Every finding on record at Holiday Resort of Salina

Based on observation, record review, and interview, the facility failed to ensure staff provided consistent bathing and/or showers for five sampled residents who were dependent on staff for activities of daily living (ADL), Resident (R) 1, R2, R3, R4, and R5. Findings included:- 1. R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), urinary tract infection (UTI-an infection in any part of the urinary system), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) 04/09/26, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R1 had impairment on both sides of her upper and lower extremities and was dependent on staff for all ADL. The Functional Abilities Care Area Assessment (CAA) dated 04/09/26, documented R1 had diagnoses that made ADLs difficult or impossible for R1 to do by herself, and staff would assist R1 with her ADLs. R1's Care Plan lacked any direction regarding R1's ADLs. The Bathing Schedule Sheets in the EMR documented R1 was scheduled to have showers every Tuesday and Saturday. R1's EMR documented R1 only had four showers from 03/24/26 through 04/22/26. On 04/22/26 at 11:00 AM, observation revealed R1 had greasy, oily hair and a distinct odor about her. On 04/22/26 at 11:00 AM, R1 stated that she had not been getting her showers the way she was scheduled, and she felt dirty and unclean. R1 stated she was used to showering every day, and waiting 7-10 days for a shower was not acceptable to her. 2. R2's EMR documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), depression, and chronic kidney disease (long-term progressive loss of kidney function). The Comprehensive MDS, dated 04/14/26, documented a BIMS score of 15, which indicated intact cognition. The MDS documented R2 had impairment on both sides of his lower extremities and was dependent on staff for all his ADLs. The Functional Abilities CAA dated 04/14/26, documented R2 had diagnoses that made it difficult for R2 to complete most of his ADLs, and staff would assist R2 with his ADLs. R2's Care Plan documented R2 preferred to shower two times a week. The care plan lacked any direction on the assistance R2 needed for bathing. The Bathing Schedule Sheet in the EMR documented R2 was to have baths/showers every Sunday and Thursday. The EMR documented R2 only had 6 baths from 03/24/26 through 04/22/26. On 04/22/26 at 10:00 AM, observation revealed R2 had an overgrowth of gray beard on his face, and R2 had a distinct body odor about him. On 04/22/26 at 10:00 AM, R2 stated he wrote everything down in his notebook that the staff did and did not do for him. R2 stated he had only had three baths in the last 30 days, and if his EMR said anything different, the staff were lying. R2 stated he preferred to be showered three days a week, but the facility would only offer two showers a week. R2 stated the facility could not even give him two showers a week. R2 stated he felt neglected when he did not get cleaned up.3. R3's EMR documented R3 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), heart failure (a condition with low heart output and the body becomes congested with fluid), and depression. The Quarterly MDS dated 03/31/26, documented R3 had a BIMS score of 15, which indicated intact cognition. The MDS documented R3 had impairment on both sides of her lower extremities. The MDS documented R3 was dependent on staff for transfers and required substantial staff assistance for showering. The Functional Abilities CAA dated 12/12/25, documented R3 had a progressive decline in her physical abilities to perform her ADLs. R3's Care Plan documented R3 preferred to have two showers a week. The Bathing Schedule Sheet in the EMR documented R3 was to receive showers/bathing every Monday and Thursday. The EMR documented R3 had only received two showers from 03/24/26 through 04/22/26. On 04.22.26 at 10:15 AM, observation revealed R3 up in a motorized scooter. R3 had unkempt hair, which was greasy and oily. R3 had a distinct odor of urine about her. On 4/22/26 at 10:15 AM, R3 stated she had not been getting her showers the way she was supposed to. R3 got tears in her eyes and stated she had not had a shower in two weeks. R3 stated she felt dirty and smelly. R3 stated staff did not have enough time to get her in the shower for bathing. 4. R4's EMR documented R4 had diagnoses of gout (inflammation of the joints), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and severe obesity. The Comprehensive MDS, dated 03/27/26, documented R4 had a BIMS score of 15, which indicated intact cognition. The MDS documented R4 was dependent on staff for toileting hygiene, lower body dressing, and transfer, and required substantial staff assistance with bathing/showering and bed mobility. The Functional Abilities CAA, dated 03/27/26, documented R4 had diagnoses which made it difficult for her to assist in transfers and bathing, and staff would provide R4 assistance with ADLs. The Bathing Schedule Sheet in the EMR documented R4 was scheduled to receive showers/baths every Monday and Wednesday. The EMR documented R4 had only received four showers from 03/24/26 through 04/22/26. On 04/22/26 at 10:30 AM, observation revealed R4 sat up in her wheelchair and waited for her care plan meeting. R4's hair was unkept and oily. On 04/22/26 at 10:30 AM, R4 stated she had not been receiving her showers/baths the way she was supposed to. R4 stated she felt neglected and uncared for by facility staff because staff did not care if she was clean or not. R4 blamed lack of staffing for not getting showers.5. R5's EMR documented diagnoses of hemiplegia and hemiparesis following a cerebral infarction, anxiety, and depression. The Quarterly MDS dated 08/16/24, documented R5 had a BIMS score of 14, which indicated intact cognition. The MDS documented R5 had impairment on one side of her upper and lower extremities. The Functional Abilities CAA dated 04/11/25, documented R5 had difficulty performing ADLs, and staff would assist her with ADLs. R5's Care Plan directed staff to help R5 wash her hair and her back during her showers. The Bathing Sheet Schedule in the EMR documented R5 was scheduled to receive showers/baths every Wednesday and Friday. The EMR documented R5 had only received five showers from 03/24/26 through 04/22/26. On 04/22/26 at 10:30 AM, observation revealed R5 up in her wheelchair. R5 had contractures of her left hand and foot. R5 had a distinct odor of urine about her, and her hair was oily. On 10/02/24 at 10:30 AM, R5 stated she was not getting her showers the way she was scheduled to and blamed the lack of staffing. R5 stated she felt smelly and gross due to the lack of showers. On 04/22/26 at 11:00 AM, Certified Medication Aide (CMA) R stated the staff was not taking care of the residents the way they were supposed to be taken care of. CMA R stated the residents were not getting showered and bathed, and were lucky if they got one every ten days. CMA R stated low staffing as the reason for the lack of care. On 04/22/26 at 01:00 PM, Administrative Nurse D stated he knew there had been some problems with baths getting done and he was currently going through bathing sheets to assess whether showers were not getting done or not getting charted. He stated he knew R3 had not had a bath in two weeks, and he had apologized to her and had staff get her in the shower right away. The facility's Activities of Daily Living Policy revised 04/27/18, documented the residents will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choices for the following: Hygiene (bathing, dressing, grooming, and oral care), Mobility (transfer and ambulation), Elimination (toileting), Dining (eating, including snacks and meals), and Communication (speech, language, functional communication systems). Residents who are unable to carry out activities of daily living and are dependent on if staff will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on record review, observation, and interview, the facility failed to develop and implement a comprehensive care plan for Resident (R) 1 to direct staff to provide R1 services for R1 to attain or maintain her highest practicable physical, mental, and psychosocial well-being. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), urinary tract infection (UTI-an infection in any part of the urinary system), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) 04/09/26, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had impairment on both sides of her upper and lower extremities and was dependent on staff for all activities of daily living (ADLs). The MDS documented R1 was frequently incontinent of bladder and bowel. The MDS documented R1 had a urinary tract infection in the last 30 days. The Functional Abilities Care Area Assessment (CAA) dated 04/09/26, documented R1 had diagnoses that made ADLs difficult or impossible for R1 to do by herself, and staff would assist R1 with her ADLs. R1's Care Plan, initiated 03/02/26, lacked any direction regarding R1's ADLs and care needs. The care plan only had three areas addressed in the care plan: advanced directives, black box warnings, and discharge. On 04/22/26 at 11:00 AM, observation revealed R1 had greasy, oily hair and a distinct odor about her. R1 lay in bed and was turned on her right side. On 04/22/26 at 11:00 AM, R1 stated that she did not think staff knew how to take care of her. R1 stated she would ask staff to turn her in a different direction because she got so sore staying in one position. R1 stated staff would come into her room, and she would ask to be turned, and they would say, Not right now. R1 stated she did not know what days her showers were supposed to be because no one had told her. R1 stated she would like to be turned towards the door. On 04/22/26 at 01:00 PM, Administrative Nurse D stated he was aware R1 did not have a complete care plan, and that was his fault. Administrative Nurse D stated he expected residents to have a comprehensive care plan in place a month and a half after admission to the facility. The facility's Care Plan Policy, dated 03/21/24, documented a care plan will be developed for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs and is consistent with the resident's desires and preferences. A comprehensive care plan must be developed within seven days of completion of the MDS and CAAs or within 21 days after admission, whichever comes first. The care plan should reflect individualized problems, goals, and interventions based on the resident's preferences and wishes.

Based on record review, observation, and interview, the facility failed to follow R1's primary care physician's orders to obtain a straight catheterization urine specimen to assess for a urinary tract infection. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), urinary tract infection (UTI-an infection in any part of the urinary system), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) 04/09/26, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had impairment on both sides of her upper and lower extremities and was dependent on staff for all activities of daily living (ADLs). The MDS documented R1 was frequently incontinent of bladder and bowel. The MDS documented R1 had a urinary tract infection in the last 30 days. The Functional Abilities Care Area Assessment (CAA) dated 04/09/26, documented R1 had diagnoses that made ADLs difficult or impossible for R1 to do by herself; staff would assist R1 with her ADLs. R1's Care Plan initiated 03/02/26, lacked any direction regarding R1's ADL and care needs. The care plan only had three areas addressed in the care plan: advanced directives, black box warnings, and discharge. The Nurses Note dated 03/11/26 at 11:31 AM, documented when changing R1 and providing peri care, staff noted blood in R1's brief and while wiping. R1 had increased urinary frequency, decreased urine output at times, and appeared to have bladder spasms. Staff notified R1's primary care physician and received an order to perform a straight catheterization to obtain a urine sample. The Nurses Note dated 03/11/26 at 04:53 PM, documented R1's primary care physician had faxed back an order to obtain a straight catheterization urine specimen and send for culture and sensitivity if indicated. The March 2026 Treatment Administration Record (TAR) documented a new order for a straight catheterization urine specimen to be obtained. The TAR lacked any documentation the order had been completed. R1's EMR lacked any urine specimen results. R1's Hospital Health and Physical (H&P) dated 03/13/26, documented R1 had been admitted to the hospital with hypoxia (low oxygen saturation), and no source for the hypoxia was found. A straight catheterization had been completed, and R1 had a UTI and was placed on an intravenous antibiotic and admitted to the hospital. On 04/22/26 at 11:00 AM, observation revealed R1 had greasy, oily hair and a distinct odor about her. R1 lay in bed and was turned on her right side. On 04/22/26 at 11:00 AM, R1 stated that she had to be admitted to the hospital and had a urinary tract infection. R1 stated her granddaughter had told her the facility did not obtain a urine specimen when it had been ordered by her doctor. R1 stated she could remember staff telling her she had blood in her urine but did not remember staff obtaining a urine sample. On 04/22/26 at 01:00 PM, Administrative Nurse D stated he was unaware of any straight catheterization order being missed for R1. Administrative Nurse D reviewed R1's EMR, and he verified the order had not been completed by staff. Administrative Nurse D stated all physician orders needed to be completed by the nursing staff, and it was unacceptable this order had not been followed. The Physician Order Policy, dated 09/21/21, documented physician orders will be followed related to the care needs of individual residents. Physician orders may be received verbally, via telephone or fax communication, or written orders in the clinical record progress note or other written forms. A licensed nurse must note all physician orders and process them as indicated, which includes entering the order into the electronic medical record.

The facility had a census of 40 residents. The sample included five residents. Based on the interview and record review, the facility failed to correctly transcribe physician orders to provide medication to Resident (R) 1 and R2, upon admission to the facility. This deficient practice caused R1 to not receive his prescription medication for 13 days and R2 to not receive the prescribed medication for four weeks. Findings included: - R1's electronic health record (EHR) documented diagnoses of HIV (Human Immunodeficiency virus, a virus that attacks the body's immune system, leading to a weakened immune system and increase in the risk for cancers and infections), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), fractured sternum (a long flat T-shaped bone located in the center of the chest wall that protects the heart and other organs), and multiple fractured vertebra (fracture affecting the spinal column). R1 's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition and received an antidepressant (a class of medications used to treat mood disorders), anticonvulsant (a class of medication used to control or prevent seizures), and opioid (a class of controlled drugs used to treat pain). The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 06/30/25, recorded R1 had a motor vehicle accident with head injuries, fractured vertebrae, and a fractured sternum. R1 was working with physical therapy and occupational therapy to regain his strength and ability to care for himself. The ADL CAA documented R1 needed assistance with all areas of ADLs and had some limitations in mobility due to the fractures and the associated pain. R1's “Back Box Warning Medication Care Plan, dated 06/23/25, recorded R1 had medications with black box warnings that were located in the medication Administration record and the Treatment administration record. The Physician's Order dated 06/18/25 directed staff to administer Biktarvy (a medication used to attack the HIV and lower the amount of HIV in the blood. The med combines three antiviral medications to lower the HIV in your body), oral tablet 50-200-25 milligrams (mg), one tablet by mouth once daily for HIV. Review of the “Medication Administration Record (MAR) revealed the following dates the facility did not have the medication available to the resident: On 06/18/25 at 10:50 PM, “Nurses Notes” documented “waiting on delivery.” On 06/19/25 at 07:46 AM, “Nurses notes” documented “waiting on delivery.” On 06/20/25 at 08:38 AM, “Nurses Notes documented “waiting on delivery.” On 06/21/25 at 10:08 AM, “Nurses Notes” documented “waiting to receive from pharmacy.” On 06/22/25 at 07:49 AM, “Nurses Notes” documented “on order.” On 06/23/25 at 08:05 AM, “Nurses Notes” documented “waiting on delivery.” On 06/24/25 at 06:34 AM, “Nurses Notes” documented “waiting on delivery.” On 06/25/25 at 11:57 AM, “Nurses Notes” documented “waiting for medication from pharmacy.” On 06/26/25 at 07:59 AM, “Nurses Notes” documented “waiting on delivery.” On 06/27/25 at 09:10 AM, “Nurses Notes” documented “waiting on delivery.” On 06/28/25 at 10:23 AM, “Nurses Notes” documented “waiting on delivery.” On 06/29/25 at 09:58 AM, “Nurses Notes” documented “waiting on delivery.” On 06/30/25 at 07:31 AM, “Nurses Notes” documented “waiting for medication from pharmacy.” On 07/ 01/25 at 06:33 AM, “Nurses Notes” documented “awaiting delivery.” R1 was discharged from the facility to home on [DATE] On 09/02/25 at 02:20 PM, License Nurse (LN) D verified she was aware R1 did not receive his physician-ordered Biktarvy while a resident at the facility. LN D stated she was aware the resident had a “grant” to cover the cost of the medication, and the facility could call the family, and they would have brought the medication into the facility to administer to the resident. On 09/02/25 at 02:38 PM, Pharmacy Consultant Staff GG verified the pharmacy received an order form the facility to fill the medication Biktarvy on 06/18/25. The pharmacy filled the prescription and attempted to get paid/preapproval through the residents' insurance, and it was denied. The pharmacy would then get approval from the facility for them to cover the charges, so they emailed the facility on 06/18/25 to get the approval, with no response. Then, I emailed the facility again on 06/19/25. Administrative Nurse D stated she was sorry she did not get back with the pharmacy yesterday. However, she would contact them with a response on 06/20/25. The pharmacy is still awaiting a response from the facility. Pharmacist Consultant Staff GG stated they would not email the facility again due to the fact that Administrative Nurse D stated she would get back with them regarding a response on 06/20/25. Pharmacist Consultant Staff GG stated the medication was $4600.00 a month, and if any medication was over $250.00, they would email the facility for approval before sending the medication to the facility, because the facility would be responsible for paying the charge out of pocket. On 09/02/25 at 02:45 PM, Consultant HH verified she was the pharmacy business manager, she had emailed the facility to get a response to have the non-covered medication paid for on 06/18/25 and again on 06/19/25 and as stated above was told by Administrative Nurse D she would get back with the pharmacy on 06/20/25 and she failed to contact them with an approval or denial for payment. On 09/02/25 at 03:15 PM, Social Service Staff X stated an out-of-town hospital had contacted the facility on 06/11/25 to accept R1 as a patient when he was discharged from their facility on 06/18/25 and told the facility he had a diagnosis of HIV and required the medication Biktarvy. The hospital stated the medication would be covered by “[NAME] Funding Care Management,” so there would not be an out-of-pocket expense for the facility for the medication. Social Service Staff X stated that both Administrative Nurse D and Administrative Nurse E were included in the email from the hospital that indicated R1 medication and how to get the medication paid for. Social Service Staff X verified she did not do anything further before the resident was admitted to the facility, assuming Administrative Nurse D or Administrative Nurse E would have pursued the [NAME] grant/funding, but apparently stated that was not followed through. She was unaware R1 had not received the medication at the facility. On 09/02/25 at 03:30 PM, Administrative Staff A verified he was unaware of R1 not receiving the physician ordered Bitkarvy and stated before a resident is admitted to the facility the facility should have gotten the medication pre-approved and if they we unable to do that they should have denied the resident's admission to the facility if they were unable to provide the resident with the required care and services. Administrative Staff A verified he had called and texted Administrative Nurse D every thirty minutes since we were in the building and had inquired about the resident medication and did not have a return call or response from Administrative Nurse D. Administrative Staff A verified Administrative Nurse D worked the night shift and got off at 06:00 AM on 09/02/25 and was probably sleeping and should be back at the facility at 06:00 PM tonight and would ask that she would call the surveyor regarding the concern. On 09/02/25 at 10:02 PM, the Administrative Nurse D was unable to be reached. The facility's “Medication Administration” policy undated, documented the facility maintains equipment and supplies necessary for the preparation and administration of medication to residents. Medications are administered in accordance with written orders of the attending physician, and at the time they are prepared. The policy documents if the resident refuses medication, document refusal on the Medication Administration Record (MAR), and notify the provider per facility protocol. The staff would document in the MAR the administration of medication, the specific time of administration, refusal, holding of dose, and dosing parameters such as vital signs and lab values. - R2's “Electronic Medical Record (EMR)” documented R2 was admitted to the facility 02/24/25 and included diagnoses of protein-calorie malnutrition (inadequate intake of both protein and calories), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), atrial fibrillation (rapid, irregular pulse) and cerebral infarction (stroke). R2's “admission Minimum Data Set (MDS),” dated 03/03/25, documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS documented R2 required partial staff assistance for activities of daily living and received insulin (a hormone that lowers the level of glucose in the blood). R2's “Care Plan,” dated 02/24/25, directed staff to administer her medication as prescribed by her physician. R2's hospital discharge orders, dated 02/24/25, listed prescribed medications to continue, including Mounjaro (injectable prescription medicine for adults with type 2 diabetes), 5 milligrams (mg)/0.5 milliliters (ml) weekly. R2's Medication Administration Record (MAR) for February and March 2025 lacked documentation of the Mounjaro order. R2's EMR lacked documentation the physician ordered Mounjaro was discontinued. On 09/02/25 at 10:55 AM, Licensed Nurse (LN) H verified Mounjaro was included in the hospital discharge orders for R2 and should have been continued at the facility. On 09/02/25 at 02:43 PM, Consultant Pharmacist GG stated the facility staff sent R2's physician-ordered medication list to the pharmacy after they entered it in the computer system. She verified that what they received did not include Mounjaro. On 09/02/25 at 02:55 PM, LN I verified R2's physician ordered Mounjaro 0.5 mg upon her admission to the facility on [DATE] and had not discontinued the order. On 09/02/25 at 03:15 PM, Administrative Staff A verified that nursing staff should have transcribed the physician orders correctly. The facility's “Medication Administration” policy, dated 01/2021, stated medications were administered in accordance with written orders of the physician.

The facility had a census of 40 residents. The sample included five residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide the physician ordered medications for one of five sampled residents, Resident (R) 1. This deficient practice placed R1 at risk for ineffective treatment of HIV (Human Immunodeficiency virus, a virus that attacks the body's immune system, leading to a weakened immune system and increase in the risk for cancers and infections). Findings included:- R1's electronic health record (EHR) documented diagnoses of HIV, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), fractured sternum (a long flat T-shaped bone located in the center of the chest wall that protects the heart and other organs), and multiple fractured vertebra (fracture affecting the spinal column). R1's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R1 received an antidepressant (a class of medications used to treat mood disorders), an anticonvulsant (a class of medications used to control or prevent seizures), and an opioid (a class of controlled drugs used to treat pain). The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 06/30/25, recorded R1 had a motor vehicle accident with head injuries, fractured vertebrae, and a fractured sternum. R1 worked with physical therapy and occupational therapy to regain his strength and ability to care for himself. The ADL CAA documented R1 needed assistance with all areas of ADLs and had some limitations in mobility due to the fractures and the associated pain.R1's Back Box Warning Medication Care Plan, dated 06/23/25, recorded R1 had medications with black box warnings that were located in the Medication Administration Record and the Treatment Administration Record. The Physician's Order dated 06/18/25 directed staff to administer Biktarvy (a medication used to attack the HIV and lower the amount of HIV in the blood. The med combines three antiviral medications to lower the HIV in your body), oral tablet 50-200-25 milligrams (mg), one tablet by mouth once daily for HIV.Review of the Medication Administration Record (MAR) revealed the following dates the facility did not have the medication available to the resident:On 06/18/25 at 10:50 PM, Nurses Notes documented waiting on delivery. On 06/19/25 at 07:46 AM, Nurses notes documented waiting on delivery. On 06/20/25 at 08:38 AM, Nurses Notes documented waiting on delivery. On 06/21/25 at 10:08 AM, Nurses Notes documented waiting to receive from pharmacy.On 06/22/25 at 07:49 AM, Nurses Notes documented on order.On 06/23/25 at 08:05 AM, Nurses Notes documented waiting on delivery.On 06/24/25 at 06:34 AM, Nurses Notes documented waiting on delivery.On 06/25/25 at 11:57 AM, Nurses Notes documented waiting for medication from pharmacy.On 06/26/25 at 07:59 AM, Nurses Notes documented waiting on delivery.On 06/27/25 at 09:10 AM, Nurses Notes documented waiting on delivery.On 06/28/25 at 10:23 AM, Nurses Notes documented waiting on delivery. On 06/29/25 at 09:58 AM, Nurses Notes documented waiting on delivery.On 06/30/25 at 07:31 AM, Nurses Notes documented waiting for medication from pharmacy.On 07/01/25 at 06:33 AM, Nurses Notes documented awaiting delivery. R1 discharged from the facility to home on [DATE].On 09/02/25 at 02:20 PM, License Nurse (LN) G verified she was aware R1 did not receive his physician-ordered Biktarvy while a resident at the facility. LN G stated she was aware the resident had a grant to cover the cost of the medication, and the facility could call the family, and they would have brought the medication into the facility to administer to the resident. On 09/02/25 at 02:38 PM, Pharmacy Consultant Staff GG verified the pharmacy received an order form the facility to fill the medication Biktarvy on 06/18/25. The pharmacy filled the prescription and attempted to get paid/preapproval through the resident's insurance, and it was denied. The pharmacy would then get approval from the facility for them to cover the charges, so they emailed the facility on 06/18/25 to get the approval with no response, then emailed the facility again on 06/19/25, and Administrative Nurse D stated she was sorry she did not get back with the pharmacy yesterday; however, she would contact them with a response on 06/20/25. The pharmacy was still awaiting a response from the facility. Pharmacist Consultant Staff GG stated they would not email the facility again due to the fact that Administrative Nurse D stated she would get back with them regarding a response on 06/20/25. Pharmacist Consultant Staff GG stated the medication was $4600.00 a month, and if any medication was over $250.00, they would email the facility for approval before sending the medication to the facility, because the facility would be responsible for paying the charge out of pocket. On 09/02/25 at 02:45 PM, Consultant HH verified she was the pharmacy business manager, she had emailed the facility to get a response to have the non-covered medication paid for on 06/18/25 and again on 06/19/25 and as stated above was told by Administrative Nurse D she would get back with the pharmacy on 06/20/25 and she failed to contact them with an approval or denial for payment. On 09/02/25 at 03:15 PM, Social Service Staff X stated an out-of-town hospital had contacted the facility on 06/11/25 to accept R1 as a patient when he was discharged from their facility on 06/18/25 and told the facility he had a diagnosis of HIV and required the medication Biktarvy. The hospital stated the medication would be covered by [NAME] Funding Care Management, so there would not be an out-of-pocket expense for the facility for the medication. Social Service Staff X stated that both Administrative Nurse D and Administrative Nurse E were included in the email from the hospital that indicated R1's medication and how to get that medication paid for. Social Service Staff X verified she did not do anything further before the resident was admitted to the facility, assuming Administrative Nurse D or Administrative Nurse E would have pursued the [NAME] grant/funding, but apparently stated that was not followed through with; she was unaware R1 had not received the medication at the facility. On 09/02/25 at 03:30 PM, Administrative Staff A verified he was unaware of R1 not receiving the physician ordered Bitkarvy and stated before a resident is admitted to the facility the facility should have gotten the medication pre-approved and if they we unable to do that they should have denied the resident's admission to the facility if they were unable to provide the resident with the required care and services. Administrative Staff A verified he had called and texted Administrative Nurse D every thirty minutes since we were in the building and had inquired about the resident medication and did not have a return call or response from Administrative Nurse D. Administrative Staff A verified Administrative Nurse D worked the night shift and got off at 06:00 AM on 09/02/25 and was probably sleeping and should be back at the facility at 06:00 PM tonight and would ask that she would call the surveyor regarding the concern.On 09/02/25 at 10:02 PM, the Administrative Nurse D was unable to be reached.The facility's Medication Administration policy, undated, documented the facility maintained equipment and supplies necessary for the preparation and administration of medication to residents. Medications were administered in accordance with written orders of the attending physician, and at the time they were prepared. The policy documented if the resident refused medication, document the refusal on the Medication Administration Record (MAR) and notify the provider per facility protocol. The staff would document in the MAR the administration of medication, the specific time of administration, refusal, holding of dose, and dosing parameters such as vital signs and lab values.

