Every finding on record at Grandview Health Care Center

Based on clinical record review, staff interviews, pharmacy interview and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 16 residents reviewed (Resident #23) for Physician orders. The facility reported a census of 35 residents. Findings includes: Resident #23's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS included diagnoses of cancer, anemia, arthritis, seizure disorder, and secondary malignant neoplasm of the brain (metastatic brain tumor).The Care Plan revised 11/3/25 revealed Resident #23 had chronic pain and had a risk for adverse (unwanted) effects due to the use of anticonvulsants medication to aid in the treatment of seizures/convulsions. The Care Plan directed staff to anticonvulsant and pain medications as ordered. The November and December 2025 Medication Administration Record (MAR) directed staff to administer Tramadol HCL (narcotic pain medication) 50 mg (milligrams) one tablet every 8 hours. A Progress Note dated 11/19/25 documented Resident #23 went out to a doctor appointment with family. The note revealed Resident #23 returned with new orders to discontinue Keppra (anticonvulsant medication) and change Vimpat (anti-epileptic medication) to 100 mg (milligrams) twice daily. In addition, the note directed to stop Rizatriptan (medication used to treat migraines) when Nurtec (medication used to treat migraines) was approved. A Telehealth Neurology Progress Note dated 11/19/25 documented Resident #23 reported daily headaches and frequent migraines. In addition, the note revealed Resident #23 continued to have tonic-clonic seizures (causes a loss of consciousness and violent muscle contractions) and agitation per the report of the nursing home and her family. The note documented the follow new orders/medication changes: 1. Start Brivaracetam (Briviact) (antiepileptic medication)100 mg two times a day (BID) for focal epilepsy.2. Increase Vimpat to 2 tabs (100 mg total) two times daily. 3. Start Nurtec 75 mg take one table by mouth every other day for migraine headachesThe Neurology Progress Note dated 11/19/25 documented the Physician directed to discontinue the Keppra medication and change to Briviact medication for seizure control and to reduce the agitation. In addition, the note directed to increase the Vimpat dose from 50 mg to 100 mg BID due to continued seizures. In addition, the note reflected Resident #23 would be a good candidate for Nurtec every other day dosing for both preventative and abortive therapy (stop migraine attack as it starts). The note documented the Rizatriptan (medication used to treat migraines) had not been beneficial due to the medication being PRN (as needed) and requiring Resident #23 to ask for it. A Physician Progress Note dated 11/24/25 documented the DNP (Doctor of Nursing) reviewed Resident #23's neurology progress notes from 11/19/25. The DNP documented Resident #23 was supposed to be on Briviact 100 mg BID for focal epilepsy and she did not see this on Resident #23's MAR. In addition, the DNP documented Nurtec was suggested in place of Rizatriptan and did see this had been given. The DNP requested the facility look into the medications. Review of the November and December MAR lacked documentation that the Briviact and the Nurtec medication had been started. The clinical record lacked documentation of clarification or follow-up for the Neurology Progress Notes from 11/19/25 and the Physician Progress Notes from 11/24/25. A Progress Note dated 11/25/25 documented Resident #23 went to a doctor's appointment and returned. The note documented Resident #23's Tramadol orders needed to be clarified. The Hematology Oncology Progress Notes dated 11/25/25 documented the Physician advised the use of the Tramadol pain medication every 6 hours for better control. Review of the Clinical Record lacked documentation of clarification or follow-up for the Tramadol order. On 12/10/25 at 2:30 PM, the Director of Nursing (DON) stated the pharmacy reported they last received a script for Tramadol medication on 11/4/25 for every 8 hours. The DON reported the pharmacy did not have orders for the Nurtec or Briviact medication. The DON reported she could not locate the Physician Appointment Note with the written Physician orders from the Neurology appointment. She said the Physician Appointment Note would have been faxed to the Pharmacy. When asked about the Physician Progress Note from 11/24/25, the DON said she was going to call the DNP to see how those orders were communicated to the facility, whether through dictation or verbally. On 12/10/25 at 3:30 PM, the DON provided an Order Summary Report for Resident #23. She reported Staff B, Registered Nurse (RN), received the summary with written changes on it when Resident #23 returned from the Neurology appointment on 11/19/25. Review of the Order Summary Report for 11/19/25 revealed writing in red ink that documented to discontinue the Keppra, change the Vimpat dose to 100 mg and wait for Nurtec to be approved, and to stop Rizatriptan medication when Nurtec was started. The form lacked directions on how to take the Nurtec. The forms lacked a Physician signature or documentation of who wrote the changes on the order summary form. The order summary form did not address starting the Briviact medication. On 12/10/25 at 3:45 PM, Staff B reported Resident #23's family handed her the Order Summary Report form when Resident #23 returned to the facility from the appointment. She said she put the changes on the MAR and faxed the summary to the Pharmacy. She said she did not call the Neurology office to clarify any of the orders. Staff B verified that she made the changes to the medication orders without a Physician signature. Staff B said she was going off what was written on the order summary form and what the family had told her. She reported Resident #23 returned with a blank Physician Appointment Communication form. On 12/11/25 at 8:25 AM, the DON verified the facility didn't initiate the Briviact and Nurtec medications. The DON reported the pharmacy did not receive any new orders from the neurology office including the script for the increase of the Vimpat. She said the DNP sent the script for the Vimpat on 11/20/25. She said she expected when the nurse obtained physician orders to transcribe them in the computer and notify the pharmacy. She said if the physician orders needed to be clarified then she expected the nurse to call the Prescribing Physician and if not available to call the Primary Care Physician. The DON reported she expected the nurse to clarify the written orders for Resident #23 on the order summary form on 11/19/25 as it didn't have a physician signature. She said she expected physician orders to be followed through. On 12/11/25 at 9:56 AM, the Pharmacist reported the pharmacy did not receive any orders for Briviact or Nurtec on 11/19/25 for Resident #23. The Pharmacist reported the physician discontinued the Keppra medication on 11/19/25 and increased the Vimpat medication to 100 mg BID. The facility policy titled Administering Medications revised December 2012 documented medications shall be administered in a safe and timely manner and as prescribed.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed (Resident #2) for pressure ulcer care. The facility reported a census of 35 residents.Findings include: Resident #2's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS identified Resident #2 required substantial/maximal assistance for transfers and toileting. Resident #2's MDS included diagnoses of a pressure ulcer to the right buttocks, stage 4 (full thickness tissue loss where skin, fat, muscle, tendon or bone can be exposed). On 12/9/25 at 1:20 PM, observed Staff A, Licensed Practical Nurse (LPN), complete wound care to Resident #2's pressure ulcer to the right buttocks. Staff A gathered supplies at the medication cart outside of the room and placed the supplies on top of a blue towel. Staff A carried the supplies on the towel along with a handful of loose gloves into the room. Staff A placed the towel with supplies on the dresser in front of the TV and then placed the loose gloves on top of the dresser without a barrier. Staff A closed the door to the room, and without completing hand hygiene, put on a blue gown and put on gloves. Staff A took Resident #2's urinal with urine in it off the tray table and emptied it in the toilet. She then rinsed the urinal out with soap and water and placed it on the side of the trash can. She removed her gloves and washed her hands at the sink. Staff A then moved the towel with the supplies on top of the towel to the tray table where the urinal had sat, without disinfecting the area beforehand. She proceeded to take the loose gloves off the dresser and put them on the towel on the tray table with the other supplies. Staff A then left the room to get the hand sanitizer off the medication cart from outside the door. She returned to the room and put the hand sanitizer on the tray table. Staff A then put on a pair of gloves from the towel on the tray table. Staff A failed to complete hand hygiene prior to putting on the gloves. Staff A proceeded to complete wound care with the gloves that sat on the dresser without a barrier (dirty surface). The contaminated gloves touched the wound care supplies including the wound cleanser bottle, gauze pads used to cleanse the wound, sliver alginate rope (dressing used to pack the wound), and the Mepilex dressing used to cover the wound. Staff A used her gloved finger to apply the Baza cream to the peri (around) ulcer skin of the wound. Staff A acknowledged she should not have placed the gloves on the dresser as it was a dirty surface. On 12/9/25 at 3:25 PM, the Director of Nursing (DON) and Infection Preventionist said she expected the nurse to place the gloves on a barrier and not on a dirty surface. In addition, she agreed they should have disinfected the tray table prior to use. A facility policy titled Infection Prevention and Control Program reviewed March 2020 documented the facility strived to prevent transmission of infections and communicable diseases, development of nosocomial infections and effectively treat and manage infections. A coordinated process was established to reduce the risk of infection in residents and employees. The process included prevention, surveillance and control which included barrier precautions, cleaning and disinfecting. A facility policy titled Handwashing and Hand Hygiene Policy documented the facility considered hand hygiene the primary means to prevent the spread of infection. The policy directed hand washing/hand hygiene to be completed before handling clean or soiled dressing and after contact with objects in the immediate vicinity of the resident.

