8/28/23 at 12:29 PM, Resident #3's representative reported that she did not know how to file a grievance at the facility. In an interview on 8/29/23 at 11:26 AM, Resident #25's family member reported that he did not have any knowledge about the grievance procedure at the facility. In an interview on 8/30/23 at 12:14 PM, Resident #3's family reported that they do not know how to file a grievance at the facility. In an interview on 8/30/23 at 4:33 PM, the Social Worker reported that residents and families can get grievance forms from her and that does not know how residents or their families could file an anonymous grievance. In an interview on 8/30/23 at 11:33 AM, the Administrator reported that at last year's recertification survey, a surveyor told him grievance forms were not required to be available for resident use, he removed them from the entry area by the grievance display. When asked the surveyor's name who advised him of this, the Administrator was not able to recall a name. The Grievances, Suggestions or Concerns- Social Services Policy with a revised date of 11/5/20 revealed: 1. A resident has the right to voice grievances orally, in writing and anonymously without discrimination or reprisal. 2. The grievance official will be responsible for posting this procedure in an area accessible to residents/families and visitors. This responsibility also includes educating employees, residents, patients, family and visitors on the use of this form, as well as where visitors, employees, patients and residents can obtain forms for filing or how to verbalize their suggestion/concerns. The Resolving the Issues Brochure dated 11/13 lacked information about how to file an anonymous grievance or where grievance are located in public areas of the facility. The brochure directed: 1. The first step in resolving compliance issues is to address your concerns with the grievance official at the location. 2. Note: You do not not need to identify yourself when you call (Corporate Compliance), as long as the Society is able to investigate the concern and take necessary corrective action without knowing your name. 3. Upon completion of the concern or suggestion form, return to Social Worker or Administrator.

Based on clinical record review, staff interview and facility policy the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 2 out of 15 sampled residents reviewed for comprehensive care plans (Resident #11 and #33) and the facility failed to revise and update care plans after a pressure ulcer was healed and a high risk medication was discontinued (Resident #25 and #37). The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 documented diagnoses of anxiety disorder, atrial fibrillation and renal insufficiency.The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of the August 2023 Medication Administration Record (MAR) revealed the following orders: Eliquis (anticoagulant medication) twice daily with an order date of 7/14/23, Risperidone (antipsychotic medication) daily with an order date of 3/17/23, Furosemide (diuretic medication) daily with and order date of 6/23/20. Review of the MDS dated [DATE] revealed anticoagulant, antipsychotic and diuretic medication taken 7 out of 7 days in the look back period. Review of the Order Summary Report signed 8/28/23 revealed the following orders: Eliquis twice daily with an order date of 7/14/23, Risperidone daily with an order date of 3/17/23, Furosemide daily with and order date of 6/22/20. Review of the Care Plan with a revision date of 8/25/23 lacked information regarding the side effects of anticoagulant, antipsychotic and diuretic medication. 2. The MDS assessment dated [DATE] for Resident #33 documented diagnoses of renal insufficiency and dependence on renal dialysis. The MDS showed a BIMS score of 15 indicating no cognitive impairment. Review of the August 2023 Medication Administration Record (MAR) revealed the following orders: Eliquis twice daily with an order date of 5/17/23, Furosemide with and order date of 4/27/23, Hydrocodone- Acetaminophen (opioid medication) with and order date of 1/10/23, Insulin (diabetic medication) with an order date of 1/10/23. Review of the MDS dated [DATE] revealed insulin injections and anticoagulant medication taken 7 out of 7 days in the look back period and diuretic and opioid medication 4 out of the 7 days in the look back period. Review of the Order Summary Report signed 8/28/23 revealed the following orders: Eliquis twice daily with an order date of 5/17/23, Furosemide with and order date of 4/26/23, Hydrocodone- Acetaminophen with and order date of 1/10/23, Insulin with an order date of 1/10/23. Review of the Care Plan with a revision date of 8/24/23 lacked information regarding the side effects of anticoagulant, diuretic, opioid and insulin medication. Interview on 8/30/23 at 10:06 a.m., with the Director of Nursing revealed the high risk medication side effects to watch for should be listed on the care plan. 3. The MDS assessment dated [DATE] for Resident #37 documented diagnoses of osteoarthritis, coronary artery disease and hypertension. The MDS showed a BIMS score of 15 indicating no cognitive impairment. Interview on 8/27/23 at 10:44 a.m., with Resident #37 revealed she had a sore on her bottom but it is healing. Review of the Care Plan with a revision date of 6/21/23 resident has pressure ulcers to right buttock and assess, record, monitor wound healing daily. Report improvements and declines to the health care provider. Review of Wound Registered Nurse (RN) assessment dated [DATE] revealed area resolved. Review of Skin Observation documentation dated 8/26/23 revealed skin check was completed and no skin conditions observed or skin condition resolved. Interview on 8/30/23 at 10:05 a.m., with the DON revealed the pressure ulcer was healed and should have been removed from the care plan. 44475 4. The MDS dated [DATE] for Resident #25 revealed a BIMS score of 14 which indicated intact cognition. The MDS revealed the resident had diagnoses of anxiety, depression, post traumatic stress disorder (PTSD), and histrionic personality disorder. The Care Plan Focus Area revised on 6/12/19 revealed the resident took antipsychotic medication therapy R/T (related to) mood. Medication: Abilify (antipsychotic medication). The Fax (facsimile) Communication to Physician signed by a physician on 8/14/23 revealed an order to discontinue Abilify. In an interview on 8/29/23 at 3:19 PM, when asked if the resident's care plan should reflect the change in Abilify order, the Director of Nursing (DON) asked what date Abilify was discontinued and then changed the topic from the issue with the care plan. In an email on 8/29/23 at 12:53 PM, a Care Plan Policy was requested from the Administrator. As of noon on 8/30/23, this policy was not received.

Based on observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 46 residents. Finding Include: 1. Interview on 8/27/23 at 10:20 a.m., with Resident #10 revealed he eats his meals in the dining room and most of the meals served are cold. 2. On 8/27/23 at 12:41 p.m., lunch meal arrived covered with a hard plastic cover. The meal consisted of mixed vegetables with a temperature of 118.4 degrees Fahrenheit (F), slice of ham with a temperature of 101.6 degrees F, stuffing with a temperature of 126.2 degrees F. The stuffing was dry with hard chunks mixed throughout. 3. On 8/28/23 at 12:17 p.m., lunch meal arrived with aluminum foil over the plate which was covered with a hard insulated plastic cover. The meal consisted of chicken breast with a temperature of 129.1 degrees F, ravioli with red sauce with a temperature of 122.6 degrees F and vegetables with a temperature of 114.5 degrees F. Review of Resident Council notes for July and August 2023 the food temperatures vary. Review of facility policy titled Food Temperatures: Proper Holding and Proper Serving - Focus Audit with a revision date of 4/13/23 revealed proper holding temperature for hot items is greater than 135 degrees F. Test trays for palatability should be done more frequently when there is a concern or a resident complaint. Interview on 8/29/23 at 3:35 p.m., with the Dietary Manager revealed the food was at temperature when the meal was served because she checked the temperatures prior to service.

Based on observation, resident and staff interviews the facility failed to ensure residents received the proper diet texture to meet the residents needs.The facility reported a census of 46 residents. Findings Include: Observation on 8/29/23 at 11:02 a.m., of Staff B, dietary aide was dividing puree sugar cookie into 4 separate cups. Observation on 8/29/23 at 11:07 a.m., with Staff C, cook. Staff C took 4 portions of beets out of the steamer and placed them into the blender and pureed them. Staff C took the puree beets and placed them into a metal pan and without measuring or checking the temperature placed the pan into the steam table. Staff C took 4 portions of beef stroganoff and added it to the blender with whole milk. Staff C took the puree beef stroganoff and placed it into the metal pan and without measuring or checking a temperature placed into the steam table. Asked Staff C what the serving size for the portions were, Staff C replied she was told to always use the green scoop. The Dietary Manager (DM) told her all puree food is served with a green handle scoop. At the end of the meal service for 4 puree portions there was approximately 2 extra servings in the metal dishes in the steam table. Interview on 8/29/23 at 11:59 a.m. with Staff B, revealed she does not measure the puree mixture she just divides it out into the 4 cups when she is finished. Interview on 8/29/23 at 12:13 p.m., with the DM revealed that if you puree food then you're going to have extra left over because the consistency is different than before. When asking about the serving sizes the DM revealed you always use the same scoop for the puree because you have the same portion amount to serve to the 4 residents. The Administrator came into the conversation and revealed if you have 4 portions prior to puree then you should have 4 portions after puree and the staff should be following the chart in the kitchen for the serving sizes. Interview on 8/29/23 at 12:38 p.m., with the Dietician revealed the staff should be following the chart unless they are pureeing individual servings. The Dietician further revealed she has talked to the DM and explained all changes needed to go through her even if there was a change in vegetable. Interview on 8/29/23 at 3:35 p.m., with the DM revealed the facility does not offer bread and butter at lunch because the residents really do not eat it anyway and they don't serve it to the residents with a puree diet either. Review of facility policy titled Acceptance Of Therapeutic and/or Texture-Modified Diet- Food and Nutrition Services with a revision date of 5/11/23 revealed a mechanically altered diet specifically prepared to alter the texture or consistency of food to facilitate oral intake.

Based on observations and staff interviews the facility failed to ensure food was covered during storage, labeled with dates after opening, maintain a clean sanitizable surface on cutting boards, and maintain a clean food storage area. The facility identified a census of 46 residents. Findings include: 1. An initial kitchen tour conducted on 8/27/23 at 9:27 a.m., the following items were stored in the kitchens refrigerator ready for service: Slices of pie on a plate stored on a cart uncovered. Open container of apple juice with no open date. 2. Cabinet under the counter with the door closed was noted to have bread crumbs on the bottom. 3. Four cutting boards stored in the cabinet had a fuzzy appearance on each side of the cutting board making the surface unable to be sanitized. 4. Four trays with the bottom left corner cut off with a fuzzy appearance on the top of the tray were in the cabinet being used as cutting boards. 5. The dry storage area was noted to have a brown debris on the floor by the door with dried leaves on the floor around the door. 6. Cooler on the snack cart was noted to have approximately an inch of water in the bottom of a cooler with an ice scoop laying in the water in the cooler. Review of the facility policy titled General Sanitation- Food and Nutrition with a revision date of 3/8/23 revealed the location stores, prepares, distributes and serves food under sanitary conditions at all times. The location ' s food preparation, kitchen and serving areas are cleaned and sanitized on a regular basis to limit contamination and prevent foodborne illness. Interview on 8/27/23 at 3:12 p.m., with the Dietary Manager (DM) revealed the food should be covered in the fridge. The DM further revealed the kitchen does not have anything to do with the cooler on the snack cart and the Certified Nursing Assistants (CNA ' s) are suppose to take care of that. The DM did not reply or comment when asked about the cutting boards and brown debri and leaves on the floor in the storage room.

