Every finding on record at Hillcrest Healthcare Center

Based on resident interviews, record review, and staff interview, the facility failed to include residents in their care plan meetings and ensure care plans were reviewed at least quarterly. Furthermore, the facility failed to revise the care plan for Resident #71's dentures. This was true for three (3) of five (5) residents sampled for care planning during the Long-Term Care Survey process. Census: 89 Resident identifier: #88, #71, #9a) Resident #71 During an interview on 06/22/26 at 12:16 PM, Resident #71 stated she had not been invited to attend care plan meetings. Review of Resident #71's medical records showed a care plan meeting had been held on 03/13/25 and the resident had attended. However, no further care plan meetings were documented since then. On 06/23/26 at 2:45 PM, the facility's Social Worker confirmed 03/13/25 was the last care plan conference that had been held regarding Resident #71. She stated she was behind on holding resident care plan meetings. During an interview on 06/22/26 at 12:16 PM, Resident #71 stated she had been fitted for an upper denture but had not received it yet. Review of the resident's medical records showed the resident had been fitted for an upper denture on 04/09/26. The expected delivery date for the denture was 07/09/26. Review of Resident #71's comprehensive care plan showed the following focus initiated on 12/04/24, The resident is at risk for oral/dental problems r/t [related to] being edentulous. She chooses to not wear dentures. On 06/25/2026 at 10:14 AM, the Director of Nursing confirmed Resident #71's care plan had not been revised to reflect the resident had been fitted for an upper denture and was awaiting arrival of the upper denture. No further information was provided through the completion of the survey process. b) Resident #9 A policy titled, Plan of Care Overview reads, Resident/representative will have the right to participate in the development and implementation of his/her own plan of care. The policy also stated that the facility will review care plans quarterly and/or with significant changes in care. During initial interview on 06/22/26 at 11:45 AM, Resident #9 stated that she had not been invited to care plan meetings. A review of the health record shows no documented invitations or attendance of care plan meetings since admission. In an interview with Director of Social Services (DoSS) #88 on 06/23/26 at 2:40 PM, she stated she was the only social worker for 90 residents and was behind on care plan meetings. The DoSS said, If it isn't in the documentation, then it probably wasn't done. This was in response to the question of whether state surveyor could find documentation of invitation or attendance of the care plan meetings. c) Resident #88 In an initial interview with Resident #88 on 06/22/26 at 12:10 PM, he stated he had not been invited to, nor participated in his quarterly care plan meetings. A review of the electronic medical record reveals that Resident #88 has participated in his care plan on 03/27/25 and 03/05/26. In an interview with DoSS #88 on 06/23/26 at 2:40 PM, DoSS stated she was the only social worker for 90 residents. DoSS said she was behind on care plan meetings. DoSS said, If it isn't in the documentation, then it probably wasn't done. This was in response to the question of whether state surveyor could find documentation of invitation or attendance of the care plan meetings.

Based on resident interview, record review, and staff interviews, the facility failed to ensure a dependent resident received services to maintain gained level of independence with activities of daily living (ADLs) after finishing therapy services. This was true for one (1) of four (4) resident sampled for ADLs during the Long-Term Care Survey process. Census: 89 Resident identifier: #9a) Resident #9 During an interview with Resident #9 on 06/22/26 at 11:49 AM, she stated she was supposed to walk daily with nursing staff since being discharged from therapy but has only walked once. A record review of the walking tasks for April, May, and June 2026 revealed Resident #9 walked with nursing staff once in the last three (3) months. The Physical Therapy discharge note dated 04/24/26 reads, discharge recommendations: transfers to wheelchair daily with assist of nursing staff. Ambulation with rolling walker with assistance from nursing staff with wheelchair follow as tolerated. The discharge also shows that Resident #9 was able to ambulate 65 feet with rolling walker with contact guard assist (CGA) with fair balance as of 04/24/26. In an interview with Physical Therapy Assistant (PTA) #110 at 9:15AM on 06/24/26, he stated he would expect a resident discharged from therapy with recommendations to ambulate with a rolling walker and nursing assistance to walk daily unless the resident refused. He stated he would also expect for Resident #9 to be able to maintain the assistance levels from discharge at least through the next quarter, when she would automatically be screened again for therapy. In an interview with Nursing Assistant (NA) #52 and NA #70 on 06/24/26 at 10:15 AM, they reported that they do not assist Resident #9 regularly. However, when they assisted her over the last 3 months, she only required minimal assistance for bed-to-wheelchair transfers, but they had never seen her walk. In an interview with CNA #76 at 10:30AM on 06/24/26, she stated Resident #9 is able to walk with touching assistance about 20 feet. CNA #76 states Resident #9 gets up daily and rarely, if ever refuses. In an interview with the DON at 10:50 AM on 06/24/26, she stated she would expect nursing staff to walk residents daily if that was the recommendation from therapy at discharge. She confirmed that according to documentation, Resident #9 has only walked once with nursing staff since discharge from therapy.

Based upon record review and staff interview, the facility failed to obtain consent from the resident's representative on the POST form, instead it was signed by a resident who did not have capacity at the time of consent. This was found to be true for one (1) of three (3) residents reviewed for Advanced Directives during the long term care survey process. Resident identifier: #11. Facility census: 89. Findings included: Findings included: a) Resident #11 Medical Record Review (MRR) revealed Resident #11 had the following mental health diagnoses:-Vascular Dementia-Major Depressive Disorder-Hallucinations-Unspecified Mood Disorder-Anxiety A [NAME] Virginia Post Form was completed for the resident on [DATE]. The resident signed the POST Form on [DATE], selecting Cardiopulmonary Resuscitation (CPR) with full treatment. On the same date ([DATE]), a physician deemed the resident to not have capacity to make medical decisions and that a medical power of attorney representative or surrogate decision-maker may be making medical decisions regarding life-prolonging intervention or mental health treatment for him/her. On [DATE], the surveyor asked the Nursing Home Administrator who in the facility oversaw the residents' POST forms. He responded, The Director of Admissions (DoA). The surveyor then reviewed with the Director of Admissions on [DATE] at 3:05 PM, the resident's POST form and the physician's determination of capacity for Resident #11. The Director of Admissions (DoA) acknowledged this error, and stated she would update this form.

Based on record review and staff interview, the facility failed to provide documentation that the Notice of Medicare Non-Coverage (NOMNC) was delivered to resident representative. This was true for one (1) of two (2) residents sampled for Beneficiary notification during the Long-Term Care Survey process. Census: 89 Resident identifier: #101a) Resident #101 The Medicare Claims Processing Manual section 260.3.8 titled NOMNC Delivery to Representatives reads as follows: The NOMNC must be annotated with the following information on the day that the provider makes telephone contact: Reflect that all of the information indicated above was communicated to the representative; Note the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called. A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the beneficiary's medical file. The NOMNC dated 11/26/25 shows that Social Services called the resident representative on 11/24/25 but was signed by only one facility representative. In an interview with Director of Social Services #88 on 06/24/26 at 12:55 PM, she confirmed that the NOMNC for Resident #101 was done verbally over the phone with only one (1) person signing as the facility representative and best practice is to have two (2) signatures. In an interview with Director of Social Services #88 on 06/25/26 at 10:30 AM, she stated she could not provide documentation that the NOMNC was mailed to the resident representative because they do not use certified mail and there is no documentation in the medical record stating this was done.

Based upon record review and staff interview, the Pre-admission Screening Resident Record (PASRR) was not updated when the resident had new mental health diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, and the PASARR was not coordinated with the Minimum Data Set (MDS). Failure to coordinate the PASARR and the MDS can lead to duplication of effort and testing. This was found to be true for one (1) of two (2) residents reviiewed during the long term care survey process. Resident identifier: #89. Facility census: 89. Findings included: a) Resident #89 Resident #89 was admitted to the facility on [DATE]. A physician determined the resident did not have decision-making capability for health care decisions. Upon admission to the facility, the resident had the following diagnoses relating to mental health: -AUDITORY HALLUCINATIONSN/A, not an acceptable Primary Diagnosis 11/25/2025-ANXIETY DISORDER, UNSPECIFIED 08/07/2025 Present on admission The resident obtained new mental health diagnoses during the stay at the facility. These included: -POST-TRAUMATIC STRESS DISORDER, CHRONIC 05/07/26-MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED 05/07/26 The Pre-admission Screening and Resident Record (PASARR) was most recently completed on 01/29/26 by the facility. On this PASARR, Section 30 Current Diagnosis the person completing the PASARR is to check all the diagnoses that apply. Checked was Other Related Conditions, and typed in below was anxiety, depression and auditory hallucinations. The resident subsequently acquired new diagnoses for Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder on 05/07/26, during the stay at the facility, and the PASARR was not updated and submitted for Level II review. The NHA was asked who normally completes the PASARR at the facility, and the NHA responded it was usually either the Director of Admissions or the Director of Social Services. During an interview with the Director of Admissions and the Director of Social Services on 06/23/26 at 3:00 PM, the PASARR was reviewed and the resident's diagnoses. It was confirmed the PASARR needed to be updated for Major Depressive Disorder and PTSD, which were diagnosed on [DATE].

