Every finding on record at Good Shepherd Lutheran Home

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided for 1 of 1 resident (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their care.Findings Include:R7's comprehensive Minimum Data Set (MDS) assessment, dated 4/3/26, identified R7 had severe cognitive impairment, and was dependent for personal hygiene which include nails care.R7's care plan dated 3/8/24 indicated bath and nailcare will be offered by nurse aid every week. R7s electronic medical record (EMR) lacked weekly nail care provided with baths. Facility Nursing Assistant Bath Day sheet dated 5/7/26 indicated nails were cleaned and not needed to be clipped. During an observation on 05/11/26 10:34 a.m., R7 was found sitting in the dining room with noted long fingernails grown passed fingertips curving downward and visible dark matter under the fingernails. During an observation on 05/12/26 9:07 a.m., R7 was assisted back from breakfast by licensed practical nurse, (LPN)-A. R 7's fingernails remained unchanged in length with noted half of a fingernail broken off a finger on the right hand. During an interview on 05/12/26 9:08 a.m., LPN-A verified R7's fingernails are long, they should have been completed last week. During an interview on 05/12/26 at 9:17 a.m., case manager and registered nurse (RN)- A confirmed, R7's fingernails were long and stated, it was unacceptable. Facility policy titled, Nursing Assistants Policies, Definitions and Standards of Care Good [NAME] Lutheran Home, reviewed on 1/6/15, indicates, resident's usual care level and minimum degree of assistance that should be provided by staff is documented in the resident's individual care plan. The plan of care is followed unless the NA recognize a decline in the resident's status.

Based on interview and document review, the facility failed to notify the Office of the State Long-Term Cate (LTC) Ombudsman for calendar years 2025 and 2026, reviewed for hospitalizations, discharges, and transfers. Findings Include: During an interview on 5/7/26 at 4:07 p.m., ombudsman (OM)-A stated she had not received any hospitalizations, discharges, and transfer notices for the year of 2025 and no notices for 2026. During an interview on 5/11/26 at 2:46 p.m., social services (SS)-A stated she is responsible for sending notification to the ombudsman about hospitalizations, discharges, and transfers; these notifications are supposed to be sent monthly. SS-A confirmed she is behind a little with submitting the notifications to the ombudsman. SS-A stated ombudsman notifications are important, so residents have an advocate if they feel they have been wrongly hospitalized , discharged , or transferred. During an interview on 5/11/26 at 3:25 p.m., administrator stated social service is responsible for sending notices about hospitalizations, discharges, and transfers to the ombudsman monthly. The administrator stated social services told her they were behind with sending notices to the ombudsman. The administrator confirmed the notices had not been sent for over a year. The administrator stated it is important to send notices to the ombudsman because the ombudsman is a resource for the residents and can support the resident if they have an issue with hospitalization, discharge, and transfer. A facility policy titled Discharge Planning dated 12/25 was provided, this policy failed to address the process for sending ombudsman notifications.

Based on observation, interview, and record review the facility failed to comprehensively assess and monitor high blood pressure and rectal bleeding for 1 of 3 residents (R2) reviewed for change in condition. Findings include The American Heart Association (AHA) defines hypertensive crisis as a systolic blood pressure higher than 180 and/or diastolic pressure higher than 120. Blood pressure in this range can result in but not limited to stroke, heart attack, loss of kidney function, and aortic dissection. AHA directs for blood pressures that meet this criteria to wait at least 1-2 minutes and take the blood pressure again and consult your doctor immediately. R2's face sheet dated 2/12/25, identified diagnoses of malignant neoplasm (cancerous tumor) of left lower lobe, neoplasm of bone, type 2 diabetes (condition that affects how the body uses sugar as fuel), hypertension (high blood pressure), anemia (low red blood cells), thrombocytopenia (low platelets), irritable bowel syndrome (chronic stomach and intestinal disorder that causes diarrhea, abdomen pain, cramps, bloating, and gas), gastroenteritis and colitis (inflammation of the digestive tract), and diverticular disease of intestines (inflammation or infection of the pouches formed in the colon). R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment, R2 needed maximum assistance with toilet hygiene, and staff assistance on and off the toilet. R2 was continent of bowel and had occasional incontinence of bladder. R2's progress note dated 12/31/24 at 3:43 a.m., identified at 12:45 a.m. R2 fell while self transferring from toilet to wheelchair. A medium amount of blood was noted in the toilet. Blood pressure reading was 200/72 (normal blood pressure range for adults is 120/80). The note did not identify where the blood originated from. In review of R2's record dated 12/31/24, there was no indication R2 vital signs were rechecked or monitored nor a comprehensive assessment and monitoring of the bleeding until approximately 3:00 a.m. when R2 had large amounts of bleeding from the rectum. R2's progress note dated 12/31/24 at 3:51 a.m., identified at 3:30 a.m., R2 was sent to the hospital via ambulance for large amount of rectal bleeding/clotting. R2's ambulance run report dated 2/12/25, identified ambulance dispatched to facility at 3:04 a.m., and arrived at emergency department at 4:21 a.m. for hemorrhage with primary impression blood in vomit or stood (GI bleed). Blood pressure readings from ambulance were as follows: -3:34 a.m. 138/64 -3:39 a.m. 111/62 -4:00 a.m. 119/63 -4:14 a.m. 97/62 R2's hospital discharge summary dated 1/6/25, identified R2 had an intensive care unit (ICU) hospital stay from 12/31/24-1/6/25 with a diagnosis of hemorrhagic shock (life threatening condition that occurs when a person loses a lot of blood and the body cannot get enough oxygen to the organs), gastrointestinal hemorrhage, secondary to a colonic arterial bleed as per imaging of the abdomen, and underwent inferior mesenteric artery embolization and given a blood transfusion. discharged back to facility 1/6/25. During a phone interview on 2/13/25 at 9:41 a.m., nursing assistant (NA)-A stated R2 had been in bed at the beginning of the shift on 12/31/24. R2 required assistance of one person to transfer and was surprised when R2's bathroom call light was on. NA-A went to R2's room and found her on the floor in the bathroom. NA-A noted blood in the toilet but R2 did not complain of pain or tenderness and did not appear hurt from the fall. NA-A assisted R2 back to bed after licensed practical nurse (LPN)-A assessed R2. NA-A stated not long after the fall, R2 again put her call light on and when she entered her room R2 said I think I made a mess in my pants. NA-A noted R2's brief was full of bright red blood and completely full. NA-A left room to get supplies and notified the nurse of blood overflowing from R2's brief. NA-A called LPN-A to the room when she realized that the blood was not stopping and they could not get ahead of it. NA-A told LPN-A that she thought R2 should be sent in and LPN-A agreed and called an ambulance. NA-A stated R2 required three complete bed changes before the ambulance got there from all the blood. NA-A was not sure if LPN-A had taken R2's vital signs again after she had fallen. During a phone interview on 2/13/25 at 9:27 a.m., LPN-A stated R2 fell while transferring from the toilet to the wheelchair on 12/31/24. LPN-A was surprised R2 did not call for help to transfer from the toilet as she required assistance of one staff for help. LPN-A noted a small amount of blood in the toilet and examined R2's rectal area and saw a small amount of blood but thought it was from hemorrhoids. R2's blood pressure was elevated at 200/72 at the time of the fall. A short time after the fall, R2 put her call light on again and said she had an incontinent episode, the incontinent garment contained a significant amount of blood. LPN-A stated she missed documentation of the incident. LPN-A stated she did recheck R2's blood pressure in-between the times R2 put in her call light on, but did not document it and did not recall what the vital signs were or if they were abnormal. During an interview on 2/15/25 at 9:13 a.m., LPN-B was unsure what signs or symptoms to monitor for high blood pressure aside from providing ordered medications and giving water to drink. LPN- B reviewed R2's chart for vital signs and fall follow-up from 12/31/24 and verified no vital signs were completed after the initial set after R2's fall and no additional documentation was completed on rectal bleeding. During an interview on 2/12/25 at 10:02 a.m., registered nurse (RN)-A stated after a fall vital signs are done immediately and then residents are assessed for the next three shifts for fall follow-up but that did not necessarily include completing vital signs. High blood pressure is typically above 140-150 systolic (top number). Right after a fall a fall you would expect the blood pressure to be a little bit higher, however, LPN-A should have re-checked R2's blood pressure to verify it did not remain that high. R2 did not have rectal bleeding prior to the fall. During an interview on 2/12/25 at 12:50 p.m., director of nursing (DON) stated anything greater than 140 systolic medical doctor (MD)-A was to be notified. 200/72 is a high blood pressure. DON would expect the licensed nurses to complete an assessment and take a manual blood pressure to verify the blood pressure results. DON felt the assessments and vital signs were taken but just not documented after the fall. DON stated every person is different and it being emergent would depend on the individual situation. MD-A was always available and requested phone calls if staff were on the fence about a situation. During a phone interview on 2/13/25 at 10:21 a.m., MD-A stated he would want to be notified of a blood pressure that was 180 or above systolically and would want the blood pressure monitored every few minutes to see if it comes down. The facilities blood pressure monitoring guidelines, undated, identified to provide trained medication aides and licensed nurses with direction regarding blood pressure and pulse monitoring when a resident is prescribed an ace inhibitor/angiotensin receptor blocker, or beta blocker. The policy does not address when high or low blood pressure is obtained when not taking these medications. The facilities procedure for falls dated 8/22, identified the nurse call MD-A's cell phone directly (with the phone number provided) as needed. MD-A must be notified by phone if a resident is on a blood thinner with active bleeding/bruising/head injury, or internal injury is suspected related to unstable vital signs, neuro exam or if the resident sustains other significant injury resulting in new or worsening pain.

Based on observation, interview, and document review, the facility failed to assess resident for safety and the ability to self-administer medications (SAM) for 1 of 1 resdient (R99) with nebulizer treatment. Findings include: R99's medical diagnoses indicate R99 with hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of right dominant side due to a stroke), dysphagia (inability to swallow food or liquid), aphasia (damage to the speaking or language areas of the the brain), depression, diabetes, and chronic obstructive pulmonary disease. R99's physician orders indicate R99 admitted to facility on 1/5/24, start date of 1/5/24 for, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG[milligram]/3 ML[milligram] 3 ml inhale orally four times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. During an observation on 1/22/24 at 3:19 p.m., R99 was in bed with nebulizer treatment mask being held in her left hand away from her face as nebulizer machine was running. At 3:20 p.m., the nebulizer mask was on her bedside table while the machine was running with liquid observed in the nebulizer cup attached to the mask and tubing. During observation and interview with the licensed practical nurse (LPN)-B on 1/22/24 at 3:35 p.m., LPN-B walked with surveyor to R99's room and assessed the nebulizer. The nebulizer machine was running with the mask on the bedside table. LPN-B stated the medication was finished and turned off the machine. LPN-B stated, I did leave the room while I administered it. She did remove the mask also this morning, so I do not know how much of the medication she [R99] received. LPN-B stated she did not know if R99 had a SAM assessment to determine if R99 was safe or competent to administer her nebulizer treatment. During interview with LPN-C on 1/22/24 at 3:45 p.m., LPN-C stated, someone is not with her [R99] the whole time to watch her take that med. She is not getting all of her medications if she takes it off and we don't know how much of the med she has taken. During interview with the unit case manager and registered nurse (RN)-A on 1/22/24 at 3:45 p.m., RN-A stated R99, is not appropriate for self-administration of meds. If she pulls off the mask then there is no way to make sure she is taking the complete dose of the medication. During interview with RN-B on 1/23/24 at 12:27 p.m., RN-B stated she was assigned to care for R99 on 1/21/24 during the evening shift. RN-B stated R99, sometimes pulls it off [nebulizer mask] and I will re-put it back on. I have left the room before and come back and it is still running so I have to put back on her. I try to stay in her room. If she pulls off the mask she is not getting the full dose. RN-B stated R99 did not have a SAM order to safely administer her own medications. During interview with LPN-D on 1/23/24 at 1:58 p.m., LPN-D stated she was familiar with R99 and stated R99 will take off the nebulizer mask several times during the administration of it. LPN-D stated she reminded R99 to keep the mask on and, when I walk past her room the face mask is on the floor [while still running]. LPN-D stated, if you are busy with 5 other patients then she [R99] won't get it put back on. LPN-D stated, My thought is that staff should be in there during the full administration [of the nebulizer]. LPN-D also stated R99 was not competent to SAM the nebulizer. During an interview on 1/24/24 at 1:00 p.m., director of nursing (DON) stated R99 was not competent to administer the scheduled nebulizer treatment because she takes it off. DON stated the SAM assessment is to be completed by the nurse manager at every admission, quarterly, or significant change Minimum Data Set (MDS) timing. DON stated R99 admitted to facility on 1/5/24 and had not had the SAM completed. Facility policy titled Self-Administration of Medications and Bedside Medications Policy and Procedure revised 11/22 state: Residents may choose to administer their own medication. Residents will be asked on admission if the do/do not wish to self-administer their own medications. Residents who wish to do so will be assessed by a minimum of three members of the health care plan team and the attending physician.