Based on clinical record review, family interview, staff interviews, and facility record review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 2 of 2 residents reviewed for elopement (Residents #6 and #12). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a total census of 45 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 6 documented diagnoses of non-Alzheimer's dementia, traumatic [NAME] injury, [CONDITION(S)], weakness, disorientation and [CONDITION(S)]. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.Resident #6 used a daily wander or elopement alarm. Review of the Care Plan with a revision date of 6/1/21 revealed the following: The resident had potential for elopement. Interventions include: Attempt non-pharmacological interventions with a silent alarm in place to notify staff of resident movements and Wanderguard used to alert staff to resident's movements. Review of Progress Notes revealed the following: a. On 3/2/21 at 12:43 a.m., Received fax from physician, ok for roam alert bracelet. b. On 3/23/21 at 7:50 p.m., Resident has been exit seeking multiple times since after supper. He has been found at the ambulance entrance door x3 and was just found in the dining room attempting to go out the dining room door. The Wanderguard alarm went off all times, and attempted to redirect resident. Resident then asked this nurse if she wanted to go home with him, it was explained it was raining out and this was his home for the time being. Will continue to keep a close eye on resident. c. On 3/30/21 at 7:34 p.m., Resident exit seeking several times setting off door alarms. d. On 5/12/21 at 2:25 p.m., resident exit seeking. e. On 6/26/21 at 8:40 a.m., Resident in w/c self propelling and wandered onto 500 hall, 500 hall is currently closed for remodeling. Resident exited 500 hall exit at end of hall in w/c. Brought safely back into the building by staff without incident. f. On 6/26/21 at 9:00 a.m., Contacted DON via phone and spoke to her about resident's elopement out of the 500 hall door. DON aware that door alarms were found all shut off for the East end of the building and that this nurse turned them back on. g. On 6/26/21 at 9:34 p.m., Resident eloped out 500 hall this am. He had some agitation noted earlier on this shift. He did not go up the hill and stayed right by this nurse as I took over. He then started swearing at other residents and their guests that were with them. h. On 6/27/21 at 2:42 p.m., Resident eloped the building through the 500 Hall door on 6/26/21. No injuries. Resident was not outside for very long. Resident has had no adverse effects from this incident. i. On 6/27/21 at 9:47 p.m., Resident eloped through 500 hall door yesterday am. Review of the Incident Report dated 6/26/21 at 8:50 a.m., revealed staff noticed the resident had not been seen in awhile, so we started looking for him. Certified Medication Aide (CMA) found him outside the 500 Hall door. Resident was brought back inside and Director of Nursing (DON) was notified by phone. DON aware and there were no injuries found. Interview on 5/18/22 at 3:45 p.m., with Staff I, Licensed Practical Nurse (LPN). Staff I revealed she was the charge nurse for Resident #6's hallway on 6/26/21. Staff I revealed there had been construction workers working up on the 500 hallway and the alarms had been turned off so the workers could go in and out of the doors down there. Staff I stated she normally keeps an eye on Resident #6, as he is always trying to get out of the building and she hadn't seen him for a bit so she started looking for him. Staff I stated it had been a good 15-20 minutes for sure since she had last seen him. Staff I revealed after she was unable to find him she radioed all staff to look for him. Staff I stated she had noticed the double doors to the 500 hallway were kind of open so she went up there to check the hallway. Staff I ended up finding him on the gravel road right behind the facility. Staff I stated Resident #6 came back in the building with no problems. Staff I assessed him and there were no injuries. Stated she let the DON know what had happened and made her Incident Report. Staff I revealed there were no alarms going off as they were shut off on the main panel by the nurses station for that end of the building. Interview on 5/19/22 at 9:36 a.m., with Staff J, Certified Nursing Assistant (CNA) revealed she was working 6/26/21 and she realized Resident #6 was missing when it was time for breakfast as he was not in the dining room and she was unable to find him. Staff J was unable to recall how long it had been since she had last seen Resident #6. Staff J stated she had looked down the 600 hallway and remembered the 500 hallway was under construction and there were a lot of beds in the hallways. She was pretty sure she remembered there were construction workers in the 500 hallway on Friday working. Staff J revealed there had not been any alarms sounding in the building that morning. Interview on 5/19/22 at 10:16 a.m., with Staff K, Registered Nurse (RN) revealed she was working that day (6/26/21) but was not Resident #6's nurse that day. Staff K revealed it was normal for Resident #6 to wander and exit seek. 2. The MDS assessment dated [DATE] for Resident #12 documented diagnoses of non- Alzheimer's dementia, arthritis, muscle weakness, anxiety, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]) and spinal stenosis. The MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Resident #12 used a daily wander or elopement alarm. The MDS revealed resident had wandering presence and frequency of this behavior in the 7 day look back period occurred 1 to 3 days. Review of the Care Plan with a revision date of 6/8/21 revealed the resident has impaired cognitive function, dementia or impaired thought processes related to dementia as evidenced by increased paranoia. Resident is at risk for elopement. Interventions included: Resident requires roam alert anklet to alert staff of attempts to open doors to exit building. Review of Progress Notes revealed the following: a. On 5/14/21 at 3:08 p.m., Resident was attempting to open the 1st (inside door). Did not exit the building. Staff was able to redirect. b. On 6/5/21 at 1:30 p.m., Resident wears a wanderguard to her ankle due to exit seeking behaviors. c. On 6/8/21 at 7:20 p.m., Kitchen staff was leaving the facility on her bike and she saw a resident on the road in front of the facility in her wheelchair. She brought her back into the facility and brought her to this nurse. Resident's wanderguard did not sound as the resident left the facility. No injury was found. Daughter and DON notified immediately of elopement. d. On 6/9/21 at 9:37 a.m., Received a return fax from physican noting she is aware of elopement on 6/9/21. Review of the Incident Report dated 6/8/21 at 7:20 p.m., revealed Resident #12 brought into the facility by kitchen staff. Stated she found the resident outside of the building as she was riding her bike home from work. Review of Incident Audit Report revealed the following information: Investigation completed. This was an isolated incident. Resident was assessed by RN upon re-entering the facility. No injuries occurred from this incident. Functioning of door alarms and roam alert bracelet system is in proper working order. Verified by maintenance. Resident's roam alert bracelet expires 6/24. On the security camera the resident was visualized exiting the west therapy entrance at 7:05 p.m., in a wheelchair. Resident was visualized on the front entrance camera being brought back into the building at 7:15 p.m., by staff without incident. Care Plan reviewed and updated. Interview on 5/14/22 at 3:08 p.m., with the DON revealed she saw Resident #12 at the west therapy door attempting to leave about a week ago and the alarm did not sound. The DON further revealed the wanderguard was not working and a new one for the resident was applied at that time. Interview on 5/18/22 at 12:33 p.m., with Resident #12's family member revealed Resident #12 eloped from the facility what they thought was early last summer. Resident #12's family member stated when they went to the building the staff were all laughing about Resident #12 getting out of the building. Resident #12's family member stated the facility staff told them Resident #12 was about a block away from the building on the main road in front of the facility. Interview on 5/19/22 at 9:15 a.m., Staff L, Dietary Aide was riding her bicycle home after work and she found Resident #12 in her wheelchair in the street approximately a block from the facility on 5th street. Staff L revealed Resident #12 told her she was going home but was unable to tell her how to get there. Staff L pushed Resident #12 back into the facility and found a nurse to assist with the situation. Review of facility policy titled Elopement with a revised date of 1/12/22 revealed the following information: a. Definition of elopement- When a resident who needs supervision leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. b. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and all follow-up required by state and federal regulations will occur. c. Notify other agencies as required by state and/or federal regulation. Interview on 5/17/22 at 3:19 p.m., with the Administrator revealed he discussed the elopements with the Nurse Consultant and she advised him the facility did not need to report to DIA. Interview on 5/26/22 at 10:25 a.m., with the Nurse Consultant revealed she did not know there had been elopements. The Nurse Consultant revealed if she had been aware of the elopements she would have advised the facility to report it to the Department of Inspections and Appeals (DIA). The State Agency informed the facility of the Immediate Jeopardy (IJ) on May 19,2022 at 1:25 p.m. and the facility was provided the IJ template. Facility staff corrected the Immediate Jeopardy on May 19, 2022 through the following actions and after the surveyor verified implementation of the removal plan the scope and severity was lowered to an E. a. All staff were provided elopement elopement education on 5/18/2022 and 5/19/2022 by the facility Clinical Learning and Development RN and required to complete a quiz reinforcing what they learned. b. Daily checks of RoamAlert Securaband will continue to be completed by the Director of Nursing or designee. Maintenance also completes weekly checks of door alarms and are utilizing their electronic TELs system to track and monitor outcomes. c. All doors and RoamAlert Securaband were checked and verified as functional on 5/18/2022 and 5/19/2022. d. An elopement drill was also conducted on 5/18/2022 in the facility.

Based on record review, staff interviews and review of the facility policy and procedures, the facility failed to provide adequate supervision to ensure against hazards from self and the environment for 2 of 4 residents reviewed. The facility reported a census of 78 residents. Findings include: 1. Resident #2 had a MDS with a reference date of 6/23/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS score of 1. A score of 1 identified the resident with severe cognitively impaired. According to the MDS, the resident experienced frequent incontinence of urine and occasionally of bowel. The MDS identified the resident had 1 fall since the last assessment period. The Care Plan dated 4/5/16 directed staff to use incontinence products and to assist the resident with routine toileting. The Care Plan directed staff to turn/reposition the resident at least every 2 hours and as needed. The Care Plan directed staff to attach a personal alarm at all times to alert staff to the resident's movement and to assist the staff in monitoring movement. A bed rail was placed on the outside of the bed for placement of the alarm. Review of the Falls Tool dated 7/12/16 indicated the resident had a high risk for falls. Review of the Incident Report dated 7/12/16 indicated at 4:45 AM, the CNA called the nurse into the resident ' s room. The resident laid on his/her left side on the floor and next to the bed. The resident ' s legs extended straight out and hands in front of his/her body. About a 12 inch pool of blood surrounded the left side of his/her head. The resident held his/her head off of the floor. The resident could not describe what happened but the resident able to state he/she hurt a little. The incident report identified the alarm did not sound and the resident was incontinent. Review of the Hospital History and Physical dated 7/12/16 indicated the resident had a 3.5 cm (centimeter) laceration to the left supra orbital rim and a 7 cm hematoma (at left eye). The treatment included a wound closure with sutures. Review of the Alarm Check Sign Off sheet dated July 2016, directed staff that all alarms are to be checked by the medications nurse at the beginning of each shift and sign following the checks. The alarm check was not documented on the AM shift but documented for the PM shift. On 8/2/17 at 4:40 PM, Staff C, RN (Registered Nurse) stated she responded to the radio call for assistance and went to the resident ' s room. Staff C stated she saw the resident on the floor with a pool of blood. The alarm was found on the back side of the bed and not attached to the resident. Staff reported the resident was last changed 4 hours prior (due to incontinence). Staff C stated the resident ' s bed had not been in the lowest position and not on Care Plan for a low bed. On 8/10/16 at 9:20 AM, Staff E, CNA stated she checked on the resident at 11:00 PM. At that time she sniffed to see if she could smell urine or feces and could not recall if she changed the resident or not. Staff E further stated she could not recall if an alarm had been present or not. She did not turn/reposition the resident during 12:00 or 2:00 AM rounds and normally changed him/her on 4:00 AM rounds. The resident became difficult to return to sleep during the night so she let the resident sleep. Staff E stated the resident ' s normally incontinent through the night. On 8/10/16 at 10:20 AM, Staff F, CNA was interviewed and stated she did not work with the resident that night. Staff F stated she last saw the resident during 4:00 AM rounds. The staff did rounds on another hall 1st and then went to the resident's hall. Staff F stated she entered another resident ' s room and on the way, looked in the resident ' s room. The resident had been in bed and appeared to be asleep. Staff F stated when she finished with the other resident; she came out into the hallway and saw the resident on the floor. The alarm did not sound and had been on the bed and not attached to the resident. Staff F stated she then called for help. On 8/10/16 at 3:45 PM, Staff I, LPN (licensed practical nurse) was interviewed and stated she had been called to the resident's room. Staff I stated she observed the resident on the floor and the alarm attached to the bed and not the resident. The alarm did not sound. She further stated at shift change, she had asked the CNAs if the resident had the alarm on and they assured her it was on. Staff I stated she documented the alarm on the CNAs word. She now physically checks resident's alarms before documenting. She had last seen the resident at 4:00 AM in bed and he/she appeared to be asleep. Review of the facility policy/procedure titled Alarms: Bed, Chair and Door, dated September 2012 directed the staff to do the following: a. Each shift of nursing staff will be responsible for visually checking placement of alarms. 2. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 3/7/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMs (Brief Interview for Mental Status) score of 15. A score of 15 identified the resident had no cognitive impairment. The MDS indicated the resident to be totally dependent for bed mobility, transfers, toilet use and bathing. The Care Plan dated 6/19/14 directed staff to provide a bath 2 times a week and as necessary. Use a reclining shower chair and shampoo hair during the shower. Review of the Falls Tool dated 9/11/15, identified the resident to be at low risk for falling. An Incident Report dated 4/18/16 indicated the nurse was called to the resident's room to see the right great toenail torn approximately half way up and 4 cm all the way across. A small amount of blood and the resident did complain of pain but the nurse did not rate the severity of pain. The CNA stated she believed she hit the resident's foot on the cabinet in the shower room during the shower. The nurse cleansed the area and applied a Band-Aid. The nurse notified the physician and made an appointment. The Investigation report dated 4/18/16 indicated the resident stated he/she had been in the shower chair going into the shower room and his/her toe hit on the lower cupboard by the shower. The CNA stated the resident did hit the side of the foot on the cabinet and hit his/her toe on the fan in the room prior to the shower. Review of the Radiology-Diagnostic Imaging report dated 4/18/16 identified a possible non to minimally displaced obliquely oriented fracture of the mid to distal right 1st proximal phalanx (great toe). During an interview with Staff A, CNA on 8/2/16 at 1:45 PM, she stated she assisted Staff D, CNA transfer the resident from the bed to the shower chair with the Hoyer (mechanical) lift. The shower chair reclines to lay back. Staff A stated she hit a fan in the resident's room with the lift but the fan did not hit the resident. Staff A stated she assisted Staff D to move the shower chair out of the room and the chair seemed hard to move. She had not noticed a problem with the chair before. Staff D then wheeled the resident to the shower room. Staff A stated the resident later told her she should have been with her going through the 2nd door (shower room). She saw the blood that looked like watery drainage from the toe. During an interview with Staff D, CNA on 8/9/16 at 2:30 PM, she stated Staff A, CNA assisted her to transfer the resident from the bed to the shower chair. The shower chair reclined for the resident but had been stiff to turn. She stated she thought the fan hit the resident's toe and not the cabinet because the top cover fell off of the fan. Staff D stated that she did not remember the resident tell her to slow down; she saw a small amount of blood on the toe when she dried the resident and notified the nurse. During an interview with the DON (Director of Nursing) on 8/10/16 at 8:50 AM, she stated she had always thought the corner of the cabinet had been what the resident hit his/her toe on. The DON stated she had spoken with Staff D.