Based on clinical record review and staff interviews, the facility failed to have a complete and accurately documented medical record for 1 of 16 residents reviewed (Resident #2). The facility reported a census of 35 residents.Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified Resident #2 as dependent on staff for transfers and toileting hygiene. The MDS documented Resident #2 as always incontinent of bowel. Resident #2's MDS included diagnoses of anemia (low blood iron level), heart failure (heart does not pump enough blood), hypertension (high blood pressure), and seizure disorder. The Care Plan revised 10/6/25 directed the staff to observe for side effects of narcotic analgesic medication which included constipation and decreased bowel sounds. Review of the bowel elimination records for October 2025 revealed Resident #2 had a large bowel movement (BM) on 10/12/25 and did not have a BM from 10/13/25 to 10/16/25. Review of the form titled Daily BM Management Audit dated 10/14/25 documented Resident #2 on day 2 without a BM. The form directed staff to offer prune juice. The form had a line/check mark documented next to Resident #2's name indicating they received prune juice. Review of the form titled Daily BM Management Audit dated 10/15/25 documented Resident #2 on day 3 without a BM. The form directed staff to give milk of magnesia (laxative). The form had a line/check mark documented next to Resident #2's name indicating they received milk of magnesia. Review of the form titled Daily BM Management Audit dated 10/16/25 documented Resident #2 on day 4 without a BM. The form directed staff to give a suppository. The form had a line/check mark documented next to Resident #2's name indicating they received a suppository.A Skilled Nursing Facility (SNF) assessment dated [DATE] documented Resident #2 had constipation and received a laxative early in the morning. The October 2025 Medication Administration Record (MAR) lacked documentation of the administration of milk of magnesia on 10/15/25. In addition, the MAR lacked documentation of a physician order for a suppository or Resident #2 received one on 10/16/25. Review of the clinical record lacked documentation regarding the administration of bowel medications, or any follow up on the effectiveness of the PRN (as needed) medication. On 12/10/25 at 2:56 PM, Staff A, Licensed Practical Nurse (LPN), reported the BM list for the morning of 10/16/25 included Resident #2. Staff A said the night nurse/Assistant Director of Nursing (ADON) told her in report he gave Resident #2 something for constipation. Staff A said she didn't know for sure what he gave. On 12/10/25 at 3:45 PM, the ADON reported when passing medications in the morning, he reviewed the BM list and give interventions/medications if needed. He said the morning of 10/16/25 he gave Resident #2 a suppository. He said he provided Resident #2 with education regarding the need for the suppository to prevent a hospitalization. He said Resident #2 agreed to take the suppository. The ADON reported he used the facility standing order according to the bowel protocol. He said the only thing he failed to do was document that he administered the suppository. He said it was at the end of his shift. He reported he thought all the residents had PRN laxatives on their orders sets. The ADON said he listened to his bowel sounds but he did not document it.On 12/11/25 at 8:25 AM, the Director of Nursing (DON) reported she expected the staff to document the bowel management interventions and assessments in the medical record. She reported she expected standing orders to be transcribed on the MAR/TAR (treatment administration record) when initiated [NAME] documented when given. The DON said she would expect the staff to follow up on PRN medication given and document the effectiveness in the medical record. On 12/11/25 at 8:50 AM, the DON confirmed the check mark/line documented on the Daily BM Management Audit form indicated what intervention or medication was given. The DON verified the Daily BM Management form as the facility process for BM monitoring.

Based on observations, record review, staff interviews, and policy review, the facility failed to change oxygen tubing and water humidifier for 1 of 2 residents reviewed (Resident #4) for respiratory services. The facility reported a census of 35 residents. Findings Include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe impaired cognition. The MDS included diagnoses of hypertension (high blood pressure), pulmonary fibrosis (a condition in which the lungs become scarred over time), respiratory failure and other disorders of the lung. The MDS documented Resident #3 received oxygen while a resident within the last 14 days. A Physician order dated 7/7/25 directed Resident #4 to wear oxygen at 2 liters per minute per nasal cannula to keep oxygen saturation above 88% every shift for hypoxia (low levels of oxygen in body tissue) related to chronic respiratory failure.A Physician order dated 11/8/22 directed staff to change oxygen tubing every week on Sunday. The Care Plan revised 9/15/25 documented Resident #4 used continuous oxygen and was at risk for alterations in oxygen levels due to diagnosis of pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. The Care Plan directed to change oxygen tubing and humidifier per facility policy. On 12/9/25 at 7:22 AM, observed Resident #4's oxygen tubing dated 11/23/25 and water humidifier dated 10/26/25. On 12/9/25 at 10:55 AM, the Director of Nursing (DON) acknowledged Resident #4's oxygen tubing was dated for 11/23/25 and the water humidifier dated for 10/26/25. The DON removed the oxygen tubing and put it in the trash can. The DON reported she would replace the tubing and water bottle. Review of the November and December 2025 Treatment Administration Record (TAR) revealed the oxygen tubing was signed off as being changed on 11/23/25, 11/30/25 and 12/7/25. The TAR lacked direction on how often to change the water humidifier. On 12/9/25 at 11:18 AM, the DON reported she expected the staff to change the oxygen tubing weekly per the physician order. The facility policy titled Oxygen Administration dated 2/1/25 directed staff to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. In addition, the policy directed to change the humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer.

Based on observation and staff interviews, the facility failed to date items in the refrigerator, freezer and dry food storage after opening. The facility reported a census of 24 residents. Findings include: During the initial tour of the kitchen on 12/2/24 at 8:45 AM observed the following items opened without a date: a. 30 plus frozen rolls b. 3/4 bag of frozen peas c. 30 plus slices of frozen garlic bread d. 30 plus frozen sausage patties e. 30 plus frozen pieces of fish f. 20 plus frozen chicken strips g. 1/2 bag Lays potato chips h. 3/4 bag bread crumbs i. 2/3 bag of shredded cheese j. 1/2 bag of lettuce During an observation on 12/2/24 at 8:55 AM, observed Staff A, Cook, dating items the open items listed above. Staff B revealed she dated the open items based on when the facility most recently used the items to her knowledge based on recent meals. During an interview 12/3/24 at 10:45 AM, the Certified Dietary Manager revealed they expected the staff to date food items after they open them. Review of facility policy dated June 2015, titled Nutritional Services Manual: Refrigerator Storage, Freezer Storage and Dry Storage, lacked information regarding dating food items after opening them.

Based on clinical record review, staff and physician interviews, the facility failed to protect residents with a previous history of suicidal ideation from possible self harm for of 1 of 1 residents reviewed (Resident #5). The facility reported a census of 30 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on August 17, 2023 at 5:09 PM. The Facility Staff removed the IJ on [DATE] through the following actions: F741 Sufficient/Competent Staff-Behavior Health Needs Resident's Care Plan was updated to include specifically suicidal ideations. All staff currently working were audited for completed education relating to supervision requirements for residents with active suicidal ideations. Audits of all residents with a history of suicidal ideations were completed to make sure their Care Plans had suicidal ideation in place. Nursing staff were educated on supervision requirements for all residents with active suicidal ideation. Any nurses that have not received this education would receive/complete the education prior to the beginning of their shift. The Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) nurse were educated on the requirements of implementing a Plan of Care for residents with a history of suicidal ideation. Licensed nurses were educated on the requirements of implementing a Plan of Care for residents with a history of suicidal ideation. Daily audits will be completed for 7 days, then weekly for 3 weeks, the monthly for 2 months to ensure new staff continue to be trained on the requirements of increased supervision for residents with active suicidal ideations. Weekly audits will be completed for 4 weeks and monthly for 2 months to ensure residents with a history of suicidal ideations continue to have a Plan of Care as required. These results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee meeting monthly for 3 months. The scope was lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: The Minimum Data Set (MDS) for Resident #5, dated 6/30/23, included diagnoses of anxiety disorder, depression, psychotic disorder, intermittent explosive disorder, and non-Alzheimer's dementia. The MDS documented that the resident received antipsychotic, antianxiety, and antidepressant medications daily. The resident's Care Plan with a revision date of 8/27/23, revealed that on 10/8/19 the Care Plan initiated an intervention that staff were to monitor/record/report to Medical Doctor (MD) risk for harm to self, such as suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. The resident's Care Plan lacked documentation of previous suicidal or self harm events or interventions put in place to prevent such actions. Review of the resident's Progress Notes revealed that on 8/17/23 at 5:09 PM Resident #5 was threatening to kill himself. The resident's call light was on and when Staff C, Certified Nursing Assistant (CNA) entered his room, he was found with his oxygen tubing wrapped around his neck. Staff C unraveled the oxygen tubing from around the resident's neck and moved it out of his reach to the top of the dresser and left the resident to get the nurse. Staff A, Licensed Practical Nurse (LPN) was working with a resident who had just fallen, so Staff C informed the Director of Nursing (DON) of what Resident #5 was doing. Moments later when walking past Resident #5's room with Staff B, CNA to get residents up for supper, Resident #5 was observed with his bed in the highest position and had both his oxygen tubing and call light string wrapped around his neck, threatening to throw himself out of bed. During an interview on 8/28/23 at 8:05 AM with Staff A, LPN she stated she was working as the floor nurse at the time of the incident. She stated the Assistant Director of Nursing (ADON) was assisting her with another resident who had just fallen, when Staff C, CNA informed her that Resident #5 was attempting to choke himself with his call light cord. She instructed Staff C to get the DON because she was busy with the fallen resident. Staff A stated that prior to this incident, the resident had expressed thoughts of self harm and staff would notify the physician and psychiatric provider. During an interview on 8/28/23 at 8:45 AM with Staff B, CNA she stated she was walking past Resident #5's room with Staff C, CNA as they were working on getting resident's up for supper. She stated that they saw that the resident had his bed in the high position and he was telling them he was going to jump off the bed. She stated that the resident had both his oxygen tubing and call light cord wrapped around his neck. She stated they asked him what was going on. She stated Staff C said that they didn't have time for this, lowered and unplugged the bed. She stated that they then put the resident in a wheelchair and took him to the DON's office. She stated the call light was not on when they saw the resident's bed in the high position. She stated that the resident made comments all the time about not having anything to live for, that he was going to kill himself, and put his bed up and jump out. During an interview on 8/28/23 at 8:58 AM the ADON stated that she was helping Staff A, LPN with a resident who had fallen when she heard Staff B and Staff C talking with the DON about the resident's behavior and wrapping the oxygen tubing around his neck. She stated she left Staff A to go help with this resident. She stated she helped to assist the resident to get into bed. During an interview on 8/28/23 at 9:07 AM with Staff C, CNA she stated Resident #5 had his call light on and when she went in to answer it, she saw that the resident had his oxygen tubing wrapped around his neck. She stated she unraveled it and put it out of the resident's reach and went to the DON's office and told her they needed to do something with Resident #5 because he had his oxygen tubing wrapped around his neck. She stated the DON told her that she would get a hold of the doctor. Staff C stated it was supper time and staff were in the process of getting residents up for supper. She stated that she and Staff B, walked past Resident #5's room and they noticed that he had his bed up in the high position. She stated the resident had both the oxygen tubing and the call light cord wrapped around his neck. She stated she took the tubing and cord off of the resident's neck and placed it on the dresser away from him. She stated Resident #5 then started to sit up and was saying that he wanted to fall out of bed. They asked him why he was doing this. Resident tried to reach for the bed remote and she decided that they would get the resident up in his wheelchair and take him to the DON's office. During an interview on 8/28/23 at 9:23 AM with the DON, she stated at the time of the incident she was on the phone in her office when Staff B came in and told her that Resident #5 had his oxygen tubing wrapped around his neck. She stated that Staff B left her office and then returned a few minutes later with the resident stating that they found him with his bed in the high position. She stated the resident was going back and forth, wanting to go to bed, wanting to leave the facility, taking his foot pedals off his wheelchair and using them to beat on his door, and running his wheelchair into the walls. She stated the ADON provided 1:1 with the resident at this time. She stated when she was able to assess the resident, he was apologetic. She stated that several staff members attempted to give the resident his evening dose of Ativan per the doctor's order before he finally took it. She stated the resident says he wants to die a lot and has put his bed in the high position before and then puts his call light on, threatening to jump out of bed. She stated he then apologizes. She stated that he has a history of attention seeking. Prior to this incident, she stated the resident had been declining and was having problems with aspirating and recently changed to a Do Not Resuscitate status. During a follow-up interview on 8/29/23 at 8:15 AM the DON clarified that Resident #5 was brought to her office after the incident and that she did not go to his room to do an assessment. During an interview on 8/29/23 at 10:30 AM with Resident #5's Primary Care Physician (PCP) and Medical Director, she stated she had been caring for him almost the entire time he has been at the facility. She stated that he had had numerous behaviors and frequent attention seeking behaviors.