The facility had a census of 45 residents. The sample includes 13 residents, with five residents reviewed for immunizations: Resident (R) 6, R8, R25, R26, and R33, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.Findings included:- Review of R6, R8, R25, R23, and R33 clinical medical records lacked evidence that the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20.Review of R6's electronic health record revealed the resident was admitted to the facility on [DATE]. R6 had not been offered or received a pneumococcal PCV20 vaccine since admission.Review of R8's electronic health record revealed the resident was admitted to the facility on [DATE]. R8 had not been offered or received a pneumococcal PCV20 vaccine since admission.Review of R25's electronic health record revealed the resident was admitted to the facility on [DATE]. R25 had not been offered or received a pneumococcal PVC20 vaccine since admission.Review of R26's electronic health record revealed the resident was admitted to the facility on [DATE]. R26 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R33's electronic health record revealed the resident was admitted to the facility on [DATE]. R33 had not been offered or received a pneumococcal PCV20 vaccine since admission.On 07/09/25 at 08:30 AM, Nurse Consultant G stated residents are offered the pneumonia vaccines on admission and as indicated. Nurse Consultant GG said the resident would sign a consent or declination for receiving the vaccine. Nurse Consultant GG verified that every resident in the building had not been reviewed to determine if they were eligible to receive the PCV20 vaccine or if they were they did not have written documentation the facility offered the PCV20 vaccination. Nurse Consultant GG verified they did not have a definitive system in place to determine who was eligible, or if they were eligible, if they had been offered or declined the vaccinations.The facility's Pneumococcal Vaccine policy dated 11/28/17, documented pneumococcal vaccinations would be offered to all residents per the Centers for Disease Control (CDC). At the time of admission, the resident, the resident representative, or attending physician would be contacted to obtain a history of previous pneumococcal vaccinations. The resident and the resident's representative would sign a consent form to receive or to refuse the vaccination. Both the Pneumococcal Conjugate (PCV13) and Pneumococcal Polysaccharide (PPSV23) vaccines would be available. At that time, the facility would provide a copy of the CDC vaccination summary (VIS) to provide them with the vaccination's risks

The facility had a census of 45 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in a sanitary manner when dietary staff did not complete hair coverage with the hairnet and beard cover. This deficient practice placed the residents of the facility who received meals from the facility at risk for foodborne illness.Findings included:- On 07/08/25 at 11:40 AM, observation revealed Dietary Staff (DS) BB in the facility kitchen preparing Resident (R) 8's pureed lemon bar dessert. DS BB wore a beard net but did not cover his entire beard or mustache, and had a hair net that did not cover the back of his hair. On 07/09/25 at 11:45 AM, observation revealed DS EE in the facility kitchen preparing to serve the residents' lunch food trays to the tables. DS EE wore a beard net but did not cover his entire beard or mustache, and had a hair net that did not cover the back of his hair.On 07/09/25 at 12:00 PM, observation revealed the stove hood with brownish gray fuzz substance covered and hanging from the front panel of the stove top hood. Continued observation revealed two commercial convection ovens behind the stove with a fan and motor assembly covered with brownish grease/sticky substance and gray fuzz covering the area located directly behind the stove cooking top. On 07/08/25 at 12:30 PM, observation in the facility kitchen revealed DS FF walked from the dining room door through the kitchen to a closet without a hair net on. DS FF then obtained a hair net and placed it on her head, then washed her hands to start working in the kitchen.On 05/14/25 at 10:00 AM, Certified Dietary Manager BB stated staff were to wear hairnets, cover beards, and have thorough hair coverage, including mustaches with a beard net. Certified Dietary Manager BB verified the maintenance staff, and Dietary staff were responsible for cleaning the kitchen and appliances. Dietary Manager BB verified the stove hood had gray fuzz on the front panel and verified the convection oven had brownish grease/sticky substance on the fan and motor assembly. The facility's Hair Restraint policy, dated 04/27/20, documented hair restraints and/or beard guards shall be worn by all staff in food production, dish washing areas, or when serving food from the steam table. Hair restraints and/or beard guards shall be used to prevent hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use items. Hair restraints shall be worn by all staff in food production, kitchen, dish washing, and serving from the steam table, and all hair must be contained within the approved hair restraint. Facial hair must be covered by a beard guard regardless of how closely trimmed. The facility's Cleaning Rotation policy, dated 04/27/20, documented the Dining Services staff would uphold sanitation of the dining and food service areas, equipment, and utensils according to a thorough, written schedule and following manufacturers' guidelines. The Director of Dining Services would record the necessary cleaning and sanitation tasks for the department. Tasks would be designated to specific departmental positions. All cleaning schedules would be posted for all cleaning tasks, and staff would initial the tasks as they were completed.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure and maintain the kitchen walk-in freezer was in a safe operating condition, as the freezer door would build up with ice and would not completely shut. This placed the 45 residents who resided in the facility and received their meals from the facility's kitchen at risk for foodborne illness.Findings included:- On 07/07/25 08:20 AM, observation in the kitchen revealed the walk-in freezer door had ice buildup on the frame of the door and was hard to keep closed.On 07/07/25 at 12:14 PM, Maintenance Staff (MS) U stated he was aware of the problems with the walk-in freezer door building up with ice and not shutting. MS U stated he had talked to six or seven refrigeration vendors, and they could only do part of what needed to be fixed in the walk-in freezer. MS U stated about a year ago that the food in the freezer had to be thrown away due to the out-of-range temperature in the freezer. MS U stated staff have to routinely clean the ice off the freezer door.On 07/07/25 at 08:20 AM, Dietary Staff (DS) DD verified the walk-in freezer door had ice buildup on it for a long time. DS DD stated staff have to break the ice off the freezer door all the time to get it to close tightly. DS DD stated the door needs to be replaced.On 07/09/25 at 10:35 AM, Consultant HH stated he was aware of the issue with the walk-in freezer and had been working on getting it repaired for approximately two months. The facility had several local contractors come out, and they could not fix it. Consultant HH stated the problem was that the two boxes available to use were not the right size, and one could not place the sprinkler in them. The facility had the roof repaired due to it was leaking water into the freezer. The door had come off at one time, and that was repaired and sealed. Consultant HH verified there was an issue approximately a year ago when they had to throw food away due to the temperature of the freezer being too warm. [NAME] stated several local companies had been out to look at repairing the issues, but turned down the job. Consultant HH stated he had recently contacted a contractor out of town who is going to come and look at it, but so far, they have not been here. Consultant HH stated that the problem with repairing it is the company would have to build a hallway to a new one due to its location. When asked if he had documentation regarding details of companies coming out, he stated he had no documentation.Upon request, the facility failed to provide a preventative maintenance policy.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed (a texture-modified diet where all foods are blended or mashed into a smooth, pudding-like consistency) diet for Resident (R) 8. This placed the residents at risk for inadequate nutrition.Findings included:- On 07/08/25 at 11:30 AM, observation revealed Dietary Staff (DS) BB prepared one pureed diet. DS BB placed one serving, approximately three ounces of baked barbecued rib patty in a food processor/blender. DS BB blended the barbecued rib patty, added an unmeasured amount of meat juice, blended to the correct pureed texture, and emptied the barbecued meat into a stainless-steel food storage container, then placed the steel food container in the oven. Continued observation revealed DS BB placed approximately four ounces of cauliflower and broccoli in a food processor/blender. DS BB blended the vegetables to the correct pureed texture and emptied the vegetables into a stainless-steel food storage container, then placed the steel food container on the steam table. Continued observation revealed DS BB placed four ounces of O'Brien potatoes in a food processor/blended. DS BB blended the potatoes to the correct pureed texture and emptied the potatoes into a stainless-steel food storage container, then placed the steel food container on the steam table. Observation revealed there was no recipe for DS BB to look at with food preparation. On 07/08/25 at 11:40 AM, observation revealed DS CC prepared one pureed dessert. DS CC placed one approximately two-inch by two-inch piece of lemon bar in the kitchen aide blender. DS CC blended the lemon bar, added an unmeasured amount of milk, blended to the correct puree texture, and emptied the pureed lemon bar in a stainless-steel food container and placed it beside the steam table covered with foil. Observation revealed there was no recipe for DS CC to look at with food preparationOn 07/08/25 at 12:35 PM, Certified Dietary Manager (CDM) DD verified that the dietary staff are expected to use a pureed recipe when preparing a pureed diet, and the facility had the recipes available. CDM DD verified she would instruct the staff on the use of the facility-provided recipes. The facility's Mechanically Altered Food Preparation policy, dated 04/06/20, documented mechanically altered foods would be prepared using standardized recipes. Standardized recipes would be used to prepare all mechanically altered foods. The recipes would be adjusted according to the number of diets needed and would indicate seasoning and technique to ensure the highest quality, to ensure quality flavor, and maximum nutritive value. The diet spreadsheets would be used for all mechanically altered diets to include mechanical soft and puree diets. Recipes would not use water on thin pureed foods; only milk, broth, juice, gravy, margarine, or other appropriate condiments that preserve the flavor shall be used. Pureed foods shall have the consistency of pudding or mashed potatoes, and a food processor is preferred, but a blender may be used. The flavor of pureed foods would be assessed, and they should have the same desirable flavor as the meu item. The staff shall be in-serviced on proper preparation of mechanically altered foods.

The facility had a census of 45 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure that its Quality Assessment and Assurance Committee adequately identified deficient areas of practice and to develop and implement appropriate plans of action to correct the deficient practices for the 45 residents residing in the facility.Findings included:- Based on observation, record review, and interview, the facility failed to identify, document the clinical rationale for administering R5, an antipsychotic medication, when staff failed to understand the resident's wants and needs due to a language barrier. Refer to F605.Based on observation, record review, and interview, the facility failed to notify the Ombudsman and provide a bed hold policy when R32 was transferred to the hospital. Refer to F628. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for R5 regarding communication, dementia care, and antipsychotic use for behaviorsRefer to 656.Based on observation, record review, and interview, the facility failed to provide R5 communication devices for a Spanish-speaking resident to communicate her wants and needs to the staff. Refer to 676.Based on observation, record review, and interview, the facility failed to provide dependent residents, R6 and R8, with bathing as care planned.Refer to 677.Based on observation, record review, and interview, the facility failed to provide a safe smoking environment for R32, who was assessed as unsafe and kept his smoking materials in his room. The facility further failed to use a gait belt for safe transfers, which resulted in a fall. Refer to 689.Based on observation, record review, and interview, the facility failed to post daily nursing staffing.Refer to 732.Based on observation, record review, and interview, the facility failed to provide non-pharmacological interventions for R5, who received antipsychotic medication for dementia. Refer to 744. Based on observation, record review, and interview, the facility failed to notify the physician when R20 had blood sugars out of the physician's parameters.Refer to 757.Based on observation, record review, and interview, the facility failed to follow a pureed diet recipe for R8.Refer to 804.Based on observation, record review, and interview, the facility failed to store, prepare, and serve in the kitchen when male dietary staff did not cover their mustache with net covers and failed to maintain clean equipment in the kitchen and failed to discard expired supplements, and lacked a label with the date on food in the nutrition center.Refer to 812.Based on observation, record review, and interview, the facility failed to collaborate the facility care plan with the hospice care plan and documented what services would be provided by hospice. Refer to 849.Based on observation, record review, and interview, the facility failed to offer or provide residents with the Prevnar 20 vaccination.Refer to 883.Based on observation, record review, and interview, the facility failed to maintain the walk-in freezer door in the kitchen.Refer to 908.On 07/09/25 at 01:10 PM, Administrative Staff A stated that the QAA meetings were held monthly and included the medical director.The undated facility's Quality Assurance and Performance Improvement (QAPI) policy documented that the facility would develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

The facility had a census of 45 residents. The sample included 12 residents, with two reviewed for Hospice (specialized care that mainly aims to provide comfort and dignity to the patients by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 5 and R2. This placed the residents at risk for inappropriate and/or unmet end-of-life care.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made or the boy cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. The MDS documented R5 required substantial staff assistance for toileting, upper body dressing, personal hygiene, mobility, transfer, and did not ambulate. The MDS further documented R5 received hospice services. R5's Care Plan, dated 06/12/25, initiated on 02/24/25, directed staff to coordinate care with the hospice staff to assure all her needs were being met, and to make sure she was able to spend quality time with family. The care plan documented R5 wanted to be involved in her healthcare and life decisions for as long as she was able. If R5 reached a point where she was no longer able to do so, please honor and respect her advanced directives and other verbalized wishes. The care plan further directed staff to let her family know what her condition was and if she needed or wanted to see them. The staff were directed to provide R5 with medications and other measures to maintain her comfort. The care plan lacked when hospice staff would be in the building and what care and supplies they would provide. The Physician's Order, dated 02/24/25, directed staff to admit R5 to hospice services. On 07/08/25 at 08:15 AM, R5 sat at the dining room table and ate her breakfast. On 07/08/25 at 12:36 PM, Administrative Nurse D stated she would ensure the care plan reflected the collaboration between the facility and hospice. The facility's Hospice policy, dated 11/28/17, documented a significant change in status assessment would be initiated, and the plan of care would be updated to reflect coordination of care and services with hospice. - R2's Electronic Medical Record (EMR) included diagnoses of chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), overactive bladder, chronic lymphocytic leukemia (a type of cancer of the blood and bone marrow) of B-cell type, polyarthritis (arthritis in five or more joints), Crohn's disease (chronic inflammation of the bowel), and chronic pain syndrome. R2's Significant Change Minimum Data Set, dated [DATE], documented R2 had severe cognitive impairment, and inattention behavior which fluctuated. R2 required partial/moderate assistance with oral hygiene, personal hygiene, lower body dressing, and sit-to-stand. R2 required substantial/moderate assistance with toileting hygiene. R2 was independent with bed rolling, sit to lying, lying to sitting, and toilet transfers. The MDS further documented R2 had occasional urinary incontinence, received a scheduled pain medication regimen, had moderate, frequent pain, which occasionally interfered with day-to-day activities. R2 had a condition or chronic disease that may result in a life expectancy of less than six months. R2's Care Plan dated 06/26/25, instructed staff to coordinate care with the hospice staff to assure all her needs were met, and she had chosen a hospice provider to assist with comfort and care. R2's Care Plan lacked specific discipline visits, medication, and supplies that the hospice provider would provide. The Physician Order dated 05/16/25 instructed staff to admit R2 to a specific hospice provider with the diagnosis of chronic lymphocytic leukemia. The Progress Note dated 05/12/25 at 02:06 PM, documented R2 had returned from a physician appointment with orders for hospice to evaluate and treat R2. On 07/08/25 at 01:20 PM, R2 ambulated with her walker into her bathroom independently, from where she sat in her recliner. On 07/09/25 at 09:07 AM, Certified Nurse Aide (CNA) P reported that the hospice provider supplied R2 with wipes and incontinent supplies. CNA P reported she thought the hospice aide came weekly and was unsure how often a nurse visited the resident. On 07/09/25 at 09:30 AM, Licensed Nurse (LN) I stated that the supplies provided by the hospice provider were on the back of the supply room door. This included gloves, wipes, bed pads, and creams for care. LN I stated that a hospice nurse came one to two times a week, unless the resident was actively dying, and then a nurse would come daily. LN I reported that a hospice aide usually came twice a week and provided bathing for residents. On 07/09/25 at 10:17 AM, Nurse Consultant GG stated that she had not included the hospice staff visits or supplies for care on the facility's plan of care. The facility's Hospice/End of Life policy, dated 11/28/17, documented hospice/end of life services will be provided according to the resident's needs and preferences. Upon the decision to elect hospice services, the physician will be contacted to obtain orders. A significant change in status will be initiated, and the plan of care will be updated to reflect coordination of care and services with hospice.