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Six medication administration errors occurred out of 26 opportunities resulting in a 23.08 % medication error rate for 1 of 4 residents (R99) observed during medication pass. Findings include: R99's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R99 had severely impaired cognition and was diagnosed with kidney disease, diabetes, depression, chronic obstructive pulmonary disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness), hypertension, a heart dysrhythmia, and a stroke. R99's Order Summary Report dated 1/24/24, indicated R99's medications should have be crushed separately, dissolved in 15 milliliters (mL) of water each, and administered separately. The report indicated the following medications were to be administered via the gastric tube: 81 milligrams (mg) of aspirin daily, 25 mg of chlorthalidone (treat high blood pressure) daily, 25 mg of carvedilol (treat high blood pressure and heart failure) two times a day, 2.5 mg of apixaban (used to prevent serious blood clots from forming due to a certain irregular heartbeat) two times a day, 10 mg of escitalopram (used to treat depression and anxiety) daily, and 20 mg of lisinopril (used to treat high blood pressure) daily. During an observation and interview on 1/23/24 at 10:12 a.m., licensed practical nurse (LPN)-E was observed removing the aspirin, chlorthalidone, carvedilol, apixaban, escitalopram, and lisinopril from its packaging and placing them in the same medication cup. The medications were then transferred to a clear medication bag and crushed together using a manual levered machine. LPN-E then transferred the crushed medications to a small cup and entered R99's room. LPN-E diluted the medications in the cup with water set them on the side table and left the resident room to gather more supplies. LPN-E stated that she had not seen an order in the medical record indicating she could safely crush, dilute, and administer the medications together. LPN-E stated she expected the pharmacist to review the medications on admission and add a note to the resident orders if she could not crush, dilute, and administer them together and had not noted this in R99's chart. LPN-E then called the director of nursing (DON) per her report, to confirm she could administer the medications together. LPN-E stated the DON said as long as an order was not in the chart to administer the medications separately, she could combine and give them together through R99's gastric tube. LPN-E re-entered R99's room, flushed the gastric tube with water, and administered the combined medication solution through the gastric tube, and then again, flushed the tube with water. During an interview on 1/23/24 at 2:52 p.m., the consulting pharmacist (CP) stated when a resident was admitted to the facility, he completed a medication reconciliation but he did not assess whether nursing staff could safely dilute and administer medications together through a gastric tube. CP stated if the nursing staff had questions regarding the safe administration of medications through a gastric tube, he would have been able to assist them with this but did not recall anyone asking for assistance with this recently. CP stated if medications were crushed, diluted, and administered together, he would worry about a possible compatibility issue between the medications and the adverse effects this could have on a resident. During an interview on 1/24/24 at 8:25 a.m., the DON stated she expected the pharmacist and physician to review the medications on admission to ensure they could have been safely crushed, diluted, and administered together through a gastric tube. The DON stated she had received a message from the pharmacist yesterday indicating he did not review the medications to ensure they could be crushed, diluted, and given together through a g-tube and she was surprised by this. The DON stated she would be concerned the medications should not have been mixed and could adversely affect the resident. During an interview on 1/24/24 at 12:48 p.m., the medical director (MD) stated he was not aware of an order or a policy indicating nursing staff could combine and administer medications together through a g-tube. The MD stated if this was the current policy, it should have been updated to indicate nursing staff should not mix medications together like this and instead administer the medications separately. The Institute for Safe Medication Practices article titled Preventing Errors When Preparing and Administering Medications Via Enteral Feeding Tubes dated 11/17/22, indicated that multiple medications should not be mixed and given at once through an enteral tube because of possible medication incompatibility issues. The facility Administration of Medication Via Feeding Tube dated 12/22, indicated that medications administered via a feeding tube could be mixed and administered together unless specific instructions not to were received.

Based on observation, interview and record review, facility failed to reassess resident's ability to safely and independently take medications and ensure appropriate storage of medications for 1 of 1 residents (R)9 reviewed for self-administration of medications who was found to keep her medications at bed-side. Findings include: According to R9's annual Minimum Data Set(MDS) assessment dated [DATE], R9 was cognitively intact. R9 suffers several medical disorders, most significantly a chronic pain syndrome for which R9 complains of nearly constant pain and requires oral medication for relief. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse to check back in 1/2 hour to make sure medications have been taken. May have certain medications at the bedside: TUMS, [MEDICATION(S)] gel [non-steroidal arthritis rub]. Tums tablet chewable ([MEDICATION(S)] antacid), give 1 tablet by mouth as needed for supplement. May self-administer and keep at the bedside. Follow label directions and [MEDICATION(S)] Sodium Gel 1% apply to affected areas topically as needed for pain management related to other hypertropic osteoarthropathy multiple sites, may keep tube at the bedside for self-administration use two times daily and PRN (as needed). A review of R9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's care plan did not include a specific area for self-administration of medications; however, a focus problem area last revised 12/2/21 indicated R9 had pain related to reverse total shoulder arthroplasty and inflammation in left wrist. Also bilateral [CONDITION(S)] of knees. Another focus problem area last revised 7/28/20 indicated R9 has forgetfulness, a decline in strength and mobility, wears bilateral hearing aids and had very independent personality. A psychosocial focus problem area last updated 10/13/21 indicated R9 had some memory impairments. On 10/11/22, at 12:03 p.m. R9 was observed to have a 30 ml plastic medication cup sitting on a table in her room full to the top with large [NAME] medication tablets of various sizes. R9 stated these were Tums and she preferred to keep them out in the medication cup as it was easier for her to get to them. R9 stated she took several Tums each evening. R9 stated the nurses would usually bring her medications to her and stand there while she took them. R9 stated she was not able to clearly see the medications as they were small, and she was not sure what medications she was taking. R9 stated she would not be able to identify what her pain pill looked like, and would not be able to differentiate between a tablet of Tylenol and her opioid pain medication. R9 said she might take 3 or 4 pills at a time, but was not able to say what they were for or describe the frequency with which she took them. R9 stated some nurses would leave her medications for her to take rather than stand to watch her take them, and sometimes she found medications had been left in her room for her when she had been out. R9 stated sometimes she would leave the room herself without taking the medications nurses had brought her, but would return later and take them. R9 said the medications simply sat at her bedside until she was ready to take them. During an interview and observation on 10/11/22, at 12:09 p.m. a licensed practical nurse (LPN)-A stated residents can self-administer medications, but first a nurse case manager must do an assessment to determine if they are able to do so safely. LPN-A stated it was important for the resident to be alert and oriented, and thought a nurse should determine if the resident was able to correctly and safely take medications before they were able to allow resident self-administration. LPN-A stated medications could not be left in a resident room unless the resident was there and had an order to self-administer. LPN-A also stated medications could not be stored in a resident's room unless there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-A went to R9's room and observed the Tums in the plastic medication cup, and after R9 allowed it, located a plastic storage container in her drawer that held loose [NAME] colored medication tablets of various sizes. This container held approximately 1.5 to 2 cups of tablets and had a hand written note on the top indicating they were Tums, but no dosage, directions or expiration date was included. R9 stated the medications were her Tums and had been supplied by a family member. LPN-A stated she would notify the case manager. During an interview on 10/11/22, at 12:57 p.m. a registered nurse (RN)-A stated residents had the right to self-administer medications if they had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A stated the facility's current assessment for self-administration of medications addresses whether a resident is oriented and has the visual and physical capacity to take medications independently. RN-A stated a resident should be able to identify their medications and have a basic understanding of what they are taking and when. RN-A stated medications must be stored in their proper containers with a printed label with medication name and directions. RN-A stated R9 needed to be re-evaluated for safety with self-administration of medications. During an interview on 10/11/22, at 1:17 p.m. the director of nursing (DON) stated self-administration of medications was allowed, but expected the nurse case manager and the interdisciplinary team to review a completed assessment and discuss the resident's ability to safely and independently take medications as ordered. DON stated residents with difficulty identifying medications should only self-administer medications that had been set up by a nurse, and even then it may not be appropriate. DON stated it would depend on the resident and how determined they were to take their medications independently. During an interview on 10/11/22, 1:56 p.m. the administrator stated she had been made aware of an incident that had occurred on 10/4/22 when a nurse, LPN-B found a cup with R9's medications in her room, pre-set, awaiting for R9 to take them. LPN-B identified an error in the medications, and removed them from the room, but R9 had not identified that there was an error. During an interview on 10/11/22, 3:30 p.m. R9 stated she did not understand a reason why non-prescription medications could not be kept in residents' rooms, saying they are safe if they are sold over the counter. R9 denied keeping any medications in her room aside from Tums; however, at that time, a tube of [MEDICATION(S)] gel was observed sitting on her overbed table. A facility policy titled Self-Administration of Medication, not dated or signed, indicated residents may choose to administer their own medications. The guidelines in the policy indicated that to prove competency, the resident must verbalize an understanding of the medications that are ordered and the potential side effects and the nurse shall set up and bring medications to the resident during the time period prescribed. The licensed nurse shall record the medication on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility failed to reassess and monitor the effectiveness of interventions and coordinate care among the interdisciplinary team for 1 of 1 residents (R10) who had a significant weight loss and poor nutritional status. Findings include: According to R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], R10's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R10 required supervision, set up and cues for eating, and did cough during meals. R10 weight was 125 pounds, had intact skin, and at risk for pressure ulcers. According to a quarterly MDS dated [DATE], R10 was not able to complete the basic cognitive assessment and had memory problems; required set up and cues for eating and weighed 130 pounds. According to both of these MDS, R10 suffered malnutrition. According to R10's care plan focus problem area dated as last revised 10/27/21, R10 had a nutritional problem, moderate protein/calorie malnutrition and unplanned weight loss. The care plan indicated R10 had previously been on a supplement of prosource for additional protein but this was discontinued on 1/27/21 because R10 did not have any skin breakdown. A 4 ounce dietary supplement was added to be given three times daily starting 4/21/22, but this also indicated R10 would often push it away and therefore the supplement should be offered with meals. According to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Bacon ok per patient/family desire. Cut to bite-size pieces. Verbal cues for 1 bite at a time. Additionally, the orders included: dietary supplement 120 cc between meals three times a day for weight loss. According to R10's recorded weights, on 10/6/22, R10 weighed 115 pounds and on 9/8/22, the resident weighed 118 lbs, a weight loss of 2.5% in one month. On 6/9/22, the resident weighed 124.9 lbs. The weight loss from 6/9/22 to 10/6/22 equaled a loss of 7.9%. On 4/7/22, R10 weighed 132 lbs. The weight loss between 4/7/22 and 10/6/22 equaled a 10.6% weight loss. According to R10's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 refused the supplement or took only sips of the supplement in 17 out of 33 offerings. A review of R10's meal intake showed the facility was offering five meals per day. In a 14 day look back from 10/12/22 R10 was offered 70 meals of which she consumed 75-100% of only eight. R10 had 40 instances where she consumed 25% or less of the meal offered and twice refused all foods offered. According to the last nutritional progress note in R10's chart 7/27/22 ,12:37 p.m. Data: Per Speech Therapy: Continue with the mechanical soft diet and thin liquids. Bacon okay per patient request (patient/family desire) Bacon cut to bite sized pieces. Moderate verbal cues for 1 bite at a time. Continued close supervision during meals, assistance with meal set up. Cues for slow rate, small bites/sips, alternate solids/liquids, upright positioning during and 30 minutes after meals, chin tuck. Thorough oral cares 3-5X/day, check for any pocketing following meals and clear residue. Action: Dietary plan of care updated. Response:[left blank]. During an interview on 10/12/22, 9:03 a.m. a family member (FM)-A stated she had talked with the facility nurse case manager for R10 regarding on-going weight loss. FM-A stated the family was concerned about R10's weight loss as they have noted it seems like she is down a few pounds every week. The family is taking turns coming to the facility to assist R10, and they generally bring in something that they know R10 will eat, but FM-A said it takes R10 a long time to finish anything. FM-A stated R10 would usually eat macaroni and cheese if she brought it, as well as soft fruits such as peaches, but she had noticed some things R10 used to eat on a regular basis she no longer seems interested in. FM-A stated she was not sure if R10 was taking the offered supplements, and did not know if anything different had been tried. FM-A stated staff took R10 to the dining room, but because of Covid limiting activities in the nursing home, FM-A did not believe she could go to the dining room to see how well R10 was doing on her own, or with staff assistance. FM-A said R10 liked soup but she did not know how often it was offered or how much R10 was eating overall. During an interview on 10/12/22, 10:12 a.m. R10 was observed to have a visitor, FM-B who provided R10 with a dish of macaroni and cheese. R10 was feeding herself with on-going cues from FM-B. FM-B stated family was aware R10 was losing weight and thought it must be a normal consequence at the end of life. FM-B was unsure what the facility could be doing to encourage R10's nutritional intake, but stated R10's food preferences seemed to have changed. FM-B stated R10 did not like the supplement that was offered, and did not seem to enjoy sweets anymore. FM-B said R10 would probably eat macaroni and cheese every day, might eat mashed potatoes if they did not put gravy on them and loved soup, but seemed to dislike textures and might spit out lumps and vegetable. On 10/12/22, 10:14 a.m. a resident assistant (RA)-A stated R10 required assistance from staff to eat. RA-A said sometimes R10 was able to eat with supervision, but usually required extensive assistance. RA-A has not noticed any special favorite foods being served to R10 at meal time but said she will start spitting it out if she does not like it and they would stop feeding her then. During an interview on 10/12/22, 11:19 a.m. the facility dietary manager (DM) stated she did not meet with the interdisciplinary team or the nursing department on a routine basis, but she expected nursing staff to notify her if a resident had on-going weight loss. DM stated she had a list of residents with weight loss that she would review on a weekly basis. DM stated R10's last nutritional review had been done by her in July when her MDS was due, but unfortunately, DM stated she fell off my radar. She is supposed to be a weekly review. DM stated she was not aware of R10's continued weight loss, and said it was the responsibility of the unit nurses to notify the dietary department. DM also stated she was not aware that R10 was not taking significant amounts of her dietary supplement or that her meal intake was low. DM stated staff could notify her in person, via a phone call or send her an email so she could review the current care plan, look again at the favorite foods list, talk with family and revise the nutritional plan for R10. During an interview on 10/12/22, 12:16 p.m. R10's physician (MD)-A stated he was concerned about R10's weight loss as it is always challenging for elderly patient's to get enough protein and overall calories to prevent cachexia (weakness and weight loss). Given R10's weight loss, MD-A stated an expectation for a nutritionist or dietician to remain involved on a regular basis in adjusting R10's plan in order to prevent continued weight loss and to be sure she was maintaining her muscle mass. MD-A stated R10 might require more frequent meals, increased assistance with feeding or a change in supplements depending on what nutritional needs were assessed by the nutritionist. MD-A stated R10 should have received more regular assessments since July for possible interventions given her on-going weight loss. During an interview on 10/12/22, 12:36 p.m. the facility's registered dietician (RD)-A stated an expectation to be notified of residents who have on-going and or significant weight loss. RD-A stated she had not been notified of R10's continued weight loss, but had she received notification she would have done a careful assessment including a review her physical condition and diagnosis, review medical notes and progress notes, watch how R10 is eating and look at her medication regime to see if she could determine what might be contributing to the weight loss. RD-A stated family may not want to take an aggressive route, but it was important to review the resident and family wishes again to ensure there is no wish to start tube feedings, to utilize appetite stimulating medications or conversely, to choose hospice care at end of life. RD-A stated that after an assessment was done, she would be able to work the DM-A and facility case manager on a change in her plan of care and suggest alternative supplements since R10 was not taking what was offered at this time. During an interview on 10/12/22, 12:52 p.m. the facility director of nursing (DON) stated weights were measured by nursing staff at least weekly. If a weight changed by 5 lbs or more, or if the electronic health record indicated a significant change in weight, the unit nurse was expected to notify the unit case manager who would then notify the DM-A. DON stated weight loss was monitored by the DM-A, but DON was unable to state when regular communication occurred between the nursing department and the dietary department. DON stated DM-A did not attend the morning meeting, and stated weight loss was not usually discussed at their morning meetings or interdisciplinary meetings. Facility provided a policy titled Weight Policy, last updated 7/15/13 that indicated a staff nurse would immediately notify the RN case manager and dietary manager of a weight loss of 5 lbs or more. The dietary manager was to notify the dietician who would evaluate a weight change of 5% in 30 days, 10% in 180 days or others as appropriate, and nursing would notify the physician. The policy indicated nursing, the dietary manager and dietician would work together to determine interventions including one or all of the following: 8 oz of whole milk at all meals, high calorie deserts for dinner and supper, health shakes or supplements between meals, supplements with medication pass, alternative food consistency, meet with residents and family to determine favorite foods and beverages and get their input on why they think there is weight loss, rule out conditions and medications that may cause a poor appetite, get recommendations from physician, family or resident, other interventions as indicated. The policy did not provide a procedure for systemic communications among team members.