Based on observation, record review, and staff interview, the facility failed to store and label medications within accepted standards of practice. A Humalog Insulin Kwikpen located in the medication cart was past its expiration date based on when the medication was opened. Additionally, a multi-use vial of tuberculin purified protein derivative (PPD) located in the medication refrigerator had not been dated when first accessed. These were random opportunities for discovery during the facility task of medication storage. Resident Identifier: #9. Facility Census: 89. Findings included:a) Policy review The facility's policy titled, Vials and Ampules of Injectable Medications, with an effective date of September 2025, stated that when a vial is opened, the nurse should record the opened date on the vial. Nurses may also record the expiration date on the vial. b) Resident #9 - Humalog Kwikpen On 06/24/26 at 8:05 AM, the west wing medication cart was inspected with Licensed Practical Nurse (LPN) #22 in attendance. In the cart was a Humalog Insulin Kwikpen for Resident #9. Written on the pen label was an opening date of 05/10/26 and a use by date of 06/10/26. LPN #22 confirmed the Humalog Insulin Kwikpen should have been discarded. Review of Resident #9's physician's orders showed the resident's Humalog insulin sliding scale coverage had been discontinued on 05/22/26. However, the resident was having fingerstick blood glucose levels checked twice a day and could have required insulin coverage for an extremely high reading. According to the Humalog Kwikpen prescribing insert, available on-line on the Food and Drug Administration (FDA) Website, Do not use your pen past the expiration date printed on the label or for more than 28 days after you first start using the pen. c) Tuberculin PPD On 06/24/2026 at 8:37 AM, the east wing medication refrigerator was inspected with Licensed Practical Nurse (LPN) #1 in attendance. The refrigerator contained a multi-use vial of tuberculin purified protein derivative (PPD) that had not been labeled when first opened. The vial's labeling showed it had been delivered by the pharmacy on 06/01/26. Tuberculin PPD is used to aid in the diagnosis of tuberculosis infection. According to the Tuberculin PPD prescribing insert, available on-line on the Food and Drug Administration (FDA) Website, a vial that has been entered and in use for 30 days should be discarded. LPN #1 confirmed the vial had not been dated when first opened but should have been dated. No further information was provided through the completion of the survey process

Based on record review and staff interview, the facility failed to ensure Cardio-Pulmonary Resuscitation (CPR) interventions were initiated and continued until the arrival of emergency medical personnel for a resident observed with absence of vital signs with a Full Code status, resulting in death for one (1) of two (2) residents reviewed for death in the facility. This had the potential to affect all residents in the facility with a Full Code status. This immediate jeopardy began on [DATE] at approximately 3:00 AM when Resident #194 was observed with absence of vital signs. LPN #125 and Nurse Aide #126 reportedly initiated CPR but discontinued it prior to the arrival of EMS. The facility Administrator was informed of the Immediate Jeopardy (IJ) tag on [DATE] at 2:55 PM. The IJ tag was removed and the deficient practice corrected on [DATE], prior to the start of the survey, and was therefore Past Noncompliance. Findings included: a) Resident #194 The closed record for Resident #194 was reviewed on [DATE] at 8:30 AM. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Chronic Pain Syndrome, Anemia, Major Depressive Disorder, Chronic Kidney Disease, personal history of Transient Ischemic Attack (TIA), Cerebral Infarction (Ischemic Stroke) without residual deficits, and Atrial Fibrillation. A Physician Determination of Capacity form, completed on [DATE], indicated that Resident #194 had capacity. A Physician Orders for Scope of Treatment (POST) form, signed by resident's physician on [DATE], indicated Resident #194 had checked the box stating she wished to receive CPR in the event she was found with no pulse and was not breathing. Review of the facility's Cardiopulmonary Resuscitation (CPR) policy revealed the following: - The facility will follow current American Heart Association (AHA) guidelines regarding CPR and ensure there are an adequate number of staff present who are properly trained/certified in CPR. - If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), licensed nurses will provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the physician order and Advance Directives. The date and time of the incident was on [DATE] at approximately 3:00 AM. LPN #125 and Nurse Aide #126 entered the resident's room to complete a dressing change and found the resident to be unresponsive. CPR was reportedly started on Resident #194 but stopped prior to the arrival of EMS. The two (2) staff members were immediately suspended pending the outcome of the facility's investigation into the incident. Per the Administrator's statement, the facility had a meeting with ambulance authority in which the EMS Supervisor stated the arriving crew for the emergency call stated to him that facility staff did not initiate CPR on the resident. The EMS call from the facility was received at 3:12 AM. Per her statement, LPN #125 entered the resident's room with Nurse Aide #125 and found the resident unresponsive and without vital signs. CPR was initiated with the help of Nurse Aide #126. They allegedly did three (3) to four (4) rounds of CPR and couldn't do anymore. Per her statement, Nurse Aide #126 began CPR with LPN #125. They reportedly stopped about five (5) minutes before EMS arrived. The Nurse Aide stated she left the room to answer another resident's call light after that. Per her statement, the crash cart (used to provide healthcare professionals with immediate access to life-saving medications and equipment during a medical crisis) was obtained by LPN #22. LPN #22 called 911 at approximately 3:12 AM. Per her statement, RN #46 was on the other side of the building and was never aware Resident #194 was not doing well until resident was taken out of the building by EMS. LPN #125 reported to her that the resident was unresponsive and was a full code. RN #46 informed staff that when there is a code in the building to call / yell / page overhead for staff to come perform CPR until EMS arrives. Throughout the facility's investigation, it was determined that the LPN #125 and Nurse Aide #126 started CPR but stopped minutes before EMS arrived. It was determined that the facility's CPR policy was not followed. Written statements were obtained from staff working at that time. LPN #125 was terminated. Nurse Aide #126 was suspended and received disciplinary action for following the LPN ' s lead and stopping CPR prior to the arrival of EMS staff. Both the LPN and the Nurse Aide were reported to their respective licensing boards. During an interview on [DATE] at 12:35 PM, the Administrator confirmed the facility initiated the following abatement plan to correct the identified deficient practice: 1. The facility completed a timeline of when the initial change in condition occurred, all events/occurrences, staff assigned, actions taken, staff interactions, communication, family interaction/comments, list of all staff involved, and when EMS was called. COMPLETED [DATE]. 2. The facility performed an audit of licensed nursing staff for current CPR cards. COMPLETED [DATE]. 3. The facility completed an audit of all POST forms / advance directives to ensure they match, and the code status order is accurate. COMPLETED [DATE]. 4. All licensed nursing staff (beginning [DATE], then upon return to work, then quarterly thereafter) completed CPR education in Relias (an online learning management system). 5. The facility provided education to all direct nursing staff on [DATE] to all staff present (and thereafter upon a staff member's return to work) on the facility's CPR policy and the fact CPR should not be stopped until EMS arrives to relieve facility staff. 6. Mock codes were performed one (1) time a week for four (4) weeks. 7. Findings were reported to the Quality Assurance Committee monthly for three (3) months then as directed by the Quality Assurance Committee. On [DATE], beginning at 3:33 PM, the Surveyor interviewed ten (10) members of the nursing staff that were on duty. During each individual interview, staff were able to outline the expectations of successfully performing CPR on a resident who had a full code order. Each individual identified the need to immediately begin CPR, call out for help so the crash cart could be delivered and someone could call 911. They were able to state that it is the expectation that all available staff be available to continue CPR in the event a staff member needed to be relieved. Each staff member emphasized that CPR was to continue up until EMS arrived in the building and took over CPR efforts. During an interview on [DATE] at 4:51 PM, the Director of Nursing explained that all new hires are provided orientation on the facility ' s CPR policy and what their role would be if a code were to be called while they are in the building. Additionally, it was reported that each employee completes an electronic training course that covers the full code process. Although the facility was not in compliance with the regulatory requirement at the time the incident occurred on [DATE], there was evidence that the facility was in substantial compliance on [DATE]. Therefore, this was considered Past Noncompliance.

