Every finding on record at Good Samaritan - Hays

The facility failed to ensure Resident (R) 1 remained free from a significant medication error. On 05/05/2026, the Infectious Disease doctor, who was consulting on R1's Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcers on his gluteus (buttocks) and coccyx (area at the base of the spine), ordered fluconazole 400 milligrams (mg) twice a day for a bone biopsy culture, which revealed C. Albicans (a microscopic yeast and fungus which can cause fungal infections). The facility failed to initiate the medication until 05/23/2026. - Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), osteomyelitis (local or generalized infection of the bone and bone marrow) of the sacral (large triangular bone/area between the two hip bones) and coccygeal (relating to the coccyx) areas, Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics) to the pressure ulcers, Vancomycin-resistant enterococci (VRE- bacteria that are normally present in the human intestines that developed resistance to many antibiotics) to the pressure ulcers, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The admission Minimum Data Set (MDS), dated 05/02/2025, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 was dependent on staff for toileting, bathing, dressing, and transfer. The MDS documented R1 had two pressure ulcers that were present on admission. The Functional Abilities Care Area Assessment (CAA), dated 04/20/2026, documented R1 required staff assistance with activities of daily living (ADLs) due to weakness and paraplegia. The Pressure Ulcer CAA, dated 04/29/2026, documented R1 admitted to the facility with pressure ulcers. The CAA documented R1 received outpatient wound care. The Care Plan, initiated 04/25/2026, documented R1 had osteomyelitis and would be free from complications related to infection. The care plan directed staff to monitor, document, and report to R1's health care provider any changes in condition. The care plan directed staff to educate R1 regarding preventative measures to contain the infection. The care plan directed staff to observe and monitor R1 for symptoms of weakness, dehydration, fever, nausea, or vomiting. The Medication Administration Record (MAR), dated May 2026, documented fluconazole 400 mg by mouth daily was started on 05/23/2026. The Infectious Disease Progress Note, dated 05/05/2026, documented this was R1's first visit post-hospital stay. The visit was held over telemedicine. The note directed facility staff to start a new medication, fluconazole (an antifungal medication used to treat and prevent infections caused by fungi and yeast) 400 mg by mouth daily through 05/12/2026, related to the bone biopsy, which indicated C. Albicans. The Infectious Disease Progress Note, dated 05/12/2026, documented the visit was held over telemedicine. The note stated R1 was not started on fluconazole 400 mg daily last week even though the order was confirmed by the facility. The note stated the Licensed Nurse (LN) at R1's bedside during the telemedicine appointment was given a verbal order to start fluconazole 400 mg by mouth daily. The note documented R1 had an acute, complicated illness that posed a threat to life or bodily function, and the risk for morbidity or morality without treatment was significant. The Facility Fax, dated 05/18/2026, documented the facility had faxed a clarification of the order for fluconazole 400 mg by mouth daily and questioned the route and the end date. The Infectious Disease Fax, dated 05/19/2026, documented the facility was faxed to confirm the order for fluconazole 400 mg from the previous visit on 05/12/2026, as the facility had still not started the medication. The fax documented they had also verbally contacted an LN at the facility who took the verbal order. The Infectious Disease Progress Note, dated 05/20/2026, documented fluconazole had yet to be started by the facility despite orders being faxed two weeks in a row and a verbal order being given with the dose and duration listed. R1was understandably frustrated. The administrative nurse at the bedside was given verbal orders to start fluconazole 400 mg by mouth daily again and explained the duration was in all the orders that had been sent. The Care Conference Note, dated 05/2120/26, documented R1 wanted to know why one of his antibiotics had been delayed. Plan to clarify the order. On 06/08/2026 at 10:30 AM, observation revealed R1 lay in bed watching TV. A wound vac (a vacuum-assisted wound treatment that applies gentle suction to a wound to help it heal) was in the corner by the bed, applying suction to R1's wound. On 06/08/2026 at 10:30 AM, R1 stated he was upset with the facility for not following the infectious disease doctor's orders and felt that not getting the medication had delayed his healing. On 06/08/2026 at 11:00 AM, Administrative Nurse D stated the nurse who had received the faxed progress note did not understand that it was a new order and thought it was just a written MAR in the progress note. Administrative Nurse D stated he felt like the medication error occurred because the orders were not clear. On 06/08/2026 at 12:30 PM, Administrative Staff A stated he thought there was a delay in getting the new order processed and wondered why staff had not called the ordering provider to clarify the order rather than fax back and forth. The Physician/Practitioner's Order Policy, dated 04/06/2025, documented upon immediate receipt of an order, the order would be processed into the EMR/MAR. All orders must be noted by the licensed nurse who processed the order. Orders may include, but are not limited to, admission orders, orders received throughout the resident's stay, consultant orders, discontinued orders, discharge orders, and therapy orders.

The facility had a census of 44 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary for one Resident (R) 44 reviewed for discharge that included a completed recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay. This deficient practice placed the resident at risk of receiving inadequate care. Findings included: - R44's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R44's Annual Minimum Data Set (MDS), dated 10/03/24, documented R44 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R44 was independent with most activities of daily living (ADL). The MDS documented R44 expected to be discharged to the community. R44's Care Plan, revised 09/12/23, documented R44 had developed independence and no longer required 24-hour care in a nursing home. The Nurse's Note, dated 12/13/2024 at 09:56 AM, documented the resident would be discharged from the facility on Monday, 12/16/24. A review of R44's EMR lacked evidence of a completed discharge summary, which included a recapitulation of her stay. On 02/24/25 at 2:15 PM, Administrative Nurse D verified that R44's discharge summary lacked documentation regarding R44's status when he was admitted to the facility. Administrative Nurse D stated that nursing and Social Service X were responsible for completing R44's discharge summary. On 02/24/25 at 01:53 PM, Social Service X verified she had not completed a recapitulation of R44's stay and was unaware she was to complete one. Social Service X stated she completed a discharge summary in her progress notes with her status when she left. The facility's Discharge and Transfer-Rehab /Skilled, Therapy and Rehab Policy, revised 01/02/24, documented when a resident was discharged to another skilled nursing facility the charge nurse or designated individual would obtain a transfer order from the physician, a complete inventory of personal effects, complete discharge or therapeutic leave medication, and complete the discharge summary. The facility failed to complete a discharge summary that included a recapitulation of R57's stay and post-discharge plan. This deficient practice placed the resident at risk of receiving inadequate care.

The facility had a census of 44 residents. The sample included 12 residents, with two reviewed for urinary catheter or Urinary Tract Infection (UTI - Infection of any part of the urinary system). Based on observation, record review, and interview, the facility failed to provide appropriate care when staff failed to provide completed incontinent and catheter care for Resident (R) 3 after a bowel movement, before a dressing change, and who had a history of urinary tract infections. This deficient practice placed the resident at increased risk for UTI. Findings included: - R3's Electronic Medical Record (EMR) documented R3 had diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and urine retention (lack of ability to urinate and empty the bladder). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had a Brief Interview of Mental Status (BIMS) of 14, which indicated intact cognition. The MDS documented R3 had a urinary catheter and no UTI during the observation period. R3's Significant Change MDS; dated 12/05/25, documented R3 had a BIMS of 14, which indicated intact cognition. The MDS documented R3 had a urinary catheter and no UTI during the observation period. R3's Urinary Incontinence Care Area Assessment (CAA), dated 12/05/25, documented R3 had a chronic indwelling urinary catheter retaining to a neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), and limited mobility. R3 saw a urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system. to manage chronic conditions retaining to her urinary system). R3's Care Plan, revised 02/06/25, documented R3 had a urinary catheter. The plan instructed staff to monitor, record, and report to the health care provider any signs and symptoms of UTI. The plan instructed staff to provide R3 catheter care every shift and as needed (PRN). A review of R3's EMR revealed R3 had a positive UTI on 11/06/24. On 02/20/25 at 10:41 AM, R3 laid in bed on her back. Administrative Nurse C donned a gown applied gloves, entered R3's room, asked the resident if she could change her dressing, and the resident replied yes. Administrative Nurse C removed R3's slacks, assisted R3 in turning on the right side, and unfastened R3's incontinent brief to reveal a moderate amount of soft brown bowel movement (bm) on her buttocks, butt crease, and up to the insertion site of the catheter. The BM touched the catheter tubing coming from the insertion site. Administrative Nurse C provided perineal care to R3's buttocks and butt crease, then removed R3's dressing but failed to provide incontinent care to R3's front perineal area or catheter care. Administrative Nurse C continued with the dressing change on R3's left gluteal fold, placed a new incontinent brief on R3, pulled up her slacks, and covered R3 up. On 02/20/25 at 11:12 AM, when Administrative Nurse C was asked if she should have provided catheter care and front urinary incontinent care after R3 had a BM, Administrative Nurse C stated yes, she should have. On 02/24/25 at 01:08 PM, Administrative Nurse D stated if a resident had a BM and a catheter, he would expect staff to provide full incontinent care. The facility's Catheter Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen Policy, revised 07/30/24, documented catheter care would be completed with morning and bedtime care and as needed. The facility failed to ensure staff provided complete incontinence and catheter care after R3 had a BM. This deficient practice placed R3 at risk for UTI.

The facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 34's blood pressure medication was administered outside the physician-ordered parameters and the parameters were transcribed incorrectly. This placed the resident at risk for physical decline, related complications, and at risk for unnecessary drugs. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS), dated [DATE], documented R34 had moderately impaired cognition. R34 required supervision from staff for personal hygiene, mobility, and ambulation. The MDS documented R34 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antidepressant (a class of medications used to treat mood disorders), and an antiplatelet (medication that prevents blood clots from forming by stopping platelets from sticking together) medication. The Annual MDS, dated [DATE], documented R34 had moderately impaired cognition. R34 required partial assistance from staff for upper body dressing, mobility, toileting, and ambulation. The MDS documented R34 received an antipsychotic, an antidepressant, and an antiplatelet medication. R34's Care Plan dated 01/23/25, initiated on 01/24/24, directed staff to monitor, document, and report to the physician any signs or symptoms of malignant hypertension, which would cause headaches, visual problems, confusion (unclear in one's mind about something), and lethargy (a lack of energy and weakness). The Physician's Order, dated 01/18/24, directed staff to notify him when the systolic blood pressure (SBP - the number, the force your heart exert on the walls of your arteries each time it beats) was less than 90 millimeters of mercury (mmHg) or greater than 150 mmHg, the diastolic (BP - minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) was less than 60 mmHg or greater than 90 mmHg. The Physician's Order, dated 01/29/24, directed staff to administer amlodipine (high blood pressure medication), 10 milligrams (mg), by mouth, daily for hypertension. The order directed staff to hold the medication if the SBP was > (greater than) 90 mmHg or < (less than) 150 Hg, and DBP was >60 mmHg or < 90 mmHg. The Physician's Order, dated 01/29/24, directed staff to administer lisinopril (high blood pressure medication, 10 mg, by mouth, [NAME] for hypertension. The order directed staff to hold the medication if the SBP was > 90 mmHg or <150 Hg, and DBP was > 60 mmHg or < 90 mmHg. A review of the EMR revealed staff administer hypertension medications outside the physician-ordered parameters as follows: February 2024: 11 of the 29 administrations March 2024: 12 out of the 31 administrations April 2024: 11 out of the 30 administrations May 2024: six out of the 30 administrations June 2024: 17 out of the 30 administrations July 2024: 17 out of the 31 administrations August 2024: 13 out of the 31 administrations September 2024: 16 out of the 30 administrations October 2024: 21 out of the 31 administrations November 2024: 25 out of the 30 administrations December 2024: 15 out of the 31 administrations January 2025: 19 out of the 31 administrations February 2025: 14 out of 20 administrations A review of the Medications Regimen Reviews (MRR) by the CP from March 2024 through January 2025 lacked evidence the CP identified and reported the amlodipine and lisinopril given outside of the physician-ordered parameters or that the parameters were transcribed incorrectly. On 02/20/25 at 08:24 AM, Licensed Nurse (LN) G administered R34's medications within the ordered parameters and without incident. On 02/20/25 at 3:45 PM, Administrative Nurse D verified the parameters on the MAR had been transcribed incorrectly and that the parameters were backward. Administrative Nurse D stated that the admission orders had directed staff to also notify the physician when the medications were out of the directed parameters. Administrative Nurse stated that the order had not been placed on the MAR. Administrative Nurse D verified the CP had not identified and reported order discrepencies. On 02/20/25 at 04:00 PM, LN G verified the greater than and less than symbols were backward on the parameters but when she had read the orders, she knew what the resident's blood pressure parameters were. The facility's Drug Regimen Review policy, dated 12/02/24, documented the licensed pharmacist assessed the medication list and chart to identify potential clinically significant medication issues. The monthly drug regimen review was used to review medications to ensure that doses and duration were appropriate to each resident's clinical condition, age, and comorbidities. The CP would complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The reports would be given to the director of nursing services. Upon completion of the report, it was shared with the attending physician, and medical director, and acted upon immediately. The facility failed to ensure the CP identified and reported R34's blood pressure medication was administered outside the physician-ordered parameters and the parameters were transcribed incorrectly. This placed the resident at risk for physical decline, related complications, and at risk for unnecessary drugs.

The facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold and notify the physician of blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 34. The facility also failed to transcribe physician-ordered parameters correctly. This deficient practice placed the resident at risk for physical decline, other related complications, and at risk for unnecessary drugs. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), atrial fibrillation (rapid, irregular heartbeat), and depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS), dated [DATE], documented R34 had moderately impaired cognition. R34 required supervision from staff for personal hygiene, mobility, and ambulation. The MDS documented R34 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antidepressant (a class of medications used to treat mood disorders), and an antiplatelet (medication that prevents blood clots from forming by stopping platelets from sticking together) medication. The Annual MDS, dated [DATE], documented R34 had moderately impaired cognition. R34 required partial assistance from staff for upper body dressing, mobility, toileting, and ambulation. The MDS documented R34 received an antipsychotic, an antidepressant, and an antiplatelet medication. R34's Care Plan dated 01/23/25, initiated on 01/24/24, directed staff to monitor, document, and report to the physician any signs or symptoms of malignant hypertension, which would cause headaches, visual problems, confusion (unclear in one's mind about something), and lethargy (a lack of energy and weakness). The Physician's Order, dated 01/18/24, directed staff to notify him when the systolic blood pressure (SBP - the number, the force your heart exert on the walls of your arteries each time it beats) was less than 90 millimeters of mercury (mmHg) or greater than 150 mmHg, the diastolic (BP - minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) was less than 60 mmHg or greater than 90 mmHg. The Physician's Order, dated 01/29/24, directed staff to administer amlodipine (high blood pressure medication), 10 milligrams (mg), by mouth, daily for hypertension. The order directed staff to hold the medication if the SBP was > (greater than) 90 mmHg or < (less than) 150 Hg, and DBP was >60 mmHg or < 90 mmHg. The Physician's Order, dated 01/29/24, directed staff to administer lisinopril (high blood pressure medication, 10 mg, by mouth, [NAME] for hypertension. The order directed staff to hold the medication if the SBP was > 90 mmHg or <150 Hg, and DBP was > 60 mmHg or < 90 mmHg. A review of the EMR revealed staff administer hypertension medications outside the physician-ordered parameters as follows: February 2024: 11 of the 29 administrations March 2024: 12 out of the 31 administrations April 2024: 11 out of the 30 administrations May 2024: six out of the 30 administrations June 2024: 17 out of the 30 administrations July 2024: 17 out of the 31 administrations August 2024: 13 out of the 31 administrations September 2024: 16 out of the 30 administrations October 2024: 21 out of the 31 administrations November 2024: 25 out of the 30 administrations December 2024: 15 out of the 31 administrations January 2025: 19 out of the 31 administrations February 2025: 14 out of 20 administrations On 02/20/25 at 08:24 AM, Licensed Nurse (LN) G administered R34's medications within the ordered parameters and without incident. On 02/20/25 at 3:45 PM, Administrative Nurse D verified the parameters on the MAR had been transcribed incorrectly and that the parameters were backward. Administrative Nurse D stated that the admission orders had directed staff to also notify the physician when the medications were out of the directed parameters. Administrative Nurse stated that the order had not been placed on the MAR. On 02/20/25 at 04:00 PM, LN G verified the greater than and less than symbols were backward on the parameters but when she had read the orders, she knew what the resident's blood pressure parameters were. The facility's Medication Administration policy dated 06/21/24 documented that the orders from the provider were required for any medication administered and must include a diagnosis, name of the medication, dose, route, and frequency. If the order was not legible or did not include the items listed, the provider was notified for clarification before administration. Medications were to be administered correctly and timely to minimize opportunities for adverse medication events and errors. The facility failed to hold and notify the physician when R34's blood pressure medications were out of physician-ordered parameters and failed to transcribe the parameters correctly upon admission. This placed the resident at risk for physical decline, other related complications, and at risk for unnecessary drugs.

The facility had a census of 44 residents. The sample included 12 residents, with two reviewed for hospice services. Based on observation, record review, and interview, the facility failed to include a hospice plan of care with a description of the services provided which included contact information, visit frequency, medications, and medical equipment for Resident (R) 8. This deficient practice placed the resident at risk of not receiving needed care. Findings included: - R8's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and atherosclerotic heart disease of the native coronary artery (the buildup of plaque (fatty deposits) within the coronary arteries, which supply blood to the heart muscle). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented R8 had short and long-term memory problems and severe cognitive impairment. The MDS document R8 was dependent on staff with oral and toileting hygiene, showering, lower body dressing, putting on and taking off footwear, personal hygiene, bed mobility, and transfers. The MDS documented R8 required substantial to maximal staff assistance with upper body dressing, and partial to moderate assistance with eating. The MDS documented R8 received hospice services. R8 's Care Plan, revised 01/30/25, documented R8 was dependent on staff with most activities of daily living (ADL). The care plan lacked a section regarding hospice services with information regarding a description of the services provided which included contact information, visit frequency, medications, and medical equipment. A review of R8s' clinical record revealed the resident was admitted to hospice care on 10/27/24. The Hospice and Nursing Facility Services Agreement, revised 01/01/25, documented the designated member of the interdisciplinary team would be responsible for providing overall coordination of the hospice care for the hospice patient with facility representatives. On 02/20/25 at 08:24 AM, R8 rested quietly in bed with eyes closed and no signs or symptoms of pain. On 02/24/25 at 01:08 PM, Administrative Nurse D verified that R8's clinical record lacked a hospice care plan, and it should have one. On 02/24/25 at 12:02 PM, Administrative Staff B stated she was responsible for updating care plans. Administrative Staff B stated R8 had a recertification for hospice services, and somehow was resolved and taken off the care plan. The facility's Hospice-Provided Services Policy, revised 11/01/24, documented a coordinated comprehensive plan of care would be jointly developed by the location and hospice. The facility failed to coordinate care between the facility and the hospice provider for R8, who received hospice services. This deficient practice placed him at risk for inadequate end-of-life care.

The facility identified a census of 42 residents Based on record review, observation, and interview, the facility failed to prevent misappropriation of medications when Administrative Nurse D diverted Resident (R)1's narcotic medications as well as other residents' discontinued narcotic medications from the waste bin. This placed all residents who received narcotic medications at risk for misappropriation and/or diversion. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of low back pain and malignant neoplasm (cancer). R1's Annual Minimum Data Set (MDS) dated [DATE] recorded R1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS recorded R1 received opioid (narcotic pain medication) all seven days of the look back period. The MDS documented R1 had frequent pain and received scheduled and as needed pain medications. R1's EMR recorded a Physician Orders dated 05/31/23 for oxycodone (opioid) 20 milligrams (mg) by mouth every four hours as needed for pain. In an electronic mail (e-mail) sent on 07/06/23, Consultant HH alerted the facility that R1's oxycodone was missing. The email documented there was communication which indicated Consultant HH destroyed the medication virtually with Administrative Nurse D, but Consultant HH wanted to clarify the medications were not destroyed virtually by Consultant HH and the medication destruction form included a forged signature from Consultant HH, The Facility Investigation dated 07/14/23 documented on the date of 06/21/23, the facility learned of a concern that on the date 06/19/23 Administrative Nurse D accidentally destroyed a pill-pack of narcotics with Consultant HH. Administrative Nurse D asked another staff member not to mention the situation as Administrative Nurse D planned to provide education to her department and get it covered. Administrative Staff A spoke with Administrative Nurse D who acknowledged and stated that she was embarrassed about the mistake that happened. The investigation documented Administrative Nurse D told Administrative Staff A the medication (R1's oxycodone) was mistakenly placed in the facility's medication waste bin and was destroyed by her and Consultant HH. Upon request, Administrative Nurse D provided Administrative Staff A with a controlled substance administration log record with R1's name on the form. The form was dated 06/07/23 and had two signatures for waste, one from Administrative Nurse D and one from Consultant HH. The investigation further documented on 07/06/21, Administrative Staff A again spoke with Administrative Nurse D who revealed at that time she had diverted medications and forged the signature of Consultant HH. The investigation documented the facility confirmed via visual surveillance Administrative Nurse D, who held the only key in the facility to the facility's medication waste bin, diverted medications from the waste bin. The investigation recorded Consultant HH came to the facility on [DATE] and, together with Administrative Nurse E, performed a reconciliation of controlled medication which identified there were further missing narcotic pain medications which affected R1 and seven other residents or former residents. In an observation on 07/12/23 at 10:00 AM, Administrative Staff A and Administrative Nurse E demonstrated how the narcotic waste bin was accessed. They verified the DNS and the Consultant Pharmacist were the only two people to have keys to the locked narcotic waste bin, but the bin could be accessed with either single key. In an observation on 07/12/23 at 11:00 AM, Licensed Nurse (LN) G demonstrated when narcotics were delivered to the facility, the nurse on duty received the medications, signed off on the delivery sheet, and counted the medications. Nursing staff then provided a copy of the signed delivery sheet to the pharmacy delivering the medications and a copy went to the Director of Nursing Services (DNS). Nursing staff then placed the narcotic medications in a double locked medication cart with the accurate count added to the narcotic sheets in the narcotic book. LN G demonstrated when a narcotic was discontinued, the narcotic count sheet was placed in the medication room with the narcotics being discontinued. Two nurse staff counted the medications and signed off on the count sheet, then placed the medication in the narcotic waste bin with the narcotic count sheet wrapped around it with a rubber band. LN G confirmed that once placed in the bin, only the DNS had access and the staff no longer conducted a two-person count of those medications. On 07/12/23 at 09:15 AM, Administrative Staff A stated that on 06/21/23, Administrative Nurse E verbalized concerns about the former DNS, Administrative Nurse D, regarding narcotic medication. Administrative Staff A stated that he spoke with Administrative Nurse D who stated the facility nurses placed R1's oxycodone pill pack into the waste bin accidentally and that the pill pack had been wasted by Consultant HH and herself. Administrative Staff A stated that it was obvious, after review of camera footage, how Administrative Nurse D diverted the medications. Administrative Staff A stated it appeared that Administrative Nurse D went into the narcotic waste bin and popped pills from the pill packs, then placed the pills into her pocket and then later began removing whole pill cards from the waste bin box and carrying them out in a plastic bin which contained other items. Administrative Staff A stated that Administrative Nurse D and the CP were the only two people that had keys the narcotic waste bin. Administrative Staff A stated that going forward, the facility would have two different locks on the narcotic waste bin which will require the DNS and CP to open the bin together. On 07/12/23 at 10:00 AM, Administrative Staff E stated that she felt something was not right when Administrative Staff D confided in her that the nursing staff had accidentally wasted a good pill pack of R1's oxycodone and now R1's pill count was off. She said Administrative Nurse D did not want to tell Administrative Staff A about it. On 07/12/23 at 10:30 AM, Consultant HH stated she went to the facility on ce a month to perform pharmacy reviews and waste narcotics with Administrative Nurse D. Consultant HH stated the last time she wasted narcotics with Administrative Nurse D was 04/04/23 because Administrative Nurse D canceled for the months of May 2023 and June 2023. Consultant HH stated that Administrative Nurse D said she did not have time to do the narcotics waste, but then called days later requesting to do the waste virtually. Consultant HH stated that she did not do any wasting of the narcotics virtually any more as that was something that was done only during the pandemic. The facility's Abuse and Neglect Policy, revised 10/13/22, documented the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility failed to prevent misappropriation of medications when Administrative Nurse D diverted narcotic medications from R1 and seven other residents. This placed all residents who received narcotic medications at risk for misappropriation and/or diversion.