Based on observation, interview and document review the facility failed to notify the medical provider for guidance for 1 of 3 residents (R1) who sustained a head injury following a fall, who was on [MEDICATION(S)] (a blood thinner) and was complaining of a headache reviewed for falls. The facility's failure to contact the physician timely resulted in actual harm for R1 who required hospitalization and was diagnosed with C1-C2 fractures. The findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R1 required extensive physical assistance of one staff with all activities of daily living except eating, had no pain, and for moving from seated to standing position and on and off the toilet R1 was not steady and only stabilized with human assistance. A report dated 6/12/22, indicated on 6/4/22, early morning, R1 had fallen off the commode after nursing assistant (NA)-A had thought something was wrong with R1 and had left R1 unattended despite the change in condition and gone to the door looking for help. The report indicated R1 had fallen fell forward off the commode, hitting her forehead on the floor and had sustained a goose egg injury and had a headache. The report also indicated after the incident licensed practical nurse (LPN)-A continued taking R1's vitals and never notified the physician but at around 5:25 p.m. in-coming PM shift registered nurse (RN)-B thought R1 needed to go by ambulance to hospital. The report further indicated at the hospital a brain scan was completed and showed there was hematoma on the outside of the brain and R1 had sustained fractures on C1 and C2 which were caused by trauma from the fall. In addition, a neurologist consult indicated R1 was not eligible for surgery due to age and taking [MEDICATION(S)] thus R1 was hospitalized from 6/4/22, through 6/8/22. Review of R1's Progress Notes revealed the following information: -6/4/22, at 3:51 p.m. note indicated R1 had a fall from the commode which was in middle of room at 8:20 a.m. after staff removed a mechanical stand away from resident to provide cares and get R1 dressed. The note indicated R1 was unable to state what happened, or what's wrong. R1 initially stated no pain when ask, then complained of back pain, then headache only and as needed Tylenol 1000 milligram (mg) was administered. The note also indicated R1 had sustained a purple/blue bruise with swelling to mid to left forearm measuring Width 8.0 centimeter (cm) by 9.0 cm, a purple/blue bruise to left side of nose measuring 3.0 cm by 3.0 cm and a small skin tear to left outer elbow. The note indicated following the incident neurological checks were within normal limits, the plan was staff was to monitor for additional bruising, pain, headaches, the responsible party was notified at 9:00 a.m. but the physician was notified until 4:05 p.m. which was 7 hours later after the incident and was notified via fax. -6/4/22, at 11:59 p.m. note indicated R1's neuro check were done and no changes from the baseline but R1 was complaining of pain on her head and on her neck with grimacing facial expression when R1 was helped to remove her coat for blood pressure reading. The writer indicated R1 was leaning more on her right side, head was stiff and complaints of pain when being moved and R1 had been sent to the hospital for medical evaluation. -6/8/22, note indicated resident was readmitted to the facility and had neck injury, bruising noted on face, under eyes, nose, and cheeks. There is a bump on the right side of the forehead sustained from the fall. -Facility Resident/Visitor Incident Report dated 6/4/22, at 8:20 a.m. indicated R1 had a fall out of the commode when staff had moved the mechanical lift away from R1 to get R1 washed and dressed. The incident report indicated staff had peeked their head out of the room yelling for nurse and in that time frame R1 started dropping to the left and fell right out of the commode. The report indicated R1 was not sure what had happened, and the case manager review of the risk factors indicated R1 had history of vasovagal episode on the toilet/commode, intermittent confusion and comments/interventions Resident sent to ER for evaluation [eval]. The incident report further indicated assessed cause/contributing factors: Resident Action. On 6/21/22, at 8:58 a.m. R1 was observed lying in bed with blue/purple bruises on the face, a large goose egg bump was observed in the middle of the forehead and R1 was wearing a neck collar. R1 was asleep at the time. R1's care plan 6/15/22, identified R1 was at risk for falls related to history of falls related to left hip fracture and mild cognitive impairment. The care plan indicated R1 had intermittent confusion and directed staff to ensure the bed was in the lowest position when occupied and my walker and/or wheelchair is out of hand reach. R1's falls Care Area Assessment (CAA) dated 8/31/21, identified R1 had the potential for falls related to decreased mobility and decreased cognition, age related muscle degeneration, and cognitive impairment. During interview on 6/21/22, at 3:06 p.m. family member (FM)-A stated following the incident LPN-A had notified her of the fall and had indicated R1 was being monitored. FM-A stated she had called a few other times during the day to check and was told R1 was okay. FM-A stated she had gotten a call from the evening nurse RN-A who informed her R1 was not doing okay and that she had to send her to the hospital due to pain. FM-A stated while at the hospital with R1 the attending physician had stated because R1 had a fall with a head injury and was on [MEDICATION(S)] she should have been brought in immediately. FM-A stated due to the fall R1 had a forehead that was swollen, she sustained fractures and one of the front teeth was knocked out. FM-A also stated following the fall, R1 was using the neck collar to immobilize the neck, had a total change of self and was having trouble with eating. During interview on 6/21/22, at 2:22 p.m. LPN-A stated after the incident they had pushed the emergency call system and multiple staff had come to the room and with the Hoyer (mechanical lift) they assisted R1 into bed. LPN-A stated R1 was complaining of her head hurting when asked about pain but later when in the bed, indicated she had a headache, and she gave Tylenol as needed. LPN-A then stated after the incident she had made some calls to the responsible party and RN-B case manager then later in the afternoon she sent a fax to the primary physician regarding the fall. LPN-A acknowledged she did not notify the physician and was relying for guidance from RN-B case manager stating, I should have called the physician hide sight. I figured the neuros were normal, I was monitoring the headache and if there were major changes, I would contact the physician. LPN-A also stated she did not remember if R1 had complained of pain but being cold when NA-A had called her to the room to assist getting R1 ready for the day as NA-A had indicated R1 was complaining of pain on her back and head when being rolled which NA-A felt was unsafe. LPN-A stated during the shift R1 was complaining of her head/headache and she assumed it was from the bruising in her forehead with swelling which later during the day spread to the side of the nose. During review of the neuro flow sheet with LPN-A at 9:40 a.m. (one hour after the fall) R1's neuros were at baseline but R1 was lethargic which she stated to her meant R1 was tired from the fall. LPN-A stated it was a normal practice to fax the physician following the fall unless it was an emergency when residents had to sent out. During interview on 6/21/22, at 2:48 p.m. NA-A stated the morning of the incident she had gone to R1's room to get her ready for the day and in the care plan they were allowed to take the E-Z stand from R1 to do the cares. NA-A then stated after she took it off, she had noticed R1 leaning to the left side and she felt the nurse needed to check on R1. NA-A stated after the incident they had transferred R1 to the bed then when she rolled R1 she started to complain of her head, back and when she was washing under the arms, she was in pain lifting the arms up to clean and was crying. NA-A then stated she had gone to get LPN-A and had reported to her the concerns and LPN-A had assisted her to get R1 ready for the day. NA-A stated during the cares, R1 was complaining of the back and headache, and she had received Tylenol and she had relief but still had the headache. During interview on 6/21/22, at 12:08 p.m. RN-C stated staff would notify the physician if something was significant via a call following a fall but if something was not significant, they would send a fax to the physician which the physician would be able to review the next day. RN-C further stated if there was an increase in pain, head injury or significant other injury then she would then say the nurses needed to call the physician right away. During interview on 6/21/22, at 4:36 p.m. RN-B case manager stated he was notified of the fall and initially the details were not clear as LPN-A was shaken. RN-B stated LPN-A had asked him if they should send R1 to the hospital for evaluation, and he had told her to call the responsible party to decide if they wanted R1 to be sent out. RN-B then stated afterwards LPN-A had called the responsible party, then reported to him the responsible party wanted R1 to remain at the facility since she was stable and monitor. RN-B then stated he had asked LPN-A to complete the necessary documentation which LPN-A indicated she had filled the appropriate paperwork including faxing the physician. RN-B then stated later that day in the evening he had received a call from RN-A who reported R1 was complaining of neck pain, and he said it was good to send R1 in to be evaluated. RN-B then stated after R1 was sent in he had received a call from FM-A who informed him R1 had the fractures in the neck. RN-B then stated hide sight he should have asked for more details at the time of the fall as he was at home while communicating with LPN-A about the fall. RN-B stated R1 was bruised after the fall because R1 was on [MEDICATION(S)] and from going through the fall and interviewing the staff it appeared R1 was experiencing a vasovagal episode as R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 6/21/22, at 11:13 the director of nursing (DON) acknowledged LPN-A should have notified the physician via call following the incident as resident was on [MEDICATION(S)], had a head injury and was complaining of a headache. The DON stated she had not realized until surveyor brought it up that LPN-A had not called the physician. The DON stated there was no training that had been provided to the nurses about notification of change either. During interview on 6/21/22, at 4:13 p.m. R1's physician (MD) stated anytime a resident had a fall with head injury, was on a blood thinner and had pain he expected the nurses to call right away for the resident to be evaluated. The MD also stated because R1 had sustained a big hematoma, had complained of pain and a headache right away this was a trauma case and he or the on-call should have immediately been notified or the ambulance should have been called to put a C-Collar on immediately. The MD further stated he expected the nurses to call emergency medical services (EMS) or someone with expertise when incidents such as these if not a physician. The facility Resident Status Change and Notification of Attending Physician Policy and Procedure revised 3/30/22, directed the following: Procedure: 1. The attending physician should be notified immediately when there is: a. An accident involving the resident that results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). c. A need to alter treatment significantly (i.e., a need to discontinue or change an existing form of treatment, Blood glucose readings greater than 400) d. A need to improve pain/symptom relief and control. e. Decision to transfer or discharge the resident from the facility. 2. Unless an extreme emergency, only an LPN or RN should notify a physician. 3. When in doubt if physician should be notified, notify physician. 4. Red Flags: fever (think respiratory and begin fluid intake encouragement/monitoring), pain, anxiety/confusion/lethargy, behavioral disturbance or change in mentation, nausea/vomiting/diarrhea, low O2 sats or SOB (start O2), chest pain (start O2), blood (emesis, stool), critical labs, glucose (high or low-sign something else going on), weight loss/poor po intake, [CONDITION(S)] (unilateral or bilateral, new/increased) .