Based on record review, staff, family and physician interviews and review of facility policy/procedures, the facility failed to administer a medication as ordered by the physician that resulted in a significant medication error. As a result of the significant medication error Resident #1 developed lethargy and respiratory distress that required hospitalization and mechanical respiratory support. Involved 1 of 4 residents that utilized a narcotic pain patch (Resident #1). The facility reported a census of 79 residents. Findings include: According to the MDS (Minimum Data Set) dated 1/12/16 Resident #1 ' s Brief Interview for Mental Status (BIMS) score of 15 reflected no cognitive impairment. The MDS lacked signs and symptoms of [MEDICAL CONDITION] or memory loss. Resident #1 required extensive assistance of one staff member for ambulation and limited assistance of one staff member for bed mobility, transfers and toilet us. Resident #1 ' s MDS revealed balance during transitions and walking required staff assistance for walking or turning and able to stabilize independently for moving from seated to standing, on or off the toilet and surface to surface transfers. Resident #1 utilized a cane/crutch, walker and wheelchair for mobility. According to the MDS Resident #1 ' s [DIAGNOSES REDACTED]. The MDS included a pain assessment which reflected Resident #1 frequently had pain that he/she rated 8 on a 0 - 10 scale. The same assessment noted Resident #1 received scheduled pain medication and pain medication as needed. The Care Plan, initiated 6/17/14 and revised 1/21/16, identified pain related to [MEDICAL CONDITION], chronic lower back pain and reflux as evidenced by the use of pain medications as needed. Interventions included: Strength: 1. Resident is able to communicate pain and need for pain medications. 2. Observe/record/report to nurse any signs and symptoms of non-verbal pain that included but not limited to changes in breathing, vocalization, mood/behavior. 3. Monitor/document for side effects of pain medication. A pain assessment, dated 1/12/16, assessed Resident #1's current pain regime effective. The assessment indicated Resident #1 reported constant pain, worst at 8, which was managed by the current pain medications. The assessment included notation Resident #1 denies need for changes at this time and states as needed pain medication was effective. physician's orders [REDACTED]. [MEDICATION NAME] is similar to a narcotic [MEDICATION NAME] used for moderate to moderately severe pain control. Review of Resident #1's Medication Administration Record (MAR) revealed the following: a. In November, 2015 Resident #1 received 12 doses of [MEDICATION NAME] 100mg and 4 doses of [MEDICATION NAME] 50mg, a total of 1400 milligrams of [MEDICATION NAME]. b. In December, 2015 Resident #1 received 6 doses of [MEDICATION NAME], a total of 600 milligrams of [MEDICATION NAME]. c. In January, 2016 Resident #1 received 11 doses of [MEDICATION NAME], a total of 1100 milligrams of [MEDICATION NAME]. On 2/1/16 at 11:50 a.m. the Director of Nursing (DON) documented the physician examined Resident #1 on rounds and ordered [MEDICATION NAME] 125mcg (micrograms) patch due to chronic pain issues. The DON documented she notified Resident #1's liver specialist, and notified his/her family member of the new order. The DON documented, she then ordered the [MEDICATION NAME] from the pharmacy. Resident #1 ' s clinical record failed to contain physician orders [REDACTED]. The Progress Notes revealed the following: a. On 2/1/15 at 11:30 p.m. Staff G, licensed practical nurse (LPN) applied [MEDICATION NAME] 125 mcg patch. Staff G indicated she applied two patches, one patch of [MEDICATION NAME] 100 mcg and one patch of [MEDICATION NAME] 25 mcg. Staff G documented Resident #1 complained of lower back pain and bilateral thigh pain. b. On 2/2/16 at 12:58 p.m. Progress Notes revealed Resident #1 exhibited no side effects from the [MEDICATION NAME] such as lethargy, gastric distress, rash or other signs or symptoms of allergic reaction. c. On 2/2/16 at 6:05 p.m. Staff B, registered nurse (RN), documented Resident #1 ' s gaze appeared distant and response to staff certified nursing assistants (CNA ' s) question was limited. Staff B, RN ' s documented it required the nurse to say his/her name twice before Resident #1 could focus on the Staff B. Resident #1 reported he/she did not know if he/she was ok. Staff B noted Resident #1 appeared unsteady and required a wheelchair for transport to the dining room for the evening meal. Staff B, RN directed staff CNA to ensure Resident #1 ate. d. On 2/2/16 at 11:54 p.m. Staff E, LPN, noted Resident #1 and increased tiredness noted, he/she fell asleep right away and wakes up easily. Staff E LPN, encouraged Resident #1 to utilize his/her call-light for transfer assistance. e. On 2/3/16 at 5:59 a.m. Staff E LPN, administered a PRN nebulizer treatment for [REDACTED]. (Rhonchi are coarse rattling respiratory sounds, usually caused by secretions in [MEDICATION NAME] airways.) f. On 2/3/16 at 10:01 a.m. the physician's office called to notify Staff C, RN of lab results. Staff C, RN indicated she notified the physician's office that Resident #1 was very tired and almost unable to answer questions; however his/her vital signs are within normal limits. g. On 2/3/16 at 10:25 a.m. Staff C, RN noted the physician ordered a decrease of [MEDICATION NAME] to [MEDICATION NAME] 50 mcg. h. A late entry on 2/3/16 at 11:10 a.m. Staff A, RN and unit manager, indicated staff made her aware of a new order to decrease [MEDICATION NAME] to 50 mcg. i. A late entry on 2/3/16 at 11:35 a.m. Staff E RN, contacted Resident #1 ' s physician to inquire on how to decrease [MEDICATION NAME] from 125mcg to 50mcg as order. The physician ' s office directed Staff E RN, to remove the 125mcg patches and then apply the 50mcg patch as ordered. j. On 2/3/16 at 12:00 p.m. Staff D, RN and Quality Assurance nurse, indicated she notified the physician's office that Resident #1 experienced a gradual decline in status as evidenced by increased lethargy and confusion. The physician authorized Resident #1 ' s transfer to the emergency room for evaluation. k. A late entry on 2/3/16 at 1:08 p.m. Staff A RN, indicated she received a phone call from Resident #1 ' s physician's office to request clarification of the [MEDICATION NAME] order. Staff A, RN responded [MEDICATION NAME] 125 mcg. Staff A, RN then received notification the physician ordered [MEDICATION NAME] 12.5 mcg not [MEDICATION NAME] 125 mcg. Staff A, RN then notified the pharmacist who confirmed two separate [MEDICATION NAME]es were delivered, one for [MEDICATION NAME] 100 mcg and one for [MEDICATION NAME] 25 mcg. l. On 2/3/16 at 1:30 p.m. Resident #1 transferred to the emergency room accompanied by Staff D, RN in the facility van. The History and Physical, dated 2/4/16, revealed Resident #1 was placed on observation status 2/3/16 after he/she received a 125 mcg [MEDICATION NAME] in place of a 12.5 mcg [MEDICATION NAME] dose. [MEDICATION NAME] was administered in the emergency room that resulted in improvement of Resident #1 ' s fatigue. Overnight the creatinine level and white blood count increased. X-Rays showed concern for free air on the abdominal film as well as left pneumonia. Resident #1was admitted to the hospital for intravenous antibiotic therapy. Interview on 2/17/16 at 11:37 a.m. the DON confirmed she noted the physician's orders [REDACTED]. The DON stated the facility requested the physician increase pain medication for Resident #1 based on information she gathered regarding PRN pain medication usage for the prior months, and based on Resident #1's MAR (Medication Administration Record) review. The DON provided information from her QAPI (Quality Assurance Performance Improvement) review in pain medication. QAPI noted for December, 2015 noted Resident #1 used 2800 mg of [MEDICATION NAME] in November, 2015 and 1000 mg of [MEDICATION NAME] in December. QAPI notes for January, 2016 noted Resident #1 continues to use large amounts of [MEDICATION NAME]. (2800 mg of [MEDICATION NAME] in November, 1200 mg of [MEDICATION NAME] in December) Question need for another pain regimen. The DON reviewed Resident #1's MAR and confirmed her numbers were inaccurate. The DON stated I don't know how I got my counts as she reviewed the QAPI information with Resident #1's MAR. She then stated, I don't know how I made that error. The DON stated she did not review the 1/12/16 pain assessment prior to determining a different pain regimen was needed. She then reviewed the 1/12/16 pain assessment and confirmed Resident #1 stated his/her current pain regimen was effective. The DON confirmed Resident #1 only received [MEDICATION NAME] as needed and no other opioid pain medication ordered prior to the administration of the [MEDICATION NAME] 125 mcg patches. The DON stated 125 mcg was not the typical dose to start with but based on the amount of [MEDICATION NAME] received and the physician's orders [REDACTED]. The DON confirmed she failed to call or question the order prior to pharmacy notification. The DON stated she never recalled a physician's orders [REDACTED]. On 2/17/16 at 8:45 a.m. the pharmacist confirmed he received a phone call on 2/1/16 from the DON with a phone order for [MEDICATION NAME] 125 mcg. The pharmacist stated upon receipt of the phone order, the pharmacy prepares the hard copy of the narcotic order and has 72 hours to get the written script. The order was provided to the physician who signs the hard copy. The physician signed the order, and the order was picked up on 2/3/16. The pharmacist stated Resident #1's routine medications are filled by another pharmacy, so he was not aware of all of the resident's current medications. He stated each month he receives medication administration records for residents in the facility as he is responsible to fill medications not delivered timely from out of town pharmacies. He then referred to Resident #1's medication administration record and noted according to this, he/she received very little [MEDICATION NAME] for the first half of January, 2016. The pharmacist stated 125 mcg of [MEDICATION NAME] is a big dose, not a dose to start with, and provided the package insert for review. He stated 50% of [MEDICATION NAME] is excreted in the first 24 hours of application, with peak at 20 hours. He stated typically a formula is utilized to determine a starting dose of [MEDICATION NAME] based on current opioid usage however there is no formula to determine the appropriate starting dose of [MEDICATION NAME] following use of [MEDICATION NAME]. The pharmacist noted a caution in the use of [MEDICATION NAME] for those with hepatic impairment. The pharmacist confirmed he was not aware the [MEDICATION NAME] was a new order for Resident #1 and part of the problem with filling medications as needed was that he was not aware of all the medications currently being administered. On 2/17/16 at 12:10 p.m. Resident #1's physician stated no official visit for Resident #1 on 2/1/16; however he did observe Resident #1 in the hallway and did not observe any obvious concerns with pain. The physician stated he completed nursing home rounds with the assistance of his clinic nurse. The physician recalled the request for a new pain medication for Resident #1 ' s chronic pain but unable to recall if the request was from staff or the Communication Book. The physician stated the facility failed to provide specific information or documentation related to the request for increased pain medication. Resident #1's pain assessment, dated 1/12/16 was reviewed and the physician noted there was no need for additional pain medication. Resident #1's medication administration records were reviewed at this time and confirmed the information provided by the DON on the QAPI documentation was not accurate based on review of the medication administration record. Based on this information I would have talked with Resident #1 because the request for increased pain medication conflicted with the medication administration record and pain assessment. The physician stated his order was based on information provided to him of Resident #1's increased usage of pain medication. He stated he ordered [MEDICATION NAME] 12.5 The physician confirmed he wrote the [MEDICATION NAME] order while in the facility, and signed the hard copy script provided by the pharmacy. Upon notification of Resident #1's decline, he decreased the medication order and later realized there was a discrepancy in orders. He requested his nurse check and see if Resident #1's liver physician changed the order. Around this same time, Resident #1 was transferred to the emergency room for evaluation. The physician shared that 2/1/16 the clinic closed related to weather, then reopened on 2/2/16 at 10:00 a.m. The physician reviewed the signed order and stated it looks like the hard copy was printed on 2/1/16, and picked up on 2/3/16. The physician stated he expects facility staff to notify him with any change in status, which included staff notation of increased lethargy following the administration of the [MEDICATION NAME], as well as change in Resident #1's breathing status noted on 2/3/16. The physician stated there should be no reason an order questioned couldn't be clarified, staff clarify all the time by phone or by fax. On 2/17/16 at 12:46 p.m. the physician's clinic nurse stated the request for increased pain medication came from review of the Communication Book that contained a request for a change in pain medication. On 2/17/16 at 12:47 p.m. the physician stated Resident #1's pneumonia and death was more likely than unlikely directly related to the overdose of [MEDICATION NAME]. Interview on 2/19/16 at 3:40 p.m. identified Resident #1's liver specialist reviewed the clinic notes and stated there was no notification of Resident #1's [MEDICATION NAME] order; however no medication interactions are noted with the use of [MEDICATION NAME] and the current liver medications administered. The physician confirmed all medication changes are to be reported to our clinic. The physician noted narcotics administered to patients with liver disease can cause [MEDICAL CONDITION] which may have been what was noted. The physician stated Resident #1 was improving on the liver medications. Unfortunate to hear about this incident as it was quite tragic. On 2/23/16 at 12:11 p.m. Resident #1's family member was interviewed. The family member stated she last saw Resident #1 on the Sunday before [MEDICATION NAME] was