Based on record review and staff interview the facility failed to provide adequate supervision to prevent avoidable accidents. This failed practice caused harm to Resident #245. Resident #245 fell from the shower bed and received hematoma and laceration to the head requiring sutures. The incident was corrected and will be sighted at past non-compliance. This failed practice was found true for (1) one of (6) six residents reviewed for accidents during the Long-Term Care Survey Process. Resident identifier: #245. Facility census: 90. Findings Include: a) Resident #245 A review of the facility reportable log on 04/15/25 at 11:30 AM, found a reportable for Resident #245 dated 09/29/24 at 9:45 AM, that summarized the incident as follows: Nursing Assistant (NA) #69 had Resident #245 in the shower room giving her a shower. Resident was laying on the shower bed when NA #69 put the rails down on the shower bed and then turned to place a blanket on the shower chair beside the shower bed and resident sat up and slid off of the shower bed onto the floor. Resident struck her head on the floor causing a laceration to the left temple area. Resident was sent to the emergency room (ER) for sutures. Resident had bruising and lacerations to her left temple area. Further record review of the Hospital emergency room (ER) report on 09/29/24 is summarized as follows: Resident had a scalp laceration requiring sutures and a hematoma to forehead, no other injuries related to the fall. A record review of the report on 04/16/25 at 9:00 AM, revealed that risk factors for Resident #245 included: Resident undergoing changes in medications, resident has a fall history, poor safety awareness, and impulsive movements. A record review on 04/16/25 at 9:15 AM revealed that Resident #245 had the diagnoses that included the following: Epilepsy, Early onset of Dementia, Altered mental status, and muscle weakness Further record review of Resident #245's fall care plan reads as follows: Focus: The resident has had falls and is at risk for further falls due to early onset Dementia, muscle weakness, and Epilepsy disorder. Goal: Resident will not sustain major injury related to falls through review date. Interventions: Bed in lowest position DEVICE: Bilateral Fall mats Device: hipsters on at all times. may be removed for hygiene. every shift for falls Device: Perimeter Mattress to bed to help identify edges Dycem to the left side of bed. Educate resident or resident representative, if applicable how to operate bed controls/call light/television Ensure resident is wearing appropriate non-skid footwear Ensure the resident's room is free of accident hazards. Ensure residents room is free of potential visible hazards Ensure that the bed locks are engaged Initiate neuro checks if fall is unwitnessed, or the head is involved. Lab work ordered Medication adjustment by NP NP to review medication Place call bell within reach, remind resident to call for assistance. Provide adequate lighting at night PT/OT eval and treat, as needed. Rearrange the room / personal items are within reach A review of the reportable investigation on 04/15/25 at 11:30 AM found that the incident happened on 09/29/24 at 9:45 AM in the shower room. The incident was reported on 09/29/24 at 1:30 PM. All staff working were interviewed to rule out abuse. The perpetrator, Nursing Assistant (NA) #69's statement read as follows: I was showering (Resident #245 name) around 9:45 AM. I moved her rolling chair by the shower bed. I turned around to remove blankets, and she rolled out of the shower bed onto the floor. Later in the investigation it came out that NA #69 had lowered the rail to the shower bed, before he turned around to remove blankets from another chair. All staff working that were interviewed contested to the facts that NA #69 had Resident #245 in the shower room, he lowered the rail to the shower bed, turned around to remove blankets from the shower chair and Resident #245 rolled off the shower bed, hitting her head on the floor causing the laceration. Five-day follow-up was completed on 10/02/24 and the incident was substantiated by the facility. NA #69 was immediately suspended pending the investigation All floor staff were educated on the correct procedures of showering residents and safety the in-service reads as follows: When having residents on a shower bed do not lower rails on the shower bed until you are ready to transfer with all needed supplies. Do not turn your attention away from the resident until the transfer is complete. Sign-in sheets for the in-service were reviewed and it was verified that all floor staff received the in-service. One on one education provided to NA #69 and a disciplinary notice was put in place that is marked for the following: Violation of safety rules Unsatisfactory quality The disciplinary notice narrative reads as follows: Resident fell out of shower bed due to bed rail being down while NA turned his back to grab a blanket, resulting in a laceration to the head. During an interview, on 04/17/25 at 2:30 PM, The Administrator stated, It was just one of those accidental things. He turned his back, and the resident fell out of the shower bed. We did in-service all floor staff and did one on one education with the aide. The State Agency feels that harm occurred to Resident #245 by NA #69 turning his back and allowing Resident #245 to fall off the shower bed acquiring a head laceration that required sutures. The State Agency further agrees that all corrective action has been taken by the facility to correct the situation and put plans in place to ensure an incident of this nature does not happen again.

Based on observation and staff interview the facility failed to provide food that was palatable by serving scorched beans. This was a random opportunity of discovery had had the potential to affect a limited number of residents residing in the facility. Facility census: 90 Findings include: 04/15/25 01:40 PM the beans had a strong smoky smell and had small bits of black burnt substance in them. When tasting them they had an overcooked burnt taste to them. 04/15/25 01:55 PM The Culinary Account Manager (CAM) #101 stated the beans were cooked today and knew they were scorched. CAM #101 stated, Yeah she (the cook serving) scrapped the bottom of the pan. This confirmed the beans had been scorched and should not have been served.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Resident identifiers: #29, #19, #17, #28, and #43. Facility census: 90. Findings included: a) Resident #29 On 04/16/25 at 8:45 AM, medication administration by Registered Nurse (RN) #12 to Resident #29 was observed. Resident #29 was ordered fluticasone nasal spray and allergy eye ophthalmic solution. RN #25 took the fluticasone nasal spray bottle out of the medication cart. She left the box for the nasal spray in the medication cart. RN #25 also took the box of allergy eye ophthalmic solution containing the bottle of solution out of the medication cart. RN #25 placed the bottle of nasal spray and the box containing the bottle of eye solution on a tissue on the resident's overbed table. The resident self-administered the nasal spray and RN #25 administered the eye solution. RN #25 then removed the bottle of nasal spray and box containing the bottle of eye solution from the overbed table and placed them on the edge of the sink while she washed her hands. She did not use a barrier between the bottle and box and the sink. She then placed the bottle and the box on top of the medication cart before returning them to the medication cart drawer. She put the nasal spray bottle back into the box upon returning it to the medication cart. RN #25 then prepared and administered Resident #29's oral medications. She then took a box containing Resident #29's fluticasone inhaler out of the medication cart. She placed the box containing the inhaler on Resident #29's bedside table. She did not use a barrier between the box and the resident's bedside table. After administering the inhaler, RN #25 placed the box containing the inhaler on the top of the medication cart before returning the box to the medication cart drawer. RN #25 was informed that infectious agents could have been transferred from the resident's room to the medication cart due to the failure to use barriers. She stated she understood. b) Resident #19 On 04/16/25 at 9:20 AM, medication administration by Licensed Practical Nurse (LPN) #30 to Resident #19 was observed. LPN #30 prepared Resident #19's oral medications and also took a box containing the resident's fluticasone inhaler out of the medication cart drawer. She placed the box with the inhaler on top of the resident's overbed table while she administered the resident's oral medications. She did not use a barrier between the overbed table and the box containing the inhaler. Following administration of the inhaler to Resident #19, LPN #30 placed the box containing the inhaler on top of the medication cart before returning the box to the medication cart drawer. LPN #30 was informed that infectious agents could have been transferred from the resident's room to the medication cart due to the failure to use a barrier. She stated she understood. During an interview on 04/16/25 at 10:31 AM, the Director of Nursing (DON) stated it was standard practice to use a barrier between resident room surfaces and multi-dose medications to be returned to the medication cart. She stated the facility did not have a policy to reflect this policy. c) Resident #17 The facility's policy and standard procedure titled Enhanced Barrier Precautions, with no implementation given, stated Enhanced Barrier Precautions (EBP) would be used for residents with wounds without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any multidrug-resistant organisms. The policy also stated a sign would be posted on the resident door to indicate EBP were required. Review of Resident #17's physician's orders showed the resident had an order written on 03/11/25 for pressure ulcer dressing changes to the right buttock and sacrum. The resident did not have an order for EBP. On 04/16/25 at 11:04 AM, the resident's door did not have a sign to indicate the resident required EBP. On 04/16/25 at 11:17 AM, the Director of Nursing (DON) confirmed Resident #17 required EBP due to pressure ulcer wounds. She also confirmed the resident did not have an order for EBP or signage on his door. 50801 d) Resident #28 During an observation of Resident #28's room, on 04/15/25 12:45 PM, rips and tears on the top of the back plastic cover of his wheelchair, exposing the inner padding were observed. e) Resident #43 During an interview and observation with Resident #43 on 04/15/25 at 12:50 PM, it was observed his wheelchair had rips, and holes in the plastic coverings on the arm rest exposing the inner padding. In an interview with the Corporate Clinical Nurse, on 04/15/ 25 at 1:55 PM, she acknowledged both wheelchairs for Residents #28 and #43 had tears exposing the inner padding and agreed the chair could not be cleaned to prevent infection. She stated she understood it was an infection control issue.