Based on clinical record review, staff and physician interviews, the facility failed to develop and implement a Care Plan that include and support the behavioral health care needs for 1 out 1 residents reviewed (Resident #5). The facility reported a census of 30 residents. Findings include: The Minimum Data Set (MDS) for Resident #5, dated 6/30/23, included diagnoses of anxiety disorder, depression, psychotic disorder, intermittent explosive disorder, and non-Alzheimer's dementia. The MDS documented that the resident received antipsychotic, antianxiety, and antidepressant medications daily. The resident's Care Plan with a revision date of 8/27/23, revealed that on 10/8/19 the Care Plan initiated an intervention that staff were to monitor/record/report to Medical Doctor (MD) risk for harm to self, such as suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. The resident's Care Plan lacked documentation of previous suicidal or self harm events or interventions put in place to prevent such actions. Review of the resident's Progress Notes revealed that on 8/17/23 at 5:09 PM Resident #5 was threatening to kill himself. He was found with oxygen tubing wrapped around his neck, and trying to choke himself with his own hands prior to this. He was threatening to put the bed in a high position and jump. Review of resident's Progress Notes revealed that on 8/18/23 at 10:00 AM, the Social Service Director documented that Resident #5 does have a long history of attention seeking behaviors. During an interview on 8/28/23 at 8:05 AM with Staff A, Licensed Practical Nurse (LPN) she stated that prior to this incident, Resident #5 had expressed thoughts of self harm and staff would notify the physician and psychiatric provider. During an interview on 8/28/23 at 8:45 AM with Staff B, Certified Nurses Assistant (CNA) she stated that the resident made comments all the time about not having anything to live for, that he was going to kill himself, and put his bed up and jump out, but had never acted on them. During an interview on 8/28/23 at 9:23 AM with the Director of Nursing, she stated the resident said he wanted to die a lot and that he had put his bed in the high position before and then put his call light on, threatening to jump out of bed. She stated he then apologizes. She stated that he has a history of attention seeking. During an interview on 8/29/23 at 10:30 AM with Resident #5's Primary Care Physician (PCP) and Medical Director, she stated she had been caring for him almost the entire time he has been at the facility. She stated that he has had numerous behaviors and frequent attention seeking behaviors. In an interview on 9/06/23 at 1:45 PM, the DON stated her expectation would be that the residents Care Plan be updated with any significant changes in resident's health and/or behavior status.

Based on record review and staff interview, the facility failed to consistently obtain post dialysis vitals and follow fluid restriction orders for 1 of 1 resident reviewed (Resident #4). The facility reported a census of 30 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS indicated that Resident #4 required limited assistance of one staff for transfers, locomotion, dressing, and toilet use. The MDS included diagnoses of diabetes mellitus, coronary artery disease, high blood pressure, renal failure, and asthma. The Care Plan for Resident #4, revised 8/25/23 identified that the resident went to dialysis three times a week, Monday, Wednesday, and Friday. The Care Plan also documented that Resident #4 was on a fluid restriction of 240 cubic centimeters (cc) four times daily and and 340 cc three times daily with meals. Review of clinical record vitals revealed the lack of post dialysis assessments for 6/7, 6/12, 6/14, 6/16, 7/5, 7/10, 7/14, 8/2, and 8/9/23. The clinical record also documented in the Task record that Resident #4 received excess fluids on the following 30 day look back days: Date - Breakfast, Lunch, Supper 8/1/23 - 240cc, 480cc, 480cc 8/3/23 - 0, 0, 480cc 8/4/23 - 0, 0, 480cc 8/5/23 - 480cc, 480cc, 480cc 8/6/23 - 0, 480cc, 720cc 8/8/23 - 0, 240cc, 480cc 8/9/23 - 480cc, 0, 480cc 8/11/23 - 480cc, 0, 0 8/12/23 - 480cc, 480cc, 0 8/16/23 - 240cc, 480cc, 0 8/17/23 - 0, 720cc, 480cc 8/18/23 - 480cc, 480cc, 336cc, 336cc 8/19/23 - 480cc, 480cc, 480cc 8/20/23 - 240cc, 480cc, 240cc, 240cc 8/21/23 - 240cc, 0, 480cc 8/24/23 - 720cc, 480cc, 240cc 8/25/23 - 240cc, 0, 480cc 8/27/23 - 240cc, 240cc, 480cc 8/28/23 - 300cc, 0, 480cc The clinical record Progress Notes also revealed the following documentation: 4/17/2023 16:15 Resident returns from dialysis with note **reminder of fluid restriction. 5/22/2023 12:08 Spoke with the nurse at dialysis and she stated that the physician wanted this facility to know that we are to take responsibility for this resident gaining weight, due to not following fluid restriction, she may end up in the emergency room (ER). This nurse explained that she has been following her fluid restriction and ever since her fluid restriction started. 7/31/2023 11:58 Call received from dialysis Registered Nurse (RN) who stated that the resident will need to come in 8/1/23 @ 10:15 for an extra dialysis day to remove excess fluid. Document titled Azria Hemodialysis Access Care Level III, revised September 2010, stated that the nurse should document in the resident's medical record any part of the report from the dialysis nurse post-dialysis given, and observations post-dialysis. Interview with the Director of Nursing, (DON) on 9/06/23 at 1:45 PM who stated her expectation is that all pre and post dialysis vitals be found in the clinical record and that resident and staff would be following the fluid restriction orders.

Based on record review and staff interview, the facility failed to meet professional standards by failing to notify the physician of out of parameter blood glucose levels for 1 out of 2 residents reviewed (Resident #4). The facility reported a census of 30 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS indicated that Resident #4 required limited assistance of one staff for transfers, locomotion, dressing, and toilet use. The MDS included diagnoses of diabetes mellitus, coronary artery disease, anemia, asthma, and hypoglycemia (low blood sugar). The current Medication Administration Record (MAR) showed the resident had orders for Levemir insulin 10 units daily, and sliding scale Aspart insulin three times daily with meals as needed and to report to (Medical Doctor) MD if blood sugar is <60 and >350 (less than 60 or greater than 350). Facility record review of Resident #4's Progress Notes revealed the following blood sugars with no physician notification: 4/17/23 glucose 34 at 9:25 PM and 406 at 11:35 PM 4/25/23 glucose 53 at 5:15 PM and 366 at 7:02 PM 5/23/23 glucose 374 at 9:50 PM with note written held per order 5/26/23 glucose 394 at 10:56 PM 6/12/23 glucose 373 at 10:55 PM 6/15/23 glucose 399 at 10:36 PM with note written held per order 6/16/23 glucose 390 at 10:05 PM 6/19/23 glucose 367 at 8:09 PM 6/23/23 glucose 358 at 10:36 PM 6/30/23 glucose 423 at 7:12 AM 7/1/23 glucose 368 at 10:08 PM with note written held per order 7/7/23 glucose 355 at 10:02 PM 7/12/23 glucose 412 at 7:58 PM 7/13/23 glucose 413 at 5:02 PM 7/16/23 glucose 406 at 11:55 AM with note written held per order 7/18/23 glucose 420 at 6:41 AM 7/21/23 glucose 365 at 4:39 PM 7/25/23 glucose 388 at 9:17 PM 7/26/23 glucose 424 at 4:14 PM and 400 at 10:06 PM 7/28/23 glucose 371 at 6:13 PM and 375 at 9:21 PM with note written held per order 7/29/23 glucose 357 at 12:50 PM and 398 at 9:55 PM 8/1/23 glucose 380 at 7:02 AM 8/2/23 glucose 421 at 5:13 PM 8/5/23 glucose 356 at 5:18 PM 8/12/23 glucose 359 at 5:32 PM 8/14/23 glucose 388 at 8:19 PM 8/15/23 glucose 397 at 2:22 PM 8/16/23 glucose 363 at 9:52 PM 8/22/23 glucose 367 at 9:52 PM 8/25/23 glucose 409 at 5:47 PM In an interview on 09/06/23 at 1:45 PM, the Director of Nursing (DON) stated her expectation would be that the physician would be notified each time a blood sugar is found to be out of stated parameters.