initiated. The family member stated Resident #1 was alert and oriented and watched television together. Resident #1 complained of some back pain but felt it was likely from staying in bed a lot. He/she rarely complained of a lot of pain, and never complained that his/her pain medications are ineffective. No contact on 2/1/16 but spoke to Resident #1 on the phone 2/2/16 later in the day. The family member stated Resident #1 was tired, but staff commented it takes 24 hours for [MEDICATION NAME] to enter the system. The family member commented the next call received was from facility staff reporting Resident #1 was lethargic and nonresponsive and requested family meet Resident #1 at the emergency room . The family member stated the emergency room (ER) staff administered [MEDICATION NAME] (a medication used to reverse the sedative effects of narcotics) and Resident #1 came around and then fell off again. The family member stated the ER staff explained Resident #1's kidney function and blood pressure are low. The family member stated both times [MEDICATION NAME] was administered Resident #1 perked up more. The next morning, Resident #1's physician called and reported tests revealed pneumonia due to the sedation from the narcotics. He also reported the kidneys failed due to the overdose of [MEDICATION NAME]. The family member reported Resident #1 continued to decline the next few days, and was intubated and transported by helicopter to another hospital out of State. The family member shared the physician reviewed Resident #1's condition and family needed to decide on continuation of life support. The physician stated Resident #1 ' s return to his/her normal function was unlikely and family decided to remove life support. According to family Resident #1 passed away. Staff Interviewed as follows: a. On 2/116/16 at 1:06 p.m. Staff A, RN and unit manager, stated she attends weekly nursing meetings to discuss resident issues such as pain, behaviors or other concerns. Staff A was unable to recall any concern regarding increased pain for Resident #1 discussed. She stated typically after the physician rounds, additional information is provided to the physician via a Communication Book (CB). Information in the CB pertains to residents not scheduled for a routine physician visit, and includes notification of non-emergent issues appropriate to wait until routine rounds. Staff A stated based on the typical routine, she thought the physician reviewed the CB, noted the information on Resident #1's pain and wrote the physician's orders [REDACTED]. Review of the CB included physician notification of increased pain medication use by Resident #1 and a request to change his/her PRN pain regimen. According to Staff A RN, the DON received and noted [MEDICATION NAME] 125 mcg patch physician's orders [REDACTED]. Staff A stated she was not aware of the [MEDICATION NAME] order until the morning Resident #1 transferred to the hospital. Staff A confirmed Resident #1 had occasional back pain and utilized a muscle relaxing medication and [MEDICATION NAME] as needed. Staff A was not aware Resident #1 experienced increased pain not relieved by the current pain regimen, and indicated there were no staff reported concerns of increased pain unrelieved by the current pain regimen. Staff A stated she failed to observe nonverbal signs or symptoms of pain when she observed him/her walk in the hall prior to the physician's orders [REDACTED]. Staff A was notified by Staff C that she received a physician's orders [REDACTED].#1's [MEDICATION NAME] from 125 mcg to 50 mcg; however Staff C was uncomfortable with the application of [MEDICATION NAME] 50 mcg. Staff A stated Resident #1 was so out of it and unable to focus. Staff A directed Staff C to not apply the patch if she felt uncomfortable and notify the physician of her concern. Staff C continued to express concern with the decline in Resident #1's condition. Staff A stated she paged Staff D RN, to assist notification of the physician. Resident #1 was transferred to the emergency room . Staff A stated the emergency room physician requested a copy of Resident #1's physician orders [REDACTED]. Staff A indicated the physician stated the order was for [MEDICATION NAME] 12.5 mcg not [MEDICATION NAME] 125 mcg. Staff A stated she had been a nurse for 7-8 years and had never seen [MEDICATION NAME] 100 mcg patch administered to a resident before and it was a huge dose and indicated she would have called the physician for clarification of that physician's orders [REDACTED].>b. On 2/18/16 at 7:34 p.m. Staff C, RN, stated the DON notified her Resident #1 had a new physician's orders [REDACTED]. Staff C informed the DON she felt that was a high dose, however the DON told her it was ok because Resident #1 was big. Staff C stated she never administered pain medications to Resident #1. According to Staff C other residents in the facility on [MEDICATION NAME]es only received 12 mcg to 25 mcg. Staff C indicated the morning Resident #1 transferred to the hospital he/she was not responding and appeared out of it. Staff C recalled Resident #1 was unable to keep his/her eyes open. Staff C stated at the time Resident #1 transferred to the hospital, he/she stood up with the assistance of 3 staff members but was unable to talk with staff because he/she was so tired. Staff C stated she checked the original physician's orders [REDACTED]. Staff C stated it could be either [MEDICATION NAME] 12.5 mcg or 125 mcg. Staff C stated Resident #1 ' s liver [DIAGNOSES REDACTED]. Staff C stated the nurse ' s needed to obtain clarification from the physician c. On 2/17/16 at 11:12 a.m. Staff D, RN and Quality Assurance nurse, stated Staff C reported Resident #1 exhibited increased lethargy and felt it was related to the [MEDICATION NAME] dose. Staff C checked vital signs and the Resident #1's blood sugar while Staff D notified the physician's office. Staff D stated Resident #1 was not responding to his/her name and kept nodding off. Staff D stated that was a change in Resident #1 ' s status. Staff C voiced concerns about administration of [MEDICATION NAME] following a physician's orders [REDACTED]. Staff D stated she notified the physician about Resident #1 ' s continued decline in status and received an order to transfer him/her to the emergency room . Staff D stated she accompanied Resident #1 to the hospital ER in the facility van. Staff D stated Resident #1 stood with the assistance of 2 getting into the van but was so lethargic and would just nod off during the transfer to the ER. Staff D provided report to the emergency room staff regarding increased lethargy, decline and suspected was related to [MEDICATION NAME]. Staff D stated she attends facility meetings related to residents and was unable to recall discussions regarding pain concerns for Resident #1. Staff D recalled a typed paper provided by the DON that identified Resident #1 used a lot of PRN [MEDICATION NAME]. Staff D identified to her, a lot indicated several daily doses of [MEDICATION NAME]. Staff D recalled Resident #1 as alert and oriented and able to report pain appropriately. Staff D stated Resident #1 was very intelligent. Staff D reviewed the 1/12/16 pain assessment and stated based on that information no need to ask for more pain medication. Staff D stated Resident #1 ' s MAR failed to reveal a large amount of [MEDICATION NAME] utilized and based on this she would have questioned the physician's orders [REDACTED]. Staff D confirmed typically residents received [MEDICATION NAME] 50 mcg or 75 mcg for residents that have a lot of pain reported by nursing staff. d. On 2/17/16 at 10:15 a.m. Staff J CNA stated she showered Resident #1 the morning he/she was transferred to the hospital. Staff J stated she got him/her up and provided the shower and it appeared Resident #1 was his/her normal self. As the day went on Resident #1 ' s status changed and became really groggy. Resident #1 wanted to sleep instead of get up for breakfast. Staff J stated Resident #1 was able to stand and follow cues but did not talk with staff which was unusual. e. On 2/17/16 at 4:47 p.m. Staff E LPN, confirmed she provided nursing care to Resident #1 prior to and after the [MEDICATION NAME] was initiated. Staff E stated Resident #1 mostly complained of pain in his/her back and legs related to diabetic nerve pain. Staff E stated typically he/she requested pain medication at night and then slept so she thought the medication was effective. Staff E stated Resident #1 never complained of increased pain after he/she received one dose of pain medication. Staff E stated she provided nursing care to Resident #1 the night after initiation of the [MEDICATION NAME] and felt Resident #1 was a little sleepier but not uncommon with [MEDICATION NAME]. Staff E stated near the end of her shift, she noticed Resident #1 developed a cough and administered a nebulizer treatment. According to Staff E Resident #1 was a little groggy at that time. Staff E questioned if related to the [MEDICATION NAME] or from Resident #1sleeping. Staff E kept Resident #1's door open for frequent visualization based on the increased lethargy. Staff E stated she typically observed residents use [MEDICATION NAME] 75 mcg at the most. Staff E recalled nursing staff questioned the higher dose but one nurse stated the DON commented [MEDICATION NAME] 125 mcg was appropriate based on the size of Resident #1. Staff E stated she would have questioned the physician's orders [REDACTED]. f. On 2/17/16 at 2:11 p.m. Staff G, LPN, stated she administered the first dose of [MEDICATION NAME] 125 mcg patches for Resident #1. Staff G stated she never questioned the order because she works the night shift and orders are received during other shifts. Staff G stated Resident #1 was able tell staff if he/she needed pain medication for muscle spasms and neuropathic pain. Staff G noted Resident #1 slept after the PRN pain medications are administered and he/she slept all night. g. On 2/18/16 at 10:45 a.m. Staff H RN, stated she worked with Resident #1 prior to the [MEDICATION NAME]. Staff H stated typically Resident #1 requested [MEDICATION NAME] for chronic back/leg/rib pain at bedtime and noted it was effective because he/she slept all night. Staff H was unable to recall a time the pain medication was ineffective and added Resident #1 was able to make his/her needs known. Staff H stated [MEDICATION NAME] 125 mcg seemed awfully high and most often sees physician orders [REDACTED]. an order for [REDACTED]. Staff H stated there was always a physician available to contact such as the physician's office or on call physician in the emergency room . h. On 2/17/16 at 2:33 p.m. Staff I, RN, recalled Resident #1 complained of back pain about once a week, but never commented the PRN [MEDICATION NAME] was ineffective. Staff I stated she would never start a Resident on [MEDICATION NAME] 125 mcg unless she contacted the physician for clarification. i. On 2/16/16 at 2:15 p.m. Staff K CNA stated he provided cares and showers for Resident #1 and never observed nonverbal signs or symptoms of pain during cares. Staff K stated Resident #1 was alert and oriented, independent in his/her room and walked to the dining room with a walker and assistance of staff. Resident #1 never complained of any pain. j. On 2/17/16 at 9:50 a.m. Staff L LPN, confirmed she provided nursing cares to Resident #1 prior to the [MEDICATION NAME] order. Staff L stated she never observed any nonverbal signs of pain and rarely utilized pain medications during the day shift. Staff L stated Resident #1 ambulated to the dining room using a walker and staff assistance was alert and oriented, able to make his/her needs known. Staff L unable to recall ever administering [MEDICATION NAME] 125 mcg before in her [AGE] years of nursing and indicated a contact to the physician's office for clarification needed to occur. k. On 2/23/16 at 2:23 p.m. Staff AA, facility van driver, confirmed he provided transportation for Resident #1 to the emergency room . Staff AA stated he transported Resident #1 about every 3 weeks to the hospital for telemedicine visits. According to Staff AA Resident #1 was pleasant and talked about common acquaintances, day's events but this transfer Resident #1appeared pretty lethargic and tired. Staff AA stated Staff D rode along to the hospital and spoke to Resident #1 but he/she just sat in the wheelchair, was conscious but not alert. Staff AA failed to remember hearing Resident #1 cough during the ride. Staff AA recalled Resident #1received oxygen this time unlike previous transfers. Staff AA stated Resident #1 just not acting the same as before. On 2/17/16 at 3:47 p.m. the facility Medical Director confirmed knowledge of Resident #1's medication issue. The Medical Director stated he understood the physician's orders [REDACTED]. The Medical Director stated the facility nurses failed to question that order and believed staff needed to evaluate 125 mcg of [MEDICATION NAME] as a starting dose of opioid medication was certainly not normal. The Medical Director added there's no defensible information one can provide for this situation. The facility Medication Errors procedure revised 12/15, identified the definition of a medication error included. a. When the resident receives an amount of medication that is greater than or less than the amount ordered by the prescriber. Transcription Error: a. Inaccurate transcription of an order. The procedure directed staff to; document all medication error occurrences on a new active incident in the Risk Management module. According to the undated Medication Error policy; when a medication error occurs, it will be reported to the attending physician promptly. The facility procedure titled [MEDICATION NAME] Patch Application, revised 11/13 directed staff members to. a. Verify physician order b. Obtain patch and read manufactures guidelines. c. Observe patch placement and that it is secure each shift. Note: At the time of the complaint and incident investigation, the complaint was coded at a J immediate and serious jeopardy. By 2/18/16 the facility had implemented measures that adequately addressed the jeopardy and the grid was lowered to a D level. The facility provided education to staff on protocol changes for administration of [MEDICATION NAME]es, changes in resident conditions regarding physician notification and changes to the pharmacy notification for medication orders. As of the 2/26/16 exit the facility had failed to monitor staff compliance regarding the proper use of [MEDICATION NAME]es and pharmacy procedures.