Based on observation, staff interview and record review, the facility failed to provide dental services by failing to schedule oral surgery in a timely manner as recommended by the dentist. This is true for Resident #7. Facility Census 90. Findings Included: a) Resident #7 On 04/14/25 at 3:18 PM Resident #7 was observed to have broken and missing teeth. On 04/15/25 at 09:08 AM a review of resident's medical records revealed the following: Resident #7's care plan stated that the resident had a potential for oral/dental health problems affecting ADLs r/t Poor oral hygiene, has own teeth, missing, requires assist of staff with oral care. The intervention included dental consult as needed. A review of resident's last Dental exam summary on 01/04/22 stated Recommending all remaining teeth to be extracted and attached a referral to see an oral surgeon. Nursing Note dated 01/4/22 at 11:12 am revealed, Referral for resident to see an oral surgeon for further tooth extractions. Resident denies mouth or tooth pain at current time. Will notify APS of dental request/referral along with NP. Resident and nursing aware. Will send referral (specific facial surgeon) to see if they will accept resident and if not will seek out another oral surgeon for further treatment. c) On 04/14/25 at 12:03 PM during an interview with Licensed Practical Nurse (LPN) #30 the LPN reported that she recently held a position in the medical records department of this facility. She reported that she had made a note that the resident had attended a dental consultation where the dentist made a referral for resident to see an oral surgeon for further tooth extractions. She reported that generally she would make these appointments with (a specific facial surgeon) but that she could not find any further information about whether she made any appointments.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to (2) one of three (3) residents reviewed for the facility's beneficiary protection notification practice and failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for two (2) of three (3) residents reviewed for beneficiary protection notification during an annual survey. Resident identifiers: #48 and #346. Facility census: 90 Findings included: a) Resident #48 On 04/16/25 at 12:00 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following resident who remained at the facility following their last covered day of Medicare Part A services: - Resident #48 began Medicare Part A skilled services on 12/23/24. The last covered day of Part A service was 12/23/24 for Occupational Therapy. Medicare Part A skilled services began on 02/11/25 and the last day of 02/12/25 for Physical Therapy. There was no evidence that a Notice of Medicare Non-Coverage (NOMNC) was signed and no evidence a SNF ABN form had been provided and signed for either date. Review of discharge summaries for the following services were reviewed and revealed reasons for discharge: -Occupational Therapy: discharge date [DATE] reason for discharge- Highest Practical Level Achieved -Physical Therapy: discharge date [DATE] reason for discharge- Highest Practical Level Achieved Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary; or - considered custodial. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. In an interview on 04/16/25 at 1:50 PM, Social Worker #99 acknowledged the facility failed to provide SNF ABN and NOMNC forms to Resident #48 prior to her last covered day of Medicare Part A skilled services. She reported that resident went home for Christmas and they had to discharge her. She stated that therapy did not make them aware that resident was at her max potential and would be completing services. In an interview with Therapy Manager #54 on 04/16/25 at 2:10 PM the resident was discharged from services due to meeting maximum potential and that residents were made aware that services would end when their goals were completed. b) Resident #346 On 04/16/25 at 12:15 PM, a review was completed regarding the beneficiary protection notice(s) given for Resident #346 who was discharged to home with a family member following his last covered day of Medicare Part A services. Resident #346's last covered day of Part A Services was on 11/21/24. There was no evidence in the electronic medical record that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Review of therapy discharge summaries (physical therapy and occupational therapy), completed on 11/21/24 at 9:40 revealed the following details: -The Physical Therapy Discharge Summary stated the discharge reason was All Goals Met. -The Occupational Therapy Discharge Summary stated the discharge reason was Highest Practical Level Achieved. In an interview on 04/16/25 at 1:50 PM, Social Worker #99 acknowledged the facility failed to provide NOMNC forms to Resident #346 prior to her last covered day of Medicare Part A skilled services. She reported that she was not aware that a NOMNC had to be presented to resident due to their decision to go home. She stated that therapy did not make them aware that resident was at her max potential and would be completing services. In an interview with Therapy Manager #54 on 04/16/25 at 2:10 PM the resident was discharged from services due to meeting maximum potential and that resident was made aware that services would end when their goals were completed.

Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Notice of Transfer/Discharge for an acute hospital transfer. This was true for one (1) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #8. Facility census: 90. Findings included: a) Hospitalization on 12/29/24 An electronic medical record review was completed on 04/15/25 at 2:45 PM. Resident #8 was discharged to the hospital on [DATE]. There was no evidence that a written Notice of Transfer/Discharge was provided to Resident #8 or her legal representative. b) Hospitalization on 01/09/25 An electronic medical record review was completed on 04/15/25 at 2:45 PM. Resident #8 was discharged to the hospital on [DATE]. There was no evidence that a written Notice of Transfer/Discharge was provided to Resident #8 or her legal representative. During an interview on 04/16/25 at 1:00 PM, the DON stated the facility was unable to produce any evidence that a Notice of Transfer/Discharge was given for the above-mentioned hospitalizations.

Based on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Bed Hold Notice for an acute hospital transfer. This was true for one (1) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #8. Facility census: 90. Findings included: a) Resident #8 Hospitalization on 12/29/24 An electronic medical record review was completed on 04/15/25 at 2:45 PM. Resident #8 was discharged to the hospital on [DATE]. There was no evidence that a written Bed Hold Notice was provided to Resident #8 or her legal representative. Hospitalization on 01/09/25 An electronic medical record review was completed on 04/15/25 at 2:45 PM. Resident #8 was discharged to the hospital on [DATE]. There was no evidence that a written Bed Hold Notice was provided to Resident #8 or her legal representative. c) Interviews with the Director of Nursing (DON) and Business Office Manager (BOM) During an interview on 04/16/25 at 1:00 PM, the DON stated the BOM had not issued bed hold notices to Resident #8 because she had Medicaid Bed Hold days. During an interview on 04/16/25 at 1:20 PM, the BOM confirmed that a written bed hold notice had not given to Resident #8 or her legal representative for either of the above-mentioned hospitalizations. The BOM stated the facility only issues a written bed hold notice when Medicaid bed holds have been exhausted.

Based on record review and staff interview the facility failed to address recommendations made by the wound care service. This failed practice was found true for (1) one of (3) three residents reviewed for pressure ulcers during the Long-Term Care Survey Process. Resident identifier #17. Facility Census 90. Findings Include: a) Resident #17 During the initial interview on 04/14/25 at 11:51 AM, Resident #17 stated, I have a couple places on my butt. I feel like they are getting better. I am not sure how they got there. A record review on 04/15/25 at 11:35 AM, revealed a progress note dated 03/11/25 from the wound care service recommending adding modular protein and multivitamin with zinc supplements. Further record review of Resident #17's orders revealed that the modular protein and the multivitamin with zinc supplements had not been added. No information could be found as to why the supplements had not been added. During an interview on 04/16/25 at 10:54 AM, The Director of Nursing (DON) stated, I cannot find anything in the chart to indicate why he did not get the modular protein. Our doctor typically does not do the multivitamin with the Zinc and Vitamin C. During an interview on 04/16/25 at 1:07 PM, The DON stated, I did not find out anything else. I guess we just got to do better.

Based on record review and staff interview, the facility failed to ensure a resident received a response to a formal grievance. This was a random opportunity for discovery. Resident identifier: #76. Facility census: 88. Findings included: a) Resident #76 Review of the grievance concern forms found on 09/25/23, Resident #76 stated he was missing a charger and cord and stated that he was not getting showers as scheduled. He stated that shower days were moved around. The actions taken to resolve the grievance were listed as: The cord and the charger were replaced by the facility. There was no reference to his concern about showers on the grievance form. The form was signed by the facility social worker (SW) and the administrator. The date the grievance was completed was not reflected on the form. At 1:18 PM on 12/18/23, the Director of Nursing (DON) said she was not involved in follow - up discussion with the resident and did not know the outcome of the grievance. At 1:30 PM on 12/18/23, the SW said the resident's showers were just mixed up because he moved to another room. The SW said she forgot to write about how the showers were addressed . At 3:20 PM on 12/18/23, the administrator reviewed the grievance form and confirmed the resident's concern about his showers were not documented on the grievance form.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Two (2) of three (3) residents reviewed for the care area of pain had incomplete pain assessments performed. Two (2) of 22 residents reviewed in the long-term care survey sample had incomplete Physician's Orders for Scope of Treatment (POST) forms. Additionally, one (1) of 22 residents reviewed in the long-term care survey sample had conflicting information regarding end-of-life wishes. Resident identifiers: #62, #21, #283, #1. Facility census: 85. Findings included: a) Resident #62 Review of Resident #62's medical records showed a nursing assessment completed on 04/01/23. The nursing assessment included a pain interview. Resident #62 reportedly answered yes to the question, Have you had pain at any time in the last five (5) days? The resident reported he had occasional pain in My foot that ain't there. However, no response was recorded to the question, Over the past five (5) days, what has been the worst level of pain you experienced? During an interview on 04/26/23 at 9:24 AM, the Director of Nursing (DON) confirmed Resident #62's pain level had not been assessed on the 04/01/23 nursing assessment. No further information was provided through the completion of the survey process. b1) Resident #21 - pain assessment Review of Resident #21's medical records showed a nursing assessment completed on 02/27/23. The nursing assessment included a pain interview. Resident #21 reportedly answered yes to the question, Have you had pain at any time in the last five (5) days? The resident reported he had frequent pain in his back. However, no response was recorded to the question, Over the past five (5) days, what has been the worst level of pain you experienced? During an interview on 04/26/23 at 9:24 AM, the Director of Nursing (DON) confirmed Resident #21's pain level had not been assessed on the 02/27/23 nursing assessment. No further information was provided through the completion of the survey process. b2) Resident #21 - POST form Review of Resident #21's physician's orders showed an order for intravenous fluids long-term, if indicated. Review of Resident #21's Physician's Orders for Scope of Treatment (POST) form dated 02/12/20 showed the resident wished to receive intravenous fluids for a trial period. However, the length of the intravenous fluid trial period was not indicated in the space provided for the information. During an interview on 04/25/23 at 12:31 PM, the Social Worker confirmed the length of intravenous fluid trial period was not indicated on Resident #21's POST form. No further information was provided through the completion of the survey process. c) Resident #283 On 04/25/23 at 10:03 AM the surveyor received only the front of the resident's Physician Orders for Scope of Treatment (POST) form. Surveyor requested from the Administrator, a copy of the back of the POST form, a copy of the resident's Medical Power of Attorney (MPOA), and a copy of the resident's capacity form. On 04/25/23 at 10:30 AM, the surveyor received a copy of the resident's MPOA and capacity form. Record review of these forms indicated the Capacity form states the resident is incapacitated long term due to short term memory loss, disorientation, and the inability to process information caused by dementia for the duration of long term. This form is signed by a provider but is not dated anywhere on the form. On 04/25/23 10:40 AM, the surveyor received a copy of the back of the resident's POST form. This form has a verbal consent from the resident's MPOA but only has one signature of a witness. The form reqiures two (2) witness signatures when a verbal consent is obtained. Staff interview with the Administrator on 04/25/23 at 11:05 AM, confirmed the resident's capacity form lacks a date and the POST form does not have two (2) witnesses to the verbal signature. Staff interview with Social Worker (SW) #91, on 04/25/23 at 12:32 PM, the resident's POST form had a verbal signature from the MPOA, but was only witnessed by one (1) person and the capacity form was not dated. SW #91 stated she was going to look to see if the provider documented anything about addressing resident's capacity in a progress note. On 04/25/23 at 3:55 PM, SW #91 provided documentation from Nurse Practitioner (NP) #107, visit date of 04/12/23 stating, .Pt does not have capacity-long term Determination of capacity: Pt does NOT have capacity: long term . d) Resident #1 On 04/24/23 at 1:05 PM, the POST form dated 07/22/21 for Resident #1 was reviewed. The POST form indicated the resident's choices were do not resuscitate (DNR) with limited interventions and artificial nutrition if indicated. On 04/24/23 at 1:15 PM, the electronic medical record (EMR) was reviewed and indicated the resident's choices were DNR with comfort measures and artificial nutrition if indicated. On 04/25/23 at 12:30 PM, Social Services (SS) #91 will review the information and clarify which of the resident's choices were correct. On 04/25/23 at 12:57 PM, SS #91 stated, the nurse practitioner changed the POST form to DNR comfort measures and artificial nutrition if indicated, but we cannot find the new POST form. No further information was obtained during the long-term survey process. 45173 47903