Based on observation, interview and document review the facility failed to supervise and implement interventions to prevent a fall for 1 of 3 residents (R1) who had unknown history of Vasovagal [CONDITION(S)] ([CONDITION(S)] spell) reviewed for falls. This resulted in actual harm for R1 who sustained a head injury, was hospitalized , and was diagnosed with C1-C2 fractures. The findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and had diagnoses which included abnormalities of gait and mobility, anxiety disorder, age-related physical debility, cognitive communication deficit, history of falling, long term use of anticoagulants (blood thinner), mild cognitive impairment, age-related [CONDITION(S)] with current pathological fracture, [CONDITION(S)] and [CONDITION(S)]. The MDS also indicated R1 required extensive physical assistance of one staff with all activities of daily living except eating, had no pain, and for moving from seated to standing position and on and off the toilet R1 was not steady and only stabilized with human assistance. A report dated 6/12/22, indicated on 6/4/22, early morning, R1 had fallen off the commode after nursing assistant (NA)-A had thought something was wrong with R1 and had left R1 unattended despite the change in condition and gone to the door looking for help. The report indicated R1 had fell forward off the commode, hitting her forehead on the floor and had sustained a goose egg injury and had a headache. The report also indicated after the incident licensed practical nurse (LPN)-A continued taking R1's vitals and never notified the physician but at around 5:25 p.m. in-coming PM shift registered nurse (RN)-B thought R1 needed to go by ambulance to hospital. The report further indicated at the hospital a brain scan was completed and showed there was hematoma on the outside of the brain and R1 had sustained fractures on C1 and C2 which were caused by trauma from the fall. In addition, a neurologist consult indicated R1 was not eligible for surgery due to age and taking [MEDICATION(S)] thus R1 was hospitalized from 6/4/22, through 6/8/22. Review of R1's Progress Notes revealed the following information: -6/4/22, at 3:51 p.m. note indicated R1 had a fall from the commode which was in middle of room at 8:20 a.m. after staff removed a mechanical stand away from resident to provide cares and get R1 dressed. The note indicated R1 was unable to stated what happened, or what's wrong. R1 initially stated no pain when ask, then complained of back pain, then headache only and as needed Tylenol 1000 milligram (mg) was administered. The note also indicated R1 had sustained a purple/blue bruise with swelling to mid to left forearm measuring Width 8.0 centimeter (cm) by 9.0 cm, a purple/blue bruise to left side of nose measuring 3.0 cm by 3.0 cm and a small skin tear to left outer elbow. The note indicated following the incident neurological checks were within normal limits, the plan was staff was to monitor for additional bruising, pain, headaches, the responsible party was notified at 9:00 a.m. but the physician was notified until 4:05 p.m. which was 7 hours later after the incident and via fax. -6/4/22, at 11:59 p.m. note indicated R1's neuro check were done and no changes from the baseline but R1 was complaining of pain on her head and on her neck with grimacing facial expression when R1 was helped to remove her coat for blood pressure reading. The writer indicated R1 was leaning more on her right side, head was stiffed and complaints of pain when being moved and R1 had been sent to the hospital for medical evaluation. -6/8/22, note indicated resident was readmitted to the facility and had neck injury, Bruising noted on face, under eyes, nose, and cheeks. There is a bump on the right side of the forehead sustained from the fall. -Facility Resident/Visitor Incident Report dated 6/4/22, at 8:20 a.m. indicated R1 had a fall out of the commode when staff had moved the mechanical lift away from R1 to get R1 washed and dressed. The incident report indicated staff had peeked their head out of the room yelling for nurse and in that time frame R1 started dropping to the left and fell right out of the commode. The report indicated R1 was not sure what had happened, and the case manager review of the risk factors indicated R1 had history of vasovagal episode on the toilet/commode, intermittent confusion and comments/interventions Resident sent to ER for evaluation [eval]. The incident report further indicated assessed cause/contributing factors: Resident Action. During further review of the medical record, it was revealed, on 1/20/22, resident had been sent to the hospital to be evaluated related to [CONDITION(S)] and was sent back to the facility. The medical record lacked documentation of the facility implementing interventions for R1 to reduce the likelihood of another incident occurring. Additionally the facility was unable to provide evidence of training they provided staff to reduce re-occurrence. On 6/21/22, at 8:58 a.m. R1 was observed lying in bed with blue/purple bruises on the face, a large goose egg bump was observed in the middle of the forehead and R1 was wearing a neck collar. R1 was asleep at the time. R1's care plan 6/15/22, identified R1 was at risk for falls related to history of falls related to left hip fracture and mild cognitive impairment. The care plan indicated R1 had intermittent confusion and directed staff to ensure the bed was in the lowest position when occupied and my walker and/or wheelchair is out of hand reach. The care plan lacked documentation of what staff was supposed to do when R1 experience a vasovagal episode or how to ensure safeguards were in place in the event she experienced a similar incident. R1's falls Care Area Assessment (CAA) dated 8/31/21, identified R1 had the potential for falls related to decreased mobility and decreased cognition, age related muscle degeneration, and cognitive impairment. During interview on 6/21/22, at 9:52 a.m. NA-B stated R1 had sustained the goose bump on her forehead from a fall about two weeks ago and according to what she heard R1 had leaned forward when seated on the commode and had fallen. NA-B stated R1 was not supposed to be left alone as she was a fall risk even prior to this fall. NA-B stated since the incident happened the only training, they had received was using the Hoyer to transfer R1 as she was a E-Z Stand at the time of the fall and no other training had been provided regarding using the call light system to call for assistance when a resident had a change of condition instead of leaving them unsupervised. During interview on 6/21/22, at 4:23 p.m. NA-C stated because of R1's history of falls, leaning to the side and not being able to support herself she had never left R1 alone. NA-C stated she had seen R1 hematoma on the face and was shocked someone had left her unattended as R1 was at risk for falls. During interview on 6/21/22, at 3:06 p.m. family member (FM)-A stated R1 was at risk of falls and R1 could not be left unsupervised and that was the reason the staff did not get R1 up on the toilet because R1 could not hold herself. FM-A stated R1 had dementia and her answers are not reliable. FM-A stated the staff told resident to use the call buttons but in this incident the staff did not use it to avoid leaving R1 alone who subsequently fell and had injuries from the fall. FM-A stated the facility had started to use the mechanical lift because R1 was not able to hold herself and was not strong. FM-A stated due to the fall R1 had a forehead that was swollen, she sustained fractures and one of the front teeth was knocked out. FM-A also stated following the fall, R1 was using the neck collar to immobilize the neck, had a total change of self and was having trouble with eating. During interview on 6/21/22, at 2:48 p.m. NA-A stated that morning of the incident she had gone to R1's room to get her ready for the day and in the care plan they were allowed to take the E-Z stand from R1 to do the cares. NA-A then stated after she took it off, she had noticed R1 leaning to the left side, and she felt the nurse needed to check on R1. When asked why she had walked away from R1 if she felt the nurse needed to see resident, NA-A stated, I did not feel it was an emergency, I knew the nurse was out there and she was okay. She was alert, talking to me and I knew she had history of blackouts but in this case, she was her normal self even though she was slouching. I felt it was safe for me to walk away. I made sure the resident was okay before I walked away from her to call the nurse outside the room. If the nurse was not outside the room, I would have put the emergency call light. There was nothing wrong she has had a spell before not in the commode. She blacks out when having a bowel movement [BM] but she was talking in this incident. NA-A stated after the incident they had transferred R1 to the bed then when she rolled R1 she started to complain of her head, back and when she was washing under the arms, she was in pain lifting the arms up to clean and was crying. During interview on 6/21/22, at 4:36 p.m. RN-B case manager stated he was notified of the fall the morning of 6/4/22 and after R1 was sent in during the evening shift, he had received a call from FM-A who informed him R1 had the fractures in the neck. RN-B stated R1 had bruised after the fall because R1 was on [MEDICATION(S)] and from going through the fall and interviewing the staff, it appeared R1 was experiencing a vasovagal episode as R1 had a history of it when having a bowel movement. RN-B stated NA-A had gone to the door to get LPN-A to evaluate and wether R1 passed out or not, it was fast session of events. RN-B acknowledged the distance between the commode where R1 sat was technically five to six feet from the doorway, and NA-A was not within arm's reach of R1 and probably putting the call light would have been more appropriate to alert the nurse. RN-B acknowledged although the staff was aware R1 had a history of vasovagal for R1, the medical record lacked a care plan to direct staff what they were supposed to do in case of another episode. RN-B further stated hind sight it took a tragedy to bring light to certain things and he acknowledged before when R1 was ambulatory the care plan directed R1 was not to be left alone. RN-B also stated since R1 stopped ambulating she had never tried or attempted to self-transfer so, I may have taken it out. During interview on 6/21/22, at 11:13 the director of nursing (DON) stated staff used the E-Z Stand (mechanical lift) to transfer R1 to the commode and on the day of the incident after NA-A had transferred R1, NA-A had moved it out of the way to assist with care, which was normal. The DON then stated after removing the E-Z Stand NA-A had noticed R1 was starting to lean over to the side and that was when NA-A left R1 alone and had gone to the door to call LPN-A to come assess R1. The DON stated as NA-A turned back she observed R1 falling forward hitting the floor head first and NA-A was not close enough to stop the fall. The DON also stated following the fall, LPN-A came right away and assessed R1 and at that time R1 was starting to have bruising on her head, was complaining of a headache and no other injuries were apparent at the time. DON stated from what she knew R1 had never been impulsive wanting to self-transfer out of the commode when staff did the cares and because of that staff did not need to stand and be with her. The DON acknowledged following the incident she had not asked NA-A other than leaning over to the side what other symptoms R1 had that prompted NA-A to feel the need to get LPN-A into the room to assess R1. The DON stated when she interviewed NA-A, NA-A had indicated after R1 was starting to lean to the side, NA-A felt she needed to get LPN-A in the room as she knew she was right outside the room in the hallway. The DON stated NA-A had thought she was getting the LPN-A as soon as possible and did not expect R1 to tip off the commode. The DON stated there had not been any education completed for NA-A and other staff following the incident on not leaving residents alone if they had concerns with a change in condition. The DON stated the facility team thought the plan of care was being followed as resident was not usually supposed to be supervised. The facility NURSING CARE PLAN policy revised 2/26/20, directed the following: 3. Interventions should be written to help meet the goal. The interventions should be individualized to the patient and person-centered. A discipline or department which will be responsible for the intervention will be listed. This may be more than one discipline. 4. The care plan is to be changed and updated as the care requirements for the resident change. The care plan will be reviewed throughout the patient's length of stay and as required for MDS assessments . The facility PROCEDURE FOR FALLS revised 3/30/22, directed the following: Fall resulting in injury requiring further medical evaluation/treatment by a Provider 4. If a fracture of leg, hip, or pelvis is suspected through examination, or the resident complains of much pain, Do not move the victim. The ambulance Attendants will transfer directly onto a stretcher .