The facility identified a census of 42 residents. Based on record review, observation, and interview, the facility failed to ensure narcotic reconciliation which included regular narcotic counts of all narcotics, including the narcotics scheduled for destruction or a system which requires two qualified staff for access to a fixed and locked medication bin. This deficient practice placed the residents at risk for misappropriation and resulted in an opioid (narcotic pain medication with a high potential for abuse) drug diversion. Findings included: - In an electronic mail (e-mail) sent on 07/06/23, Consultant HH stated there was oxycodone missing from the waste bin. The email documented there was communication which indicated Consultant HH destroyed the medication virtually with Administrative Nurse D, but Consultant HH wanted to clarify the medications were not destroyed virtually by Consultant HH and the medication destruction form included a forged signature from Consultant HH. The Facility Investigation dated 07/14/23 documented the facility confirmed via visual surveillance Administrative Nurse D, who held the only key in the facility to the facility's medication waste bin, diverted medications from the waste bin. The investigation further recorded upon questioning; Administrative Nurse D confirmed she diverted medications from the waste bin. In an observation on 07/12/23 at 10:00 AM, Administrative Staff A and Administrative Nurse E demonstrated how the narcotic waste bin was accessed. They verified the DNS, and the Consultant Pharmacist were the only two people to have keys to the locked narcotic waste bin, but the bin could be accessed with either single key. In an observation on 07/12/23 at 11:00 AM, Licensed Nurse (LN) G demonstrated when narcotics were delivered to the facility, the nurse on duty received the medications, signed off on the delivery sheet, and counted the medications. Nursing staff then provided a copy of the signed delivery sheet to the pharmacy delivering the medications and a copy went to the Director of Nursing Services (DNS). Nursing staff then placed the narcotic medications in a double locked medication cart with the accurate count added to the narcotic sheets in the narcotic book. LN G demonstrated when a narcotic was discontinued, the narcotic count sheet was placed in the medication room with the narcotics being discontinued. Two nurse staff counted the medications and signed off on the count sheet, then placed the medication in the narcotic waste bin with the narcotic count sheet wrapped around it with a rubber band. LN G confirmed that once placed in the bin, only the DNS had access and the staff no longer conducted a two-person count of those medications. On 07/12/23 at 09:15 AM, Administrative Staff A stated that on 06/21/23, Administrative Nurse E verbalized concerns about Administrative Nurse D, regarding narcotic medication. Administrative Staff A stated that he spoke with Administrative Nurse D who stated the facility nurses placed an oxycodone pill pack into the waste bin accidentally and that the pill pack had been wasted by Consultant HH and herself. Administrative Staff A stated that it was obvious, after review of camera footage, how Administrative Nurse D was diverting the medications. Administrative Staff A stated it appeared that Administrative Nurse D went into the narcotic waste bin and popped pills from the pill packs, then placed the pills into her pocket and then later began removing whole pill cards from the waste bin box and carrying out in a plastic bin which contained other items. Administrative Staff A stated that Administrative Nurse D and the CP were the only two people that had keys the narcotic waste bin. Administrative Staff A stated that going forward, the facility would have two different locks on the narcotic waste bin which will require the DNS and CP to open the bin together. The facility's Controlled Medications Policy, revised 12/05/22, documented the facility along with the consultant pharmacist will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled and meets all state and federal requirements for controlled medications. Controlled medications that have been discontinued should be placed in a locked box in the medication room as soon as they have been discontinued or as indicated by state regulation. Controlled medications should continue to be counted by two nurses until disposal is completed. Disposal of any medication will be carried out under local, state, and federal guidelines or in consultation of the pharmacist for the appropriate disposal procedure. Documentation of medication disposal will be made using the GSS #247 or Controlled Substance Bound Book and will include the resident's name, medication name, prescription number, quantity disposed, date and method of disposition, and the involved nurses, consultant or other applicable individuals allowed per state regulations. The facility failed to ensure narcotic reconciliation which included regular narcotic counts of all narcotics, including the narcotics scheduled for destruction or a system which requires two qualified staff for access to a fixed and locked medication bin. This deficient practice placed the residents at risk for misappropriation and resulted in an opioid drug diversion.

The facility had a census of 41 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)16, and R28's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen with the date opened and expiration date, failed to discard R6's and R38's expired insulin vial and failed to discard expired stock medications on two medication carts. This placed the affected residents at risk for ineffective medications. Findings included: - On 05/09/23 at 08:45 AM, observation of Hall-One medication cart revealed the following: R28's Novolog (a short acting insulin) flex pen lacked a date opened, and date of expiration. R38 's Novolog flex pen opened 03/01/23, expired 03/29/23 (28 days). The medication cart revealed five individualized packets of famotidine (antacid) tablets, expired 09/2022. On 05/09/23 at 09:15 AM, observation of the Hall-Two medication cart revealed the following: R16's Tresiba (long acting insulin) flex pen open and undated. R6's Novolog vial opened 03/26/23, expired 04/23/23 (28 days). The medication cart revealed one bottle of calcium (calcium supplement) 60 (mg) milligram, 60 tablets, expired 03/2023. On 05/09/23 at 08:50 AM, Licensed Nurse (LN) G verified the stock medication on the Hall-One medication cart was expired. LN G stated the nurses were to look at the bottles and verify expiration dates before administering the medications and to the discard expired medications. LN G verified the nurses were to date the insulin pens/vials when opened and discard the expired insulin. On 05/09/23 at 09:20 AM, LN H verified the stock medication won Hall-Two cart was expired. LN H stated the nurses were to look at the bottles and verify expiration dates before administering the medications, and to discard expired medications. LN H verified the nurses were to date the insulin pens/vials when opened and discard expired insulins. On 05/15/23 at 9:30 AM, Administrative Nurse D verified the nurses should label and date the insulin pens and vials with the resident's name and discard expired items. Administrative Nurse D verified expired stock medications were to be discarded. The facility's Storage of Medications policy, dated 04/26/23, documented multi-dose vials should have the open date written on the vial, Refer to Insulin Storage Parameters for storage times based on manufactures recommendations. The staff would ensure the correct type of insulin and date vial was opened. Staff would look at the insulin flex pen physician order, the expiration date and the number of days the pen has been opened. The facility failed to label and date the residents insulin vials, discard expired insulin flex pen and discard expired stock medications, placing the residents at risk for ineffective medication.

The facility had a census of 41. The sample included 13 residents. Based on record review, interview and observation the facility failed to treat residents with respect, dignity, and privacy during blood glucose testing. This placed the resident at risk for impaired psychosocial wellbeing. Findings included: - On 05/09/23 at 11:25 AM, observation revealed Licensed Nurse (LN) H obtained Resident (R)6's blood sugar reading using a glucometer (a blood glucose meter monitor device that you test the amount of glucose [sugar] in the blood) from R6's right middle finger at the table in the dining room, with two other residents seated at the table and five other residents seated in the dining room eating lunch. On 05/15/23 at 09:30 AM, Administrative Nurse D stated staff should not check residents' blood sugar at the dining room table; they should take the resident to the room or to a private area. The facility's Resident's Right policy, dated November 2016, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The facility failed to promote care for R6 in a manner to maintain and enhance dignity and respect placing the resident at risk or impaired psychosocial wellbeing.

The facility had a census of 41 residents. The sample included 13 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R) 16, who received dialysis treatment. This placed the resident at risk for complications and health decline. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (decline in kidney function.) R16's Admission Minimum Data Set (MDS), dated [DATE], recorded R16 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded he required extensive assistance of two staff for bed mobility, transfers, limited assistance of one staff with personal hygiene, and limited assistance of two staff with toilet use. The MDS further recorded R16 was frequently incontinent of urine and recorded the resident received dialysis treatment. The Dialysis Care Plan, dated 01/25/23, documented R16 received dialysis three times a week on Tuesdays, Thursdays and Saturdays. The Care Plan documented the resident was on a fluid restriction of 1500 millimeters (ml) a day. The Physician Order, dated 12/13/22 resident documented the resident would receive dialysis treatment three times a week. The Physician Order, dated 01/25/23, documented R16 had fluid restriction of 1500 ml a day. The facility's Fluid Intake revealed the following days R16 received greater than the physician ordered 1500 ml/day: Intake: 02/13/23 - 1710 ml 02/15/23 - 1540 ml 02/27/23 - 1560 ml 03/05/23 - 1830 ml 03/17/23 - 1640 ml 04/03/23 - 2280 ml 04/06/23 - 1520 ml 04/11/23 - 2690 ml 04/12/23 - 2175 ml 04/15/23 - 2585 ml 04/16/23 - 2600 ml 04/17/23 - 2200 ml 04/21/23 - 2250 ml 04/29/23 - 2260 ml 05/01/23 - 2040 ml 05/08/23 - 1780 ml On 05/09/23 at 09:15 AM, observation revealed sat in a recliner in the room. Licensed Nurse (LN) G administered a Novolog (fast acting insulin) injection in her right upper arm. Continued observation revealed R16 was dressed in street clothes and nicely groomed. On 05/15/23 at 10:30M, Administrative Nurse D verified R16 received dialysis three times a week on Tuesday, Thursday and Saturday. Administrative Nurse D verified R16 was on a 1500 ml fluid restriction and the facility intake documentation revealed R16 had received greater than the 1500 ml /day multiple time the last few months. The facility's Dialysis - Renal Diets-Food and Nutrition Services, policy, dated 02/21/23, documented the facility would provide residents with nutritional care addressing renal needs to attain or maintain optimal nutrition status. The dietician would individualize nutritional care of each resident to maintain adequate calorie, protein and fluid intake and fluids may be restricted if medically necessary. The facility failed to implement R16's physician ordered 1500 ml fluid restriction, placing the resident at risk for complications and health decline while receiving dialysis treatment.

The facility had a census of 41 residents. The sample included 13, with six reviewed for unnecessary medications. Based on record review and interview the facility failed to provide appropriate and adequate narcotic drug reconciliation, when staff failed to accurately record controlled substance doses on the narcotic count record and further failed to immediately report a discrepancy in Resident (R) 142's liquid Ativan (drug used to treat anxiety) count. This placed R142 at risk for missed, doses, misappropriation and/or diversion. Findings included: - R142's Electronic Medical Record (EMR) documented the resident had a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder. R142's Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score 13, which indicated intact cognition. The MDS documented R142 received an antianxiety medication for six days during the lookback period. R142's Medication Care Plan, revised 1/15/22, documented R142 received Ativan and instructed staff to monitor for side effects from the medication. R142's Physician Order, dated 12/20/21, instructed staff to administer 0.25 milliliters (ml), by mouth, one time a day for anxiety. The facility's Incident Report, dated 01/16/22, documented on 01/16/22 around 08:00 PM, Licensed Nurse (LN ) J notified the director of nursing there was a discrepancy in the amount of R142's liquid oral Ativan, with almost nine ml missing. The incident report documented the last signed out dose on the sheet was 01/13/22 but was charted in R142's Medication Administration Record (MAR) as given by LN K on 01/14/22 and 01/15/22 and there were four more instances where doses were charted on the MAR but not deducted from the narcotic book which accounted for 1.5 ml of the Ativan leaving a shortage of 7.75 ml. The incident report documented the director of nursing was unable to find a reason for the missing amount. The incident report documented LN L and LN GG noted on 01/07/22 the count had been off by seven ml. The case was reviewed, and it was decided that since the medication was short a week prior to when the incident initially occurred there was no reason to pursue any further with LN K since the medication had been administered by so many staff during that time and showing a gradual loss of the medication since the first time it was noticed; it was a matter of education with staff. The facility Witness Statement, from LN L and LN GG documented R142's Ativan counted by them on 01/07/22 was off/short by approximately seven mls. R142's Narcotic Record, documented R142's Atvian, first opened on 12/07/21, had missing documentation on the following dates: 12/25/21-12/27/21 12/25/21-12/27/21 12/30/21-12/01/22 01/05/21-01/07/22 01/13/22 - 01/16/22 At the bottom of the narcotic record LN K documented administering R142's Ativan on the missing dates. On 05/15/23 at 12:32 PM, Administrative Nurse D stated she was not the facility's director of nursing at the time of the incident. Administrative Nurse D said staff should report a medication count discrepancy immediately to the director of nursing when they note one. On 05/15/23 at 3:07 PM, Administrative Staff A stated staff should have reported the Ativan count discrepancy immediately and the reconciliation of R142's Ativan was incomplete. The facility's Medications : Controlled, revised 12/5/22, documented the facility would along with their consultant pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs would be maintained and periodically reconciled and meet all state and federal requirements for controlled medications. Each time the keys, that secure controlled medications, change from one nurse/medication aide to another, the oncoming and off going nurse/medication aide would work together to reconcile all controlled medications, including all discontinued controlled medications and documented the same. If the physical count is not in agreement with the controlled substance bound book the error must be found or an incident report must be completed prior to the end of the shift and reported to the director of nursing services before any staff administering medications for the shift leave the building. The facility failed to provide appropriate and adequate narcotic drug reconciliation, when staff failed to complete the narcotic count record and further failed to report R142's Ativan count discrepancy. This placed R142 at risk for missed medication and diversion.

The facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure one of three residents, reviewed during medication administration pass, remained free of medication errors. This placed the resident at risk for adverse reaction from the medication. Findings included: - Resident (R)16's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (decline in kidney function.) R16's Admission Minimum Data Set (MDS), dated [DATE], recorded R16 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS recorded he required extensive assistance of two staff for bed mobility, transfers, limited assistance of one staff with personal hygiene, and limited assistance of two staff with toilet use. The MDS further recorded R16 was frequently incontinent of urine and recorded the resident received dialysis (procedure where impurities or wastes were removed from the blood) treatment. R16's Physician Order, dated 01/26/23 instructed staff to administer Sevelamer Carbonate (medication used to control phosphorus levels for resident's who received dialysis, 800 milligrams (mg) three tablets, three times a day with meals. On 05/10/23 at 08:30 AM, observation revealed License Nurse (LN) I popped two tablets of Sevelamer Carbonate 800 milligrams (mg), in a plastic medication cup and administered to R16. On 05/15/23 at 10:30 AM, Administrative Nurse D verified the physician ordered Sevelamer, 800 mg three tablets, three times a day. Administrative Nurse D verified LN I had administered two tablets on 05/10/23 and verified the blister medication card sent from the pharmacy had the order documented to administer two of the 800 mg tablets not three. Administrative Nurse D confirmed, after investigation, the physician order on 01/26/23 was for three 800 mg tablets and was unsure if the incorrect dose had been administered since January or how long the pharmacy had sent out the incorrect dose. Administrative Nurse D verified the nurses were expected to check the six rights for medication for medication administration (right medication, right dose, right resident, right route, right time and right documentation) and the nurse failed to do so. The facility's Medication Administration policy, dated 03/29/2023, documented medications are administered to the resident according to the Six Rights, right medication, right dose, right resident, right route, right time and right documentation. The policy documented the staff would perform three checks; read the medication ion the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication. All employees passing medications are familiar with action and adverse reactions of medications. The facility failed to prevent a significant medication error when staff administered the incorrect dose of medication to R16. This placed the resident at risk for adverse reaction from the medication.

The facility had a census of 41 residents. The sample included 13 residents. Based on record review and interview the facility failed to consistently deliver the 41 residents mail on Saturdays. Findings included: - On 05/11/23 at 11:30 AM, during resident council meeting, Resident (R) 26, R19, and R12 reported they had not consistently received their mail on Saturdays. On 5/11/23 at 8:34 AM, Activity Staff AZ verified the residents were not receiving mail on Saturdays. Activity Staff Z stated the mail is delivered on Saturday to the facility and placed in bucket in the entrance foyer. She said she picked it up on Mondays and delivered it to residents. Activity Staff Z stated the managers on duty take turns being in the facility on Saturdays, but some of them do not know who can have their mail or if it goes to the resident's representative. She stated there was a time when she was gone from the facility for two weeks and residents did not receive their mail during that time. Activity Staff Z stated on holiday weekends, there was no management on duty in the facility. She stated management took turns being in facility on weekends and she would go without a turn for three months. She did say if she was in the facility on Saturdays, she would deliver the mail to the residents. The facility's Resident's Rights Policy, dated revised 11/16, documented the residents have the right to send and receive mail and to receive letters, packages and other materials delivered to the facility for the resident through a means other than the postal service. The facility's Resident Mail Policy, revised on 12/13/22 documented mail or other materials sent to the resident would be delivered within 24 hours of delivery by the postal service. The facility failed to consistently deliver the 41 residents or their representatives, who resided in the facility, their mail on Saturdays.

The facility had a census of 43 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve foods in a sanitary kitchen for the 43 residents of the facility. Findings included: - On 10/20/21 at 10:30 AM observation in the facility kitchen revealed: The Ice machine had brown, slimy substance on the inside surface which easily wiped off with a clean paper towel. The plate-holder cart had food crumbs in the bottom and in the one column without plates. The wall knife holder had dust and food crumbs on top, where the knives slide in. Three of eight overhead fluorescent lights had cracked plastic covers, one had visible lint on the surface. Three utensil drawers under the steam oven had dried food or liquid spills inside the drawer. The Kitchen Equipment Cleaning Log dated September/October 2021 documented, prior to 10/20/21, staff cleaned the ice machine 09/18/21. Staff cleaned the dish holder 10/06/21 and lacked documentation the wall knife holder was cleaned. On 10/20/21 at 10:30 AM, Dietary BB verified the ice machine needed cleaned. On 10/20/21 at 03:25 PM, Administrative Staff A verified the inside of the ice machine needed cleaned, the light covers needed exchanged for new ones and the soiled cover needed cleaned. He verified the knife holder, utensil drawers, and the plate cart had dried food crumbs and needed cleaned. The facility policy Ice Machines Use and Maintenance-Food and Nutrition dated 04/20/21, recorded the ice machine would be cleaned, descaled and filters changed monthly according to manufacturer recommendation. It directed staff to adjust the frequency based upon use and conditions related to the ice machine (location, quality of water, etc.). The facility policy Cleaning Schedule-Food and Nutrition Services dated 03/31/21 directed staff to check each equipment item in the kitchen for cleanliness. It further recorded staff should check the ceiling daily for cobwebs, dust, dirt or condensation so it cannot fall from the ceiling. It further directed staff to place light fixtures on a cleaning schedule. The facility failed to ensure the kitchen area and food service equipment was maintained in a sanitary manner. This deficient practice placed the residents in the facility at increased risk for illness and decreased quality of meals.

The facility had a census of 43 residents. Based on observation, record review, and interview, the facility failed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for three unsampled residents, Resident (R) 9, R21, and R25 and three sampled resident R2, R19, and R30 when staff failed to store oxygen tubing per the standards of care to reduce contamination. The facility failed to sanitize contact precaution isolation room for Resident (R) 38's room to prevent spread of infection. Findings included: - On 10/20/21 at 01:45 PM, observation revealed R30's oxygen cannula (device used to deliver supplemental oxygen) and tubing unbagged and wrapped in the handle of the oxygen concentrator. On 10/20/21 at 01:50 PM, observation revealed R25's oxygen cannula and tubing unbagged and wrapped in the handle of the oxygen concentrator. On 10/20/21 01:55 PM, observation revealed R9's oxygen tubing and nasal cannula unbagged and laying on top of the portable oxygen cylinder tank. On 10/20/21 at 02:00 PM, observation revealed R19's oxygen cannula and tubing lying on the floor. On 10/20/21 at 02:05 PM, observation revealed R2's oxygen cannula and tubing unbagged and lying on top of the oxygen concentrator. On 10/20/21 at 02:10 PM, observation revealed an uncovered oxygen cannula and tubing lying on R21's floor. On 10/20/21 at 02:15 PM, Licensed Nurse (LN) H stated the oxygen tubing and nasal cannulas should be stored in bags on the side of the concentrator and oxygen cylinder tanks. On 10/21/21 at 10:30 AM, Administrative Nurse D stated the oxygen concentrators have bags on them for the oxygen tubing and should be stored in them when not in use . The facility's Oxygen Administration Safety policy, dated 05/19/21, documented the facility would administer and store the oxygen in a safe manner. The policy documented the oxygen equipment would be cleaned and maintained in good condition and documented to attach a bag to the concentrator to allow storage of oxygen cannula or mask when not in use. The facility failed to ensure R2, R9, R19, R21, R25 and R30's oxygen tubing and nasal cannula was properly stored in a plastic bag, placing the residents at risk for infection. - On 10/20/21 at 08:48 AM, Housekeeper U prepared to enter R38's room. She stated R38 had [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)]- a type of bacteria resistant to many antibiotics) in the urine. Housekeeper U prepared to enter R38's room by gathering cleaning supplies of broom, mop, dustpan, and cleaning cloths. She then donned (put on) a gown, gloves, and mask. She used appropriate cleaning products to sanitize [CONDITION(S)]. The rooms' hand washing sink, overbed table and cleansing cloths sprayed with Ecolab Peroxide Surface Cleaner and Disinfectant. Housekeeper U then wiped down the overbed table, handrail to the bed, oxygen concentrator, counter and sink, doorknobs, and light switches. Housekeeper U had not sprayed or wiped R38's wheelchair or vinyl recliner. Next the toilet was cleaned. The toilet, which was shared with a resident in the next room, had been sprayed with Ecolab Heavy Duty Alkaline Bathroom Cleaner and Disinfectant. Housekeeper U then mopped the contact precaution room floor and then the shared toilet room floor with the same mop head. On 10/21/21 at 08:48 AM, Housekeeper U verified she had not wiped the wheelchair or recliner in R38's room because she had not visualized R38 out of bed and did not think the resident used the wheelchair or recliner. She also verified she had used the same mop head to cleanse the room and shared bathroom. Upon request the facility failed to provide a policy on contact isolation room cleaning. The facility failed to provide an environment to prevent the transmission of infectious disease process, placing the residents at risk for infections.

The facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff applied a patch to Resident (R) 7's right shoulder at the dining room table, with five residents in full view. Findings included: - On 10/21/21 at 08:35 AM, observation revealed R7 seated at the dining room table eating breakfast. Licensed Nurse (LN) I approached the resident at the dining room table and explained to the resident she had to apply a patch, pulled her shirt down over the right shoulder then applied the patch, then pulled the shirt up and over the shoulder. Continued observation revealed five residents eating breakfast in the dining room. On 10/21/21 at 10:30 AM, Administrative Nurse D verified staff should not apply patches in the dining room and verified it was a dignity issue. The undated facility Resident Rights policy, recorded each resident shall have the right to personal privacy and confidentiality of personal and clinical records, Privacy shall be provided during medical and nursing treatment, written and telephone communications, personal cares, visits, meetings of family and resident groups. The facility failed to promote care for R7 in a manner to maintain and enhance dignity and respect.

The facility had a census of 43 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide staff assistance with eating to Resident (R) 22, who required assistance of one staff for eating and who had a recent weight loss . Findings included: - R22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] depressive disorder (MDD -abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion), [CONDITION(S)] (lack of adequate of healthy red blood cells to carry adequate oxygen to the body's tissue), and [CONDITION(S)] (rapid, irregular heart beat). The ADL Care Plan, dated 08/17/21, documented the resident needed limited assistance of one staff with meals. On 10/20/21 at 07:40 AM, observation revealed the resident sat in wheelchair at the dining room table across from another resident eating breakfast. Continued observation revealed the resident had a plate full of scrambled eggs, two cut up sausage links, and a donut cut in bite sized pieces with cranberry juice. Continued observation revealed the resident did not eat any of her meal independently and staff did not come over to the table to assist her with eating her meal. At 8:30 AM Certified Nurse Aide (CNA) M sat down to assist the resident to eat and gave her a bite of sausage and the Surveyor intervened and asked staff for a temperature of the food. Dietary BB obtained the temperature of the sausage and scrambled eggs at 80 degrees. The dietary staff verified the food was too cold to serve to the resident and threw it away and brought the resident a new plate of scrambled eggs, two sausage links cut up and a few strawberries. Observation revealed the resident ate 20% of the food after she received staff assistance. On 10/21/21 at 10:40 AM, Administrative Nurse D verified the resident had a weight loss of 8.9 lbs. in one month. Administrative Nurse D verified the resident did require staff assistance and cueing at times and other times ate independently. Administrative Nurse D stated the resident would be assessed for requiring staff assistance with every meal to increase her weight and nutrition. The Identifying Residents with Impaired Nutrition Status and Nutritional Risk, policy dated 05/25/21, documented the facility would identify and monitor residents at nutritional risk including hydration. The facility would ensure each resident maintain acceptable parameters of nutritional status such as body weight, fluid and electrolyte balance, and hydration status unless the resident's clinical condition demonstrates that this is not possible. Residents with newly identified impaired nutritional status or nutritional risk are added to the Nutritional Risk List and discussed at the next nutritional risk committee meeting The facility failed to provide staff assistance with eating for R22, placing the resident at risk for weight loss.

The facility had a census 43 residents. The sample included 12 residents with one reviewed for a decrease in activities of daily living (ADL) and mobility, Resident (R) 10. Based on record review, observation, and interviews, the facility failed to prevent a decline in functional ability for R10 when the facility failed to implement a restorative program. Findings included: - R10's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, required extensive assistance of two staff for bed mobility and toileting, was totally dependent on one staff for personal hygiene and dressing. The MDS further documented R10 was not steady and only able to stabilize with human assistance with moving from seated to standing position, moving on and off a toilet. He had functional range of motion impairment of upper and lower extremities of both sides, used a wheelchair, and received Physical (PT) and Occupational (OT) therapy. The ADL Care Area Assessment (CAA), dated 07/23/21, recorded R10 had a self-care deficit related to immobility and history of a stroke. The CAA further documented the care plan would address ADL function improvement with skilled PT and OT with goals and interventions to minimize risks for pressure ulcers, poor hygiene, nutrition, and falls. The Care Plan, dated 07/29/21, documented R10 had limited physical mobility related to stroke as evident by loss of function in his extremities. The Care Plan documented the resident required extensive assistance of two staff for bed mobility, toileting, and transfers. The Physical Therapy note, dated 09/02/21, documented discharged from skilled PT/OT, will start Restorative Aide (RA) program to continue with exercises, and to discharge to home with home health for continued PT/OT. The Therapy POS, dated 09/07/21, documented R10 discharged from skilled PT and OT services on 09/02/21 and started RA program to continue with exercises. The Progress Note, dated 10/07/21, documented a nurse was called to R10's room and observed R10 laying on his left side next to his bed. R10 stated he was reaching for water and rolled out of his bed. Review of the clinical record lacked evidence R10 received restorative services after discharge from PT/OT services. On 10/19/21 at 08:34 AM, observation revealed R10 in bed and he had several Styrofoam cups on the overbed table next to the bed. On 10/20/21 at 03:47 PM, Administrative Staff A stated the resident had not received restorative therapy following the discharge from skilled PT/OT services (five weeks). On 10/20/21 at 10:14 AM, Administrative Nurse D stated the therapy department sets a restorative program for residents when they come off skilled services. Administrative Nurse D confirmed the resident should have received restorative therapy to maintain function that the therapist had achieved to prevent decline and safety from falls. The facility's Restorative-Identifying Decline in Activities of Daily Living-Rehab/Skilled Therapy and Rehab policy, dated 12/11/20, documented the purpose of a restorative program was to consider interventions to avoid ADL decline in residents that had a potential for decline. The facility failed to implement a restorative therapy program following PT/OT skilled services to maintain R10's level of function, placing the resident at risk for ADL decline.

The facility had a census of 43 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement effective nutritional interventions to prevent weight loss for one of five sampled residents, Resident (R) 22, who had a weight loss. Findings included: - R22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. The MDS recorded the resident required extensive assistance with most activities of daily living (ADLs) and required limited assistance of one staff with eating. The Nutrition Care Area Assessment (CAA), dated 05/24/21, documented R22 had the potential for impaired nutrition or unplanned weight changes secondary to dementia. Staff would monitor weight trends with the goal for weight maintenance and no significant changes, continue with current dietary plan, and refer to the Registered Dietician as needed. The ADL Care Plan, dated 08/17/21, documented the resident needed limited assistance of one staff with meals. R22's Vital Signs-Weights documented the following weights: 09/19/21 - 126.0 lbs. 10/03/21 - 125.0 lbs. 10/10/21 - 124.8 lbs. 10/17/21 - 116.8 lbs. 10/19/201 - 115.6 lbs. 10/21/21 - 116.2 lbs. (weight loss of 9.8 lbs.) The Meal Intake Log from 09/19/21 through 10/19/21, documented the resident oral intake at meals was approximately 40 percent (%.) The Physician Order, dated 09/23/21, directed staff to administer the resident a regular diet. The Registered Dietitian (RD) Assessment, dated 05/12/21, documented the resident currently weighed 123.2 lbs, and had been trending up. The assessment documented staff served the resident a regular diet that was supplemented with shakes three times a day and two calorie supplement twice a day. Staff were to monitor the resident weight trends with goal for weight maintenance and no significant weight changes, continue with the current dietary plan, and refer to the Registered Dietician as needed. The RD Assessment, dated 10/19/21, documented staff notified her of the resident's weight loss recorded at 115.6 lbs. The assessment recorded staff served the resident a regular diet with meal fortification and supplement to provide extra calories and proteins, with fair intakes recorded. The assessment directed staff to increase two calorie supplements to three times a day for an additional 240 calories and provide magic cups with supper daily which will provide an additional 290 calories. The RD directed staff to monitor weight trends and intake and RD to follow and make additional recommendations as needed. On 10/20/21 at 07:40 AM, observation revealed the resident sat in wheelchair at the dining room table across from another resident eating breakfast. Continued observation revealed the resident had a plate full of scrambled eggs, two cut up sausage links, and a donut cut in bite sized pieces with cranberry juice. Continued observation revealed the resident did not eat any of her meal independently and staff did not come over to the table to assist her with eating her meal. At 8:30 AM Certified Nurse Aide (CNA) M sat down to assist the resident to eat and gave her a bite of sausage and the Surveyor intervened and asked staff for a temperature of the food. Dietary BB obtained the temperature of the sausage and scrambled eggs at 80 degrees. The dietary staff verified the food was too cold to serve to the resident and threw it away and brought the resident a new plate of scrambled eggs, two sausage links cut up and a few strawberries. Observation revealed the resident ate 20% of the food after she received staff assistance. On 10/21/21 at 10:40 M, Administrative Nurse D verified the resident had a weight loss of 8.9 lbs. in one month and contacted the registered dietician who reviewed the resident's dietary status after it was brought to her attention from the Surveyor. Administrative Nurse D verified the resident had been stable and trending up the last 6 months and was not aware of the resident weight loss. Administrative Nurse D verified the resident did require staff assistance and cueing at times and other times ate independently. Administrative Nurse D stated the resident would be assessed for requiring staff assistance with every meal to increase her weight and nutrition. The Identifying Residents with Impaired Nutrition Status and Nutritional Risk policy, dated 05/25/21, documented the facility would identify and monitor residents at nutritional risk including hydration. The facility would ensure each resident maintain acceptable parameters of nutritional status such as body weight, fluid and electrolyte balance, and hydration status unless the resident's clinical condition demonstrates that this is not possible. The director of food and nutrition services and the dietician would identify residents with impaired nutrition or at nutritional risk, such as pressure ulcers, significant weight change, gain or loss of three pounds in one week, five percent in one month, 7.5 percent in three months, 10 percent in six months. The director of food and nutritional services would review the resident's weights at minimum monthly to identify residents with significant weight loss /gain- 5 percent in 30 days, 7.5 percent in 90 days or 10 percent in 180 days. Residents with newly identified impaired nutritional status or nutritional risk are added to the Nutritional Risk List and discussed at the next nutritional risk committee meeting. The facility failed to implement timely and effective interventions to prevent weight loss for R22, who had weight loss which placed the resident at risk for further weight loss.

The facility had a census of 60 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 1 with the physician ordered mechanical texture ground meat diet, which caused the resident to choke, and resulted in R1's death, placing the resident in immediate jeopardy. This deficient practice had the potential to affect 19 other residents in the facility who received mechanically altered diets. Findings included: - R1's Physician order [REDACTED]. hypertension (high blood pressure), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and [MEDICAL CONDITION] (having a tendency towards excessive orderliness, perfectionism, and great attention to detail). The POS further documented the resident required a Level 2 mechanical texture, ground meat diet due to decreased endurance with chewing and had a (DNR) do not resuscitate order. The resident's [DATE] quarterly Minimum Data Set (MDS) assessment, documented the resident had long and short- term memory problems and severely impaired cognition. The assessment documented the resident was dependent upon 1 staff for eating, received mechanically altered diet, and had no swallowing disorder. The [DATE] Care Area Assessment (CAA) for nutrition documented the resident was at risk for nutritional status impairment, served a Level two diet (includes only soft foods, regular foods modified to make them easier to chew and swallow), and required assistance with meals. The [DATE] care plan documented the resident had an order for [REDACTED]. The [DATE] at 12:05 PM, nurse's note documented the resident was in the dining room eating lunch and choked on fruit. The note documented staff preformed the [MEDICATION NAME] Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) unsuccessfully. The note documented staff removed the resident from the dining room, continued the [MEDICATION NAME] Maneuver, and the resident vomited a piece of peach. The note documented staff applied supplemental oxygen, obtained vital signs, and the resident died at 12:18 PM. On [DATE] at 09:29 AM, Administrative Nurse D stated at approximately 12:10 PM, staff alerted her that R1 was choking in the dining room. Administrative Nurse D ran to the dining room and observed Licensed Nurse (LN) G performed the [MEDICATION NAME] Maneuver on the resident. Administrative Nurse D directed Certified Nurse Aide (CNA) M and LN G to stand the resident so Administrative Nurse D could attempt to perform the [MEDICATION NAME] Maneuver. Administrative Nurse D stated staff removed the resident from the dining room and continued to perform the [MEDICATION NAME] Maneuver in a private office. Administrative Nurse D stated the resident vomited a bite size piece of peach, a small amount of ground pork, and staff obtained the airway cart. Administrative Nurse D stated the resident exhibited agonal breathing (inadequate pattern of breathing associated with extreme physiological distress, usually seen just prior to [MEDICAL CONDITION]), and she applied supplemental oxygen to the resident. Administrative Nurse D stated the resident's vital signs were assessed and began to deteriorate until respirations ceased at 12:18 PM. (8 minutes after the resident began to choke) On [DATE] at 09:42 AM, LN H stated she was notified by dietary staff that R1 was choking in the dining room. LN H stated she immediately responded and found Administrative Nurse D performed the [MEDICATION NAME] Maneuver on the resident. LN H stated the resident became unresponsive, LN H checked for a pulse, but did not feel one. LN H stated staff placed the resident in a wheelchair and took him/her to a more private office. LN H stated the resident began to cough, and staff initiated the [MEDICATION NAME] Maneuver again, which caused the resident to vomit a piece of peach. LN H stated the resident began breathing again, staff assessed R1 and found she had a pulse of 42 beats per minute (bpm) (normal 60 bpm), and oxygen saturation (the amount of oxygen in the blood) of 62% (normal ,[DATE]%). LN H stated staff applied oxygen to the resident. The resident's vital signs continued to drop until 12:18 PM, when the resident's pulse and respirations ceased. On [DATE] at 10:03 AM, Dietary Staff (DS) BB stated, she was being trained by Dietary Manager (DM) DD in the dining room. DS BB stated she was told to pass out fruit, when she got to R1's table she asked CNA M if the resident could have fruit. DS BB stated CNA M said, yes so CNA M gave the resident fruit. DS BB stated DM DD informed her there were resident who received Level two and Level three meals, these residents should not have fruit, and directed DS BB to remove the pineapple out of the fruit cups. DS BB stated she returned to R1's table and CNA M stated the fruit cup was ok, so DS BB left R1's fruit there. DS BB stated she had not had any training on which residents received Level two or Level three meals. On [DATE] at 10:15 AM, CNA M stated while she assisted R1 in the dining room, CNA M heard DM DD tell dietary staff to remove the pineapple from the cups of fruit already served to the residents. CNA M stated R1 had already been eating the fruit, peaches, pears and papaya, but did not know if there was any pineapple in the cup. CNA M stated R1 started gurgling (making or characterized by a hollow bubbling sound) and thought the resident was choking (severe difficulty in breathing because of a constricted or obstructed throat or a lack of air). CNA M stated she told a dietary staff member to go get a nurse for assistance. CNA M stated nursing staff performed the [MEDICATION NAME] Maneuver and the resident expelled a piece of peach, but still was not breathing well. CNA M stated she was unaware the resident had any dietary restrictions except for ground meat. On [DATE] at 10:55 AM, LN G stated shortly after 12:00 PM, she was in the dining room, returning her lunch tray and was notified that R1 was choking. LN G stated she began the [MEDICATION NAME] Maneuver and sent the dietary aid to get more help. LN G stated Administrative Nurse D arrived and attempted to perform the [MEDICATION NAME] Maneuver, which was unsuccessful. LN G stated staff removed the resident from the dining room to a private office and continued to perform the [MEDICATION NAME] Maneuver until the resident vomited a piece of peach and a small amount of ground pork. Administrative Nurse D brought in the crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) and staff applied oxygen to the resident. LN G performed a finger sweep of the resident's mouth and did not feel any other food. Staff attempted to contact the physician and resident's family without success and monitored the resident's vital signs (indicate the status of the body's vital functions). The resident's vital signs deteriorated, and the resident stopped breathing and had no heartbeat. On [DATE] at 11:07 AM, DS CC stated, all the desserts and fruit went to the dining room on a cart, and stated that day the cart had watermelon, peaches, applesauce and tropical fruit on it. DS CC stated he did not know which resident received the fruit and had only dished up the resident's lunch meal of ground pork, mashed potatoes, and gravy. DS CC stated the facility had not trained him to identify a Level 2 diet. On [DATE] at 04:40 PM, Consultant Staff (C) GG stated he expected staff to be trained regarding the different diet types and textures for the residents. The facility's Choking Prevention policy, dated (MONTH) (YEAR), documented education would be provided for employees in prevention of resident choking incidents, all employees involved in assisting residents with eating would be trained on the signs/symptoms of chewing/swallowing challenges. The policy documented any employee involved in assisting the resident with eating would be trained how to perform the [MEDICATION NAME] Maneuver trained on choking and to ensure the resident's meal/snack matches the diet card. The diet as tolerated, or texture as tolerated diet orders were not acceptable and would be clarified as diet orders must include therapeutic diet, food and liquid consistencies. The facility failed to provide R1 with mechanical texture diet, which caused the resident to choke, and resulted in R1's death, This defieicent practice placed R1 in immediate jeopardy. The facility removed the immediate jeopardy on [DATE] at 06:55 PM, when the facility removed the dessert and fruit cart from the dining area, educated staff on the correct diet textures, updated the resident diet orders, reviewed policy and procedures regarding diet orders, food textures, and modified diets, and conducted audits on all meals regarding special diet orders. The deficient practice remained at a G (isolated with actual harm) scope and severity following the removal of the immediate jeopardy.

The facility had a census of 58 residents. The sample included 17 residents with 4 reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent the development of a facility acquired, unstageable pressure ulcer to the right heel for 1 of 4 sampled residents. (#11) Findings included: - Resident #11's (POS) physicians order sheet, dated 9/18/18 recorded [DIAGNOSES REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 8/17/18, recorded the resident had long and short term memory problem with moderately impaired decision making skills. The resident required extensive assistance of 2 staff for bed mobility, transfers,dressing, and personal hygiene. The assessment further revealed the resident was at risk for skin breakdown and did not have any unhealed pressure ulcers. The 8/17/18 (CAA) Care Area Assessment for pressure ulcer recorded the resident had a history of [REDACTED]. The CAA further recorded there were preventative measures in place to help prevent skin breakdown and pressure ulcer development. The 8/17/18 care plan (initiated on 6/19/18), recorded the resident was at risk, had a history of [REDACTED]. The care plan directed staff to provide a heelz up cushion (cushions are designed to aid in the prevention and treatment of [REDACTED]. The 7/17/18 care plan directed staff to remove the air mattress from the resident's bed per family request. The 7/18/18 physician's orders [REDACTED]. (discontinued 8/9/18) The 8/17/18 Braden Scale assessment recorded the resident was at risk for skin breakdown. The 9/13/18 physician's orders [REDACTED]. (discontinued on 10/29/18) The 9/13/18 physician's orders [REDACTED]. The 10/20/18 at 2:46 AM, nurse's note documented the resident had a fluid filled blister on he/her right heel. The 10/31/18 physician's orders [REDACTED]. The 10/31/18 wound data collection record recorded the resident had a dark purple, black in color wound bed on the resident's right heel. The record directed staff to keep the right heel offloaded and minimize the amount of time the resident wore his/her shoes. The 11/1/18 physician's orders [REDACTED]. The 11/1/18 at 11:28 AM, nurse's note recorded staff educated the family on the bilateral cushion boots for offloading pressure to the resident's heels. The note further documented the resident's family verbalized understanding and was agreeable for the use of the cushioned boots. The 11/7/18 Wound Data Collection Tool recorded the resident had a 2.5 (cm) centimeters x 2.5 cm dark purple/black area on his/her right heel without redness, swelling, or drainage to the wound area. The tool further recorded the area had 10% slough (dead skin tissue) and 90% eschar (necrotic tissue). The 11/13/18 Registered Dietician Assessment recommended staff give the resident double portions of protein at breakfast and [MEDICATION NAME] nutritional supplement twice daily until the wound is healed. On 11/8/18 at 8:41 AM, observation revealed staff removed the cushion boot from the resident's right foot and revealed a blackened area on the outer aspect of the resident's right heel, approximately the size of a silver dollar. On 11/8/18 at 8:45 AM, Licensed Nurse G stated the staff repositioned the resident every 2 hours and verified the resident did not start wearing the bilateral cushion boots until after the resident acquired the pressure injury. On 11/13/18 at 1:45 PM, Registered Dietician GG stated he/she was unaware the resident had skin breakdown and would expect the facility to contact him/her for any stage 2 and above pressure ulcers. On 11/14/18 at 10:33 AM, Dietary Staff BB stated he/she was responsible for notifying the registered dietician of any weight loss or skin breakdown. The Dietary Staff BB further stated the dietician received a weight report and he/she documented any resident that had skin breakdown. On 11/14/18 at 10:39 AM, Administrative Nurse D verified the resident should have had protective boots on due to his/her history of skin breakdown prior to obtaining the area on his/her right heel. The (MONTH) (YEAR) facility's Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements Procedure documented the purpose of the procedure was to assess residents with regard to the risk of skin breakdown, document observations and assessments of residents, and to use prevention techniques and pressure redistribution surfaces on those resident at risk for pressure ulcers. The procedure further documented all residents would be identified for their risk of developing pressure ulcers on admission, readmission by the registered nurse and the nurse would evaluate the resident's risk factors to identify which factors can be removed or modified. The facility failed to implement preventative measures for cognitively impaired Resident #11, who developed an unstageable pressure ulcer on his/her right heel, placing the resident at risk for further skin breakdown.