The facility had a census of 45 residents. The sample included 12 residents, with two reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for one resident, Resident (R) 5, who had dementia and received psychotropic (alters mood or thought) medication. This placed R5 at risk for decreased quality of life.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. The MDS documented R5 required substantial staff assistance for toileting, upper body dressing, personal hygiene, mobility, transfer, and did not ambulate. The MDS further documented R5's preferred language was Spanish, did not reject care, and had other behaviors for one to three days. R5 received antipsychotic, antianxiety (a class of medication that calms and relaxes people), antidepressant (a class of medications used to treat mood disorders), and diuretic (a medication to promote the formation and excretion of urine) medication daily.R5's Care Plan, dated 06/12/25, lacked an individualized care area for dementia care.The Physician's Order, dated 03/03/25, directed staff to administer trazodone (an antidepressant medication), 150 milligrams (mg), by mouth, at bedtime, for depression.The Physician's Order, dated 03/19/25, directed staff to administer venlafaxine hci (an antidepressant medication), 75 mg, by mouth, twice a day, for depression.The Physician's Order, dated 05/02/25, directed staff to administer sertraline hci (an antidepressant medication), 5 milliliters (ml), by mouth, daily, for major depressive disorder.The Physician's Order, dated 06/06/25, directed staff to administer Ativan (an antianxiety medication), 0.5 mg, by mouth, twice daily for agitation and anxiety.The Physician's Order, dated 06/27/25, directed staff to administer Seroquel (an antipsychotic medication), 25 mg, two tablets, by mouth, twice daily, for major depressive disorder. This was discontinued on 06/03/25The Physician's Order, dated 07/01/25, directed staff to administer Seroquel, 25 mg, two tablets, by mouth, three times daily for major depressive disorder.The Physician's Order, dated 06/30/25, directed staff to administer Compound Medication (lorazepam, one mg, diphenhydramine (an antihistamine medication) 25 mg, and Haldol (an antipsychotic medication), 1 mg, apply to inner wrist topically, every two hours, as needed for anxiety, restlessness, and agitation. This was discontinued on 07/03/25.The Physician's Order, dated 07/03/25, directed staff to administer Compound Medication (lorazepam, one mg; diphenhydramine (an antihistamine medication) 25 mg, and Haldol (an antipsychotic medication), 1 mg, apply to inner wrist topically, every two hours, as needed for anxiety, restlessness, and agitation. This is to be discontinued on 07/14/25.The EMR lacked documentation R5's family received a risk versus benefit or any other treatment alternatives.The Nurse's Note, dated 03/19/25, documented R5 sat on the side of her bed, speaking and pointing to the room across the hall, asking if there was a problem in that room. R5 began to speak faster Spanish, then leaned forward and went down onto the mat on her knees. R5 stated she was looking for something. The note documented staff called R5's family and was advised to administer Ativan to R5.The Nurse's Note, dated 04/20/25, documented R5 had multiple behaviors today, attempted to stand up from her wheelchair, and then walk. The note further documented R5 also bothered her daughter in her room.The Nurse's Note, dated 06/22/25, documented R5 was very agitated, restless, yelled, and cried that she wanted to go home. Staff asked R5 if she wanted to go to her room to be near her daughter, and she stated yes. The note documented staff were able to medicate R5 for her agitation.The Hospice Note, dated 06/30/25, documented, during a routine visit, facility staff attempted to keep R5 in her wheelchair as R5 was agitated and attempted to stand up. R5 spoke very rapidly in Spanish and allowed a Spanish-speaking employee to wheel her into her room. The note further documented R5 hit, screamed, and bit at staff during the day, and an order to increase R5's Seroquel was obtained.On 07/08/25 at 01:08 PM, R5 hollered out in Spanish, cried, and Licensed Nurse (LN) G told her she needed to speak in English. R5 stated 'I don't want to speak English. R5 continued to cry, and LN G asked her if she could take her to her room to be close to her daughter. LN G pushed R5 to her daughters room.On 07/08/25 at 09:40 AM, Certified Nurse Aide (CNA) M stated that R5 liked to be close to her daughter as they are in the same room. CNA M further stated she can understand English some of the time, but when she was frustrated and mad, she spoke in Spanish. CNA M stated she does not always know what she wants or what she is saying. CNA M stated there were a couple of Spanish-speaking staff members, but they were not always in the building to assist with R5.On 07/08/25 at 10:45 AM, Certified Medication Aide (CMA) R stated R5 would often become anxious and agitated and would speak mostly in Spanish. CMA R further stated that Seroquel was given because R5 would get frustrated when staff did not know what she was saying or what she wanted. CMA R stated there was at least one Spanish-speaking staff member, but she was not always working.On 07/08/25 at 10:45 AM, LN G stated R5 could speak some English and could understand what the staff were saying. LN G stated R5 would get agitated, refused medications, and care. LN G stated R5 received medication for her agitation.On 07/08/25 at 12:36 PM, Administrative Nurse D stated R5 should have a dementia treatment plan for staff to know what to do for R5 when she was agitated. Administrative Nurse D further stated that staff should document in the EMR any behaviors she had.The facility's Dementia policy, dated 04/27/18, documented residents who are diagnosed with dementia or display signs of dementia would receive appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility would provide dementia treatment and services based on the comprehensive care plan. The facility would ensure adequate medical care, diagnosis, and support based on the diagnosis. The facility would ensure a person-centered, individualized, non-pharmacological approach to care.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision for Resident (R) 32, who smoked and had a staff-assisted descent to the ground while being assisted with a chair-to-chair transfer. This placed R32 at risk for injuries from smoking and falls.Included findings:- R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the left non-dominant side, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), nicotine dependence, cigarettes, lymphedema (tissue swelling caused by accumulation of protein rich fluid), polyarthritis, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic respiratory failure with hypoxia (inadequate supply of oxygen).R32's Quarter Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition, had verbal symptoms directed toward others, and rejected care, which occurred one to three days of the look-back period. R32 used a wheelchair for mobility, required setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, upper body dressing, and was dependent with toileting hygiene. The MDS further documented R32 required partial/moderate assistance with transfers, was frequently incontinent of urine, and had no pain or falls. R32 received insulin (a hormone that lowers the level of glucose in the blood), a diuretic (a medication to promote the formation and excretion of urine), an antiplatelet (a medication used to prevent blood components from clumping together), a hypoglycemic (a medication used to lower blood sugar), and an anticonvulsant medication (medication used to prevent seizures). R32's Care Plan, dated 03/31/25, documented that R32 smoked and had been educated on the risks of smoking even with the diagnosis of COPD. The Care Plan documented that R32 could not safely smoke, although he would not give up his smoking materials or allow someone to assist with smoking. R32 signed an informed risk agreement to allow R32 to keep smoking materials on his person and continue to smoke independently against recommendations from the facility. The plan of care documented R32 did not follow directions for the designated smoking area, and staff were to redirect R32 when he went to other areas to smoke. R32's plan of care documented he often fell asleep while smoking and knew the risks associated with this. The plan of care directed staff to set a timer when R32 went outside to check on him. The plan of care documented R32 understood the danger of smoking without assistance. The plan of care documented staff had discussed with R32 where the designated smoking areas were, that he could not smoke in the facility, and how to properly dispose of the cigarette butts. The plan of care directed staff to remind R32 of the need to follow the rules for the safety of himself and others. The facility Smoking Assessment dated 11/14/24, documented R32 reported he would put cigarettes out and put them back into his pack. The assessment documented R32 put a cigarette out in a Styrofoam cup that was located in his room and noted the resident had not safely disposed of cigarettes.The facility's Smoking Assessment dated 12/26/24, documented R32 experienced a recent illness and dozed off when attempting to light and smoke cigarettes. R32 was no longer safe to smoke alone.The Progress Note dated 12/26/24 at 03:52 PM documented that the Social Service Designee (SSD) witnessed R32 outside in the smoking area three times throughout the day, falling asleep while smoking, trying to light an already lit cigarette, and dropping cigarettes on himself. The SSD was with the Certified Dietary Manager (CDM) and other residents who also witnessed the event and had concerns.The Progress Note dated 12/26/24 at 04:00 PM, documented R32 was observed outside smoking and sleeping on multiple occasions. R32 was unable to stay awake long enough to finish his cigarette. R32 fell asleep with a cigarette in his mouth, as well as trying to light a cigarette and getting the flame close to his facial hair while falling asleep. Staff woke R32 up on all of the occasions and became upset with the staff.The Progress Note dated 12/27/25 at 07:46 AM documented R32 had had issues with falling asleep while smoking following a recent illness. The facility presented R32 with the smoking policy and he verbalized understanding. R32 had intact cognition and completed a smoking assessment. R32 was notified that due to facility policies and the recent smoking assessment, it was not recommended that he keep smoking materials on his person or smoke independently.The Progress Note dated 01/24/25 at 09:45 AM documented the nurse went into R32's room to administer medication and found R32 seated in a wheelchair with his eyes closed and a lit cigarette in his hand. The nurse immediately told R32 he could not smoke in his room. R32 apologized and put the cigarette out, stating it was just a habit, as he woke up, pulled a cigarette out of his pocket, and lit it without thinking about it. The nurse reported the incident to the Director of Nursing (DON) and SSD.The Progress Note dated 01/24/25 at 10:22 AM documented the SSD spoke with R32 and explained he was not able to keep his cigarettes and lighter in his room any longer, after lighting up a cigarette in his room. R32 was aggravated and refused to turn over the items, stating it was a complete accident and it would not happen again. The SSD explained to R32 if it did, he would no longer be allowed to keep his smoking items in the room due to safety issues.On 07/08/25 at 01:38 PM, R32 stated the smoke detector in his room malfunctioned and was removed approximately two to three weeks prior. R32 wore a blue plaid shirt with numerous holes on the chest and abdominal area, which appeared to be burn holes. On 07/08/25 at 01:40 PM, Maintenance Director U stated that around a week prior, he was notified by facility staff the smoke detector in R32's room was going on and off. Maintenance Director U reported he went to the facility and removed the smoke alarm from R32's room, due to a malfunction. Maintenance Director U stated he placed a battery-operated smoke detector in the room, which was not directly connected to the fire alarm system. On 07/09/25 at 08:33 AM, observation revealed R32 sat outside in the designated smoking area, smoking a cigarette. He was seated in an electric wheelchair, watching birds eat toast off the ground. No staff or other residents were present. On 07/09/25 at 10:18 AM, Nurse Consultant GG and Administrative Nurse D reported R32 continued to not follow the facility rules related to smoking and discussed the behaviors he exhibited with smoking. They reported the facility provided a smoking apron for the resident, but he refused to wear it. Administrative Nurse D stated that the staff were to set a timer to check on the resident after 30 minutes. Administrative Nurse D and Nurse Consultant GG also reported R32 smoked outside of the designated smoking area and verified R32's smoking materials were kept in his room. The facility's Smoking policy, dated 11/28/17, documented that if a resident chooses to smoke, the facility would offer the resident the opportunity to do so in a safe environment within the guidelines outlined. If the resident is determined to be safe to smoke independently, he/she will be allowed to do so in a designated smoking area. If a resident's smoking assessment indicates he/she is unable to smoke independently, the facility will implement a supervised smoking program. The care plan will reflect the resident's needs regarding smoking. Smoking is not allowed in areas where oxygen is being stored or in any area that is designated as a no-smoking area. Smoking in non-smoking areas, resident rooms, or in bed is prohibited. If the Smoking Assessment indicates the resident is no longer able to smoke independently, the supervised smoking procedure will be followed. - R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body)following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the left non-dominant side, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), nicotine dependence, cigarettes, lymphedema (tissue swelling caused by accumulation of protein rich fluid), polyarthritis, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic respiratory failure with hypoxia (inadequate supply of oxygen).R32's Quarter Minimum Data Set (MDS), dated [DATE], documented that the resident had intact cognition, had verbal symptoms directed toward others, and rejected care occurred one to three days of the look-back period. R32 used a wheelchair for mobility, required setup or clean up assistance with eating, substantial/maximal assistance with oral hygiene, upper body dressing, and dependent with toileting hygiene. The MDS further documented R32 required partial/moderate assistance with transfers, frequently incontinent of urine, no pain or falls. R2 received insulin (a hormone that lowers the level of glucose in the blood), a diuretic (a medication to promote the formation and excretion of urine), an antiplatelet (a medication used to prevent blood components from clumping together), a hypoglycemic (a medication used to lower blood sugar), and an anticonvulsant (medication used to prevent seizures). R32's Care Plan dated 03/31/25, documented R32 was a fall risk. The Care Plan documented R32 could transfer with the assistance of one staff member, a gait belt, and his walker, and chose to be mobile in the wheelchair. The Care Plan documented R32 had a restorative program, but would refuse to participate.The Fall Investigation dated 12/08/25, documented that R32 had been found on the floor of his room, next to the air conditioning unit, with the wheelchair tipped on its side. R32 stated he was trying to readjust in the wheelchair and stood slightly, and felt himself going down, and reached for the wheelchair, but it got away from him. He stated he went down slowly and easily and denied hitting his head. The staff utilized a mechanical lift to assist R32 off the floor and into his wheelchair. R32 vital signs were within normal range, and no injuries were discovered.The Fall Investigation dated 01/20/25, documented R32 heard hollering for help. R32 was found lying in a sitting position on the floor of his room. R32 denied pain or injury. R32's vital signs were within normal range and staff utilized a mechanical lift to raise him from the floor. R32 reported that he attempted to give a treat to a dog and slipped out of the wheelchair. R32 was educated on call light use.On 07/08/25 at 10:14 AM, observation revealed Certified Nurse Aide (CNA) N assisting R32 from the electric wheelchair to the recliner. R32 was able to pivot transfer to the recliner. CNA N did not use a gait belt while assisting the resident to the recliner. CNA N reported not having difficulties with assisting the resident with transfers, but if he was not feeling well, the staff could use a mechanical lift.On 07/07/25 at 03:09 PM, R32 reported he had fallen while being assisted by staff for a transfer from his wheelchair to his recliner. R32 stated that the staff assisting him also went down with him. R32 stated a family member had placed a camera in his room just before he fell. R32 further stated the family member was not happy because she was not informed of the fall and was told the incident was not a fall, because the fall because staff assisted/guided R32 to the ground. On 07/08/25 at 11:55 PM, a family member via a phone conversation reported that the facility failed to notify her that R32 had fallen. The family member stated she had recently placed a camera in the resident's room. The family member was able to report the time of the fall on 04/30/25 at 09:44 PM. The family member stated R32 was being assisted by one staff member with transferring from the wheelchair to his recliner when one of the brakes had not been locked and rolled away, and the staff lowered the resident to the floor. The family member stated that when she had talked to the facility staff, the staff stated it was not considered a fall because the resident was guided to the floor.On 07/09/25 at 10:18 AM, Administrative Nurse D reported that staff had told her R23 had not been on the floor, but on the foot pedal of the wheelchair, so two staff members assisted R32 up into the recliner. Administrative Nurse stated she was not aware of the resident sitting on the floor, and did not consider it to be a fall, or she would have investigated the situation. Nurse Consultant GG verified that the occurrence was defined as a fall.The facility's Falls policy, dated 04/27/18, documented a fall is defined as unintentionally coming to rest on the ground, floor, or other lower level but is not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Individualized care plan interventions will be developed for residents identified through assessment as being a fall risk. Those interventions will be reviewed and updated regularly, and if/when a fall occurs.

The facility had a census of 45 residents. The sample included 12 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to implement alternative communication methods for one resident, Resident (R) 5, who spoke Spanish. This placed the resident at risk for unmet needs, frustration, and agitation.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbances, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the boy cannot respond to the insulin).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. The MDS documented R5 required substantial staff assistance for toileting, upper body dressing, personal hygiene, mobility, transfer, and did not ambulate. The MDS further documented that R5's preferred language was Spanish.R5's Care Plan, dated 06/12/25, lacked an individualized care area for communication.On 07/07/25 at 02:01 PM, R5 spoke in Spanish as an unidentified Certified Nurse Aide (CNA) tried to assist her further back into her wheelchair. R5 continued to speak Spanish when the CNA stated, I don't speak Spanish. At that time, three other staff members approached R5 and surrounded her to get her further back into her wheelchair. R5's Spanish because faster and louder when a staff member went up to her and was able to speak to her in Spanish, and R5 was less agitated and even laughed at something the staff said to her.On 07/08/25 at 10:00 AM, a Certified Medication Aide (CMA) R administered medications to R5. R5 spoke in Spanish, and CMA R made a drinking motion with her hand. R5 said something again in Spanish. CMA R continued to make the drinking motion, and R5 drank her water.On 07/08/25 at 01:08 PM, R5 hollered out in Spanish, cried, and Licensed Nurse (LN) G told her she needed to speak in English. R5 stated 'I don't want to speak English. R5 continued to cry, and LN G asked R5 if she could take R5 to R5's room to be close to her daughter. LN G pushed R5 to her room.On 07/08/25 at 09:40 AM, Certified Nurse Aide (CNA) M stated that R5 liked to be close to her daughter as they were in the same room. CNA M further stated she could understand English some of the time, but when she was frustrated and mad, she spoke in Spanish. CNA M stated she does not always know what she wants or what she is saying. CNA M stated there were a couple of Spanish-speaking staff members, but they were not always in the building to assist with R5.On 07/08/25 at 10:45 AM, Certified Medication Aide (CMA) R stated R5 would often become anxious and agitated and would speak mostly in Spanish. CMA R further stated that Seroquel was given because R5 would get frustrated when staff did not know what she was saying or what she wanted. CMA R stated there was at least one Spanish-speaking staff member, but she was not always working.On 07/08/25 at 10:45 AM, LN G stated R5 could speak some English and could understand what the staff were saying. LN G stated R5 would get agitated, refuse medications, and care. LN G stated R5 received medication for her agitation.On 07/08/25 at 12:36 PM, Administrative Nurse D stated that there should be an application on the staff's IPAD (a portable device with a touchscreen, designed for various tasks) that would assist them to understand R5, but stated the application had not been downloaded yet. Upon request, a policy for communication was not provided by the facility.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan with individualized, resident-centered interventions for dementia (a progressive mental disorder characterized by failing memory and confusion) care, behaviors, and communication for one resident, Resident (R) 5. This placed the resident at risk for unmet care needs.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made or the boy cannot respond to the insulin).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. The MDS documented R5 required substantial staff assistance for toileting, upper body dressing, personal hygiene, mobility, transfer, and did not ambulate. The MDS further documented R5's preferred language was Spanish, did not reject care, and had other behaviors one to three days. R5 received antipsychotic (a class of medication used to treat major mental conditions that cause a break from reality), antianxiety (a class of medication that calms and relaxes people), antidepressant (a class of medications used to treat mood disorders), and diuretic (a medication to promote the formation and excretion of urine) medication daily.R5's Care Plan, dated 06/12/25, lacked an individualized care area for dementia care, behaviors, and communication.The Physician's Order, dated 03/03/25, directed staff to administer trazodone (an antidepressant medication), 150 milligrams (mg), by mouth, at bedtime, for depression.The Physician's Order, dated 03/19/25, directed staff to administer venlafaxine hci (an antidepressant medication), 75 mg, by mouth, twice a day, for depression.The Physician's Order, dated 05/02/25, directed staff to administer sertraline hci (an antidepressant medication), 5 milliliters (ml), by mouth, daily, for major depressive disorder.The Physician's Order, dated 06/06/25, directed staff to administer Ativan (an antianxiety medication), 0.5 mg, by mouth, twice daily for agitation and anxiety.The Physician's Order, dated 06/27/25, directed staff to administer Seroquel (an antipsychotic medication), 25 mg, two tablets, by mouth, twice daily, for major depressive disorder. This was discontinued on 06/30/25The Physician's Order, dated 07/01/25, directed staff to administer Seroquel, 25 mg, two tablets, by mouth, three times daily for major depressive disorder.The Physician's Order, dated 06/30/25, directed staff to administer Compound Medication (lorazepam, one mg; diphenhydramine (an antihistamine medication) 25 mg, and Haldol (an antipsychotic medication), 1 mg, apply to inner wrist topically, every two hours, as needed for anxiety, restlessness, and agitation. This was discontinued on 07/03/25.The Physician's Order, dated 07/03/25, directed staff to administer Compound Medication (lorazepam, one mg, diphenhydramine (an antihistamine medication) 25 mg, and Haldol (an antipsychotic medication), 1 mg, apply to inner wrist topically, every two hours, as needed for anxiety, restlessness, and agitation. This is to be discontinued on 07/14/25.The EMR lacked documentation of R5's family receiving a risk versus benefit or any other treatment alternatives.The Nurse's Note, dated 03/19/25, documented R5 sat on the side of her bed, speaking and pointing to the room across the hall, asking if there was a problem in that room. R5 began to speak faster Spanish, then leaned forward and went down onto the mat on her knees. R5 stated she was looking for something. The note documented that staff called R5's family and was advised to administer Ativan to R5.The Nurse's Note, dated 04/20/25, documented R5 had multiple behaviors today, attempted to stand up from her wheelchair, and then walk. The note further documented R5 also bothered her daughter in her room.The Nurse's Note, dated 06/22/25, documented R5 was very agitated, restless, yelled, and cried that she wanted to go home. Staff asked R5 if she wanted to go to her room to be near her daughter, and R5 stated yes. The note documented staff were able to medicate R5 for her agitation.The Hospice Note, dated 06/30/25, documented that, during a routine visit, facility staff attempted to keep R5 in her wheelchair as R5 was agitated and attempted to stand up. R5 spoke very rapidly in Spanish and allowed a Spanish-speaking employee to wheel her into her room. The note further documented R5 hit, screamed, and bit at staff during the day, and an order to increase R5's Seroquel was obtained.On 07/07/25 at 02:01 PM, R5 spoke in Spanish as an unidentified Certified Nurse Aide (CNA) tried to assist her further back into her wheelchair. R5 continued to speak Spanish when the CNA stated, I don't speak Spanish. At that time, three other staff members approached R5 and surrounded her to get her further back into her wheelchair. R5's Spanish became faster and louder when a staff member went up to her and was able to speak to her in Spanish. R5 was less agitated and even laughed at something the staff member said to her.On 07/08/25 at 10:00 AM, a Certified Medication Aide (CMA) R administered medications to R5 and handed R5 her glass of water. R5 spoke in Spanish. CMA R made a drinking motion with her hand, and R5 again said something in Spanish. CMA R continued to make the drinking motion, and R5 drank her waterOn 07/08/25 at 01:08 PM, R5 hollered out in Spanish and cried. Licensed Nurse (LN) G told her she needed to speak in English. R5 stated 'I don't want to speak English. R5 continues to cry, and LN G asked R5 if she could take R5 to R5's room to be close to her daughter. LN G pushed R5 to her room.On 07/08/25 at 10:45 AM, CMA R stated she would look in the EMR to know how to care for R5.On 07/08/25 at 10:45 AM, LN G stated she did not document in the care plan but knew that she could look at it any time to know how to care for R5.On 07/08/25 at 12:36 PM, Administrative Nurse D stated everyone works on the care plans and that there should be a care plan for dementia, behaviors, and for communication so the staff know how to assist R5.The facility's Care Plan policy, dated 03/21/24, documented that a care plan would be developed for each resident that included measurable objectives to meet a resident's medical, mental, and psychosocial needs and were consistent with the resident's desires and preferences.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification and State Ombudsman Agency notification of Resident (R) 32's discharge from the facility. This placed R32 at risk for being uninformed.Findings included:- R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the left non-dominant side, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), obesity (excessive body fat), nicotine dependence, cigarettes, lymphedema (tissue swelling caused by accumulation of protein rich fluid), polyarthritis, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic respiratory failure with hypoxia (inadequate supply of oxygen).R32's Quarter Minimum Data Set (MDS), dated [DATE], documented that the resident had intact cognition, had verbal symptoms directed toward others, and rejected care occurred one to three days of the look-back period. R32 used a wheelchair for mobility, required setup or clean-up assistance with eating, substantial/maximal assistance with oral hygiene, upper body dressing, and dependent with toileting hygiene. The MDS further documented R32 required partial/moderate assistance with transfers, frequently incontinent of urine, no pain or falls. R32 received insulin (a hormone that lowers the level of glucose in the blood), a diuretic (a medication to promote the formation and excretion of urine), an antiplatelet (a medication used to prevent blood components from clumping together), a hypoglycemic (a medication used to lower blood sugar), and an anticonvulsant (medication used to prevent seizures).R32's MDSs recorded:On 12/11/24, a Discharge Return Anticipated.On 12/16/24, an Entry into the facility.On 12/30/24, a Discharge Return Anticipated.On 01/03/25, an Entry into the facility.On 01/08/25, a Discharge Return Anticipated.On 02/03/25, an Entry into the facility.The EMR documented a Bed Hold Notification was provided to R32 or the resident representative on 12/30/25 and 01/08/25. The EMR lacked a Bed Hold Notification for the discharge on [DATE].On 07/08/25 at 12:06 PM, Social Services Staff X stated she was responsible for providing the residents who were discharged to the hospital with the facility's bed hold policy and notifying the State Ombudsman's Agency department also of discharges. Social Services X stated she had failed to provide this information as related to R32's hospitalizations and must have slipped through the cracks. The facility's Bed-Hold Policy Notice dated 11/28/17 documented that a written notice will be issued to the resident or resident representative upon transfer to a hospital or therapeutic leave. The notice will specify the duration of the bed-hold policy.

The facility had a census of 45 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure one resident, Resident (R) 5 was free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication without an appropriate indication for use. The facility failed to ensure the physician provided the risk versus benefit for the continued use of antipsychotic medications. This placed R5 at risk of unnecessary medication administration and related complications.Findings included:- The Electronic Medical Record (EMR) for R5 documented diagnoses of dementia without behavioral disturbances (a progressive mental disorder characterized by failing memory and confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition. The MDS documented R5 required substantial staff assistance for toileting, upper body dressing, personal hygiene, mobility, transfer, and did not ambulate. The MDS further documented R5's preferred language was Spanish, did not reject care, and had other behaviors for one to three days. R5 received antipsychotic, antianxiety (a class of medication that calms and relaxes people), antidepressant (a class of medications used to treat mood disorders), and diuretic (a medication to promote the formation and excretion of urine) medication daily.R5's Care Plan, dated 06/12/25, lacked a care area for antipsychotic medications to direct staff of the indications for the use of the medications, as well as what signs and symptoms to look for.The Physician's Order, dated 06/27/25, directed staff to administer Seroquel (an antipsychotic medication), 25 mg, two tablets, by mouth, twice daily, for major depressive disorder. This was discontinued on 06/03/25.The Physician's Order, dated 07/01/25, directed staff to administer Seroquel, 25 mg, two tablets, by mouth, three times daily for major depressive disorder.The Physician's Order, dated 07/03/25, directed staff to administer Compound Medication (lorazepam, one mg, diphenhydramine (an antihistamine medication) 25 mg, and Haldol (an antipsychotic medication), 1 mg, apply to inner wrist topically, every two hours, as needed for anxiety, restlessness, and agitation. This is to be discontinued on 07/14/25.The EMR lacked documentation of R5's family receiving a risk versus benefit or any other treatment alternatives.The Nurse's Note, dated 03/19/25, documented R5 sat on the side of her bed, speaking and pointing to the room across the hall, asking if there was a problem in that room. R5 began to speak faster Spanish, then leaned forward and went down onto the mat on her knees. R5 stated she was looking for something. The note documented staff called R5's family and was advised to administer Ativan to R5.The Nurse's Note, dated 04/20/25, documented R5 had multiple behaviors today, attempted to stand up from her wheelchair, and then walk. The note further documented R5 also bothered her daughter in her room.The Nurse's Note, dated 06/22/25, documented R5 was very agitated, restless, yelled, and cried that she wanted to go home. Staff asked R5 if she wanted to go to her room to be near her daughter, and she stated yes. The note documented staff were able to medicate R5 for her agitation.The Hospice Note, dated 06/30/25, documented during a routine visit, facility staff attempted to keep R5 in her wheelchair as R5 was agitated and attempted to stand up. R5 spoke very rapidly in Spanish and allowed a Spanish-speaking employee to wheel her into her room. The note further documented R5 hit, screamed, and bit at staff during the day, and an order to increase R5's Seroquel was obtained.On 07/08/25 at 01:08 PM, R5 hollered out in Spanish, cried, and Licensed Nurse (LN) G told her she needed to speak in English. R5 stated 'I don't want to speak English. R5 continued to cry, and LN G asked R5 if she could take R5 to R5's room to be close to her daughter. LN G pushed R5 to her room.On 07/08/25 at 09:40 AM, Certified Nurse Aide (CNA) M stated that R5 liked to be close to her daughter as they are in the same room. CNA M further stated she can understand English some of the time, but when she was frustrated and mad, she spoke in Spanish. CNA M stated she does not always know what she wants or what she is saying. CNA M stated there were a couple of Spanish-speaking staff members, but they were not always in the building to assist with R5.On 07/08/25 at 10:45 AM, Certified Medication Aide (CMA) R stated R5 would often become anxious and agitated and would speak mostly in Spanish. CMA R further stated that Seroquel was given because R5 would get frustrated when staff did not know what she was saying or what she wanted. CMA R stated there was at least one Spanish-speaking staff member, but she was not always working.On 07/08/25 at 10:45 AM, LN G stated R5 could speak some English and could understand what the staff were saying. LN G stated R5 would get agitated, refuse medications, and care. LN G stated R5 received medication for her agitation.On 07/08/25 at 03:00 PM, Consultant Nurse GG stated hospice obtained the order for the Seroquel and that she would assist with the education to staff for documentation of R5's behaviors. Consultant GG further stated that they would have most likely caught that there was no risk versus benefit or physician indication for the use of Seroquel when the Consultant Pharmacist reviewed R5's EMR. On 07/09/25 at 07:45 AM, Consultant GG stated she was unable to find any risk versus benefit or anything from the physician for the indications related to the Seroquel use.The facility's Psychoactive Medications policy, dated 12/4/24, documented psychoactive medications, including antipsychotics, antianxiety, and antidepressants. The medications require gradual dose reduction documentation and informed consent. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits of the medication, the risks of the medication, including any black box warning for any antipsychotic medications, and alternatives for the medication. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. A written consent form will serve as evidence of the resident's consent to psychotropic medication.