Based on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. These were random opportunities for discovery. Resident Identifiers: #17, #59, #7, #77, #74, and #5. Facility Census: 85. Findings Included: a) West Wing Medication Cart On 04/25/23 at 8:34 AM, Licensed Practical Nurse (LPN) #95 was observed during medication administration. At this time, the medication cart on the west wing was audited. The medication cart audit found two (2) insulin kwik pens not dated upon the initial administration. The first insulin kwik pen (Lantus) not dated was for Resident #17 and the second insulin kwik pen (Novolog) was for Resident #59. On 04/25/23 at 8:38 AM, LPN #95 confirmed neither insulin kwik pen was dated upon the initial administration. On 04/25/23 at 9:15 AM, the Director of Nursing (DON) was notified and confirmed the insulin kwik pens should have been dated upon the initial administration. b) East Wing Medication Cart On 04/25/23 at 8:15 AM, inspection of the east wing medication cart was made. Licensed Practical Nurse (LPN) #86 was in attendance. In the medication cart were four (4) vials of aspart (Novolog) insulin that had been dated when first accessed more than 28 days ago. Instructions on the insulin boxes stated to dispose of the vials after they had been in use for 28 days. The aspart (Novolog) insulin vials were for the following residents: - Resident #7, dated 02/06/23 - Resident #77, dated 03/14/23 - Resident #74, dated 02/23/23 - Resident #5, dated 02/06/23 LPN #86 confirmed the vials had been in use for longer than 28 days. Review of the residents' medical records showed the residents were receiving aspart (Novolog) insulin for sliding scale coverage as needed based on their fingerstick blood glucose results. No further information was provided through the completion of the survey process. 45173

Based on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of 22 residents reviewed during the long-term care survey process. Resident identifiers: #44, and #81. Facility census: 85. Findings included: a) Resident #44 Review of Resident #44's medical records showed a pressure ulcer assessment on 01/24/23 which documented a deep tissue injury (DTI) on the resident's right toe. A stage two (2) pressure ulcer of the dorsal foot was noted to be healed. A pressure ulcer assessment on 02/07/23 continued to document a DTI of the right toe. Resident #44's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 02/08/23 documented the presence of one (1) stage two (2) pressure ulcer and one (1) DTI. During an interview on 04/25/23 at 1:01 PM, the Corporate Registered Nurse (RN) confirmed a stage two (2) pressure ulcer should not have been coded on Resident #44's MDS with ARD 02/08/23. No further information was provided through the completion of the survey. b) Resident #81 During a medical record review on 04/26/23, it was discovered the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/09/23, was completed due to resident being discharged to another nursing home. Section A Discharge Status was coded wrong, it indicated resident was transferred to an acute care hospital. An interview with the MDS Coordinator on 04/26/23 at 9:15 AM, verified the MDS discharge status for Resident #81 was coded incorrectly. 39043

Based on observation and staff interview, the facility failed to maintain appropriate professional standards for the care of urinary catheters to prevent infections. This was a random opportunity for discovery. Resident Identifiers: #26. Facility Census: 85. Findings Included: a) Resident #26 On 04/24/23 at 10:53 AM, Resident #26's urinary catheter bag was observed laying in the floor by the bed. On 04/24/23 at 10:56 AM, Registered Nurse (RN) #72 confirmed the catheter bag was laying in the floor by the bed. RN #72 stated, I'll fix this. On 04/24/23 at 2:00 PM, the Director of Nursing (DON) was notified and confirmed the catheter bag should not be laying in the floor. No further information was obtained during the long-term survey process.

Based on medical record review, staff interview, and review of the facility's policy and procedure for, "Introduction to Prevention and Management of Wounds," the facility failed to; accurately and timely assess the pressure areas, administer treatments as ordered by the physician to promote wound healing, evaluate the effectiveness of the treatments in place, and follow their policy for treatment of [REDACTED]. This was true for two (2) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #81 and #18. Facility census: 89. Findings include: a) Resident #81 Resident #81 was admitted to the facility on [DATE] at 7:34 p.m.. According to the nursing admission note, he was admitted with a stage II pressure ulcer to the coccyx. Upon admission, an order was present to clean the Stage II pressure area to the coccyx with normal saline solution, pat dry and apply Combiderm every day. Review of the treatment administration record (TAR) for July found the treatment was not provided as ordered from 07/13/12 through 07/24/12, when the resident was discharged from the facility and admitted to the hospital. On 07/27/12 the resident was readmitted to the facility at 3:50 p.m.. admission orders [REDACTED]. On 07/27/12 a physician's order was present to, cleanse The Stage II pressure ulcer to coccyx with Saf-clens, AF wound cleanser, apply [MEDICATION NAME], change every three (3) days and as needed. Review of the TAR found the first treatment to the pressure area was not provided until 07/30/12. Review of the medical record found no assessment, including a measurement of the pressure area, or evaluation of the pressure ulcer from 07/13/12 until 08/02/12. There was no documentation present to verify the measurements of the pressure area on the 07/13/12 admission or the re-admission on 07/27/12. On 08/02/12 a, "pressure ulcer evaluation," form was completed which included measurements, treatment, and a description of the wound. On 08/02/12 the Stage II pressure ulcer had increased to a Stage III pressure ulcer according to the information contained in the evaluation. The pressure ulcer evaluation form, with a facility effective date of 07/01/12, was not completed until 08/02/12. Review of the facility policy and procedure for introduction to prevention & management of wounds, found, "... If the patient / resident is admitted with an open wound or develops a wound after admission, the plan will then expand to include the use of an appropriate debridement and dressing regimen and the consideration for the use of modalities for wound healing . . . weekly staging of pressure ulcers." The director of nursing (DON), Employee #88 and the regional director, Employee #89 were interviewed at 2:15 p.m. on 10/02/12. These employees were unable to provide any further information to verify the resident's pressure ulcers was treated according to physician's orders and the pressure area was assessed and monitored on a weekly basis from 07/13/12 thorough 08/02/12. b) Resident #18 The resident was admitted to the facility on [DATE]. The admitting nursing note included, "... Open area to coccyx measures 1.5 cm. (centimeters) by 1.5 cm. Wound bed white in color with no drainage noted. Open area to right buttock measures 1.5 cm. by .5 cm. Wound bed pink with no drainage noted. ..." admission orders [REDACTED] "1. Cleanse open area to coccyx with normal saline solution, pat dry, apply [MEDICATION NAME] and cover with border gauze, change every three (3) days and as needed. 2. Cleanse open area to right buttocks with normal saline solution, pat dry. Apply [MEDICATION NAME], cover with border gauze, change three (3) days and as needed." Review of the TAR found the above orders were never transcribed to the TAR and the treatment was not provided. On 09/12/12 new orders were written for : "1. discontinue previous treatment order to coccyx and right buttock. 2. Cleanse stage III to coccyx and stage II to right buttocks with saf-cleanse, pat dry, apply saf-gel to stage III slough area and cover both stage III and stage II with combiderm every 3rd day and as needed." Further review of the TAR found these ordered were not implemented until 09/15/12. Therefore, the resident did not receive any treatment for [REDACTED]. Upon admission a non-pressure skin condition form was completed for the area on the coccyx which measured 1.5 cm. in length and 1.5 cm in width, depth 0.0. On 09/14/12 a pressure ulcer evaluation form was completed and detailed the measurements of the Stage III pressure area to the coccyx. On 09/14/12, the wound to the coccyx measured 1.7 cm. in length and 1.8 cm in width, depth was 0 cm. The pressure area to the coccyx increased in size from 09/10/12 to 09/14/12. The DON, Employee #88 and the regional corporate nurse, Employee #89, were interviewed on 10/02/12 at 2:15. No further information was provided to verify the resident's pressure ulcers were treated according to physician's orders. There was no evidence the resident received treatment to the pressure area for five (5) days after admission and no evidence to support the resident's pressure ulcers had not increased in size during the time the treatments were not provided. .