The facility had a census of 58 residents. The sample included 17 residents, of which 5 residents were reviewed for nutrition. Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional status for 3 of 5 sampled residents. Resident #42 had a severe weight loss of 11.22% in 48 days. Resident #24 and #46, had weight loss, inadequate weight monitoring and no (RD) Registered Dietician assessment to implement appropriate weight loss interventions. Findings included: - Resident #42's physician's orders [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 09/27/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 5 (severe impaired cognition), physical and verbal behaviors, and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS recorded the resident required extensive staff assistance with transfers, toileting, personal hygiene, and staff supervision with eating. The MDS further recorded the resident received a mechanically altered diet, weighed 140 (lbs) pounds, and had no recent weight loss. The annual (CAA) Care Area Assessment for nutrition, dated 07/06/18, recorded the resident was at risk for nutritional problems related to cognitive impairment, disruptive behaviors, restlessness and anxiety. The nutrition CAA recorded staff provided the resident fortified foods two times a day, and supervision when the resident independently. The 10/12/18 care plan recorded the resident was at risk for nutritional problems related to cognitive impairment, disruptive behaviors, reduced appetite, and history of weight loss. The care plan directed staff to provide supervision and assistance as the resident allowed, at meals and snack times, and offer the resident food preferences. Review of the resident's weight record revealed the following: 04/22/18 - 149.0 lbs. 05/20/18 - 147.0 lbs. 06/17/18 - 148.0 lbs. 07/29/18 - 143.4 lbs. 08/28/18 - 142.6 lbs. 09/10/18 - 140.4 lbs. 10/18/18 - 127.0 lbs. (13.4 lb severe weight loss (9.54%) since last weight 38 days ago) 10/25/18 - 121.4 lbs. 11/01/18 - 127.4 lbs. 11/08/18 - lacked evidence of a weekly weight 11/14/18 - 126.6 lbs. (16.0 lb severe weight loss (11.22%) since 08/28/18 (78 days)) The surveyor requested staff weigh the resident on 11/14/18 due to last resident weight completed on 11/01/18. The RD Nutritional Status Assessment, dated 08/01/18, recorded the resident ate independently and staff offered fortified foods 2 times a day. The RD assessment recorded the resident's weight fluctuated between 143 to 148 lbs the past three months and was within the resident's usual body weight. The RD assessment directed staff to continue the resident's current nutritional care plan, monitor the resident's weight and notify the RD as needed. The quarterly Mini-Nutritional Assessment, dated 10/04/18, recorded the resident had a score of 5, which indicated the resident was malnourished. The assessment recorded the resident had severe dementia, decreased food intake and a greater than 6.6 lb. weight loss in the past three months. The RD Nutritional Status Assessment, dated 11/13/18, (completed 104 days after the last RD assessment) recorded the resident had a significant weight loss in the past 90 and 180 days. The RD assessment recorded the resident ate independently with staff supervision, and the resident had inadequate nutrient intake due to varied oral intake. The RD assessment recommended staff provide Ensure (nutritional supplement) 2 times a day, between meals for nutritional support. The medical record lacked documentation staff notified the physician of the resident's severe weight loss. On 11/08/18 at 8:29 AM, observation revealed the resident sat in a wheelchair at a dining table eating breakfast. Continued observation revealed staff encouraged the resident to increase his/her meal intake and offered food preferences. Continued observation revealed the resident ate more than 50% of a pancake with syrup and peanut butter. On 11/13/18 at 2:12 PM, Nurse Aide M stated the resident was confused, often refused cares, and required supervision at meals. Nurse Aide M stated the resident had a poor appetite and staff often offered the resident food preferences. On 11/13/18 at 2:49 PM, Nurse H stated the resident had severely impaired cognition, often resisted cares, and required supervision and encouragement at meals. Nurse H stated staff weighed the resident as directed, documented the weight, and residents with nutritional problems were monitored by the facility's risk committee. On 11/13/18 at 2:47 PM, Registered Dietician GG stated nursing staff provided names of residents with weight loss and/or nutritional risk, for him/her to assess and make nutritional recommendations. Registered Dietician G stated staff reported the resident's weight loss 2 weeks ago and he/she would assess the resident's nutritional status today. Registered Dietician GG stated he/she had not assessed the resident's nutritional status since 08/01/18, and the resident had significant weight loss the past 90 and 180 days. Registered Dietician GG further stated staff should weigh residents with nutritional problems weekly, accurately monitor the resident's weight, and report to the RD as needed. On 11/14/18 at 9:30 AM, Administrative Nurse D stated staff should weigh residents with weight loss and/or nutritional problems every week and accurately monitor the resident's weight. Administrative Nurse D stated the RD should assess residents with nutritional problems, recommend corrective interventions, and staff should notify the physician about the resident's nutritional problems. The facility's Weight Policy, dated 10/2017, directed staff to identify residents with nutritional problems, weigh the residents weekly, and accurately monitor the residents' weight. The policy directed staff to notify the physician immediately if the resident had a significant weight loss. The facility's Dietician Policy, dated 10/2018, directed the RD to review residents' medical records with nutritional problems, complete a nutritional assessment, and provide written recommendations for nutrition and weight loss interventions. The facility failed to adequately monitor Resident #42's weight, complete a nutritional assessment, and implement interventions to prevent severe weight loss, placing the resident at risk for continued weight loss and nutritional problems. - This deficient practice also affected Resident #24, who had weight loss, inadequate weight monitoring and no (RD) Registered Dietician assessment to implement appropriate weight loss interventions. - This deficient practice also affected Resident #46, who had weight loss, inadequate weight monitoring and no (RD) Registered Dietician assessment to implement appropriate weight loss interventions.

The facility had a census of 60 residents. The sample included 3 residents reviewed for elopement risk. Based on observation, record review, and interview, the facility failed to ensure Resident #1 received adequate supervision and appropriate interventions to prevent elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness, leaves the facility, without the knowledge of staff) after he/she was identified at risk for elopement, and failed to follow the facility's elopement policy and procedure. The facility further failed to ensure staff checked outside doors after the alarm sounded as directed in the elopement policy. The resident remained outside, unsupervised, without staff knowledge for approximately 13 minutes. This deficient practice placed Resident #1 in immediate jeopardy. Findings included: - The 4/1/18 physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 3/9/18, documented the resident's Brief Interview for Mental Status score was 3, which indicated severely impaired cognition. The resident had inattention, disorganized thinking, used a walker for mobility, and wore a Wanderguard (bracelet that sets off an alarm when residents wearing one, attempt to exit the building without an escort) for safety. The admission (CAA) Care Area assessment for cognition, dated 12/1/17, documented the facility recently admitted the resident from an assisted living facility. The resident had a [DIAGNOSES REDACTED]. The elopement risk assessment, dated 3/9/18, documented the resident at risk for elopement and wore a Wanderguard. The resident's care plan, dated 3/9/18, recorded the resident was at risk for elopement related to cognitive impairment, dementia, and exit seeking behavior. The care plan recorded the resident wore a Wanderguard on his/her left wrist to alert staff to his/her movement. The revised care plan, dated 4/26/18, directed staff to place a Wanderguard on the resident's walker, per his/her family's request, check the Wanderguard every shift for proper functioning, minimize potential of behavior problems by modifying environmental factors and daily routine, such as offering food, drinks, magazines, and walking with staff outside or throughout the facility. The 4/25/18 at 8:06 PM (late entry), nurse's note documented at 8:06 PM, staff notified Administrative Nurse D by phone that Dietary Aide BB observed the resident outside the facility, in the staff parking lot, at 7:54 PM. The door alarm sounded at 7:41 PM. Dietary Aide BB immediately notified staff for assistance and Direct Care Staff M and Direct Care Staff N assisted the resident back inside the facility without difficulty. Licensed Nurse G performed a complete head to toe assessment and no injuries were noted, and a head count showed all residents were accounted for. The note documented staff notified Administrative Staff A, Social Service Staff X, and Maintenance Staff U, who arrived at the facility at 8:30 PM. The 4/25/18 at 8:30 PM, nurse's note documented the resident wandered and exited outside the 400 hall door, staff found him/her in the parking lot, and he/she returned to the facility with no injuries noted. The note documented staff notified Administrative Nurse D, Social Service Staff X, and the resident's family by phone, and the resident's physician by fax. There was no documentation of how the resident was dressed. According to www.Wunderground.com, on 4/25/18 at 7:56 PM, the outside temperature was 54 degrees Fahrenheit, north-east wind at 8.1 (mph) miles per hour, and clear skies. The resident's Wanderguard check list documented staff checked the resident's Wanderguard for proper functioning on 4/25/18, for the day and evening shifts, and his/her Wanderguard functioned appropriately. On 4/30/18 at 11:00 AM, observation of the area where staff located the resident revealed a parking lot at the back of the facility, with 2 sets of speed bumps, parking spaces, cement blocks at the front of each parking space, a slight ramp towards the south end of the lot, exits on both ends of the lot, a residential street with a speed limit of 30 (mph) miles per hour, and approximately 0.5 blocks from a busy city street with speed limit of 30 mph. On 5/1/18 at 11:15 AM, observation revealed the resident sat on a couch in the facility's front living room area, with his/her walker placed in front of him/her, and a Wanderguard in place on his/her walker. Further observation revealed the resident's eyes were closed, his/her head bent forward, and his/her chin rested on his/her chest. On 4/30/18 at 2:10 PM, Direct Care Staff N stated on 4/25/18, at approximately 7:30 PM, he/she delivered a food tray back to the kitchen door on the 400 hall, when Dietary Aide BB, stood at the exit door at the end of the hall, and yelled out there was a resident outside unattended. Direct Care Staff N put the tray down, ran out the door and found the resident standing in the staff parking lot, with his/her walker. Direct Care Staff N, assisted by Direct Care Staff M, assisted the resident back inside the facility. Direct Care Staff N stated the door alarm sounded, but the Wanderguard alarm did not. Direct Care Staff N verified he/she is aware of the facility's policy and procedure for elopement. On 4/30/18 at 4:10 PM, Direct Care Staff M stated he/she heard Direct Care Staff N say there was a resident outside, and he/she ran to the door, and outside to assist Direct Care Staff N, and brought the resident back inside the facility. Direct Care Staff M stated he/she last saw the resident at approximately 6:30 PM, when he/she sat in the living room area with other residents. On 4/30/18 at 4:25 PM, Dietary Staff BB stated he/she finished his/her shift on 4/25/18, clocked out, and left through the 400 hall exit door, when he/she observed the resident walking, with his/her walker, in the staff parking lot. Dietary Staff BB stated he/she turned around and saw Direct Care Staff M and Direct Care Staff N in the hallway and yelled for them to come because there was a resident outside, unattended. Dietary Staff BB said staff assisted the resident back inside the facility. On 5/1/18 at 8:45 AM, Maintenance Staff U stated staff notified him/her on the evening of 4/25/18, that a resident eloped out the exit door on the 400 hall. Maintenance Staff U stated the door alarm worked when he/she checked it, but the Wanderguard alert was not functioning. Maintenance Staff U stated he/she placed a call to the door company and they were at the facility the next day to service the door and alarms. On 5/1/18 at 1:20 PM, Administrative Nurse D stated review of the camera footage revealed a resident exited from the facility out the 400 hall door at 7:41 PM. The alarm was shut off 52 seconds after that by Direct Care Staff M, and verified by Direct Care Staff M he/she had not checked outside the door that was alarming, until Dietary Staff BB notified Direct Care Staff M and N at 7:54 PM (13 minutes later) a resident was outside. Administrative Nurse D stated Dietary Staff BB found the resident outside in the staff parking lot at 7:54 PM, and notified Direct Care Staff M and Direct Care Staff N. The resident was outside for 13 minutes, unsupervised by staff. Administrative Nurse D verified staff had not followed the elopement policy and procedure by not physically checking the door that alarmed, and did not go outside to check the area. The facility's 1/2017 Missing Resident Protocol/Drill documented in the event of an elopement, the charge nurse should be notified immediately, and staff should begin to search for the resident. The charge nurse should call on the over-head pager Code Purple. The protocol documented the response team should report to the nursing office, and the charge nurse would assign different staff to search in the designated areas. The charge nurse should conduct a resident head count, and two staff should go out the main front door and search the front parking lot, and the south side of the building. Two staff should go out the hall 4 door and search the north side of the building, courtyard and the employee parking lot. One staff should check the front door of the special care unit, the back door, patio, and search the fenced area. One staff should be assigned to go into the main dining room and search the green house, the outside building, and around the kitchen door. Two to three staff should search all resident rooms and bathrooms, all rooms and offices in the building, and make sure the doors on the ends of hall 1 and 2 are locked. One staff should be assigned to go in a car and drive the streets around the facility, and one staff should search the Good Samaritan Apartment building. The facility failed to provide adequate supervision for cognitively impaired Resident #1, who eloped, and staff failed to follow the facility's elopement policy and procedure on 4/25/18. Staff did not physically go to the door and check outside the area. This deficient practice placed Resident #1 in immediate jeopardy. The deficient practice was identified as past non-compliance, and was corrected on 4/25/18, when the facility placed a motion sensor at the exit door on hall 400, and educated staff working at the facility at the time of the incident on the elopement policy and procedure. On 4/26/18 all staff were educated on the elopement policy, initiated a mock elopement drill, and the door company came to the facility and fixed the Wanderguard sensor on the 400 hall door.

The facility had a census of 67 residents. The sample included 3 residents reviewed for abuse and neglect. Based on observation, record review and interview the facility failed to protect the residents in the facility from potential abuse when Nurse Aide C continued working the remainder of his/her shift (approximately 7 hours) after staff overheard him/her verbally abuse 1 of 3 sampled residents, Resident #1. Nurse Aide C had access to all the residents in the facility. The facility also failed to report an allegation of missing controlled substances for Resident #1. - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/7/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment, with a mood severity score of 3, indicating minimal depression with no behaviors. The MDS recorded the resident required extensive assistance of 1 staff for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toilet use, personal hygiene, and independent with setup help only for eating. The MDS recorded the resident received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). The (ADL) Activities of Daily Living (CAA) Care Area Assessment, dated 1/4/17, recorded the resident had an ADL deficit, and required staff assistance with all of his/her ADLs except for eating. The CAA recorded the resident worked with the restorative program to improve his/her function. The 7/12/17 care plan recorded the resident had an ADL self care performance deficit related to a history of an injured left foot and generalized deconditioning. The care plan recorded the resident required one staff assistance with ambulation with a gait belt and walker for short distances, and instructed staff to provide a wheelchair for long distances and assist the resident to destinations when in his/her wheelchair. The care plan recorded the resident required 1 staff participation to dress and instructed staff to encourage the resident to do as much for himself/herself as possible. The care plan recorded the resident required 1 staff assistance with personal hygiene, toileting, bathing, and transfers. The care plan further recorded the resident had behavior symptoms related to anxiety and directed staff to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed, provide opportunity for positive interaction, attention, minimize potential of resident behavior problems by initiating ([MEDICATION NAME]) [MEDICATION NAME] administration log, encourage resident to report signs or symptoms of distress related to anxiety such as sleepiness or nightmares, especially with changes/dose reduction trials of his/her medication for anxiety. The nurse's notes on 7/21/2017 at 11:26 PM (late entry) recorded Nurse D accompanied Resident #1's family member to Resident #1's room, and within about ten feet from Resident #1's door, overheard Nurse Aide C announced in a loud voice, If you're going to snap at me, I'll snap right back. The notes recorded Resident #1's family member was immediately at the door, standing face to face with Nurse Aide C and said, How dare you speak to my (family member) that way! What is your name? I'm going to report you! Resident #1's family member stated Resident #1 was upset about the incident and when Nurse D asked Resident #1 about the incident, the resident agreed he/she was upset, but did not appear emotionally distraught. The note recorded Nurse Aide C had not physically touched the resident and there was no injury noted, and Nurse D called the information on to the Director of Nursing. The facility's investigation recorded on 7/21/17 staff reported an incident regarding Resident #1 when Nurse Aide C was overheard by Nurse D and the resident's family member telling the resident in a loud voice If you are going to snap at me, I'll snap right back. The investigation recorded staff assessed the resident and found him/her to be without injury. Nurse D reported the resident told him/her he/she was upset, but did not appear to be emotionally distraught. The investigation recorded Nurse Aide C did not provide cares for Resident #1 the rest of the night. The investigation recorded on 7/25/17 (4 days after the incident), the staff contacted Resident #1's family member regarding the incident. The resident's family member reported Resident #1 called him/her around 10:40 PM on 7/21/17, and said he/she was afraid to push the call light to go to the bathroom, because he/she pushed the call light so much. The investigation recorded Resident #1's family member came to the facility to see the resident right after the call. The resident's family member stated he/she and Nurse D were walking to Resident #1's room when the family member overheard Nurse Aide C tell the resident, If you are going to be snotty, I am going to be snotty right back. The investigation recorded Resident #1's family member told Nurse Aide C, how dare you talk to my (family member) like that? What is your name? The investigation recorded Nurse Aide C provided the family member with his/her name and then left Resident #1's room immediately. The resident's family member stayed with the Resident for a little while and then left. Review of Nurse Aide C's July time card documented the aide continued to work his/her scheduled shift on 7/21/17 from approximately 10:00 PM to 6:00 AM. The nurse's notes on 7/28/2017 at 11:04 AM, recorded staff spoke with the resident's family member and informed him/her of the results of the investigation, including staff instruction to Nurse Aide C to take another person in with him/her if he/she took care of the resident. Resident #1's family member voiced that this was fine with him/her, he/she had no concerns with the investigation results and the resident was ok with it as well. On 8/16/17 at 10:30 PM, observation revealed Nurse Aide E assisted Resident #1 to get ready for bed, provided personal hygiene care, then assisted the resident to bed, ensuring the resident was comfortable and the call light was in reach. On 8/15/17 at 1:12 PM, Administrative Nurse A stated Nurse Aide C was taking care of Resident #1 on 7/21/17, Resident #1 called many times after Nurse Aide C started his/her shift, complaining of his/her eye hurting/itching. Administrative Nurse A stated there was a new nurse on Resident #1's hall, Nurse Aide C went to the new nurse and told him/her about Resident #1's eye. Nurse Aide C told the resident that he/she was not able to do anything with his/her eye, and it was up to the nurse. The resident called his/her family member in the middle of this, when Nurse D was letting the family member in the building, he/she overheard Nurse Aide C say if you get snippy with me, I'll get snippy with you. Around 11:00 PM, the resident's family member heard this and went in to the room and told Nurse Aide C to stop and not speak to his/her family member that way. Nurse D assisted Resident #1 to the bathroom and once Resident #1 was settled, he/she called Administrative Nurse A. Administrative Nurse A stated he/she told Nurse D to keep Nurse Aide C away from Resident #1 because Administrative Nurse A stated he/she thought it was a personality conflict. Administrative Nurse A stated he/she told Nurse D to check Resident #1 for any bruises. The next day, Administrative Nurse A stated he/she talked to (SSD) Social Services Designee and decided to suspend Nurse Aide C. The facility did the investigation, interviewed the residents, family members, and workers, and nobody had a problem with Nurse Aide C. Everybody interviewed stated Nurse Aide C was very caring. Nurse Aide C apologized to Resident #1's family, Nurse Aide C had to go through in-services on the computer, how to deal with stress, how to communicate with residents. Nurse Aide C has to call in and talk to Human Resources personnel each week about how his/her week had gone, and his/her stress level. Nurse Aide C was suspended 7/22 and 7/23, until after he/she had finished his/her education. Nurse Aide C had not had any problems since he/she came back to work, he/she would call if he/she had any questions or if the nurse had not explained their thoughts completely to him/her. Nurse Aide C was not to take care of Resident #1, he/she felt horrible, he/she knew he/she should not have said what was said. On 8/16/17 at 9:00 AM, Administrative Nurse A stated the verbal incident was overheard by Nurse D and Resident #1's family member. Nurse D asked the resident and Resident #1 said he/she was very upset, but he/she did not appear distraught, and no injury was noted, as the resident was not physically touched by Nurse Aide C. Administrative Nurse A stated Nurse D did not elaborate, but Nurse D and the resident's family member both looked Resident #1 over. Administrative Nurse A stated he/she expected the residents to be treated with respect. Administrative Nurse A stated the administrative staff told Nurse Aide C he/she should have just walked away and came back later with another staff member so the resident could calm down, staff could calm down, and retry the assistance later. Administrative Nurse A stated staff did follow the policy, when Nurse D called Administrative Nurse A immediately. Administrative Nurse A stated he/she thought it was more of a personality conflict, and did not think of it as verbal abuse, not until the next day. Nurse Aide C should have walked away but Administrative Nurse A stated he/she did not know if Nurse Aide C was ever trained that way, but he/she was aware now. Administrative Nurse A stated Nurse Aide C did not follow the policy and Nurse Aide C should not have spoken to Resident #1 that way. On 8/16/17 at 10:21 AM, Administrative Staff B stated he/she would have expected staff to take the best care of the residents, treat them right, and do the right thing. Nurse Aide C did not follow the policy, instead of stepping away or getting help, he/she continued to go into the resident's room, and should have removed himself/herself and had someone else take care of the resident. The facility had since suspended Nurse Aide C, corrective actions have been done, education for Nurse Aide C (online learning) related to dealing with stress and difficult residents. Administrator B stated these things had to be completed before Nurse Aide C was able to come back to work. The facility assigned Human Resources to be Nurse Aide C's go to person, the person he/she talks to if he/she is stressed and how to handle it. The facility made a referral to (EAP) Employee Assistance Program for Nurse Aide C and it was made available. On 8/16/17 at 3:39 PM, Nurse Aide C stated on 7/21/17 at 10:00 PM, he/she came to work, received report, and started passing water, Resident #1's call light came on, so Nurse Aide C answered it, and reported to the nurse the resident needed something for his/her eyes. Nurse Aide C stated the light came on again, so he/she answered it, Resident #1 stated the call light had just fallen. Nurse Aide C stated he/she fixed the call light and went back to passing water, when the call light came on a third time. Nurse Aide C stated he/she told the nurse the resident was having problems with his/her eyes, the resident was getting snippy, and he/she was in an agitated grouchy mood. Nurse Aide C stated he/she told the resident that you don't need to get snippy with me because I can get snippy back, as soon as Nurse Aide C said that the resident's family member walked in and asked Nurse Aide C for his/her name, which was given, and Nurse Aide C stated he/she offered to write it down for the resident's family member, who declined the offer. Nurse Aide C stated he/she went on his/her way, and did not go in the resident's room the rest of the night. Nurse Aide C stated Nurse D was there and overheard Nurse Aide C's statement to the resident too. After the incident, Nurse Aide C finished passing water and then had Nurse D place fresh ice water and towels in Resident #1's room. Nurse Aide C stated he/she worked the rest of the shift, ending at 6:00 AM. Nurse Aide C stated he/she was suspended for a day and had to do some online tests over (ANE) Abuse, Neglect, Exploitation, and one other one. Nurse Aide C stated he/she was not allowed in Resident #1's room for one month, and was required to call and talk to Human Resources every Friday. Nurse Aide C stated he/she was off of work for 1 day, had the weekend off, came in on Monday for the investigation, was scheduled off on Tues (4 day weekend), and then came back to work on Wednesday, 7/26/17. On 8/17/17 at 12:37 PM, (SSD) Social Services Designee F stated the facility talked to the resident's family member, and informed him/her what had happened, the family member said his/her sister told the family member what had happened, the facility asked the family member if he/she was fine with Nurse Aide C working at the facility and he/she said yes, a couple days later the family member said the family did not want Nurse Aide C taking care of Resident #1. On 8/21/17 at 3:11 PM, Nurse D stated on 7/21/17 at 10:00 PM everyone showed up for the shift, Nurse D went to the nurse's station and received report, it was getting close to 11:00 PM when Nurse D received a phone call from Resident #1's family member, who stated Resident #1 had been calling him/her so the family member came right up and was standing at the front door requesting to come into the facility, as the doors were locked. Nurse D stated he/she let the family member in, and as he/she and the family member walked around the corner toward Resident #1's room, about 10 feet from the resident's door, both Nurse D and the resident's family member heard Nurse Aide C say If you're going to be snotty to me, I'm going to be snotty to you, Nurse Aide C was coming out of Resident #1's room when his/her family member and Nurse D heard this. Nurse D stated the resident's family member said to Nurse Aide C, how dare you talk to my (family member) that way. The family member then asked Nurse Aide C what his/her name was and Nurse Aide C told the family member, the family member than stated he/she was going to report Nurse Aide C, to which Nurse Aide C replied, that's ok. Nurse D stated he/she talked to Nurse Aide C about an hour later to see what happened, Nurse Aide C stated the resident had turned his/her call light on several times and had been told he/she had to wait as the nurses were in report. After 3 to 4 times Resident #1's call light fell on the floor so he/she was tapping on the bedside table to get Nurse Aide C's attention, this was when Nurse Aide C became upset and yelled at Resident #1. Nurse D stated he/she notified Administrative Nurse A after talking to Nurse Aide C, sometime before midnight. Administrative Nurse A told Nurse D to keep Nurse Aide C busy, but out of Resident #1's room. Nurse D stated Administrative Nurse A did not tell Nurse D to send Nurse Aide C home. Nurse D stated since Nurse Aide C had been back to work he/she had been instructed to refrain from Resident #1's room on Hall 2, but Nurse D was sure that he/she had not, and still worked on Halls 2 and 4. The facility's Abuse and Neglect policy, dated 11/2016, stated the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location, employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility failed to protect all residents in the facility from potential abuse, after Nurse Aide C continued to work after verbally abusing Resident #1. - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/7/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment, with a mood severity score of 3, indicating minimal depression with no behaviors. The MDS recorded the resident required extensive assistance of 1 staff for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toilet use, personal hygiene, and independent with setup help only for eating. The MDS recorded the resident received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). The [MEDICAL CONDITION] Drug Use CAA, dated 1/4/17, recorded the resident took [MEDICATION NAME] (class of medications used to treat mood disorders and relieve symptoms of depression) for depression and [MEDICATION NAME] (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for anxiety. The CAA recorded the resident was at risk for falls and had anxiety that could be a side effect of the antidepressant. The 7/12/17 care plan recorded the resident had an ADL self care performance deficit related to a history of an injured left foot and generalized deconditioning. The care plan recorded the resident required one staff assistance with ambulation with a gait belt and walker for short distances, and instructed staff to provide a wheelchair for long distances and assist the resident to destinations when in his/her wheelchair. The care plan recorded the resident required 1 staff participation to dress and instructed staff to encourage the resident to do as much for himself/herself as possible. The care plan recorded the resident required 1 staff assistance with personal hygiene, toileting, bathing, and transfers. The care plan recorded the resident received Tylenol (pain medication) and [MEDICATION NAME] (narcotic pain medication) for pain, used anti-anxiety medications related to a [DIAGNOSES REDACTED]. The care plan further recorded the resident had behavior symptoms related to anxiety and directed staff to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed, provide opportunity for positive interaction, attention, minimize potential of resident behavior problems by initiating ([MEDICATION NAME]) [MEDICATION NAME] administration log, encourage resident to report signs or symptoms of distress related to anxiety such as sleepiness or nightmares, especially with changes/dose reduction trials of his/her medication for anxiety. The 1/14/15 physician order [REDACTED]. The 1/19/17 physician's orders [REDACTED]. The 3/25/17 physician's orders [REDACTED]. On 7/21/17 the facility reported to the State agency misappropriation of property regarding missing [MEDICATION NAME], but lacked information regarding missing [MEDICATION NAME]. Review of the resident's PRN [MEDICATION NAME] 7.5-325 mg narcotic count sheets for July 17-21, 2017 recorded Nurse G signed out a [MEDICATION NAME] on 7/17/17 at 6:30 PM. Review of Resident #1's July (MAR) Medication Administration Record lacked documentation Nurse G administered the PRN dose of [MEDICATION NAME] to the resident on 7/17/17 at 6:30 PM. Review of Resident #1's PRN [MEDICATION NAME] 0.25 mg narcotic count sheets for July, 2017, documented Nurse G signed the medication out on the following days: 1, 2, 5, 6, 7, 10, 11, 12, 14, 15, 16, 17, 19, 28, 29, 30, 31. Review of Resident #1's July (MAR) Medication Administration Record lacked documentation Nurse G administered the PRN dose of [MEDICATION NAME] 0.25 mg to the resident on July 7, 11, 15, and 16. Review of the facility ordered drug test for Nurse G, dated 7/20/17, documented positive results for alpha [MEDICATION NAME][MEDICATION NAME] (combination drug with antianxiety and sedative-hypnotic actions, that is efficacious in the treatment of [REDACTED]. On 8/15/17 at 1:12 PM, Administrative Nurse A stated Resident #1 had a physician order [REDACTED]. Administrative Nurse A stated Nurse G was re-educated and Administrative Staff thought it was stolen drugs, at first he/she thought it was both [MEDICATION NAME] and [MEDICATION NAME] that were missing. Administrative Nurse A stated he/she received an anonymous letter with a copy of the sign off sheets and a copy of the July MAR. The [MEDICATION NAME] and [MEDICATION NAME] were signed out on the narcotic sheets, but were not documented on the MAR. Administrative Nurse A stated there were 4 PRN [MEDICATION NAME] and 1 PRN [MEDICATION NAME] that were not charted, so the facility completed a drug test on Nurse G, who was suspended from 7/20-7/27, and the drug test came back positive. He/she was suspended on 7/20/17 around 11:00 AM, Nurse G had another drug test on 7/27, and was re-educated. Administrative Nurse A stated he/she did not know what the results were of the drug test on the 27th, but they were better or Nurse G would have been terminated. Administrative Nurse A stated for Nurse G to return to work, the test had to be less than the level it was previously, it did not have to be clear. On 8/15/17 at 3:15 PM, Administrative Nurse A stated he/she completed an audit of all the narcotics, especially on that hall, where Resident #1 resided. Administrative Nurse A stated the [MEDICATION NAME] was not reported because he/she thought it was just a medication error. The administration of the PRN [MEDICATION NAME] and [MEDICATION NAME] were not recorded on the MAR, but were signed out on the narcotic count sheet. Administrative Nurse A stated he/she thought, with the [MEDICATION NAME], the resident had been given too much, so Nurse G was suspended over that. On 8/16/17 at 9:00 AM, Administrative Nurse A stated there were no witnesses regarding the undocumented [MEDICATION NAME] and [MEDICATION NAME]. Administrative Nurse A stated he/she received the anonymous note on 7/20/17, and talked to Resident #1 and his/her daughter on that day, at 7:20 PM. Administrative Nurse A stated he/she expected the residents to receive their medications timely and they are not anxious or in pain. Administrative Nurse A stated Nurse G did not follow the policy, when he/she failed to document the medication administration correctly. Administrative Nurse A stated Nurse G was retrained, and on July 21, 2017, the narcotic count sheets were checked to ensure no further discrepancies were identified, as Nurse G worked Hall 2 (16 residents). On 8/16/17 at 10:21 AM, Administrative Staff B stated staff had not notified the police of Nurse G's positive drug test, because there were no missing medications, and the counts were correct. Administrative Staff B stated he/she expected the residents get the best care possible, and that Nurse G would sign out the administered medications. Administrative Nurse B stated Nurse G was suspended, drug tested , and received corrective action before he/she was able to return to work. On 8/16/17 at 2:01 PM, Nurse G stated Resident #1 had an order for [REDACTED]. Nurse G stated on 7/17/17 he/she gave Resident #1 a scheduled [MEDICATION NAME] at 4:00 PM, and about an hour later he/she was hurting so staff tried to change the resident's position and rub his/her back, an hour later the resident was still in pain, so Nurse G gave him/her a PRN [MEDICATION NAME]. Nurse G stated the computer system was not supposed to let staff administer a medication that was too early, and it was not too early. Nurse G stated he/she was unsure if the [MEDICATION NAME] administration had been documented in the MAR, there were also a couple of undocumented [MEDICATION NAME] in the MAR. Nurse G stated the facility made him/her do a drug test because it looked like he/she was signing the medication out and not charting it. Nurse G stated he/she tested positive for [MEDICATION NAME] and [MEDICATION NAME] and had a prescription for the [MEDICATION NAME] ([MEDICATION NAME]), but the physician stated the prescription was over a year old. Nurse G stated he/she had not taken the prescription for 1 1/2 or 2 years, but was suspended for a week until the results of the drug test came back. Nurse G stated the facility asked him/her if he/she wanted to go into rehab and the facility asked for the old prescription. Nurse G stated he/she attended the initial therapy consult, but had not heard a date to start therapy, and for the next 2 years he/she was subject to random drug testing per the facility. Nurse G stated he/she had to take a second drug test a week after the first one, and the second one was positive [MEDICATION NAME](medication to help people fall asleep) that he/she was taking. Nurse G stated there were no medications that were positive on the first test, that showed up on the second test, so he/she was allowed to return to work. Nurse G stated the facility did not say anything to him/her regarding the [MEDICATION NAME], but he/she thought it was included in his/her therapy. The facility's Abuse and Neglect policy, dated February 2013, stated alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator and to other officials in accordance with state survey and certification agency. The facility failed to report an allegation of missing controlled substances.