The facility had a census of 45 residents. The sample included 12 residents, with 4 reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two residents, Resident (R) 6 and R8. This placed the residents at risk for complications related to poor hygiene.Findings included:- The Electronic Medical Record (EMR) for R6 recorded diagnoses of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), heart failure, dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition. R6 was independent for eating, oral hygiene, dressing, personal hygiene, mobility, and transfers. R6 required substantial staff assistance with bathing. R6's Care Plan, dated 06/26/25, initiated on 06/12/19, directed staff to assist her to wash her back and hair during showers and allow her to wash the rest of herself with a washcloth. The update, dated 11/28/22, documented R6 preferred to take two showers or whirlpools per week. The June and July 2025 Bathing Record documented R6 requested showers on Monday and Thursday, and documented R6 had not received a shower during the following days:06/25/25 - 0707/25 (13 days) The EMR lacked documentation R6 refused her showers. On 07/07/25 at 09:29 AM, R6's hair was greasy, and she stated she did not get a shower very often. R6 stated she was supposed to get one twice per week. On 07/08/25 at 10:00 AM, Certified Medication Aide (CMA) R stated R6 did not refuse her baths, and staff filled out bathing sheets and turned them into the nurse. On 07/08/25 at 10:45 AM, Licensed Nurse G stated that if a resident refused her bath, they would reapproach later and try again. If the resident still refused, they would be put on the schedule for the following day, but R6 did not refuse her baths. On 07/09/25 at 10:39 AM, Administrative Nurse G stated she would be doing more bathing audits to make sure residents received their baths. The facility's Bath and Shower policy, dated 11/28/17, documented that the facility ensured the residents' baths and showers were performed and documented as scheduled according to resident preferences to maintain each resident's hygiene and dignity. The Director of Nursing or designated personnel would review the Bathing Report to ensure each resident received a bath/shower and hair care as required. - R8's EMR documented R8 had diagnoses of intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life) and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). R8's Quarterly MDS, dated [DATE], documented R8 had a Brief Interview of Mental Status (BIMS) score of eight, which indicated severe cognitive impairment. The MDS documented R8 was dependent on the staff for showering. R8's Care Plan, revised 04/23/25, documented R8 would like a bath twice a week, not in the early morning. R8's Bathing Schedule documented R8 received a shower on Wednesday and Saturday evenings. R8's Showering Report documented he had a shower on the following days:May last shower 05/31/2506/18/25, 06/25/25, 06/29/25 (refused 06/04/25, 06/07/25, 06/11/25, 06/14/25, and 06/28/25).07/03/25 and as of 07/08/25 (5 days without a shower) refused. On 07/07/25 at 02:36 PM, R8 sat in a wheelchair in the small dining room off the main dining room at a ball-hitting activity with greasy hair. On 07/09/25 at 10:14 AM, Consultant GG stated residents should receive their baths as requested. The facility's Bath and Shower Policy, revised 11/28/17, documented to ensure the resident's baths and showers are performed and documented as scheduled according to resident preference to maintain each resident's hygiene and dignity.

The facility had a census of 45 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of blood sugars (a system which measures blood glucose in the body) outside of ordered parameters for one resident, Resident (R) 20. This placed the residents at risk for adverse effects related to medication.Findings included:- The Electronic Medical Record (EMR) for R20 documented diagnoses of Diabetes Mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had moderately impaired cognition. R20 required substantial assistance from staff for upper body dressing, personal hygiene, and transfers. R20 received seven days of insulin (a hormone that lowers the level of glucose in the blood), antidepressant (a class of medications used to treat mood disorders), and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications during the lookback period. R20's Care Plan, dated 05/08/25, initiated on 11/17/23, directed staff to administer insulin as prescribed by the physician and to notify him if her blood sugar was greater than 70 or less than 300. The care plan further directed staff to monitor her blood glucose (blood glucose monitoring test) as ordered by the physician and as needed.The Physician's Order, dated 11/18/23, directed staff to monitor blood glucose before meals and at bedtime and notify the physician if R20's blood glucose was greater than 300 milligrams (mg) per deciliter (dL) or if below 70 mg/dl.R20's Medication Administration Record, dated May 2025, documented the following days R20's blood sugar was out of parameters, and the physician was not notified.05/22/25 - 325 mg/dl05/29/25 - 302 mg/dlR20's Medication Administration Record, dated June 2025, documented the following days R20's blood sugar was out of parameters, and the physician was not notified.06/04/25 - 313 mg/dl06/06/25 - 303 mg/dl06/08/25 - 321 mg/dl06/25/25 - 69 mg/dlOn 07/08/25 at 08:13 AM, R20 sat in her recliner watching television.On 07/08/25 at 10:45 AM, Licensed Nurse (LN) G stated that if R20's blood sugar was out of parameters, she would retake her blood sugar. LN G further stated that it would be written in a progress note if the physician was notified by phone or by fax.On 07/08/25 at 03:00 PM, Administrative Nurse D stated she was unable to find that the physician was notified of the out-of-parameter blood sugars and would reeducate staff on the procedure. On 07/09/25 at 10:30 AM, Consultant GG verified that the care plan for blood sugar monitoring parameters was backwards and would correct the care plan.The facility's Notification of Changes policy, dated 04/27/18, documented that the facility would inform the resident, the resident's physician, and the resident's representative of any changes in the resident's status. The facility would immediately consult the physician if a need to alter treatment significantly.

The facility had a census of 45 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift. This placed the residents at risk of being uninformed of nursing staff hours.Findings included:- On 07/07/25 at 08:10 AM, upon entrance into the facility, the Daily Nurse Staffing Report was observed posted on the desk pillars on the North side of the nurse's station, dated 07/06/25 and indicated a census of 45 residents. On 07/08/25 at 07:30 AM, observation revealed the facility lacked a Daily Nurse Staffing Report.On 07/09/25 at 08:10 AM, Nurse Consultant GG verified it was the night shift's responsibility to make sure the Daily Nurse Staffing Report was posted for the current day. Nurse Consultant GG verified on 07/07/25 that the facility had posted a schedule dated 07/06/25, and on 07/08/25, the facility lacked a nursing staffing schedule posting for part of the day. The facility's Daily Nursing Staff Posting policy, dated 11/28/17, documented the facility would post the full-time equivalent number of personnel responsible for providing direct care daily for each shift. At the beginning of each shift, the number of licensed nurses (RNs and LPNs) and the number of unlicensed nursing personnel (CMAs, CNAs, nurse's aide trainees) who provide direct care to the residents would be posted using the Daily Nurse Staffing form. The shift posting information shall include the number of full-time equivalents on duty for that day for that shift. Daily nursing shall be recorded on each facility's Daily Nurse Staff Fork, which will be retained for 18 months.

The facility identified a census of 40 residents. The sample included three residents. Based on observation, interview, and record review, the facility failed to ensure residents remained free from significant medication errors when staff administered ten times the ordered dose of morphine sulfate (opioid pain medication) on three separate occasions. Resident (R)1 admitted to the facility for a Hospice respite stay on [DATE]. On [DATE] the facility received an order for morphine sulfate oral solution 10 milligrams (mg)/5 milliliters (ml), give 2.5 ml (5 mg) by mouth two times a day for pain management. The facility received a bottle of morphine concentrate 100 mg/5 ml from the pharmacy. Facility nursing staff administered and R1 received three 2.5 ml doses of the morphine, equaling 50 mg of morphine per dose (45 mg more than ordered) on three occasions: [DATE] in the 06:,d+[DATE]:00 AM medication pass and at 08:00 PM in the Midnight medication pass, and again on [DATE] in the 06:,d+[DATE]:00 AM medication pass. On [DATE] at 10:57 PM a nurses note documented the staff held R1's morphine administration at R1's representatives request due to the resident had increased lethargy, confusion, hallucinations, and was resistive to care due to the increased confusion. The facility failed to ensure R1 remained free from significant medication errors, which resulted in three doses of morphine administered to R1 at receiving more than the physician ordered dose of morphine on three occasions. As a result, R1 had hallucinations, and increased confusion and agitation; R1 expired in the facility on [DATE]. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of ischemic cardiomyopathy (reduced blood flow heart disease), heart failure (a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (fast, irregular heartbeat). The Admission Summary, dated [DATE] at 01:40 PM, documented R1 admitted to the facility for short term hospice respite care. R1 arrived at the facility via personal transportation. R1 was alert and oriented to person, place, and time. The General Note, dated [DATE] at 05:00 PM, documented the facility nurse was notified R1 had episodes of vomiting and a headache that tramadol (pain medication) was not helping with. The note recorded staff requested an order for as needed Tylenol (pain medication) as R1's representative stated it helps R1 and received an order for Tylenol 500 mg one to two tablets every four hours as needed. The General Note, dated [DATE] at 05:00 PM, documented the hospice nurse was in to see R1. The facility nurse notified the hospice nurse R1 only had an order for tramadol every six hours for pain but R1's representative gave the facility a bottle of morphine ER (extended release) 30 mg pills and a bottle of liquid morphine as well. The General Note, dated [DATE] at 09:41 PM, documented the staff received a physician order to administer morphine 5 mg by mouth twice a day. The facility nurse called the hospice nurse for clarification of the order. The morphine order was not put into the computer due to not having clarification from the hospice nurse on the morphine order. A New Order Note, dated [DATE] at 09:38 PM, documented morphine sulfate oral solution 10mg/5ml; give 2.5 ml by mouth two times a day for pain management. The September Electronic Medication Administration Record (EMAR), documented staff administered 2.5 ml of morphine sulfate oral solution 10mg/5ml on [DATE] on the 06:00 AM - 10:00 AM medication pass, to R1. The September EMAR, documented staff administered 2.5 ml of morphine sulfate oral solution 10mg/5ml on [DATE] on the 08:00 PM - Midnight medication pass, to R1. The September EMAR, documented staff administered 2.5 ml of morphine sulfate oral solution 10 mg/5 ml on [DATE] on the 06:00 AM - 10:00 AM medication pass, to R1. The General Note, dated [DATE] at 10:57 PM, documented staff held R1's oral morphine that night per R1's representative's request, due to R1 being increasingly lethargic and confused. R1's representative stopped and voiced his concerns to nursing staff that evening. R1 was presenting with increased confusion, verbalizations related to hallucinations, and resistance to cares. R1 was not making any sense when talking. The General Note, dated [DATE] at 11:05 PM, documented the facility nurse called and notified on-call Hospice Nurse GG and was waiting for a call back. The General Note, dated [DATE] at 11:10 PM, documented Hospice Nurse GG called the facility nurse back and received report regarding R1's condition. The General Note, dated [DATE] at 11:29 PM, documented the facility nurse contacted R1's representative and reported the situation to him and notified him Hospice Nurse GG was coming to see R1. R1's representative stated he did not want R1 to have any more morphine. R1's representative stated R1 did well with the tramadol when at home. The facility nurse advised R1's representative she would update the hospice nurse with the information and contact him if needed. The General Note, dated [DATE] at 00:14 AM, documented the facility nurse clarified the morphine sulfate dosing with the Hospice Nurse GG and hospice doctor. The staff administered R1's evening dose at that time. The staff applied oxygen to R1 at 4 liters (L) per minute and received a new order for oxygen at 1 to 5 L as needed to keep R1's oxygen saturation level above 90%, or for comfort. The staff notified R1's representative of the morphine clarification and that the hospice doctor suggested a dose be given at that time. R1's representative agreed. The September EMAR, documented the changed morphine order on [DATE] at 00:13 AM to morphine sulfate concentrate solution 100 mg/5 ml. Give 0.25 ml sublingually two times a day for pain management. The General Note, dated [DATE] at 05:08 PM, documented the shift nurse and a second nurse assessed R1 and noted R1 had no vital signs and no cardiac function. The Facility Incident Report, dated [DATE], documented on [DATE] at 04:30 PM, Hospice Nurse GG reported to Administrative Nurse D a liquid morphine medication error that occurred on [DATE] and [DATE]. Per Hospice Nurse GG, the dosage on the morphine in the facility received from the pharmacy was 100 mg / 5 ml. The order received by hospice written as morphine 10 mg / 5 ml, given 5 mg twice daily. On [DATE], Licensed Nurse (LN) G and LN H both clarified with the hospice nurse that the correct amount of morphine sulfate was 2.5 ml, which would correspond with the 10 mg / 5 ml written order. The hospice nurse confirmed the amount to give was correct. On [DATE] the facility educated all nurses to check both the written order and the medication box/card when they came from pharmacy. On [DATE] at 10:10 AM, observation revealed a bottle of morphine concentrate 100 mg / 5 ml with R1's name on. It listed a date of [DATE]. Administrative Nurse D stated the Hospice nurse took the other bottle of morphine for R1. On [DATE] at 10:30 AM, Hospice Nurse GG, stated she did not feel like the medication error caused R1 to die, but the medication error had an effect on R1's change in condition. Hospice Nurse GG stated the facility nurses gave R1 50 mg of morphine per dose instead of 5 mg per dose. On [DATE] at 11:00 AM, LN G stated she clarified the dose with the hospice nurse the dose was 2.5 ml. LN G stated she did not remember the dosage on the bottle, whether it was 10 mg / 5 ml or 100 mg / 5 ml. LN G stated the family brought it and the residents own medications, since she was a respite patient and there were sharpie marks all over the bottle and the box. On [DATE] at 11:30 AM, Administrative Nurse D stated she felt like the medication error was not just on the facility nurses but also on the hospice nurses and the pharmacy. Administrative Nurse D stated her nurses should have looked at the dosage on the bottle and realized it was an incorrect dose and not the 5 mg that was ordered. The facility Medication Administration Policy, dated January of 2021, documented the facility maintains equipment and supplies for the preparation and administration of medications to residents. Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the residents age and condition or a medication seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the physician for clarification prior to the administration of the medication. This interaction with the physician and the resulting clarification are documented in the medical record as appropriate. Nurses will read medication label and compare with the medication administration record before administering. The facility failed to ensure R1 remained free from significant medication errors when staff administered three separate doses of morphine sulfate, each were 45 mg more than the physician ordered, to R1. This placed R1 in Immediate Jeopardy. The following corrections were completed by [DATE]: All nurses were educated on medication administration and specifically, to check both the written order and the medication box/card when they come from pharmacy. The facility performed an audit on all residents with orders for liquid morphine to verify the orders were checked and verified against the dosage on the bottle. All corrections were completed prior to the onsite survey, therefore the deficient practice was deemed past noncompliance and remained at a scope and severity of J.

The facility had a census of 49 residents. The sample included 13 residents with two reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development of one facility acquired Stage 3 pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) for one of two sampled residents, Resident (R) 14. Findings included: - R14's Physician order [REDACTED]. The Annual Minimum Data Set (MDS), 05/22/20, recorded R14 had mild cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12. R14 required extensive assistance of two staff for bed mobility and transfers, upper and lower extremity impairment on one side, no pressure ulcers, and was at risk for developing pressure ulcers. The resident had a pressure relieving device for her chair and bed, and was on a turning/repositioning program. The Quarterly MDS, dated [DATE], recorded the same information as the 05/22/20 assessment. The Pressure Ulcer Care Area Assessment (CAA), dated 05/22/20, recorded R14 had occasional incontinence and required staff assistance for toileting. The CAA recorded the resident required assistance of one person for changing positions in bed, used a pressure reducing mattress and wheelchair cushion, and had limited movement of the left arm and leg secondary to a [MEDICAL CONDITION]. The revised Skin Care Plan, dated 09/28/20, initiated 06/24/20, directed staff to apply Prevalon boots (cradles your foot and ankle, elevating the heel and relieving pressure) to both feet, intervention resolved on 06/27/20 and no new interventions to relieve heel pressure. The care plan recorded R14 was unable to reposition independently and directed staff to reposition the resident at least every two hours to prevent skin breakdown. The care plan recorded R14 had a pressure relieving mattress and cushion for her wheelchair, and fragile skin that tore very easy. The care plan directed staff to report any redness or skin breakdown to the charge nurse and the licensed nurse performed weekly skin assessments. The care plan directed staff to serve the resident fortified food. The Braden Scale Assessment, (assessment for predicting pressure ulcer risk) dated 05/22/20, documented a score of 17, indicating at risk for pressure ulcer development. The Braden Scale Assessment, dated 08/14/20, documented a score of 11, indicating high risk for pressure ulcer development. R14's Electronic Medical Record (EMR) lacked a Braden Scale Assessment after staff identified the left heel pressure ulcer on 09/20/20. The Wound Assessment Note, dated 09/20/20, documented a Stage II pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) to the resident's left heel measuring 1.0 centimeter (cm) by 1.5 cm by 0.2 cm, with slough. The note documented no drainage, odor, redness, swelling or warmth, and wound edges well defined. The note documented the physician ordered a new treatment to paint the wound with [MEDICATION NAME] (antiseptic used to treat wounds), cover with [MEDICATION NAME] (foam dressing) and tape, and to change daily and as needed (PRN). The note further directed staff to apply Prevalon boots to the resident's feet, to be worn at all times. The Physician's Progress Note, dated 09/21/20 documented the physician noted the following concerns: quarter sized pressure ulcer to left heel first noticed two days ago. Wound treated with [MEDICATION NAME], positive for pain, and heel protectors applied. The Wound Assessment Note, dated 09/28/20, documented the resident's Stage 2 left heel pressure ulcer worsening with approximately 80% of wound bed covered with slough, and scant amount of serosanguineous drainage (drainage that contains both blood and a clear yellow liquid) noted. The note documented the wound measured 2.0 cm by 2.5 cm by 0.2 cm, redness noted around wound, and no warmth, swelling, or odor. The note documented staff notified the resident's physician of wound changes and requested a telemed (exchange of medical information from one location to another using electronic communication) visit. The note documented the resident's physician ordered [MEDICATION NAME] (a medical grade honey applied to wounds) to the wound bed, cover with [MEDICATION NAME] foam and secure, change daily and PRN. The note documented slough to 80 % of the wound bed. The resident complained of pain with assessment and treatment, Prevalon boots worn at all times, and staff notified the resident's representative. The Physician's Progress Note, dated 09/28/20, documented wound with some yellow drainage, resident complained of occasional pain, wound hurt when touched or pressure applied, and pain radiated up the leg. The Registered Dietitian Progress Note, dated 10/02/20, documented a weight loss trend in the last six months of 5.3% in one month and down 10% in six months. The note documented the changes were considered significant, progress notes reviewed, intakes do appear variable, and may average around 50%. The progress notes documented the resident received a regular diet and occasionally reported she was not hungry. The progress note documented the physician started the resident on [MEDICATION NAME] (medication to increase appetite) on 09/28/20, the resident often refused supplements, and was noted to have a skin concern to her left heel. The dietitian recommended adding 30 milliliters (ml) liquid protein daily and also suggested offering a protein snack daily since the resident often refused supplements and intakes were variable. The note directed staff to encourage good intakes at meals, monitor weights, and Dietary Staff (DS) DD was available as needed. The Fax to Physician, dated 10/02/20, documented DS DD's dietary recommendations. The physician responded with no new orders. Review of the resident's EMR lacked follow up by nursing staff to the resident's physician regarding dietary recommendations. The Physician's Progress Note, dated 10/05/20, documented follow up left heel wound, apply [MEDICATION NAME], wound worsened with a lot of slough, and pain to area with movement. The Physician's Progress Note, dated 10/09/20, documented the physician saw resident via telemed, and ordered for Santyl (medication used to promote healing of skin ulcers and wounds) to the left heel daily and PRN. The Physician's Progress Note, dated 10/12/20, documented follow up acute wound, increased odor and pain, wound macerated and increased slough. Order for silver alginate (antimicrobial dressing with silver) with moistened [MEDICATION NAME] (dressing that absorbs drainage and contains a low level of silver that aids in killing bacteria), change daily and start liquid protein. (liquid protein was not ordered by facility). The Wound Assessment Note, dated 10/16/20, documented a Stage 2 pressure ulcer on the resident's left heel with approximately 50% slough noted to wound bed in various areas and small amount of serous (thin, watery and clear) drainage. The note documented the wound measured 1.6 cm by 3.0 cm by 0.2 cm, no redness, swelling, or warmth noted, wound edges well defined, and drainage noted to dressing. The note documented the resident continued to wear Prevalon boots at all times and new orders received with a telemed visit. The Physician's Progress Note, dated 10/19/20, documented the left heel wound worsened, but improved again, new dressing helping more, and continue current care. The Wound Assessment Note, dated 10/21/20, documented observation of dressing change with no drainage noted to previous dressing. The note documented peri wound red with rolled edges, wound measured 2.0 cm by 3.0 cm by 0.2 cm, yellow slough covered 95% of wound bed with one pinpoint area that was red and beefy in color, and no odor. The note documented left heel wound cleansed with normal saline and moistened [MEDICATION NAME] applied to wound bed, covered with silver alginate, 4 x 4 gauze and [MEDICATION NAME] foam, secured with [MEDICATION NAME] (medical tape that is not corrosive to skin) tape. The note documented the resident denied pain with dressing change and stated, I can feel it, but it's not pain. The National Pressure Injury Advisory Panel Definition, dated 04/09/16, defined a Stage 2 Pressure Injury: (partial-thickness skin loss with exposed dermis) as the wound bed viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. A Stage 3 Pressure Injury: defined as full-thickness skin loss with adipose (fat) visible in the ulcer with granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. On 10/20/20 at 12:10 PM, observation revealed the resident sat in her wheelchair with pressure relieving cushion in place, her left arm on a pillow, and blue pressure relieving boot to her left foot. The resident picked at her food and took a few small bites. On 10/20/20 at 01:14 PM, observation revealed the resident sat in wheelchair leaning to the right, left arm elevated on a pillow, and blue pressure relieving boot to her left foot. On 10/20/20 at 01:44 PM, observation revealed the resident remained in her wheelchair leaning to the right, pressure relieving boot on left foot, and feet elevated on foot pedals of wheelchair. On 10/20/20 at 03:00 PM, observation revealed Administrative Nurse D and Certified Nurse Aide (CNA) M entered the resident's rooms to assist resident to the bathroom with the sit to stand lift. On 10/21/20 09:11 AM, observation revealed the resident lying in bed, for dressing change. LN H removed the old dressing, no drainage noted on dressing, and peri wound red with rolled edges. Wound measured 2.0 cm by 3.0 cm by 0.2 cm, yellow slough covered 95% of the wound with one pinpoint area that was red and beefy in color, no odor noted. LN H cleansed the left heel wound with normal saline, applied moistened [MEDICATION NAME] to wound bed, covered wound with silver alginate, 4 x 4 gauze and [MEDICATION NAME] foam secured with [MEDICATION NAME] tape. Resident denied pain with the dressing change stating, I can feel it but it's not pain. On 10/20/20 at 01:00 PM Administrative Nurse D verified that any protein or supplement would be on the Medication Administration Record [REDACTED]. On 10/21/20 at 10:26 AM CNA M stated the resident did not like wearing the blue boots so we did not put them on her. The resident should be repositioned every two hours, but sometimes it goes every 2-3 hour because she doesn't want to be awakened at night. On 10/21/20 at 02:00 PM, CNA O stated before the resident acquired a pressure ulcer on her left heel she wore shoes on her feet and staff elevated her heels when she was in bed. CNA O stated sometimes the resident would leave the Prevalon boots on, but when not wearing the boots the resident would use her right foot to move her left foot off of the pillow it was elevated on. On 10/21/20 at 11:00 AM, Dietary Staff (DS) BB stated the resident received fortified cereal. DS BB stated the resident does not like a lot of things, she was on our house shakes at one point, but she started refusing them because she said they taste just like milk and if she was going to drink those then she might as well drink milk which she doesn't like. On 10/21/20 at 01:45 PM, LN I stated that she did not see any interventions in the care plan for pressure relief of the heels prior to the intervention put in place on 10/19/20. She was unsure as to why the interventions for pressure reliving boots were initiated 06/24/20 and then resolved on 06/27/20, the resident did have a left heel pressure ulcer on 11/29/16 measuring 1.3 cm x 2.4 cm that resolved on 01/31/17, but there was no documentation of any further pressure ulcers. On 10/22/20 at 02:17 PM, Administrative Nurse D stated staff missed the physician order [REDACTED]. On 10/28/20 at 02:27 PM, LN H stated Physician GG staged the wound as a Stage 2 when she saw it the first time. LN H stated that she recorded the staging of the wound, the wound had not been re-staged after the dressing change on 10/21/20 when there had been 95% slough to the wound bed. Physician GG observed the wound again on 10/26/20 and the wound was much improved at that time with < 50% slough to the wound bed. The facility's revised Wound Assessment, Treatment, and Prevention policy, dated 11/28/17, documented a resident who enters the facility without pressure ulcers will not develop them unless the individual's clinical condition demonstrates that they were unavoidable. Residents will be evaluated and monitored to prevent the development of pressure ulcers and to promote rapid healing of any pressure ulcers that are present. Pressure ulcer risk prevention will be accomplished by: Completion of the Braden Pressure Ulcer Risk Assessment Identifying and evaluating the risk factors and changes in resident condition Identifying and evaluating factors that can be removed or modified Implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors Monitoring the impact of the interventions for effectiveness and modifying them as appropriate. The facility failed to implement interventions to prevent the development of a facility acquired Stage 3 pressure ulcer, prevent pressure ulcer from worsening, and implement dietary recommendations, placing the resident at risk for infection and worsening pressure ulcers.