Based on clinical record review, resident, physician and family interview the facility failed to ensure residents received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #1 ' s lack of assessments related to change in condition following an identified medication error. Resident #15 ' s lack of assessment related to change in condition related to urinary frequency and unresponsiveness. The investigation involved two of two sampled residents that required hospitalization (Resident #1 and #15). The facility reported a current census of 79. Findings include: 1. According to the MDS dated [DATE] Resident #1 ' s BIMS score of 15 reflected no cognitive impairment. The MDS lacked signs and symptoms of [MEDICAL CONDITION] or memory loss. Resident #1 required extensive assistance of one staff member for ambulation and limited assistance of one staff member for bed mobility, transfers and toilet us. Resident #1 ' s MDS revealed balance during transitions and walking required staff assistance for walking or turning and able to stabilize independently for moving from seated to standing, on or off the toilet and surface to surface transfers. Resident #1 utilized a cane/crutch, walker and wheelchair for mobility. According to the MDS Resident #1 ' s [DIAGNOSES REDACTED]. The MDS included a pain assessment which reflected Resident #1 frequently had pain that he/she rated 8 on a 0 - 10 scale. The same assessment noted Resident #1 received scheduled pain medication and pain medication as needed. The Care Plan, initiated 6/17/14 and revised 1/21/16, identified pain related to [MEDICAL CONDITION], chronic lower back pain and reflux as evidenced by the use of pain medications as needed. Interventions included: Strength: 1. Resident is able to communicate pain and need for pain medications. 2. Observe/record/report to nurse any signs and symptoms of non-verbal pain that included but not limited to changes in breathing, vocalization, mood/behavior. 3. Monitor/document for side effects of pain medication. On 2/1/16 at 11:50 a.m. the DON documented the physician examined Resident #1 on rounds and ordered [MEDICATION NAME] 125mcg (micrograms) patch due to chronic pain issues. The DON documented she notified Resident #1's liver specialist, and notified his/her family member of the new order. The DON documented, she then ordered the [MEDICATION NAME] from the pharmacy. The Progress Notes revealed the following: a. On 2/1/15 at 11:30 p.m. Staff G, LPN applied [MEDICATION NAME] 125 mcg patch. Staff G indicated she applied two patches, one patch of [MEDICATION NAME] 100 mcg and one patch of [MEDICATION NAME] 25 mcg. Staff G documented Resident #1 complained of lower back pain and bilateral thigh pain. b. On 2/2/16 at 6:05 p.m. Staff B RN, documented Resident #1 ' s gaze appeared distant and response to staff CNA ' s question was limited. Staff B RN documented it required the nurse to say his/her name twice before Resident #1 could focus on the Staff B. Resident #1 reported he/she did not know if he/she was ok. Staff B noted Resident #1 appeared unsteady and required a wheelchair for transport to the dining room for the evening meal. Staff B, RN directed staff CNA to ensure Resident #1 ate. The progress note failed to contain any assessment of the change to Resident #1 ' s condition or notification to the physician. c. On 2/2/16 at 11:54 p.m. Staff E, LPN, noted Resident #1 and increased tiredness noted, he/she fell asleep right away and wakes up easily. Staff E LPN, encouraged Resident #1 to utilize his/her call-light for transfer assistance The progress notes failed to contain any assessment of the change to Resident #1 ' s condition or notification to the physician. d. On 2/3/16 at 5:59 a.m. Staff E LPN, administered a PRN nebulizer treatment for [REDACTED]. (Rhonchi are coarse rattling respiratory sounds, usually caused by secretions in [MEDICATION NAME] airways.) The progress notes failed to contain any assessment of the change to Resident #1 ' s condition or notification to the physician. e. On 2/3/16 at 10:01 a.m. the physician's office called to notify Staff C, RN of lab results. Staff C, RN indicated she notified the physician's office that Resident #1 was very tired and almost unable to answer questions; however his/her vital signs are within normal limits. The progress notes failed to contain an assessment of Resident #1 other than documentation of vital signs with in normal limits. f. On 2/3/16 at 10:25 a.m. Staff C, RN noted physician ordered a decrease of [MEDICATION NAME] to [MEDICATION NAME] 50 mcg. g. On 2/3/16 at 12:00 p.m. Staff D, RN and Quality Assurance nurse, indicated she notified the physician's office that Resident #1 experienced a gradual decline in status as evidenced by increased lethargy and confusion. The physician authorized Resident #1 ' s transfer to the emergency room for evaluation. The progress notes failed to contain any assessment of the change to Resident #1 ' s condition. The History and Physical, dated 2/4/16, revealed Resident #1 was placed on observation status 2/3/16 after he/she received a 125 mcg [MEDICATION NAME] in place of a 12.5 mcg [MEDICATION NAME] dose. [MEDICATION NAME] was administered in the emergency room that resulted in improvement of Resident #1 ' s fatigue. Overnight the creatinine level and white blood count increased. X-Rays showed concern for free air on the abdominal film as well as left pneumonia. Resident #1was admitted to the hospital for intravenous antibiotic therapy. Interview on 2/17/16 at 12:10 p.m. Resident #1's physician stated he expects facility staff to notify him with any change in status, that included staff notation of increased lethargy following the administration of the [MEDICATION NAME], as well as change in Resident #1's breathing status noted on 2/3/16. On 2/17/16 at 12:47 p.m. the physician stated Resident #1's pneumonia and death was more likely than unlikely directly related to the overdose of [MEDICATION NAME]. Interview on 2/19/16 at 3:40 p.m. identified Resident #1's liver specialist reviewed the clinic notes and stated there was no notification of Resident #1's [MEDICATION NAME] order. The physician confirmed all medication changes are to be reported to the clinic. On 2/23/16 at 12:11 p.m. Resident #1's family member was interviewed. The family member stated she last saw Resident #1 on the Sunday before [MEDICATION NAME] was initiated. The family member stated Resident #1 was alert and oriented and watched television together. Resident #1 complained of some back pain but rarely complained of a lot of pain, and never complained that his/her pain medications are ineffective. No contact on 2/1/16. The family member commented the next call received was from facility staff reporting Resident #1 was lethargic and nonresponsive and heading to the emergency room (ER). The family member stated the ER staff administered [MEDICATION NAME] (a medication used to reverse the sedative effects of narcotics) and Resident #1 came around and then fell off again. The family member stated the ER staff explained Resident #1's kidney function and blood pressure are low. The family member stated both times [MEDICATION NAME] was administered Resident #1 perk up more. Resident #1's physician called and reported tests revealed pneumonia due to the sedation from the narcotics. He also reported the kidneys failed due to the overdose of [MEDICATION NAME]. The family member reported Resident #1 continued to decline the next few days, and was intubated and transported by helicopter to another hospital out of State. The physician reviewed Resident #1's condition and family needed to decide on continuation of life support. The physician stated Resident #1 ' s return to his/her normal function was unlikely and family decided to remove life support. According to family Resident #1passed away. Staff Interviewed as follows: a. On 2/18/16 at 7:34 p.m. Staff C RN, indicated the morning Resident #1 transferred to the hospital he/she was not responding and appeared out of it. Staff C recalled Resident #1 was unable to keep his/her eyes open. Staff C stated at the time Resident #1 transferred to the hospital, he/she stood up with the assistance of 3 staff members but was unable to talk with staff because he/she was so tired. Staff C checked the original physician's orders [REDACTED]. Staff C stated it could be either [MEDICATION NAME] 12.5 mcg or 125 mcg. Staff C stated Resident #1 ' s liver [DIAGNOSES REDACTED]. Staff C stated the nurse ' s needed to obtain clarification from the physician. b. On 2/17/16 at 4:47 p.m. Staff E LPN, confirmed she provided nursing care to Resident #1 the night after initiation of the [MEDICATION NAME] and felt Resident #1 had been a little sleepier but not uncommon with [MEDICATION NAME]. Staff E stated near the end of her shift, she noticed Resident #1 developed a cough and administered a nebulizer treatment. According to Staff E Resident #1 had been a little groggy at that time. Staff E kept Resident #1's door open for frequent visualization based on the increased lethargy. Staff E stated she would have questioned the physician's orders [REDACTED]. 2. The MDS dated [DATE], for Resident #15 ' s listed a BIMS score of 15 that indicated no cognitive impairment. Resident #15 lacked signs and symptoms of [MEDICAL CONDITION]. According to the MDS, Resident #15 required extensive assistance of two staff members for transfers and toilet use. The MDS identified Resident #15 utilized a walker and wheelchair for mobility. According to the MDS [DIAGNOSES REDACTED]. The MDS noted Resident #15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The Care Plan, initiated 2/1/16, identified an activity of daily living self-care performance deficit with an intervention provide assistance of one staff with toilet use. The Care Plan noted Resident #15 may stand up from bed or chair with assistance of one, gait belt and walker to utilize a urinary collection device. The Care Plan also identified Resident #15 experienced limited mobility related to arthritis and left total hip arthroplasty (hip replacement) and directed staff assist with mobility and ambulation. Review of the Facility Progress Notes revealed: a. On 2/1/16 at 11:02 a.m. arrived to the facility per family vehicle. Assessment included notation of clear yellow urine and alert and oriented. b. On 2/1/16 at 11:43 p.m. nursing notes indicated Resident #15 reported increased need to go to urinate but denied dysuria (painful urination) or urgency. c. On 2/2/16 at 7:07 a.m. Resident #15 reported frustration with cares provided, complaints of urinary urgency and frequent urination. Nursing notes failed to include any assessment of Resident #15 ' s urgency or frequency. d. On 2/2/16 at 8:06 a.m. Staff G LPN noted Resident #15 complained of urinary frequency. The nursing notes failed to include any assessment of Resident #15 ' s complaints of frequency. e. A late entry dated 2/2/16 at 6:00 p.m. revealed Staff B was notified Resident #15 ' s not waking up much. After two attempts of verbal stimulation and shaking arms, Resident #15 moaned and fluttered his/her eyelids but failed to verbally respond. Staff B raised the head of the bed and continued to try to stimulate Resident #15 with minimal response. Staff B assessed the resident's vital signs and summoned the float nurse for assistance. The nursing notes failed to include any assessment of Resident #15 ' s unresponsiveness or documentation of vital signs obtained. f. On 2/2/16 at 6:13 p.m. revealed Resident #15's family member and emergency room staff notified of transfer to the hospital. Progress Notes dated 2/2/16 at 9:20 p.m. revealed the facility received notification that Resident #15 was admitted to the hospital with [REDACTED]. Review of the hospital History and Physical, dated 2/2/16, revealed Resident #15 presented to the emergency room hypotensive with pressures in the 60's - 80's and appeared quite dry. Resident #15 had [MEDICAL CONDITION] with 1,000 cc of urine in his/her bladder. The physical examination section revealed, Resident #15 ' s posterior pharynx was extremely dry, the emergency room staff attempted to wet (his/her) lips and oropharynx a little but this failed to make much difference. Resident #15 ' s mouth seemed rather parched. Admission [DIAGNOSES REDACTED]. Under the Plan and impression, Resident #15 admitted for intravenous antibiotics, dehydration, unknown unresponsiveness, over flow incontinence secondary to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Staff must be cautious with his/her hydration and noted a urinary catheter placed and clamped following a drop in blood pressure. Review of Intake/Output information provided by the facility revealed the following: a. On 2/1/16 at 1:00 p.m. Resident #15 drank 200 cc of fluids with his/her meal (1 ounce equals approximately 30 cubic centimeters or cc). (One can of soda pop was approximately 355 cc.) b. On 2/2/16 at 1:40 p.m. Resident #15 drank 180 cc of fluids with his/her meal. Interview on 2/23/16 at 1:08 p.m. Staff B RN stated, a Resident #15 on the toilet and 90% unresponsive on 2/2/16 with his/her eyes closed. Staff B noted he/she had a bowel movement and determined Resident #15 experienced a vagal response. Staff B failed to recall notification to the physician regarding the vagal response incident. Interview on 2/23/16 at 2:57 p.m. the DON stated she was aware Resident #15 reported he/she held urine all night and was incontinent. The DON reviewed the intake sheets and acknowledge inadequate fluid intake for Resident #15. According to the DON the failed to notify the physician regarding each change in resident condition and felt Resident #15's transfer could have been prevented. On 2/24/16 at 8:59 a.m. Resident #15's physician stated he wanted notified of any change in resident's condition. The physician indicated knowledge of the dehydration [DIAGNOSES REDACTED]. On 2/16/16 at 4:35 p.m. during an interview Resident #15's family stated he/she was admitted to the facility on [DATE] following a hip replacement. The first night at the facility, Resident #15 experienced urinary urgency. The family members stated Resident #15 required assistance of 2 staff members with toileting/mobility upon admission to the facility. The family reported staff failed to respond adequately after activation of the call light regarding the need to toilet. Resident #15 held his/her urine as long as possible then was incontinent. At approximately 6:30 p.m. on 2/3/16 the facility notified Resident #15's spouse that he/she was being transferred to the hospital for unresponsiveness and slurred words. Resident#15 ' s spouse was concerned about the potential of a stroke related to the conditions identified. While hospitalized Resident #15 was diagnosed with [REDACTED]. Interview on 2/17/16 at 10:35 a.m. Resident #15 stated the first night at the facility, he/she experienced urinary urgency and staff members failed to respond to the call light so he/she wet the bed. Resident #15 stated he/she was wet from head to toe and laid in urine all night. The following morning, the night nurse entered his/her room to remove a urinary collection device and Resident #15 refused and requested to speak with management. Resident #15 stated the next day 2/3/16 he/she was admitted to the hospital for a urinary tract infection.

Based on observation, clinical record review, and staff interviews, the facility failed to plan for and implement care plan intervention(s) to ensure one (1) of four (4) residents received adequate supervision from hazards in the environment (Resident #3). Resident #3 fell while ambulating with one staff and a gait belt. The staff was unable to lower the resident to the floor. The activity of daily living (ADL) sheet and care plan directives did not match resulting in an inconsistent number of staff used to ambulate the resident. Facility census was seventy-seven (77) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 10/8/13 assessed Resident #3 with short and long term memory impairments and severely impaired decision making ability. The MDS assessed the resident to require assistance of two staff with transfers and ambulation. A "balance during transitions and walking" test identified the resident as unsteady and only able to stabilize with staff assistance in all areas of testing (not limited to moving from seated to stand, when walking, turning around and facing the opposite direction). The resident had [DIAGNOSES REDACTED]. The resident had one fall with injury since the previous assessment. The resident was 71 inches tall and weighed 180 pounds. Fall History: An incident details form dated 6/5/13 at 6:45 a.m. revealed the resident fell in the hallway landing on the left knee. The resident then turned to his/her buttocks with legs extended and rested their back against the wall. One staff ambulated the resident when the fall occurred. The resident sustained [REDACTED]. One measured 1.2 centimeters (cm.) by 0.1 cm. and the other one measured 0.3 cm. by 0.1 cm. The resident sustained [REDACTED]. bruise to the left knee, 13.4 cm. by 1.7 cm. on the outer right forearm and 2 cm. by 1.4 cm. on the inner right forearm. The intervention following the fall was: Ambulate with two staff and gait belt the first walk of the morning. An incident details form dated 7/25/13 at 6:40 a.m., revealed one staff ambulated the resident and the resident fell . The resident put one foot directly in front of the other when he/she attempted to take a step when the resident's toe on one foot caught the heel of the other foot causing the resident to go down to the floor landing on his/her bottom. The resident's right hand received a 2.8 cm. by 1.2 cm. skin tear from impact with the floor. The intervention following the fall was: Ambulate with two staff for first walk of the day. Care Plan in Place when 11/6/13 fall with fracture occurred: A care plan dated 10/23/13 identified the resident with a problem of self care deficit related to Alzheimer's Dementia manifested by inability to independently bathe, dress, groom or perform oral care. The care plan directed staff to use extensive assistance of two staff with transfers, toileting, ambulation on unit and bed mobility at night. The care plan also identified the resident with a problem of potential for injury related to Alzheimer's Dementia and Gait Disturbance manifested by resident unaware of safety needs. The care plan again directed staff to ambulate the resident with two staff while on the unit. An incident details form dated 11/6/13 at 8:45 p.m. revealed one staff ambulated the resident with a gait belt when he/she stumbled over their own feet and fell to the ground. Interdisciplinary Progress notes, dated 11/6/13 at 10 p.m. identified the nurse aide could not lower the resident to the floor and the resident received a skin tear to the right third finger. Staff applied 4 steri strips to the area and covered it with a telfa pad. The skin tear measured 0.2 centimeters (cm.) by 3 cm. Staff notified the Director of Nursing and Administrator and then sent a facsimile (fax) to the physician. An ADL sheet in place when the fall occurred, directed staff to ambulate the resident with one staff and use two if the resident was incontinent or resisted care. On 11/13/13 an x-ray identified a subcapital fracture with lateral displacement of the right hip. The resident underwent [REDACTED]. Staff Interviews: On 12/5/13 at 2:50 p.m. Staff H (certified medication aide) stated she ambulated the resident to his/her room from the dining room around 8:30 p.m. on 11/6/13 and the resident lost their balance and tripped on the way. She stated she used the gait belt but could not stop the fall. She stated the resident crossed his/her legs during the walk and then fell forward onto his/her knuckle. She stated the ADL sheet directed her to ambulate the resident by herself. She stated nurse aides do not look at the overall care plan where it said to use two staff because the ADL sheets are what staff goes by and they are to supposed to be updated weekly. Staff H stated the resident was not incontinent or resistive prior to and during the walk. On 12/5/13 at 3:23 p.m., Staff I (registered nurse) stated she was charge nurse when the incident occurred. She stated one staff ambulated with the resident when he/she fell . At the time, the ADL sheet did not match the care plan. The CNA merely followed what she had access to. Staff I reported she assessed the resident after the incident. On 12/10/13 at 2:07 p.m. Staff E (care plan nurse for the CCDI(Chronic Confusion and Dementing Illness) unit stated the resident had a prior incident of going down while staff ambulated him/her so she went back and forth regarding how many staff should ambulate the resident. She stated the number of staff needed depended on the resident's mood and which staff walked the resident and whether the resident was tired. She stated she wasn't sure how many staff were needed so that is why the ADL sheet said one staff and the care plan said two. On 12/5/13 at 2:35 p.m. the Director of Nursing confirmed the ADL sheet said the resident should walk with one but the care plan said two staff were needed. On 12/11/13 at 11:27 a.m. she stated physical therapy (PT) had not evaluated the resident within the year prior to the 11/6/13 fall. On 12/11/13 at 1:04 p.m. Staff K (nurse aide/medication aide) stated she always ambulated the resident with two staff. On 12/10/13 at 3:45 p.m. Staff A (nurse aide) stated she walked the resident with two staff. She stated the resident would walk and one foot wouldn't go or they would get tangled up and a foot would drag as the reason she used two staff. On 12/10/13 at 2:53 p.m. Staff B (nurse aide) stated sometimes it took two staff to walk the resident and other times one staff. She played it by ear. On 12/10/13 at 2:33 p.m. Staff C (medication aide) stated they always used two staff to walk the resident because that is what was on the care plan. She stated the resident's right knee would give way while ambulating and she didn't want to take any chances so she used two staff. On 12/10/13 at 11 a.m., Staff D (nurse aide) stated she always used two staff to stand the resident but she could walk the resident by herself. On 12/10/13 at 10:50 a.m. Staff F (registered nurse) stated the resident's spouse walked the resident in the hall by him/her(self). On 12/10/13 at 10:40 a.m. Staff G (nurse aide) stated she ambulated the resident with two staff. Observation: On 12/10/13 at 1 p.m., observation showed two staff transferred the resident from a wheelchair to recliner via the EZ stand lift. On 1/3/14 at 10 a.m. during phone exit the Administrator stated the ADL sheet said to use one to two staff for ambulation so the number of staff would not be consistent from one walk to another.