The facility had a census of 67 residents. The sample included 3 residents reviewed for abuse and neglect. Based on observation, record review and interview the facility failed to provide an environment free from verbal abuse for 1 of 3 sampled residents. Resident #1 was verbally abused by facility staff. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 7/7/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment, with a mood severity score of 3, indicating minimal depression with no behaviors. The MDS recorded the resident required extensive assistance of 1 staff for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing, toilet use, personal hygiene, and independent with setup help only for eating. The MDS recorded the resident received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). The (ADL) Activities of Daily Living (CAA) Care Area Assessment, dated 1/4/17, recorded the resident had an ADL deficit, and required staff assistance with all of his/her ADLs, except for eating. The CAA recorded the resident worked with the restorative program to improve his/her function. The 7/12/17 care plan recorded the resident had an ADL self care performance deficit related to a history of an injured left foot and generalized deconditioning. The care plan recorded the resident required one staff assistance with ambulation with a gait belt and walker for short distances, and instructed staff to provide a wheelchair for long distances and assist the resident to destinations when in his/her wheelchair. The care plan recorded the resident required 1 staff participation to dress and instructed staff to encourage the resident to do as much for himself/herself as possible. The care plan recorded the resident required 1 staff assistance with personal hygiene, toileting, bathing, and transfers. The nurse's notes on 7/21/2017 at 11:26 PM (late entry) recorded Nurse D received a phone call from Resident #1's family member, stating he/she was standing outside the nursing home at the front door and had come to see his/her family member, Resident #1, after speaking to him/her on the phone. The notes documented Nurse D let Resident #1's family member inside. He/she accompanied the family member to Resident #1's room, and within about ten feet from Resident #1's door, overheard Nurse Aide C announced in a loud voice, If you're going to snap at me, I'll snap right back. The notes recorded Resident #1's family member was immediately at the door, standing face to face with Nurse Aide C and said, How dare you speak to my (family member) that way! What is your name? I'm going to report you! Resident #1's family member stated Resident #1 was upset about the incident and when Nurse D asked Resident #1 about the incident, the resident agreed he/she was upset, but did not appear emotionally distraught. The note recorded Nurse Aide C had not physically touched the resident and there was no injury noted, and Nurse D called the information regarding the incident to the Director of Nursing. The facility's investigation recorded on 7/21/17 staff reported an incident regarding Resident #1 when Nurse Aide C was overheard by Nurse D and the resident's family member telling the resident in a loud voice If you are going to snap at me, I'll snap right back. The investigation recorded staff assessed the resident and found him/her to be without injury. Nurse D reported the resident told him/her he/she was upset, but did not appear to be emotionally distraught. The investigation recorded Nurse Aide C did not provide cares for Resident #1 the rest of the night. The investigation recorded on 7/25/17 (4 days after the incident), the staff contacted Resident #1's family member regarding the incident. The resident's family member reported Resident #1 called him/her around 10:40 PM on 7/21/17, and said he/she was afraid to push the call light to go to the bathroom, because he/she pushed the call light so much. The investigation recorded Resident #1's family member came to the facility to see the resident right after the call. The resident's family member stated he/she and Nurse D were walking to Resident #1's room when the family member overheard Nurse Aide C tell the resident, If you are going to be snotty, I am going to be snotty right back. The investigation recorded Resident #1's family member told Nurse Aide C, how dare you talk to my (family member) like that? What is your name? The investigation recorded Nurse Aide C provided the family member with his/her name and then left Resident #1's room immediately. The resident's family member stayed with the Resident for a little while and then left. Review of Nurse Aide C's July time card documented the aide continued to work his/her scheduled shift on 7/21/17 from approximately 10:00 PM to 6:00 AM. The nurse's notes on 7/28/2017 at 11:04 AM, recorded staff spoke with the resident's family member and informed him/her of the results of the investigation, including staff instruction to Nurse Aide C to take another person in with him/her if he/she took care of the resident. Resident #1's family member voiced that this was fine with him/her, he/she had no concerns with the investigation results and the resident was ok with it as well. On 8/16/17 at 10:30 PM, observation revealed Nurse Aide E assisted Resident #1 to get ready for bed, provided personal hygiene care, then assisted the resident to bed, ensuring the resident was comfortable and the call light was in reach. On 8/15/17 at 1:12 PM, Administrative Nurse A stated Nurse Aide C was taking care of Resident #1 on 7/21/17, Resident #1 called many times after Nurse Aide C started his/her shift, complaining of his/her eye hurting/itching. Administrative Nurse A stated there was a new nurse on Resident #1's hall, Nurse Aide C went to the new nurse and told him/her about Resident #1's eye. Nurse Aide C told the resident that he/she was not able to do anything with his/her eye, and it was up to the nurse. The resident called his/her family member in the middle of this, when Nurse D was letting the family member in the building, he/she overheard Nurse Aide C say if you get snippy with me, I'll get snippy with you. Around 11:00 PM, the resident's family member heard this and went in to the room and told Nurse Aide C to stop and not speak to his/her family member that way. Nurse D assisted Resident #1 to the bathroom and once Resident #1 was settled, he/she called Administrative Nurse A. Administrative Nurse A stated he/she told Nurse D to keep Nurse Aide C away from Resident #1 because Administrative Nurse A stated he/she thought it was a personality conflict. Administrative Nurse A stated he/she told Nurse D to check Resident #1 for any bruises. The next day, Administrative Nurse A stated he/she talked to (SSD) Social Services Designee and decided to suspend Nurse Aide C. The facility did the investigation, interviewed the residents, family members, and workers, and nobody had a problem with Nurse Aide C. Everybody interviewed stated Nurse Aide C was very caring. Nurse Aide C apologized to Resident #1's family, Nurse Aide C had to go through in-services on the computer, and how to deal with stress, how to communicate with residents. Nurse Aide C has to call in and talk to Human Resources personnel each week about how his/her week had gone, and his/her stress level. Nurse Aide C was suspended 7/22 and 7/23, until after he/she had finished his/her education. Nurse Aide C had not had any problems since he/she came back to work, he/she would call if he/she had any questions or if the nurse had not explained their thoughts completely to him/her. Nurse Aide C was not to take care of Resident #1, he/she felt horrible, he/she knew he/she should not have said what was said. On 8/16/17 at 9:00 AM, Administrative Nurse A stated the verbal incident was overheard by Nurse D and Resident #1's family member. Nurse D asked the resident and Resident #1 said he/she was very upset, but he/she did not appear distraught, and no injury was noted, as the resident was not physically touched by Nurse Aide C. Administrative Nurse A stated Nurse D did not elaborate, but Nurse D and the resident's family member both looked Resident #1 over. Administrative Nurse A stated he/she expected the residents to be treated with respect. Administrative Nurse A stated the administrative staff told Nurse Aide C he/she should have just walked away and came back later with another staff member so the resident could calm down, staff could calm down, and retry the assistance later. Administrative Nurse A stated staff did follow the policy, when Nurse D called Administrative Nurse A immediately. Administrative Nurse A stated he/she thought it was more of a personality conflict, and did not think of it as verbal abuse, not until the next day. Nurse Aide C should have walked away but Administrative Nurse A stated he/she did not know if Nurse Aide C was ever trained that way, but he/she was aware now. Administrative Nurse A stated Nurse Aide C did not follow the policy, that Nurse Aide C should not have spoken to Resident #1 that way. On 8/16/17 at 10:21 AM, Administrative Staff B stated he/she would have expected staff to take the best care of the residents, treat them right, and do the right thing. Nurse Aide C did not follow the policy, instead of stepping away or getting help, he/she continued to go into the resident's room, and should have removed himself/herself and had someone else take care of the resident. The facility had since suspended Nurse Aide C, corrective actions have been done, education for Nurse Aide C (online learning) related to dealing with stress and difficult residents. Administrator B stated these things had to be completed before Nurse Aide C was able to come back to work. The facility assigned Human Resources to be Nurse Aide C's go to person, the person he/she talks to if he/she is stressed and how to handle it. The facility made a referral to (EAP) Employee Assistance Program for Nurse Aide C and it was made available. On 8/16/17 at 3:39 PM, Nurse Aide C stated on 7/21/17 at 10:00 PM, he/she came to work, received report, and started passing water, Resident #1's call light came on, so Nurse Aide C answered it, and reported to the nurse the resident needed something for his/her eyes. Nurse Aide C stated the light came on again, so he/she answered it, Resident #1 stated the call light had just fallen. Nurse Aide C stated he/she fixed the call light and went back to passing water, when the call light came on a third time. Nurse Aide C stated he/she told the nurse the resident was having problems with his/her eyes, the resident was getting snippy, and he/she was in an agitated grouchy mood. Nurse Aide C stated he/she told the resident that you don't need to get snippy with me because I can get snippy back, as soon as Nurse Aide C said that the resident's family member walked in and asked Nurse Aide C for his/her name, which was given, and Nurse Aide C stated he/she offered to write it down for the resident's family member, who declined the offer, Nurse Aide C stated he/she went on his/her way, and did not go in the resident's room the rest of the night. Nurse Aide C stated Nurse D was there and overheard Nurse Aide C's statement to the resident too. After the incident, Nurse Aide C finished passing water and then had Nurse D place fresh ice water and towels in Resident #1's room. Nurse Aide C stated he/she worked the rest of the shift, ending at 6:00 AM. Nurse Aide C stated he/she was suspended for a day and had to do some online tests over (ANE) Abuse, Neglect, Exploitation, and one other one. Nurse Aide C stated he/she was not allowed in Resident #1's room for one month, and was required to call and talk to Human Resources every Friday. Nurse Aide C stated he/she was off of work for 1 day, had the weekend off, came in on Monday for the investigation, was scheduled off on Tues (4 day weekend), and then came back to work on Wednesday, 7/26/17. On 8/17/17 at 12:37 PM, (SSD) Social Services Designee F stated the facility talked to the resident's family member, and informed him/her what had happened, the family member said his/her sister told the family member what had happened, the facility asked the family member if he/she was fine with Nurse Aide C working at the facility and he/she said yes, a couple days later the family member said the family did not want Nurse Aide C taking care of Resident #1. On 8/21/17 at 3:11 PM, Nurse D stated on 7/21/17 at 10:00 PM everyone showed up for the shift, Nurse D went to the nurse's station and received report, it was getting close to 11:00 PM when Nurse D received a phone call from Resident #1's family member, who stated Resident #1 had been calling him/her so the family member came right up and was standing at the front door requesting to come into the facility, as the doors were locked. Nurse D stated he/she let the family member in, and as he/she and the family member walked around the corner toward Resident #1's room, about 10 feet from the resident's door, both Nurse D and the resident's family member heard Nurse Aide C say If you're going to be snotty to me, I'm going to be snotty to you, Nurse Aide C was coming out of Resident #1's room when his/her family member and Nurse D heard this. Nurse D stated the resident's family member said to Nurse Aide C, how dare you talk to my (family member) that way. The family member then asked Nurse Aide C what his/her name was and Nurse Aide C told the family member, the family member then stated he/she was going to report Nurse Aide C, to which Nurse Aide C replied, that's ok. Nurse D stated he/she talked to Nurse Aide C about an hour later to see what happened, Nurse Aide C stated the resident had turned his/her call light on several times and had been told he/she had to wait as the nurses were in report. After 3 to 4 times Resident #1's call light fell on the floor so he/she was tapping on the bedside table to get Nurse Aide C's attention, this was when Nurse Aide C became upset and yelled at Resident #1. Nurse D stated he/she notified Administrative Nurse A after talking to Nurse Aide C, sometime before midnight. Administrative Nurse A told Nurse D to keep Nurse Aide C busy, but out of Resident #1's room. Nurse D stated Administrative Nurse A did not tell Nurse D to send Nurse Aide C home. Nurse D stated since Nurse Aide C had been back to work he/she had been instructed to refrain from Resident #1's room on Hall 2, but Nurse D was sure that he/she had not, and still worked on Halls 2 and 4. The facility's Abuse and Neglect policy, dated 11/2016, stated the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, location, employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility failed to provide an environment free from abuse for Resident #1, who was verbally abused by Nurse Aide C.