Based on interview and document review, the facility failed to ensure the administrator and State agency (SA) were notified within 2 hours of allegations of abuse, for 1 of 1 resident (R1) reviewed for abuse. Findings include: Facility filed incident report to state agency regarding an allegation of staff to resident abuse on 5/29/21 at 8:29 p.m. and indicated the incident occurred on 5/29/21 at 4:00 p.m. During an interview on 6/7/21 at 12:21 p.m., social worker (SW)-A stated she filed the incident to the state agency late and was aware of the 2-hour regulation. During an interview on 6/7/21 at 12:58 p.m., director of nursing (DON) verified the policy did not include the timeframe regulation for reporting to the state agency. DON stated she will make sure it is added to the policy. DON stated the expectation is to report allegations of abuse immediately to the state agency and not 4 hours following the allegation. During an interview on 6/7/21 at 1:59 p.m., administrator stated any concern should be reported immediately and report to state agency. Administrator stated she reviewed the policy and there is no indication of the mandated reporting timeframe's. Administrator stated she did review the regulation and any allegation of abuse should be reported to the state agency within 2 hours. Facility policy freedom from abuse, neglect, and exploitation/vulnerable adult policy revised 10/27/16 did not include mandated reporting timeframe's.

Based on interview and document review, the facility failed to ensure an allegation of employee to resident abuse was thoroughly investigated for 1 of 1 residents (R1) reviewed for abuse allegation. Findings include: Review of facility investigation documentation did not include other residents interviewed for concerns of abuse. Review of facility investigation documentation indicated other staff working during the shift were interviewed, the record lacked documentation of the interviews in the file. During an interview on 6/7/21 at 12:21 p.m., social worker (SW)-A stated staff working the evening of the alleged incident were interviewed but there is no documentation of the interviews or what was discussed. SW-A stated other residents were not interviewed for concerns of abuse following the allegation of abuse. During an interview on 6/7/21 at 12:58 p.m., director of nursing (DON) stated residents have not shared any concerns recently regarding staff or abuse. DON stated residents were not interviewed following the recent abuse allegation. DON stated staff working were interviewed but the interviews were not documented. DON stated it is expected to keep resident safe by staff reporting concerns and removing the alleged perpetrator if known from the situation and monitor if not sent home. During an interview on 6/7/21 at 1:59 p.m., Administrator stated she would expect the alleged perpetrator to be removed from the situation and monitored until removed from facility to keep all residents safe. Administrator stated residents and staff had not voiced any concerns prior and they were talked to but it was not documented and stated it should have been. Facility policy freedom from abuse, neglect, and exploitation/vulnerable adult policy revised 10/27/16 included all reports will be reviewed by a minimum of two staff to determine if the occurrence is reportable and take all necessary corrective actions depending on the results of the investigation. It included internal investigation information will be kept on file.

Based on observation, interview, and document review, the facility failed to ensure proper disposal of [MEDICATION NAME]es (an opioid patch delivery system), to prevent potential diversion. This had the potential to affect all residents who resided in the facility. Findings include: During medication storage review of the north medication cart on 8/15/19, at 10:03 a.m. licensed practical nurse (LPN)-A stated if a resident was receiving [MEDICATION NAME], the patch was removed with gloves on, folded in half, folded inside a plastic glove that was then placed in a sharps container that was in the medication cart. LPN-A opened the med cart drawer, a sharps container was observed, the opening of the sharps container, LPN-A verified someone could reach in with a couple of fingers and/or use an object to retrieve the glove. During medication storage review on the unit referred to the Add unit on 8/15/19, at 12:10 p.m. licensed practical nurse LPN-B stated the same process for [MEDICATION NAME] disposal as LPN-[NAME] LPN-B opened medication cart which had the same type of sharps container as the north unit medication cart. During an interview on 8/15/19, at 1:54 p.m. consulting pharmacist (CP)-B stated [MEDICATION NAME]es were supposed to be wasted with two nurses and flushed down the sewer. During an interview on 8/15/19, at 6:17 p.m. CP-A indicated it was not appropriate to put used [MEDICATION NAME]es in a sharps container. CP-A stated that the facility was currently looking into a medication destroying system that does not go into the sewer to meet environmental protection guidelines. Policy was requested and not received.

Based on interviews, and document reviews, the facility failed to establish an on-going infection prevention program including comprehensive analysis and interpretation of data to identify and respond to possible patterns of infection. This had the potential to effect all residents in the facility. Findings include: During an interview and record review 8/15/19, 10:14 a.m. registered nurse (RN)-A stated she was responsible for the Infection Prevention program in the facility; however, RN-A stated surveillance to identify possible communicable diseases or infections falls on the nurses. RN-A said, they watch those who don't feel good. They monitor them. We have staff who work pretty much in one or two areas so they know if they(residents) are out of sorts. RN-A said she would check a log book each day to see if any staff had been ill, but confirmed she had not taken notes or compared staff illness to resident illness to determine any possible spread. RN-A said a multidisciplinary team would meet each morning at 10:30 a.m. and discussing resident illness and any symptoms that might need to be monitored. RN-A stated she did take notes to refer back to, but during a review of notes, RN-A confirmed the only notes related to infection were when nurses had sent urinalysis to the lab. RN-A was unable to identify any actions, such as auditing of cares, hand washing or the provision of education done in response to reported symptoms or infections identified in order to prevent a possible spread. She was unable to define how the facility assured staff were following the facility policies and procedures for infection prevention and control. RN-A did say, a few years ago we did some mandatory testing and education. In addition, RN-A stated she did keep a log of facility infection rates that she would complete at the end of the month; however, she confirmed she was not documenting symptoms or diagnosed infections on a daily basis in order to monitor for patterns or possible spread of infection. A review of the facility infection monitoring log showed a line listing of persons who had had a diagnosed infection which included any lab work done, the infectious organism, start and stop dates for antibiotics. The monthly logs did not include any residents who may have had symptoms indicative of an infection not treated with antibiotics (such as [MEDICAL CONDITION] symptoms, example: cold symptoms or gastro-intestinal symptoms such as diarrhea). The monthly log did not include information to identify if the infections were facility acquired or community acquired and did not include information about employee infections or any possible correlation or absence of correlation. The logs did not include a comprehensive analysis of the type of infections, locations and whether or not there were any patterns or spread within the facility. Month to month patterns and correlations were not included. For each person listed on the log, an additional form was included for review of the facility practice related to documentation, follow-up and outcomes. The forms were inconsistently filled out, leaving blank spaces where guidance was provided to document actions taken to prevent the spread of infection. During an interview on 8/15/19, at 2:09 p.m. the director of nursing (DON) stated the morning 10:30 meeting was the time they would talk about infections. DON confirmed that the meeting minutes related to infection control or prevention were not documented, but said they listed the names of people they had discussed. DON said because they had a meeting every day the information sticks in your head and if they heard about a problem multiple times they would then talk about what might be causing it. DON said anything significant as far as resident infections would be put on a sheet that gets sent to the physician, but was unable to identify what happened to that sheet as far as providing a record of action. DON confirmed the facility had a monthly log of infections, but it was not done in real time and was a look back listing of what had occurred during the month, not a record that provided an interpretation the data collected. Facility provided policies and procedures related to infection prevention. A policy titled Good[NAME]Lutheran Home Infection Control Policy last revised 5/18/19 indicated infections are identified, investigated, controlled, reported as appropriate and prevented through implementation of the infection control program .A designated Infection Control Nurse assists in the vaccination programs, TB screening, monitoring of infection, updating infection control practices, and quality improvement program .The Director of Nursing, Infection Control Nurse, Case Managers and Staff Development Coordinator will meet daily Monday through Friday to review any new infections and evaluate for any patterns or potential for exposure to other residents and staff. The Infection Control Nurse will track all infections according to the wind the resident resides on and monitor staff illnesses during the month. At the end of each month, the Infection Control nurse will compile all infection and they will again be reviewed and a synopsis of the month's infections will be added to the log. This synopsis will also correlate any resident illnesses during the month with any staff illnesses that were reported ruing the same month. The policy fails to indicate that an ongoing process should be outlined related the analysis of the data or monitoring of the facility practices related to infection control and prevention.

Based on interview and document review the facility failed to complete a level II preadmission screening and resident review (PASRR) for 1 of 1 residents (R15) reviewed with a new mental illness diagnosis. Findings include: Review of R15's [DIAGNOSES REDACTED]. R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident received an antipsychotic medication daily. Review of R15's current physician orders [REDACTED]. Review of R15's care plan printed 8/15/19, included: I have alteration in mood/[MEDICAL CONDITION] drug use with s/s (signs/symptoms) of depression related to [MEDICAL CONDITION], hallucinations, and depression and use of [MEDICAL CONDITION] drugs m/b (manifested by) episodes or crying. When interviewed on 8/14/19, at 2:55 p.m. the social services director (SSD) confirmed R15 did not have a level II PASARR since diagnosed with [REDACTED]. SSD further stated she had just made a referral to the county to have one completed.