Based on clinical record review and staff interview, the facility failed to document all diagnoses identified as relevant to the appropriate state-designated authority for Level II Pre-Admission Screening and Resident Review (PASRR) evaluation and determination for 2 out of 3 residents reviewed for PASRR requirements (Residents #5 & #19). The facility reported a census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #5, dated 6/30/23, included diagnoses of anxiety disorder, depression, psychotic disorder, intermittent explosive disorder, and non-Alzheimer's dementia. The MDS documented that the resident received antipsychotic, antianxiety, and antidepressant medications daily. Review of PASRR Level 1 Screen form dated 8/6/21, documented only major depression and anxiety disorder as Mental Health diagnoses for Resident #5. 2. The MDS assessment for Resident #19, dated 7/24/23, included diagnoses of anxiety disorder, depression, and post-traumatic stress disorder. The MDS documented the resident received antipsychotic, antianxiety, and antidepressant medications daily. Review of PASRR Level I Screen form dated 8/31/22, documented only major depression and anxiety disorder as Mental Health diagnoses for Resident #19. Interview on 8/30/23 at 4:11 PM, the Social Services Director confirmed had not submitted PASRR change with diagnosis of post-traumatic stress disorder for Resident #19, or additions of psychotic disorder, intermittent explosive disorder and non-Alzheimer's dementia for Resident #5. She stated she was now submitting an update for the PASRR's.

Based on observation, record review, staff interview, and policy review the facility failed to complete an accurate comprehensive assessment by not completing the pain assessment interview for a resident receiving scheduled pain medication daily and as needed (PRN) for 1 of 12 residents reviewed (Resident #25). Findings include: The Minimum Data Set (MDS) for Resident #25 dated 6/26/23, included diagnoses of migraines and pain in left shoulder. The MDS documented the resident received a schedule pain medication regimen and received PRN pain medication. The MDS lacked documentation of the pain assessment interview completed, with the MDS instructions to attempt to conduct the interview with all residents. Observation on 8/27/23 at 3:07 PM, Resident #25 in their room and complaining of left ankle pain to Social Services Director (SSD), and SSD encouraged the resident to lay down. Facility policy Resident Assessment Instrument (RAI)/MDS documented the RAI/MDS is an assessment tool that assists skilled nursing facility staff to accurately and routinely compile information regarding resident needs and strengths to facilitate the development of an individual plan of care for the resident. Interview on 8/30/23 at 1:47 PM, the Assistant Director of Nursing/MDS Coordinator stated the expectation is for the pain assessment to be completed on the MDS.

Based on observation, staff interviews, and policy review the facility failed to follow the menu, did not serve the dinner roll/bread and margarine at lunch for 30 of 30 residents. During an observation of the lunch meal on 8/29/23 starting at 11:30 AM, a meal of chicken, potatoes, peas, and a cookie was served to all 30 residents. The 30 residents were not provided or offered the dinner roll/ bread and margarine as scheduled. Review of facility Week-At-A-Glance menu documented the lunch meal of marinated chicken thigh, sugar snap peas, oven browned potatoes, dinner roll/bread with margarine, and chocolate chip cookie. Facility policy, Menus revised 9/2017 documented menus will be planned to meet the nutritional needs of the residents in accordance with established national guidelines and menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. Interview on 8/29/23 at 1:00 PM, the Dietary Manager confirmed the lunch menu for today included roll/bread/margarine, was not provided to any of the residents, and the expectation is to follow and serve all food items on the menu.