The facility had a census of 68 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to provide necessary care and services, and assessment/re-assessment, for 1 of the 3 residents, when staff failed to assess a resident who had a low oxygen saturation and was later found unresponsive and with a low oxygen saturation. (#1) Findings Included: - The 6/1/16 physician's orders [REDACTED]. Resident #1's significant change (MDS) Minimum Data Set assessment, dated 5/11/16, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 7, which indicated he/she had severe cognitive impairment. The MDS indicated the resident required extensive assistance from staff with bathing and personal hygiene, limited assistance with dressing, supervision with toileting, and he/she was independent with bed mobility, transfers, ambulation, and eating. The MDS indicated the resident used a walker for mobility, received oxygen therapy and a diuretic (medication used to promote the formation and excretion of urine) medication. The 5/19/16 care plan directed staff to provide oxygen therapy at 2 liter per minute per nasal cannula, provide extension tubing or portable oxygen, to be aware the resident removes his/her oxygen most of the time, encourage the resident to be compliant with his/her oxygen, and elevate the head of the bed as tolerated. The care plan further directed the staff to elevate his/her legs and feet when he/she is seated, observe for signs and symptoms of swelling in his/her extremities and report to the nurse, and monitor for signs and symptoms of respiratory distress (difficulty in breathing) and report to his/her physician. The 6/14/16 at 1:59 PM, dietary note stated the resident had some [MEDICAL CONDITION] to his/her eyes and lower extremities. The 6/23/16 at 10:26 AM, nurse's notes stated staff notified the physician of the resident's general body [MEDICAL CONDITION], shortness of breath, and an oxygen saturation of 60% on room air. The note stated the resident's oxygen saturation increased to 92% when staff applied oxygen. The 6/23/16 at 10:30 AM fax to the resident's physician, stated the resident had symptoms of fluid overload (medical condition where there is too much fluid in the blood), with general body [MEDICAL CONDITION], shortness of breath, and oxygen saturation of 60% without oxygen, and 92% with oxygen. The physician's office notified the facility staff to bring the resident into his/her office for evaluation at 3:00 PM on 6/23/16. The 6/23/16 at 10:45 AM, nurse's note stated the resident's blood pressure was 164/99 (normal range is 120/80), pulse was 72 and regular, respirations were 20, temperature was 97.3 degrees Fahrenheit, and his/her oxygen saturation was 90% on 2 liters of oxygen. The clinical record lacked documentation of assessment between 10:45 AM and 2:10 PM. The 6/23/16 at 2:10 PM, nurse's note stated staff found the resident unresponsive and he/she would not arouse. The note stated the resident's oxygen saturation was 45%. The note stated staff had observed the resident with shortness of breath earlier in the day, and he/she would not leave his/her oxygen on. The note stated staff called for an ambulance to transport the resident to the hospital. The medical record lacked documentation staff had assessed the resident since 6/23/16 at 10:45 AM, and did not assess the resident until the ambulance arrived and the (EMS) emergency medical service staff assessed the resident, approximately 3 hours later. The 6/23/16 at 2:11 PM, nurse's note stated (EMS) emergency medical services transported the resident to the hospital due to being unresponsive. The note included the most recent vital signs for the resident, which were done at 10:45 AM that morning (3 hours earlier). The note stated the resident had low oxygen saturations, had breathing problems, shortness of breath, refused to wear his/her oxygen, had confusion and short term memory loss. The note stated the resident had been scheduled to see his/her physician at 3:00 PM 6/23/16 for fluid overload, but he/she became un-responsive. The 6/23/16 at 2:17 PM, EMS record stated the EMS responders located the resident in the special care unit, after several minutes of searching. The record stated staff reported the resident had low oxygen saturation all day, and staff found the resident unresponsive. Upon the arrival, the resident was alert and oriented, had labored breathing at a rate of 30, pale, warm, dry skin, deep [MEDICAL CONDITION] (demonstrated by applying pressure to the swollen area by depressing the skin with a finger. If this causes an indentation that stays for some time after the release of the pressure, this type of [MEDICAL CONDITION] is referred to as [MEDICAL CONDITION]) in his/her lower extremities, and complained of a little trouble breathing and of feeling not good. The note stated the resident's lungs had clear air movement in all lobes, and no crackling or wheezing noted. The record stated the EMS staff increased the resident's oxygen to 6 liters per minute during the assessment, and once he/she was in the ambulance his/her oxygen to 15 liters per minute via a non re-breathing mask, with an immediate rise in his/her oxygen saturation. The record stated staff finally showed up as the resident was leaving the facility, and provided a short report, saying the resident had trouble breathing and he/she was not sure why. The record stated at 2:20 PM the resident's blood pressure was 170/104, pulse 94, respirations 30 and labored, and oxygen saturation was 78% on 2 liters of oxygen. The 6/23/16 emergency room record stated the resident had shortness of breath, increased lower extremity swelling and an episode of unresponsiveness due to [MEDICAL CONDITION] (inadequate supply of oxygen). The 6/23/16 at 5:41 PM, social service note stated staff contacted the hospital and received report that the resident would be admitted to acute care. The 6/23/16 hospital report stated the resident had a history over the last few days of increasing lower extremity swelling, and shortness of breath. The note stated the resident was brought to the emergency room by ambulance, with an oxygen saturation of 78% on 2 liters of oxygen, which was increased to 4 liters, and the resident was given [MEDICATION NAME] (diuretic) 40 (mg) milligrams per IV (intravenous). The note stated the resident would be admitted to acute care with [DIAGNOSES REDACTED]. On 6/29/16 at 7:30 AM, observation revealed the resident, seated in a chair, in the living room area of the unit, with his/her oxygen on. Further observation revealed a few minutes later, he/she removed his/her oxygen and draped the tubing over the portable oxygen tank. Further observation revealed staff assisted the resident with his/her oxygen, and encouraged him/her to leave it on. On 6/28/16 at 9:50 AM, Nurse Aide A verified he/she worked the day shift on 6/23/16. Nurse Aide A stated the resident asked staff to take him/her to his/her room to lie down. Nurse Aide A stated the resident had his/her oxygen on at that time, and staff used a wheelchair to take the resident to his/her room. Nurse Aide A stated a short time later, staff found the resident with his/her oxygen off, blue lips, slumped over to one side, drooling, and with oxygen saturation in the low 40's. Nurse Aide A stated staff could not get the resident to respond. Nurse Aide A stated Nurse B and Nurse C were at the nurses station and staff reported the resident's condition, and he/she told them to call 911. Nurse Aide A stated Nurse B was leaving the facility after his/her shift, and Nurse C called 911. Nurse Aide A stated Nurse B or Nurse C did not come to the resident's room to assess the resident. Nurse Aide A stated Nurse C did not come to the resident's room to talk to the ambulance staff until they had the resident on the cart and were leaving the facility. On 6/28/16 at 10:55 AM, Nurse Aide D verified he/she worked the day shift on 6/23/16. Nurse Aide D stated the resident had been sitting in the living room area, when the resident asked staff to take him/her to his/her room. Nurse Aide D stated the resident had trouble walking, and staff placed him/her in a wheelchair to go to his/her room. Nurse Aide D stated the resident's lips were slightly blue, and when he/she reported this to the nurse, he/she was told to put the resident's oxygen on. Nurse Aide D stated at approximately 2:00 PM, he/she did rounds with the evening aides, when staff found the resident in his/her wheelchair, his/her oxygen off, slumped over to one side, blue lips and drooling. Nurse Aide D stated staff could not get the resident to respond to them. Nurse Aide D stated staff asked Nurse C , the on-coming evening nurse, to come to the resident's room several times, but Nurse C did not come to assess the resident. On 6/28/16 at 2:45 PM, Nurse B verified he/she worked the day shift on 6/23/16. Nurse B stated the resident had problems with his/her oxygen saturation all day and the resident would not leave his/her oxygen on. Nurse B stated the resident appeared to be full of fluid, he/she notified the resident's physician, and the resident was then scheduled to see his/her physician that afternoon at 3:00 PM. Nurse B stated before he/she left the facility at the end of his/her shift, staff reported the resident was in his/her room, in a wheelchair, slumped over to one side, drooling, and unresponsive. Nurse B stated as he/she walked by the resident's room to leave the unit, at approximately 2:15 PM, and staff told him/her the resident was not acting right. Nurse B stated he/she saw the resident slumped over in his/her wheelchair, drooling and unresponsive, but he/she had an appointment to get to, and he/she did not go in and assess the resident. On 6/29/16 at 10:43 AM, Administrative Nurse E stated neither Nurse B or Nurse C assessed the resident after staff reported the resident slumped over in his/her wheelchair, drooling, with blue lips, unresponsive and with oxygen saturations in the 40's. Administrative Nurse E stated he/she would have expected Nurse B and Nurse C to assess the resident. On 6/30/16 at 10:00 AM, Physician G stated he/she would have expected staff to do a full assessment of the resident when the resident was found unresponsive. Physician G stated staff had informed him/her of the resident's low oxygen saturations earlier that day, and he/she informed them to encourage the resident to keep his/her oxygen on. The facility failed to provide necessary care and services for Resident #1, when staff did not re-assess the resident for approximately 3 hours, after he/she had low oxygen saturation, and became unresponsive. The resident required transfer by EMS to the hospital where he/she was admitted for [MEDICAL CONDITIONS] secondary to heart failure exacerbation and volume overload.

The facility had a census of 69 residents, of which 16 resided in the special care unit. The sample included 3 residents, of which 3 were reviewed for behaviors. Based on observation, interview, and record review the facility failed to protect the residents of the opposite gender from Resident #1, who inappropriately touched 2 cognitively impaired residents of the opposite gender, in a sexual manner, on 3 occasions witnessed by staff. The facility failed to provide protection to the 4 residents of the opposite gender on the special care unit. On 8/28/15 staff observed Resident #1 kissing Resident #3. On 10/20/15 staff observed Resident #1 in Resident #3's room, with his/her clothing off, rubbing against Resident #3. On 5/11/16 staff observed Resident #1 in Resident #2's room, with no clothing other than an open robe, rubbing the external genitals of Resident #2, and Resident #2 rubbing Resident #1's external genitals. This failure placed the 4 residents of the opposite gender, who resided in the special care unit, in immediate jeopardy. The facility also failed to report the 8/28/15 incident to the state agency as required. Findings included: - Resident #1's admission (MDS) Minimum Data Set assessment, dated 7/1/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 4 and displayed disorganized thinking behaviors. The MDS further indicated the resident required supervision of 1 staff for toilet use, limited assistance of 1 staff for dressing, and independent with transfers and locomotion. The 7/1/15 cognitive loss (CAA) Care Area Assessment indicated the resident had a decline in cognition and the family wanted him/her in a safe place. The CAA further indicated the resident had impaired memory, confusion, forgetfulness related to [DIAGNOSES REDACTED]. The 7/1/15 care plan informed staff the resident had impaired cognitive function or impaired thought process, impaired decision making, and short term memory loss. The care plan instructed staff to provide the resident with supervision with all decision making tasks, and to provide the resident with necessary cues or redirection. The 8/31/15 care plan update further instructed staff to discourage him/her from visiting with residents of the opposite gender in their rooms, and for staff to supervise the resident. The care plan informed staff the resident had been observed kissing a resident of the opposite gender. The 10/21/15 care plan update informed staff the resident displayed inappropriate sexual advances towards another resident, related to his/her dementia, evidenced by kissing, touching, and removal of his/her clothing with a married resident. The care plan instructed staff to monitor the involved residents, to know their whereabouts, and to check them after going to bed at night. The care plan further instructed staff to distract one of the involved residents to another task. The 5/11/16 care plan update instructed staff to attempt non-pharmalogical interventions, to explain to the resident his/her behavior is inappropriate, to check on the resident every 2 hours at night to monitor sexual behaviors, and redirect as needed. The 8/28/15 at 9:28 PM, nurse's note indicated staff found Resident #1 kissing Resident #3, and staff notified the resident's DPOA (Durable Power of Attorney), physician, director of nursing, and administration. The 8/31/15 at 4:42 PM, nurse's note indicated the care plan was reviewed and updated to address supervision and discouragement of kissing residents of the opposite gender. The 9/19/15 at 9:17 PM, nurse's note indicated staff frequently observed the resident close to a resident of the opposite gender. The note further indicated redirection lasted for short periods of time. The 9/30/15 at 12:48 PM, nurse's note indicated the resident continued to seek attention from a resident of the opposite gender and staff monitored boundaries. The note further indicated staff redirected the resident by taking him/her outside for fresh air. The 10/16/15 at 1:31 PM, nurse's note indicated staff observed a resident of the opposite gender in Resident #1's room, and staff redirected Resident #1 several times by watering plants. The 10/18/15 at 7:45 PM, nurse's note indicated staff observed Resident #1 hanging around a resident of the opposite gender, and staff attempted to distract him/her. The 10/20/15 at 4:25 AM, nurse's note indicated at approximately 11:30 PM, last evening on 10/19/15, staff observed Resident #1's roommate in the hallway crying, stating he/she did not want to tell and get anyone in trouble. The note revealed staff noticed Resident #3's door to his/her room was closed, and when staff opened the door, observed Resident #1 with his/her clothes off, rubbing up against Resident #3, who is standing in the middle of the room, not doing anything back, and is fully dressed. The note indicated staff redirected the resident back to his/her room, and no further incidents occurred. The 10/29/15 physician's orders [REDACTED]. The 11/7/15 at 9:32 PM, nurse's note indicated the resident had behaviors and was confused, asking for his/her spouse. The note further indicated the resident was triggered by Resident #3's spouse sitting on his/her lap, and caused Resident #1 to be jealous. The note indicated staff supported and encouraged the resident to relax, and later in the evening staff found the resident in Resident #3's room hugging him/her. The 11/8/15 at 8:43 PM, nurse's note indicated the resident was delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) and thought a resident of the opposite gender was his/her spouse. The 12/8/15 psychotherapy note indicated the visit focused on boundaries with residents of the opposite gender, and staff reported the resident had no recent inappropriate behaviors. The 2/13/16 at 8:36 PM, nurse's note indicated a resident of the opposite sex continued to make advances towards Resident #1, and staff observed them holding hands numerous times, and staff attempted to separate the residents numerous times. The note indicated staff assured Resident #1 they could remain friends, and the resident stated I don't know what to do, it is hard when you like someone, and the resident went to bed. The 3/8/16 psychosocial note indicated the resident had a reduction in inappropriate behaviors. The 4/26/16 psychosocial note indicated the resident had a reduction in inappropriate behaviors, and presented with features of poor adjustment, increase in dementia, and decrease in social inhibitions. The note further indicated the resident had poor insight in his/her cognitive loss. The 5/9/16 at 2:00 AM, nurse's note indicated staff observed the resident out of his/her room, walked for the exit door, and stood for a while before heading back to his/her room. The note further indicated staff found the resident in Resident #3's room standing over his/her bed. The note indicated staff assisted the resident out of the room, and he/she became upset, but went to his/her room. The 5/11/16 at 5:05 AM, nurse's note indicated staff observed the resident in Resident #2's room, with his/her robe open, with no clothes underneath. The note further indicated staff observed Resident #1 rubbing the external genitals of Resident #2, while Resident #2 rubbed Resident #1. The 5/11/16 at 1:38 PM, nurse's note indicated Resident #1 is difficult to redirect when he/she follows a resident of the opposite gender, and he/she believes they are someone else. The 5/12/16 at 12:19 PM, nurse's note indicated staff observed the resident following a resident of the opposite gender and became upset when staff redirected him/her. The 5/12/16 at 4:40 PM, nurse's note indicated the care plan was updated to reflect the resident to have a sensor alarm intact in his/her doorway to alert staff of his/her movement out of his/her room at night. The note further indicated staff are to monitor the resident when he/she is out of his/her room to ensure appropriate interaction. On 5/17/16 at 10:39 AM, observation revealed Resident #1 seated in the dining room, and Resident #3 seated at another table in the dining room. Continued observation revealed Resident #1 stuck his/her tongue out at Resident #3 multiple times, and Resident #3 laughed. Further observation revealed at 10:41 AM, staff left the residents unattended in the dining room, along with 6 other residents the same gender as Resident #1. Continued observation revealed at 10:42 AM, Resident #4 ambulated independently into the dining room with his/her walker, and had a verbal altercation with Resident #3. Further observation revealed staff returned to the dining room at 10:44 AM, and redirected Resident #4. (Which left the cognitively impaired residents unsupervised for 5 minutes) On 5/17/16 at 3:52 PM, observation revealed Resident #1 ambulated down the hall in the special care unit without staff supervision. Further observation revealed Resident #5 in bed with his/her eyes closed in his/her room, and Resident #1 ambulated into Resident #5's room, looked at him/her for approximately 30 seconds, left Resident #5's room, and ambulated down the hall to his/her room. When Resident #1 entered his/her room no alarm sounded, and at 3:56 PM, when he/she exited his/her room no alarm sounded. Continued observation revealed the resident walked into the dining room with no staff supervision, and stood next to Resident #3. On 5/12/16 at 3:07 PM, Nurse Aide A stated he/she walks up and down the halls about every 10 to 15 minutes, and would redirect a resident if they were in the wrong room. On 5/12/16 at 3:14 PM, Nurse Aide B verified Resident #1 does wander around a lot, and has redirected him/her from Resident #5's room. Nurse Aide B further verified Resident #1 will wander in and out of male and female resident rooms, and had caught Resident #1 in Resident #2's room before, but Resident #2 was not in there. On 5/12/16 at 3:37 PM, Unit Coordinator G verified staff are to visualize the residents at least once every 2 hours, and staff had seen Resident #1, 15 minutes prior to the incident on 5/11/16. Unit Coordinator G further verified Resident #1 had disrobed for another resident prior to the 5/11/16 incident. Unit Coordinator G verified checking a resident every 2 hours would not prevent a future occurrence. Unit Coordinator G verified the facility would initiate a floor alarm to notify staff Resident #1 had left his/her room, and staff should constantly monitor him/her when out of his/her room. On 5/17/16 at 10:00 AM, Nurse F verified on 5/11/16, he/she was doing bed checks, and noted Resident #1 in Resident #2's room. Resident #1 stood next to Resident #2's bed, with no clothes on, and they were rubbing each other's genitals. Nurse F stated he/she asked Resident #1 where his/her room was, and he/she became upset. Nurse F stated staff try to know where the residents are, and staff do bed checks to prevent future occurrences. Nurse F verified he/she does not know how often the nurse aide does bed checks but he/she walked through at least hourly. On 5/17/16 at 12:45 PM, Nurse Aide D verified staff would find Resident #1 undressing in other resident rooms, and it was best for staff to keep a close eye on him/her, especially if he/she went into another resident's room. Nurse Aide D stated staff would keep Resident #1 occupied to keep him/her from wandering. Nurse Aide D further verified staff had to prevent Resident #1 and Resident #3 from being with each other, and not allow the residents to wander in the halls together, or sit by one another. On 5/17/16 at 12:53 PM, Nurse Aide C verified on 5/11/16 he/she was at the computer at the nurse's station, training a new employee. Nurse Aide C stated Resident #1 was up wandering and had went back to his/her room. Nurse Aide C verified it had been about 15 minutes after Resident #1 was seen going to his/her room when the nurse found him/her in Resident #2's room. Nurse Aide C verified he/she did not see Resident #1 leave his/her room. Nurse Aide C verified staff generally walk up and down the halls every 15 to 20 minutes on the night shift, and generally Resident #1 is asleep. Nurse Aide C stated when Resident #1 does come out of his/her room at night, staff will redirect him/her or offer him/her to come into the living room with staff supervision. On 5/17/16 at 1:20 PM, Nurse E stated Resident #1 had poor boundaries, thought some the residents of the opposite gender were former spouses, and would treat them as such. Nurse E stated Resident #1 had been more confused recently, and would go into Resident #2's room, confused why a mechanical lift was in the room. Nurse E verified Resident #1 and Resident #3 had a time period where they would hold hands, Resident #1 would get Resident #3 ice cream or sugar, and would want to sit by him/her. Nurse E stated Resident #3 participated at first, but staff would remind both residents Resident #3's spouse would not appreciate that type of affection. Nurse E further stated residents do have delusions and get attached to people, but they immediately redirect, keep them apart, and find them separate activities to do. Nurse E stated staff do not allow the bedroom doors shut, so when there is a door shut staff know to investigate. Nurse E stated staff generally know where the residents are, but if Resident #1 disappears staff look for him/her. On 5/17/16 at 1:56 PM, Medication Aide D verified Resident #1 will get up and wander, and voice concerns over a previous spouse. Medication Aide D stated residents are generally checked at least every 15 minutes on the night shift, and there is generally only 1 staff at night in the special care unit. Medication Aide D verified a sensor had been placed in Resident #1's room to alert staff if Resident #1 left his/her room. Medication Aide D verified he/she is not always able to get to alarms right away when they go off if he/she is providing care to another resident, he/she would have to finish cares, and make sure the current resident was safe to leave. Medication Aide D verified he/she had seen Resident #1 hold hands with Resident #3 months ago when he/she came into the unit for training. On 3/17/16 at 2:50 PM, Nurse Aide H verified he/she had witnessed Resident #1 hold hands and flirt with residents of the opposite gender. Nurse Aide H stated he/she will lead Resident #1 or the other resident away to redirect. Nurse Aide H verified after the incident with Resident #3, staff did not monitor Resident #1 as much because staff did not have a reason to, but after the incident with Resident #2, staff monitor Resident #1 more often. On 5/17/16 at 3:00 PM, Administrative Nurse J verified the incident on 8/28/15 when Resident #1 and Resident #3 were observed kissing was not reported. Administrative Nurse J stated the facility reviewed the incident and did not feel it needed to be reported. On 5/17/16 at 3:24 PM, Nurse I verified he/she had observed Resident #1 hold hands and rub shoulders of residents of the opposite gender. Nurse I verified staff observe the residents when they are holding hands, and make sure they do not go into the rooms. Nurse I stated if the resident of the opposite gender is comfortable with the attention then staff allow it, and staff would monitor to make sure it does not go any further. Nurse I stated staff visualize the residents at least every 30 minutes, and if staff have not seen a resident for 30 minutes then staff look for them. The facility's 9/2013 Abuse and Neglect policy directed staff any alleged or suspected violations that involved mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the administrator and to the other officials in accordance with state law, including the state survey and certification agency. The policy directed staff to intervene in any situation in order to protect the residents, and remove any individual from the facility if necessary for the protection of residents or staff, including but not limited to employees, visitors, contractors or family members. The policy further directed staff to have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in process. The facility's 10/2015 Abuse and Neglect policy instructs staff to identify, correct and intervene in situations in which abuse and or neglect is more likely to occur. The policy directed staff to deploy staff on each shift in sufficient numbers to meet the needs of the residents, and assure staff members assigned have knowledge of the individual residents care needs. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to a conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering residents rooms, residents with self injurious behaviors, residents with communication disorders, those that require heavy nursing care and or are totally dependent on staff. The policy directed staff to investigate the different types of incidents, identify the staff responsible for the initial reporting, and investigate alleged violations and reporting of results to the proper authorities. The policy further directed staff to protect residents from harm during an investigation, report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility failed to protect the residents of the opposite gender from Resident #1, provide adequate supervision for Resident #1 who displayed behaviors of inappropriate touching in a sexual manner to Resident #2 and Resident #3, and failed to protect the 4 residents of the opposite gender in the special care unit. The deficient practice placed the 4 residents of the opposite gender in immediate jeopardy. The facility failed to report an incident on 8/28/15 to the state agency. The facility abated the immediate jeopardy on 5/18/16 after completion of training of all staff regarding the protection of residents after inappropriate touching in a sexual manner by a resident, implementation of 1 to 1 as needed, and following the behavioral protocol developed on 5/17/16. The training also included importance of following the abuse, neglect and exploitation policy, reporting, and protection of the residents. The facility also provided 1 to 1 staff supervision of Resident #1, and evaluation and treatment in a behavioral health facility. The deficient practice remains at the scope and severity of an E.