The facility had a census of 67 residents. The sample included 3 residents reviewed for medication errors. Based on observation, interview, and record review the facility failed to hold [MEDICATION NAME] (medication used to treat or prevent blood clots in veins or arteries) as directed by the physician, for 1 of 3 sampled residents, Resident #1, which resulted in the resident having rectal bleeding, being sent to the (ER) emergency room , admitted to the hospital, and administered Vitamin K (vitamin that plays a key role in helping the blood clot, preventing excessive bleeding) and fresh frozen plasma cells (a blood product made from the liquid portion of whole blood. It is used to treat conditions in which there are low blood clotting factors or low levels of other blood proteins). This failure placed the resident in immediate jeopardy. Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 12/19/18, recorded the (BIMS) Brief Interview for Mental Status score was not completed, and had no behaviors. The MDS recorded the resident required total assistance of 2 staff for bathing, extensive assistance of 2 staff for bed mobility, transfers, walking in room, dressing, toilet use, personal hygiene, extensive assistance of 1 staff for locomotion on and off the unit and eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had functional limitation in (ROM) Range of Motion on one side in both upper and lower extremities, and used a walker and wheelchair for mobility. The MDS recorded the resident was occasionally incontinent of bowel and bladder and received anticoagulant (blood thinner) medication 7 days. The 6/26/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident often required extensive assistance with his/her ADLs, and ambulated with a walker, although his/her abilities varied. The CAA recorded the resident moved slower than others as would be expected with a [DIAGNOSES REDACTED]. The CAA recorded the resident preferred routines and managed better when there were no changes to how and when things were done. The CAA recorded the resident continued with a restorative program to maintain his/her strength and mobility, with no significant changes in ADL abilities noted at that time. The 1/13/19 care plan recorded the resident received medication which thinned his/her blood placing him/her at risk for bleeding. The care plan directed staff to administer the resident's anticoagulant medication as directed by the physician, check the resident's PT/INR ([MEDICATION NAME] Time - test to determine how long it takes for blood to clot/international normalized ratio is a calculation based on results of a PT that is used to monitor treatment with the blood-thinning medication [MEDICATION NAME] ([MEDICATION NAME]) as ordered and contact the physician with results before administering the resident his/her next dose. The care plan directed staff to observe the resident for signs or symptoms of bleeding, such as red, black, or tarry stools, pink or red colored urine, excessive bruising or bruises that progressively increase in size, petechiae (pinpoint, round spots that appear on the skin as a result of bleeding), bleeding gums, nosebleeds, blood in the sputum (mucus), or emesis that appears to have blood or a coffee grounds appearance and notify the resident's physician if observed. The 1/4/19 physician order [REDACTED]. The 2/7/19 lab results documented a PT of 63.9 seconds (normal range 12.1-14), and an INR of 8 (normal range 0.8-1.1). The physician clinic record of phone communication recorded the following: 2/7/19 at 4:59 PM - hospital called the clinic to report a critical INR lab result of 8.02 2/7/19 5:03 PM - clinic notified the nursing facility to hold the resident's [MEDICATION NAME] and recheck his/her INR on Monday, 2/11/19. The 2/7/19 at 9:05 PM, nurse's note recorded staff received an order to hold the resident's [MEDICATION NAME] and recheck his/her PT/INR on Monday 2/11/19. Current INR was 8.2. The (MONTH) 2019 (MAR) Medication Administration Record [REDACTED]. The resident's medical record lacked documentation staff obtained a PT/INR on 2/11/19 as physician ordered. The 2/13/19 at 2:40 PM clinic telephone record conversation between the clinic and the facility staff, at about 1:50 PM today, when Nurse G called the physician's office and asked when the resident's next INR was to be drawn, as the resident now had blood coming from his/her rectum. The physician's nurse informed Nurse G the facility staff were to check the INR on Monday 2/11/19 as the resident had a critical INR on 2/7/19. Nurse G stated staff had not held the resident's [MEDICATION NAME] as ordered on [DATE], and the resident continued to receive [MEDICATION NAME] 5 mg daily. Nurse G stated he/she would do a finger check INR and call the physician's office with the results. The documentation recorded as of 2:30 PM, the facility had not reported the INR results to the clinic. The physician's nurse called the facility and gave verbal orders to facility staff to send the resident to ER STAT (immediately) secondary to blood in his/her stools and a previous INR of 8.0 on 2/7/19. The physician's nurse notified the ER of the resident's condition and the current situation. The 2/13/19 at 2:58 PM, nurse's note recorded the physician's office called the facility and requested staff transport the resident to the ER via (EMS) Emergency Medical Service to have his/her PT/INR evaluated. The 2/13/19 at 6:55 PM, nurse's note recorded the facility called the ER, who informed the staff the resident had been admitted to the hospital with [REDACTED]. The resident's hospital medical record recorded the following lab results: 2/13/19 - Hemoglobin (measure of blood that carried oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells to the lungs) 12.6 (g/dl) grams/deciliter (normal 13.5-17.5) 2/13/19 - [MEDICATION NAME] 59.8 seconds 2/13/19 - INR 7.3 The 2/13/19 hospital (H&P) history and physical documented the resident had an INR of greater than 8. A hold on the resident's [MEDICATION NAME] was apparently not done and a report of some blood in the resident's stools, therefore, he/she transferred to the hospital ER. The H&P recorded the resident's Hemoglobin was 12.7, a [MEDICATION NAME] consult (a physician of internal medicine who specializes in diagnosing, treating and preventing diseases of the digestive system) in the ER provided and the resident received Vitamin K as well as fresh frozen plasma. The hospital staff had a lengthy discussion with the resident's family, they decided with his/her [DIAGNOSES REDACTED]. INR (amounts of a drug that are greater than the therapeutic concentration or maximum dose in a medical treatment) and possible bleed, the resident was admitted to the hospital for additional therapy, if needed, and appropriate monitoring. The 2/14/19 resident's hospital lab results recorded the following: Hemoglobin 12.7 (13.5-17.5) PT 17.7 (12.1-14) INR 1.5 (0.8-1.1) The 2/14/19 physician order [REDACTED]. This order was discontinued on 2/15/19. The 2/14/19 at 10:27 PM, nurse's note recorded the resident returned to the facility in a wheelchair per facility van. The note recorded the physician's office was notified and orders were clarified, including order to obtain a [MEDICATION NAME] in the morning. On 2/20/19 at 11:08 AM, observation revealed the resident sat in his/her recliner. Nurse Aide N applied a gait belt to the resident and placed his/her walker in front of him/her. Nurse Aides M and N assisted the resident to stand and ambulate to the bathroom. Observation revealed the resident held onto the grab bar on the bathroom wall beside the toilet as Nurse Aide N removed the residents incontinent brief, the resident was incontinent of bowel and no blood observed. The aides finished providing hygiene care and assisted the resident to sit in his/her wheelchair. On 2/20/19 at 9:25 AM, Nurse G stated Nurse H took the order to hold the resident's [MEDICATION NAME], did not place the order in the computer or pass it along in report. Nurse G stated, normally the facility discontinued a medication when it was put on hold, the order to hold the [MEDICATION NAME] did not show up on the (MAR) Medication Administration Record. Nurse G stated he/she gave the [MEDICATION NAME] on 2/8/19, and on 2/13/19 the resident had blood in his/her incontinent brief, and again later that afternoon. Nurse G stated, on 2/13/19 the resident was passing blood, so Nurse G called the physician's office and was told the resident's [MEDICATION NAME] was supposed to be held, and the physician gave orders to send the resident to the ER. Nurse G stated the resident received Vitamin K and plasma in the hospital, and he/she had not had any problems since his/her return to the facility. Nurse G stated the physician now wanted the resident's lab drawn early in the day, so the lab results could be processed by the same person who drew it. On 2/20/19 at 2:42 PM, Administrative Nurse D stated he/she expected staff to follow the physician's orders [REDACTED]. Administrative Nurse D stated staff notified the physician because the resident started bleeding. Administrative Nurse D stated he/she understood Nurse H received the order to hold the resident's [MEDICATION NAME] on 2/7/19, did not enter the information into the computer, so staff continued to administer the medication, and on 2/13/19, the resident started bleeding. Administrative Nurse D stated on 2/13/19, Nurse G called the physician and received orders to send the resident to the ER. On 2/25/19 at 11:39 AM, Physician GG stated he/she expected staff to discontinue the [MEDICATION NAME] and complete follow up lab as he/she ordered. Physician GG stated he/she would have to hope that if the facility had held the resident's [MEDICATION NAME] the bleed would not have occurred. If the facility had not noticed the bleeding, the resident could have potentially had a stroke or an exacerbation of his/her other medical issues. Ultimately this was a life-threatening situation, the resident's not in the greatest health in general. On 2/20/19 at 3:08 PM, Consultant HH stated the facility had no policy regarding following physicians orders, staff are expected to follow nursing standards of practice. The facility failed to hold [MEDICATION NAME] as directed by the physician for Resident #1, which resulted in the rectal bleeding, being sent to the ER, and hospital admission. This failure placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 2/20/19 at 6:45 PM when the facility reviewed INR results, [MEDICATION NAME] orders, and orders for PT/INR for all residents taking [MEDICATION NAME] had been completed with no other discrepancies identified. A PT/INR log was created on 2/20/19 for all residents currently taking [MEDICATION NAME]. All licensed nurses were re-educated on anticoagulant protocols including: desired therapeutic range for INR for residents on [MEDICATION NAME], auto-stop orders for [MEDICATION NAME] on the date of the next scheduled PT/INR, use of PT/INR log for each resident taking [MEDICATION NAME] to allow tracking of [MEDICATION NAME] dosage orders, INR results, physician notification, the next ordered PT/INR date, and PT/INR log must be checked daily by the charge nurse at shift change. Follow-up monitoring will be completed by the DON or designee by review of the PT/INR logs at least 3 times per week for one month. Results will be provided to (QA) Quality Assurance for review. The deficient practice remains at a scope and severity of a G.

The facility had a census of 67 residents. The sample included 3 residents. Based on observation, interview, and record review the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely, and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 of 3 sampled residents. (#1) Findings included: - Resident #1's quarterly (MDS) Minimum Data Set assessment, dated 12/19/18, recorded the (BIMS) Brief Interview for Mental Status score was not completed, and had no behaviors. The MDS recorded the resident required total assistance of 2 staff for bathing, extensive assistance of 2 staff for bed mobility, transfers, walking in room, dressing, toilet use, personal hygiene, extensive assistance of 1 staff for locomotion on and off the unit and eating. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had functional limitation in (ROM) Range of Motion on one side in both upper and lower extremities, and used a walker and wheelchair for mobility. The MDS recorded the resident was occasionally incontinent of bowel and bladder and received anticoagulant (blood thinner) medication 7 days. The 6/26/18 (ADL) Activities of Daily Living (CAA) Care Area Assessment recorded the resident often required extensive assistance with his/her ADLs, and ambulated with a walker, although his/her abilities varied. The CAA recorded the resident moved slower than others as would be expected with a [DIAGNOSES REDACTED]. The CAA recorded the resident preferred routines and managed better when there were no changes to how and when things were done. The CAA recorded the resident continued with a restorative program to maintain his/her strength and mobility, with no significant changes in ADL abilities noted at that time. The 1/13/19 care plan recorded the resident received medication which thinned his/her blood placing him/her at risk for bleeding. The care plan directed staff to administer the resident's anticoagulant medication as directed by the physician, check the resident's PT/INR ([MEDICATION NAME] Time - test to determine how long it takes for blood to clot/international normalized ratio is a calculation based on results of a PT that is used to monitor treatment with the blood-thinning medication [MEDICATION NAME] ([MEDICATION NAME]) as ordered and contact the physician with results before administering the resident his/her next dose. The care plan directed staff to observe the resident for signs or symptoms of bleeding, such as red, black, or tarry stools, pink or red colored urine, excessive bruising or bruises that progressively increase in size, petechiae (pinpoint, round spots that appear on the skin as a result of bleeding), bleeding gums, nosebleeds, blood in the sputum (mucus), or emesis that appears to have blood or a coffee grounds appearance and notify the resident's physician if observed. The 1/4/19 physician order [REDACTED]. The 2/7/19 lab results documented a PT of 63.9 seconds (normal range 12.1-14), and an INR of 8 (normal range 0.8-1.1). The physician clinic record of phone communication recorded the following: 2/7/19 at 4:59 PM - hospital called the clinic to report a critical INR lab result of 8.02 2/7/19 5:03 PM - clinic notified the nursing facility to hold the resident's [MEDICATION NAME] and recheck his/her INR on Monday, 2/11/19. The 2/7/19 at 9:05 PM, nurse's note recorded staff received an order to hold the resident's [MEDICATION NAME] and recheck his/her PT/INR on Monday 2/11/19. Current INR was 8.2. The (MONTH) 2019 (MAR) Medication Administration Record [REDACTED]. The resident's medical record lacked documentation staff obtained a PT/INR on 2/11/19 as physician ordered. The 2/13/19 at 2:40 PM clinic telephone record conversation between the clinic and the facility staff, at about 1:50 PM today, when Nurse G called the physician's office and asked when the resident's next INR was to be drawn, as the resident now had blood coming from his/her rectum. The physician's nurse informed Nurse G the facility staff were to check the INR on Monday 2/11/19 as the resident had a critical INR on 2/7/19. Nurse G stated staff had not held the resident's [MEDICATION NAME] as ordered on [DATE], and the resident continued to receive [MEDICATION NAME] 5 mg daily. Nurse G stated he/she would do a finger check INR and call the physician's office with the results. The documentation recorded as of 2:30 PM, the facility had not reported the INR results to the clinic. The physician's nurse called the facility and gave verbal orders to facility staff to send the resident to ER STAT (immediately) secondary to blood in his/her stools and a previous INR of 8.0 on 2/7/19. The physician's nurse notified the ER of the resident's condition and the current situation. The 2/13/19 at 2:58 PM, nurse's note recorded the physician's office called the facility and requested staff transport the resident to the ER via (EMS) Emergency Medical Service to have his/her PT/INR evaluated. The 2/13/19 at 6:55 PM, nurse's note recorded the facility called the ER, who informed the staff the resident had been admitted to the hospital with [REDACTED]. The 2/14/19 at 10:27 PM, nurse's note recorded the resident returned to the facility in a wheelchair per facility van. The note recorded the physician's office was notified and orders were clarified, including order to obtain a [MEDICATION NAME] in the morning. On 2/20/19 at 11:08 AM, observation revealed the resident sat in his/her recliner. Nurse Aide N applied a gait belt to the resident and placed his/her walker in front of him/her. Nurse Aides M and N assisted the resident to stand and ambulate to the bathroom. Observation revealed the resident held onto the grab bar on the bathroom wall beside the toilet as Nurse Aide N removed the residents incontinent brief, the resident was incontinent of bowel and no blood observed. The aides finished providing hygiene care and assisted the resident to sit in his/her wheelchair. On 2/20/19 at 9:25 AM, Nurse G stated Nurse H took the order to hold the resident's [MEDICATION NAME], did not place the order in the computer or pass it along in report. Nurse G stated, normally the facility discontinued a medication when it was put on hold, the order to hold the [MEDICATION NAME] did not show up on the (MAR) Medication Administration Record. Nurse G stated he/she gave the [MEDICATION NAME] on 2/8/19, and on 2/13/19 the resident had blood in his/her incontinent brief, and again later that afternoon. Nurse G stated, on 2/13/19 the resident was passing blood, so Nurse G called the physician's office and was told the resident's [MEDICATION NAME] was supposed to be held, and the physician gave orders to send the resident to the ER. Nurse G stated the resident received Vitamin K and plasma in the hospital, and he/she had not had any problems since his/her return to the facility. Nurse G stated the physician now wanted the resident's lab drawn early in the day, so the lab results could be processed by the same person who drew it. On 2/20/19 at 2:42 PM, Administrative Nurse D stated he/she expected staff to follow the physician's orders [REDACTED]. Administrative Nurse D stated staff notified the physician because the resident started bleeding. Administrative Nurse D stated he/she understood Nurse H received the order to hold the resident's [MEDICATION NAME] on 2/7/19, did not enter the information into the computer, so staff continued to administer the medication, and on 2/13/19, the resident started bleeding. Administrative Nurse D stated on 2/13/19, Nurse G called the physician and received orders to send the resident to the ER. On 2/25/19 at 11:39 AM, Physician GG stated he/she expected staff to discontinue the [MEDICATION NAME] and complete follow up lab as he/she ordered. Physician GG stated he/she would have to hope that if the facility had held the resident's [MEDICATION NAME] the bleed would not have occurred. If the facility had not noticed the bleeding, the resident could have potentially had a stroke or an exacerbation of his/her other medical issues. Ultimately this was a life-threatening situation, the resident's not in the greatest health in general. On 2/20/19 at 3:08 PM, Consultant HH stated the facility had no policy regarding following physicians orders, staff are expected to follow nursing standards of practice. The facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the Resident #1's needs safely, and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being when nursing staff failed to follow physician's orders [REDACTED]. This deficient practice placed the resident at risk for further bleeding and stroke.