Based on clinical record reviews, facility policy reviews, hospital clinical records, the Centers for Disease Control and Prevention (CDC), and staff interviews the facility failed to provide adequate monitoring and assessment of 1 of 3 residents with a catheter to identify an infection (Resident #15) this resulted in an immediate jeopardy to the resident's health. Resident #15 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Certified Nurse Aide (CNA) reported signs and symptoms of a [CONDITION(S)] to the nurse. The clinical record lacked an assessment on the evening shift of 10/8/22 and on the overnight shift of 10/9/22. The nurse observed the resident shaking and complaining of freezing with a low body temperature between 5 a.m. and 6 a.m. with no report to the physician. At 8 a.m. the resident had pain in his lower abdomen with pressure and was slow to respond, with still no call to the physician. At 10:15 a.m. the resident did not respond, his face appeared flushed, diaphoretic (sweaty), with clammy skin. The resident had a low blood pressure. The nurse called the physician who ordered the resident to be transferred to the hospital. Upon evaluation in the hospital, the resident received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 13, 2022 at 2:43 PM, the department contacted the facility to notify them of the determination of an Immediate Jeopardy for this resident. The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #15 scored a 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required extensive assistance with toilet use and personal hygiene. The resident had an indwelling urinary catheter. The MDS included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The current Care Plan revised 8/26/22 identified the resident with an alteration in urinary elimination related to retention and [CONDITION(S)]. The interventions included a. Changing the catheter monthly and as needed (PRN). b. Catheter care every shift and PRN. c. Changing the drainage bag 2 times a month and PRN. The Progress Notes dated 5/29/22 at 11:31 a.m. documented that the nurse became aware that the resident had complaints of discomfort to his urinary catheter site. An assessment revealed the resident's vitals as a blood pressure of 152/88 (average 120/80), a pulse of 91 (average 80-100), respirations of 17 (average 12-20), temperature of 99.4 (average 98.6), a pulse oximeter of 93% (average 90-100%), and a fasting blood sugar (FBS) of 213 (average 70-150). The resident appeared alert but slow to respond, he experienced tremors, and a urine output of 75 cubic centimeters (cc) by the end of the shift (average output for eight hours 240 cc). The resident's condition declined rapidly. The Physician notified, and ordered to send the resident to the hospital. At 1:03 p.m. the hospital called to update that the hospital admitted the resident to the third floor for a [CONDITION(S)]. A History and Physical dated 5/30/22 documented that the resident had an indwelling urinary catheter and presented to the hospital with a fever. The assessment determined the chronic indwelling urinary catheter to be clogged. The hospital staff changed it. In the emergency room (ER) the resident initially had low blood pressure that improved with intravenous (IV) fluid. The resident's principal problem was a [CONDITION(S)] with catheterization of the urinary tract. The Summary of hospitalization documented at the resident's time admission he also had an acute kidney injury (AKI), improved. The Progress Notes dated 6/3/22 at 6:06 p.m. documented that the resident readmitted to the facility at 4:45 p.m. The resident appeared alert and oriented without complaints of pain. The resident would resume all prior medication. [MEDICATION(S)] (antibiotic) to be taken orally for two days, one 300 milligram capsule for two days. The Progress Notes dated 9/5/22 at 5:10 p.m. documented the staff attempted to irrigate the resident's catheter three times during their shift. The urinary catheter had dark red blood with sediment and clots come out. The resident complained of pain and had a distended abdomen. The nurse called the physician for an order to transport the resident to the ER for evaluation and treatment. On 9/6/22 at 12:36 a.m. the resident returned from the ER in the facility van in a wheelchair status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident new orders for [MEDICATION(S)] (antibiotic) 500 mg three times a day and to encourage fluids. The resident denied pain or discomfort. An emergency department (ED) report dated 9/5/22 at 7:12 p.m. documented that the resident presented to the ED for blood in his urine. The resident had an indwelling urinary catheter, without a clear reason for him being there. The resident said the nurses where he lived tried to do something with it, or had trouble removing it, and that's when it became bloody. It was unclear what happened where he lived. The resident also said one of their nurses changed his catheter (before the physician went in to see him). The resident said he had no pain and was ready to go home. The resident had an abnormal urinalysis. It was unclear what exactly occurred with the urinary catheter to necessitate the resident's ED visit. All symptoms resolved after the replacement of his urinary catheter. Since there was uncertainty regarding the underlying events necessitating the resident's going to the ER and a large amount of white blood cells the physician would treat empirically or presumptively with antibiotics. The resident would return to the facility with a new catheter in place and asymptomatic. The impression was a problem with the catheter, acute [MEDICATION(S)], and hematuria. The resident returned to the facility with new orders for [MEDICATION(S)] 500 mg one capsule three times a day for seven days. The Progress Notes dated 10/9/22 at 10:15 a.m. documented a Certified Nursing Assistant (CNA) reported that the resident had not eaten any breakfast and wasn't verbally responding to her. The nurse assessed the resident's condition and observed the resident's face flushed. When the nurse pulled back his blankets, he was covered in sweat with clammy skin. The resident had a blood pressure of 80/54, heart rate of 90, pulse oximetry fluctuating between 90-94% on room air, temperature 98.9, and respirations of 20. Nonverbal responses, but would open his eyes when spoken to. Blood sugar 139. The nurse called the physician, who provided orders to send him by ambulance to the hospital. The nurse called the emergency medical technicians (EMT's) to transfer him to the ED. The nurse called the resident's family and left a voicemail to return their call. The nurse called the ED and gave a nurse to report to a hospital Registered Nurse (RN). At 2:18 p.m. staff called the ED to follow up on the resident's condition. The staff spoke with a Physician who reported they were admitting him to the intensive care unit (ICU) for septic shock, intravenous (IV) fluids, and IV antibiotics. The physician stated that they placed a new catheter due to large amounts of pus in the old catheter. The Physician stated the resident appeared more alert and starting to be able to answer questions. The Ambulance report dated 10/9/22 at 10:45 a.m. documented the resident's skin as clammy with a somnolent (sleepy, drowsy) mental status. The report indicated the patient's condition as unresponsive for two hours. The resident's pulse oximetry read 86%. At the scene the resident could only respond to painful stimuli of a sternal rub. He opened his eyes and made a noise. The EMTs checked the resident's pulse oximetry and the EMT's immediately put the resident on oxygen at 4 liters per nasal cannula (L/NC) with improvement shown. The nurse stated the resident last seen acting normal at 6 a.m. The resident did not eat breakfast and became unresponsive by 8 a.m. During transport the EMTs noticed a terrible smell from his indwelling catheter, with his abdomen slightly distended, and he grimaced with palpation (touch). A History and Physical dated 10/9/22 at 1:59 p.m. documented that the resident had a past medical history that included chronic kidney disease (CKD) stage IV, chronic catheter placement secondary to urinary retention, urology follows, recurrent UTIs, and type II diabetes. The resident presented from the facility after he developed [CONDITION(S)] after changing his chronic indwelling urinary catheter. Upon presentation to the emergency department, the resident had a low blood pressure (hypotensive). He was provided with IV fluid resuscitation (specialized fluids through the IV) and required pressor (medications used to raise the blood pressure) support with low-dose [MEDICATION(S)] (medication similar to adrenaline, used to treat life-threatening low blood pressure). After replacement of the catheter, it drained grossly purulent urine (an elevated number of white blood cells in the urine, which can cause the urine to appear cloudy or contain pus). The resident also had an altered mental status and appeared minimally responsive. Following resuscitation his mentation improved although he still had encephalopathic (altered brain function). The resident could not provide a history given his clinical condition. The staff obtained a majority of his history through chart review. His laboratory work indicated leukocytosis and a severely elevated Procalcitonin level (indicator of infection). A UA showed evidence of frank infection. The provider started the patient on [MEDICATION(S)] and [MEDICATION(S)] due to his prior history of resistant E. coli and Morganella species in previous urine samples. A computerized tomography (CT) scan of the head was negative for acute findings. The provider admitted the resident to the ICU for continued support. The resident's Lab work showed a white blood count of 17.41 (normal 5-10). The Endothelial Dysfunction of the Kidney in [CONDITION(S)] dated 2019 retrieved from https://www.sciencedirect.com/science/article/pii/B 0893 indicated that fluid resuscitation is the cornerstone of the management of [CONDITION(S)]-induced acute kidney injury. Staff interviews included: On 10/11/22 at 1:45 p.m. Staff C, Licensed Practical Nurse (LPN), stated on October 9th she came in a little before 5:00 a.m. to relieve the night nurse. The night CNA reported the resident's urine seemed more cloudy than usual. She said the first thing she did was flush the catheter which had about 100 cc's in it at the time. She flushed it with 60 cc's of normal saline and felt like he got another 300 out, and none of that was documented. She said when they went and checked on him he shook like he was cold. As he only had a sheet on, they covered him up. His temperature was down to 95 point something. She checked his vital signs and he did not have a low blood pressure until she checked on him at 10:15 a.m. At that time, his vital signs were off. She did not document some information but had it in her notebook. She retrieved the notebook. Staff C's Notebook included the following information: Sunday 10/9/22, the resident shaking, no pain reported, denied dyspnea, harsh, short respirations on expiratory breaths, blood sugar of 133. At 6 a.m. temperature of 95.5, heart rate 64, respirations 20, blood pressure 136/80, pulse oximetry 92% on room air, lung sounds clear to auscultation, flushed catheter with 60 cc of normal saline. At 8:10 a.m. the resident complained of pain to his lower abdomen with pressure. Slow to verbally respond, eyes open, lung sounds clear, pulse oximetry 90% down to 88% on room air. Blood pressure 122/60, heart rate 74, respirations 18, temperature 98. Urine dark yellow, cloudy, with sediment noted. On 10/11/22 at 3:01 p.m. an RN at the hospital (when the resident transferred) stated the resident arrived at the hospital in poor condition. She said the catheter bag had pus in it, and the pus also came out around the catheter. The RN said that did not just happen. Someone should have noticed it before this. The physician did an ultrasound of his abdomen, and she obtained 500 cc when she changed the catheter. It didn't appear the resident had been cleaned in a while. On 10/11/22 at 4:34 p.m. the ER physician stated the resident was quite ill when he got to the ER. He had urine that was tremendously foul in odor. The resident had distension in the abdomen. He did a scan and his bladder was full. They changed the catheter and he had a large amount of pus that came immediately. The pus had also leaked around the catheter and on to his perineum. The ER physician said this didn't just start when he arrived at the ER. He said the resident was in septic shock and had to be treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/22 at 11:20 p.m. the resident's personal Physician stated septic shock is a continuum of [CONDITION(S)]. She said (when they called her) Staff C did a nice job of presenting the information, and that he needed to go to the hospital. She couldn't say if she should have been called earlier. She said if they had called earlier and they reported that he had trouble with his catheter or his urine she probably would have sent him (to the hospital) because of his history. At 12:29 p.m. the physician communicated septic shock was life threatening, and the resident was probably at an early stage when Staff C called her, was her best estimate. On 10/12/22 at 2:35 p.m. Staff E, CNA, stated that on the night shift of October 9th she went to check on the resident at about 5:00 a.m. When she went in he was shaking really bad and she knew something was wrong, he had never done that before. He said he was freezing, so she got him more blankets, then she went right away, and reported it to Staff C. She said Staff C checked his vitals and they were okay at that point. She said when she emptied his catheter his urine appeared really different. It looked like apple cider and it was really thick, like the consistency of applesauce. She said that it smelled really foul. She said that she thought he had output that night. She can't remember if it was 250 or 500, she usually told someone. She said she'd told the night nurse about his urine, the way it smelled and the way it looked. The night nurse said that he had sediment in his urine. Staff E said it didn't look like sediment. On 10/12/22 at 3:20 p.m. Staff G, CNA, stated that she worked the 2 to 10 shift on Saturday, 10/8/22. She reported being worried about the resident because of the way his urine looked and smelled. He had less output, the urine looked dark and foggy and it smelled very strongly, not like it normally did. She was concerned, so she reported it to the nurse, Staff A, LPN. Staff A dismissed her and told her that it was like that because he'd had a recent catheter change. She also reported that she felt his behavior had changed in the way he was acting. She wasn't surprised to learn that he had gone to the hospital when she returned to work on Sunday (10/9/22) at 2:00 p.m. On 10/12/22 at 3:54 p.m. Staff A stated she worked from 6 p.m. on Saturday, 10/8/22, until the following morning. She denied getting reports about concerns with the resident's urine or with the way the resident acted. On 10/13/22 at 8:55 a.m. Staff H, CNA, stated that on the day shift of 10/9/22 she did not provide care for the resident. She probably went in and checked on him. She said Staff I, CNA, went to the kitchen, so it was just her and Staff F, CNA, on the floor. She said the resident required two people to assist with his care. She didn't know much about what went on until they were sending him out. On 10/13/22 at 9 a.m. Staff I stated she worked the kitchen Sunday morning. She took the resident's tray to him for breakfast and he didn't look right. He had his eyes open and he tried to respond to her but could not. She reported this to the nurse, Staff C. When she picked up his tray he did not eat anything from it and he did not respond. On 10/13/22 at 11:21 a.m. Staff F stated the only thing she did with the resident on 10/9/22 was give him his food. He usually fed himself, but he was not responsive. She did not do peri care on him, as they usually did it after breakfast. On 10/13/22 at 11:48 a.m. the acting Director of Nursing (DON) stated she did not know there was a problem until the surveyor started asking for things. She said there was nothing documented on 10/9/22 prior to right before the resident transferred out. When she found there was other information, she could see there was a problem. She said if the evening and night shift CNA's said they reported their concerns she believed them. Per the CDC [CONDITION(S)] is the body's extreme response to an infection. It is a life-threatening medical emergency. [CONDITION(S)] happens when an infection triggers a chain reaction throughout the body. Infections that lead to [CONDITION(S)] most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, [CONDITION(S)] can rapidly lead to tissue damage, organ failure, and death. Anyone can develop [CONDITION(S)], but some people are at higher risk for [CONDITION(S)] including adults over [AGE] years old, people with weakened immune systems, people with chronic medical conditions, and people with recent severe illness or hospitalization . A person with [CONDITION(S)] might have one or more of the following signs or symptoms: high heart rate or weakened pulse, confusion or disorientation, fever, shivering or feeling very cold. The facility Clinical Change in Condition Management policy dated June 2015 documented that the Interdisciplinary team strived to identify and manage all residents that were experiencing a change in condition. Daily observation and communication was important in identifying changes in a resident that required further investigation. The clinical care management included routine assessment, evaluation, response to changes in clinical condition and communication with residents and/or families/responsible parties. The procedure included assessing the resident's clinical status when a change in condition was identified, reviewing the resident medical record, reviewing the resident condition with an RN, contacting the physician, providing clinical data. and information about the resident's condition. The facility decreased the scope of the deficiency from an immediate jeopardy to a D level deficiency on October 13, 2022 by a. Assessing the facility's other residents with urinary catheters and those with a history of a urinary tract infection for signs and symptoms of infection by the acting DON/Designee. The facility notified the physician as necessary. b. The Acting DON provided education to the licensed nurses regarding completing an assessment and initiating an intervention due to a change in condition for residents that have a history of UTIs within the last 60 days or have had a catheter. Then update the primary care provider as needed. c. The Acting DON would complete an audit weekly for four weeks and then montly for two months to ensure residents with catheters or a history of UTIs within the last 60 days continue to be monitored for infection and changes of condition continue to be sent to the primary care provider as needed.