Based on review of citations and the associated plans of correction issued to the facility in 2012, staff interview, and the findings of the current complaint survey, the governing body failed to ensure all deficient practices cited during a combined quality indicator survey (QIS) and a complaint survey on 02/01/12, and a second complaint survey occurring on 06/01/12, were corrected, as alleged in the plan of correction. Non-compliance remained in the following groupings: Resident Behavior and Facility Practices, Quality of Care, Resident Assessment, and Nursing Services. This had the potential to affect more than an isolated number of residents who reside in the facility. Facility census: 89. Findings include: Repeat deficiencies were found in the following areas: a) The facility failed to ensure two (2) residents received timely treatments for pressure ulcers. Medical record review, staff interview, and review of the facility's policy and procedure for, "Introduction to Prevention and Management of Wounds," found the facility had failed to assess pressure areas accurately and timely, had failed to provide treatments as ordered by the physician to promote wound healing, had failed to evaluate the effectiveness of the treatments in place, and had failed to follow their policy for treatment of [REDACTED]. (This was previously cited during the 02/01/12 complaint survey at a level of harm.) b) The governing body failed to ensure allegations of abuse/neglect were reported to the appropriate state authorities. Review of the facility's request / concern forms, staff interview, review of resident / visitor incident reports, and the facility's policy and procedure for "Resident Advocacy Protocols," found the facility had failed to report allegations of abuse / neglect to the appropriate State authorities. (This was previously cited on the 02/01/12 QIS.) c) The governing body failed to ensure a comprehensive care plan was developed to address a resident with [MEDICAL CONDITIONS]. Medical record review and staff interview found the facility's interdisciplinary care team had failed to develop a comprehensive care plan with realistic goals and interventions to address care of [MEDICAL CONDITIONS]. Additionally, the care plan did not include parameters to make the goal measurable. (This was previously cited during the 02/01/12 QIS.) d) The facility failed to ensure a physician's orders [REDACTED]. Medical record review and staff interview found the facility failed to ensure a treatment for [REDACTED]. The original order for treatment contained no frequency for the treatment, in addition there was no evidence any treatment was initiated until eleven (11) days after the original order. (This was previously cited during the 02/01/12 complaint survey.) e) The facility failed to ensure caregivers had the necessary equipment available to facilitate safe transfers. Medical record review, review of the facility's request/concern forms, and staff interview, found the facility had failed to follow orders for a safe transfer of a resident and failed to ensure the necessary equipment was available to facilitate a safe transfer. (This was previously cited during the 06/01/12 complaint survey.) .

Based on observations, record review, review of citations and the associated plans of correction issued in 2012 , and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement and monitor actions to ensure previously cited deficient practices were corrected and did not recur. This visit found five (5) repeat deficiencies, including one (1) repeat deficiency with non-compliance at a severity level of harm. This had the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) Quality Assurance and Assessment Committee During the complaint survey completed on 10/01/12, the survey team found non-compliance with four (4) regulatory requirements which were found to be deficient during the 02/01/12 survey and the 06/01/12 complaint survey. The facility's QAA committee did not ensure areas of deficient practice did not recur. Additionally, there was no evidence the QAA committee was aware these areas were out of compliance. The QAA committee did not ensure corrective actions were implemented and monitored to ensure on-going compliance. The following areas were identified: 1. Quality of Care -- Medical record review, staff interview, and review of the facility's policy and procedure for, "Introduction to Prevention and Management of Wounds," found the facility had failed to assess pressure areas accurately and timely, had failed to provide treatments as ordered by the physician to promote wound healing, had failed to evaluate the effectiveness of the treatments in place, and had failed to follow their policy for treatment of [REDACTED]. (This was previously cited during the 02/01/12 complaint survey at a level of harm.) -- Medical record review and staff interview found the facility failed to ensure a treatment for [REDACTED]. The original order for treatment contained no frequency for the treatment, in addition there was no evidence any treatment was initiated until eleven (11) days after the original order. (This was previously cited during the 02/01/12 complaint survey.) -- On 10/02/12, at approximately 3:00 p.m., the corporate nurse, Employee #89, acknowledged there had been a past problem with residents receiving treatments as ordered. This employee and the DON thought a designated employee had been auditing the medical records daily to ensure treatments were provided as ordered. 2. Resident Behavior and Facility Practices Review of the facility's request / concern forms, staff interview, review of resident / visitor incident reports, and the facility's policy and procedure for "Resident Advocacy Protocols," found the facility had failed to report allegations of abuse / neglect to the appropriate State authorities. (This was previously cited on the 02/01/12 QIS.) 3. Resident assessment Medical record review and staff interview found the facility's interdisciplinary care team had failed to develop a comprehensive care plan with realistic goals and interventions to address care of [MEDICAL CONDITIONS]. Additionally, the care plan did not include parameters to make the goal measurable. (This was previously cited during the 02/01/12 QIS.) 4. The facility also failed to ensure caregivers had the necessary equipment available to facilitate safe transfers. Medical record review, review of the facility's request/concern forms, and staff interview, found the facility had failed to follow orders for a safe transfer of a resident and failed to ensure the necessary equipment was available to facilitate a safe transfer. (This was previously cited during the 06/01/12 complaint survey.) .

Based on medical record review and staff interview, the facility failed to provide the necessary care and services for one (1) of forty-nine (49) Stage II sample residents to prevent an avoidable pressure ulcer [MEDICAL CONDITION]. This failure resulted in a finding of harm to the resident. The resident developed a stage I pressure ulcer on the right heel. Ortho boots were applied to relieve pressure. Weekly skin audits were ordered by the physician, but were not done. The pressure ulcer developed into an unstageable ulcer with necrotic eschar and infection, which required hospitalization for debridement and a course of IV antibiotic therapy. The unstageable ulcer was discovered during an outside cardiac consult. When discovered, the resident was taken directly to the hospital emergency room by his family. Resident identifier: # 68. Facility census: 82. Findings include: a) Resident # 68 During medical record review, a physician's orders [REDACTED]. The order was, "D/C (discontinue) all previous treatment to right heel and cleanse right heel with NSS (normal saline solution) pat dry. Apply saf-gel cover with non-adherent pad. Wrap with Kling wrap and change every day PRN (as needed)." This discovery prompted further investigation that revealed the resident had developed an avoidable pressure ulcer. Medical record review revealed a note, written by the midnight nurse on 12/08/11. The note stated, "Assessed resident finding unstageable pressure ulcer to right medial heel measuring 7.6 cm X 0.0 cm. Ulcer covered with gray soft, leathery, adherent tissue. Scant amount clear drainage with no odor observed. Also noted to left medial heel stage II closed blister measuring 2.1 cm x 1.9 cm Stage II closed blister to left arch of foot measuring 1.4 cm. x 2.1 cm. Treatment in place to apply [MEDICATION NAME] bilaterally every shift, also had nutritional supplements to aid in wound healing...." Review of physical therapy notes, dated 12/08/11, revealed an Ortho boot had been recommended and applied to prevent pressure on both heels. During a review of a hospital consult report, dated 12/15/11, it was discovered the resident's family had picked the resident up at the facility for a cardiac consult. The consult report also stated the consulting physician discovered a large right heel decubitus ulcer during the examination. This area had not been identified by the facility. It was also revealed the resident's family was concerned about his condition and took the resident to the hospital emergency room following the cardiac consult for further evaluation. The resident was admitted to the hospital. Review of the hospital discharge summary revealed the right heel had an unstageable decubitus ulcer, approximately 10 cm with necrotic eschar, which was debrided and a course of IV antibiotics ordered. The resident returned to the facility on [DATE]. The resident's medical record included a standing order for weekly skin audits. Results of the weekly skin audits were requested from staff on 01/30/12 for the months of August, September, October, November and December 2011. During review of the weekly skin audits, it was discovered the audits had been done only on 08/13/11, 09/11/11, and 10/16/11. There was no evidence of any other audits until the resident returned to the facility, after debridement of the right heel decubitus ulcer, on 12/24/11. There was no evidence the facility monitored the resident's skin on a weekly basis, as ordered by the physician, to detect any changes in skin condition. The failure to perform the skin audits weekly contributed to the failure of the facility to identify changes and worsening of the pressure ulcer on the right heel after the Ortho boots were applied. The resident [MEDICAL CONDITION] and required a hospital debridement of a Stage IV pressure ulcer. During an interview with the facility CQI nurse (Employee # 92), on 01/31/12 at 1:30 p.m., it was confirmed the weekly skin audits were not done as ordered by the physician. .