The facility had a census of 59 residents. The sample included 3 residents of which 3 residents were reviewed for abuse. Based on observation, interview, and record review the facility failed to ensure staff assessed, protected, provided follow up care, and initiated an investigation for 1 of 3 sampled residents, #1, who reported an allegation of rape, placing the resident and other same gender residents in immediate jeopardy. Findings included: - Resident #1's 3/7/18 (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/18/18, documented the resident had a (BIMS) Brief Interview for Mental Status score of 7, which indicated moderately impaired cognition. He/she had verbal behaviors, did not wander, required supervision of 1 staff for (ADLs) Activities of Daily Living, and used a walker. The 8/22/17 ADL (CAA) Care Area Assessment documented the resident was alert and oriented, made his/her needs known to staff, and communicated when he/she needed assistance. The CAA documented the resident performed his/her ADLs independently, and used a cane for ambulation. The 4/5/18 care plan documented the resident had dementia, short-term memory loss, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and believed untrue events. The care plan documented the staff worked to coordinate a psychiatric evaluation, and assisted the resident with touch assistance when walking, with use of a wheeled walker. The care plan directed staff to provide assistance with bathing, dressing, and perineal (the region of the body between the thighs from the genitals to the anus) care. The 5/30/18 care plan update documented a mental health evaluation was set up and the resident preferred to sleep on the couch in the commons area. The 5/19/18 at 12:04 AM, progress note documented staff approached the resident and asked if he/she was ready for bed. The resident replied Oh no, I don't sleep in here. I don't like it. The note documented the resident walked to the television room, sat on the couch, and fell asleep. The 5/22/18 at 11:44 AM, progress note documented staff placed a call to the physician and informed him/her the resident continued to have behaviors and became angry at times. The staff requested an order for [REDACTED].>The 5/27/18 at 12:05 PM, progress note documented the resident refused to go to bed. Staff accompanied the resident to his/her room, the resident stated No I can't sleep in there. A man raped me on that couch (referred to bed), and began to cry. The note lacked any follow-up documentation. The 5/29/18 at 10:31 AM, progress note documented the resident as alert and oriented to himself/herself only. Vital signs: blood pressure 139/82, pulse 71, respirations 18, oxygen saturation 98%, temperature 98.0 degrees Fahrenheit, with no redness or discoloration noted to the resident's skin. The note documented the resident's answers were at times inappropriate to the questions asked. The 6/4/18 at 2:10 PM, witness statement by Nurse I documented the resident sat on the couch by the nurse's station. At 11:30 PM the resident stated he/she needed to use the bathroom. Nurse I accompanied the resident to his/her room. The witness statement documented as the resident approached the room door with Nurse I, the resident stated, I can't go in there, that person raped me on the end table at the end of the bed and he/she began to cry. The statement further documented the resident chose to stay with the nurse at the nurse's station and used a public restroom. The statement documented the nurse recorded the incident in the progress notes of the resident's medical record. Nurse I documented he/she did not ask the resident further questions concerning the allegation, or report the incident to administration. The 6/4/18 at 3:15 PM, witness statement by Nurse E documented on 5/29/18 at 10:00 AM, he/she reviewed the clinical nurse's notes for Resident #1, and discovered the progress note entry for 5/27/18, which documented the nurse accompanied the resident to his/her room and the resident made an allegation of rape. The witness statement further documented Nurse E informed Administrative Nurse D of the allegation of rape. Nurse E documented Administrative Nurse D notified the corporate regional nurse and waited for a reply. Nurse E documented after Administrative Nurse D received a reply, he/she reported the incident to the state agency hotline. Nurse E documented the physician, the resident's responsible party, and the police were notified. The staff member, who did not report the abuse, was educated and placed on leave from work. On 5/23/18 at 11:34 AM, observation revealed staff attempted to coax the resident to stand up from the couch next to the nurse's station, and walk to the dining room. Observation revealed the resident remained seated, although staff attempted to assist the resident to the noon meal. On 5/29/18 at 3:25 PM, Administrative Nurse D verified no changes were made to this resident's care, or other residents, between 5/27/18 to 5/29/18. Administrative Nurse D stated he/she expected staff to inform him/her and administrative staff for any allegation of abuse, at the time of the incident. Administrative Nurse D stated he/she was informed of the incident the morning of 5/29/18, but did not specify a time frame. Administrative Nurse D emailed the allegation of abuse information to the state agency hotline. The investigative notes documented Administrative Nurse D notified the local law enforcement on 5/31/18 at 10:00 AM and a case number was assigned. On 5/31/18 at 9:55 AM, Nurse I stated he/she attended the abuse/neglect training in-service training on 5/23/18, provided 1 week prior to the incident. On 6/4/18 at 12:30 PM, the Administrative Nurse D verified the staff did not follow the facility's Abuse/Neglect policy and procedure, to report immediately to the administrative staff. Administrative Nurse D stated he/she educated Nurse I on the Abuse/Neglect policy and procedure and placed Nurse I on leave from work until completion of the investigation. On 6/4/18 at 2:40 PM, Administrative Staff A stated he/she expected the staff to follow the facility's Abuse/Neglect policy and procedure for reporting immediately to administration. Administrative Staff A verified the nurse on shift needed to report immediately and did not follow the facility's Abuse/Neglect policy and procedure. Administrative Staff A stated he/she initiated one on one staff training on 6/1/18, reviewed incident reporting, and what to do for lost items. On 6/4/18 at 2:52 PM, Nurse Aide P stated he/she worked the night shift on 5/26/18 PM to 5/27/18 AM, and staff did not inform him/her of the resident's allegation of rape. Nurse Aide P stated he/she attended the facility's abuse/neglect in-service training on 5/23/18. The facility's 11/28/17, Abuse/Neglect policy and procedure directed staff to report allegations immediately to the administrator or his/her designee to assist with conducting the investigation. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately by the person who identified it to the administration, director of nursing, and charge nurse. Reporting to the state survey agency, adult protective services, police and others should be done in accordance with state law and will be made no later 2 hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury or not later than 24 hours if the events that caused the abuse do not result in serious bodily injury. The administrator shall notify the original reporter that the occurrence has been reported to local law enforcement. The facility failed to ensure staff assessed, protected, provided follow up care, and initiated an investigation, for Resident #1's allegation of rape, which placed the resident in immediate jeopardy for emotional and physical injury. The facility abated the immediate jeopardy on 6/5/18, when the facility completed in-service training for all staff, which included a review of abuse, neglect, and exploitation, reporting requirements, and steps involved in an investigation. Follow up monitoring will be completed by weekly interview of 3 random residents addressing possible concerns. The plan of correction includes continuation of daily review of the nursing documentation. The deficient practice remains at the scope and severity of a D.

The facility had a census of 53 residents. Based on observation, interview and record review the facility failed to ensure the facility free of accident hazards with unsafe water temperatures 149 degrees (F) fahrenheit. This deficient practice placed the 23 independently mobile residents in immediate jeopardy for potential burns. Findings included: - On 8/3/15 at 8:00 AM, observation in the facility's north dining room revealed the water temperature of the hand sink at 149 F. Environmental Staff A verified the finding and immediately disabled the hot water valve on the sink. On 8/3/15 at 9:07 AM, Environmental Staff A stated he/she checked water temperatures on the resident halls daily. Environmental Staff A verified he/she had not checked the water temperature in the north dining room or the activity room on a regular basis and was unaware the temperature exceeded safety levels until the surveyor brought it to his/her attention. Environmental Staff A stated the activity room used the same water line and he/she needed to install mixing valves on those faucets. Observation revealed the door to the activity room locked. Environmental Staff A unlocked the activity room, checked the water temperature in the sink at 137 degrees F, and immediately disabled the hot water valve on the sink. Environmental Staff A verified the dining and activity room sinks should have a mixer valve in place to prevent the water from getting too hot, greater than 120 degrees F. Review of the facility's water temperature logs revealed the resident rooms ranged from 101-114, and bathing areas ranged from 102-111. Further review of the logs revealed no documentation of temperatures for the north dining room sink or the activity room. On 8/3/15 at 10:15 AM, Dietary Staff F stated 10 residents ate in the north dining room and 3 residents were able to independently leave the room. On 8/3/15 at 10:20 AM, Administrative Nurse E stated 11 to 12 residents eat in the north dining room, and 4 of them are independently mobile. Administrative Nurse E stated he/she had not observed residents use that sink and stated staff use the sink in the main dining room. Administrative Nurse E identified 23 independently mobile residents in the facility who have access to the dining room. On 8/3/15 at 10:32 AM, Nurse B stated he/she was not aware of the unsafe water temperature. On 8/3/15 at 10:42 AM, Nurse Aide C stated some of the residents who ate in the north dining room were independent with mobility. He/she reported no observations of any residents using that sink and stated he/she was not aware of the unsafe water temperature. On 8/3/15 at 10:48 AM, Nurse D verified he/she was not aware of the unsafe water temperature in the dining room sink. On 8/3/15 at 1:56 PM, observation revealed Environmental Staff A installed a mixing valve on the hot water line for the north dining room and the activity room. Environmental Staff A checked the temperatures and both sinks tested less than 110 degrees F. The federal regulation Time and Temperature Relationship to Serious Burns table indicated many residents have conditions that put them at increased risk for burns caused by hot water. The table indicated hot water at 148 F. could potentially cause 3rd degree (burns which cause the most damage and can extend through every layer of skin and can reach the bloodstream) burns in as little as 2 seconds of exposure. The facility's undated Water Temperature Testing protocol directed staff to ensure resident room water temperatures were between 105 and 115 F. The protocol further directed staff to test water temperatures in common areas and adjust water heating as necessary. The facility failed to ensure an environment free of potentially dangerous hot water temperatures in the north dining room placing the independently mobile residents who reside in the facility, in immediate jeopardy. The facility abated the immediate jeopardy on 8/3/15. At 8:00 AM, Environmental Staff A disabled the hot water valve on the north dining room sink. On 8/3/15 at 1:56 PM, Environmental Staff A installed a mixing valve on the hot water line for the north dining room and the activity room. At 4:45 PM, in-service education was completed with all staff, including nursing, dietary, housekeeping and laundry staff, regarding safe water temperatures and actions to take when water temperatures felt too warm. Ongoing monitoring to be completed by staff obtaining water temperatures in the activity and dining area sinks 3 times weekly and the administrator to audit the temperature logs 2 times per week. This deficient practice remains at the scope and severity of an E.

The facility had a census of 54 residents with 10 sampled for review and 1 reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to provide necessary services and treatment to prevent pressure sores from developing and promote healing. Resident #12's hospital acquired stage 2 pressure ulcer worsened after admission to the facility and the resident developed another stage 2 pressure ulcer while in the facility. The facility also failed to provide appropriate wound care and ensure the resident's prescribed dressings remained in place. (#12) Findings included: - Resident #12's 4/2/15 signed physician orders [REDACTED]. Resident #12's 9/26/14 admission MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 15 which indicated intact cognition. The resident required extensive assistance of 1 person for bed mobility and transfers. According to the assessment the resident lacked the ability to walk. The resident had functional limitations in range of motion on one side of both upper and lower extremities. He/she used a wheelchair for mobility and had an indwelling urinary catheter. The assessment identified the resident as at risk for pressure ulcer development with no unhealed pressure ulcers at the time of the assessment. The resident was on a turning/repositioning program and had pressure reduction devices for his/her chair and bed. The resident's 9/29/14 ADL (activities of daily living) CAA (care area assessment) stated the resident required extensive assistance of 1-2 staff for most ADL care, except for meals which required limited assistance. He/she was unable to walk for quite awhile and the resident reported the MS was affecting his/her right side of the body with the left side of his/her body being flaccid. The incontinence CAA indicated the resident had a urinary catheter in place. The resident's Braden assessment score (rating to determine risk for pressure ulcer development) of 17 which indicated the resident was at risk. The CAA stated staff applied barrier cream and should offer/provide repositioning every 2-3 hours. The resident spent much of his/her day in the wheelchair and some days would accept laying down between meals. The resident had the ability to make frequent slight changes in position, though major position changes presented a challenge. Resident #12's 12/24/14 and 3/25/15 quarterly MDS assessments both revealed the resident required extensive assistance of 2 persons for bed mobility and transfers and used a wheelchair for mobility. The resident had an indwelling catheter. The resident remained at risk for pressure ulcer development with no unhealed pressure ulcers. The resident was on a turning/repositioning program and used pressure relief devices for his/her chair and bed. Resident #12's 9/29/14 nursing care plan indicated the resident had a pressure reduction mattress to his/her bed and a pressure reduction cushion for his/her chair. The care plan directed staff to provide barrier cream when changing his/her incontinence brief. The care plan further stated that if open areas develop, staff should let the dietician know and let the doctor know right away if any skin areas worsen. Staff should look over the resident's skin every time they provide care and let the nurse know if there are any new issues. An update to the care plan on 1/20/15 instructed staff to check dressings and surrounding skin daily if dressings are not changed daily. The nurse should completely assess open areas at least weekly and if the areas do not show improvement within 2-4 weeks, he/she should let the physician know so treatments can be changed. The care plan lacked updates after the resident returned to the facility from a local hospital with open wounds on 6/11/15. A nursing admission assessment dated [DATE] by licensed nurse J revealed the resident had open areas to the left buttock that measured 1.7 cm (centimeters) by 2 cm, an area to the upper right buttock that measured 5 cm by 1 cm, and an area to the lower right buttock that measured 3 cm by 1 cm. The assessment also indicated the resident's buttocks appeared excoriated. Resident #12's Braden score on 6/11/15 was 15, which indicated he/she was at risk for pressure ulcer development. Review of the clinical record lacked evidence of physician notification of the resident's open wounds when re-admitted to the facility on [DATE]. Review of the physician orders [REDACTED]. On 6/16/15 licensed nurse K, the wound nurse, assessed resident #12's wounds. The assessment revealed the open area to the left upper buttock measured 5 cm by 3.2 cm (increased in size since admission on 6/11/15) with granulation tissue in the wound bed and the surrounding tissue was red. The assessment also described an area that was present on admission to the left lower buttock that measured 2.2 cm by 1 cm with granulation tissue in the wound bed and the surrounding tissue was red. The initial admission assessment on 6/11/15 did not address any wounds to the left lower buttock. The assessment on 6/16/15 failed to mention the areas on the right upper and lower buttock that were mentioned on the admission assessment. According to the 6/16/15 assessment, the charge nurse was to notify the physician to request treatment orders. A physician's orders [REDACTED]. Wound assessments on 6/23/15 by licensed nurse K revealed the resident had a new area to the right upper buttock that measured 3.5 cm by .5 cm with serosanguinous exudate (thin, bloody drainage). The wound bed had granulation tissue, no odor, and the surrounding tissues was red. The assessment also stated the resident's entire buttocks seemed excoriated and red. The assessment indicated the nurse called resident #12's physician to notify him/her of the new area and to request treatment orders. Nurse K also assessed the area on the resident's left upper buttock. The resident's entire left buttock was excoriated and the previously described areas changed to 2 small open areas that measured 0.4 cm by 0.4 cm and 0.3 cm by 0.3 cm. The wound beds had granulation tissue with serosanguinous drainage and the tissue surrounding the wounds appeared red. The area to the left lower buttock measured 2 cm by 0.5 cm with serosanguinous exudate and the wound bed had granulation tissue with the excoriated tissue surrounding the wounds. The assessment indicated the area worsened compared to the previous week. The [MEDICATION NAME] dressings failed to adhere to the resident's buttocks and nurse K placed a call to the physician for new treatment orders. A physician's orders [REDACTED].#12's buttock wounds until healed. Review of resident #12's June 2015 TAR (treatment administration record) directed staff to monitor the resident's dressing to the left upper buttock every shift and to monitor for redness, warmth, and drainage starting on 6/23/15. The TAR also stated to monitor the left lower buttock dressing every shift starting on 6/23/15. Review of the nurses notes from 6/11/15 to 6/24/15 lacked evidence of daily assessments of the condition of the dressings or tissue around the dressings. During an observation on 6/23/15 at 8:15 a.m., with the assistance of direct care staff L, licensed nurse K assessed resident #12's wounds and applied dressings. Staff L and nurse K turned resident #12 to his/her left side. The resident's wounds were open to air with no dressings in place. Nurse K confirmed the resident should have dressings in place and looked in the bed and brief to see if the dressings had come off, but none were found. The resident's buttocks appeared red with open areas present. Nurse K stated the area on the right buttock was new and measured the area. He/she also stated the left buttock was now 2 small open areas instead of one larger area. Nurse K measured the 2 small areas as well as the area on the lower left buttock. Nurse K cleansed the buttocks with wound cleanser and applied the prescribed [MEDICATION NAME] and [MEDICATION NAME] dressing. During an observation on 6/23/15 at 3:17 p.m. direct care staff M and N provided catheter and peri care to resident #12. Staff M and N turned the resident to his/her left side. The dressings on the residents buttocks appeared loose and direct care staff M removed the dressings. He/she then cleansed the resident's entire buttock area with peri wash. Staff M and N then placed a clean incontinence brief and positioned the resident on his/her left side with pillows. The dressings to the wounds remained off. During an interview on 6/23/15 at 9:10 a.m., licensed nurse G stated he/she worked the previous night shift. Nurse G stated no one reported to him/her that resident #12's dressings came off or needed to be replaced. An interview on 6/23/15 at 5:22 p.m. with direct care staff M verified he/she removed the dressings from the resident because they were loose. Staff M stated he/she thought staff N notified the charge nurse that the dressings came off. During an interview on 6/23/15 at 5:50 p.m., licensed nurse O stated no one reported to him/her that resident #12's dressings were removed by direct care staff. An interview on 6/24/15 at 10:47 a.m. direct care staff P stated the resident came back from the hospital with pressure ulcers. Staff P stated they turn and reposition the resident every 2 hours and also encourage him/her to shift their weight while in the chair. Staff P stated if the dressings were loose, he/she would get the nurse and would not remove them. During an interview on 6/24/15 at 11:14 a.m., licensed nurse Q stated the resident returned to the facility after a hospitalization for pneumonia and had pressure ulcers at the time of admission. Nurse Q stated he/she worked the next day after the resident returned from the hospital and was not informed of any open areas to his/her buttocks, but had darker, superficial areas. Nurse Q was told that staff were treating the areas with Remedy Skin Repair Cream (a type of barrier, protectant cream). Nurse Q was unaware of the open wounds present on admission. An interview on 6/24/15 at 4:42 p.m. with licensed nurse K revealed if a newly admitted resident has skin breakdown at the time of admission, the nurse admitting the resident should notify the physician of the issues and obtain treatment orders at that time. Licensed nurse K stated Remedy cream was not an appropriate treatment for [REDACTED]. Nurse K stated he/she was aware resident #12 had open areas on 6/12/15 and did not assess the wounds until 6/16/15. Nurse K confirmed the open area on the left upper buttock measured larger when he/she measure the wound 5 days after admission. Nurse K also verified the open wound identified on 6/23/15 on the resident's right buttock was newly acquired in the facility. During an interview on 6/24/15 at 12:29 p.m., administrative nurse A stated the admission nurse should notify the physician of any wounds present on admission and request treatment orders for the wounds. Nurse A stated the Remedy cream would be appropriate for excoriation, but not for open wounds. Nurse A stated he/she would expect the wound nurse to assess and document the condition of any wounds by the next day after admission to the facility. Unsuccessful attempts were made to interview resident #12's physician on 6/24/15 at 12:47 p.m., 6/25/15 at 10:38 a.m., and 6/30/15 at 11:12 a.m. According to manufacturer's instructions, Remedy Skin Repair Cream should be used on intact skin. The facility's undated Wound Assessment, Prevention and Treatment policy stated if a resident has a wound, the skin nurse will assess weekly from admission or date of wound identification. The care plan will reflect all wounds and appropriate interventions. The facility failed to notify the physician and obtain appropriate treatment orders for resident #12 when he/she returned to the facility from the hospital with stage 2 pressure ulcers. During the first 5 days of admission the ulcer on the left buttock worsened and increased in size. The resident also developed another stage 2 pressure ulcer while in the facility. The facility also failed to ensure the prescribed dressings remained intact.

The facility had a census of 60 residents. The sample included 3 residents, who were reviewed for falls. Based on observation, record review and interview the facility failed to appropriately train the staff and provide an adequate safety assessment for the use of a toileting sling for Resident #1, who had a fall and sustained a concussion (damage to the brain caused by a violent jarring or shaking, such as a blow) and scalp laceration. Findings Include: - The physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. state characterized by exaggerated feelings of sadness, worthlessness and emptiness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue and an increased fracture risk), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and hypertension (elevated blood pressure). Resident #1's annual (MDS) Minimum Data Set assessment, dated 10/22/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 13 (cognitively intact). The MDS also indicated the resident required total assistance of 2 staff for bed mobility and transfers. The MDS further indicated the resident had impaired balance, that required human assistance to stabilize and functional limitation in range of motion of the upper and lower extremities on one side of his/her body. The 10/22/14 care plan directed 2 staff to assist the resident with bed mobility and repositioning. The care plan also directed 2 staff to use a mechanical lift with a full body sling to transfer the resident. The care plan revealed no documentation to direct the staff to use a toileting sling to transfer the resident. The 10/22/14 Lift Chair Safety Assessment indicated the resident required a mechanical lift for transfers due to his/her right upper extremity and bilateral lower extremity paralysis. The lift assessment directed the staff to provide an individualized assessment for the resident to promote lift safety. Continued review of the lift assessment revealed no documentation to direct the staff to assess the resident for the safe use of different types of lift slings. The 10/22/14 Fall Risk Assessment indicated the resident was a high risk for falls due to his/her muscular weakness and equipment needs for transfers. Review of the facility's Competency Checklist for Sling Lift revealed no documentation to direct the staff training and/or use of a toileting sling. The 11/15/14 at 6:19 PM, nurse's note indicated the resident fell from the toileting sling, while the staff transferred the resident with a mechanical lift. The nurse's note also indicated the resident's head was on the floor and the resident's feet were still in the sling. The nurse's note further indicated the resident had a head injury and the staff sent the resident to the hospital. The 11/15/14 Emergency Department Report indicated the resident had a closed head injury (brain injury caused by trauma) with a concussion and an occipital (pertaining to the back of the head) scalp laceration, that required 9 staples to close. The 11/17/14 facility's accident report indicated the staff transferred the resident from his/her recliner to the wheelchair and the resident fell out of the mechanical lift sling. The report also indicated the staff used a toileting sling to transfer the resident. Review of the Invacare Operator's Manual website (www.invacare.com) indicated the sling size and fit can vary " significantly " and staff should provide an individualized assessment for the resident ' s use of the toileting sling. The undated Operator's Manual for Invacare Patient Slings directed the staff to provide an individualized assessment for the resident's safety and comfort. The manual indicated the Invacare slings were made specifically for use with Invacare lifts and directed the staff not to intermix slings and lifts of different manufacturers due to safety issues for the resident. On 12/08/14 at 1:27 PM, observation revealed the facility had only a Vancare lift to transfer residents in a sling and Administrative Nurse F verified the observation. The facility intermixed the use of a Invacare sling with a Vancare lift, despite the adverse warning for resident safety in the Invacare Operator's Manual. On 12/08/14 at 1:30 PM, observation revealed Nurse Aide A and B used a mechanical lift with a full sling to transfer the resident from his/her wheelchair to the bed. Continued observation revealed the resident was unable to participate in his/her cares and the staff moved the resident's extremities and repositioned the resident's torso as needed during the transfer. On 12/08/14 at 1:48 PM, observation revealed the toileting sling designed as a U-shaped fabric with a 9 inch strip of fabric with a security belt (styled like a seat belt) positioned across a person's lower back to support the whole upper torso and neck/head and the lower portion of the sling tapered to 3.5 inches of fabric positioned behind the person's knees to support the lower body. The toileting sling had a large, central gap with no support, to allow the person's lower body to sit on a commode or toilet and allow the staff easy access to provide personal hygiene cares. Continued observation revealed the toileting sling provided little or no support for the person's arms, shoulders, neck or head and from the waist to the person's knees. On 12/08/14 at 11:40 AM, the resident stated he/she was unable to move his/her arms and legs and the staff provided total care for all his/her activities of daily living. The resident stated 2 staff transferred him/her with the " short sling " (resident's description of the toileting sling) and he/she suddenly slipped through the back of the sling and struck his/her head on the floor. On 12/08/14 at 1:20 PM, Nurse Aide A stated the staff provided the resident total assistance with all (ADLs) activities of daily living and 2 staff assistance to transfer the resident with a sling lift. Nurse Aide A stated the facility had not provided training for the use of the toileting sling. On 12/08/14 at 3:06 PM, Occupational Therapy Staff D stated he/she was not aware the therapy staff had evaluated the toileting slings for use by the facility and/or any individual residents. On 12/08/14 at 3:10 PM, Physical Therapy Staff E stated he/she was not aware the therapy staff had evaluated the toileting slings for use by the facility and/or any individual residents. On 12/08/14 at 3:18 PM, Nurse Aide C stated 2 staff provided total assistance to transfer the resident with a sling lift. Nurse Aide C stated the staff used a toileting sling to transfer the resident from a recliner to a wheelchair and the resident's head and upper torso slipped out of the toileting sling and struck the floor. Nurse Aide C stated he/she was not aware of any documentation to direct staff on how to use the toileting sling to transfer the resident. Nurse Aide C further stated he/she was not aware of a competency checklist to train the staff to use the toileting sling for the resident's transfers. On 12/08/14 at 3:52 PM, Nurse F stated the former (DON) Director of Nursing had ordered the toileting sling about a year ago and he/she was not aware if the therapy staff had evaluated the toileting slings for use by the facility and/or any individual residents. Nurse F stated the facility's lift assessment had not addressed the resident's use of a toileting sling and the facility had no competency checklist to direct the staff to use the toileting sling. Nurse F further stated the resident's care plan did not address the use of the toileting sling for toileting and/or transfers. The facility failed to appropriately train the staff and provide an adequate safety assessment for the use of a toileting sling for Resident #1, who had a fall and sustained a concussion (damage to the brain caused by a violent jarring or shaking, such as a blow) and scalp laceration.