Based on personnel file reviews and staff interviews the facility failed to assure staff completed their 2-step [CONDITION(S)] testing when hired by the facility for 5 of 5 staff reviewed (Staff G, H, K, L and the acting DON). The facility reported a census of 25 residents. Findings include: The facility [CONDITION(S)]: Prevention and Management policy revised May 2016 documented that residents, routine volunteers, and healthcare workers (HCW) would receive a TB screen and 2-step [MEDICATION(S)] skin test (TST) upon admission/hire. 1) Staff G ' s Personnel File Checklist documented a hire date of 5/16/22. The checklist included a TB test (2-step) or chest x-ray. An Employee, HCW, Volunteer [MEDICATION(S)] Skin Test/chest x-ray Log lacked documentation that Staff G received any TST. A Record of TB Tests and Immunization with Staff G's name on it indicated she received a Mantoux (TB test) on 5/17/22. The record lacked documentation of results from the test. The record lacked documentation of a second TST. 2) Staff H ' s Personnel File Checklist documented a hire date of 9/1/22. The checklist included a TB test (2-step) or chest x-ray. An Employee, HCW, Volunteer [MEDICATION(S)] Skin Test/CXR Log documented that Staff H had a TST on 8/18/22. The log lacked the lot number or expiration date of the TB testing solution. The log lacked a second TST. 3) Staff K ' s Personnel File Checklist documented a hire date of 1/19/22. The checklist included a TB test (2-step) or chest x-ray. An Employee, HCW, Volunteer [MEDICATION(S)] Skin Test/CXR Log documented that Staff K had a TST on 1/24/22 and the results documented on 1/27/22 indicated a negative reading. The log lacked a 2nd TST. 4) Staff L ' s Personnel File Checklist documented a hire date of 8/5/22. The checklist included a TB test (2-step) or chest x-ray. An Employee, HCW, Volunteer [MEDICATION(S)] Skin Test/CXR Log documented Staff L had a TST on 8/1/22. The log lacked documentation of the test results. The log lacked a 2nd TST. 5) The acting Director of Nursing ' s (DON) Personnel File Checklist documented a hire date of 4/18/22. The checklist included a TB test (2-step) or chest x-ray. An Employee, HCW, Volunteer [MEDICATION(S)] Skin Test/CXR Log documented the DON had a TST on 4/11/22 and the results documented on 4/13/22 indicated a negative reading. The DON had a second TST on 4/23/22 and the results documented on 4/26/22 indicated a negative reading. The log lacked a lot number or expiration date for the TB solution used for either test. On 10/18/22 at 10:18 a.m. the Administrator stated they had no other documentation or information regarding TB testing of staff.

Based on clinical record reviews and staff interviews the facility failed to provide ongoing communication and collaboration with the outpatient [CONDITION(S)] facility. In addition the facility failed to complete full nursing assessments and monitoring of a resident before and after going to the outpatient [CONDITION(S)] center for treatment for 1 of 1 residents reviewed on [CONDITION(S)] (Resident #128). The facility reported a census of 25 residents. Findings include: Resident #128's Minimum Data Set (MDS) assessment dated [DATE] identified an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS coded that Resident #128 required extensive physical assistance of one to two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified that Resident #128 received [CONDITION(S)] during the lookback period. The Care Plan problem initiated on 7/27/22 identified that the resident needed peritoneal [CONDITION(S)]. The interventions dated 7/27/22 directed the following a. monitoring and documenting peripheral [CONDITION(S)] b. Monitoring, documenting, reporting to the physician as needed (PRN) for signs/symptoms of [CONDITION(S)] such as: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Review of the [CONDITION(S)] Communication sheets for Resident #128 revealed: a. On 9/7/22 the pre-[CONDITION(S)] assessment had most of the vital signs dated 8/31/22, and the post assessment lacked any vital signs. b. On 9/9/22 most of the vital signs were dated 8/30/22, the [CONDITION(S)] center had a few questions answered, and post-[CONDITION(S)] assessment lacked a weight and a blood pressure. c. On 9/14/22 the residents pre-[CONDITION(S)] assessment included all but the blood sugar dated 9/12/22 or before, with no information from the [CONDITION(S)] center, and no post-[CONDITION(S)] vital signs. d. On 9/26/22 the resident's pre-[CONDITION(S)] assessment included a weight from 9/21/22, minimal information from the [CONDITION(S)] center, and no-post [CONDITION(S)] assessment. e. On 9/28/22 the residents pre-[CONDITION(S)] vital signs were taken at 4:09 p.m. except the weight, and were the same as the post-[CONDITION(S)] vital signs, and had no recorded weight post [CONDITION(S)]. No information recorded from the [CONDITION(S)] center. f. On 10/3/22 some of the pre-[CONDITION(S)] vital signs were from 9/30/22, the assessment lacked information completed from the [CONDITION(S)] center, and the post assessment lacked a blood pressure. g. On 10/7/22 the pre [CONDITION(S)] vital signs were from 10/5/22, the assessment had no information from the [CONDITION(S)] center, and no post [CONDITION(S)] assessment. h. On 10/10/22 the clinical record lacked any assessments related to [CONDITION(S)]. On 10/5/22 at 3 p.m. the Director of Nursing (DON) said that sometimes in the morning the resident left before the nurse could get their vital signs. The resident left around 8 or 8:30 a.m. She said they had done some education when they noticed something missing. Some of the areas with lack of post assessments were agency staff. The resident didn't always return directly after [CONDITION(S)]. On 10/10/22 at 1:15 p.m. the DON stated the [CONDITION(S)] Communication in the electronic health record was what they were supposed to do. The DON explained that they did not have a policy.

Based on clinical record reviews and staff interviews, the facility failed to perform post-fall assessments on 1 of 3 residents reviewed (Resident #126). The facility reported a census of 25 residents. Findings include: According to the Minimum Date Set (MDS) assessment dated [DATE] Resident #126 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required supervision with transfers and ambulation. The MDS included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The current Care Plan revised 9/28/22 identified that the resident had an actual fall with no injury on 8/23/22. The interventions dated 8/25/22 included the following: a. monitoring, documenting, and reporting as needed (PRN) for 72 hours. The Care Plan directed to notify the physician of signs or symptoms of pain, bruises, a change in mental status, or a new onset of confusion, sleepiness, inability to maintain posture, agitation. b. Neurological (Neuro) checks initiated The Progress Notes dated 8/24/22 at 1:45 a.m. documented a report of the resident lying on the floor in the bathroom. The staff assessment determined no injuries. The resident stated she tried to go to the bathroom. Neuro checks were initiated and were within normal limits. No complaints of pain, headache or nausea. The Progress Notes dated 8/25/22 at 5:29 p.m. documented that the resident fell and hit her head. The resident's vital signs were stable and her lung sounds sounded clear to auscultation. The resident denied pain other than the back of her head. The family called and updated that the resident would be sent to the hospital for an evaluation of a scalp laceration. The Progress Notes dated 8/26/22 at 12:07 a.m. documented that the resident returned from the emergency room in a van at 10:20 p.m. alert and oriented, with no new orders. An Emergency Department (ED) Provider Note documented that the resident presented for a head laceration. She reported she tripped, fell , and hit the back of her head. The bleeding stopped on arrival. She exhibited a bruise to her lateral left elbow with tenderness on exam. The report showed the position of the head laceration just right of midline to the back of the head. A computerized tomography (CT) scan showed no acute [CONDITION(S)], and x-ray of the left elbow showed no fracture. The clinical record lacked any follow-up of the injury to the back of the resident's head or left elbow. The Progress Notes dated 9/4/22 at 6:45 p.m. documented when going into a room the resident realized it wasn't her room. She tried backing out and fell hitting her head. She had a laceration with unknown measurements, and uncontrolled bleeding observed. The facility notified the resident's family and they awaited transport to the hospital. The family member stated she would meet her at the hospital. At 11:24 p.m. the resident returned to the facility with her family, with no new orders and a report that her CT scan appeared clear. An ED assessment dated [DATE] at 7:27 p.m. documented that the resident presented with a headache after a fall. She had a hematoma in the occipital area (back of the head) that had no bleeding. The resident had a CT scan with no acute intracranial process. The resident's clinical record lacked any follow-up of the resident's head injury after either fall. The resident had neurological assessments starting on 8/23/22 at 7:15 p.m. with incomplete assessments of four of the every eight hour assessments. After the resident ' s fall on 8/25/22, her chart lacked additional assessments related to her fall and the facility failed to provide additional neuro assessments. Following the resident ' s second fall, the facility failed to have neuro assessments. During an observation on 10/10/22 at 10:20 a.m. the resident felt around on the back of her head and indicated the location of her injury. She said the scab fell off after she took a shower. The acting Director of Nursing (DON) moved her hair around to try and visualize where the injury occurred. There was no scab or any visible post injury. The resident said it was sore after it occurred. She didn't remember if it was two different injuries the last two times she fell or if the injury occurred on the same site both falls. On 10/6/22 at 2:45 p.m. the DON stated she would expect the staff to complete follow-ups after a resident ' s fall and injury. On 10/12/22 at 11:20 a.m. the resident's physician explained that after a fall that involved hitting their head and getting a CT scan, you would still want to do neuros for a while to assure there was no latent issue. On 10/12/22 at 1:38 p.m. the resident's family member stated she went to the ED after the resident fell on [DATE]. Apparently the laceration to the back of her head sealed itself off because they marked it as a hematoma. When they saw the wound before she went to the hospital she saw it bleeding. She said it was probably a half to one inch long and with a goose egg. Her mother didn't want anybody to look at it that night because it was very tender. The facility ' s Fall Risk Reduction and Management policy revised April 2013 included evaluating and documenting on the clinical condition once per shift for at least 72 hours following a fall. A Neurological Assessment form directed to complete an assessment for 72 hours: every 15 minutes for one hour, then every 30 minutes for one hour, then every one hour for four hours, then every four hours for two shifts, then every eight hours for six shifts.

Based on review of the nursing schedule and staff interviews, the facility failed to assure the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. The facility reported a census of 25 residents. Findings include: Review of the facility ' s October 2022 schedule listed the following nurses scheduled to work from 12 a.m. on 10/9/22 to 12 a.m. 10/10/22 as Staff A, Staff C, and Staff J. Per the staff list, all were Licensed Practical Nurses (LPN's) and the schedule had no Registered Nurses scheduled. On 10/18/22 at 11:40 a.m. the acting Director of Nursing (DON) reviewed the October 2022 schedule and confirmed that all of the nurses that worked 10/9/22 were LPN's. She further confirmed they had no RN coverage for that day. On 10/18/22 at 1:32 p.m. the Nurse Consultant stated they did not have a policy on RN coverage but knew they needed it 8 hours every day.