Based on medical record review, observation, and staff interview, the facility failed to ensure seven (7) of forty-nine (49) Stage II sampled residents received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Two (2) residents were not assessed and / or monitored for pneumonia; a resident was not assessed and provided ordered medications for pain; a resident was not assessed or provided services for social isolation; two (2) residents were not provided timely administration of medications after hospitalization ; one (1) resident did not receive an ordered x-ray; a resident's oxygen saturation was not monitored as ordered; and a resident's urine output and change of condition was not assessed or monitored. The facility's failure to ensure nursing staff members provided appropriate assessments, monitoring, and physician notification of a change in the physical condition of Resident #87 resulted in a finding of harm. The resident was transported to the hospital and expired at the the hospital with a [DIAGNOSES REDACTED]. Resident identifiers: #87, #85, #101, #55, #92, #75, and #41. Facility census: 82. Findings include: a) Resident #87 Review of the medical record found a nursing note written at 10:58 p.m. on [DATE]. The nursing note documented the resident had no urine output "...times eight hours will pass onto oncoming nurse to monitor urine output". Review of the documentation related to urine output found no evidence of the resident passing urine as of 9:07 a.m. on [DATE]. This time frame was thirteen (13) hours, not (8) eight hours. The medical record contained no evidence the physician was notified. Additionally, there was no evidence of assessments or monitoring of the resident by nursing staff members until 3:39 a.m. (4.5 hours later). At that time, the nursing note, dated [DATE] at 3:39 a.m., documented the resident was found to have an oxygen saturation of around 70 and an axillary temperature of 100.3 degrees. The resident was transferred to the hospital with [DIAGNOSES REDACTED]. The resident expired on [DATE]. b) Resident #85 Review of the medical record found this resident was prescribed [MEDICATION NAME] 400 mg. every day for a [DIAGNOSES REDACTED]. Review of the care plan found nursing staff members were to assess and document the resident's lung sounds, temperature, and sputum at least every shift. Review of the medical record found no evidence nursing staff members were conducting the assessments of the resident's lungs and physical condition related to the [DIAGNOSES REDACTED]. The registered nurse (RN) supervisor, Employee #2, was interviewed on [DATE] at 2:00 p.m. She was asked for information concerning assessments of Resident #85's condition related to the [DIAGNOSES REDACTED]. She stated these residents' names were placed on a clipboard to remind staff to obtain these assessments. Employee #2 referenced the clipboard and found Resident #85' name had not not been placed on the clipboard. She printed the vital signs records from [DATE] through [DATE]. Review of the records found nursing staff members did not conduct and / or document the necessary monitoring and assessments. . c) Resident #101 Review of the medical record found this resident was readmitted to the facility, at 11:50 p.m. on [DATE], following hospitalization . Review of the nursing note, written at 12:21 a.m. on [DATE], found the resident complained of pain at a level of ten (10) on a scale of one (1) to ten (10). The nursing pain evaluation form, completed on [DATE], included the following current [DIAGNOSES REDACTED]. The pain evaluation form also included, in the section related to behaviors present indicating pain, "Resident alert and verbalized pain in R (right) foot." According to the admission orders [REDACTED]. Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. . . d) Resident # 55 During observations of this resident, since entering the facility on [DATE] at 10:45 a.m., the resident was always in bed with raised full bilateral padded side rails. The privacy curtains were also pulled between the bed and the door to the hallway. Further observations revealed the resident was positioned flat in bed, preventing the resident from seeing over the side rails. The padding on the side rails also prevented the resident from seeing through the side rails. The resident had multiple contractures and was unable to move independently in bed. Review of the comprehensive care plan revealed the psychosocial well-being, associated with the use of full bilateral padded side rails and the use of the low air loss bed, had not been care planned. This resident's psychosocial needs had not been identified or assessed.. During an interview with the CQI nurse, on [DATE], at 4:50 p.m., it was agreed the resident was socially isolated due to the padded side rails, the resident's position in the bed and the curtains pulled. It was also agreed the facility had not provided for this resident's psychosocial needs. . . e) Resident #92 1. When reviewed on [DATE], the medical record for Resident #92 revealed a nurse's note on [DATE] at 4:45 p.m. stating: "Resident continues to voice concerns about non- productive cough, assessed resident with bilateral lung sounds noted to having wheezing in upper lobes, contacted (physician's name) and received new order 1-obtain chest x-ray due to wheezing and cough". No further entries were made in the nurses' notes until 12:51 a.m. when a note stated, "Oxygen saturation is 76%." At 1:03 a.m., an additional nurse's note described inspiratory and expiratory wheezes bilaterally, elevated pulse and respiration levels. There was a statement the resident was transferred, according to a physician's order, to a local hospital. The resident was admitted with a [DIAGNOSES REDACTED]. The resident was ordered a chest x-ray on [DATE] at 4:45 p.m. There was no evidence this x-ray was obtained by the facility. The director of nurses (DON) was interviewed at 12:00 noon on [DATE]. She was asked why the x-ray was not completed as ordered. The DON stated the x-ray was not ordered "stat" (immediately), and that in those cases they can wait. The DON did not offer any guideline to indicate how long the x-ray could and would have waited. It was pointed out to the DON, when the physician was contacted and the order for the x-ray was received, there had been no assessment of the resident, other than lung sounds and coughing. There were no vital signs, no oxygen saturation testing, etc. to provide to the physician to assist in his determination of the need for a "stat" x-ray as opposed to an x-ray that could wait until later. The DON could provide no evidence a thorough assessment had been completed with the onset of symptoms, which could be utilized in making the determination the ordered chest x-ray could wait until a later time. 2. Upon return from hospitalization for pneumonia on [DATE], the physician's orders for Resident #92 revealed an order for [REDACTED]. The resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] A nurse's note, on that day, stated the hospital was contacted to inquire about the medication and the pharmacist informed staff that it "was not provided through inpatient pharmacy." The DON was interviewed, on ,[DATE] at 11:00 a.m., related to this finding. She stated no one knew what the medication was so the order was dropped. There was no physician's order to clarify or discontinue the order. . f) Resident #41 Review of the medical record for Resident #41 disclosed the resident returned to the facility following hospitalization on [DATE]. Accompanying the resident was an order for [REDACTED]. The MAR for the month of [DATE] revealed the initial dose of the medication was not administered until 6 a.m. on [DATE]. A registered nurse (Employee #2) was interviewed related to this finding, on [DATE] at approximately 11:30 a.m. This employee stated the medication order was overlooked until it was bought to their attention by the resident's family. Employee #2 provided evidence the medication was received from the pharmacy on [DATE], three (3) days after it was ordered. The employee further confirmed, although the medication was received on [DATE], the first dose of the medication was still not administered until [DATE] an additional delay of two (2) days. . . g) Resident #75 Review of the nurses' notes revealed this resident experienced a fall at the facility on [DATE]. Later in the day, the resident was complaining of pain to the left leg and was sent to the hospital for evaluation. The resident returned from the hospital on [DATE] with no injuries noted as a result of the fall. She did however return with a new [DIAGNOSES REDACTED]. There was no stop date for the monitoring of the oxygen saturation. Employee #2, the registered nurse, was interviewed, at 3:45 p.m. on [DATE]. and was unable to verify the resident's oxygen saturation had been checked each shift as ordered by the physician. .

Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - "N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted." - On [DATE] at 11:00 a.m. - "S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor." - On [DATE] at 12:05 p.m. - "Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor." According to the hospital history and physical, "... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had "diarrhea for several days" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under "Nursing Actions: Physical Assessment" on page 704: "Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..." Under "Nursing Actions: Patient Education" on page 704: "... Report persistent or severe diarrhea or abdominal cramping ..." Under "Geriatric Considerations" on page 704: "Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...." - For Senna Plus, under "Nursing Actions: Patient Education" on page 385: "...Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..." -- 7. Review of the "Shift to Shift Report" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day on [DATE], [DATE], and [DATE]; less than 35% of her estimated fluid needs on [DATE] and [DATE]; and she consumed on 240 cc of fluid on day shift on [DATE], prior to her transfer to the hospital. (See also citation at F327.) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, "Her daughter came to me and said she was acting different, and I sent her to the hospital." -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. ---- Part II -- Based on closed record review, the facility failed to provide daily laxatives as ordered by the physician for one (1) of eleven (11) sampled residents who was identified as being at risk for constipation. On [DATE], Resident #45 was treated for [REDACTED]. In [DATE], Resident #45 had orders for four (4) different laxatives to be administered daily: [MEDICATION NAME] 1 tab by mouth daily; Senna Plus 2 tabs by mouth twice daily; [MEDICATION NAME] 15 cc by mouth daily; and Power Pudding 60 cc by mouth at bedtime. Record review revealed found no evidence to reflect the evening dose of Senna Plus was administered as ordered; thirteen (13) doses of [MEDICATION NAME] were not administered as ordered; and fifteen (15) doses of Power Pudding were not administered as ordered, thirteen (13) of which were marked as refused by the resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her care plan, on [DATE], revealed the following problem statement: "Resident is at risk for constipation: limited mobility; medications; history of constipation." The goal associated with this problem statement was: "Resident will have bowel movments (sic) at least every three day s (sic) thru next review." Interventions to achieve this goal included: "Monitor bowel movments (sic), if none in three days start bowel regimen. Monitor BM (sic) if none every 3 days notify nurse. [DATE] D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME], start Senna-S 2 tab po BID. [DATE] Power pudding 1xd (daily). ,[DATE] [MEDICATION NAME] 15 ml PO BID. [DATE] [MEDICATION NAME] 1 tab PO daily x 30 days then re-eval constipation. [DATE] leets enema per rectum x 1 dose D/T 0 (no) BM x 4 days per standing order." - Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. - Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no evidence to reflect that both doses of Senna Plus were administered daily in September. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. (See citation at F514.) Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on [DATE]. Documentation on the reverse side of the MAR indicated [REDACTED]." There were no initials for the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (with the last dose initialed as having been administered on [DATE]). (See also citation at F514.) This represents a total of thirteen (13) doses not administered as ordered. .

Based on family interview, closed medical record review, and staff interview, the facility failed to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on [DATE]. This was followed nine (9) BMs on [DATE]; three (3) BMs on [DATE]; seven (7) BMs on [DATE]; six (6) BMs on [DATE]; and one (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. (See citation at F309.) -- 5. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer them except when the resident refused. (See also citation at F309.) -- 6. Review of the "Shift to Shift Report" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 7. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 8. Review of Resident #45's POST form, signed by the facility's social worker on [DATE], revealed the resident's medical power of attorney representative (MPOA) had indicated, in Section D, the desire for the resident to receive IV fluids and tube feeding for a defined trial period to maintain hydration and nutritional status. There was no evidence in the medical record that staff identified a change in the resident's hydration status for which the administration of IV fluids for a trial period was indicated. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE]. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. .

Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a "blackened area" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as "10", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, and toilet use, and she was to be transferred using a mechanical lift. She had no pressure sores during the assessment reference period. Review of the resident's care plan found the following problem statement with an onset date of 06/21/10: "Potential risk for skin breakdown d/t (due to) decreased physical mobility." The goal associated with this problem statement was: "Maintain intact skin integrity thru 09/21/10." Approaches to be implemented to meet this goal included: "up (sic) in geri chair as tolerated. weekly (sic) body audit. Provide diet as ordered ... Reposition resident every 2 or 3 hours and PRN (as needed). Instruct resident / family on consequences of noncompliance with therapeutic regime (sic). Cleanse perineal area with peri wash following each bowel and/or bladder episode." -- Review of the facility's incident / accident reports, on 11/09/10, found an Incident Investigation Report involving Resident #50 and dated 10:00 a.m. on 08/13/10. Under the heading "Describe Circumstances of the Incident (Be very specific):" was written, "CNA (certified nursing assistant) (initials) notified this nurse of discoloration area to Resident's (Lt) (left) heel, black in color, measures 2.5 cc diameter (sic) soft to touch. Resident has poor bed mobility. Dr. (name) in facility and aware. New order [MEDICATION NAME] apply (sic) (Lt) heel q (every) shift. Heel lift boots (sic) @ (at) all times." Under the heading "Analysis of the Incident: (apparent cause)" was written, "Poor bed mobility." Under the heading "Describe Corrective action (sic) or Protective Action Taken: (be specific)" was written: "[MEDICATION NAME] Apply (Lt) heel q shift. Heel lift boots @ all times." -- Product information for [MEDICATION NAME] (found on the Internet at http://www.udllabs.com/pdfs/[MEDICATION NAME].pdf) revealed the following "Uses" for [MEDICATION NAME]: - "Management of decubitus ulcers." - "Forms protective barrier and speeds healing by increasing capillary blood flow into the ulcerated area. " - Product information for Heelift Suspension Boots (found on the Internet at http://www.heelift.com/) revealed the following product claims: " The Heelift ? completely eliminates pressure as the heel is floated in protective space. Studies prove Heelift Suspension Boots provide a pressure-free environment to help eliminate and prevent pressure ulcers. " -- On 11/10/10 at 11:00 a.m., the facility's unit supervisor (Employee #66) was asked to provide evidence to reflect this resident received weekly body audits in an effort to avoid skin breakdown. After review of facility documents, Employee #66 was only able to produce evidence that weekly body audits were performed on Resident #50 on the following Wednesdays: 06/09/10, 06/16/10, and 07/28/10. Employee #66 confirmed there were no additional body audits for this resident. The blackened area to the heel was discovered on 08/13/10. Based on the documentation presented by Employee #66, Resident #50 did not receive weekly body audits on 08/04/10 or 08/11/10 (before the blackened heel was identified by staff). -- A facility nurse (Employee #72) was interviewed on 11/09/10. When asked how residents were evaluated for skin breakdown, this nurse stated, "We do weekly body audits." When further questioned about how an area would not be recognized until it had become black, the nurse stated, "It should have been caught before it was black." .

Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide goods and services necessary to avoid physical harm and to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician and the resident's legal representative any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and "everything was fine", but when she returned on [DATE], she found her mother in a "gravely ill" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to "(symbol for 'change') in mental status", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of "altered mental status". Under the heading "History of Present Illness" was found: "This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." Under the heading "Physical Examination" was found: "... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..." Under the heading "Labs" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading "Assessment / Plan" was found the following: "1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... "2. UTI (urinary tract infection) ... "3. Altered mental status secondary to the above. "4. Acute hemorrhagic stroke in parietal lobe ... "5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..." -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - "N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted." - On [DATE] at 11:00 a.m. - "S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor." - On [DATE] at 12:05 p.m. - "Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor." According to the hospital history and physical, "... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..." However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had "diarrhea for several days" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician that this resident, beginning on [DATE], was having excessively frequent BMs. (See also citation at F309.) -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under "Nursing Actions: Physical Assessment" on page 704: "Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..." Under "Nursing Actions: Patient Education" on page 704: "... Report persistent or severe diarrhea or abdominal cramping ..." Under "Geriatric Considerations" on page 704: "Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...." - For Senna Plus, under "Nursing Actions: Patient Education" on page 385: "... Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..." (See also citation at F309.) -- 7. Review of the "Shift to Shift Report" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: "LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals." To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was "at risk for weight loss" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: "Encourage fluids with meals." According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. (See also citation at F327.) -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, "Her daughter came to me and said she was acting different, and I sent her to the hospital." -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. .

Based on medical record review, review of the facility's incident / accident reports, review of the facility's self-reported allegations of abuse / neglect, and staff interviews, the facility failed to provide adequate supervision and/or assistance devices to prevent avoidable accidents. One (1) of eleven (11) sampled residents (#23) was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. On 10/26/10, she was identified as having swelling and bruising to the left ankle and coccyx; these injuries were of unknown source, although the facility's investigative report revealed the bruising on the resident's coccyx may have been associated with contact with the resident's wheelchair armrest during a transfer within a mechanical lift. On 11/03/10, the resident was identified with swelling and redness to the right leg; she was subsequently diagnosed with [REDACTED]. There was no evidence the facility implemented any measures to protect this totally dependent resident from further injury after the first injury was identified. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. -- Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. -- Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident "when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone." The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed "no evidence for fracture or other significant bone, joint, or soft tissue abnormality." -- On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. This interview revealed that neither an incident report or an investigation of the injury of known source identified on 10/25/10 could be located. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report of an incident said to have occurred at 11:00 a.m. on 10/26/10. In the report under the heading "Analysis of the Incident: (apparent cause)" was written: "Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest." Under the heading "Describe Corrective action (sic) or Protective Action Taken: (be specific)" was written: "X-ray to ankle (-) (negative). "Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries." -- On 11/11/10 at 12:25 p.m., the DON was asked to provide evidence of the content of the staff training provided and to whom this education was provided. The DON stated this information was not available, because she "educated the staff that were on the spot that day." This process did not assure all staff members who might utilize the mechanical lift with this resident, on all shifts, were educated. -- Review of the facility's abuse / neglect self-reports for the previous three (3) months revealed Resident #23 had sustained another of injury of unknown source on 11/03/10. Review of nursing notes, dated 11/03/10 at 1:00 p.m. (eight (8) days after the injury of unknown source to the left leg), revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's "Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg." The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to "... R/O (rule out) DVT (deep vein thrombosis) of R (right) LE (lower extremity)." At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: "A nondisplaced fracture of the proximal fibula accompanies the distal tibia fracture. Osteopenia is apparent." -- Review of facility records and staff interview revealed no evidence to reflect effective measures were implemented to prevent further injury to this totally dependent resident, after the resident was found to have bruising and swelling to her left ankle and coccyx. Eight (8) days, later she sustained fractures to her right leg. .