The facility had a census of 66 residents. The sample included 6 residents, with 3 residents reviewed for falls/accidents. Based on observation, interview, and record review, the facility failed to ensure 2 of the 3 residents reviewed for accidents received adequate supervision and assistive devices to prevent accidents when staff failed to use fall prevention devices as directed by the care plan for resident #6. The resident fell and sustained an injury (laceration) which required sutures. The facility also failed to assess for causative factors of two fall and then implement appropriate interventions to prevent additional falls for resident #11. Findings included: - Resident #6's electronic record listed multiple diagnoses, including macular degeneration (progressive deterioration of the retina), and dementia (progressive mental disorder characterized by failing memory, confusion). Resident #6's 2/7/14 Admission MDS (Minimum Data Set) assessment reported he/she usually understood others, made him/herself understood, and had moderately impaired cognition. He/she needed limited assistance of one staff to transfer and toilet. The resident had balance issues between transitions and walking, had no limitation in range of motion, and used a walker. He/she experienced occasional urinary incontinence and staff placed the resident on a toileting plan. The resident experienced falls within one month and within 2-6 months prior to admission and he/she fell on ce without injury after admission. Resident #6's 2/13/14 Falls CAA (Care Area Assessment) summary reported the resident presented as a fall risk due to falls at home, had slipped out of bed after admission, and fell at home prior to admission. The resident had cardiovascular disease, arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement), and experienced a TIA (transient ischemic attack, or episode of cerebrovascular insufficiency) in the recent past that may have contributed to the fall at home. A 1/13/14 "Fall Risk Data Collection" documentation reported the resident posed a medium risk for fall on admission. On 4/18/14, staff updated the form and documented the resident posed as a high risk for falls. Resident #6's 2/17/14 care plan informed staff the resident presented as a fall risk due to experiencing urinary incontinence, unsteady gait, and decreased vision from macular degeneration. The care plan instructed staff to assist the resident with 1-2 staff during transfers. On 4/4/14, staff updated the care plan to include use of non-slip gripper socks and placed a pressure alarm to the resident's bed and chair. Staff revised the care plan on 4/18/14 to place a fall mat by the resident's bed. On 4/24/14, staff updated the care plan to ensure the resident's alarm functioned every shift, especially when the resident sat in his/her bed and chair in his/her room. Staff revised the care plan on 4/28/14 to assist the resident with one staff to toilet and re-evaluated the bowel and bladder to toilet the resident every 3 hours or sooner when awake, especially between 9:00 p.m. and 10:00 p.m. On 5/13/14, staff updated the care plan to prompt and assist the resident to toilet every 2 to 3 hours to help decrease incontinence during the day and awaken/prompt to toilet twice during the night. A 2/7/14 incident report documented that staff found the resident on the floor of his/her room laying on his/her right side at 7:45 a.m. Staff documented the resident did not wear gripper socks, assessed the resident, and found that the resident did not have any injuries. The nurse placed non-slip socks on the resident, notified the physician and family of the incident, and reviewed/revised the care plan as mentioned above. A 4/3/14 incident report documented that staff found the resident laying on the floor of his/her room laying on his/her right side. Staff documented the resident's mouth bled, he/she presented as confused, and experienced urinary incontinence. The resident reported pain in the right arm, had a weakened right hand grip, and documented that the resident's walker was not near the resident. A wet floor sign sat in front of the resident's bathroom and staff noted the floor as dry at time he/she found the resident. Staff notified the resident's physician who ordered to send the resident to the local emergency room where the resident received treatment for [REDACTED]. Documentation lacked evidence that the resident wore or did not wear proper footwear, such as non-slip socks or sturdy shoes, at the time of the incident. After evaluating the causal factors of the fall, staff reviewed/revised the care plan as mentioned above. A 4/18/14 incident report revealed staff found the resident on the floor lying in a pool of blood at 2:31 a.m. Staff documented that staff held pressure to a laceration above the resident ' s right eyebrow. Staff documented " the alarm did not sound because it was not turned on " and notified the physician and family of the incident. The physician ordered to send the resident to the emergency to treat the laceration to the right eyebrow. The 4/18/14 emergency room record revealed staff sutured resident #6 ' s 2 inch right eyebrow laceration that resulted from a fall at the facility. During an observation on 5/13/14 at 11:21 a.m., resident #6 sat in his/her room chair while wearing non-slip socks on his/her feet and had a call light within reach. The resident presented with a long, pink scar above his/her right eyebrow. A floor mat rested under the resident ' s feet. The resident had no pressure alarm under him/her. At 11:33 a.m., direct care staff D came into resident #6 ' s room, prompted/assisted the resident to stand with use of a gait belt, and assisted the resident to the dining room while the resident used a walker. During an observation on 5/13/14 at 1:43 p.m., resident #6 laid in bed with pressure alarm pad under him/her and a light on the alarm box indicated the alarm functioned. His/her bed presented in the lowest position, a call light presented as within the resident ' s reach, and a fall mat rested on the floor in front of the bed. During an observation on 5/13/14 at 3:36 p.m., resident #6 wore non-slip socks and walked with a walker next to a family member. Licensed nursing staff E followed the resident and family member into resident #6 ' s room and assisted the resident to the bathroom. At 3:39 p.m., Staff E assisted the resident to his/her chair, the resident sat on a pressure pad alarm, and a fall mat sat on the floor in front of the resident ' s chair. Staff E ensured the alarm functioned and placed a call light within the resident ' s reach. During an interview on 5/13/14 at 11:37 a.m., direct care staff D reported that resident #6 fell several times in the recent past and interventions to prevent further falls included a floor mat and an alarm on his/her bed. Staff D reported that the resident did not need an alarm on the chair any longer because the resident usually used the call light prior to needing help. During an interview on 5/13/14 at 4:37 p.m., direct care staff K reported resident #6 fell recently and cut his/her head as a result of the fall. Staff K reported interventions staff used to prevent falls included utilizing a pressure alarm in the resident ' s bed, in the chair in his/her room, and in the chair in the lobby area when not attended by staff. Staff K also reported that staff ensured the resident wore non-slip socks and placed a fall mat on the floor of his/her room. During an interview on 5/14/14 at 11:40 a.m., licensed nursing staff C reported resident #6 presented as a fall risk and staff used interventions to prevent falls including use of a pressure alarm to the resident ' s chair and bed. Staff C verified that staff failed to follow the care planned interventions to use the pressure alarm when the resident cut his/her head that resulted from a fall on 4/18/14. Staff C also verified that staff failed to follow the care plan on 5/13/14 when staff failed to place a pressure alarm under the resident while he/she sat in a chair. During an interview on 5/19/14 at 9:58 a.m., Physician L reported resident #6 posed a high risk for falls and staff implemented interventions such as alarms to prevent further falls. He/she reported the resident fell several times, one of which the resident cut his/her forehead and needed sutures. The facility's "Alarms: Bed, Chair, and Door" policy, last revised in October 2008, instructed "each shift of nursing staff will be responsible for visually checking placement of alarms". The facility's "Prevention and Management of Falls Practice Guidelines" policy, last revised in April 2011, instructed staff to evaluate each resident for risk of falls and implement preventive strategies, such as monitor the resident ' s environment, to prevent falls. The facility failed to ensure resident #6 received adequate supervision and assistive devices to prevent accidents when staff failed to use pressure alarms during an observation as care planned. On 4/18/14, staff also failed to use a pressure alarm as care planned and the resident needed sutures for a laceration as a result of a fall. - Resident #11 ' s electronic record indicated the resident had multiple diagnoses, including dementia (progressive mental disorder characterized by failing memory, confusion). Resident #11 ' s 2/28/14 Quarterly MDS (Minimum Data Set) Assessment reported the resident had short/long term memory problems with moderately impaired decision making skills and presented with fluctuating inattention/continuous disorganized thinking. He/she needed supervision of one staff for transfers and limited assistance of one staff for toilet use. The resident had balance issues and could stabilize without assistance of staff. He/she experienced frequent bladder and bowel incontinence and staff placed the resident on a toileting plan. The resident had one fall with minor injury since the last assessment period. Resident #11 ' s 12/9/13 Fall CAA (Care Area Assessment) summary reported the resident posed as a risk for falls due to incontinence, decreased vision, and a [DIAGNOSES REDACTED]. On 12/24/13, staff documented on a " Fall Data Collection " form that the resident presented as high risk for falls. On 4/14/14 and 4/15/14, staff revised the form and documented the resident posed as a medium risk for falls. Resident #11 ' s 12/3/13 care plan, revised on 2/27/14, instructed staff that the resident posed as a risk for falls due to dementia and blindness in his/her right eye. Interventions included to provide assistance with transfers and mobility as needed. The care plan listed the resident ' s toileting plan as one staff to assist with toileting every 2 to 3 hours around the clock and to take the resident to the toilet between 11:30 p.m. and 12:00 a.m. to help prevent falls. Interventions to prevent falls also included assisting the resident with putting on socks and shoes prior to ambulating and to place his/her bed in the lowest position. On 3/5/14, staff revised the resident care plan to include a " sing-song " floor mat alarm by the resident ' s bed to alert the staff when the resident got out of bed. Staff revised the resident ' s care plan on 4/11/14 to monitor the resident closely when ambulating due to impaired cognition and visual impairment. A 4/14/14 incident report revealed staff witnessed resident #11 stand from a chair, lose his/her balance, and fall to the floor at 3:57 p.m. Staff witnessed the resident immediately stand up and walk without difficulty independently. Staff assessed the resident, found no injuries, and notified the resident ' s physician/family of the incident. Review of the clinical record lacked evidence that staff assessed the cause of the fall and then developed/implemented appropriate interventions to prevent additional falls. A 4/15/14 incident report revealed at 2:45 p.m., staff visualized resident #11 walk into a semi-private room, heard a sound, and saw the resident lying on the floor next to his/her roommates bed. Staff alerted the charge nurse and the resident stood up independently without waiting for an assessment from the nurse. The charge nurse assessed the resident and found a bump/swelling to the right leg below the knee without a break in the skin. The resident indicated the area had pain and moved all limbs without difficulty. Staff placed an ice pack to affected area and notified the resident ' s physician/family. Review of the clinical record lacked evidence that staff assessed the cause of the fall and then developed/implemented appropriate interventions to prevent additional falls. Review of nurses ' notes throughout the day on 4/16/14 revealed staff followed the physician's order [REDACTED]. During an observation on 5/15/14 at 7:56 a.m., resident #11 laid in his/her bed with his/her eyes closed while wearing non-slip socks and a floor mat pressure alarm rested on the floor next to the bed. During an observation on 5/15/14 at 9:25 a.m., direct care staff D checked on resident #11 and found the resident awake in bed. After assisting the resident to dress and groom, Staff D held the resident ' s hand while they walked together to the dining area. Resident #11 had no right eye and walked with a steady gait while he/she wore sturdy shoes. During an interview on 5/15/14 at 10:24 a.m., licensed nursing staff I reported that resident #11 presented as a risk for falls and experienced two falls with no serious injury in April 2014. Staff I verified the facility failed to implement new interventions to prevent further falls when the resident fell on [DATE] and 4/15/14. The facility ' s " Prevention and Management of Falls Practice Guidelines " policy, last revised in April 2011, instructed staff to evaluate each resident for risk of falls and implement preventive strategies, such as monitor the resident ' s environment, to prevent falls. The facility failed to ensure resident #11 received adequate supervision and assistive devices to prevent accidents when staff failed to assess the cause of the falls on 4/14/14 and 4/15/14 and then develop/implement appropriate interventions to prevent additional falls.

The facility had a census of 69 residents, with 5 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 2 of 5 sampled residents with the necessary care and services (thorough and timely nursing assessments after a significant change in each residents' physical condition, appropriate treatment of [REDACTED]. Both residents' conditions deteriorated and the residents subsequently required hospitalization . (Residents #1, #2) Findings included: - Record review for resident #1 included physician's orders [REDACTED]. An [DATE] Quarterly MDS (Minimum Data Set) identified resident #1 with moderate cognitive impairment, the ability to understand and to make his/her self-understood, no wandering behaviors, independence with bed mobility, transfers and walking, unsteady balance but with the ability to stabilize without staff assistance, use of a walker and/or wheelchair, no recent falls, and on oxygen therapy. CAAS (Care Area Assessment Summaries) completed after the [DATE] Annual MDS lacked evidence of further assessments/analysis of findings related to ADLs (activities of daily living) and Falls. Resident #1's [DATE] care plan included the following interventions related to monitoring of medical symptoms and reporting to the physician: o "Monitor/document changes in lung sounds, [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues)....may get order for something to make (him/her) more comfortable" ([DATE] intervention) o "Monitor for signs/symptoms of respiratory distress.....encourage use of O2 (oxygen) continuous and assist as needed" ([DATE] intervention) o "Resident has oxygen therapy related to [DIAGNOSES REDACTED]. Monitor for signs/symptoms of respiratory distress and report to health care provider PRN (as needed) respirations, pulse oximetry, increased heart rate, restlessness, headaches, skin color....." Nurses Notes for resident #1 included the following: o [DATE] at 6:24 a.m.: Described resident #1's fall in another resident's room. At the time of this entry, staff documented a temperature of 99.2 degrees F (Fahrenheit), a pulse rate of 106, a blood pressure of ,[DATE] and oxygen saturation level of 71%. The clinical record included no evidence of physician notification of the resident's increased body temperature, elevated pulse rate, low blood pressure and/or decreased oxygen saturation levels. According to the National Institutes of Health website "nih.gov", normal vital signs ranges include: o Blood pressure ranges from ,[DATE] to ,[DATE] o Respiratory rates range from ,[DATE] breaths per minute o Pulse rate ranges from 60 - 100 beats per minute o Temperature ranges from 97.8 to 99.1 degrees Fahrenheit o Oxygen saturation rates range from 95 - 100%, with anything less than 88% considered "dangerous" Additional Nurses Notes included: o [DATE] at 10:11 p.m.: Described resident #1's second fall of the day when staff found the resident kneeling on the floor near his/her bed. Although the entry indicated staff monitored the resident's vital signs at the time of the fall, the clinical record included no evidence of such monitoring. o [DATE] at 10:01 p.m.: Described resident #1's fever of 102 degrees F at 3:35 p.m., critical lab values and physician's orders [REDACTED]. According to the note, the physician admitted resident #1 to the hospital with [DIAGNOSES REDACTED]. Review of the clinical record revealed no evidence of thorough nursing assessments in the 56 hour time period between [DATE] at 6:24 a.m. when staff assessed the resident and found him/her to have significantly abnormal vital signs, and [DATE] at 3:35 p.m. when the physician ordered the resident transferred to the emergency room . Review of vital sign documentation from [DATE] at 6:00 a.m. to [DATE] at 3:35 p.m. revealed the following: o Temperatures: Staff monitored resident #1's temperatures 17 times during the 56 hour time period. Eight of the temperatures recorded were 100 degrees F or higher , ranging from 100 degrees to 102 degrees. Of the eight temperatures of 100 degrees or higher, 4 were "axillary" (armpit) temperatures which range from 0.5 to 1 degree lower than oral temperatures. o Pulse rate: Staff monitored resident #1's pulse rate 21 times during the 56 hour time period. Four of the 21 pulses recorded were in excess of 100 beats per minutes, ranging from ,[DATE]. o Respiratory rate: Staff monitored resident #1's respiratory rate 21 times during the 56 hour time period. Twenty of the respiratory rates were in excess of normal ranges of ,[DATE] breaths per minute, ranging from 20 - 26. o Blood pressure: Staff monitored resident #1's blood pressure 17 times during the 56 hour time period. The vital sign documentation did not include the blood pressure of ,[DATE] recorded in the nurse ' s notes on [DATE] at 6:24 a.m.. All blood pressures recorded in the vital signs documentation were within normal ranges during the time period. o Oxygen saturation rates: Staff monitored resident #1's oxygen saturation levels 20 times during the 56 hour time period. Eight of the oxygen levels were done on "room air" (not monitored while resident received supplemental oxygen) and ranged from 71 - 96%. Twelve saturation levels taken while the resident was on supplemental oxygen ranged from 90 - 96%, with eight of the twelve readings less than 95%. Review of the clinical record revealed no evidence staff notified resident #1's physician of the previously listed abnormal vital signs and oxygen saturation levels with the exception of the [DATE] abnormalities identified at 6: 24 a.m. which they faxed the physician about even though it was a Saturday and the physician would not be expected to see the information until Monday. Faxed communication to the physician's office on Saturday and Sunday, February 8th and 9th, 2014 included: o [DATE] (Saturday) at 6:45 a.m.: Described resident #1's non injury fall in another resident's room and listed vital signs as 99.2 (temperature) - 106 (pulse rate) - 20 (respiratory rate) - ,[DATE] (blood pressure) O2 (oxygen) saturation on room air 71%. o [DATE] (Saturday) at 4:50 p.m.: Described a second fall in which staff found the resident kneeling on the floor beside his/her bed. Staff recorded vital signs as blood pressure ,[DATE], pulse 80, respirations 20, temperature 98.6 degrees Fahrenheit, oxygen saturation levels of 94%. o [DATE] (Sunday) at 12:40 p.m.: Described a third falls in which staff found resident #1 on the floor in the doorway of the restroom in a confused state. Staff recorded an axillary (arm pit) temperature of 100 to 100.9 degrees Fahrenheit and requested an order for [REDACTED]. Review of resident #1's medication orders revealed no specific medications ordered for treatment of [REDACTED]. The orders included a [DATE] order for [MEDICATION NAME]/[MEDICATION NAME] ,[DATE] mg (milligrams) every 6 hours as needed for generalized pain. [MEDICATION NAME] could be used to lower body temperature. Review of the February 2014 MARs (medication administration records) revealed staff did not administer the [MEDICATION NAME]/[MEDICATION NAME] medication in the February 8th - February 10th, 2014 time period. Resident #1's Narcotic Record documented staff administered [MEDICATION NAME]/[MEDICATION NAME] 5 - 325 four times in the time period from February 8th - February 10th, 2014, although the MAR indicated [REDACTED]. According to the [DATE] "emergency room Note" from the local hospital, the physician noted "moderate respiratory distress" at the time of arrival at the hospital. The physician admitted the resident to the hospital with [DIAGNOSES REDACTED]. During observations on [DATE] at 8:30 a.m. and 11:15 a.m., resident #1 slept on his/her bed with the head of the bed raised as high as possible. The resident used continuous supplemental oxygen. During an interview on [DATE] at 12:30 p.m., Licensed Nurse B reported he/she worked the day shift on [DATE] and [DATE] and had the responsibility for providing care to resident #1. According to Nurse B, the resident had low oxygen saturation levels early in the shift on [DATE], but the levels returned to normal upon placing oxygen on the resident. The resident also had a fever but lacked a physician's orders [REDACTED]. Nurse B reported resident #1 asked for medication for pain every morning anyway, so he/she decided to administer that medication to the resident because it contained [MEDICATION NAME] which would help lower the fever. Additionally, Nurse B reported he/she believed resident #1 was "stable" and therefore the faxes to the physician were appropriate even though the physician would not see them until Monday. During an interview on [DATE] at 2:35 p.m., Administrative Nurse A reported the facility did not have specific parameters in place which guided nurses on when to notify the physician of abnormal vital signs and oxygen saturation levels, and nurses should use "good nursing judgment" of what needed to be reported. Upon review of resident #1's clinical record, Nurse A reported staff should not have taken axillary temperatures due to inaccuracy, and staff should have notified resident #1's physician of the oxygen saturation level of 76% rather than sending a fax. According to Nurse A, staff should also have called the physician to notify him/her of the fever and get orders for appropriate medications to treat the fever. Although requested, Administrative Nurse A could not provide evidence of timely and thorough nursing assessments in the 56 hour time period between [DATE] at 6:34 a.m. when staff first documented abnormal vital signs and oxygen saturation levels and [DATE] at 3:35 p.m. when the resident went to the emergency room . During an interview on [DATE] at 10:30 a.m., Physician C, resident #1's primary care physician, stated he/she expected staff to notify him/her of changes in the resident's physical condition via telephone call rather than fax on the weekend. Physician C further reported the facility knew to call the "on call" physician on weekends. According to Physician C, resident #1 experienced a significant and severe decline in his/her medical condition, particularly respiratory status, over the weekend of [DATE] and [DATE] due to staff failure to obtain/provide adequate treatment, and that decline resulted in the resident's admission to the hospital on [DATE]. According to the facility's "Notification of Change in Resident Status" policy dated [DATE] with a revision date of February 2005, "The center will IMMEDIATELY inform the resident, if appropriate, and consult with the resident's physician......in the following cases:......significant change in the resident's physical, mental or psychosocial status." The facility failed to provide resident #1 with the necessary care and services (thorough and timely nursing assessments of significant changes in the residents' physical condition, appropriate treatment of [REDACTED]. Due to lack of assessment and treatment, the resident experienced significant declines in his/her condition which necessitated hospitalization . - Resident #2's clinical record included signed physician's orders [REDACTED].#2 with multiple medical diagnoses, including [MEDICAL CONDITION] (a condition when the heart output is low and the body becomes congested with fluid), and shortness of breath. A [DATE] Medicare 5 day MDS (Minimum Data Set) identified resident #2 with mild cognitive impairment. CAAS (Care Area Assessment Summaries) completed after the [DATE] Admission MDS lacked additional assessments/analysis of findings relevant to this deficient practice. Resident #2's undated care plan included the following interventions as related to monitoring of medical symptoms and reporting to the physician: o ([DATE])" Monitor/document/report to health care provider as needed ......SOB (shortness of breath) upon exertion, weakness, crackles and wheezes upon auscultation of the lungs, fatigue, lethargy" o ([DATE]) "Monitor for signs/symptoms of respiratory distress and report to health care provider as needed: increased respirations, decreased pulse oximetry, increased heart rate, restlessness.....cough, accessory muscle usage" Nurses Notes included: o [DATE] at 9:56 a.m. described resident #2's "moist cough" and use or [MEDICATION NAME] cough medicine for treatment of [REDACTED]. o [DATE] at 11:44 a.m. described effectiveness of the [MEDICATION NAME] in suppressing resident #2's cough and noted the physician planned to see the resident in the afternoon hours that day. The clinical record lacked physician's progress notes/documentation of the physician's visit on [DATE]. Additional Nurses Notes documented administration of as needed oral cough medicine and/or nebulizer breathing treatments on [DATE] at 8:30 p.m., [DATE] at 4:06 p.m., [DATE] at 5:50 a.m., [DATE] at 9:17 a.m., [DATE] at 12:49 p.m., [DATE] at 8:00 a.m. , 10:10 a.m., 12:26 p.m. and 9:00 p.m., [DATE] at 9:17 a.m., 5:09 p.m. and 9:35 p.m.. Documentation in the Nurses Notes on [DATE] at 9:35 p.m. noted physician notification of resident #2's condition and subsequent physician orders [REDACTED]. The clinical record revealed no evidence of timely and thorough nursing assessments of resident #2's physical condition, including assessment of respiratory status, in the 107 hour time period from [DATE] at 9:56 a.m. to [DATE] at 9:35 p.m. when staff notified the physician. According to the Nurses Notes dated [DATE] at 5:30 a.m., resident #2 had a fever of 100.9 degrees F and the nurse faxed the physician even though the clinic would not be open at that time of the morning. On [DATE] at 9:30 a.m., 10:06 a.m., and 12:24 p.m., licensed nurses documented resident #2's "coughing and wheezing" as well as lack of response to [MEDICATION NAME] cough medicine and nebulizer breathing treatments. On [DATE] at 2:40 p.m., the nurse wrote, "Resident had been requesting to be hospitalized .....". Resident #2's primary care physician subsequently ordered transfer to the emergency room for evaluation and treatment. A [DATE] transfer sheet sent with resident #2 at the time of transfer from the facility to the emergency room noted the presence of "coarse lung sounds, green plem (sic), crackles and sharp cough." Review of the clinical record revealed no other documentation related to the presence of green phlegm (respiratory secretions) and undesired lung sounds. The clinical record lacked documentation related to the presence of "green phlegm" production in the hours/days prior to resident #2's admission to the hospital on [DATE]. A [DATE] Nurses Note described the resident's admission to the hospital at 3:00 p.m. with a [DIAGNOSES REDACTED]. Documentation from the emergency room dated [DATE] noted the presence of "constant, moderate to severe cough" that started one week previously and worsened that day. The [DATE] "Admission History and Physical" from the hospital documented the presence of a cough with greenish colored sputum and problems breathing for one week. According to the document, the resident reported the illness started off as a cough which developed into increased production of phlegm and progressed to dyspnea (uncomfortable breathing). A hospital "Discharge Summary" dated [DATE] noted multiple discharge diagnoses, including "sepsis - resolved" and "acute [MEDICAL CONDITION] versus atypical pneumonia." During an observation on [DATE] at 1:25 p.m., resident #2 sat on the edge of his/her bed and ate lunch. The resident was alert and oriented and able to communicate effectively. The resident had no respiratory issues at the time of the observation. During an interview on [DATE] at 12:30 p.m., Licensed Nurse B reported the facility does not have specific parameters to follow as related to physician notification of changes in a resident's medical condition. According to Nurse B, staff typically fax the physician to notify of changes unless the changes are serious enough to be considered an emergency. Nurse B recalled that resident #2 developed a cough that worsened over time and eventually required hospitalization . During an interview on [DATE] at 2:35 p.m., Administrative Nurse A reported nurses should use "good nursing judgement" when deciding if they need to notify a physician directly or if a faxed notification would be adequate. Nurse A denied specific knowledge of resident #2's illness prior to hospitalization other than to note he/she "was sick for a long time." Although requested, Nurse A could not provide evidence of timely, thorough nursing assessments of resident #2's physical condition, particularly respiratory condition, in the 6 day time period prior to transfer to the hospital with "coarse lung sounds, green phlem (sic), crackles/sharp cough." During an interview on [DATE] at 1:25 p.m., resident #2 confirmed he/she required recent admission to the hospital for treatment of [REDACTED]." According to the resident, "I kept getting sicker and sicker. They were giving me medicine but I finally told them to take me to the emergency room .....I really feel like they neglected me here. I don't know what would have happened if I wouldn't have insisted on going to the hospital. I really think I would have died here. I was coughing up a lot of green stuff and couldn't breathe. I knew I was sick, real sick.....". According to the facility's "Notification of Change in Resident Status" policy dated [DATE] with a revision date of February 2005, "The center will IMMEDIATELY inform the resident, if appropriate, and consult with the resident's physician......in the following cases:......significant change in the resident's physical, mental or psychosocial status." Two attempts to contact resident #2 ' s primary care physician and/or mid-level practitioner were unsuccessful on [DATE]. The facility failed to provide resident #2 with the necessary care and services (thorough and timely nursing assessments of significant changes in the residents' physical condition, appropriate treatment of [REDACTED]. The resident's condition deteriorated and the resident subsequently required hospitalization .