Based on observation, clinical record review, policy review, resident interview, and staff interview the facility failed to assure a complete and thorough initial assessment and weekly follow up assessments were completed for 1 of 2 residents reviewed (Resident #128) with impaired skin. Resident #128 admitted to the facility from the hospital on 6/24/22. The facility failed to complete a full skin assessment for Resident #128, including the abdominal wound, present on admission to the facility, until 7/8/22. The facility failed to complete an assessment of an additional skin impairment identified on 7/9/22, until 7/17/22 when deterioration of the area noted and revealed 2 open areas. The facility reported a census of 26 residents. Findings Include: Resident #128's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS coded that Resident #128 required extensive physical assistance of one to two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #128 as a risk for developing pressure ulcers. She used a pressure reducing device for her bed and her chair. The MDS documented that Resident #128 received an application of nonsurgical dressings and an ointment/medications for skin and ulcer/injury treatment. The facility failed to develop a comprehensive care plan for Resident #128, that included a Focus area, a Goal and/or Interventions related to her risk for impaired skin integrity and/or actual skin impairment. On 7/25/22 at 2:00 PM, Resident #128 sat in her recliner with her feet elevated wearing a hospital gown on. Staff E, Licensed Practical Nurse (LPN), informed Resident #128 that they would change the dressing on her abdomen. Resident #128 removed the old dressing dated 7/24/22 and revealed a large necrotic (dark black) area surrounded with redness along the bottom of her abdominal fold. Noted an open area with a red base along the bottom side, the length of the necrotic area that measured approximately 1 cm wide. Resident #128 stated that the area started as two scratches and bruises that developed into the large black scabbed area. Resident #128 said that [CONDITION(S)] told her the cause of the area happened by calcification under the skin. Resident #128 stated the wound deteriorated at home, as she did not go out for [CONDITION(S)], and eventually got admitted to the hospital due to the pain of the wound. On 7/26/22 at 10:37 AM, Resident #128 sat in her recliner with her feet elevated. Resident #128 stated that she just did not feel well that day and that she had pain. Resident #128 reported that she spoke with the nurse about it and she had received all the pain medications she could have. Resident #128 explained that she did not feel up to an interview at the time. On 7/26/22 at 3:20 PM, Resident #128 sat in her recliner, with feet elevated and covered with a blanket. Resident #128 reported that she just took a bunch of medication and would like to take a nap, and did not feel like being interviewed. The Progress Notes for Resident #128 revealed: a. On 6/24/22 at 7:30 PM, the Admission Nursing Note documented that Resident #128 arrived at the facility via family care from the hospital. b. On 6/24/22 at 12:00 AM, the Health Status Note (HSN) recorded that Resident #128 arrived at the facility from the hospital with family. The note indicated that Resident #128 able to make her needs known due to being alert and oriented. The resident had triple lumen to the upper right arm, a bruise noted across the abdominal area and fistula to the right upper arm with several bruises observed c. On 6/28/22 at 10:10 AM, HSN documented Resident #128 as alert and oriented to person, place, time, and able to make her needs known. Resident #128's skin appeared pale, warm, and dry as her baseline. The wound noted to her abdomen appeared without signs or symptoms of infection. Resident #128's left arm fistula with bruit and thrill, her port appeared to have no signs or symptoms of infection d. On 7/6/22 at 3:02 PM, HSN indicated that Resident #128 continued with her abdominal treatment. The wound contained an intact scab that appeared to be tender to the touch. No new skin issues identified. e. On 7/8/22 at 9:47 AM, HSN recorded a new order received from the Wound Center to apply iodine 10% (antimicrobial used to treat wounds) via a swab stick to the scabbed area on the abdominal wound. Continue the medi-honey (gel used for hard to dress wounds and dry to moderate draining wounds) to the open area below the scabbed area on the abdomen. f. On 7/8/22 at 9:48 AM, HSN documented a scabbed wound to Resident #128's abdomen that measured 17.5 centimeters (cm) in length x 5.4 cm in width x 0 cm in depth. The open area below the scabbed area measured 6.7 cm x 1.5 cm x 0.5 cm. g. On 7/10/22 at 1:02 PM, HSN indicated that during Resident #128's shower, the staff observed a superficial area on her right buttock. The nurse cleaned the area, applied [MEDICATION(S)] (ointment to prevent and heal minor skin irritations), and covered the wound with [MEDICATION(S)] (foam dressing). The nurse sent a fax to Resident #128's primary care provider (PCP). Resident #128 continued with her wound treatment. h. On 7/17/22 at 2:15 PM, HSN indicated that while performing the treatment to Resident #128's abdomen, Resident #128 said that she had a patch to her right hip area. The nurse noted a large bordered foam dressing dated 7/9/22. The nurse removed the dressing, then cleaned the area revealing two open wounds. Wound #1 (closest to the coccyx) measured 4 cm x 2.5 cm x 0.1 cm. Wound #2 measured 4.6 cm x 3.4 cm x 0.1 cm. The nurse applied [MEDICATION(S)] (ointment used to treat skin infections) to both of the areas and covered them with a bordered foam dressing. The nurse sent a fax to Resident #128's PCP. Resident #128's Nursing Daily Skilled assessment dated [DATE] - 7/27/22 lacked documentation of an assessment related to the abdominal wound and/or the skin impairment to the right buttock or hip area. Resident #128's Weekly Skin Assessments revealed one assessment dated [DATE]. The assessment identified intact dressings to her lower abdomen and her right buttock. The assessment lacked documentation of the open areas including measurements. Resident #128's Resident Bath/Skin Observation documented the following: 1. On 6/25/22 - identified an abdominal area while applying [MEDICATION(S)]. 2. On 6/29/22 - no skin impairments identified. 3. On 7/6/22 - an open area to her lower abdomen, the nurse treated the wound. 4. On 7/10/22 - lower abdomen dressing intact and new area to her right buttock. 5. On 7/16/22 - lower abdomen dressing intact and no documentation related to the area on her right buttock Resident #128's Wound Healing Center documentation included the following: 1. On 7/6/22 - midline abdomen, lower quadrant caused by [CONDITION(S)] (serious uncommon disease where calcium accumulates in the small blood vessels of the fat and skin tissues, causing painful skin ulcers). Date acquired 5/1/22, 5 weeks of treatment. Measurements: 7 cm x 15 cm x 0.8 cm. Small amount of yellow, brown, and green purulent drainage. Large amount of eschar (black) tissue. 2. On 7/27/22 midline abdomen, lower quadrant measured 6 cm x 18 cm x 0.8 cm. Right gluteus caused by [CONDITION(S)] acquired on 7/1/22. Measured 2.5 cm x 6 cm x 0.1 cm. small amount of granulation with medium amount of slough. The paper and electronic clinical record lacked weekly skin assessments of Resident #128's abdominal wound from her admission on 6/24/22 until 7/8/22. Resident #128's paper and electronic clinical record lacked a thorough assessment of the areas identified on the right buttock on 7/9/22 until the identification of two areas on 7/17/22. The facility failed to develop a comprehensive care for Resident #128. The Skin Care and Wound Management policy dated 6/15, identified the components of the program to include: weekly monitoring of Resident #128 skin status, daily monitoring of existing wounds, and the interdisciplinary team (IDT) to review the identified skin impairments. 1. Procedure: a. Complete admission skin sweep and the admission clinical information/readmission data collection and initial care plan on admission. Initiate weekly skin sweep thereafter. Identify areas of skin impairment and any pre-existing signs. b. Develop a care plan with input from the IDT and Resident #128 and family. Document individualized goals and interventions to manage risk factors. c. Communicate risk factors and interventions to the caregiving team, resident/family. d. Evaluate for consistent implementation of the interventions and evaluate effectiveness of the interventions during care management meetings. 1. Treatment: a. Select and complete the appropriate form: Skin Grid, Pressure or Skin Grid Other (all skin impairment issues that require measurement to indicate healing occurred) b. Monitor and document progress towards goals c. Evaluate effectiveness d. Modify and document goals and interventions On 7/26/22 at 11:15 AM, the Director of Nursing (DON) explained the the weekly wound assessments got documented in Resident #128's progress notes and denied having a separate skin book. The DON stated all of Resident #128's clinical record would be located in the hard chart and/or the electronic health record (EHR). On 7/28/22 at 7:19 AM, Staff A, Nurse Consultant, confirmed in an email that Resident #128 had wound clinic documentation from 7/6/22 and 7/27/22 with measurements. Staff A explained her next scheduled appointment as 8/8/22. Staff A acknowledged that during Resident #128 bath, the bath sheets acknowledged a wound for 6/25/22, 7/6/22, 7/10/22, and 7/16/22; however, the bath sheets lacked measurements. On 7/28/22 at 8:13 AM, the DON stated Resident #128 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained that he started in the position after Resident #128's admission to the facility. The DON stated he believed that Resident #128 had the areas to abdomen and/or right buttock upon admission. The DON said that Resident #128 received [CONDITION(S)] and she had been in and out of the hospital. The DON reported that he ordered a new commode for Resident #128 due to the new area on her right hip and that he educated the bath aide (a Registered Nurse) about body assessments and measuring open areas. The DON confirmed Resident #128 did not have a complete thorough skin assessment upon admission and/or every week thereafter. The DON confirmed Resident #128 did not have an assessment of her skin impairment identified on 7/9/22 to her right buttock until 7/17/22. The DON added that on a resident's admission to the facility, he expected a full head to toe assessment and initiation of the Care Plan immediately. The DON said the Baseline Care Plan could be a Pocket Care Plan and would expect Resident #128, her family, and the staff to be involved. The DON reported that he expected ongoing weekly skin assessments and an assessment of any new areas identified. The DON explained that he reviewed the facility protocol with the facility nurses on duty related to the skin assessments and expected all residents in the facility to have a skin assessment completed on 7/27/22 and/or 7/28/22. On 8/1/22 at 2:28 PM, Staff B, Licensed Practical Nurse (LPN), explained that the weekly skin assessments were completed under the assessment tab in the resident's EHR. Staff B reported that skin assessments should be done every week, however, they did not get assigned to anyone specifically. For that reason, the assessments do not get completed. Staff B reported that they worked one day a week, and when they arrived to work on Monday mornings the aides would report skin impairments to the agency nurses, who did nothing about them all weekend.