The facility had a census of 67 residents. The sample included 7 residents. Based on observation, interview and record review the facility failed to assess, reassess and seek physician interventions for 2 of 7 sampled residents who had significant changes in condition, and both required hospitalization .(#1, #2) Findings included: - Resident #2's physician's orders [REDACTED]. (usually the left ventricle) or both (left and right) ventricles during diastole, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), bacteremia (presence of bacteria in the blood), acute kidney failure and (is an abrupt loss of kidney function), ascites (accumulation of fluid in the abdominal cavity). The quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/10/14, indicated the resident had intact cognition with a (BIMS) Brief Interview for Mental Status score of 15. The MDS indicated the resident required extensive assistance for bed mobility and transfers, total assistance from 1 staff for toilet use, personal hygiene, and was independent with assistance from 1 staff for eating. The MDS further indicated the resident had an ostomy (an opening in the body for the discharge of body wastes), frequent bowel incontinence, and had shortness of breath with exertion, when sitting at rest, and when lying flat. The MDS indicated the resident had a feeding tube, received antidepressant, anticoagulant, and diuretic medications and used oxygen. The 6/13/14 care plan instructed the staff to assess the quality of the output from the resident's ileal conduit (a small urine reservoir is created from a segment of a bowel and is located just under the abdominal wall) for consistency, clarity, and malodor, and to measure the output every shift. The care plan instructed the staff to notify the nurse if there were any changes in the resident's output. The care plan further instructed the staff to monitor the resident's output from his/her nephrostomy tubes (a small rubber tube that is placed through a hole in the skin and that extends into the kidney that allows direct drainage from the kidney) for color, appearance, output, and signs and symptoms of infection. The 7/4/14 at 5:03 AM nurse's note indicated the staff observed the dressing to the right nephrostomy tube insertion site was red, had a wrinkled dressing and the right nephrostomy was not draining as much as the left side and the drainage was red in appearance and minimal. The note further indicated the tubing possibly needed to be assessed by the physician and staff passed the information along to the day shift. The 7/4/14 physician's orders [REDACTED]. The 7/5/14 at 10:57 AM nurse's note indicated the staff observed the resident's drain lying on the resident's bed next to him/her. The note further indicated staff notified the physician and instructed staff to send the resident directly to the hospital for admission. The 7/5/14 hospital history and physical indicated the resident had recent bilateral nephrostomy tubes placed to dry up an anastomotic leak (a breakdown of the connection and subsequent leakage of digestive system fluid from a surgical anastomosis of the digestive system structures), which yesterday became dislodged and was removed. The note further indicated the resident's drain which managed his/her urinary leak was found in his/her bed. The note continued to indicate the physician instructed the facility to send the resident to the hospital for admittance to have his/her blood thinning medications reversed, and to have surgery for [REDACTED]. The 7/10/14 physician's orders [REDACTED]. The physician order [REDACTED]. The 8/7/14 physician's orders [REDACTED]. The physician's orders [REDACTED].>200 or <90 and diastolic blood pressure (represented by the bottom number in a blood pressure reading, was when the heart was resting) measuring >115 or <60. Review of the August 2014 (TAR) Treatment Administration Record, revealed the following blood pressures outside of the physician ordered parameters: 8/8/14, night shift, 86/58 8/9/14, evening shift, 85/47 8/9/14, night shift, 85/47 8/11/14, night shift, 83/45 8/12/14, day shift, 87/55 8/12/14, evening shift, 83/53 8/14/14, evening shift, 86/48 8/16/14, day shift, 81/51 8/16/14, night shift, 80/53 8/17/14, day shift, 83/58 8/17/14, evening shift, 87/36 The medical record lacked evidence that staff notified the resident's physician of the low blood pressures, on 11 occasions within 104 days. Review of the August 2014 TAR revealed the resident had no output from his/her ileal conduit on the following: 8/1/14, day and night shift 8/2/14, evening and night shift 8/3/14, evening shift 8/4/14, evening shift 8/5/14, day shift 8/7/14, evening shift 8/9/14, day shift 8/10/14, day, evening, and night shift 8/11/14, day and evening shift 8/12/14, evening and night shift 8/13/14, day, evening, and night shift 8/14/14, day, evening, and night shift (2 ? days without output) 8/15/14, evening and night shift 8/16/14, night shift 8/17/14, day and evening shift The medical record lacked evidence that the staff notified the resident's physician of the resident's decreased output, on 14 occasions within 147 days other than 8/4/14, per the resident's family request. The 8/1/14 at 1:10 AM nurse's note indicated the resident's bilateral nephrostomy tubes were draining without concern and his/her ileal conduit was draining normally without concern. (Although no output was documented by the staff) The 8/1/14 at 2:23 PM nurse's note indicated the resident's ileal conduit to his/her abdomen had straw colored fluid in the dependent drainage bag. The note further indicated his/her right and left nephrostomy tube had straw colored urine in the collection bag. The 8/2/14 at 4:10 AM nurse's note indicated the resident's nephrostomy tubes were patent with yellow urine draining and the ileal conduit draining straw colored urine. (Although no output was documented by the staff) The 8/2/14 at 4:19 PM nurse's note indicated the resident's ileal conduit to his/her abdomen had straw colored fluid into the dependent drainage bag and the ileal conduit bag was leaking and staff changed the drainage bag. The note further indicated to the right of the ileal conduit, had a pin head sized open area with pus like drainage, which expressed a moderate amount of thick odorous drainage from the site. The note further indicated the right nephrostomy tube to be kinked and the dressing was loose with leakage of urine. (Although no output was documented by the staff or notification to the physician in reference to the ileal conduit site) The 8/4/14 at 2:11 AM nurse's note indicated the staff changed the resident's [MEDICAL CONDITION] bag and had a small opening on the bottom of the bag with light brown drainage noted. The staff cleansed the area around the [MEDICAL CONDITION] site and applied gauze. The note further indicated the resident had redness to the right lower quadrant of his/her abdomen by the nephrostomy tube. The note continued to indicate the resident's family member had requested the staff call the physician for an appointment to be evaluated for right side discomfort. The clinical record lacked evidence the facility staff notified the resident's physician at this time. The 8/4/14 at 3:45 PM nurse's note indicated staff updated the physician, as requested by the resident's family member, and included notification of the drainage, color and odor of the right nephrostomy tube. The note continued to indicate the physician would come to the facility to evaluate the resident. (4 days after staff documented no drainage of the ileal conduit on day and night shift) The 8/4/14 at 6:27 PM nurse's note indicated the physician changed the resident's dressing to the left nephrostomy tube insertion site. The 8/5/14 at 9:30 AM nurse's note indicated staff noted the resident's ileal conduit drained straw colored fluid to dependent drainage. (Although no output was documented by the staff) The 8/5/14 at 7:55 PM nurse's note indicated staff changed the ileal conduit bag due to purulent (producing or containing pus) drainage coming from the old drain site. The 8/7/14 at 5:17 AM nurse's note indicated the staff noted scant yellow drainage to the resident's ileal conduit. The 8/12/14 at 2:40 AM nurse's note indicated the staff noted the ileal conduit had yellow drainage and the bilateral nephrostomy tubes noted to have dark yellow urine. (Although no drainage was documented by the staff) The 8/12/14 at 3:12 PM nurse's note indicated the resident remained in his/her room most of the day. The note further indicated the resident's skin was very pale in color and his/her abdomen was slightly distended. The note further indicated the resident refused his/her tube feedings and water boluses. The 8/14/14 at 3:48 AM nurse's note indicated the staff noted the resident's bilateral nephrostomy tubes drained amber colored urine with a scant amount of light tan drainage to the ileal conduit bag. The 8/14/14 at 3:22 PM nurse's note indicated the staff noted the resident's skin was very pale in color and his/her abdomen was slightly distended. The note further indicated the resident had a poor appetite and refused his/her tube feedings and water boluses. The 8/15/14 at 3:39 AM nurse's note indicated the staff noted the resident had amber colored urine in his/her nephrostomy tube drainage bag and had a scant amount of light brown drainage to his/her ileal conduit drainage bag. The 8/17/14 at 11:55 PM nurse's note indicated the staff administered the resident's tube feeding and noted his/her abdomen was distended and the resident was very sleepy and refused his/her evening meal. The note further indicated the staff noted the resident's skin was cool to the touch and dry with the color of ashen gray. The note indicated the resident's bilateral nephrostomy tubes drained amber urine and his/her ileal conduit drained scant dark amber urine. The note indicated the staff held the resident's blood pressure medications due to a blood pressure of 87/36, and the resident had slept most of the shift when not disturbed. The clinical record lacked evidence the staff contacted the resident's physician regarding his/her low blood pressure. The 8/18/14 at 4:08 AM nurse's note indicated the resident's blood pressure remained low at 93/27, and his/her abdomen remained distended with no bowel sounds. The note further indicated the staff performed a bladder scan (is a diagnostic tool that measures the amount of urine in the bladder or to determine how much urine remains in the bladder after urination) and measured 578 (cc) cubic centimeters of urine in his/her bladder. The note indicated the staff noted the resident's skin was cool to touch and pale in color, and the day shift would contact the resident's physician. The 8/18/14 at 5:09 AM nurse's note indicated the resident had a loose stool and staff noted the resident had pale, cool skin and his/her knees were mottled (changes occurring to the skin, especially to the hands and feet, near the end of life caused by slow blood circulation, skin may look blue and blotchy). (59 minutes later) The 8/18/14 at 10:25 AM nurse's note indicated the resident's abdomen was distended and firm and the left and right nephrostomy tube had decreased output. The note further indicated the staff notified the resident's physician and left a message on the office nurse's voice mail. (More than 6 hours after the previous nurse's shift assessment) Review of the medical record revealed no documentation the staff notified the resident's physician regarding the gradual change in status since 8/11/14. The 8/18/14 at 10:54 AM nurse's note indicated the staff received an order to send the resident to the emergency room for evaluation. The 8/18/14 emergency department report indicated the resident had a systolic blood pressure of 70 and was seen for weakness, [MEDICAL CONDITION] (low blood pressure), abdominal pain, and diarrhea. The report indicated on physical exam of the resident the physician noted the resident had dry mucous membranes (a layer of [MEDICATION NAME] tissue which lines an area of the body which comes into contact with air, ex: mouth and nose), was lethargic (causing a state of physical slowness and mental dullness), had a chronically ill appearance, and was very thin. The report indicated the resident had a white blood cell count (a blood test which indicates an increased white blood cell count is an increase in disease-fighting cells (leukocytes) circulating in your blood, which indicates infection) of 30.8 (normal 4.0-11.0), a calcium level (blood test which measures the level of calcium in the body, not stored in bones) of 7.5 (normal 8.5-10.5), a total protein level (a blood test which measures the total amount of two classes of proteins found in the fluid portion of your blood) of 5.1 (normal 6.4-8.2), and an [MEDICATION NAME] (a blood test which measures the amount of this protein in the clear liquid portion of the blood) of 1.8 (normal 3.5-5.5). The report indicated the resident's abdominal and pelvis (CT) Computed Tomography (a technology that uses computer-processed x-rays to produce tomographic images (virtual slices') of specific areas of the body) indicated severe pan-[MEDICAL CONDITION] (an [MEDICAL CONDITION] bowel disorder that affects the entire internal lining of the colon) and ascites. The report indicated the resident's condition was critical and would be admitted into the intensive care unit for further treatment and evaluation. The 8/18/14 (UA) urinalysis (a test of the urine used to diagnose infections and conditions of the urinary system) indicated the resident had a positive UA with Escherichia coli (a large and diverse group of bacteria) present. The 8/20/14 hospital physician consultation report indicated the resident was extensively swollen with diffuse [MEDICAL CONDITION] (a condition of abnormally large fluid volume in the circulatory system or in tissues between the body's cells) with fluid overload (medical condition where there is too much fluid in the blood) and was minimally responsive. The report indicated upon assessment the resident was in acute [MEDICAL CONDITION], anasarca (the accumulation of watery fluid in connective tissue and cavities, resulting in swelling), hypercapneic [MEDICAL CONDITION] (increased amounts of carbon [MEDICATION NAME] and the respiratory system fails in one or both of its gas exchange functions) with respiratory acidosis (a condition that occurs when the lungs cannot remove all of the carbon [MEDICATION NAME] the body produces), and [MEDICAL CONDITION]. The note indicated the resident was septic (a condition in which the body is fighting a severe infection that has spread via the bloodstream) from a urinary tract infection (infection of the urinary tract). The report indicated the resident's prognosis was grim and the hospital treatment course would include aggressive diuresis (removal of fluid accumulated in the body by the use of medications) and if ineffective to consider [MEDICAL TREATMENT] (is a process for removing waste and excess water from the blood, and is used primarily as an artificial replacement for lost kidney function in people with [MEDICAL CONDITION]). On 8/27/14 at 11:22 AM, Administrative Nurse A stated the facility did not educate the staff on how to care for a resident with nephrostomy tubes and an ileal conduit. Administrative Nurse A indicated the facility used the hospital discharge instructions to care for the resident. On 9/2/14 at 3:45 PM, Administrative Nurse A stated the facility staff should have notified the resident's physician with the change in condition the resident experienced prior to his/her hospital admission on 8/18/14. Administrative Nurse A verified the resident had low blood pressure readings, decreased output from his/her ileal conduit, and change in color of his/her output, along with abdominal distension, and the resident appearing pale upon nursing assessment. Administrative Nurse A verified the resident required medical management, and stated he/she had instructed a nurse on the night shift to inform the resident's physician of the resident not having any output from his/her ileal conduit. Administrative Nurse A further verified the nurse did not notify the resident's physician that shift. The facility failed to assess and reassess and seek physician involvement for Resident #2 who had a physical decline and required hospitalization . - Resident #1's physician's orders [REDACTED]. The admission (MDS) Minimum Data Set 3.0 assessment, dated 8/7/14, indicated the resident had severe cognitive impairment with moderately impaired decision making skills. The MDS further indicated the resident required extensive assistance from 2 staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and independent with eating. The MDS indicated the resident was 69 inches tall, weighed 199 pounds, had surgical wounds, and received surgical wound care. The 7/31/14 admission nursing assessment indicated the resident had 3 surgical incisions on his/her left hip. The assessment indicated the top incision measured 8 (cm) centimeters with 13 intact staples, the middle incision measured 6 cm with 7 intact staples and the bottom incision measured 6 cm with 7 intact staples. The assessment further indicated no drainage was noted with a dressing intact and the resident received as needed pain medications for discomfort. The 8/5/14 physician's orders [REDACTED]. The 8/8/14 at 8:03 PM nurse's note indicated the resident had a moderate amount of serous (various bodily fluids that are typically pale yellow and transparent) drainage from his/her hip incision and the staff administered pain medication to the resident upon his/her request. The 8/11/14 physician's orders [REDACTED]. The 8/12/14 at 4:01 AM nurse's note indicated the staff attempted to remove the staples from the resident's incisions to his/her left hip. The note indicated the resident's upper incision was draining serosanguinous (consisting of serum and blood) drainage. The note further indicated the resident had not tolerated the procedure well and the staff administered pain medications to the resident. The note indicated the staff removed 12 staples from the upper incision and the staff was unable to remove 2 staples from the bottom incision and left the staples intact. The 8/13/14 at 11:35 AM nurse's note revealed the staff left a message for the physician in regards to the staples that remained intact in the resident's incision. (No documentation the physician returned the staff's phone call or follow up by the staff) The 8/13/14 at 3:48 PM nurse's note revealed the staff removed all but 1 staple from the resident's incision. The note stated the nurse was unable to remove the staple because the staple was bent and stated the resident's incision was red with a moderate amount of red/clear drainage. The 8/17/14 at 3:12 PM nurse's note indicated the resident's skin was taut (tight) on the left hip and thigh area. The note continued to indicate the resident's left hip incision had steri strips intact with a moderate amount of serous brown drainage. Review of the medical record from 8/13/14 at 3:48 PM to 8/19/14 revealed no further documentation of an assessment or physician notification related to the bent staple that staff was unable to remove from the resident's left hip incision. (5 days) The 8/19/14 emergency department report indicated, at 5:40 PM, a family member brought the resident to the emergency department for evaluation, a physician evaluated the resident regarding yellow pus and drainage when the resident's staple was removed from his/her incision, after being transferred to a different nursing facility. The report indicated the resident had increased pain, confusion, decreased appetite and energy. The report indicated the resident's laboratory report indicated a hemoglobin was 7.7 (normal value 13.5-17.5), and a white blood cell count of 15.6 (normal value 4.0-11.0). The report indicated the resident had a wound infection. The 8/19/14 hospital history and physical indicated the resident had left hip soft tissue swelling with subcutaneous [MEDICAL CONDITION] (air is in the layer of tissue under the skin) suggesting [MEDICAL CONDITION] (a common skin infection that happens when bacteria spread through the skin to deeper tissues) with possible abscess (a collection of pus that has built up within the tissue of the body) formation. The 8/23/14 discharge summary indicated the resident had a positive Staphylococcus Aureus (a bacteria and is frequently found in the human respiratory tract and on the skin) in his/her wound and urine cultures, blood loss [MEDICAL CONDITIONS], and protein calorie malnutrition. On 9/2/14 at 9:59 AM, Nurse D stated the staff noted some redness around the staples and when he/she attempted to remove the staples, he/she was unable to remove all the staples. Nurse D stated he/she notified administrative nursing staff that he/she was unable to remove all the staples from the resident's left hip incisions. Nurse D stated he/she assumed the administrative staff removed the rest of the staples. Nurse D further verified the resident's hip was healing and the bruising had not become darker or increased in size. On 9/2/14 at 3:45 PM, Administrative Nurse A stated he/she thought the staff had removed the staple from the resident's incision and would have expected the staff to notify the physician if they were unable to remove it. The facility failed to assess and reassess and seek physician input for Resident #1 who developed an infection in a surgical wound. The resident required hospitalization . The 8/7/14 Pain (CAA) Care Area Assessment indicated the resident was alert and oriented with intermittent confusion and had frequent pain, related to his/her hip surgery, which interfered with his/her daily activities. The 8/5/14 admission care plan instructed the staff to administer routine and as needed pain medications and to monitor and document the level of pain and relief obtained. The 7/31/14 physician's orders [REDACTED]. The August 2014 (TAR) Treatment Administration Record revealed the staff assessed the resident's pain level 4 times daily, as ordered by the physician. Continued review of the TAR revealed the resident often complained of pain greater than 3. (Pain scale of 1-10, with 10 being the highest and pain is generally managed when level is reported as less than or equal to 3) The August 2014 (MAR) Medication Administration Record [REDACTED] 8/1/14 at 7:18 AM for a pain level of 7 (1 tablet) 8/1/14 at 11:45 AM for a pain level of 8, un-resulted (2 tablets) 8/1/14 at 6:04 PM for a pain level of 7 (1 tablet) 8/2/14 at 7:17 AM for a pain level of 6 (1 tablet) 8/3/14 at 5:02 PM for a pain level of 5 (1 tablet) 8/4/14 at 9:21 AM for pain level of 5 (1 tablet) 8/4/14 at 8:52 PM for a pain level of 5, un-resulted (2 tablets) 8/5/14 at 1:47 PM for a pain level of 4 (1 tablet) 8/6/14 at 3:44 AM for a pain level of 5 (2 tablets) 8/7/14 at 6:53 AM for a pain level of 9, with no relief (2 tablets) 8/7/14 at 6:21 PM for a pain level of 8 (2 tablets) 8/8/14 at 2:05 AM for a pain level of 8 (2 tablets) 8/8/14 at 9:12 AM for a pain level of 3 (2 tablets) 8/9/14 at 2:40 AM for a pain level of 8 (2 tablets) 8/9/14 at 1:50 PM for a pain level of 5 (2 tablets) 8/9/14 at 10:54 PM for a pain level of 8 (2 tablets) 8/10/14 at 7:33 AM for a pain level of 5 (1 tablet) 8/10/14 at 1:49 PM for a pain level of 7 (1 tablet) 8/10/14 at 8:03 PM for a pain level of 5 (1 tablet) 8/11/14 at 11:34 AM for a pain level of 6 (2 tablets) 8/11/14 at 9:19 PM for a pain level of 6 (2 tablets) 8/12/14 at 7:06 AM for a pain level of 7 (2 tablets) 8/12/14 at 12:02 PM for a pain level of 7 (2 tablets) 8/13/14 at 12:01 AM for a pain level of 8 (2 tablets) 8/13/14 at 4:00 AM for a pain level of 8 (2 tablets) 8/13/14 at 10:46 AM for a pain level of 7 (2 tablets) 8/14/14 at 3:31 PM for a pain level of 7 (2 tablets) 8/14/14 at 8:36 PM for a pain level of 10 (2 tablets) 8/15/14 at 12:45 AM for a pain level of 8 (2 tablets) 8/15/14 at 7:34 AM for a pain level of 8 (2 tablets) 8/15/14 at 12:40 PM for a pain level of 8 (2 tablets) 8/15/14 at 5:42 PM for a pain level of 5 (2 tablets) 8/16/14 at 12:14 AM for a pain level of 8 (2 tablets) 8/16/14 at 5:03 AM for a pain level of 8 (2 tablets) 8/16/14 at 11:42 AM for a pain level of 7 (2 tablets) 8/17/14 at 2:40 AM for a pain level of 8, un-resulted (2 tablets) 8/17/14 at 9:17 AM for a pain level of 8 (2 tablets) 8/17/14 at 2:51 PM for a pain level of 8 (2 tablets) 8/17/14 at 8:06 PM for a pain level of 8 (2 tablets) 8/18/14 at 2:30 AM for a pain level of 8, with no relief (2 tablets) 8/18/14 at 7:09 AM for a pain level of 7 (2 tablets) 8/19/14 at 9:05 AM for a pain level of 5 (2 tablets) The 8/7/14 at 12:24 PM nurse's note indicated the resident woke up this morning in extreme knee pain and the staff sent him/her to the emergency room . The note further indicated the resident had swelling present down his/her legs into his/her feet and range of motion was painful with moving his/her left leg. The 8/7/14 emergency room report indicated the resident was seen in the emergency room after a fall from the previous day. Nursing staff reported the resident had increased pain to his/her left lower extremity and increased bruising and [MEDICAL CONDITION] that morning and would not bear weight. The report indicated the resident reported a pain level of 10, and was sent back to the nursing facility to continue rehabilitation, the xray reports were negative for new fractures and the resident's hardware was intact from his/her previous hip surgery. The 8/15/14 at 1:27 AM nurse's note indicated the resident moaned, was restless and the staff administered pain medication, to the resident, for a pain level of 8. The 8/17/14 at 1:58 AM nurse's note indicated the resident received pain medication for moaning and restlessness. On 9/2/14 at 9:15 AM, Medication Aide I verified the resident frequently had pain, to the point where he/she hurt all over. Staff administered pain medication and offered repositioning, which would sometimes help to decrease the pain. On 9/2/14 at 3:45 PM, Administrative Nurse A verified the resident often complained of pain and the staff had not notified the physician for possible changes in pain medication. The facility failed to effectively manage pain for Resident #1 after hip surgery. Resident #1's 7/31/14 physician's orders [REDACTED]. The 8/5/14 admission care plan informed the staff the resident received anticoagulant (blood thinning) medications and directed the staff to monitor the resident for signs and symptoms of bleeding, to monitor labs as ordered by the physician, and to protect the resident from injury. The 8/4/14 at 6:39 PM nurse's note indicated the resident reported to the staff he/she had a black bowel movement. The note further indicated the staff educated the resident on the importance of notifying the staff so the staff could assess the bowel movement. (No further follow up or documentation noted about the resident possible black bowel movement) The 8/13/14 laboratory results revealed the resident had a hemoglobin of 8.8 (normal 13.5-17.5), a white blood cell count of 9.4 (normal 4.0-11.0), a calcium level of 7.8 (normal 8.6-10.3), and Iron level of 11 (normal 45-182). The 8/19/14 emergency department report indicated at 5:40 PM a family member brought the resident to the emergency department for evaluation. The report indicated the resident had increased pain, confusion, decreased appetite and energy. The report indicated the resident's laboratory report indicated a hemoglobin was 7.7 (normal value 13.5-17.5). The report indicated the resident had possible [MEDICAL CONDITION], and the patient would be admitted and receive a blood transfusion. The 8/19/14 consultation report indicated the resident had dark heme positive bowel movements (blood present) and would be treated for [REDACTED]. The note indicated that if bleeding became more acute or significant further testing and treatment would begin. On 9/2/14 at 3:45 PM, Administrative Nurse A verified he/she expected the staff to notify the physician and monitor for black stools after the resident had reported he/she had a black stool. The facility failed to monitor Resident #1 for bleeding while on a blood thinner medication, who developed a [MEDICAL CONDITION] and required hospitalization .