Based on observation, interview and document review, the facility failed to provide meaningful activities for 2 of 2 residents (R41 and R28) reviewed who were dependent on staff to meet their activity needs. Findings include: R41's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R41 had cognitive impairment, and identified the resident's daily activity preferences to include: listening to music, to be around animals such as pets, keep up with the news, participating in religious activities or practices, and to be able to do favorite activities. Each of these activities were coded on the MDS as very important to R41. R41's quarterly MDS dated [DATE], indicated R41 had severe cognitive impairment and required total dependence with locomotion on the unit. During observation on 8/12/19, at 3:13 p.m. R41 was lying in bed on her back. During observation on 8/13/19, at 10:20 a.m. R41 was lying in bed on her back with her eyes closed, covered with a blanket. During observation on 8/13/19, at 2:41 p.m. R41 was lying in bed on her back with her eyes closed, covered with a blanket. During observation on 8/14/19, at 1:36 p.m. R41 was lying in bed with eyes closed. R41's Admission Record identified an admitted [DATE], and [DIAGNOSES REDACTED]. R41's current care plan, identified R41 as social and willing to attend activities, uses a wheelchair and needs assistance in getting to groups. The care plan further indicated R41 can be anxious, and requires reassurance from staff. R41's goals included: R41 to agree to attend 2-3 social groups, R41 would like sensory/1:1 visits from activity staff weekly. In addition, interventions included: Activity staff to assist with card playing in group, supplies and location, assist in planning leisure-time activities, and encourage to plan own, engage in group activities, give verbal reminders of activity before commencement of activity, transport to activities, when seated in church an empty chair facing backwards should be next to her to deter others from sitting at arm's length beside her. Review for R41's activity participation for the last 3 months identified the following: On 5/22/19, at 4:26 p.m. 1:1, R41 and I played a match game, R41 was pleasant and did very well. On 5/29/19, at 4:16 p.m., 1:1, I sat with R41 and asked if she wanted a break from coloring, R41 nodded yes to color coordinating colored embroidery floss. R41 worked very well at separating. On 6/4/19 at 4:41 p.m. 1:1, R41 very quiet but wanted to go to the dining room. I showed her flowers in the garden. R41 said they were pretty. On 7/10/19, at 1:26 p.m. R41 continued to spend time in the lobby coloring and watching what is taking place. Activities have 1:1's with her and take her to music events. There are no activity concerns at this time. On 7/23/19, at 4:49 p.m. R41 seemed sleepy, just nodded and smiled when talked with. On 8/8/19 at 12:36 p.m. R41 was coloring and I chatted with her. R41 smiled and nodded her answers. R41 said she was cold and I got her a blanket covering her shoulders. R41 was thankful and pleasant. Review of R28's point of care (P[NAME]) Response History, from 7/14/19 to 8/14/19, identified the following activities that were attended: 7/20/19: family or pastoral visit 7/23/19: beauty shop/grooming 8/6/19: beauty shop/grooming 8/8/19: napping 8/11/19: afternoon religion During interview on 8/15/19, at 11:00 a.m. therapeutic recreational specialist (TRS)-A stated, I have worked here for [AGE] years. When a resident is first admitted , we ask what their hobbies are, and at every care conference we should be updating the care plan as to what their hobbies are. We document in PCC (point click care) anytime anyone attends an activity. (R41) enjoys 1:1's, coloring, she gets her fingernails done every week, folding washcloths, music and church activities. TRS-A verified the music activities are usually in the afternoon when R41 naps. TRS-A verified R41's care plan has not been updated for quite some time to reflect her current activities and that R41's needs have changed. TRS-A also stated, We need to get better at documenting resident refusal to activities. During interview on 8/15/19, at 3:08 p.m. activity director (AD)-A stated, ( R41) has declined, she used to like to play cards, she likes to color, it all depends on her current mood. Her care plan needs to be updated to reflect the changes in her activities. R28 During observation on 8/12/19, at 3:27 p.m. R28 was seated in her recliner. During observation on 8/13/19, at 10:23 a.m. R28 was seated in a Broda chair (a tilt in space positioning chair), up to a table in the lobby with her head slumped to the side and eyes closed. During observation on 8/13/19, at 2:45 p.m. R28 was seated in her recliner in her room with her legs elevated and a blanket over her legs with her eyes closed. During observation on 8/14/19, at 10:34 a.m. R28 was seated in her Broda chair up to the table in the lobby drinking some coffee, with a newspaper in front of her on the table. R28's annual, MDS, dated [DATE], identified R28 to have short and long term memory problems, severely impaired cognitive skills for daily decision making. No [MEDICAL CONDITION], behavioral symptoms, or rejection of care. Staff assessment of activity preferences identified R28 prefers reading books, newspapers, magazines, listening to music, spending time outdoors, and participating in religious activities or practices. R28's Admission Record identified an admitted [DATE], and [DIAGNOSES REDACTED]. R28's care plan revised 6/21/19, identified R28 is independent on activity staff for social interaction and would like to have one to one visits from staff. R28 goal will be to maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions for R28 are to encourage ongoing family involvement, invite family to attend special events, activities, and meals, R28 needs escorts to activity functions, introduce R28 to residents with similar background, interests and encourage and facilitate interaction, invite me to scheduled activities, R28 preferred activities are social groups and music. Review of R28's activities for the last 3 months of progress notes identified the following: On 5/22/19, at 4:57 p.m. 1:1 sat with R28 and asked how she was. R28 said she felt dirty and scared, something about a man. R28 was assured she was safe, after chatting for a while she said she was feeling better. I gave her birds and blooms to look over and she said thank you. On 6/13/19 at 4:26 p.m. R28's care conference was held with care plan team and hospice. There have been no activity changes, will continue one to one with staff. On 6/19/19 at 11:12 a.m. 1:1, showed her flowers in a magazine and chatted, R28 was so busy, but didn't know with what. On 7/10/19, at 1:37 p.m. 1:1, R28 sat with her eyes shut, she answered a few questions, very tired. On 7/16/19, at 3:10 p.m. 1:1, tried to play matching game, no response, asked if she would like to fold washcloths and R28 replied, no, it's too hard for me. Read to her, she fell asleep. Review of R28's P[NAME] Response History, from 7/14/19 to 8/14/19, identified a family or pastoral visit on the following days: 7/22/19, 8/5/19, 8/7/19, 8/9/19, 8/12/19, and 8/15/19, no other activities were noted in R28's medical record. During interview on 8/15/19, at 11:30 a.m. TRS-A stated, R28 has been more tired since being on hospice and has been progressively declining. R28 has not really been participating in activities, she needs more one on one activities. TRS-A verified there was very little documentation of activities offered. During an interview on 8/15/19, at 3:15 p.m. activity director (AD)-A verified there was not much documented for R28's activities and stated, R28's goal would be to at least have 2, one to one visits per week. During interview on 8/15/19, at 3:24 p.m. director of nursing (DON) stated, I would expect a resident, regardless of their ability, to have activities offered to them whether it be an individual, group, or one to one activity. The facility's untitled, undated facility policy, identified the following: We are responsible for providing purposeful/meaningful activities to the residents, and at times their families as well. Activities are provided on the basis of personal interests of the resident and specific goals established upon admit with the activity director. These interests and desires for specific activities are re-evaluated every 3 months, and new goals are established again at that time. This department is responsible for providing activities that assist the resident to maintain or promote social skills. Spiritual/emotional well-being, physical function, and problem solving/cognitive skills. The resident has the right to refuse activities, or choose visits of one to one nature within their room, rather than the group setting. Our main focus in this department is to provide a program that motivates residents to become comfortably involved in the facility, and ultimately maintain an active and fulfilling lifestyle.

Based on observation, interview and record review the facility failed to give a medication as prescribed by the physician for 1 of 2 residents (R40) reviewed for hospitalization , and the facility failed to monitor and assess respiratory status for 1 of 1 residents (R164) review as a closed record. Findings include: MISSED MEDICATION R40's quarterly Minimum Data Set ((MDS) dated [DATE], included a brief interview for mental status (BIMS) score of 15/15 indicating intact cognition, and [DIAGNOSES REDACTED]. When interviewed on 8/12/19, at 4:00 p.m. R40 stated being hospitalized around a month ago as had terrible thrush (An infection of the mouth caused by the [MEDICAL CONDITION], also known as yeast.) and couldn't eat. R40 stated her sister had taken her to the ER (emergency room ) in (name of city) and was hospitalized from there. R40's hospital discharge summary dated 7/17/19, included the following: Patient was admitted on [DATE] to OBSERVATION for throat pain and dehydration secondary to oropharyngeal thrush. She was given IV (intravenous) fluids overnight and started on oral [MEDICATION NAME] (medication used for fungal infections). The following morning her mouth pain had resolved and she ate breakfast and drank fluids. She felt well and wanted to go home. She should continue [MEDICATION NAME] swish and swallow for 10 days. R40's physician order [REDACTED]. R40's Temporary Care Plan: Infections, dated 7/18/19, included: [MEDICATION NAME] suspension swish mouth QID (four times a day) x 10 days. Review of R40's Medication Administration Record [REDACTED]. D/C (discontinued date) 7/22/19. The MAR indicated [REDACTED]. R40's progress note dated 7/22/19, at 13:23 (1:23 p.m.) indicated: Consultant Pharmacist Medication Regimen Review Review Findings:: Hospital readmission pharmacy review and medication reconciliation performed. Noted no entries for [MEDICATION NAME] administration MAR for her thrush. Also no administration instructions to rinse mouth after [MEDICATION NAME]. Recommendations: Confirm she is getting her [MEDICATION NAME] and have note to rinse mouth with water or mouth wash after [MEDICATION NAME] to reduce thrush risk. Further review of R40's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Further, the resident had a lapse of 3.5 days when she did not receive the medication. When interviewed on 8/15/19, at 9:55 a.m. clinical manager (CM)-B confirmed the nurse that transcribed R40's [MEDICATION NAME] order dated 7/17/19, had transcribed the order incorrectly. CM-B further confirmed this was not caught until 4 days later when the consulting pharmacist identified the error. CM-B also stated R40 had recently completed another course of the [MEDICATION NAME] as the thrush had started to return. Review of a fax to R40's physician dated 8/2/19 included the following: 7/17 had thrush in mouth - hospitalized at (initials of hospital) x 1 day. Today has white patches under tongue similar to B/4 (before). The (initial of hospital) ordered below plus to hold her [MEDICATION NAME] (inhaler) thinking it might be the cause of the thrush. 1) [MEDICATION NAME] 5 ml swish & swallow 4 x daily x 10 days. (100,000 u/ml suspension) 2) Do you want to hold [MEDICATION NAME] while on [MEDICATION NAME] Physician response: 1) OK to proceed with above orders. 2) Hold [MEDICATION NAME] while on [MEDICATION NAME]. When interviewed on 8/15/19, at 11:27 a.m. R40 stated when she returned from the hospital it took a while for her mouth to start feeling better. R40 confirmed there was a period upon return where she didn't have the [MEDICATION NAME] swish and swallow; wasn't sure if it was because they didn't have it or someone thought she wasn't supposed to get it. R40 confirmed her mouth was still sore upon return from the hospital and it was still difficult to eat regular foods unless they were soft or mashed. R40 further stated having thrush once before but not nearly as bad. R40 confirmed the thrush was terribly painful and utilized her as needed [MEDICATION NAME] (a narcotic pain medication) that she also took for her other aches and pains, to help with the mouth pain. R40 stated it was probably a week before the pain got better. When interviewed on 8/15/19, at 1:57 p.m. the pharmacist consultant confirmed on 7/22/19 while conducting R40's medication review, discovering R40's [MEDICATION NAME] had not been given past 7/18/19. Pharmacist confirmed the residents thrush potentially could have gotten worse with the lapse in receiving the medication. When interviewed on 8/15/19, at 2:22 p.m. the medical director confirmed R40's thrush potentially could have gotten worse with the lapse in administering the [MEDICATION NAME] swish and swallow as ordered. When interviewed on 8/15/19, at 2:49 p.m. the director of nursing (DON) stated when a resident returns from the hospital the nurse who readmits the resident would look over their paper work for any new orders or order changes. If there was a new order another nurse or TMA (trained medication aide) would double check the transcribed orders. DON confirmed there should have been 2 staff that signed off on R40's [MEDICATION NAME] order dated 7/17/19. DON reviewed R40's medical record and confirmed the order was put in by the case manager but did not have it double checked. DON confirmed this shouldn't have happened with R40's [MEDICATION NAME] order because there was a system in place. DEATH RECORD R164's Admission Sheet indicates R164 had a [DIAGNOSES REDACTED]. R164's physician orders [REDACTED]. Orders also indicated oxygen saturations (SpO2) where to be checked every two hours during the night if R164 was not wearing her bi-pap. Oxygen therapy was to be provided at 2 liters per minute to maintain SpO2 levels of 86-90%. On 7/23/19, R164's progress notes indicate R164 went to her routine [MEDICAL TREATMENT] treatment. Facility received call at 1:00 p.m. that due to low BP and low SpO2, R164 was transferred to the hospital intensive care unit. [MEDICAL TREATMENT] recommended transfer to a different (larger) hospital's emergency room (ER) for further evaluation due to a decline in her status. At 2:28 p.m. facility received a call from the [MEDICAL TREATMENT] treatment center informing them that R164 would be returning to the facility from the ER as condition had stabilized, but they wanted to attempt [MEDICAL TREATMENT] again the following morning. R164 progress notes indicated R164 returned to the facility from theER on [DATE] at 3:45 p.m. At 6:30 p.m. progress note stated nurse found R164's oxygen saturation to be low at 75% and nurse applied oxygen at a rate of 2.5 liters per minute. Nurse wrote it took an hour for R164's oxygen saturation to fall into the desired range of 86 and 90%. Progress note also indicated staff provided bedtime cares to R164 at 10:00 p.m. and she refused to have her bi-pap machine (a machine that applies pressure to maintain an open airway when a person has significant sleep apnea) applied. Progress note was entered into the record at 11:05 p.m. A review of R164's record failed to show any further documentation of assessments, vital signs, oxygen saturation checks or cares by nurse or nursing assistant after 11:05 p.m. On 7/24/19, 6:33 a.m. a progress note indicated that R164 was found unresponsive and nurse attempted to assess vital signs but was unable to identify signs of life. Family, physician and funeral home were notified of R164's death. During an interview on 8/15/19, at 3:56 p.m. the director of nursing (DON) stated she remembered that R164 had refused to be admitted to the hospital and that was the reason she was returned to the facility. DON said she understood R164's oxygen saturation rates were running lower than they were supposed to. DON stated the facility did not have a protocol for vital sign frequency unless a person had been returning from a hospital admission. DON said she had received report that R164 had been alert and talking to staff at 3:30 a.m. but confirmed there was no further documentation in the record during that shift. A request was made for a policy related to oxygen use and monitoring vital signs with a change in condition. Facility provided a policy titled Oxygen Administration Policies and Procedures last reviewed 4/4/19. According to the policy, residents will have physician orders [REDACTED]. Oxygen may be administered by a licensed nurse in an emergency according to each resident's Standing Orders. The attending physician will be notified of a status change and for continued oxygen orders. Policy does not indicate vital signs or respiratory assessment that should be done when a person is receiving oxygen. A policy titled Resident Status Change and Notification of Attending Physician Policy and Procedure, not dated, was provided. The policy stated all nursing home staff are responsible for observing and reporting changes in a resident's status. Licensed Nurses and other care plan team members are responsible for assessing these changes to identify potential or actual problems and responding with intervention. These interventions are communicated to appropriate staff and through the multidisciplinary care planning process. The procedure identified that the attending physician should be notified immediately when there is: .a significant change in the resident's physical, mental or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). In addition, the procedure included the following Red flags: .low O2 sats (SpO2) or SOB (shortness of breath) . The procedure also indicated a nurse should look for a reference book called Symptom Pursuit at the nursing station which would provide guidance in assessment and documentation needs.