The facility had a census of 70 residents with 23 residents selected for sample and 3 residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide 2 of 3 sampled residents with the necessary treatment to prevent the development of pressure ulcers. (#26 and #36) After admission to the facility on [DATE], resident #26 developed a facility acquired unstageable pressure ulcer on the right great toe on 4/26/13 that healed on 6/12/13, then developed again on the right great toe on 7/31/13 as an unstageable pressure ulcer. Resident #36 developed 2 unstageable pressure ulcers, one on each heel. The facility identified the resident as at risk for pressure ulcer development and failed to place appropriate interventions to prevent pressure ulcers from developing on the resident's heels. The facility also failed to provide resident #36 with a timely change of position, as care planned. Findings included: - Resident #26's physician's orders [REDACTED]. Resident # 26's 7/17/13 significant change MDS (Minimum Data Set) assessment reported the resident had severely impaired cognition and required extensive assistance of 2 persons for bed mobility and toileting. The assessment identified the resident as " at risk " for pressure ulcer development and had no unhealed pressure ulcers or foot problems at the time of the assessment. The assessment also stated the resident used pressure reducing devices for the chair/bed and was on a repositioning program. The resident was not on a nutrition/hydration program to manage skin problems. Resident #26's 7/17/13 CAA (Care Area Assessment) summary related to pressure ulcers reported the resident had dementia with overall deterioration in activities of daily living. The CAA further revealed the resident had significant weight loss last month and in 6 months. According to the summary, the resident had no pressure ulcers or skin breakdown, but was at risk due to poor nutrition and weight loss. Resident #26's most recent care plan dated 7/25/13 instructed staff to assist with position changes every 2 hours as needed and a cushion should be placed in the wheelchair when resident was up. The care plan directed staff to monitor the resident's skin during his/her shower per protocol. The care plan instructed staff to use gripper socks or new shoes. Changes to the care plan on 7/31/13 directed staff to use gripper socks only. Resident #26's admission data sheet dated 4/10/13 revealed the resident had intact skin on admission to the facility. Resident #26's Braden Scores on 4/17/13 and 7/19/13 revealed a mild risk for development of pressure sores. The "Wound Flow Sheet" described the area on the right great toe on 5/8/13 that measured 0.25 cm (centimeters) by 0.25 cm with a scab present. The "Wound Flow Sheet" form had weekly documentation from 5/8/13 - 6/12/13 related to an unstageable pressure ulcer on the right great toe described as a "scabbed area". On 6/12/13, the wound record revealed the area healed. A "Wound Flow Sheet" dated 7/31/13 reported the resident had an unstageable area on the right great toe that measured 1.0 cm by 1.0 cm with a scabbed area present. Although requested, the facility could not provide evidence of skin assessments completed between 6/12/13 after the wound healed and 7/31/13 when a new ulcer developed, a time period of more than 7 weeks. Review of resident #26's physician orders [REDACTED]. The physician ordered "Copa" , a type of foam dressing. On 5/6/13 the physician ordered the dressing to be changed to normal saline with triple antibiotic ointment covered with a Band-Aid. The physician ordered Keflex on 5/7/13 for [MEDICAL CONDITION] (skin infection caused by bacteria that is characterized by heat, redness, and swelling) and re-ordered [MEDICATION NAME] dressing. The physician then ordered a consult with a podiatrist on 5/10/13. The resident saw the podiatrist on 5/22/13 and he/she ordered [MEDICATION NAME] cream (antibiotic) to the toe. A physician's orders [REDACTED]. Review of resident #26 ' s dietician notes revealed documentation from 4/30/13 until 7/22/13 with identification of the resident as at risk for skin breakdown and at risk for dehydration. Dietician notes on 4/30/13 and 6/17/13 lacked mention of resident #26 ' s wound on the right great toe. During an observation on 7/31/13 at 11:00 a.m. resident #26 wore shoes and socks. Licensed nurse Y removed the shoe and sock from the right foot and revealed a red raised scabbed area to the right great toe. After an assessment by licensed nurse Y, he/she replaced the sock and shoe to the right foot. During an observation on 8/1/13 at 1:00 p.m. licensed nurse X changed the dressing to resident #26's right great toe. Licensed nurse X placed a bunion pad, as ordered by the physician to relieve pressure to the scabbed/reddened area on the toe. During an interview on 7/30/13 at 4:30 p.m., direct care staff AA reported he/she noticed changes in the resident ' s toe about a month ago and stated he/she reported this to the charge nurse. An interview on 7/31/13 at 11:15 a.m. with direct care staff P revealed he/she noticed the red area on the resident ' s toe that morning but did not notify the charge nurse because he/she thought the charge nurse knew of the sore toe. During an interview on 8/1/13 at 8:40 a.m., licensed nurse X stated resident #26 should not have shoes on. At 10:55 a.m. licensed nurse X further stated he/she could not find any record of weekly skin assessments for resident #26 in the time period from 6/12/13 to 7/31/13. An interview on 7/31/13 at 11:10 a.m. with administrative nurse B revealed he/she was unaware of the area on resident #26's toe. He/she further added the resident had a "hammer toe" diagnosed on [DATE] and staff should use gripper socks instead of shoes so there would be no pressure on the toe. Nurse B verified the resident currently wore shoes rather than the gripper socks. An interview with the consultant dietician HH on 8/5/13 at 9:30 a.m. revealed that he/she made rounds, staff provided the wound record and skin assessment sheets for review. He/she did not recall any wound documentation for resident #26 and stated if he/she was aware of the wound, it would be documented in the dietician ' s notes. During an interview on 8/7/13 at 10:49 a.m., nurse practitioner KK confirmed resident #26 was "at risk" for pressure ulcer development and stated the resident's previous shoes caused the pressure area on the resident's toe and he/she stated the resident's family provided new shoes to prevent pressure to the area. The facility's March 2007 Pressure Ulcer policy related to skin assessments stated, "Residents at risk for pressure ulcer development should be monitored daily for changes in skin condition. Any abnormal finding/changes should be documented ...and report to the licensed nurse assigned to the resident for assessment and follow up. Weekly skin checks are recommended to be performed on all residents, but especially those identified as " at risk " ." The facility failed to provide resident #26 with the necessary treatment to prevent the development of pressure ulcers when staff failed to complete skin assessments as directed by facility policy and as directed by the care plan. The resident developed an unstageable pressure ulcer which healed on 6/12/13. The resident then developed an additional unstageable pressure ulcer on 7/31/13 on the same right great toe. - Resident #36's 7/7/13 physician's orders [REDACTED]. Resident #36's 4/23/13 Quarterly MDS (Minimum Data Set) reported the resident experienced short and long term memory problems with severely impaired decision making skills and continuous inattention. The resident needed extensive assistance of 2 staff for bed mobility, transfer, and toileting, and experienced limited range of motion in both sides of his/her upper and lower extremities. The MDS reported the resident presented as high risk for impaired skin integrity with no skin breakdown during the observation period. Interventions to prevent breakdown included pressure relieving devices on his/her chair and bed and a turning/repositioning program. Resident #36's 10/26/12 CAA (Care Area Assessment) summaries related to pressure ulcers reported that the resident depended on staff to eat, change his/her position, to keep him/her clean, and the resident presented as high risk for skin breakdown. The Pressure Ulcer CAA reported his/her Braden scale also presented the resident as high risk for skin breakdown. Resident #36's 1/31/13 care plan instructed staff that due to the resident's dementia and severely impaired cognition, the resident needed extensive assistance with all cares like bed mobility, transfers, and eating. The care plan informed staff that the resident presented as high risk for skin breakdown and instructed to reposition the resident every 2 hours, use a cushion while in a wheelchair and a pressure relieving mattress in bed, and instructed the night shift to place pressure relieving boots on both feet at night. The care plan included a 5/20/13 intervention for "every shift (use) Prevalon boots (a type of cushioned boot) at all times, keep heels off-loaded every shift". The care plan included two 5/29/13 updates: "every shift assist to reposition every 1 to 2 hours as needed" and "keep heels off-loaded, use pillows to help off-load them in bed, recliner, and wheelchair". The care plan lacked evidence of measures to protect the resident's heels prior to the presence of the 2 unstageable pressure ulcers on his/her bilateral heels. Review of resident #36's "Wound Flow Sheet" forms revealed on 5/20/13 the resident presented with facility acquired, unstageable/deep tissue injury pressure ulcers on each of his/her heel. Nursing staff documented both pressure ulcers as intact "unstageable blisters", measured the left heel ulcer as 6 cm (centimeters) by 6 cm, and measured the right heel ulcer as 7 cm by 7 cm. Review of resident #36's 5/20/13 physician order [REDACTED]. Review of resident #36's clinical record revealed between 5/20/13 and 7/24/13, nursing staff monitored the resident's unstageable bilateral heel pressure ulcers, changed treatments when the wound worsened, and healed both wounds on 7/24/13. During an observation on 7/31/13 between 8:50 a.m. and 9:00 a.m., staff placed resident #36 in bed equipped with an air mattress on his/her back with Prevalon boots on both feet and pillows under both of his/her legs. Further observations on 7/31/13 at 9:15 a.m., 9:25 a.m., 9:31 a.m., 9:45 a.m., 10:01 a.m., 10:15 a.m., 10:31 a.m., 10:42 a.m., 11:00 a.m., 11:14 a.m., and 11:30 a.m., the resident remained in the same position without the benefit of a position change (2 hours and 30 minutes). Upon request on 7/31/13 at 11:31 a.m., Licensed Nursing Staff E informed Direct Care Staff K and GG to reposition resident #36. At 11:43 a.m., Staff K and GG provided resident #36 with perineal care and the resident's skin on his/her bottom presented as pink and intact. Staff K and GG assisted the resident to pivot transfer to his/her wheelchair using a gait belt. During an interview on 7/31/13 at 11:43 a.m., Direct Care Staff K and GG reported resident #36 needed assistance from staff to reposition every 2 hours and to wear the Prevalon boots at all times. Staff GG reported he/she assisted another resident between 11:00 a.m. and 11:30 a.m. that needed more care and could not leave but verified he/she did not ask another staff member to reposition resident #36 at 11:00 a.m. Staff K reported the resident previously needed extensive assistance from staff to reposition and had an air mattress on his/her bed before the unstageable pressures appeared in May 2013. Staff K reported resident #36's care plan used to have an intervention to wear the Prevalon boots only at night even though the resident had been at risk for skin breakdown at the time. During an interview on 8/1/13 at 8:31 a.m., Licensed Nursing Staff E reported resident #36 needed staff to reposition him/her every 2 hours and presented at risk for breakdown prior to the facility acquired, unstageable pressure ulcers on both heels. Staff E reported staff had an intervention to only use the Prevalon boots at night and reported the boots should have been used any time pressure presented to his/her heels such as from a recliner foot rest, mattress while in bed, or padding on a wheelchair foot pedals. During an interview on 8/1/13 at 2:13 p.m., Administrative Nursing Staff B reported the facility expected staff to reposition resident #36 every 1 to 2 hours and agreed that staff did not utilize heel protectors or any other measure to protect the resident's heels while the resident presented as high risk for skin breakdown. Attempted to phone physician NN and physician assistant OO regarding resident #36 on 8/7/13 at 8:51 a.m. Both practitioners were unavailable for interview. The facility's "Pressure Ulcer" policy, last revised in March of 2007, instructed staff on initial risk assessments, staff should identify risk factors that increase a resident's susceptibility to develop pressure ulcers, which included impaired/decreased mobility and cognitive impairment. The policy instructed staff to implement a specific turning and repositioning program based upon individual resident assessments and use support surfaces, such as mattresses and wheelchair cushions, to decrease ischemia (lack of blood flow) of bony prominences (areas prone to have reduced blood flow during times of applied pressure). The facility failed to ensure resident #36, who entered the facility without pressure ulcers, did not develop a pressure ulcer when staff failed to implement appropriate measures to protect his/her bilateral heels from developing unstageable pressure ulcers. The facility also failed to reposition resident #36 timely as instructed in the resident's comprehensive care plan.

The facility had a census of 70 residents with a sample size of 23 residents with 3 reviewed for weight loss. Based on observation, record review and interviews, the facility failed to ensure that one (#26) of the three residents sampled for nutritional status maintained acceptable parameters of nutritional status. Resident #26 experienced a 24 pound weight loss (12.6% of body weight) from his/her admission on 4/10/13 until 6/17/13, a period of 2 months. The facility failed to implement interventions to address the resident ' s severe weight loss prior to 7/2/13, a period of 11 weeks. (#26) Findings included: - Resident #26's physician's orders [REDACTED]. The admission MDS (Minimum Data Set) on 4/17/13 identified Resident #26 as severely impaired for decision making and the resident required limited assistance of one person for eating. The resident required a therapeutic diet, had no swallowing problems or weight loss in 6 months prior to admission. Review of Resident #26's 7/17/13 significant change MDS (Minimum Data Set) identified the resident with severely impaired daily decision making abilities. The MDS reported the resident needed extensive assistance of one staff for eating. The MDS reported the resident experienced weight loss since the last assessment and received a mechanically altered diet. Resident #26's CAA (care area assessment) Nutrition summary dated 7/17/13 revealed the resident had significant weight loss in the last month and in a 6 month period. According to the summary the resident received nutritional supplements and required a mechanically altered diet to manage weight loss. Resident #26's care plan dated 7/25/13 instructed staff to assist the resident with meals and be served coffee at all meals to encourage fluid intake. Beverages served to the resident needed to be placed in a nosey cup (cup that has a special cutout that helps maintain proper head and neck positioning when swallowing) for the resident's hydration needs. The care plan directed staff to provide nutritional supplement drinks with meals and between meals, totaling 6 times daily. Resident #26's weight record revealed the following: * 4/10/13 Admission 190 pounds * 6/2/13 187 pounds * 6/16/13 166 pounds * 7/08/13 158 pounds * 7/28/13 145 pounds Resident #26 experienced a weight loss of 12.6% in 2 months and 16.8% in 3 months since admission to the facility. A review of notes from dietician consultant HH regarding resident #26 revealed an initial assessment done on 4/30/13 with the resident's weight of 190 pounds. The resident took 75-100% of the diet when assisted by staff. "Consultants Progress Notes" documentation on 6/17/13 had the resident's weight listed at 187 pounds. The actual weight on the weight flow sheet on the facility's weight record revealed the resident weighed 166 pounds on 6/13/13. The resident's weight loss of 24 pounds calculated to be a total weight loss of 12.6% from the admission date of [DATE]. The notes by the dietary consultant HH lacked documentation of the severe weight loss in the two month period as the weight provided to the dietician was not the most recent/accurate weight. The dietician's progress note on 7/9/13 noted the resident's weight of 152 pounds and recommended a house supplement three times a day and noted "[MEDICATION NAME] (antidepressant medication that also stimulates appetite) and [MEDICATION NAME] (an anti-psychotic medication) should help". According to the clinical record Resident #26's physician saw the resident on 6/14/13 and documented in the "review of systems" , no recent weight changes. A fax sheet dated 6/19/13 reported the physician agreed to a dietician recommendation from 6/17/13 to change diet to ground meat and stopped the "no added salt" or "no added fat" to the diet. The fax lacked communication to the physician regarding the resident's weight loss of 12.6% in two months Resident #26's physician order [REDACTED]. An order on 7/10/13 increased the house supplement to 6 times a day. An order on 7/17/13 included an order for [REDACTED]. Nurses' notes on 7/8/13 stated, "Resident continues to lose weight, weight 152 pounds, doctor notified, referred to dietician, takes supplement". Record review revealed the resident had normal serum [MEDICATION NAME] and total protein levels (labs used to help determine a resident's nutritional status) done on 4/11/13. The record lacked any follow-up of the [MEDICATION NAME] or protein levels after the resident experienced weight loss. Observation made 7/29/13 at 11:45 a.m. revealed staff served resident #26 the noon meal at 11:45 a.m. with staff assistance provided at 12:01 p.m. The resident waited 16 minutes for staff assistance with food sitting in front of him/her for that period of time. During an observation of the breakfast meal served 7/31/13 at 8:23 a.m., direct care staff P began to assist feeding resident #26. The plate contained ground sausage and scrambled eggs. Drinks given to the resident included water and a nutritional supplement. Staff member P attempted to feed resident for approximately 4 minutes when the staff member left the table with the resident ' s plate left on the table in front of him/her. Resident #26 picked up ground sausage with his/her right hand and put it into his/her mouth. The resident then attempted to scrape the eggs into his/her hand, but was unable get the food in to his/her mouth. At 8:39 a.m. the resident picked up plate and tried to eat off of the plate putting his/her face directly into the plate. Direct care staff P took the plate out of resident's hand and moved it and the drinks outside the reach of the resident. At 9:20 a.m. staff wheeled resident #26 away from the dining area without assisting him/her with the remainder of the meal. Resident #26 consumed 1/2 of supplement and less than 25% of the sausage. During an interview on 8/1/13 at 11:25 a.m., administrative nurse B stated he/she was not aware of the weight discrepancy in the dietician's notes and stated it must have been a "misprint" . Nurse B verified he/she failed to notice the error in documentation of weights made available to the dietician on 6/17/13. An interview conducted with consultant dietician HH on 8/5/2013 at 9:30 a.m. revealed the dietician expected to be notified by the dietary manager or nursing personnel if they found any errors in documentation, such as noted on 6/17/13 with documentation of 3 pound weight loss when it was actually 24 pounds. The dietician stated he/she was unsure if nursing personnel read the notes, but the dietary manager normally followed up with recommendations, especially related to significant changes related to weight loss. During an interview on 8/7/13 at 10:49 a.m., Nurse Practitioner KK stated that when providers make rounds on residents, the facility provided the most recent MAR (Medication Administration Record), current weight, and vital signs. He/she verified staff notified him/her of the diet recommendations by the dietician on 6/17/13, but staff did not notify him/her at that time that the resident had a 24 pound weight loss. Nurse Practitioner KK further stated interventions could have been implemented sooner if he/she had that information. A review of the facilities "Policy for Weight Monitoring" issued November 2002 with a revised date of February 2005 confirmed the facility should immediately report significant weight changes to the physician and family. "Procedure for Weight and Height" revealed significant weight loss defined as 5% weight loss in 30 days, 7.5% in 90 days, and 10% in 180 days. The facilities procedure for "Interventions for Nutritional Risk of Residents" documented residents and/or caregivers will receive education on their nutrition or hydration risk and the plan of care. According to the procedure residents are observed during meal times, with encouragement at meals and provide feeding assistance as needed. The facility failed to ensure resident #26 maintained acceptable parameters of nutritional status. Resident #26's experienced a 24 pound weight loss (12.6% of body weight) from his/her admission on 4/10/13 until 6/17/13, a period of 2 months. The facility failed to implement interventions to address the resident's severe weight loss prior to 7/2/13, a period of 11 weeks. (#26)