The facility had a census of 67 residents. The sample included 9 residents. Based on record review and interview the facility failed to provide assessment, reassessment, physician notification and interventions for 1 of 9 sampled residents who experienced respiratory compromise. Resident #6 had a low oxygen saturation level of 72 % (percent) and the medical record lacked a thorough assessment of the resident ' s respiratory status including breath sounds, use of accessory muscles, difficulty breathing, further oxygen saturations, skin status checks or physician intervention until the staff found the resident with mottling (patchy discoloration of skin) the next morning. (#6) Findings included: - Resident #6 ' s signed physician's order [REDACTED].) Resident #6 ' s quarterly (MDS) Minimum Data Set 3.0 assessment, date 06/12/12, revealed the resident had short and long term memory problems and moderately impaired decision making skills. The MDS further indicated the resident needed limited to extensive assistance of staff with bed mobility, transfers, walking in room, eating and toilet use, and minimal assistance of 1 with dressing and personal hygiene, and eating. The MDS indicated the resident did not receive oxygen therapy. The 06/14/12 care plan directed the staff to anticipate the resident ' s needs to decrease the resident ' s frustration due to altered thought process. The care plan further directed the staff to actively assist with (ADLs) Activities of Daily Living due to the resident ' s self-care deficit requiring extensive assistance of 1 to 2 staff members. The care plan lacked any interventions to address the resident ' s respiratory status. The 08/27/12 at 3:00 A.M., nurse ' s note revealed the resident had a fall at approximately 10:00 P.M. on 08/26/12 and the staff found the resident sitting on his/her buttocks on the floor, in front of the recliner in his/her room. The nurse ' s notes indicated the resident had on gripper socks and when assessed by the staff, the resident ' s (AROM) Active Range of Motion and (PROM) Passive Range of Motion were (WNL) Within Normal Limits for this resident. The resident denied hitting his/her head and denied pain. The resident ' s Temperature 98.4, Pulse 66, Respirations 24, Blood Pressure 144/79, and oxygen saturation of 92%. The staff notified the physician by facsimile at 2:30 A.M. The 08/28/12 at 4:00 A.M. nurse ' s note revealed at 2:00 A.M. the staff observed the resident scooting out of bed. The staff assisted the resident to the restroom then transferred him/her to the Merrywalker for locomotion. No bruising, or signs and symptoms of pain were noted by the staff. The medical record lacked documentation of vital signs recorded in this entry. The resident vital sign report on 08/29/12 at 2:01 P.M. revealed a blood pressure of 113/71, pulse 93, respiration 16, temperature 97.8 and oxygen saturation rate at 92%. The 08/29/12 at 4:45 P.M. nurse ' s note revealed at 3:45 P.M. the staff called the nurse to the resident ' s room and the nurse observed the resident sitting on his/her buttocks on the floor next to the bed, with one gripper sock on. Upon assessment, the AROM and PROM normal for this resident. The nurse ' s note revealed staff assisted the resident from the floor, with extensive assistance times 3 staff, to his/her bed. The resident ' s temperature was 97.3, Pulse 156, Respirations 20, Blood Pressure 142/67 and oxygen saturation of 72%. The nurse ' s notes revealed the resident had no injuries, was non-verbal and no indication of pain, moaning, groaning or tears noted. The medical record lacked documentation of a thorough assessment including decreased or absent breath sounds, crackles, decreased heart sounds, level of of dyspnea, (difficulty in breathing) in comparison to the resident ' s baseline, use of accessory muscles for breathing, and use of abdominal muscles during expiration. The note indicated the staff had notified the resident ' s physician by facsimile at 4:30 P.M. and the staff called the resident ' s DPOA, with no answer and the note indicated the staff would try again. The record lacked evidence the staff followed up on the facsimile notification to the physician. The Lippincott Manual of Nursing Practice, Eighth Edition, indicated a nursing assessment of a resident with the [DIAGNOSES REDACTED]., noting amount, color and consistency of sputum and determining the oxygen saturation at rest and with activity. The facility ' s Neurological Assessment form initiated after the resident ' s fall on 8/29/12 at 3:45 PM revealed no further documentation of the resident ' s vital signs including blood pressure, temperature, pulse, respirations or oxygen saturation when the staff further assessed the resident. The staff documented further assessment of the resident on the form related to the coma scale, limbs, eyes, and smile on 8/29/12 at 4:00 PM, 4:15 PM, 4:30 PM, 4:45 PM, , 5:30 PM, 6:00 PM but the form lacked any documentation of the resident ' s blood pressure, pulse, temperature, or respiratory status including oxygen saturation. Review further revealed the staff documented the resident ' s blood pressure, temperature, pulse and respirations along with the coma scale, limbs, eyes and smile on 8/29/12 at 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM, 8/30/12 at 3:30 PM, 9:15 PM and 8/31/12 at 12:18 AM, although the form revealed no documentation of any thorough assessment of the resident ' s respiratory status including oxygen saturation since the nurse ' s note on 8/29/12 at 4:45 PM. The resident ' s vital sign report on 08/30/12 at 6:01 A.M. revealed a blood pressure of 112/66, pulse 70, respiration 22, temperature 97.6 and the pulse oxygen saturation rate or thorough assessment of the resident ' s respiratory status was not documented. The medical record lacked any documentation of further assessment of the resident ' s respiratory status including the oxygen saturation, use of accessory muscles for breathing, lung sounds, skin color or depth of respirations from 8/29/12 at 3:45 PM to 8/30/12 at 8:30 AM (16 hours and 45 minutes)when the staff found the resident with mottling (patchy discoloration) of his/her hands and feet. The medical record also lacked any documentation the staff attempted to contact the physician after sending a fax to physician ' s office on 8/29/12 at 4:30 PM. The 08/30/12 at 8:30 A.M. nurse ' s note revealed the staff summoned the nurse to the resident ' s room due to mottling (patchy discoloration) of the resident ' s hands, feet, and knees. The note indicated the nurse applied oxygen at 2 liters per mask and the resident had jerking movements while in his/her bed. The nurse called the physician and was awaiting a return call and a facsimile also was sent. The 08/30/12 nurse ' s note at 12:10 P.M. revealed a new order from the physician. The medical record lacked any documentation the staff had applied oxygen to the resident prior to the 8/30/12 at 8:30 AM nurse ' s note or completed a thorough assessment of the resident ' s respiratory status. The 8/30/12 at 2258 (10:58 PM) physician ' s telephone order directed the staff to administer : 1) [MEDICATION NAME] (antianxiety) 0.5 (mg) milligram tablet, 1 or 2 tables every 4 hours, as needed for agitation/terminal restlessness 2) [MEDICATION NAME] 20 mg per (ml) milliliter, 0.25 to 1.0 ml, orally, every two hours, as needed for pain or air hunger. The 08/30/12 at 9:00 A.M. nurse ' s note revealed the staff notified the resident's DPOA of the resident ' s condition and the family was at the facility on and off that morning. The 8/30/12 untimed physician ' s telephone order directed the staff to apply oxygen per nasal cannula or mask to the resident and maintain the resident ' s oxygen level greater than 90%. The order further directed the staff to discontinue all oral meds. Administer [MEDICATION NAME] (an antianxiety medication), 0.5 (mg) milligrams, and every 4 hours, as needed for agitation. [MEDICATION NAME], (a pain and air hunger medication), 5 mg, every 3 hours, as needed for pain and sedation. The 9/17/12 Physician Q ' s letter indicated residents respond favorably to appropriate comfort medications including [MEDICATION NAME] and as death nears vital signs are expected to be abnormal including oxygen saturation, " due to the redefined goals of care " . The physician stated that oxygen is one of many interventions that can be used to help alleviate " dyspnea " (difficulty breathing) but is frequently ineffective for an unresponsive resident who is actively dying. Review of the medical record lacked any documentation the resident was unresponsive from the documentation on 8/29/12 at 4:45 PM, when the staff found the resident sitting on the floor with the elevated pulse and oxygen saturation of 72% to when the nurse documented on 8/30/12 at 8:30 AM, the staff found the resident with mottling of his/her hands, legs and feet. The medical record lacked any documentation the physician had directed the staff to implement comfort measures or consult Hospice services for palliative care until 8/30/12. On 09/18/12 at 1:05 P.M., Physician P verified that a facsimile on 08/29/12 at 4:30 P.M. was not received at his/her office and his/her records do not show he/she received a facsimile in regards to the resident ' s respiratory status. The physician reported findings of the resident ' s temperature of 97.3, Pulse of 156, respiration 20, blood pressure 142/67 and pulse oxygen saturation of 72%, should be telephoned to the office, not faxed. The physician reported he/she had lack of notification of this resident ' s condition status change. On 09/13/12 at 12:00 P.M., Nurse D verified the lack of monitoring and assessment of the resident, lack of providing care and treatment to the resident in a timely manner, lack of following the policy for change in condition and lack of timely notification of change in the resident ' s condition to the physician and the family. On 09/17/12 at 3:45 P.M., Nurse O verified the process of faxed orders to the physician include: 1) The original facsimile is sent to the physician office with the request. 2) The request is then placed on the clip board. 3) When the original facsimile is returned with the physician response, it is filed in the chart. 4) The first sent facsimile is shredded. Nurse O verified that facsimile orders are used for non-urgent medical needs. On 09/17/12 at 4:00 P.M., Nurse G verified the facility was unable to locate a facsimile the staff had sent to the physician on 08/29/12 at 4:30 PM as documented in the nurse ' s notes. Nurse G verified the staff should have called the physician ' s office on 08/29/12 at 4:30 PM, when they assessed the resident and determined the change of condition including the high pulse rate and low oxygen saturation level instead of sending a facsimile. On 09/17/12 at 4:00 P.M., Nurse D verified the 08/29/12 at 4:30 P.M. facsimile to the physician, with the resident condition update, was not found. Nurse D verified the assessment of the resident on 08/29/12 at 4:30 P.M. should have been called to the physician ' s office, not sent by a facsimile. Nurse D verified the facility policy was to telephone a significant change of a resident to the physician's office. On 09/17/12 at 4:10 P.M., Nurse G verified if the assessments of the resident were not found in the resident ' s medical record, and the staff had not located them upon request then the facility did not have them. The facility ' s policy for Symptoms of Lower Respiratory Infection directed the staff to notify the physician immediately if the resident ' s oxygen saturation was less than 90%. The policy further directed the staff to monitor vital signs every 4-8 hours and provide oxygen supplementation as indicated. The facility failed to complete a through respiratory assessment, notify the physician for treatment or complete thorough ongoing reassessments of the respiratory status of Resident #6 who had a change of condition including a low oxygen saturation level of 72%. The resident had a decline in condition resulting in mottling of his/her legs, hands and feet.

The facility had a census of 67 residents. The sample included 9 residents, of whom 3 were reviewed for falls. Based on observation, record review and interview the facility failed to provide supervision and assistive devices to prevent accidents and accident hazards for 1 of 3 sampled residents. (#5) Findings included: - The facility admitted Resident #5 to the facility on [DATE] and the initial care plan indicated the resident had problem area including falls, severe debility, reduced self-cares, and weakness. The care plan directed the staff to provide the following: call light within reach; appropriate lighting, room free of clutter; instruct resident and family on safety measures; extensive assistance of 2 with toileting, transfers; assess footwear for proper fit and non-skid soles; and consult (PT) Physical Therapy/(OT) Occupational Therapy as needed. The admission (MDS) Minimum Data Set 3.0 assessment, dated 6/15/12, revealed a (BIMS) Brief Interview for Mental Status score of 4 (indicating memory loss with severely impaired decision making skills). The MDS indicated the resident required extensive 1 staff assistance for most (ADLs) Activities of Daily Living, except independence with eating. The MDS indicated the resident had unsteady balance, a fall and fracture prior to admission and 1 fall with a major injury since admission or prior MDS. The initial care plan, updated 6/15/12, after the resident had fallen and sustained a hip fracture, directed the staff to move the resident to a room closer to the nurse's station and to continue the 2 hour toileting schedule. The 6/21/12 (CAAS) Care Area Assessment Summary indicated the facility initially admitted the resident for skilled care following hospitalization as a result of falls, weakness and decreased ability to provide self-care. The CAAS indicated the resident had experienced multiple falls recently, with fractures to the pelvis as well as compression fractures to his/her spine prior to his/her admission to the facility. The CAAS indicated the resident displayed inappropriate safety awareness. The CAAS indicated the resident experienced a fall on 6/15/12 and required hospitalization for a fracture of his/her left hip. The Fall Risk Assessment, dated 6/8/12, had a score of 8, which indicated the resident at risk, but not at high risk for falls (even though the facility admitted the resident after multiple falls and hospitalization with a pelvic fracture). Review of the medical record revealed no other Fall Risk Assessment. The 7/10/12 care plan directed staff to provide: call light within reach, although the resident doesn't remember to use it most of the time; when the resident wakes up during the night, he/she needs to toilet "very badly". The care plan directed the staff to check the resident every 2 hours and each time staff passed by his/her doorway; assess fall risk every quarter; ensure the resident wears non-skid socks or shoes for transfers; ensure wheelchair locks are set; ensure the resident's bed in lowest position because he/she could roll out of bed; cane rail on bed; remind resident not to lean over and pick up things as he/she has trouble with balance; 1-2 staff assistance and use of a gait belt for transfers; assist with turning and repositioning in bed because the resident cannot do it himself/herself. The 6/8/12 at 5:20 PM, nurse's note stated the facility admitted the resident from the hospital after he/she fell at home. The assessment indicated the resident was alert and oriented and able to make his/her needs known. The nurse's note stated the resident suffered from severe debility, reduced self care skills, was extremely fearful of future falls and reported he/she did not like to be left alone in the restroom. The facility lacked further documentation of an assessment of the resident until he/she was found over 14 hours later, with his/her head down, caught between the bed and the wall. The 6/9/12 nurse's note and nursing assessment stated at 8:05 AM, staff reported to the nurse the resident was "almost out of bed". The report stated the nurse found the resident's body halfway out of bed, in a horizontal position, with both legs on the mattress and his/her trunk and head in a downward position, with the resident's face against the wall. The report stated the resident's head and left side of his/her face had edema and his/her eyes were swollen shut. Staff noted a large amount of mucous, brownish/yellow in color, to the resident's right nare. The resident answered only "yes and no" to questions and was unable to open his/her eyes. The resident denied pain, but became agitated when staff attempted to obtain vital signs. Vital signs were: temperature 96.2; pulse 82; respirations 16; blood pressure 128/84; and oxygen 94%. Staff initiated neurological checks and at 8:15 AM, notified the on call physician who gave orders for the staff to monitor the resident and keep the HOB (Head of the Bed) elevated for 2 hours. The report stated the resident's family came to the facility at 9:30 AM, and the staff notified him/her of the incident and he/she voiced no concerns. Review of the medical record revealed documentation of the resident's vital signs and neurological checks. The next nurse's note, dated 6/9/12 at 1:20 PM, stated staff continued to perform neurological checks and vital signs and stated the edema to the resident's head was improving. The note stated the resident remained lethargic, but able to put 4-5 words together to make a sentence and answered questions appropriately. The note stated the resident was unable, on command, to open either eye and staff indicated the pupil size at 3 (mm) millimeter, with a brisk response to light. The note indicated a phone call was placed to the resident's DPOA (Durable Power Of Attorney) who asked the staff to let him/her know if the facility needed to send the resident to the ER (emergency room ). The note indicated at 1:30 PM, staff contacted the on-call physician and informed him/her they were unaware of how long the resident was in the position with his/her head down. Staff reported to the physician the facial/head edema was improving some, although the resident remained lethargic. The note indicated the staff informed the physician the resident was able to follow commands, had full (ROM) Range of Motion and his/her hand grip was equal. The note indicated the physician ordered the staff to send the resident to the ER via ambulance. Further review of the note indicated: At 1:35 PM, the staff notified the DPOA, and at 1:50 PM, the staff called (EMS) Emergency Medical Service. At 2:15 PM, the resident departed in the ambulance. The 6/9/12 at 4:20 PM, nurse's note indicated the ER nurse reported the resident's status to the facility and reported the (CT) Computerized Tomography scan of the resident's neck and head had no abnormality. The note indicated the facility sent staff to transport the resident back to the facility. Review of the medical record revealed no review or revision to the resident's care plan to prevent the resident from further incidents after finding the resident with facial edema, eyes swollen shut and his/her head in a downward position with his/her legs on the bed and requiring evaluation in the emergency room . The 6/15/12 at 9:30 PM, nurse's note stated staff found the resident sitting on the floor. The note stated the nurse assessed the resident's ROM to all extremities and the resident had no complaints of pain. The 6/15/12 at 10:00 PM, nurse's note indicated the staff found the resident out of bed twice this evening without using the call light for assistance. Once he/she was found in the bathroom and once he/she was found sitting on the floor. The 6/16/12 at 1:30 AM nurse's note indicated when the staff assisted the resident to the bathroom, he/she was unable to bear weight on his/her left leg and unable to lift or rotate the leg outward. The note indicated staff contacted the physician and he/she ordered the staff to send the resident to the ER and the staff notified the resident's DPOA. At 4:30 AM, the notes indicated the physician admitted the resident to the hospital for a left hip fracture. The notes indicated the resident returned on 6/20/12 at 3:00 PM. The 8/14/12 at 6:15 AM, nurse's note indicated the staff found the resident on his/her knees on the floor beside the bed. The note stated the bed was in high position (not in lowest position as outlined in the care plan). The resident complained of pain with palpation and flexion of his/her left hip. The note stated 2 staff used a gait belt and transferred the resident to bed. The nurse noted the resident's left leg shortened and rotated internally. The note indicated the nurse notified the physician and received orders to transfer the resident via EMS to the hospital and staff notified the resident's DPOA. The 8/14/12 at 12:25 PM, nurse's note indicated the staff contacted the resident's DPOA regarding the resident's status and the note stated the DPOA requested staff place a floor mat beside the resident's bed. The note indicated the nurse passed that information on for the next care plan meeting. Review of the resident's care plan, updated 8/14/12, directed the staff to provide a floor mat beside the resident's bed, as requested by the resident's family, after the 6/9, 6/15 and 8/14 accidents. The 8/23/12 at 7:30 AM, nurse's note indicated the staff found the resident with his/her legs and the trunk of his/her body off the side of the bed. The note indicated the resident complained of shoulder pain with range of motion and had redness and a scratch on his/her lower arm. The note indicated the staff notified the physician and received orders to transfer the resident to the ER. Review of the facility's witness statements for the resident's 8/23/12 accident, revealed the staff found the resident halfway out of his/her bed with his/her arm caught between the cane rail and the bed. Further review of the witness statement revealed the staff had to release the resident's arm before lowering her to the floor for evaluation. The 8/23/12 emergency room physician report stated the staff had found the resident hanging from his/her bed and his/her arm was bluish in coloration. The [DIAGNOSES REDACTED]. On 9/13/12 at 1:00 PM, Nurse C stated the staff are to update the care plan after a fall, and should have updated the resident's care plan with interventions, such as a lipped mattress, to prevent further issues of the resident rolling out of bed or falling. Nurse C also stated staff should have updated the Fall Risk Assessment after the 6/9/12, 6/15/12 and 8/14/12 falls. Nurse C verified staff should provide immediate interventions after an accident and should not wait until the next care plan meeting as indicated in the 8/14/12 nurse's note. On 9/13/12 at 2:30 PM, Administrative Staff H verified the facility had not reported, to the appropriate state agency, the resident's unwitnessed accidents on 6/9/12, 8/14/12 and 8/23/12. On 9/17/12 at 1:00 PM, Nurse D and Nurse G verified the facility staff were to document assessments on the nurse's notes and when the resident received skilled care or had an accident, staff were to assess the resident at least every shift and document the assessment in the nurse's notes. Nurse D and Nurse G also verified the staff had not updated the care plan with interventions after the staff found the resident caught between the bed and the wall on 6/9/12 and then again on 8/23/12. Nurse D and Nurse G verified the documentation lacked a nursing assessment, other than neurological checks and vital signs, from the initial assessment at 8:05 AM to 1:20 PM (5 hours). Nurse D and Nurse G also verified the lack of nursing assessment after the resident returned from the hospital on [DATE]. Nurse G stated, as an experienced nurse, he/she would have assessed the resident for pain, edema and documented more frequently than the nurse on 6/9/12 had done. Nurse D verified the resident had been in the same room since his/her admission at the time of the accident on 6/15/12, when the resident sustained [REDACTED]. On 9/17/12 at 1:30 PM, Nurse D and the surveyor checked for gaps between the mattress and the cane rail on several facility beds. He/She verified most mattresses fit snugly, however, one bed with only 1 cane rail up had a gap of approximately 2-3 inches between the rail and the mattress. He/She stated the mattress had slid over on the bed toward the wall. The facility's undated Accidents and Occurrences Policy stated it was the facility's policy to ensure that each resident received adequate supervision and assistive devices to prevent accidents/occurrences. The policy stated all occurrences must be investigated and reported to the administrator. The policy stated that regardless of how minor an occurrence, including injuries of unknown source, it must be reported to the department supervisor, who will conduct an immediate investigation. The policy stated the nurse will complete documentation, update the plan of care and complete a physical assessment every shift for 72 hours following the occurrence and document in the nurse's notes. The policy stated the Director of Nursing will review all documentation and ensure relevant, individualized interventions have been added to the care plan. The policy further suggested fall reduction interventions such as provide illumination/night lights, inspect use and safety of resident equipment, low bed, mat on floor for rolling out of bed, increased visual observation of the resident at specific time intervals, provide with body pillows, monitor closely with specific time periods post fall and assess for the ability to use the call light and provide alternate device. The facility failed to provide adequate supervision and assistive devices to prevent Resident #5 from having further falls.