Based on observation, interview, and document review the facility failed to ensure a narcotic emergency kit (E-kit) was appropriately secured in 1 of 1 emergency kits reviewed. Findings include: On 8/15/19, at 9:45 a.m. a tour of the north locked medication storage room was completed with licensed practical nurse (LPN)-[NAME] LPN-A indicated the north medication room was where the facility's emergency kit was kept. The E-kit was located on an open shelving unit inside the medication room that was accessible to any staff who had a key to the room. The E-kit resembled a medium size fishing tackle box that had two breakaway plastic ties that were numbered. Contents of the E-kit included: -6 tabs [MEDICATION NAME] 0.5 milligram (mg) tablets -2 vials [MEDICATION NAME] 2mg/milliliter (ml) injectable 1 ml -1 30 ml vial [MEDICATION NAME] 2mg/ml oral solution -6 tabs [MEDICATION NAME] (narcotic pain medication) 5/325 mg tab -1 30 ml vial [MEDICATION NAME] 20mg/ml oral solution -6 tabs [MEDICATION NAME] 15 mg immediate release -6 tabs [MEDICATION NAME] 5 mg immediate release LPN-A confirmed the E-kit with opioid narcotics was not secured by double locking system. LPN-A stated nurses, trained medication assistants (when they pass medications), quality assurance coordinator, and the director of nursing (DON) had keys to the locked medication room. LPN-A stated the E-kit was opened when a medication was needed, the numbered breakaway tabs were removed, the medication was removed and logged, then new breakaway tabs were put back on, and pharmacy was notified a medication was removed. LPN-A indicated the pharmacy would then come pick up the box and replace it. LPN-A stated the narcotic medication was not counted by nursing staff. During an interview on 8/15/19, at 10:14 a.m. director of nursing (DON) stated the pharmacy tags serve as a double lock because they have to sign out the tags. DON indicated that the narcotic medication was not counted every shift. During an interview on 8/15/19, at 10:22 a.m. pharmacist confirmed that the facilities E-kit was not double locked and probably should be. During an interview on 8/15/19, at 6:17 p.m. consultant pharmacist (CP)-A indicated that the emergency kit opioid medications should be double locked and counted as the other narcotic medications in the facility. CP-A indicated that the narcotic medications should be more controlled and there should be limited staff access to the controlled medications. Undated facility policy Storage of Drugs included: 2) Schedule II and III controlled drugs are stored in separately locked compartments under double lock. The policy did not address schedule IV and V. Emergency Drug Administration did not did not specifically address the security requirement for opioid medications.

Based on observation, interview, and document review, the facility failed to provide provision of physician services 24 hours a day, to respond to emergencies that do not require medical care in an alternative setting. This had the potential to affect all 65 residents. Findings include: During an interview on 9/26/18, at 3:18 p.m. licensed practical nurse (LPN)-A stated the facility did not have an on-call physician and nurses were to call the emergency room (ER), and get orders from there, however, usually ER providers wouldn't give orders over the phone and the resident would have to go to the emergency room . LPN-A stated during the daytime hours there is a provider available. During an interview on 9/26/18, at 3:40 p.m. case manager (CM)-C stated the facility did not have an on call physician and that had changed a while ago. CM-C indicated if a resident needed something, they would have to be sent to the ER. During an interview on 9/27/18, at 12:53 p.m. director of nursing (DON) verfied there was not 24 hour a day physician services available to call. DON then said that they had it in the past except(NAME)Health had determined the cost of having an on-call physician was not cost effective. DON stated the facilities primary physician (acting medical director) and nurse practitioner are not always available after hours. DON stated the facility was advised to fax notifications for such things as falls over to the clinic and also indicated(NAME)Health staff representatives advised the facility on sending residents to the emergency department for care and treatment even if the need was not emergent. During interview via phone on 9/27/18, at 1:49 p.m. with the nursing home's medical director (MD) who verified there have not been any on-call physician services for the last few months. When asked who the nurses would contact with a blood sugar over 400 after hours or on the weekend, MD stated, they would have to go to the ER. Facility provided a document addressed to medical director from the administrator, it indicated, that effective on 6/1/18, there will be no NP (nurse practitioner) coverage available to care for resident's after 5:00 p.m. and weekends. To meet the care needs of residents after 5:00 p.m. and weekends Good(NAME)will have the nurse on duty determine if a resident needs to be sent to(NAME)Health Emergency Department. As Medical Director of Good(NAME)Lutheran Services of Rushford please advise if you have a different plan than sending residents to the ED (emergency department) at(NAME)Health after 5:00 p.m. and weekends when the nurse on duty at Good(NAME)makes that determination. Facility provided a document from the director of nursing (DON) to all nurses dated 8/16/18, and it indicated, If you need after hours/weekend MD assistance first call(NAME)Health Emergency Department. (If it is an emergency just send them via ambulance), but if the emergency department can't/won't help you and it is minor/something you really don't need to send them for, call a case manager or me and we will see if we can help. We need to be calling the ED first though, so our calls get logged to prove/disprove the need for an on call/after hours provider, so it is very important you start with them. Background: There was a discussion at a recent meeting between(NAME)Health and area nursing homes regarding the loss of the on call provider for afterhours/weekends. At this time they are not reinstating a specific on call provider. What(NAME)Health representative noted was, There has been some discussion with the ED Chief. Decided this should be monitored for frequency and reason and use that data for a future discussion with the ED. See F684: R61's significantly high blood sugars were not reported to a physician. Policy for physicians services requested and not provided.

Based on interview, and document review the facility failed to develop policies and procedures to ensure non-emergent resident needs were met outside an alternative care setting and failed to take action in order to procure 24 hour physician services for non-emergent medical needs that could be addressed at the facility instead of an emergency room setting. This had the potential to effect all 65 residents residing in the facility. Findings include: Facility provided a document addressed to medical director from the administrator, it indicated, that effective on 6/1/18, there will be no NP (nurse practitioner) coverage available to care for resident's after 5:00 p.m. and weekends. To meet the care needs of residents after 5:00 p.m. and weekends Good(NAME)will have the nurse on duty determine if a resident needs to be sent to(NAME)Health Emergency Department (ED). As Medical Director of Good(NAME)Lutheran Services of Rushford please advise if you have a different plan than sending residents to the ED at(NAME)Health after 5:00 p.m. and weekends when the nurse on duty at Good(NAME)makes that determination. Facility provided a document from the director of nursing (DON) to all nurses dated 8/16/18, and it indicated, If you need after hours/weekend MD (medical doctor) assistance first call(NAME)Health Emergency Department. (If it is an emergency just send them via ambulance), but if the emergency department can't/won't help you and it is minor/something you really don't need to send them for, call a case manager or me and we will see if we can help. We need to be calling the ED first though, so our calls get logged to prove/disprove the need for an on call/afterhours provider, so it is very important you start with them. Background: There was a discussion at a recent meeting between(NAME)Health and area nursing homes regarding the loss of the on call provider for afterhours/weekends. At this time they are not reinstating a specific on call provider. What(NAME)Health representative noted was, There has been some discussion with the ED Chief. Decided this should be monitored for frequency and reason and use that data for a future discussion with the ED. During interview via phone on 9/27/18, at 1:49 p.m. with medical director (MD) verified there have not been any on-call physician services for the last few months. On 9/27/18, at 5:28 p.m. administrator verified there was no on-call 24 hour physician services for residents who did not need emergency care in an alternative site. Administrator indicated an unawareness of the need and/or the requirement for providing 24 hour a day physician services.

Based on observation, interview, and document review, the facility failed to ensure appropriate infection control measures to prevent the spread of infection for 2 of 2 residents (R3 & R13) during wound care and personal cares. Also the facility failed to provide a policy and procedure for the prevention of legionella/water borne infections/diseases, which had the potential to affect all 65 residents who resided in the facility, staff and visitors. Findings include: R3 had been observed on 9/25/18, at 6:31 p.m. to receive personal cares by nursing assistant (NA)-I and NA-J. There was a basin of water located on a table. Nursing assistant (NA)-I assisted R3 to roll over onto her right side, while NA-J washed R3's back, and put the towel next to the basin of water. NA-J then used wet-wipes to provide stool incontinence care, used a new washcloth to wash R3's bottom, and returned the soiled washcloth to the basin of water. NA's then assisted R3 to rollover onto the back. NA-J did not change gloves, and without changing the water and using the same washcloth that was used to clean R3's bottom, NA-J cleaned R3's peri-area and vaginal area. During an interview on 9/25/18, at 6:44 p.m. NA-J confirmed R3's front was not washed first, and the washcloth used to clean R3's bottom was placed in the water and then same water and cloth used to clean R3's vaginal area. NA-J stated after cleaning R3's bottom, should have changed soiled gloves, got new water and a new washcloth. During an interview on 9/26/18, at 4:28 p.m. case manager (CM)-B indicated the peri-care was not performed appropriately, stated NA should have changed glove after soiling gloves, obtained new water, and a new washcloth. R13 had been observed on 9/26/18, at 9:25 a.m. seated on a shower chair. Nursing assistant (NA)-G washed hands, donned gloves, clamped R13's indwelling catheter, removed R13's urine collection bag, then sanitized the collection bag and catheter ends, and placed the collection bag on the back of R13's wheelchair. NA-G with the same soiled gloves on, removed R13's wound dressing from his right heel. NA-G then washed her hands. NA-G verified she had used the same gloves to sanitize and handle R13's urine collection bag and removed the wound dressing with the same gloves. NA-G stated she should have removed her gloves washed and/or sanitized her hands and use new gloves to remove the wound dressing. During an interview on 9/26/18, at 10:42 a.m. licensed practical nurse (LPN)-A stated the NA should have changed gloves between handling the catheter bag and taking off the wound dressing. During an interview on 9/27/18, at 12:53 p.m. director of nursing (DON) stated the NA should have changed gloves between handling the catheter and removing the wound dressing. LACK OF WATER BORNE INFECTION/DISEASE PLAN: Review of facility document, Legionnaires Prevention Plan, dated May, (YEAR), indicated minimal information of a purpose, procedure, water source and initial assessment, with an attached sheet showed visual checks for stagnant water were performed once in (MONTH) and (MONTH) of (YEAR). The attached sheet had a yellow note pad that had handwritten in pen the following words, this is what I have for now if surveyors ask. During interview on 9/25/18, at 1:37 p.m. registered nurse (RN)-B (head of infection control program) stated, our legionella plan is nonexistent. I told the administrator it needed to be done and he was going to check with other administrators, and it never got done. During interview on 09/26/18 02:34 p.m. director of nursing (DON) stated, as far as I know this is all we have for Legionella (see above), a legionella prevention plan. I am not sure if we have a current policy, the administrator handled all of that.