Based on observations, clinical record reviews, and staff interviews the facility failed to adequately supervise, thoroughly investigate falls that occurred, and implement interventions to prevent further falls for 1 of 1 residents (Resident #10) reviewed. Resident #10 sustained falls on 6/1, 6/10, 6/12, and 6/26/22 without a thorough investigation and/or intervention implemented to prevent further falls. On 6/12/22, Resident #10 found on the floor in Resident #10's room with a deep cut to the back of head that required transfer to the emergency room , and resulted in staples being placed. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #10 dated 6/2/22, identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed Resident #10 required extensive physical assistance of one staff for bed mobility, transfers, ambulation, toilet use, and personal hygiene. The MDS coded Resident #10 ' s balance during transitions and walking, as not steady and only able to stabilize with staff assistance. The MDS coded Resident #10 as frequently incontinent of bowel and bladder. The MDS included diagnoses of hypertension, diabetes, non-Alzheimer's dementia, and repeated falls. The MDS identified Resident #10 fell since her admission/entry, reentry, or her prior assessment. The MDS coded Resident #10 had two or more falls with no injury, 2 or more falls with injury, and no falls with major injury. The Care Plan with date initiated 1/29/22, identified Resident #10 had an actual fall with no injury related to poor balance and unsteady gait. The Care Plan interventions included: a. Anti-roll back wheelchair to reduce the wheelchair rolling backwards when Resident #10 stands up and sits back down (2/25/22) b. Assist x 1 with ambulation, after toileting, when Resident #10 became restless and attempting to get out of the wheelchair if restlessness continues (6/1/22) c. Back of wheelchair seat to be lowered (4/2/22) d. Continue interventions on the at-risk plan (1/29/22) e. Ensure call light in reach, place on walker/wheelchair or near body (2/3/22) f. Keep frequently used items on right side (3/12/22) g. Keep walker and/or wheelchair in resident's reach for visual cue for safety (2/24/220 h. Anti-tip wheels on wheelchair if indicated (2/15/22) i. Offer snacks and activities when up in wheelchair (4/3/22) j. Pharmacy consult to evaluate medications (3/12/22) k. Provide room in high traffic area (3/14/22) l. Physical therapy consult for strength and mobility (3/12/22) m. Ambulate resident three times a day (2/23/22) n. Encouraged to propel self in wheelchair in hallway, instead of ambulating independently (2/23/22) o. Resident to wear shoes when out of bed and non-skid socks in bed (1/30/22) p. Avoid telling Resident #10 what you don't want her to do (2/18/22) q. When not pushing wheelchair, ensure pedals are locked and to the side (4/29/22) r. Encourage Resident #10 to use a controller to lower the footrest of the recliner (1/30/22) The Care plan for Resident #128 with date initiated 1/29/22, identified Resident #10 mixed bladder incontinent related to dementia. The Care Plan interventions included: a. Ensure unobstructed path to the bathroom (1/29/22) b. Establish voiding patterns (1/29/22) c. Check every 2 hours and as needed for incontinence (1/29/22) On 7/25/22 at 10:22 AM, Resident #10 up in a wheelchair in the hallway, sitting outside of the door to the room. The resident was well-groomed with non-skid footwear on. The resident with hand up on forehead and leaning forward, eyes closed. On 7/25/22 at 11:25 AM, Resident #10 at the dining room table in a wheelchair with nursing staff sitting with Resident #10. On 7/26/22 at 8:52 AM, the nursing staff assisted Resident #10 in the dining room with breakfast. The resident had well-groomed and non-skid footwear on. On 7/26/22 at 3:16 PM, Resident #10 in the hallway in a wheelchair. The resident had well-groomed and non-skid footwear on. The resident attempted to propel the wheelchair back and forth. The Progress notes for Resident #10 revealed: a. On 6/1/22 at 1:45 PM, The Alert Note (AN) identified Resident #10 observed on the floor on the left side in front of the wheelchair by the nurse's station. No sign/symptoms of injuries, bruising, laceration, or redness. The resident denied pain or discomfort. Range of motion (ROM) within normal limits. Assist of 2 for short walk, gait steady. Vitals sign stable and neurological assessment initiated. Family and physician notified. b. On 6/1/22 at 3:46 PM, AN identified an intervention of assist x 1 with ambulation, after toileting, when Resident #10 became restless and attempted to get out of wheelchair if restlessness continued c. On 6/10/22 at 4:08 PM, a health status note (HSN) stated Resident #10 was on the floor, lying on the right side with a wheelchair behind. The resident was unable to explain what occurred. The resident denied pain and was able to demonstrate ROM to all extremities. No bruising or abrasions noted. The resident assisted by standing and in a wheelchair. The resident assisted at the nurse's station and provided. Family and physician notified. d. On 6/12/22 at 11:41 AM, HSN revealed Resident #10 was found on the floor in a room with blood at the back of head, deep cut and bump notes. The resident was transferred to a wheelchair and sent to the emergency room after family and physician notification. e. On 6/12/22 at 2:49 PM, HSN stated the facility received call from the emergency room (ER) and Resident #10 to return to the facility, and Resident #10 CT scan negative f. On 6/12/22 at 4:32 PM, HSN stated Resident #10 returned to the facility with family, 3 staples placed to the left parietal scalp and to be removed on 6/19/22. g. On 6/19/22 at 4:41 PM, HSN identified 3 staples removed from the back of Resident #10's head, area clean, dry, and intact. The resident denied pain or discomfort. h. On 6/26/22 at 8:31 AM, HSN identified Resident #10 found on the floor of the room, on the left side with legs extended. The resident incontinent and briefly saturated, with yellow stain on bedding. The resident self-transferred from the bed. Neurological assessment initiated and Resident #10 denied pain or discomfort. The Fall Investigation dated 6/1/22 at 1:45 PM, identified Resident #10 found lying on the left side in front of the wheelchair by the nurses station. a. Immediate action: Intervention: assist of one with ambulation after using the toilet when Resident #10 became restless and attempted to get out of her wheelchair. b. Predisposing environmental factors: furniture c. Predisposing physiological factors: gait imbalance and impaired memory d. Predisposing situation: wanderer and ambulated without assist The Fall Investigation dated 6/10/22 at 4:03 PM, identified Resident #10 found in the hallway lying on the floor with a wheelchair behind Resident #10. a. Immediate action: Resident #10 assessed and vital signs obtained. ROM assessed Resident #10 assisted to wheelchair b. Mental status: oriented to person c. Predisposing physiological factors: gait imbalance and impaired memory The Fall Investigation dated 6/12/22 at 11:27 AM, identified Resident #10 found on the floor in the room with blood at the back of head, deep cut and bump noted. a. Immediate action: Resident #10 sent to the hospital b. No injuries observed at time of the incident c. Predisposing environmental factors: other d. Predisposing physiological factors: confused, gait imbalance and impaired memory e. Predisposing situation factors: used wheeled walker The Fall Investigation dated 6/26/22 at 8:25 AM, identified Resident #10 found on the floor in the room on the left side with legs extended. The resident incontinent with saturated briefs and yellow stains on bedding. The resident self-transferred. a. Immediate action: neurological assessment b. No injuries observed at time of the incident c. Mental Status: oriented to person and place d. Predisposing environmental factors: other, detail in note e. Predisposing physiological factors: confused, incontinent, gait imbalance and impaired memory f. Predisposing situation factors: ambulated without assist and improper footwear g. Other information: intervention gripper socks and check and change every two hours The emergency room Provider Report dated 6/12/22 at 11:37 AM, identified Resident #10 ' s chief complaint as a fall with a head injury. Resident #10 presented to the ER by ambulance for a head injury associated with a fall. Resident #10 appeared at her baseline of confusion. The facility staff assumed Resident #10 fell out of bed onto the hard floor, approximately one to two feet. Resident #10 hit her head when she fell , resulting in an injury to the left occipital part of her head. Resident #10 had a history of recurrent falls. The section labeled Additional Documentation indicated that Resident #10 received three staples, antibiotic ointment, and a bulky dressing. The Radiology Impression identified a closed head injury with concussion, left parietal scalp hematoma, and laceration of the occipital scalp. On 8/1/22 at 9:23 AM, the Director of Nursing (DON) said the facility staff asked about Resident #10 falls when he started at the facility at the end of June 2022. The DON stated he inquired about a scooped mattress. The DON explained that Resident #10 did not have any further falls from her bed since placing the scoop mattress. The DON denied knowing the date of the placement of the scooped mattress on Resident #10's bed. The DON reported that he knew Resident #10 had a lot of falls from her bed. The DON explained that he did not have the chance to look into Resident #10's falls. The DON said he expected the falls to be looked into, to determine if the previous interventions implemented were sufficient. The DON added that within 24 to 48 hours he expected an intervention to be put in place following a fall and additional interventions to follow as needed. The DON acknowledged that falls needed to be looked at facility wide.

Based on staff interviews and the Centers for Medicare and Medicare Services (CMS) the facility failed to provide the residents with a certified Infection Control Nurse that completed the specialized training related to infection prevention and control. The facility reported a census of 26 residents. Findings Include: During the Entrance Conference on 7/25/22 at 10:15 AM, the Director of Nursing (DON) reported that he was working on the Infection Prevention Certification. The DON stated the facility's Corporation had a certified Infection Preventionist that assisted the facility with Infection Control. On 8/1/22 at 11:11 AM, during a follow-up interview, the DON explained that he did not have a certificate related to infection control and prevention. The DON said he went to the Centers for Disease Control and Prevention (CDC) website, but he did not enrolled in the class at that time. The Center of Clinical Standards and Quality/Survey and Certification Group Ref: QSO-20-38-NH dated 8/26/20 indicated that the Infection Preventionist should complete the specialized training in infection prevention and control.