Based on record review and physician, family and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and ensure staff applied a personal alarm as planned for one of five residents to prevent accident/injury. The staff used an ADL (Activities of Daily Living) form to direct staff how to care for the resident. The staff did not utilize the care plan for interventions and instead used the ADL form. The care plan had not been revised to mirror the ADL form interventions. The facility identified a census of 67 residents (Resident #5). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive staff assistance with transfers, ambulation, dressing, toileting, personal hygiene and bathing. A "balance during transitions and walking" assessment identified the resident as not steady and only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around, and moving on and off toilet and surface to surface transfers. The resident used a walker for ambulation. A falls data collection tool dated [DATE] identified the resident scored 19. A score of 19 identified the resident as high risk for falls. A nursing documentation form dated [DATE], identified the resident as noncompliant at times due to increased confusion and attempts to stand on own at times. The resident utilized an attached alarm at all times and used a gait belt and wheeled walker. The form identified the resident with a fall on [DATE]. An incident details form dated [DATE] at 6:10 p.m., identified staff found the resident lying flat on his/her back with legs straight out on the floor outside the dining room. Staff documented the alarm was not in place prior to the fall. The resident complained of pain to the right posterior rib area. Following the fall, staff administered Tylenol and attached the resident's alarm. Staff sent a facsimile to the physician at 7:30 p.m., notifying them of the fall. The facility investigated the fall. The investigation revealed the care plan dated [DATE], contained the intervention "attach alarm at all times when in room". Following the fall on [DATE], the facility updated the care plan to read "alarm at all times". Interdisciplinary progress notes dated [DATE] at 2:50 a.m., documented the resident slept until that time. The resident woke up and requested pain medication. The resident complained of right posterior rib cage pain and stated it hurt to breath. The resident stated when he/she took a deep breath, he/she "could cry". The resident's respiration appeared shallow and the resident's oxygen saturation read 85 percent. Staff applied oxygen at 2 liters per minute. Staff did not document vital signs. Observation showed no discoloration from the fall. Staff administered Tylenol. At 3:15 a.m., the resident's oxygen saturation read 95 percent with oxygen running at 2 liters per minute. At 5:00 a.m., staff documented the resident slept after administering the Tylenol. At 9:00 a.m., staff documented the resident complained of pain on the left rib area. The facility telephoned the physician and the resident transported to the emergency room at 10:00 a.m. Interdisciplinary progress notes dated [DATE] at 2:45 p.m., identified the resident was admitted to the hospital and returned on [DATE] at 12:15 p.m. with [DIAGNOSES REDACTED]. The resident returned on routine pain medication and oxygen. The History and Physical report dated [DATE] identified old and new fractures of the ribs. The reason for admission to the hospital was pain management and respiratory support. The [DATE], Medication Administration Record (MAR) revealed the resident had an order for [REDACTED]. The resident did not receive the Tylenol until after the fall. The resident received Tylenol on [DATE] at 6:45 p.m. and results at 8:00 p.m. identified the medication "helped". The resident received the medication four hours later at 10:45 p.m. The results identified the resident slept until 2:50 a.m. on [DATE] when staff administered more Tylenol. The results at 5:55 a.m. were resident asleep. Interdisciplinary progress notes dated [DATE] at 7:40 a.m., revealed the facility notified the physician of the resident's pain which did not appear to be controlled with the resident's current pain medication. At 9:15 a.m., the resident was prescribed a Duragesic patch 25 micrograms per hour and increased Tramadol to 25 milligrams four times per day and every four hours as needed for pain. Interdisciplinary progress notes dated [DATE] at 11:30 a.m., revealed the resident continued to decline and complain of pain. The physician again increased the resident's pain medication and ordered Hospice for the resident at the family's request. On [DATE] at 2:33 p.m., Staff J, Certified Nurse Aide, CNA stated she/he worked the day of the incident. Staff J stated she/he ambulated the resident to the dining room the day of the incident and forgot to apply the alarm. Staff J stated when she/he got the resident to the dining room, call lights started going off and answered the call lights and that caused Staff J to forget to apply the alarm. Staff J stated prior to taking the resident to the dining room, she/he asked the resident if needed the toilet and the resident stated no. Staff J stated that according to the Activity of Daily Living (ADL) sheet which was supplied to the nurse aides at the start of every shift directed staff to apply an alarm at all times. Staff J stated the resident tried to get up per self maybe once every couple weeks. Staff J stated no nursing staff were present in the dining area where the resident ate. The resident ate in the west dining room. The only staff present in the west dining room where the resident ate were dietary staff. Staff J stated the resident got up by self to use the toilet and following the fall, the resident complained of his/her ribs hurting and staff then took the resident to the toilet and got the resident ready for bed. The resident fell asleep in the recliner. The resident slept that night until he/she woke up and complained of pain in his/her back. It was unusual for the resident to complain. The resident did not usually have aches and pains. Staff J stated she/he worked down a hall when the resident fell , answering a call light. On [DATE] at 2:33 p.m., Staff D, unit manager provided the ADL sheet dated [DATE] from the 2:00 p.m. to 10:00 p.m. shift. The ADL sheet directed staff to apply an alarm at all times. On [DATE] at 10:45 a.m. Staff D stated there was a discrepancy between the care plan interventions and the ADL sheet because they made a mistake when editing the ADL sheets. Staff D may have accidentally deleted the "in room" segment of the attached alarm directive on the ADL sheet. On [DATE] at 4:25 p.m., the Director of Nursing stated because nurse aides were supposed to follow the ADL sheet, they disciplined Staff J for not applying the alarm. On [DATE] at 3:55 p.m., Staff H, Registered Nurse stated they worked the day of the incident. Staff H stated as long as they could remember the resident used an alarm when he/she sat in the dining room. After the fall, Staff H assessed the resident. The resident identified his/her ribs as achy. The resident did not appear short of breath and palpation did not cause pain so Staff H administered Tylenol and the resident slept. Staff H stated staff worked off the ADL sheet directives and the ADL sheet directed staff to apply an alarm at all times. On [DATE] at 5:25 p.m., Staff I, CNA stated another resident got her attention on [DATE] and then they saw Resident #5 on the floor. Resident #5 did not have the alarm on. Staff I stated staff normally applied the alarm on the resident in the dining room. Staff knew to apply the alarm because of the ADL sheet. Staff always looks at the ADL sheet for changes. Staff I stated the ADL sheet was an important sheet that staff relied on to know what to do for the resident. Staff I stated the resident does not try to get up often and if he/she does try the alarm sounds and staff gets to the resident. On [DATE] at 3:05 p.m. Staff M, licensed practical nurse was in the east dining room when the incident occurred. Staff M stated they could not see the resident in the west dining room when in the east dining area. Staff M stated staff normally applied an alarm and they knew to apply it because of the ADL sheet. Staff M stated the nurses give the sheet to the nurse aides at the start of each shift. Staff M stated they thought there was probably dietary staff in the west dining room but was unsure if they pay attention. If the resident used an alarm, staff could have heard it and gone to the resident. Staff M stated the resident has tried to get up a few times when in the dining room within the last 6 months. On [DATE] at 4:08 p.m., Staff N, CNA stated they were assisting residents in the east dining room when the resident fell . Staff N did not realize the resident fell until they heard Staff I on the walkie talkie device trying to tell staff something. After the incident, Staff N stated they asked Staff J where the resident's alarm was and Staff J informed them the day shift never used it. Staff N asked Staff J if they looked at the ADL sheet because the ADL sheet directed staff to apply it at all times. Staff N stated a couple days before the incident; they saw the resident try and get up per self in the room. Staff N stated the alarm has activated in the dining room often indicating the resident tried to get up by themselves. On [DATE] at 4:35 p.m. Staff P, CNA stated they were assisting residents in the east dining room when they heard a commotion. At that time, Staff P knew someone fell . Staff P stated the resident was usually alarmed when in the dining room and staff knows that because of the ADL sheet. Staff read the ADL sheet when they come on duty. On [DATE] at 10:55 a.m., the resident's daughter stated they had no objection to the resident using an alarm in the dining room. On [DATE] at 9:20 a.m., the physician stated the facsimile sent at 7:30 p.m. went to a dead machine because no one was at the clinic at that hour. No one would see it until the following day. The physician stated they did not have a concern not receiving a call at that time. The physician identified the resident's condition change at 2:50 a.m., as a "red flag" and stated they would have liked a telephone call at the time. If the physician had known the resident's condition change, they would have sent the resident to the emergency room at that time. The resident would have received pain management approximately 12 hours sooner but treatment provided would not be different. The resident was no worse when seen the morning of [DATE] than when the nurse assessed the resident at 2:50 a.m. The physician stated the resident had rib fractures and pulmonary contusion and admitted the resident for pain control overnight. The physician stated the resident returned to the facility and his/her condition dwindled and the resident slipped away. A physician progress notes [REDACTED]. Per family request and resident's pain management, staff provided palliative care that progressed with respiratory complications from fall. With the resident's chronic bronchitis and multiple rib fractures, the resident became quite uncomfortable. The resident was also a new Hospice resident for recent trauma/fall and complications of rib fractures and chronic bronchitis. The resident expired on [DATE]. The physician documented on [DATE] on the resident's facility discharge summary the final diagnosis/cause of death as respiratory failure second to traumatic chest wall injury.