Based on observation, interview and record review the facility failed to provide adequate supervision and interventions to protect vulnerable residents from resident to resident altercations for 4 f 4 residents (R46, R70, R15, R44) in the sample who were subject to R18 ' s verbal and sexual physical behaviors. This deficient practice resulted in Immediate Jeopardy (JP). The administrator and director of nursing were notified of the IJ on 6/17/1`1 at 3:30 p.m. The IJ was removed and corrected on 6/20/11 at 11:30 a.m. In addition, the facility failed to secure an oxygen tank for 1 of 1 resident (R61) reviewed in the sample who received continuous oxygen. Findings include: A review of R18 ' s progress noted from 11/12/10 to 06/15/11, revealed that R18 had had exhibited multiple inappropriate verbal and physical behaviors towards other residents, staff and visitors and many of these behaviors were sexually inappropriate. It also revealed that R18 had been involved in inappropriate physical contact with R46, R70, R15 and R44 and the facility failed to provide adequate supervision to protect these residents. R46 had a facial growth picked at by R18, without adequate supervision of R18, without facility investigation, and without reporting to the designated state agencies. This was the first documented physical resident to resident altercation by R18. No other information concerning this incident was provided by the facility. R46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of R46's admission Minimum Data Set ((MDS) dated [DATE], revealed R46 had severely impaired cognitive skills for daily decision making, did not ambulate and was totally dependent on staff for locomotion. A review of R46's care plan revealed that R46 had impaired cognitive function, needed staff " supervision for safety " and was " highly vulnerable to abuse." During the resident council representative interview, the resident stated that R18 had twisted a mole on R46's face. The resident stated she had reported it to a nurse. During an interview on 06/16/2011, at 3:02 p.m. R18's case manager, licensed practical nurse (LPN)-E verified that the incident had been reported to the nurse and that it had occurred on 02/03/2011. During an interview on 06/16/2011, at 3:17 p.m. registered nurse (RN)-B verified that the incident had been reported to her and that she had written a note dated 02/03/2011, in R18's record indicating that R18 "went up to another resident and started picking at a mole on (R46's) face." R46's record contained no mention of this incident. There was no further information provided or found in the medical record that R46 had interventions put in place to protect them from further resident to resident altercation with R18. R18 had not been reassessed following the resident to resident altercation and behavior interventions reviewed for effectiveness or if new interventions were needed to address R18 ' s behaviors. During an interview on 06/16/2011, at 1:06 p.m. the director of nursing (DON) was asked if changes to R18 ' s care plan interventions had been put in place or if the current interventions were appropriate and she said that there had been no change following this incident with R46. R70 was physically grabbed in the groin by R18, without adequate supervision of R18. Record review of R18's progress notes dated 2/26/11, at 10:02 p.m.; revealed R18 grabbed the groin of R70 which lasted 1/2 minute. The note revealed staff intervention was to remove R18 from the area and informed R18 that behavior was not ok. Record review of facility progress notes for R70 revealed from 2/1/11-3/1/11, there was no documented evidence of R70 grabbed in the groin by R18 on 2/26/11. Record review of facility incident reports revealed no documented evidence of R70 touched in the groin by R18 on 2/26/11. During observations on 6/15/11, at 3:15 p.m. and 6/16/11, at 1:40 p.m., R70 sat quietly in a wheelchair in his room watching television. Record review revealed R70 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of the facility vulnerability risk factors dated 1/25/11, revealed R70 was not oriented to time, place, or person, demonstrates no aggressive behaviors toward others, unable to report abuse or neglect, had history of physical and verbal abusive behavior, no history of sexually abusive behavior, and R70 was considered vulnerable but there were no signs of maltreatment, abuse, or neglect. The facility resident care plan review date of 5/9/11, revealed a focus of high vulnerability to abuse, potential to cause harm to self/others related to dementia, major depression with psychosis, decreased independence with cares/mobility, delusional thoughts/occasional hallucinations. Staff was directed to monitor and remove from harmful situations, provide calm reassurances, monitor visitors and intervene as needed when upsetting to resident, and offer reassurance. During interview on 6/16/11, at 1:10 p.m., RN-A stated she was not aware of any incidents involving R18 toward R70. RN-A verified she would be the person to be notified if there had been any incidents. During interview on 6/16/11, at 1:25 p.m., nursing assistant (NA)-H and NA-M stated they had no knowledge of any instances when R70 had been touched by R18. During interview on 6/17/11, at 8:00 a.m., the director of nursing verified there had been no new interventions put in place to protect R70 from neither R18 ' s physical aggression nor an evaluation of the current interventions being effective in keeping R18 from exhibiting physical aggression towards others. R15's groin was touched by R18, without adequate supervision of R18. R15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During observations on 6/16/11, at 10:19 a.m., R15 sat in the wheelchair. The resident did not communicate. Record review of R18's progress notes dated 5/6/11; revealed R18 had been involved in an incident with R15 which included touching R15 ' s " crotch " and " feeling to see how big he is." R15 had been diagnosed with [REDACTED]. R15 had been assessed as having severely impaired cognitive skills, and being highly vulnerable to abuse. R18 ' s behavior interventions again were not evaluated for effectiveness nor were new interventions developed to prevent further aggressive behaviors towards residents. Record review of the facility vulnerability risk factors dated 12/16/2008 indicated that R15 was considered vulnerable. Record review of the psychosocial note dated 6/13/11, revealed the resident was alert with impaired memory ability and partial disorientation. During interview on 6/17/11, at 10:25 a.m., LPN-H stated on 5/6/11, she had been outside with R18. She stated R18 entered the facility ahead of LPN-H and immediately placed her hand on R15's groin, on the outside of the slacks. LPN-H stated she intervened with both residents. She stated she reported this to the charge nurse immediately and the charge nurse would document the incident. LPN-H stated she reports all incidents like this. R44 was touched on the breasts and groin by R18, without adequate supervision of R18. During a review of an untitled report that was provided to the survey team on 6/15/11 at 10:24 a.m. by the DON it was noted that R44 had a physical altercation with R18 on 6/11/11, in the lobby area at 4:15 p.m. The report indicated that R18 lifted up R 44's shirt and touched R44 ' s breasts and crotch area. This incident was reported by another resident to the nurses and had been observed by a visitor. Record review of a nursing home note dated 3/16/11, by the nurse practitioner, listed R44's diagnosis, which included dementia, osteoporosis and degenerative joint disease. The quarterly MDS dated [DATE] indicated R44 had short term and long term memory loss and cognitive skills for daily decision making were severely impaired. R44 uses a wheelchair and requires total dependence for locomotion on and off the unit. R44 care plan dated 3/25/11 had a focus that indicated that R44 was assessed as highly vulnerable to abuse, goal R44 would be free from harm, and an intervention which included staff would remove R44 from harmful situations. Progress notes from 6/11/11-6/16/11 were reviewed for R44. No information regarding resident to resident altercation on 6/11/11 was noted to be documented. The DON was interviewed on 6/15/11 at 2:14 p.m. and verified that R18 had lifted up R44's shirt in the front lobby and touched R44's breasts and crotch area. The DON verified that a visitor witnessed this incident and was not interviewed concerning this altercation. The DON verified that there was no new behavior interventions neither put in place for R18 nor were the current behavior interventions assessed to be effective for reducing or eliminating R18 ' s physical aggression towards R44. R18 lacked adequate supervision to prevent resident to resident altercations and an ongoing reassessment of behaviors to evaluate interventions for effectiveness and develop other interventions to protect other residents, staff and visitors. R18 was admitted to the facility on [DATE]. R18's [DIAGNOSES REDACTED]. R18's quarterly Minimum Data Set (MDS) (a screening and assessment tool) dated 06/03/2011, indicated that R18 had exhibited behavioral symptoms directed towards others during the seven day assessment window. On 6/13/11, at 4:30 p.m. R18 was observed sitting in a regular chair in the dining room with no one seated by her. A nurse was in the hallway just outside the door, and dining staff were in dining room. R18 said, " Hey, hey you, come over here," in a loud voice. R18 asked "How tall are you?" "You are taller than that," and "Where do you get your hair done?" A review of R18's psychiatric history, it was noted R18 was evaluated on 09/16/09 by the DBART team. The DBART team noted that R18's behaviors had included disinhibited and sexually inappropriate behaviors, eating food off of others plates and violating boundaries of other residents. There had been no psychiatric evaluation since 02/26/10, even though R18's behaviors had increased, and starting 2/11, R18 began physical contact with other residents, with the majority of the incidents being sexual contact. On 6/15/11, at 5:00 p.m., surveyor interviewed the visitor to the home who was a witness of the 6/11/11 incident between R18 and R44. The witness verified the facility had not talked to them about the incident. The witness stated R18 had both hands under R44's shirt, one hand on each breast and then placed one hand on R44's groin, on the outside of the slacks. The witness stated another resident yelled at R18 and then staff came. The witness stated this had occurred in the lobby with other residents present but no other visitors were present. During interview on 6/17/11 at 8:00 a.m., the director of nursing verified the last psychiatric visit for R18 was on 2/26/10 and verified none since that time. During interview on 6/17/11, at 9:40 a.m., the social worker stated when there were incidents of resident to resident altercations, with dementia, the facility looked at intent to harm, and was there injury. She stated that if there was no observable injury, then the incident was not reportable. She stated if psychological harm, the facility looked at facial changes, comments, and crying. She stated she expected staff to document incidents of resident to resident altercations. The social worker stated R18's inappropriate touch was escalating. The social worker verified the 6/11/11 incident occurred while R18 had been seated in the lobby. She verified the visitor who witnessed the incident was not interviewed by the facility. During interview on 6/17/11, at 10:40 a.m., the social worker stated regarding the 6/11/11 incident of touching bare breasts and groin, the facility put into place 1:1 supervision of R18 effective 6/16/11. However, there were no other interventions put into place or the current interventions had not been assessed as being effective for preventing or eliminating R18 ' s aggressive behaviors. During interview on 6/17/11, at 11:10 a.m., the director of nursing stated she expected nursing assistants to document behaviors according to number of times a shift that the specific behavior occurred and report to the nurse. She expected nursing to document the behavior incident. She stated their computer system could not retrieve behavior documentation by nursing assistants and corresponding nurse documentation of the behavior. The director of nursing verified the facility lacked evidence of tracking inappropriate physical and sexual behaviors for R18. During interview on 6/17/11, at 11:30 a.m., the administrator stated he was aware of the physical incidents by R18 including: 2/3/11 toward R46, 2/26/11 toward R70, 5/6/11 toward R15, and 6/11/11 toward R44. He stated the facility had no reportable incidents since 2009. He verified the facility had investigated those incidents for actual physical harm to R46, R70, R15 and R44 and it had been determined that none occurred. During interview on 6/17/11, at 12:45 p.m., R18 ' s physician stated he was aware of all behavior incidents with R18. He stated he is involved with her care plan and has made suggestions for interventions which included monitoring her closely and documenting the behaviors. The Immediate Jeopardy was identified on 6/15/11, at 11:00 a.m.; further investigation was needed to confirm the Immediate Jeopardy. The Immediate Jeopardy began on 6/17/11, at 3:10 p.m. The administrator and director of nursing were notified of the Immediate Jeopardy on 6/17/11, at 3:30 p.m. related to the lack of supervision of R18 and failure to protect residents from resident to resident altercations. The Immediate Jeopardy was removed and corrected on 6/20/11, at 11:30 a.m., when surveyors confirmed the facility had implemented the plan of action related to the Immediate Jeopardy. Surveyors observed staff supervision of R18, interviewed staff regarding continued supervision of R18, reviewed R18 reassessment, and reviewed the care plan changes. Oxygen not secured. R61 was observed with a portable oxygen tank laid across the bottom bars of the walker and had not been secured to the walker or in a secured holder. Observations throughout the survey and on 6/13/11 at 12:15 p.m.; 6/15/11 at 11:45 a.m.; 6/16/11 at 9:30 a.m.; 6/16/11 at 3:30 p.m.; revealed R61 sat in the lobby with a portable oxygen tank laid across the lower side bars of the walker, with no support underneath the tank. The oxygen tank was not secured. During the environmental tour on 6/16/11 at 9:30 a.m., the environmental services director stated he was not aware that the oxygen tank should be stored upright. During interview at that time, RN-B stated R61 always had the oxygen tank laid across the walker. RN-B stated she was not aware the oxygen tank should be stored upright. During observations on 6/16/11 at 3:30 p.m., R61 was seated in the lobby with the walker directly in front of the resident. R61 was observed with a nasal cannula in place and connected to a portable oxygen tank that was laid across the bottom bars of the walker frame, with no support under the tank, and the tank was not secured. The portable oxygen tank was observed balanced on the lower support bars of the walker with the tank extended approximately 4 inches over each side of the walker. During interview at that time, the R61 stated he always used the tank laid on its side with his walker. R61 verified the oxygen tank was turned on. He stated the tank lasted 4 hours and that staff changed the tank when needed. During observations at that time, surveyor was able to roll the tank back and forth. Record review revealed R61 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of physician orders [REDACTED]. Record review of the facility resident care plan dated 11/13/10, identified a focus of congestive heart failure and directed staff that the resident used oxygen 2-3 L per nasal cannula continuous, resident requested staff assistance to change the tank, liked to be up walking, worked best for resident to lay the tank across the support bars of the walker, tank is secure and did not move, resident is steady and able to navigate walker without bumping the tank, and if problems the resident may need a tank holder attached to the walker. Record review of the facility oxygen storage policy review date 10/15/09, revealed oxygen cylinders would be stored in appropriate storage stand/holder and stored in an upright position. Record review of the facility incident reports 11/1/10 -6/17/11, revealed no incidents occurred with the unsecured oxygen tank. During interview on 6/17/11 at 8:00 a.m., the director of nursing stated she was not aware that the portable oxygen tank was not secured on the walker and not aware oxygen was not to be stored laid down. She stated R61 always had the oxygen laid across the lower bars of the walker. The director of nursing verified R61 had no falls and no incidents of the oxygen tank dropping during the period reviewed of 1/1/11 to 6/17/11.