Based on record review, staff, family and physician interviews and review of facility policy/procedures, the facility failed to assess a resident with an onset of adverse symptoms from unnecessary drugs which represented a change in mental and physical condition, notify the physician of an adverse change and provide the nursing care and services so the resident ' s needs are met for 1 of 6 residents reviewed (Resident #5). The facility reported a census of 79 residents. Findings include: The Interdisciplinary Progress Notes (IDP) dated [DATE] indicated Resident #5 was readmitted to the facility for skilled care after hospitalization . Prior to admission, the data reflected the resident could feed self and had no aggression. The hospital discharge instructions directed staff if the resident had sedation, notify the psychiatric physician. The IDP Assessment of [DATE] indicated the resident as lethargic, depending on need for a PRN (as needed) medication for behaviors. The dining record revealed intakes which revealed the resident did not consume the needed fluids and food consumption. The resident had significant weight loss within 30 days and in 6 months. On [DATE], the resident's personal physician documented the staff should contact the psychiatric practioner due to not eating or drinking and the renal function laboratory tests were abnormal and showed acute [MEDICAL CONDITION]. The staff contacted the psychiatrist physician and reported the resident as sedated and still physically aggressive at times on [DATE]. The physician adjusted the medications. The vital signs on [DATE] revealed to be: blood pressure ,[DATE] and pulse 43. On [DATE] the resident only took sips of water when able to wake but lethargic and sedated. On [DATE] the resident ' s level of care changed and the blood pressure medications were held. An interview with the psychiatric physician revealed the facility had not informed him/her of the change of condition between [DATE] to [DATE]. The family requested the resident be sent to the hospital. The family allowed the resident to be allowed to die and no treatment provided to sustain the resident ' s life. On [DATE] the resident was admitted to Hospice. Resident #5 could not always be aroused to give medications the last 2 weeks of his/her life, but continued to receive [MEDICAL CONDITION] medication when he/she could, until he/she became unresponsive. The facility did not notify the prescribing physician until Resident #5 had been unresponsive for 3 days. 1. According to the Minimum Data Set (MDS) assessment, with a reference date of [DATE], Resident #5 scored a 1 on the Brief Interview for Mental Status (BIMS) which indicated severe cognitive impairment. Resident #5 required extensive assistance with transfers, ambulation, dressing, eating, toilet use, and personal; hygiene. Resident #5 had [DIAGNOSES REDACTED]. A Pre-Admission Case Management Data sheet dated [DATE] documented information received from a nurse. Resident #5 was pleasantly confused, ambulated with 2 assist and a gait belt. Resident #5 usually took medications without problem. Resident #5 fed him/herself, and showed no aggression for quite awhile. The general hospital Discharge Instructions dated [DATE] included: If sedated notify the Psychiatric Physician. The discharge instructions were noted by 3 nurses. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 11:45 a.m. documented Resident #5 readmitted to the facility for skilled level of care. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. [MEDICATION NAME] 10 milligrams (mg) (for dementia) 2 times a day. b. [MEDICATION NAME] Patch 9.5 mg (for Alzheimer ' s disease) topically every bedtime. c. [MEDICATION NAME] 25 mg (anticonvulsant) every day. d. [MEDICATION NAME] 100 mg (for [MEDICAL CONDITION]) every bedtime. e. [MEDICATION NAME][MEDICATION NAME], 12.5 mg (antipsychotic) every 2 weeks. f. [MEDICATION NAME] 5 mg (antianxiety) 2 times a day and 2.5 mg every bedtime. The MAR indicated [REDACTED] a. [MEDICATION NAME][MEDICATION NAME] 25 mg every 2 weeks (increased-doubled). b. [MEDICATION NAME] 25 mg 4 times a day (increased frequency). c. [MEDICATION NAME] 7.5 mg 4 times a day (increased dosage and frequency). The MAR indicated [REDACTED] a. Decreased [MEDICATION NAME] to 25 mg 2 times a day noon and bedtime ([DATE]). b. Decreased [MEDICATION NAME] dosage to 5 mg 4 times a day ([DATE]). c. Added Trazadone 25 mg (antidepressant) at bedtime ([DATE]). A physician's orders [REDACTED]. The MAR indicated [REDACTED] a. [MEDICATION NAME]: fatigue, pain, dizziness. b. [MEDICATION NAME]: nausea, vomiting, stomach pain. c. [MEDICATION NAME]: nausea, vomiting, dizziness. d. [MEDICATION NAME]: dizziness, drowsiness, unsteadiness. e. [MEDICATION NAME] Consta: dizziness, drowsiness, fatigue, f. [MEDICATION NAME]: dizziness, drowsiness, lightheadedness. g. Trazadone: (none listed on the MAR). According to the facility reference, the Nursing 2011 Drug Handbook: a. The adverse reactions to [MEDICATION NAME] include, fatigue, somnolence, anorexia and weight loss. Contraindications and cautions included the drug was not recommended for patients with severe renal impairment and to use cautiously in patients with moderate renal impairment. The Nursing considerations included: In elderly patients, even those with a normal creatinine level, use of this drug may impair renal function. The teaching included to report adverse effects. b. The adverse reactions to the [MEDICATION NAME] Patch include, fatigue, malaise, somnolence, [MEDICAL CONDITION], anorexia, and weight loss. c. The adverse reactions to [MEDICATION NAME] include, drowsiness, somnolence, [MEDICAL CONDITION], and anorexia. An alert directed to watch for signs of anorexia or subtle appetite changes, which may indicate excessive drug level. d. The adverse reactions of [MEDICATION NAME] include fatigue and somnolence. e. The adverse reactions to [MEDICATION NAME][MEDICATION NAME] somnolence, fatigue, anorexia, and weight loss. The drug may enhance hypotensive effects, monitor blood pressure. With CNS depressants may cause additive CNS depression, use together cautiously. The contraindications and cautions included to use intramuscular injection cautiously in those with hepatic or renal impairment. f. The adverse reactions to [MEDICATION NAME] include drowsiness and fatigue. Use of the drug with CNS depressants may increase CNS depression, use together cautiously. Monitor the resident closely for adverse CNS reactions. The drug is less sedating than other anxiolytics, but CNS effects may be unpredictable. The contraindications and cautions included the drug was not recommended for patients with severe hepatic or renal impairment. g. The adverse reactions to Trazadone include, drowsiness, fatigue, weakness, orthostatic [MEDICAL CONDITION] and anorexia. Antihypertensives may increase the hypotensive effect of Trazadone. Use with other CNS depressants may enhance CNS depression, avoid using together. An IDP Assessments and Summary Review dated [DATE] documented Resident #5 alert at times, others lethargic, depending on need for as needed (prn) medications for behaviors. The nutrition assessment documented the resident did not always consume adequate fluids. They would monitor and change nutrition interventions as needed. On [DATE] the review documented Resident #5 continued to be resistive to care and disrobed. Medications were adjusted. At the time of the interview unable to arouse the resident. The IDP Assessments and Summary Reviews dated [DATE] documented the care plan team did care conference with Resident #5's family member. They spoke of his/her behavior and the need to sedate him/her to provide needed cares. Resident #5's family member asked how the resident ate. A Nutrition assessment dated [DATE] documented Resident #5's estimated calorie needs at 1400 to 1600 a day and fluid needs at 1800 cubic centimeters per day. The Dining record recorded the following intakes for Resident #5: a. On [DATE], 100% food, 260 cc'c fluid. b. On [DATE], not available. c. On [DATE], 100% food, 400 cc's fluid. d. On [DATE], 33% food, 480 cc's fluid. e. On [DATE], 91% food, 540 cc's fluid. f. On [DATE], 68% food, 780 cc's fluid. g. On [DATE], 25% food, 240 cc's fluid. h. On [DATE], 68% food, 720 cc's fluid. i. On [DATE], 68% food, 1470 cc's fluid. j. On [DATE], 66% food, 690 cc's fluid. k. On [DATE], 0 food, 360 cc's fluid. l. On [DATE], 75% food, 360 cc's fluid. m. On [DATE], o food, 970 cc's fluid. An average of 57% food, 982 cc's fluid. n. On [DATE], 33% food, 1120 cc's fluid. n. On [DATE], 62.5% food, 510 cc's fluid. o. On [DATE], 0 food, 80 cc's fluid. p. On [DATE], 62.5% food, 560 cc's fluid. q. On ,[DATE], 43.75% food, 650 cc fluid. r. On [DATE], 12.5% food, 90 cc's fluid. s. On [DATE], 12.5% food, 320 cc's fluid. t. On [DATE], 0 food, 0 fluid. u. On [DATE], 0 food, 820 cc's fluid. v. On [DATE], 8.33% food, 790 cc's fluid. w. On [DATE], 0 food, 300 cc's fluid. An average of 20% food, 476 cc's fluid. x. On [DATE], 0 food, 390 cc's fluid. y. On [DATE], 8.33% food, 320 cc's fluid. y. On [DATE], 0 food, 90 cc's fluid. z. On [DATE], 0 food, 520 cc's fluid. aa. On [DATE], 12.5% food, 500 cc's fluid. bb. On [DATE], 0 food, 90 cc's fluid. cc. On [DATE], 0 food, 120 cc's fluid. dd. On [DATE], 0 food, 460 cc's fluid. ee. On [DATE], 0 food, 0 fluid. An average of 2% food, 276 cc's fluid. The Weight Record documented Resident #5 weighed 144.4 # on [DATE], a loss of 7.2% in 30 days, 9.18% in 90 days and 13.53% in 180 days. A physician's Patient Progress Note dated [DATE] documented the physician spoke with the facility and had been notified Resident #5 was not taking his/her medication, just kind of spitting it out, nor was he/she eating or drinking. Labs performed. Discussed Resident #5's status. Vital signs remained stable and he/she did not appear ill. The resident sat in a wheelchair with a buddy guard. At times Resident #5 seemed interactive and responsive in his/her environment, otherwise not. Labs showed some acute [MEDICAL CONDITION]. Not taking [MEDICATION NAME] and reviewed the remainder of his/her medications. Advised the staff to contact the psychiatric practitioner in regards to interventions with medications most appropriate for combativeness and resisting. The physician documented him/she would review their response and make comment back to the family as far as interventions appropriate in the resident ' s situation. A Counseling and Psychotherapy note dated [DATE] documented Resident #5 seen for [MEDICAL CONDITION] medication check, psychotherapy appointment and treatment plan at the facility. Staff reported Resident #5 as sedated, often sleeping during the day and not sleeping well at night, and still physically aggressive at times. Resident #5 did not eat and took a supplement. The Physician saw Resident #5 in his/her room and demonstrated a pleasant mood. Review of the nursing notes, reported on [DATE], the resident combative with cares. On [DATE], the resident up at 3:45 a.m. On [DATE], the resident as combative with cares. Medication helped during lethargy [DATE]. [DATE]th [MEDICATION NAME] reduced. Treatment plan update and orders: the Resident continued to have sleep problems and behavior problems. Discontinued [MEDICATION NAME]. Added Trazadone 25 mg at bedtime and may repeat 1 time but not after 3:00 a.m. [MEDICATION NAME] 25 mg 2 times a day at noon and bedtime. Continue other medications as directed, treatment plan and precautions. Return appointment in 3 to 12 months. A physician's Patient Progress Note dated [DATE] documented concerns recently with Resident #5 not eating or drinking. The Psychiatric physician saw Resident #5 the previous day and made medication adjustments. Staff reported the resident ate a little the day before but not very much. They had been monitoring renal function with this. Healthy appearing... fairly good mucous membranes... Resident #5 smiled and interacted with the physician... chatty. Mild to moderate [MEDICAL CONDITION] secondary to poor intake. Supportive cares at this point and medication changes. Not inclined to hospitalize for forceful feedings or intravenous interventions with her chronic diagnoses. We'll follow this carefully. The Daily skilled Notes documented the following: a. On [DATE] at 12:00 a.m. restless, [MEDICATION NAME] given. At 4:30 a.m. restless, [MEDICATION NAME] given. At 8:00 a.m. unable to awaken for breakfast, very sedated. At 10:30 a.m. up for the day. At 10:30 p.m. Resident #5 taken back to bed after receiving [MEDICATION NAME], but again attempted to self transfer, [MEDICATION NAME] given. b. On [DATE] at 3:15 p.m. Resident #5 received [MEDICATION NAME] for restlessness. At 8:05 p.m. Resident #5 again received [MEDICATION NAME] for restlessness. At 10:45 p.m. Resident #5 received [MEDICATION NAME] for restlessness and behaviors. c. On [DATE] at 10:30 a.m. unable to wake Resident #5 for breakfast, but now awake silting on the edge of the bed. At 11:00 p.m. [MEDICATION NAME] given for restlessness. At 4:50 p.m. staff reported Resident #5 constantly got up. activating chair alarm, resistant to assistance, resists wearing gait belt... Last [MEDICATION NAME] at 2:00 p.m., unable to give another until 6:00 p.m. At 4:55 p.m. called the physician's office. At 5:12 p.m. received a new order to give [MEDICATION NAME] now for agitation, if not effective, give [MEDICATION NAME]. At 5:15 p.m. [MEDICATION NAME] given. At 8:15 p.m. [MEDICATION NAME] given for agitation. At 9:30 p.m. [MEDICATION NAME] given again. d. On [DATE] at 11:00 a.m. staff sent a fax to the psychiatric physician regarding the MARS (Medication Administration Record) and behaviors. At 11:15 a.m. the nurse received a return call from the psychiatric physician's office with new orders to increase the [MEDICATION NAME] Consta, [MEDICATION NAME] and [MEDICATION NAME]. At 11:35 a.m. informed family of medication changes and if no improvement would need to consider hospitalization . At 1:25 p.m. received a new order for a lap buddy as needed due to restlessness and many attempts to try and get up on her own. At 2:00 p.m. Resident #5 able to ambulate with a wheeled walker a gait belt and 1 assist. e. On [DATE] at 10:30 a.m. ambulated in hallway and did well. At 8:25 p.m. Resident #5 combative with staff, resistive with cares, [MEDICATION NAME] given. f. On [DATE] at 1:30 p.m. Resident #5 had been restless in wheelchair since 10:00 p.m. g. On [DATE] at 11:00 a.m. needed 3 staff to get Resident #3 in the wheelchair due to behavior. Resident #5 falls asleep and attempts to feed breakfast and lunch fail. At 8:00 p.m. Resident #5 combative with staff and attempting to self transfer. [MEDICATION NAME] given. h. On [DATE] at 12:00 p.m. Resident #5 had been up all morning. Resident #5 was drowsy, but did eat meals well. Uncooperative with dressing. Did not bear weight well and was difficult to transfer... Wheelchair used for destinations because Resident #5 did not cooperate with ambulation. i. On [DATE] at 10:00 a.m. Resident #5 up in the wheelchair, alert but confused. Resident to ambulate to and from meals using the wheeled walker and gait belt, but resident sits down or bears no weight when gotten up. Mood swings. j. On [DATE] at 1:00 p.m. Resident #5 alternated between being pleasant and cooperative to combative and uncooperative with care. Given prn medication for restlessness. Resident #5 could ambulate with a wheeled walker, gait belt and 1 staff assist, however frequently required 2 staff for all care due to combativeness. After prn given Resident #5 was drowsy but willing to have cares done. k. On [DATE] at 6:00 a.m. Resident #5 was up in the wheelchair until about 3:00 a.m. At 11:00 a.m. Resident continued to work with PT (physical therapy) and OT (occupational therapy). Uncooperative with ambulation. Took 2 to 3 assist for transfers due to behaviors. No behaviors that day because in bed sleeping. Up in wheelchair for lunch. l. On [DATE] at 2:00 p.m. Resident #5 assisted to bed with 2 assist and a gait belt. Resident #5 had been falling asleep in the wheelchair. m. On [DATE] at 9:45 p.m. attempted to hit the writer, increased agitation while in room. Resident #5 spit out some of the medication, [MEDICATION NAME] given. At 10:15 p.m. increased agitation, no results from [MEDICATION NAME]. [MEDICATION NAME] IM given. n. On [DATE] at 12:00 p.m. assisted Resident #5 with transfers from bed to wheelchair, from wheelchair to toilet. Did well with 4 wheeled walker but needed cues. Loose bowel movement 2 times today. Needed 2 staff to ambulate with 4 wheeled walker and a gait belt. Did not eat well at lunch today, pouring water from glass to glass and attempting to pour water on food. Resident #5 rather subdued and seemed more tired. o. On [DATE] at 12:30 p.m. Resident #5 very sedated at breakfast and unable to wake for the meal. Had several loose bowel movements. At lunch was unwilling to open eyes and would not open mouth to eat. p. On [DATE] at 6:00 p.m. very sedated. q. On [DATE] at 10:00 a.m. the physician called with concerns for labs drawn, Resident #5 not taking medication, and blood pressure low yesterday. Requested the psychiatric physician be notified. At 11:30 a.m. the psychiatric physician faxed activity, behaviors, MARs, lab, bowel movement activity and vital signs. New orders received to decrease [MEDICATION NAME] and would see [DATE]. At 1:00 p.m. Resident #5 had been lethargic all day... unable to wake enough to offer fluids. Up at lunch time in wheelchair, but continued lethargic and unable to give food or fluids. r. On [DATE] at 9:30 a.m. unable to wake for breakfast, however awake then and attempting to get out of bed. s. On [DATE] at 5:00 a.m. Resident #5 was up all night. At 2:00 p.m. Resident #5 refused to eat and drink. Some drooling noted. At 4:30 p.m. the medication nurse requested to administer [MEDICATION NAME]. t. On [DATE] at 1:30 p.m. Resident #5 seen by the physician. Vital signs, weights, the psychiatric physician's orders [REDACTED]. At 1:45 p.m. up most of the day, generally pleasant and cooperative. Dozed in the wheelchair at times. Needed extensive assistance with ADL's. Transferred with 2 assist. Did ambulate with a wheeled walker. Occasionally drooled specifically after drinking. u. On [DATE] at 1:30 p.m. ate very little at both meals. Drank supplement. Assisted with toileting, stools loose, had no control. Water pushed but intake poor. At times let fluid run back out of mouth. Resident #5 sleepy and not very responsive to verbal stimuli. v. On [DATE] at 9:00 a.m. Resident #5's pulse registered 38 and blood pressure ,[DATE]. Staff placed a call to the physician on call for Resident #5's physician, to report this. At 11:00 a.m. blood pressure ,[DATE] and pulse 51. Resident #5 was lethargic during the assessment. At 1:00 p.m. Resident #5's family member informed he/she needed to sign a permission form for Trazadone. At 3:00 p.m. current blood pressure ,[DATE] and pulse of 43. Resident was up in the chair and verbally responded. MARS faxed to Resident #5's physician's office. At 5:30 p.m. received a phone call from the physician's office to get a clean catch UA, hold blood pressure medications, every shift for 3 days and report. w. On [DATE] at 11:45 a.m. Resident #5 was up for breakfast but took only 90 cc's of supplement. Took sips of water when able to wake a bit, was sedated and lethargic. The Interdisciplinary Progress (IDP) Notes dated [DATE] documented Resident #5 went to Intermediate level of Care. On [DATE] at 2:15 p.m. staff faxed Resident #5's vital signs from last week on [DATE] when the physician ordered to hold all blood pressure medications. Resident #5 had no medications that day and still slept at that time. The social worker from the recent hospitalization called and inquired about Resident #5's condition. A hospital 1 month Discharge Follow-Up Survey Form dated [DATE] documented Staff J Licensed Practical Nurse (LPN) reported Resident #5 ate poorly, and slept good/plenty. Behaviors: Not good, no pattern, eats 1 day then next 3 days out of it. During an interview on [DATE] at 1:58 p.m. the social worker from the hospitalization stated they call and do follow up on every patient discharged from the hospital. They asked about eating, sleeping, and behavior. Staff J stated if she had called the psychiatric physician on Resident #5's condition between [DATE] and [DATE] she would have documented it. The clinical record lacked documentation of notification of the psychiatric practitioner of Resident #5's condition as reported to the hospital social worker. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 9 a.m. documented staff faxed recent vital signs to the physician. On [DATE] at 6:00 p.m. the CNA's reported Resident #5 did not hold on to the sit to stand lift when transferring, They were advised to use the total lift at bedtime for safety. At 7:00 p.m. Resident #5 ate no supper, but did take 90 cc's fluid including 30 cc's of supplement. On [DATE] at 1:40 p.m. staff turned Resident #5 often to check and change position. Resident #5 did not even flinch when touched or moved. Took no medications. On [DATE] at 12:00 a.m. staff repositioned Resident #5 with assist of 2 residents.. Resident #5 did open eyes, but no verbal response. On [DATE] at 1:30 a.m. Resident #5 did not stir while nurse in the room. At 9:00 a.m. updated the physician regarding Resident #5's elevated temperature, unresponsiveness, and increased respirations of 36. At 10:00 a.m. received a call from the physician's nurse for APAP 650 mg rectally every 4 hours as needed. [MEDICATION NAME] 500 mg intramuscularly every day times 3. Discontinue [MEDICATION NAME]. Call an update to the physician on Friday. On [DATE] at 9:00 a.m. staff called the physician and questioned if [MEDICATION NAME] should be given because Resident #5 had been basically unresponsive for the past 3 days. At 9:30 a.m. received a call from the physician's nurse with orders to send the psychiatric physician a fax with medications, weights, and condition. Hold all antipsychotic medications until the physician responds. On [DATE] at 11:30 a.m. received a telephone order to send Resident #5 via ambulance to the emergency room for evaluation per the family's request. Staff updated the physician who would see Resident #5, by phone. At 12:30 p.m. faxed to the psychiatric physician MARS, weight, and meal intakes along with update of condition. At 3:35 p.m. Resident #5 admitted to hospice. A Fax Communication to the Physician dated [DATE] notified the psychiatric practitioner Resident #5 experienced weight loss, past 3 days basically unresponsive, decreased intake, decreased blood pressure. Resident #5's physician gave the order to hold all antipsychotic medications until psychiatric practitioner faxed regarding further orders. A Transfer form dated [DATE] documented the reason for the transfer: Lethargic-unresponsive. A hospital physician's orders [REDACTED]. A Discharge Summary dated [DATE] identified Resident #5's cause of death: Dementia, Alzheimer's type, [MEDICAL CONDITION]. A Recapitulation of Resident's Stay documented Resident #5 was hospitalized several times to get behaviors under control. After the resident ' s last return, Resident #5 readmitted to the facility and his/her health status started to decline and he/she passed away. During an interview on [DATE] at 10:56 a.m. the office manager of the Psychiatric Physician stated there were no reports of Resident #5's condition between [DATE] and [DATE]. During an interview on [DATE] at 11:02 a.m. Staff E Certified Nursing Assistant stated she worked with Resident #5 after he/she returned from the hospital. She stated they mostly had to feed Resident #5, and she took small bites. Staff E stated it came to a time when they couldn't wake Resident #5 to feed him/her. If they could get Resident #5 to wake a little, the nurses told them to try to get sips of water down, and they also tried Pepsi, because the resident liked it. During an interview on [DATE] at 11:20 a.m. Staff B CNA stated when Resident #5 first came back he/she responded and could be a little combative. Staff B stated she didn't know what happened, but after awhile Resident #5 would not wake up. The staff did not get Resident #5 up very much because he/she was limp and unresponsive. Staff B thought about the last week. Staff B stated they would try to give Resident #5 water, but there wasn't any way to give him/her food. They tried giving him/her Pepsi, but that didn't work well either. During an interview on [DATE] at 11:33 a.m. Staff C Registered Nurse (RN) stated she assessed Resident #5 related to his/her skilled care. Staff C stated she could remember Resident #5 being sedated and letting fluids run out of his/her mouth. Staff C at times would take physician's orders [REDACTED]. She didn't see the family. Staff C stated she was surprised when she heard Resident #5 died . During an interview on [DATE] at 3:30 p.m. Staff F, Activities stated she saw a big change in Resident #5's level of consciousness, and thought the resident was sedated on medications. Staff F stated she was also a CNA, but she would not even try to give Resident #5 fluids because the resident seemed so "out of it". During an interview on [DATE] at 5:06 p.m. The Psychiatric Physician stated when residents are released from the hospital the facility is instructed to call him if the resident experiences side effects. He stated sedation is one of the most common side effects and these medications can build up and require a reduction. Changes were made on [DATE] and if those changes did not result in improvement, or the resident's condition worsened, the facility should have notified him/her and would have made further changes in the medication. The physician stated he had been notified of Resident #5's condition on [DATE] and the resident had been unresponsive for 3 days. The physician stated he/she had not received notification of the resident's condition between [DATE] and [DATE]. During an interview on [DATE] at 1:15 p.m. Resident #5's personal physician stated if he/she had problems with behaviors or the [MEDICAL CONDITION] medications the facility needed to call the psychiatric physician. The Physician stated he saw Resident #5 on [DATE]. The Physician was gone for 9 days after that and his associates dealt with issues that came up. During an interview on [DATE] at 11:26 a.m. the facilities consultant pharmacist stated residents needed to be adequately hydrated to excrete drugs. If not adequately hydrated drugs could build up in the system. The pharmacist stated some drugs were metabolized. During an interview on [DATE] at 9:31 a.m. Resident #5's pharmacist stated when researching Resident #5's [MEDICAL CONDITION] medications, it was found adequate hydration with Trazadone and [MEDICATION NAME], should be maintained. During an interview on [DATE] at 12:50 p.m. Staff G LPN stated if a resident could not be aroused to provide nourishment then she would notify the physician. During an interview on [DATE] at 12:54 p.m. Staff J stated Resident #5 had not been receiving his/her medication because staff could not wake him/her up. Staff J stated she did not know what was going on with Resident #5. During an interview on [DATE] at 2:58 p.m., Staff H (Licensed Practical Nurse) stated after Resident #5 went off skilled care, the staff would only document if needed. Staff H wasn't sure if Resident #5's level of consciousness went down gradually, or he/she just became unresponsive. Staff H didn't think Resident #5 received his/her medication on the day shift due to sedation. Staff H didn't think Resident #5 ever ate well, and he/she experienced fluctuating problems with diarrhea. When asked about assessing Resident #5 for dehydration Staff H stated "I'm sure I did". Staff H stated she notified the physician of Resident #5's condition on [DATE] because he/she had a fever. Prior to that she had not discussed the resident's condition with the physician. Staff H had faxed vital signs to the physician. Staff H did not notify the physician of Resident #5's level of consciousness prior to [DATE] or the intakes. Staff H stated a nurse from the MCU worked a weekend before Resident #5 died and first told her to leave a note to call Dr. Liautaud on Monday, then said she would come in and do it herself. Staff H thought that might have been the 20th. Staff H didn't know what happened with that. Staff H stated she did talk to Resident #5's family on 2 occasions about the resident's condition. Staff H could not give dates of the conversations or exactly what she said, and acknowledged it may not be documented. An ER Report dated [DATE] documented Resident #5 went to the hospital at the request of his/her family member. Over the last 4 days Resident #5 had stopped eating, he/she had not eaten or drank anything or taken any of his/her medications for at least three days. The resident last took [MEDICATION NAME] on [DATE]. Resident #5 did have an [MEDICATION NAME] Patch on, but otherwise had no [MEDICAL CONDITION] medications. Blood pressure medications also withheld. Resident #5's family member concerned the resident would not wake up. Late last week he/she drank some Pepsi but really had not eaten or drank anything for the previous 3 days. Resident #5's temperature registered 97.5 degrees, pulse 96, respirations 40, blood pressure ,[DATE], and oxygen saturation 90% on room air. Resident #5 made minimal wincing with sternal rubbing done by the nurse. Resident #5's eyes had to be opened by the examiner. The resident ' s pupils were equal, though they certainly didn't seem to be focusing. The resident ' s mouth was extremely dry and was mouth breathing. The heart beated regularly, and he/she breathed rapidly (tachypneic). Resident #5's family member attended. The family had a conversation regarding what he/she wished as far as workup. The family member thought Resident #5 just wanted to sleep and he/she could not wake him/her up. The physician was more likely thinking Resident #5 was somewhat comatose. Discussed a possible workup such as blood work, urine tests, and chest x-rays, intravenous fluids, etc... versus letting the resident " go " . The family member talked with other family members and they concluded the resident be allowed to die. During an interview on [DATE] at 8:56 a.m. Resident #5's family member stated he/she had been gone for 3 days, and when returned, could not arouse Resident #5. Resident #5's family member went to find someone to see what was wrong and staff informed him/her that Resident #5 had not eaten for 3 days. No one called to inform him/her of Resident #5's condition. At some point he/she called the physician's office to see if Resident #5 could be seen. Resident #5 went to the emergency room . During an interview on [DATE] at 1:17 p.m. the physician in the emergency room (ER) on [DATE] stated he remembered when Resident #5 came in to the ER The physician told the family Resident #5 was comatose and going to die pretty quickly if something wasn't done. The ER physician told the family they could do a workup and put fluids back in the resident but it would not change the situation (end stage [MEDICAL CONDITION]). The family decided to allow the resident to die. If they had brought the resident in 3 days earlier they would have had the same decision to make. The physician did not put dehydration down, but was sure Resident #5 was dehydrated, since it had been days since the resident had drank. The Comprehensive Care Plan dated [DATE] ident